Prof Elma de Vries, Doing What Her Hands Find To Do

In this inspiring episode of Awakening Doctor, senior family physician and MBChB Programme Coordinator at Nelson Mandela University, Professor Elma de Vries, reflects on her journey from growing up in apartheid-era South Africa to becoming a passionate advocate for marginalised communities and a leading champion for gender-affirming care.  

Drawing on a rich tapestry of personal and professional experiences, Prof. de Vries provides insights into the systemic challenges of building a new medical school in the Eastern Cape, reflects on the enduring legacy of inequality in healthcare, and shares her groundbreaking contributions to transgender health, including co-authoring South Africa’s first gender-affirming care guidelines.  

The episode delves into themes of resilience, empathy, and activism, and explores the power of recognising shared humanity in the face of intersecting inequalities.
From advocating for rural healthcare to navigating the complexities of professional identity formation as a researcher and academic, Prof. de Vries offers a deeply personal and thought-provoking perspective on driving meaningful change in a challenging environment.  

We discuss the critical importance of creating safe, affirming spaces for all patients, her vision for a more compassionate healthcare system, and her enduring hope for a world where everyone is free to live as their authentic self.

Join us for a conversation that will leave you informed, inspired, and challenged to embrace compassion as a force for change.

Key Takeaways:  

• Insights into systemic barriers facing marginalised populations in South African healthcare.  
• The transformative potential of gender-affirming care and inclusive medical education.  
• How empathy and perseverance can inspire profound change in healthcare and beyond.

Resources mentioned in this episode:

SOUTHERN AFRICAN HIV CLINICIANS SOCIETY GENDER-AFFIRMING HEALTHCARE GUIDELINE FOR SOUTH AFRICA: https://sahivsoc.org/Subheader/Index/sahcs-guidelines

Professionals Association for Transgender Health (PATHSA): https://pathsa.org.za/

South African Family Practice journal article: https://safpj.co.za/index.php/safpj/article/view/5770/8174

Gender Dynamix: https://www.genderdynamix.org.za/

Helplines: https://findahelpline.com/countries/za/topics/gender-sexual-identity

Chapters

• 0:00 Challenges and Perseverance in Healthcare
• 9:45 Medical Education Challenges and Global Perspectives
• 15:57 Journey of Advocacy in Healthcare
• 34:38 Advocating for Gender-Affirming Healthcare
• 40:45 Gender-Affirming Healthcare Challenges
• 52:25 Professional Identity in Medicine
• 1:00:59 Redefining Power in Medical Practice
• 1:06:31 Celebrating Achievements and Personal Growth
• 1:12:36 Navigating Challenges in Transgender Healthcare
• 1:28:47 Reflections and Resilience

Transcript

Prof Elma de Vries: 0:00

I had a deep awareness of suffering and how systems can make suffering even worse if people don't care. And I've often wondered, can't one manufacture a vaccine for health workers that you can inject caring into them? Wouldn't that be wonderful? Because the experience is so often that people don't care. That affects the lives of so many vulnerable people who want to access care and then don't get what they should be getting, and that makes me very sad about where we are in terms of health care in this country. So many people voted for a better life and 30 years into democracy we still have children falling into pit latrines at schools and children dying of malnutrition and systems not working as they could be working, if people cared. I guess I'll be a 'bitter einder' and keep on making the little difference I can, where and when I can.

Dr Maria Christodoulou: 1:16

Welcome. I'm Dr Maria Christodoulou, and this is the Awakening Doctor podcast, a space where we discover the personal stories of those who work in the medical and health professions. Join me as I explore the hopes, the fears, the aspirations and the real-life challenges of those who carry the title, responsibility and privilege of being a doctor. My guest today is Professor Elma de Vries, the MBChB Program Coordinator at Nelson Mandela University in the Eastern Cape. A family physician with more than 30 years of experience in the public healthcare sector in South Africa, and one of South Africa's foremost activists in the field of gender-affirming care. Welcome, Elma, it's fantastic to have you with us here today.

Prof Elma de Vries: 2:05

Thank you. I look forward to our conversation.

Dr Maria Christodoulou: 2:08

Me too. Also in the room with us is Amy Kaye, the producer and editor of the Awakening Doctor podcast. Welcome, Amy. [Amy Kaye: Thank you. H ello everybody.] So, Elma, you tell me, where is a good place for us to begin telling your story?

Prof Elma de Vries: 2:21

I've been thinking about that and sometimes I think in a bit of a linear way, although I have been challenged on that. If one starts maybe in childhood and see where things go?

Dr Maria Christodoulou: 2:33

So let's go back there, tell us about your childhood and how that led you to where you are in the world today.

Prof Elma de Vries: 2:40

My dad was a Dominee in the NG-Sending Kerk. So his congregation were the farm workers and I went to the white school with the farmer's children. Ja, so from a young age I could observe inequality and how wrong things were in our society and just develop a very keen sense of injustice, frustration with the injustices in South Africa, growing up as a white child in a small town, and people were not treated equally.

Dr Maria Christodoulou: 3:23

I guess I'm curious about what makes it possible for you to recognize that, because I think there were many South Africans who grew up in that era who were in similar situations, who blinded themselves to the injustices and the inequalities.

Prof Elma de Vries: 3:36

I guess, with my dad being the Reverend and us going to the church where there were no other white people except for the Dominee's children and my mother. When they built a house next to the church in the non-white part of town, we needed a permit to stay there, because we weren't living in the white part of town. I met amazing people like Allan Boesak, and I had access to reading stuff about liberation theology. I think that opened my eyes. My dad was also kind of involved in the resistance to apartheid movement within the church and went to meetings. I think I had a very different experience than people who just lived in a white bubble. So I want to go even further back. So that was my childhood, and part of my childhood was also going to visit our grandparents, who were retired by that time, but they had been missionaries in Malawi and later on in what is now Zimbabwe, and the story of my grandparents definitely influenced who I became. So I think our ancestors definitely play a role in who we become and we need to deal with the stories of our ancestors, which is not always easy.

Prof Elma de Vries: 5:06

So my grandmother, as a single white woman, went to Beira by ship, then went on land to Malawi, and that time it was a lot of walking and there wasn't all the things we have now for transport, and she had gone to work there because she really believed that the people in Malawi needed to be uplifted. Where did she come from? It was from Western Cape. It was a long way to travel and it was a hard journey. And then she worked there at a school for young women where they were taught cooking skills and so on. And then she met my grandfather, who was also from NG kerk stock. They got married and my mother was born there at Nkhoma Hospital in Malawi, and my grandfather built many churches and really did a lot of good things in his life, but had this view of, the white people are here to save the world.

Dr Maria Christodoulou: 6:09

Which many of the missionaries of that time and even this time still have.

Prof Elma de Vries: 6:13

And didn't... From where I sit, I don't think the missionaries saw the Malawians as equals, and I had to work with this. I visited my grandfather when I was a student and we were going to go on a hike and on the way we stopped over there because he had organized the permit for us to go to the Steenbras Dam and I had a fellow student with me who happened to be not white. Oh, my grandfather was so upset.

Dr Maria Christodoulou: 6:42

Gosh.

Prof Elma de Vries: 6:43

Ja, that was in the late 80s. I had to realize that they were children of their time and they had a particular worldview, which is very different from how I see the world and how I see other people. It's not very helpful for me to judge them. They were children of their time and I have to accept they were who they were. I think it would be very difficult for them to understand where I am today, but that's okay. The world changes and I think the world just in our lifetime has changed such a lot.

Dr Maria Christodoulou: 7:20

Absolutely. S o you've taken us back to that time, and the grandmother who traveled all the way to Malawi and met your grandfather, the missionary sort of background. How does that still live on in the way you see the world today?

