EXPLORING THE USE OF TELEMEDICINE FOR GENDER- AFFIRMING CARE IN SOUTH AFRICA: A STRUCTURED CRITICAL REVIEW OF CHALLENGES, OPPORTUNITIES, AND IMPLEMENTATION PRIORITIES

Gender-affirming care in South Africa remains unevenly available despite a comparatively progressive constitutional and human-rights framework. Services are spatially concentrated, waiting times are prolonged, and many transgender and gender-diverse people still report stigma, provider ignorance, and fragmented referral pathways. Telemedicine has been proposed as one way to extend access, but its value in South Africa depends on whether it reduces inequity rather than merely digitising existing exclusion. This manuscript presents a structured critical review of peer-reviewed and guideline literature relevant to telemedicine-enabled gender-affirming care in South Africa. Searches were undertaken across PubMed, Scopus, Web of Science, PsycINFO, CINAHL, Google Scholar, and South African journal and guideline sources up to 26 March 2026. Evidence was included when it addressed at least one of the following: gender-affirming care, transgender or queer healthcare access, telemedicine or telehealth implementation, or South African regulatory and service- delivery considerations. Twenty-six sources were retained for final synthesis. The evidence indicates that telemedicine is best conceptualised as a hybrid service-enabling layer rather than a complete substitute for in- person care. The strongest opportunities lie in psychosocial support, informed-consent discussion, routine follow-up, laboratory result review, support for antiretroviral and pre-exposure prophylaxis adherence, and referral coordination. The strongest constraints are digital inequality, data and device costs, privacy limitations in home environments, provider capability gaps, fragmented referral systems, and uncertainty regarding service governance and reimbursement. South African differentiated service-delivery models and recent cross-sectional evidence suggest that telemedicine is likely to be most effective when integrated into primary care, HIV services, laboratory pathways, peer navigation, and specialist back-up arrangements. Telemedicine can make a meaningful contribution to gender-affirming care in South Africa, but only if implemented as a public-interest, equity-sensitive, and clinically governed hybrid model. Publication-grade scholarship should therefore move beyond generic claims of convenience and instead specify who benefits, under what conditions, and through which operational pathways.