Cuts to foreign aid under the Trump administration could have a modest impact on the funding of sex trait modification medicalization and trans-mainstreaming in South Africa, though other donors might readily fill the gap. South Africa, home to over 8 million people living with HIV, has historically been the largest recipient of funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).*
The Wits Reproductive Health and HIV Institute (Wits RHI) is just one institution that has received hundreds of millions of dollars via PEPFAR. It has directed at least a portion of this funding towards advancing “transgender rights” including initiatives to normalise transgender ideology and medicalization in South African at primary healthcare level. Amongst other projects, Wits RHI used PEPFAR funding to support the development of the 2021 Southern African HIV Clinicians’ Society “Gender-Affirming Healthcare Guideline”. These guidelines, authored by members of the South African chapter of WPATH, promote the “informed consent, affirmation-only” approach, with social transition support, binders and packers, puberty blockers, cross-sex hormones, and surgeries and no lower age limit.
Source: https://sahivsoc.org/Files/SAHCS%20GAHC%20guidelines-expanded%20version_Oct%202021(3).pdf
Additionally, a $37 million, five-year PEPFAR award to Wits RHI facilitated the establishment of four fixed-site “transgender” clinics. Ostensibly focused on HIV-related services – such as testing, prophylaxis, and treatment – these clinics also provided “gender-affirming care” to trans-identifying individuals, including adolescents aged 18 and above. Nearly half of the individuals that they saw were adolescent men under the age of 25 (1717/3535, 48.5%). Most of these young men were probably effeminate presenting young gay men. Who can say if they would have sought out trans-medicalisation without active recruitment by Wits RHI, and the partner organisations that they sub-contracted to for, inter alia, “demand creation and community mobilization”? It scarcely seems ethical of Wits RHI to have been prescribing harmful cross-sex hormones to this already very vulnerable population.
Age & sex of individuals recruited under the Wits RHI Key Populations Programme. Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9557019/, accessed 3 March 2025
Recently Wits RHI and other players in South Africa’s HIV/AIDS sector seem to have engaged in significant online content removal. Over the past month, websites have been scrubbed of references to “LGBTQI”, “transgender” and “gender-affirming care.” The Wits RHI landing page provides one example of this reverse-trans-washing.
Source: Web Archive, November 2024; https://wrhi.ac.za/, accessed 2 March 2025
Source: Web Archive, November 2024; https://wrhi.ac.za/, accessed 2 March 2025
It is far too early to tell whether the U.S. policy changes and funding cuts will have any broader effect on trans mainstreaming in South Africa. Powerful donors like ARCUS, the Global Fund to Fight HIV, AIDS and Malaria (whose PEPFAR funding has not yet been cut), the Elton John AIDS Foundation and the Bill & Melinda Gates Foundation continue to promote the “trans” narrative in the country within the HIV space, showing no signs of altering their course. Meanwhile, transactivist institutional capture remains entrenched across South Africa’s NGO and public health sector, major teaching hospitals, and various government departments, including those of health & wellness, and social development.
*We certainly don’t wish for South Africans living with HIV to be denied access to testing, PreP and ART. Fortunately these are all available for free at the point of access in the South African public health service, at most primary health care clinics, as well as at hospitals in the secondary and tertiary sectors. It is not yet clear how the public health sector will respond to cuts in PEPFAR, whether donors will step in, or which projects may receive waivers and be able to continue. PEPFAR cuts will almost certainly create capacity issues and add strain to South Africa’s overburdened public health system.