Prof Elma de Vries: 7:37

Well, it's that 'bitter einder', that perseverance. That being willing to stick it out for something you believe in, even though it's difficult. My grandfather told stories of how he, in his young days, had to go and sometimes hunt a lion that was threatening the village. We went back to Nkhoma where my mother was born, and in the museum there there's stories of people having really difficult lives and being attacked by a leopard, and this one getting malaria, and this was the context in which they persevered because of what they believed in.

Prof Elma de Vries: 8:19

I guess I carry on in the Eastern Cape building a new medical school, but it's hard, it's very hard. There are many doctors who find it too hard and psychologists and other health professionals who leave the country and go and find a life elsewhere, and I can't judge them because people make their individual choices. E ven though it's heartbreaking for me when South Africa loses excellent, excellent clinicians. I need to be here. I think that sense of purpose, I think is in my genes. Ja, sometimes the hard-headedness of, we have to carry on.

Dr Maria Christodoulou: 9:05

Right. It's an admirable quality, but I imagine it makes life difficult.

Prof Elma de Vries: 9:10

Ja, ja. They said about Albert Schweitzer... His wife said it's much easier to be a saint than to live with one. And I can imagine that. Not that I'm a saint. If one is strong-willed, there was a time that a friend of mine and I had hard-headed women as our theme song.

Dr Maria Christodoulou: 9:30

Yes, well, we could go into the whole patriarchal framing of women as hysterical and hard-headed and all those not-so-nice descriptions that they have for women who stand firm in what they believe in, but let's maybe stay with your story for now. You said it's hard. It's very hard were your exact words. What makes it so hard for you?

Prof Elma de Vries: 9:52

I think the hardest thing is that when this new medical school was planned, it was in a very different economic climate, where there was enough money to employ enough doctors, that when they planned the new medical school, they didn't think staffing was going to be a problem because there were enough doctors back in 2014. But since then things have become so difficult in terms of Department of Health budgets that the Department of Health in the Eastern Cape has something like a R60 million deficit on their budget for the year, and they have to pay their staff, and when people leave it's very hard for them to then fill the post. And that has been carrying on for some time, so that we now have clinical departments who are crippled and hardly have enough people to deliver a service. If you get to a stage where you're not sure how you're going to fill the on-call roster because there's not enough people and you had interviews in May already, but you haven't heard confirmation that the person will be appointed, it makes it very hard for clinicians. A nd there's a hierarchy. T he patients come first, but then we're adding students to the mix, and now I've got fourth year students and next year we'll have fifth year students in the hospitals and we want our students to learn from people.

Prof Elma de Vries: 11:25

But there's so few people and that makes it hard, because it's not something that was anticipated when the medical school was planned and it's not the fault of one particular individual.

Prof Elma de Vries: 11:37

It's a systemic thing and not just here. In the other provinces as well, it's very hard for Department of Health to fill posts and there's austerity measures in all the provinces, and we have this dream that we want to graduate a Mandela doctor. It's the concept that we created from a doctor that is caring and competent and can work in a district hospital and know what they're doing, and for that we need clinical teachers. I think that that's the most difficult thing of knowing or imagining. How are we going to do this? And we do what we can from the medical school side, the clinicians on the platform really do what they can. Our students have been amazing and somehow we will get there, and I think one of our things our students will learn is how to function in a resource- constrained environment. They have good role models of that, of how to carry on when you don't have the drip sets you need and when this is out of stock, and when that doesn't happen, you still have to make a plan because the patients still need care.

Dr Maria Christodoulou: 12:47

So they're learning how to be 'bitter einders'? [Prof Elma de Vries] Yes, indeed. I will say that some of the audience might know I've been spending a couple of months in Cyprus and I'm still here with my mother in this tiny little village in a rural part of Cyprus, and one of the things I've done in my time here is interact with some of the academics at the private universities, private medical schools in Cyprus, and chat to other colleagues and kind of get a sense of what the landscape of healthcare is like here. And one of the things that really stirred up a lot of emotion for me was the difference in how students here experience medical school. For example, at this private medical school they do a four-year degree after which they graduate and then they do two years of practical experience, after which they can go straight into a specialty and, of course, they can apply to almost any university in the EU to do that. And I did find myself feeling like the legacy of our past is still having a dramatic impact on the very people who should be benefiting from the changes that supposedly have come into place since apartheid was dissolved, and it brought up a lot of feelings for me and I'm not quite sure what we do about that.

Dr Maria Christodoulou: 14:05

The other thing that came up for me which is what reminded me of that now when you were speaking was that at the private medical schools, they are training doctors who can work in any European hospital.

Dr Maria Christodoulou: 14:14

There is no focus on the context of the people in Cyprus. When it's a private medical school, it's just doctors who meet a certain standard European- recognised standard who can then go on to work in any European hospital, but it's not based on population-based needs. They're not trying to create a doctor who's going to meet a specific need in the community. I say that. I don't know enough and I'm sure that the European councils are looking at what those requirements should be, but there was this sense of, it's so different back home. Our students are dealing with so much more and so much complexity and carrying a burden of things that are not of their making. So let's come back to you and your experiences, and you spoke about, you need to be here and that it makes you sad when doctors leave, and usually very expert and skilled doctors leave South Africa. What makes you say that you need to be there?

Prof Elma de Vries: 15:14

I think when I was young, I thought about it as a calling, that... Almost as if medicine chose me and, with my background, growing up and becoming aware of injustices, wanting to make a difference. And I am now in a context where I'm able to make a difference, where my particular skill set can add value and where I can work with a team to create an environment where we develop the next generation of doctors who will go out and make their difference. Can I tell you a story? Well, this is about storytelling I guess. I went to study medicine and then I did my internship here in Gqeberha at Livingston Hospital many years ago and then went off and worked in KZN and then got a job in Limpopo Province. So, my husband is a linguist and he got a job at the University of Venda, so I worked at Tshilidzini Hospital.

Prof Elma de Vries: 16:20

And that was in 1996, just after liberation, and it was an amazing experience for me to work at a rural hospital. And my grandfather was so happy that his grandchild is now working at this ex-mission hospital. It was an amazing experience for me, but when I was there, government decided no, there's too many ghost people collecting grants. We are going to redo the disability grant system and we are just going to stop everybody's grant and the doctors just have to fill in new forms for everybody. And at that stage, I think, we were about seven doctors at the hospital delivering a whole district hospital service, and all these patients came and they needed new forms to be completed and they were legit, they really had disabilities, and the administrative system was so pathetic that for some people I filled in forms three times. And then there was a psychiatric patient in the area of Malamulele Hospital and he went to collect his grant and was told no, you have to have a new form completed, it's going to take three months. And he was so devastated that he then set himself alight and he died.

Prof Elma de Vries: 17:40

And at that time the medical officers took turns to do the postmortems. So I became aware of this thing of the disability grants and I was furious because it was so unjust and I wrote a letter to the Mail and Guardian, and said this is really wrong. T hey can't just stop it, t here needs to be a process first. A nd then that Monday, it was my turn to do the postmortems, and I do this postmortem of this body who was completely burnt, and I was obviously very upset. That evening a journalist phones me and I am livid and I tell them the whole story. That Friday morning there was a MinMEC meeting, the Minister of Health and MEC's meeting. The headline of the Mail and Guardian was, 'The MEC has blood on her hands.' They had quoted me without first checking with me, whether I was happy for all that to be said. So obviously the next week, it was still then Pietersburg...

Dr Maria Christodoulou: 18:52

Did you say that the MEC had blood on her hands?

Prof Elma de Vries: 18:55

Ja, because they made this callous decision to stop very poor people... and you know, in those rural areas the unemployment is like 80%. So many people depend on grants. So I really thought it was a very callous decision and I probably did say that because I was very emotional after doing that post-mortem.

