Although the recent concepts ‘gender dysphoria’ (according to the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders, 2022) and ‘gender
incongruence’ (as defined in the World Health Organization’s 2022 International
Classification of Diseases, ICD-11) may seem to refer to recent phenomena, research
has shown that gender diversity has affected individuals since the earliest times.
Recent years have seen a rapid increase in the number of adolescents and children
diagnosed with gender dysphoria. The prevalence of gender dysphoria is also
reflected in growing public attention and fierce debates regarding gender
reassignment procedures. Despite opposition to the procedures, an increased
acceptance of gender diversity in some parts of the world has been noted,
accompanied by the emergence of adolescent gender affirming health care and the
establishment of gender responsive health services. Not all adolescents affected by
gender dysphoria are able to express their gender incongruence from an early stage,
often leading to feelings of social alienation, anxiety and depression. Past medical
practices, as this thesis shows, have created unintended barriers to care for genderdiverse
adolescents. Adolescents and children were initially not incorporated in clinical
practice guidelines and standards of care issued by the World Professional
Association for Transgender Health (WPATH), an international body that sets the
standards of care for transgender medicine. In recent years, WPATH has
recommended medical interventions for adolescents and children with gender
incongruence. This is because delaying or minimising such medical interventions may
prolong the manifestation of gender dysphoria in adolescents and children. Early
intervention has been found to have a positive effect on the psychological well-being
and social functioning of these children, as well as establishing an external physical
appearance more closely aligned with their gender identity. Despite the
recommendation of early medical intervention, the optimal age of introducing genderaffirming
therapies remains a contested issue in this sensitive field of medicine and
law.
The thesis identifies several legal challenges obstructing adolescents’ access to
gender affirming health care in South Africa. Drawing on a comparative legal overview
of both proactive and restrictive approaches regarding the provision of gender
affirming care in Australia, the United Kingdom, New Zealand, Canada and Denmark, the thesis postulates that the current South African legal framework governing gender
affirming health care fails to meet the bests interests of children and adolescents
suffering from gender dysphoria. In order to address this, the thesis first explores,
through the lens of the best interests of children, different perspectives regarding
children and adolescents’ informed consent to gender affirming health care. Secondly,
the thesis concludes with sound recommendations informed by the legal comparative
analysis, which provides a firm foundation for the consideration of children and
adolescents’ access to gender affirming health care. This foundation will promote
ongoing civil discourse and deliberative dialogue toward better shared decisionmaking
in adolescent gender affirming health care and beyond. In the final instance,
the thesis demonstrates how access to gender affirming health care services must be
grounded in a human rights discourse, strengthened by the application of the yardstick
of the best interests of the child.
Dikgopolotaba tsa moraorao e leng ‘masisapelo a tliswang ke bong ba tlhaho le bong
bo fapaneng le bong ba motho ba boitsebiso’ (ho ya ka 5th Edition of the Diagnostic
and Statistical Manual of Mental Disorders, 2022) le ‘bong ba tlhaho bo sa
dumellaneng le bong ba motho ba boitsebiso’ (jwalo ka ha ho hlaloswa ke World
Health Organisation’s 2022 International Classification of Diseases, ICD-11) eka di
bua ka diketsahalo tsa matsatsing a jwale, feela diphuputso di bontsha ha phapano
