Rapid Review of Gender-Affirming Healthcare for Children and Adolescents: Evidence Synthesis (2021–2025) and Recommendations for South Africa

INTRODUCTION In a context of growing international debate over gender-affirming healthcare (GAHC) for youth, South African stakeholders require an up-to-date, locally grounded, evidence-informed assessment of health outcomes associated with gender-affirming interventions for transgender and gender-diverse (TGD) young people. This rapid review synthesises research indexed between January 2021 and August 2025 to evaluate whether new evidence supports, updates, or recommends changes to, South African GAHC guidelines.​ METHODS A rapid review approach was adopted to balance rigour with timeliness. Searches spanning January 2021 to August 2025 were conducted across 12 databases via EBSCO Host (University of Pretoria), supplemented by targeted searches for recent systematic reviews, with date limits of 2021-01-01 to 2025-12-31. Eligible reports included peer-reviewed primary studies (N ≥ 5) using any empirical design that reported psychosocial or physical health outcomes of psychosocial, endocrine, surgical, non-medical, or policy/legal interventions involving TGD youth under 18 (or a family with a TGD youth). Systematic, scoping, narrative, and grey literature reviews with transparent and reproducible search protocols were also eligible. Commentaries, opinion pieces, editorials, very small case series (N < 5), reviews lacking reproducible search strategies, and studies without intervention-related outcomes for TGD youth < 18 were excluded. Formal de novo risk-of-bias or certainty grading across individual studies was not undertaken; instead, existing methodological and certainty appraisals from included systematic reviews were used qualitatively to inform interpretation, and findings were synthesised narratively by intervention domain.​ The review was not registered in any registry. RESULTS The final dataset comprised 200 primary studies, 29 academic systematic reviews, and four grey literature systematic reviews, covering psychosocial, endocrine, surgical, non-medical, and policy/legal interventions for TGD youth. Consistent evidence shows that affirming psychosocial interventions, including family engagement, school inclusion, and social transition, are associated with reductions in distress, anxiety, and suicidality, alongside improved functioning and sense of belonging. Puberty pausers and gender-affirming hormone therapy produced expected and desired physiological outcomes under specialist monitoring, with adverse events generally mild, reversible, and consistent with known paediatric endocrine profiles, and mental-health outcomes ranging from neutral to improved. Evidence for surgical interventions under age 18 remains limited and focuses mainly on masculinising chest reconstruction, for which complication and revision rates were very low, regret was exceedingly rare, and patient satisfaction and short term psychosocial benefit were high. Restrictive or hostile policy environments were associated with increased distress, self-harm, suicidality, and social withdrawal, whereas protective policies such as anti-discrimination regulations, legal gender recognition, and inclusive school protocols were linked with improved mental health and reduced risk behaviours. Most studies were small and observational, with short follow-up, limited representation of Global South populations, and heterogeneous outcome measures, constraining causal inference and comparability.​ DISCUSSION This Rapid Review affirms the safety and effectiveness of gender-affirming healthcare for TGD youth. It highlights the importance of affirming psychosocial care, timely access to endocrine and surgical interventions when indicated, and protective policy environments. Opportunities to strengthen GAHC within South Africa's legal, historical, and health-system context will support realisation of South Africa’s constitutional affirmations of bodily autonomy and access to healthcare. The primary source of support for this review was volunteer effort from a South African queer- and trans-led team, with partial financial support for three authors provided by Gender DynamiX.​