Prof Elma de Vries: 19:16

Understandably so. A nd so I was called into the Department of Health and made to apologize. Fortunately, I didn't lose my job, probably because they were so desperate for doctors in rural Limpopo. That did teach me a lesson about being careful what you say to the media. But thinking about it now it reminds me of how I just had to speak out against injustice.

Prof Elma de Vries: 19:47

Right. A nd really, I had a deep awareness of suffering and how systems can make suffering even worse if people don't care. And I've often wondered can't one manufacture a vaccine for health workers that you can inject caring into them? Wouldn't that be wonderful? Because the experience is so often that people don't care that affects the lives of so many vulnerable people who want to access care and then don't get what they should be getting, and that makes me very sad about where we are in terms of health care in this country. So many people voted for a better life and 30 years into democracy we still have children falling into pit latrines at schools, and children dying of malnutrition, and systems not working as they could be working if people cared. I guess I'll be a bitter einder and keep on making the little difference I can where and when I can.

Amy Kaye: 21:00

Where does that sense of deep empathy for suffering come from? Because, like you said, the average person doesn't have it. They... At some point they switch off or they disconnect, for whatever reason. But why and how do you care so much?

Prof Elma de Vries: 21:17

I think part of it has to do with genetics of my ancestors who were caring people. So on the one side it was the missionaries, on the other side it was farmers from the Free State. I grew up with that being nurtured. The caring and the concept of the first thousand days I find a very meaningful one. The first thousand days is from conception until your second birthday and during that time 80% of your brain development happens, and you need to have sufficient food and you need to be cared for and be stimulated, for those caring pathways in your brain to develop. And kids who are just in fight and flight all the time because they feel unsafe and they're not getting the nutrition they need, don't develop those caring pathways.

Prof Elma de Vries: 22:18

Those are then the young ones who end up in gangs, end up in Pollsmoor. I mean, Don Pinnock wrote this wonderful book, Gang Town, where he goes into quite a lot of detail that if we can make a difference to the first thousand days, we won't have the problem of gangs, because if people have th at sense of belonging when they are little and that is nurtured, they may not have the need to go and find community, and family, and a gang where they are accepted and seen. So now, walking home from the white school, all down the hill to the Pastorie and the non-white part of town, and having lunch sitting in the sunroom with my mother and just, okay, t hings at school were a bit difficult. I didn't have many friends, I was seen as a nerd, but there, sitting with my mother in the sunroom I felt so safe and nurtured that I wanted to give that to a child one day. I think many, many people become uncaring because they didn't have a good first thousand days. I guess the caring was nurtured and built in from even before birth.

Dr Maria Christodoulou: 23:45

You describe d medicine as a calling. Tell me more about that.

Prof Elma de Vries: 23:51

So, I think at different times I've conceptualised that differently. When I was a medical student I was very involved in the student church as well and really thought that we are called to serve. I had a wonderful superintendent at Tshilatini Hospital and I was wanting to change the world as this young doctor, and she said, Elma, just do what your hands find to do. And I guess my thinking I have a calling to save the world changed into, just do what your hands find to do. And over the years my hands have found different things to do, but it's things that give me meaning because it's working to improve the lives of marginalised people.

Prof Elma de Vries: 24:41

So when I was a young doctor I was involved in the Rural Doctors Association. That's my tribe. Rural doctors are such caring people and we organised to try and influence policy and make things better for rural populations. And then I got involved with caring people who want to make a difference to people who are vulnerable. And then we came to Cape Town and I worked on the Cape Flats for many years and did what my hands find to do. And then I got pulled into advocacy for transgender health care. Life is a mystery. One doesn't always understand very clearly who is doing the calling,

Dr Maria Christodoulou: 25:40

Hmm. Ja, I find myself kind of thinking about what that means in different contexts and this idea of do what your hands find to do and all the interesting places it seems like it's led you in your career. Maybe you want to tell us a little bit about the different things your hands have found to do, and I'm particularly interested in your work in rural settings and your description, I guess, of marginalised communities, because we spoke earlier about missionaries and the ancestral sort of thing of missionary work and going into areas and working as missionaries with this idea that it is our role to uplift people. How is that different from what your hands are finding to do today?

Prof Elma de Vries: 26:25

Hmm, that's a good question. I think what I didn't like about my grandparents' understanding of things was that it was very paternalistic, whereas the circles I move in, it's much more a human rights approach about recognising the other as an equal human being.

Dr Maria Christodoulou: 26:50

Being involved in transgender activism and gender-affirming health care. What initially inspired you to become involved in that work?

Prof Elma de Vries: 26:59

So that's an interesting story. When we moved to Cape Town I was looking for a church where I could be comfortable, and it was hard to find. So at that stage we had a young son and we were not a typical family, I guess. We adopted a little boy and we didn't look like the typical white family. A nd, at that stage, I'd also read lots of theology over the years and I wasn't comfortable anymore in the Afrikaans NG gemeente, although we did have him baptised in an NG kerk. But then later on I was looking for where could I really just be comfortable.

Prof Elma de Vries: 27:43

And then somebody invited me to Good Hope Metropolitan Community Church, which is an inclusive church, and I walked in there and I just felt at home. It was a church that was started in 1969 in the States, with the Stonewall Riots, in that time. And it was a Baptist minister, who was gay, was kicked out of the church and then said but people need somewhere to belong, and then started this inclusive church. And then later on there were branches all over the world, including in Cape Town, and you walk in there and you don't feel judged. You can just be, and same-sex couples can hold hands as they walk to the front for communion, and it was just a really affirming space.

Prof Elma de Vries: 28:44

And then that also gave me the space to explore my own sexuality and identity further, because I never completely felt comfortable in a hetero, cis-normative world where people get put into boxes of, this is how you have to behave as a woman and this is who you are allowed to love. It gave me the space to explore my own bisexuality and later on also my gender identity as non-binary. It was really a wonderful space for me to be. And then there was a workshop about transgender health at the church, because the secretary of the church at the time had started an organisation called Gender DynamiX to advocate for the rights of transgender people. And I came to this workshop and I realised nobody taught me anything about this in med school.

Dr Maria Christodoulou: 29:30

Right.

Prof Elma de Vries: 29:31

This is a whole community that I have no knowledge of how to assist. So that started my interest and I got involved with Gender DynamiX and I ended up being part of the team that wrote the first ever hormone guidelines for South Africa for how to prescribe gender- affirming hormones. And then the church had a library and we had books, but also videos, and this... W hat shall we say? At that stage, a beautiful young gay boy that we thought was a boy, took out a video and then called me and said, Elma, now I know who I am. It was a video about being transgender. So we then followed the journey from when this beautiful human being realised, I'm actually not an effeminate boy, I'm not gay, I'm actually a woman. And going through that whole process of accessing care, accessing hormones, eventually accessing surgery, and now she's a beautiful woman who is so happy being who she is and just watching that journey was profoundly meaningful. Then, through my work with Gender DynamiX, I also got to know more trans people and their stories and listened to their stories and just realised how hard life is with all these intersecting inequalities and how people are being discriminated against on so many different fronts. It Imade me more aware of my own privilege. It was relatively easy for me to get into med school. At the time that I studied medicine from 1988, only 15% of the class was not white a t Stellenbosch University. I had the privilege that my dad could afford to get a bank loan to put me through med school. I've had so many privileges over the years. And there's other people who are being so judged for who they are. People are economically disadvantaged because they're trans. Kids get bullied at school. People drop out. It can really just be so difficult with society's judgment.