ya bong e le tlhobaboroko ho batho ho tloha sethathong. Sesosa sa bokudi, e leng
masisapelo a tliswang ke bong ba tlhaho le bong bo fapaneng ba motho ba boitsebiso,
se atile ka sekgahla dilemong tsa jwale dipalong tsa bana le batjha. Ketsahalo ena e
hlalositsweng ka hodimo e iponahatsa ka tsela eo setjhaba se tsepamisitseng maikutlo
le dingangisano tse matla mabapi le oporeishene tse fetolang bong. Ho hlokometswe
ho eketseha ha mafatshe a amohelang bong bo fapaneng, mme ho tsamaya mmoho
le ho ropoha ha ditshebeletso tsa bophelo tse tshehetsang batjha le ho thehwa hwa
ditshebeletso tsa bophelo tse arabelang bong ba motho, le ha ba bang ba le
kgahlanong le tsona. Ha se batjha bohle ba anngwang ke masisapelo a tliswang ke
bong ba tlhaho le bong bo fapaneng ba motho ba boitsebiso, ba kgonang ho hlalosa
bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso ba sa le banyane,
mme sena se lebisa ho maikutlo a ho kgetholleha setjhabeng, ngongoreho le kgatello
ya maikutlo. Ditlwaelo tsa bophelo tsa kgale, jwalo ka ha thesese ena e bontsha, di
bakile dithibella tsa tlhokomelo tseo e seng tsa ka boomo ho hlokomeleng batjha ba
bong bo fapaneng. Ho tloha sethatong, batjha le bana ba ne ba sa kenyelletswa
ditataisong tsa ditshebeletso tsa bongaka le boemong ba tlhokomelo bo nehelanweng
ke World Professional Association for Transgender Health (WPATH), e leng mokgatlo
wa matjhabatjhaba o thehang boemo ba tlhokomelo bitsong la meriana ho ba fetolang
bong. WPATH e kgothalleditse bonamodi ba bongaka bitsong la batjha le bana ba
nang le bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso dilemong
tsa jwale. Lebaka ke hore tiehiso kapa ho nyenyefatsa ha bonamodi bona ba bongaka
bo ka atolosa boiponahatso ba bong ba tlhaho bo sa dumellaneng le bong ba motho
ba boitsebiso ho batjha le bana. Ho ile ha fumaneha hore bonamodi bo nakong bo na
le ditlamorao tse ntle maemong a bana bana a kelello le tshebetsong ya phedisano,
le hona ho thehweng ha tjhebeho e kantle ya sebopeho sa mmele e tshwanang le
bong ba bona ba boitsebiso. Ntle le dikgothalletso tsa bonamodi ba bongaka bo etswang nako e sa le teng, dilemo tse dumellesehang tsa ho kenya tshebetsong
theraphi e tshehetsang bong e ntse e le taba e lwanelwang maemong ana lekaleng la
bongaka le molao.
Thesese e hlwaya dikgwehlo tse mmalwa tse thibellang batjha ho fumana tlhokomelo
ya bophelo e netefatsang bong Aforika Borwa. Thesese e sisinya hore motheo wa
semolao wa Aforika Borwa wa jwale o laolang tlhokomelo ya bophelo e netefatsang
bong e hloleha ho ananela dikgahlehelo tse bohlokwa tsa bana le batjha ba nang le
bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso, ka ho bapisa
tjhebeho tsa Australia, United Kingdom, New Zealand, Canada le Denmark, tsa
semolao tsa katamelo e nang le dipehelo le e se nang dipehelo sepheong sa
tshebeletso e netefatsang bong. Ho phenyekolleng sena, thesese e lekotse
dikgahlehelo le tumello e nang le tsebo ya tshebeletso ya bophelo e netefatsang bong
ba bana le batjha pele, Bobeding, thesese e phethela ka dikgothalletso tse tsepameng
ho manollo le papiso ya semolao eo e leng motheo wa tshekatsheko ho ananelweng
hwa bana le batjha ho fihlelleng ditshebeletso tsa bophelo. Motheo ona o tla
kgothalletsa dipuisano setjhabeng le dingangisano tsa maikemisetso tse tswellang
pele e le ho nka diqeto tse kopanetsweng ditabeng tsa ditshebeletso tsa bophelo tse
netefatsang bong ba batjha ho ya ho ile. Qetellong, thesese e bontsha hore ho fihlella
ditshebeletso tsa bophelo tse netefatsang bong di tshwanetse ho thehwa dipuisanong
tsa ditokelo tsa botho mme di tshehetswe ka ho sebedisa dikgahlehelo tse bohlokwa
tsa ngwana.
Nakuba kunezimvo ezahlukene ngenxa yengcindezi yokwehluka kwemizwa nobulili
(njengokwethula kwesishicilelo sesi-5 Somqulu Wamanani Okuxilongwa Kwezifo
Zengqondo sezi-2022) kanye nempicabadala ngobulili (njengokuchaza
Kwenhlangano Yezempilo Yomhlaba ohlelweni lwesifo lomhlaba onyakeni wezi-2022,
i-ICD-11) okubukeka kuqondiswe esimweni sakamuva socwaningo esiveza ukuthi
ukwehluka kobulili sekubalimaze kanjani abantu ngabodwana kulesi sikhathi. Kule
