A study published in the South African Medical Journal has put numbers to something trans people across South Africa already know in their bodies: wanting care and being able to get it are two entirely different things. The research, led by Lynn Bust at the University of the Western Cape and the Desmond Tutu HIV Centre at the University of Cape Town, surveyed 150 transgender and gender-diverse people in the Western Cape and Eastern Cape. What it found is both straightforward and damning.

Almost everyone in the study had socially transitioned: a different name, a different way of dressing, a different gender expression. That part, at least, people had found a way to do for themselves. But only 4% had been able to legally change their gender details on their identity documents. And when it came to medical care, the gap between what people needed and what they had received was enormous. Among those who had not accessed medical gender-affirming care, 77% were in need of psychosocial support, and nearly seven in ten wanted hormone therapy. The care existed, in principle. It simply was not there for them.

The same walls, a different country

This is not a South African problem. The barriers Lynn Bust and the team identify here are cost, clinical ignorance, stigma, and geography. I have heard those exact four words used to describe the situation in the UK, in Australia, in Germany, in the United States, in Brazil. The access crisis is global, and what this study does is give it data in a context that is too often left out of the international conversation.

Trans people in South Africa already face higher rates of HIV, sexually transmitted infections, tuberculosis, and mental health difficulties than the general population. The study found that 34.2% of trans people assigned male at birth who participated were living with HIV. That figure demands attention on its own. But the researchers make a point that matters just as much: these health inequalities are not random. They are the predictable consequence of discrimination, violence, and a healthcare system that does not yet know how to care for trans people well. When you deny someone care that affirms who they are, the harm does not stay contained to gender. It spreads.

What the researchers are asking for

The team's call is direct: urgent improvements to make gender-affirming care part of an inclusive public health system, with collaboration between healthcare providers, government health departments, legal institutions, and trans communities. They note that the public health sector is best placed to deliver this care affordably and sustainably. That matters, because private provision, the kind that can fill gaps when public systems fail, is simply not accessible to most people. If gender-affirming care only exists for those who can pay for it privately, it does not really exist for most people who need it.

The legal gap is part of this too. Only 4% of participants had been able to update their identity documents. That is not indifference. The process in South Africa, as in many countries, is slow, expensive, and inaccessible to people without resources or reliable legal support. An identity document that does not match who you are creates problems in healthcare, in employment, in housing, in every encounter with any institution. It is not a bureaucratic inconvenience. It is a daily source of exposure and risk.

What 98.7% tells you

The figure that stays with me from this study is 98.7%. That is the proportion of participants who had socially transitioned. Nearly everyone. They had found a way to live as themselves, quietly and largely without institutional support, using the resources available to them: chosen names, different clothes, community. That is not a failure. That is people doing what people do, finding a way through regardless.

But social transition without medical support, without legal recognition, without psychological care, and with constant exposure to discrimination and violence is survivable for some and not for others. The researchers warn that the lack of access to gender-affirming care has substantial implications for mental health outcomes. People are being harmed by the absence of care that is neither experimental nor difficult to provide, if the will and the funding exist.

The work that Lynn Bust and the team have done here deserves to be read widely, not because the findings are surprising, but because documented evidence has a different weight than lived testimony, unjustly so, but that is the world as it is. This is the evidence. Now comes the harder part: making sure it leads somewhere.

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Dr Helen Webberley is a Gender Specialist, Medical Educator, writer, and advocate, and the founder of GenderGP. She writes about gender diversity, trans healthcare, and the lives of trans people and their families.