Prof Elma de Vries: 32:00

You asked earlier where does the caring come from? I think it also comes from a deep sense of responsibility. As a white South African, I have a responsibility to do something to make things better for people. I can't just sit in my own privilege and I guess we all... well, those of us who do introspection about where we come from realise that one can feel very guilty about what our collective ancestors have done by destroying so many people's lives. And, as you earlier said, we still see the consequences of that. One of the things is that so many brilliant black leaders were eliminated by the apartheid government and their genetic material is no longer around because they were killed when they were young. They never had children. Just imagine who we could have had as political leadership if not so many excellent genetic material were eliminated. It's not helpful to wallow in guilt. One needs to transform that into doing something about the injustices of the past.

Dr Maria Christodoulou: 33:18

Do you feel guilty?

Prof Elma de Vries: 33:20

have felt guilty for my tribe. I'm Afrikaans. And just reading the atrocities of seeing other people as less than and thinking that it's okay to do the most horrible things. It was Alan Paton, I think, who wrote that the only way that we can bear the inhumanity of man to man is by demonstrating in our own lives the humanity of man to man. It is a very sexist thing, but Alan Paton was a man of his time, so that's how he expressed it. At Mandela University o ur logo is, be the change, so trying to be the change, and life is so fragile. We have such a limited time here, and in the time here, I guess I want to make the difference I can.

Dr Maria Christodoulou: 34:18

So if I was speaking to people who have had the privilege of interacting with you, what might they be saying about the difference you have already made?

Prof Elma de Vries: 34:37

That's an interesting question. So I met somebody again recently that I was at med school with, and we hadn't seen each other for many years, and he said Elma, even at that time you were pushing boundaries. And I thought, wow, that's good to think about it like that.

Dr Maria Christodoulou: 34:59

Tell us more about the stereotypical medical student.

Prof Elma de Vries: 35:02

Well, the stereotypical white medical student was just interested in having white friends and studying and preparing to go to private practice and where we studied, Tygerberg was divided into the white side and the non-white side.

Prof Elma de Vries: 35:16

And the white side always had empty beds and quite enough nursing staff and on the non-white side there were always too little beds and too little staff. And I guess at med school, a lot of my friends were not white and we had this organisation called Koinonia t hat was kind of a religious organisation where we tried to bring people together and to have projects. And for people growing up in a purely white environment it was difficult, but fortunately for me it was easier, because I had had an upbringing that wasn't just purely white.

Dr Maria Christodoulou: 35:58

Right, and I guess you were exposed on a day-to-day basis to the reality of life for the other half of the population. I remember those days at Tygerberg. It was like that when I was a student there. It was still like that when I graduated and did my internship there and I still worked there as a medical officer for a couple of years. And I have memories of white Afrikaans tannies in the F1 ward with their crocheted little bed jackets, refusing to let staff of colour or students of colour examine them or touch them.

Prof Elma de Vries: 36:28

Ja, many of my colleagues have had experiences like that from when they were students. I think something that is a thread for me is just seeing people as people, seeing the humanity and not seeing the difference, or not focusing on what makes us different but focusing on our common humanity. So I guess I need to think more about your question, about what would people say? What difference have I made?

Dr Maria Christodoulou: 37:01

Hmm.

Prof Elma de Vries: 37:05

I think because gender-affirming care has been so new in this country, not many people knew what to do. What is this thing of somebody asking for medical care to transition, to align their outward appearance more with how they know themselves to be inside?

Dr Maria Christodoulou: 37:31

Right.

Prof Elma de Vries: 37:32

There was a great... Well, there is still a great need for education, for health professionals understanding this thing, because we didn't learn about it in med school, and so I got involved with writing guidelines, with training, and then to see people that we've trained have practices where transgender people come and feel safe, oh, it was so amazing. The other day I got an email. People write to me and ask where can I access care and I said, oh, if you're in Gqeberha, go to this doctor. And then I got an email back that said this doctor really saw me, and I felt so comfortable to know that, because of the guidelines work and the training work, there are more and more places where people can access care. I think that is a difference that I have been part of, not like a lone individual, it's always part of a team, but I think I add value to the team of people who are advocating for more access to gender-affirming health care.

Dr Maria Christodoulou: 38:45

I also know that the issue of gender- affirming healthcare is quite a hot topic and that there is a fair amount of both political and societal opposition to this idea of gender- affirming healthcare. How do you deal with that?

Prof Elma de Vries: 39:00

With difficulty.

Prof Elma de Vries: 39:03

What's going on in America at the moment is horrendous, and there's things in South Africa as well that the anti-gender movement spreads misinformation and disinformation, and come from the premise that no, it can't be right, but without understanding. If society can just let people be, it would be so wonderful. But to come from a point of ignorance and think no, it's wrong, is not very helpful at all and complex, because I think in the political sphere it's become a scapegoat. L ike years ago, women didn't have the vote and women had to know their place and then, fortunately, things have changed. But it was hard and then the gay issue was being used as a political thing. It's very unfortunate now that the whole transgender thing is being used as a political thing, which... I'll declare that I'm not objective.

Prof Elma de Vries: 40:18

But Kamala Harris saying, why do you focus on anti-trans ads and spend millions where there are real issues affecting people on the ground like access to health care and environmental change and global warming? So it's very, very, very unfortunate and very sad, and very damaging. Even in South Africa, the negative things in the media affect trans young people immensely. It increases their levels of anxiety, it makes them feel unsafe, and unfortunately, I don't know if you're familiar with the idea of minority stress. It's a concept of, if you've been treated badly, you already anticipate that you're going to be treated badly and you internalize some of that, whether it's homophobia or transphobia or whatever, and you are easily then triggered, because of previous negative experiences and unfortunately that happens with the comments on social media.

Prof Elma de Vries: 41:37

Some of my friends really become triggered and traumatized by how horrible people can be. [Dr Maria Christodoulou] For the listener who may not fully comprehend what you and I are talking about,

Prof Elma de Vries: 41:49

when you say gender affirming healthcare, what do you mean? [Prof Elma de Vries] Okay, so the terminology has also changed over time, but it's basically if someone would come to know themselves that their sense of gender identity, of who they are as female or male or somewhere in between, doesn't align with their body. So we can use the example of the person I knew at church who was a young boy, a student, and had grown up in a male body but then knew there's something not right, this doesn't fit, and then coming to know that actually I've always been a woman, and then seeking care. And the care often starts with speaking to someone to explore your identity and to understand who you are, and psychologists and counselors and general practitioners can be very helpful there.

Prof Elma de Vries: 43:00

And previously we understood... We incorrectly understood this as you have to diagnose this person with gender dysphoria before they can access care, which is nonsense. It is just facilitating the person's understanding of themselves and then, if they do want to access care, helping with that. So some people will just socially transition and change their hairstyle and the way they dress and then present as the gender they know themselves to be. So when the person I knew at church then would start wearing dresses, and make always sure that she shaved so that the skin appeared more smoothly and started wearing makeup. So a short transition. But then, if one does want to transition in terms of your secondary sexual characteristics, there's hormones that can help, and then surgery. Unfortunately, very few people in South Africa have access to surgery, but that can be part of the journey and then the hormones would be prescribed by a doctor to then bring some changes to align your body more to your identity. Does that explain it a little bit?

Dr Maria Christodoulou: 44:12

I think so. Amy, anything you want to ask about that? [Amy Kaye] No, it's pretty clear to me. [Dr Maria Christodoulou] I'm curious, because obviously, there's the logistics and there's things like access to hormones, access to surgery, the difficulty kind of engaging with the conversation, that initial conversation that someone might have. What are some of the other challenges that you believe transgender individuals are facing, maybe particularly in the South African context? [Prof Elma de Vries] Do you mean in terms of health care or generally... ? [Dr Maria Christodoulou] Ja, in terms of health care.