minyaka esanda kudlula kube nokunyuka okukhulu kubantwana abasemabangeni
okukhula abaxilongwe batholakala bekule mpicabadala yobulili. Ukukhula kwale
mpicabadala ibonakala emiphakathini nasezingxoxweni ezivutha uphondo mayelana
nobulili nengqubo ehambisana nabo. Noma kukhona ukungaboni ngasolinye kulezi
zingqubo, ukukhula kwabemukelayo ukwehluka kwabantu ngezinhlobo
zokuzikhethela ubulili kuyaqapheleka emhlabeni jikelele, kuhambisana nokuvumbuka
kwabantu abaqinisekisa nanezempilo ezeseka ukwamukelwa kwezinhlobo zobulili
ezahlukene emkhakheni wezempilo. Akubona bonke abantwana abasebangeni
lokukhula abathintekayo kule mpicabadala yobulili, abanye basheshe babonakale
besebancane ukuthi bayiluphi uhlobo lobulili, nokuthi imizwa yabo ingakuluphi
uhlangothi, noma bazibona bengena ngaphansi kwamaphi amaqembu emphakathini,
okumbandakanya ukukhathazeka nokucindezeleka. Ezokwelapha zesikhathi esidlule
nemiqulu yocwaningo esibhalilwe isiveze imingcele edinga ukuqashelwa
ngokwehluka kwezinhlobo zobulili kubantwana abasebangeni lokukhula. Abantwana
abasebangeni lokukhula nabantwana nje bonke bebengafakiwe ezinhlelweni
zokwelapha ezinemihlahlandlela nezimiso zokunakekela ezikhishwe Inhlangano
Yezemikhakha Yomhlaba Yokuguqulwa Kobulili Yezempilo (i-WPATH), lena
inhlangano yomhlaba ebeka izimiso zokunakekeleka nezokwelashwa kokuguqulwa
kobulili. Eminyakeni esanda kudlula i-WPATH ilethe iziphakamiso zokungenelela
kwezokwelasha kubantwana abasebangeni lokukhula nabantwana basebancane
abanobulili obunesidingo sokuqondiswa. Lokhu kunonembe lokuhamba ngonyawo
lonwabu noma ukuba mbalwa kwamathuba okwelashwa okwenza impicabadala
yobulili iqhubekele phambili kubantwana abasebangeni lokukhula nasebantwaneni
abasebancane. Ukungenelela kusesemabangeni aphansi okukhula kutholakale
kunomphumela omuhle ekwelekeleleni umqondo nobuyena umntwana,
nokwamukeleka kwakhe emphakathini kanjalo nokwakhekha kwezicubu zomzimba ezihambelana nobulili abuncamelayo nazizwa eyiyona umntwana. Ngaphandle
kwezincomo zokungenelela kwabezokwelapha umntwana esemncane, kunebanga
umntwana okufanele uma esefike kulona akwazi ukuzibona emukeleka ebulilini
obuthize ngokwenziwa kwezinhlelo ezelekelelayo okugcine kuwudaba olusabhungwa
futhi olubucayi emikhakheni yezomthetho neyezempilo.
Lo mqulu wocwaningo uhlonze izinselelo ezimbalwa zezomthetho ezigqashula
izibopho zokufinyelela kubantwana abasebangeni lokukhula abadinga ukwelekelelwa
ukuze baqiniseke ubulili babo ngokwezempilo eNingizimu Afrikha. Ukuhogela
imikhondo ekuqhathanisweni kwesendlalelo somthetho nalokho kokubili,
ukulungiselela kusenesikhathi nezimiso ezinqabayo mayelana nokuhlelelwa
kokuqinisekisa ubulili ngokuqaphela e- Australia, eNgilandi, e-New Zealand, e-
Canada naseDenmark, lo mqulu wocwaningo unikeza imibandela yezivumelwano
zokuthi ezomthetho zaseNingizimu Afrikha zibe nesisekelo esilawula ukuqinisekisa
kobulili ngokwezokwelashwa nokunakekela okuhambisana nezifiso zabantwana
abasebangeni lokukhula abanenselelo yale mpicabadala yobulili. Ukuze kuzanywe
isixazululo, lo mqulu wocwaningo uqala ngokuhlola usebenzisa izinjulakuhlola
ezihambisana nezifiso zabasemabangeni okukhula, ubheka nezimvume
nokwelashwa nokunakekelwa. Okunye lo mqulu wocwaningo uphetha ngokwethula
iziphakamiso eziya emkhakheni wezomthetho oqhathanisa ukuhlaziya okuyikona
okunikeza isisekelo esinzulu ngokulandelwa kwendlela yokufinyelela kubantwana
abasebangeni lokukhula ukufinyelela ekwelashweni okumayelana nokuqinisekisa
kobulili nokwelashwa. Lesi sisekelo sizophumelelisa izingxoxo ezinohlonze nemibono
eqhubezela phambili ukwabelana ngezimvo nokuthatha izinqumo ngabantwana
abasemabangeni okukhula ukufinyelela ekwelashweni okumayelana nokuqinisekisa
ubulili, ukwelashwa nokuqhubekela phambili. Ngasekuphethweni lo mqulu wethula
ukuthi kungafinyelelwa kanjani ekwelashweni okumayelana nokuqinisekiswa kobulili
nokwelashwa okuhambisana nezinsizakusebenza okumele zesekwe ngamalungelo
abantu, kuqiniswe nangokwethulwa kwenkombandlela ebeka izidingo zabantwana
phambili.