Prof Elma de Vries: 44:40

So there's something called the Rechitsa Report where individuals from key populations have been interviewed. I think they've done about three reports now. They interviewed individuals from key populations, so its transgender people, men who have sex with men, sex workers, people who inject drugs, and to hear about their access to health care, and specifically also for HIV prevention and care. According to that report, a significant percentage of respondents said we're not welcome at health facilities. We've been denied access to care because of our gender identity or our sexual orientation, which are different things. But specifically now in terms of transgender people, where people have either been denied access to care at the clinic level or ridiculed and not treated with respect.

Prof Elma de Vries: 45:36

So the attitudinal thing from a health worker perspective is so important and that's where a lot of work still needs to be done and is starting to be done. The Department of Health have rolled out this training for sensitisation of health workers and more and more health workers are being empowered to understand better and to treat a person coming to them without judgment. So there's difficulty getting access to hormonal care. We managed to get hormones into the essential medicines list for South Africa, but only for tertiary care at the moment. In theory, you first need to go to a tertiary hospital for a prescription before it can be down-referred, which is not very good for access to care and that is still ongoing advocacy with Department of Health to change that. The other thing is access to psychological care is totally inadequate in the whole public sector.

Dr Maria Christodoulou: 46:42

Ja, I was going to say it's not just in this area. I think it's across the board.

Prof Elma de Vries: 46:46

Across the board. There's way too few psychologists in the public sector in the country for all kinds of issues, and not every trans person needs a psychologist, but often there are... because of this minority stress and people have had bad experiences. It can be helpful to have that support and also, ideally, if you do go on hormones and your body starts changing, it's helpful to be able to talk about that and to also have talked about it before it happens, because there are things that change. If you were born as a male and now you go on feminising hormones, you become weaker, your muscles become weaker, your role in society changes, and suddenly you don't have male privilege anymore if you present as a female, and it's useful to talk through those things before it happens. So in the ideal package of gender- affirming care, there would be mental health support as part of it.

Dr Maria Christodoulou: 47:50

I guess it's a reflection of issues society is dealing with as a whole. It's just being reflected in our healthcare settings and people's attitudes and perceptions and judgments and assumptions and all of those things are just being mirrored in the healthcare system. But I guess the burden of duty to care kind of adds a different dimension to what happens or what it means when it shows up in those settings, in the clinics and in the hospitals and in the interaction with a health professional. What have been some of the stories that stand out for you in your own interaction with patients, and maybe not just in gender- affirming healthcare, but as a clinician, in all your time in practice? What are some of the patient encounters that stay with you?

Prof Elma de Vries: 48:39

Ai, ai, ai. So I'm now working at the medical school, so I'm not in clinical practice at the moment. If I think back to my time in rural practice and driving to the rural clinics, people are so grateful to have a visiting doctor. Ja, seeing people who are really having such hard lives, having diabetes and really struggling having enough to eat, and then you have to eat before you take your insulin. We treated crocodile bites and trauma from fireworks having exploded on New Year's Eve. There's many things over the years.

Prof Elma de Vries: 49:22

And then, when I worked in Mitchell's Plain and in Heideveld on the Cape Flats, also just the desperation of the mothers about their children who are not on the straight and narrow, and then the child probably then didn't have a good first thousand days. But you can't really blame the mother if the father was absent and the mother had to go and work. L ooking down that dark abyss of suffering and also realising one's own limits, that a doctor can't always solve the problem. As a doctor I want to solve the problem. I want to... A lmost like a compulsive carer, I want to fix things and sometimes you can't.

Dr Maria Christodoulou: 50:33

Ja. That thing of peering into that dark abyss of suffering and particularly the inclination to want to fix and to want to save the world. And you spoke earlier about being a young doctor with this idealistic thing of wanting to save the world. I remember being in that space and I remember, and I've often spoken to young students who enter medical school with that same idealistic thing, and then at some point in the journey there's this kind of having to reckon with the reality that you're not going to save the world, and that you're not necessarily going to be able to fix everything. What was that turning point for you? At what point did you have to grapple with that?

Prof Elma de Vries: 51:03

I think it was already when I was a young doctor at the rural hospital, because the need was overwhelming and there was very little we could do. So the advice at that time of just do what your hand finds to do was very helpful. I guess, also, within the Rural Doctors Association, meeting other people who are also doing what they can in their corner, but also realising that this is a long fight for the access to care, because it's really unfair, the postal code lottery that if you happen to be born in a small village in the Eastern Cape, and the nearest hospital is 100 kilometres away by foot, over two hills, and over a river, or whether you are born in privilege in Joburg and Cape Town, and have easy access to health care, even if you use the public sector, that postal code lottery, even within one city, if you live in the drainage area of a certain hospital, your chance to get a CT scan after a stroke is much bigger than if you live in another part of town that drains to a different hospital that doesn't have a CT scanner.

Dr Maria Christodoulou: 52:25

Let's talk about your PhD. You've spoken about the history of this country and how we should be doing some reflection on our backgrounds and what that has meant in South Africa. So tell us about the PhD. I know it was about identity construction. What informed the PhD, and what you've got to in terms of your research, what you've discovered.

Prof Elma de Vries: 52:47

So that was also a long journey. I was working in Mitchell's Plain at the time when I did a wonderful 'train the clinical trainer' course through family medicine, and part of this was for us to think about our own journeys as educators and I thought about where I want to go, and that at that stage I was still very much a clinical educator, with one foot in the clinical world and one foot in medical education. And I thought, where do I want to be long term? And I realised I want to be in medical education. And then I started to explore shall I do a Master's in health professions education? What would work? And looked at different courses. And then at UCT, because I'd been part of the family medicine department for a long time and had been involved in the health professions education there, they said, oh well, you've got some experience. You can just go on and do a PhD without having done... because I had a Master's in family medicine, s o they said you can go on and do a PhD in health science education. And then I wanted to combine this thing of what I'm really interested in, in terms of transgender advocacy, and learning more about medical education, and it took quite a while to refine my topic, but eventually, there's this fascinating thing in health professions education about professional identity formation. A bout, how do we move from being a novice into being socialised into a profession and internalising those value, so that in the end we are not only performing what it means to be a professional, but that we have really internalised the values. It's about the being and not just the doing. I found that fascinating. It doesn't help to just say what must be in the curriculum for transgender care. We first need to understand how do people get there? How do you become an affirming practitioner? That then became my question of how can the professional identity formation of a gender- affirming practitioner inform medical curriculum change?

Prof Elma de Vries: 55:08

And then I interviewed people who were known in the community, in the trans community, to be affirming practitioners, doctors and psychologists, and I interviewed some medical students who aspire to become gender affirming. And I used narrative inquiry, which is a wonderful research method because it's about stories, and I got wonderful, wonderful and harrowing stories. Some of my participants were transgender themselves and also told stories of their difficulty in accessing care, of not being seen for who they are and for being judged. I looked from a critical perspective and specifically also at power relationships. In an affirming encounter th ere isn't that, it's the doctor at the top that knows the best and the patient is down here. It is a much more equal interaction where the trans person who comes to you, they know who they are and they want you to help them, but it's not that you have to diagnose and decide what is best for them. So the whole conceptualisation of what does gender- affirming mean was beautiful, also in terms of power relationships.

Prof Elma de Vries: 56:31

And then the journey that people described of becoming affirming included reflecting about oneself and who am I and what judgments might I hold? In the story, I describe it as, you have to look in the mirror and know who you are and how you see your patients. So that needs to be part of the professional identity formation of any practitioner, and that is why we bring more reflective practice into medical education. That it isn't just about the doing, but also about reflecting on one's own who we are and who we become as professionals. And then I also looked in the study at the context in which the learning happens. Our medical schools are a reflection of broader society.

Prof Elma de Vries: 57:34

Things are changing, which is wonderful, but there's still many contexts that are not really very conducive to becoming an affirming practitioner. With the hierarchies and.. yoh, some of the medical students told stories of how they can see a patient as being misgendered and treated badly, and they can't speak out because these people are responsible for their marks. And it's not only in my study that that came out. Prof Lionel Green-Thompson did some work on social accountability of medical students and so on, and he also got stories in his research of how students really felt silenced because of the hierarchy. They couldn't speak out about injustices, and they just have to keep their head down to get their degree. So there was a lot of description of that and then imagining how it can change.

Prof Elma de Vries: 58:33

Gender-affirming care has a gift to medical education more broadly, that we can rethink these power relationships in terms of the institutions where we train. I f the leadership can be more open and affirming and not just cis-heteronormative and create the space for looking at other possibilities and create the space for respect for diversity and bringing things like that into the curriculum, and then we would need to develop the medical educators to understand more about gender- affirming care, but also more about the relationship between educators and students and how that power relationship can influence how students learn, and there can be amazing role models that really help students' professional identity formation, but there can also be very bad role models. A friend of mine says in Afrikaans, jy kry rol modelle en drol modelle.

Dr Maria Christodoulou: 59:46

Right. I'm happy for us to include that, because it's true. [Prof Elma de Vries] I'm just going to interrupt my PhD story with a current story at our medical school. So we help our students to realise that there is a hidden curriculum, that is not the formal written down curriculum, but the interactions that they experience on the clinical platform, and that they will witness things that they may not be in a powerful position to say something, but they do have the power to decide, am I going to be like this, become like this, or do I want to reject it and say this is not the kind of doctor I want to be? So for those negative role models, they can say, I don't want to be the kind of doctor who is derogatory towards a young woman who happens to be sexually active. That's not who I want to be.

Dr Maria Christodoulou: 1:00:45

I want to respect the rights of women and that they actually have a choice as students, as they experience and observe things. They don't necessarily have to become like the people who teach them. So, coming back to the PhD, so that is the second thing, and then the third one is thinking about the doctor-patient relationship, and in family medicine t here's wonderful work being done on that. Prof Tasleem Ras at UCT has done wonderful work on Ubuntu and how the values of Ubuntu can help us rethink the consultation. T hat it's not this hierarchical thing but much more a community thing, where the patient who comes to you also bring their own wisdom and experience and it's not just the doctor who knows.

Dr Maria Christodoulou: 1:01:40

[Dr Maria Christodoulou] But then you have to really challenge societal assumptions about the role of the doctor, don't you? I think it's pervasive and it's one of the things I've always been passionate about. Identity construction was the theme of some of the research I did when I was still at the medical school, and for me this power differential is such an important one and it shows up in so many different ways within the hierarchy of medicine, but also in the doctor- patient encounter. And when I first started coaching, part of the idea was to shift that dynamic. I stopped calling people patients and I started referring to them as clients, because in my mind that created a little bit more of a sense of equality and I consciously stepped out of the role of, I must be the diagnostician, I must be the one who prescribes or intervenes or treats, and wanted to engage in a more collaborative conversation about people's health issues. But what I realized very quickly is that that was also a developmental thing, that there were patients who were not ready for that and that there were patients for whom that was actually quite terrifying and left them feeling like they were out there without someone telling them what to do, and they wanted someone to tell them what to do. T o know when and how to hold the power skillfully.

Dr Maria Christodoulou: 1:02:50

Because we have to acknowledge that we do have power. We have a level of knowledge and experience of the human body and of physiology and of anatomy and of disease and pathology, and we often can become the gatekeepers to that knowledge, but also the gatekeepers to the treatments and the interventions. So how we hold that power... But in the same way that you spoke earlier about how we internalise some of those beliefs of inferiority in different domains, we also internalise the superiority of being a doctor from a very young age, long before we enter medical school, and I see it a lot in our student population who are first generation to go to university, where there's pride of the family and the burden of responsibility on who you will be and who you will become if you go to medical school and what that will mean, about what you will do for the community, for the family, for the country, for the healthcare system, and I think different people carry that differently.

Dr Maria Christodoulou: 1:03:44

But I think it's exciting that this work is being done, and I always say that the one -ism that is not being acknowledged. We talk about racism, we talk about sexism, we talk about all these other things. We don't talk about professionalism, and that that too is an ideology of superiority and inferiority, based often on academic status, but that that too has ways in which it marginalises and disenfranchises people.

Prof Elma de Vries: 1:04:11

That brings me to another thought. Another lens to look through is decolonisation, and in our universities there's been a lot spoken about, and written about, decolonising and Africanising, and the beauty of that is questioning that what comes from the global north is superior and what comes from the continent is inferior, and that it brings with it, in my view, a democratisation of knowledge. That it's not necessarily the white professor who knows and the black student who doesn't know. A nd I think that that has the possibility to help us rethink these things of, is the professional really just the expert,

Prof Elma de Vries: 1:05:08

or is it a meeting of experts, when, in a consultation where... A nd we were also, at this university, quite influenced by the teaching of Paolo Freire, who's

Prof Elma de Vries: 1:05:20

an educator from South America who wrote amazing, wonderful things, and he spoke about the banking concept of education, where educators think it's these empty minds and they're just pouring knowledge into it, which is ridiculous, because the learner brings their own life experience with them and the educational encounter is an interaction, it's not a one-way giving of knowledge. I see that interlinked. T hat conversation about power in the educational encounter and then in the clinical encounter. So it's part of the decolonisation work we need to do in this country and in the global south more broadly.

Dr Maria Christodoulou: 1:06:08

I would argue that the global north needs to do some work in that domain too.

Prof Elma de Vries: 1:06:13

Absolutely, to rethink this professionalism that you refer to, that the doctor is the one who knows. Very often we don't know, and fortunately, as family physicians, we also learn how to deal with uncertainty, because we don't always know. In terms of the decolonisation, I think when we had our initial conversation I mentioned a song by Johnny Clegg that is about being a third- world child and I just love the words. If you don't mind, can I... [Dr Maria Christodoulou] Absolutely. [Prof Elma de Vries] So he sings, 'learn to speak a little bit of English, don't be scared of a suit and tie. Learn to walk in the dreams of the foreigner. I am a third- world child.' And just that thing of, the dreams of the foreigner is what we aspire to. If our children can just know that they are beautiful and valued and not inferior, and that we can have our own dreams and not have to aspire to what the West holds up as the gold standard.

Prof Elma de Vries: 1:07:30

And then talking about gold standard, i n the Rural Doctors Association, we've had conversations about Department of Health coming with a new policy and then they want the gold standard, but the gold standard is actually totally impractical for a rural clinic. So then Dr Karl le Roux gave a wonderful talk about silver needs to be the new gold. Actually, we need to aim for the silver medal because that is something that is more practical and doable and will actually be implemented. R ather than aiming for the gold, which is totally unrealistic in our context. So silver is the new gold.

Dr Maria Christodoulou: 1:08:16

Maybe linked to the idea of doing what your hands find to do.

Prof Elma de Vries: 1:08:19

Absolutely. Absolutely. T he striving for perfection. We know at our medical school things aren't going to be perfect. It's not a perfect program, but we are going to do the best we can with what we have to produce the best doctors that we can.

Dr Maria Christodoulou: 1:08:34

So in some ways it feels like the conversation has veered more into the academic and intellectual terrain and hasn't really focused on you and your story. So if I were to ask you, who are you? Who is Professor Elma de Vries? What would you say?

Prof Elma de Vries: 1:08:50

Elmatjie doesn't want to fit into boxes. As a girl, I didn't want to wear pink. I just want to be. B e in nature, hike, and that's where I feel most human. When I'm in nature and I can hug a tree and just realise I'm an organism in a much bigger whole. There's this, I don't know if it's tension or opposites of one is so small in this huge world, but on the other hand, the amazingness of one human being and the inner landscapes and the infinitudes of what is inside and what one can still learn about oneself. I'm in my 50s and I'm still learning about myself.

Dr Maria Christodoulou: 1:09:51

What have you learnt about yourself?

Prof Elma de Vries: 1:09:55

Oh, I'm no longer surprised by the fact that I do make mistakes. You know, when you're young you think, ah, I'm going to know how to do this, and then you realise you get things wrong. So now I laugh at myself when I make assumptions and I end up being wrong. One gets to know yourself and then you realise, oh, I didn't realise I actually like jazz. I can actually be in a jazz concert at the National Arts Festival and sit there and just be part of the crowd, and that's not something that I thought would be part of who I am. I guess one can be open to new experiences and discover new things about oneself.

Dr Maria Christodoulou: 1:10:43

And looking back on your medical career thus far, w hat are the things that you celebrate?

Prof Elma de Vries: 1:10:49

What do I celebrate? I guess the most recent celebration was completing the PhD after seven years.

Dr Maria Christodoulou: 1:10:57

Congratulations. That is a big achievement, ja.

Prof Elma de Vries: 1:11:05

I think h aving built the Rural Doctors Association. I was a secretary for some time and then I was chair for some time as well, and that has really created a kind of community for people to think together t hat, I think, has been very valuable over the years. I think I can celebrate that we've come a long way in terms of developing guidelines for gender-affirming healthcare. So the original 2013 was kind of cowboy guidelines and we've come such a long way, and the HIV Clinician Society has been amazing to host the process for developing the guidelines, and that there, I surprised myself by being able to be in a difficult process. It was deliberately a group of activists and health professionals, and we were in different places about how to phrase things in terms of access to care, where at the one end of the spectrum, some people just say just prescribe hormones like this.

Prof Elma de Vries: 1:12:09

On the other hand, there's the more careful, n o, we need to follow a careful process and not rush this, and to be part of holding those tensions and coming to a product that we all could be happy with. That is now being recognised internationally as an excellent guideline in this field, and ja, I guess I can celebrate having been one of the authors of the world guidelines, as well, on gender-affirming healthcare for the World Professional Association for Transgender Health.

Prof Elma de Vries: 1:12:41

And then I'm very proud of the South African Professional Association for Transgender Health t hat has just turned four years old. So we were talking about it for years, that we need a South African professional association, and it was difficult to get it going, but eventually we managed. We created a voluntary association with all the legal paperwork and registered with Department of Social Development. That has really also been a safe space for health professionals involved in gender- affirming care to be able to learn from each other, and that is really something I celebrate as well. And then in terms of my personal life, being a parent and I prefer the gender- neutral term, just seeing one's children grow up and find their way of being in the world and thinking, ah, we must have done something right. [Dr Maria Christodoulou] How many children do you have? [Prof Elma de Vries] Two, ja, 25 and turning 22. And it's just good to see that we raised them to think for themselves and to think critically and to become independent, and that is lovely to see.

Dr Maria Christodoulou: 1:14:06

What's the thing you've found most challenging as a parent?

Prof Elma de Vries: 1:14:12

One sentence communication from a teenage boy. I mean, one word sentences. Yoh, you have no idea what this child is thinking and they're not going to tell you, and you just have to guess.

Prof Elma de Vries: 1:14:27

But there's a beautiful story to that. During COVID, suddenly we had a young boy in grade 11 who couldn't go to school, couldn't interact with friends and was just at home. And it was these one-word sentences. And then suddenly we got a puppy. He had heard about this little dog who was the runt and the mom didn't have enough milk and the little dog was going to be killed and he said no, I'll buy the dog. So we got this three-week-old little puppy who couldn't even walk yet. It was this tiny thing and it was lockdown, b ut we had to find puppy milk from a vet and this little thing had to be fed every two hours. He didn't have temperature control so he had to sleep in the bed with our son and suddenly we had something to talk about. It made such a difference to our lockdown time that we had this little puppy that we could talk about.

Dr Maria Christodoulou: 1:15:25

Tell us a bit about that lockdown time, because I know you were quite instrumental in setting up a field hospital in that time, right?

Prof Elma de Vries: 1:15:31

Yes, I initially did not believe that this thing was going to come. We heard about this thing happening in the East and there had been viruses before that managed to be contained and then people started talking about, but we have to flatten the wave and I thought what? It was a time of a steep learning curve in terms of this pandemic from a medical perspective. And then we had to set up a field hospital in Cape Town and they asked me to come and assist to help manage the process and it was an amazing team of the Mitchell's Plain Klipfontein substructure office coming together. It was in about two weeks. I think the decision was taken, we're going to use this rehab space for a field hospital. The decision was taken on 16th of December and we opened on the 1st of January. And it was so many public holidays in that time, b ut we managed to get a team of staff appointed. We managed to get the beds there.

Prof Elma de Vries: 1:16:39

Gift of the Givers helped to put up an oxygen bank and we could then provide a step-down facility for the acute hospitals to decompress to, which really, really helped so that people who didn't require the level of care in the tertiary facility could come to us to recover or to end their lives. We had high mortality rates, but it was an amazing time of dedicated people working together and going beyond the call of duty to do the best that we can. To do what our hands found to do to give people the best journey, even if it meant then making sure that the person who was very sick could speak to their loved one on the phone. They couldn't come and visit, but we could facilitate the telephone conversations and keep the families informed. We had social workers as part of the team. We had physios as part of the team. As people then got better, the physios helped them to walk again. It was an amazing experience of teamwork.

Dr Maria Christodoulou: 1:17:53

I guess it's quite a theme, this idea that people rally in times of crisis and then somehow that experience of teamwork and collaboration, and everybody working towards the greater good starts dissipating the minute the threat is, I don't want to say gone, because it's not gone, but is diminished in some way.

Prof Elma de Vries: 1:18:13

So, in terms of transgender health, there have been tensions between healthcare providers and transgender activists, and with good reason, t ransgender activists haven't always trusted health professions because they've had bad experiences and people gatekeeping care, wanting them to fit a certain mould. One of the people in my research said you have to perform, to be palatable to the doctor and to fit the certain thing of being trans enough to be granted access to care. So there have been this difficult relationship. But the wonderful thing, there's often a gift in difficult things. So the difficult thing of the anti-gender movement is that it has brought the transgender activists and the health professionals closer together, because we have to work together to counter this narrative of trans people don't exist, trans youth can't access care. It's not evidence-based and nonsense like that.

Dr Maria Christodoulou: 1:19:25

The one thing I often hear and I'm sure is going to come up in conversations when people listen to this podcast is young people are just confused and doctors are enabling them in their confusion. And look at all the young people who are regretting their decisions to undergo gender corrective surgery. What is your response to that?

Prof Elma de Vries: 1:19:47

Sadness, deep sadness, that young people are not given the agency to find their own path. Because, yes, many children play with gender. And what's wrong with that? If somebody, as a young child, say, no, but I rather want to play with other toys or dress differently? They are exploring, they're discovering what the world is about, and if we just can allow them to do that, there are some children who then become adolescents and become deeply unhappy about the puberty changes t hat is not them, and at that time they need help.

Prof Elma de Vries: 1:20:35

And in terms of gender- affirming care for adolescents, it's not something that's decided overnight. It's a process with a multidisciplinary team, and the young person and their family form part of that multidisciplinary team. It needs to be a collective decision-making that this is the right path for this child. And, yes, some people will regret it later. But if you look at the research, it's less than 1%. The regret rates for many types of plastic surgery is much higher than that. So there are some - maybe up to 2-3% of people - who have started a process of transitioning and will then detransition, but that's not always accompanied by regret. There's now more and more research coming out where they interview people who then say, but it was actually because of family pressures, or it was difficult in my work environment, or there were other external reasons, but they don't regret the journey they've been on, and our position as the Professional Association of Transgender Health South Africa is that people in that position need our support and care. For some people it's just part of the journey. Our journeys are all different and people find in practice that there are people who start exploring the journey and maybe even start on hormones and then decide but no, this is not so important for me, I don't need to continue on this journey, and that's okay because as humans, we are so beautifully complex. We're not the same person now than we were a year ago. There's continuous growth and development and people grow and develop differently and that's okay. In all situations, people need to be affirmed and not judged.

Prof Elma de Vries: 1:22:39

But the problem is that there's a few people who detransitioned, who are being recycled and used everywhere in a way where this is weaponised and kind of being shown as, because of this child, the 99% of children can't. And just seeing the distress of a young person who's not able to access care, t hat's heartbreaking. In the states now, in the specific states where it's not legal anymore to do gender-affirming care for young people, t here's an increased rate of suicide amongst trans kids. If you don't give young people that space to be who they are, it can have detrimental consequences. W hereas if we allow them to be and be with them on the journey, wherever that journey leads, leads to beautiful outcomes.

Prof Elma de Vries: 1:23:36

I've got a trans friend who says people are surprised that I'm so happy, but I'm happy because now I am the man I am. My problem with people saying no, young people mustn't access care, is they are being paternalistic. They want to make decisions on behalf of these children, as if these children don't have voices themselves to tell us what their needs are. And one listens carefully to the young person's voice and you don't rush into a decision. It is a whole careful, multidisciplinary team process.

Dr Maria Christodoulou: 1:24:13

So what advice would you have for a young person who might be listening to this and is in need of, or seeking, gender-affirming health care? What should they do? Where should they go?

Prof Elma de Vries: 1:24:25

There's so much to read nowadays online and that has changed dramatically. There was so little information out there, but now it's wonderful. One can read, one can find online communities, and I think the important thing for a young person is to trust that you are enough, that you can trust your gut about who you are. You don't have to dance to other people's music. It's okay to have your own drumbeat and dance to that. It's helpful to speak to your family. Families don't always understand initially, but they can understand with time and especially if they get professional help as well, and there's also support groups for parents of trans kids where they help each other along the journey.

Prof Elma de Vries: 1:25:17

Seeking access to care if one is younger than 18 is not that easy, especially in the public sector. There's not a lot of places where there is access to a child psychologist or a child psychiatrist who can help you explore who you are and then refer you for further care. Many young people also find it difficult that their parents don't understand yet. For the older adolescents, it becomes a little bit easier to access care and there's different clinics in the country where one can access psychological support and hormones. It's a difficult journey and it's helpful to have support. There are support groups where there are other people further along the journey who can give you tips on how do you socially transition, how do you navigate things at university, how do you navigate things in a work context, how do you navigate things with your family. It's not an easy journey and the support is so important and that can mitigate some of the minority stress if there is a support structure of other people who get you and who see you.

Dr Maria Christodoulou: 1:26:36

And what about a colleague, a health professional, who maybe, as a result of this conversation, realises gosh, I didn't learn anything about this at university. Perhaps I've been insensitive, or perhaps I haven't created a space for patients to bring these kinds of conversations to the table. What advice would you have? Where does one begin to educate oneself about these things?

Prof Elma de Vries: 1:26:58

So there's the HIV Clinician Society guidelines and we've written a short guideline for busy health professionals and that's the one that's published in the journal, and then there's a more extended guideline that gives more details. We had psychologists on the team and psychologists love to elaborate on things.

Prof Elma de Vries: 1:27:19

The expanded guidelines also on the HIV clinician's website and it describes beautifully that it's about seeing the human being and seeing where they are and seeing how you can support them on their journey, but see them in the context of, it's a whole person and the gender identity is one aspect of their being. So in transgender health, they have this thing about the broken arm syndrome that if you are transgender and you happen to come to casualty with a broken arm, everybody wants to know what's between your legs, because you happen to be trans and don't really focus on what you actually are bringing as a health issue. People just want to be seen and recognized and not judged. So one can read the guidelines. There's an article in the SA Family Practice Journal about what a GP should know about gender-affirming health care.

Prof Elma de Vries: 1:28:16

There's the Professional Association of Transgender Health where we have monthly talks and the Desmond Tutu Health Foundation is having a symposium coming up on LGBTQI health. There are opportunities where one can learn more, but an important aspect, and that came out in my PhD research as well, is learning from your patients. So many gender-affirming practitioners also learned from their patients.

Dr Maria Christodoulou: 1:28:46

Absolutely. Is there anything you regret about medicine or about your career?

Prof Elma de Vries: 1:28:55

There was a time where I felt I'm not really making a huge contribution and it was in a dysfunctional context. I lost my cool and it took me a long time to understand what had happened, that I had been triggered and did not respond in a very helpful way. I think it was bad for the place where I was working at the time that it then limited my contribution to the functioning of the facility. But we keep on learning. I regret how I responded on that day and that it took me a long time to really understand what had happened, but it is what it is. Life is so hard. We need to be so kind to ourselves. It doesn't help to judge. So yes, I guess there is regret, but I need to know that I'm also just a human being.

Prof Elma de Vries: 1:29:47

And not a perfect doctor. [Dr Maria Christodoulou] Is there such a thing? [Prof Elma de Vries] Very, very human and vulnerable? No, there isn't. Even the amazing people that I look up to as role models, everybody has their strong points and then their not-so-strong points, and we're all very human and that is something that Nelson Mandela also emphasized, that nobody's just good or bad. Even the more difficult characters have some positive aspects. I have often found that when I reflect about difficult things in a work context is that many people have had very difficult lives that have influenced why they became who they are, and that it's not always helpful to judge.

Dr Maria Christodoulou: 1:30:35

Is there anything you would do differently if you could go back and begin your career again?

Prof Elma de Vries: 1:30:42

That's a good question. I've had my disappointments along the way. Things didn't go the way that I would have wanted them to, but I did what my hands found to do in different contexts. I loved working in a rural context and then I had a meaningful time working on the Cape Flats, managed to do some difficult things. We also started Mitchells Plain District Hospital, which was a completely new hospital, and working with the team there. I'm very grateful where I am now that I've got the privilege to be full-time in medical education, and I can see that my previous work and life experiences have prepared me for where I am now.

Dr Maria Christodoulou: 1:31:34

And where to from here? What do you see in your future?

Prof Elma de Vries: 1:31:38

Oh, in two years' time we will hopefully graduate our first Mandela doctors. We are now in year four of a six-year program, so in 2026. T hat will be a proud day, and I want to build this medical school and some of the things that I found in my PhD research about the hierarchy of medicine, we are already doing some things differently at Nelson Mandela University, and not just because of me. It's things that were here even before I came. T he humanising pedagogy concepts that come from Paulo Freire, really seeing the student as somebody who brings something to the table. Our deliberate focus on professional identity formation of our medical students and bringing in that reflective practice. And building the program so that... We won't have perfect graduates...

Prof Elma de Vries: 1:32:27

Well, we just said there are no perfect doctors, but we want to equip them, at least to keep on learning. T hat they can become change makers and influence where healthcare in this country will go. I see my big investment still here at the medical school and then also continuing to, in terms of transgender health advocacy, being one of the, I guess, resource people who can be there.

Dr Maria Christodoulou: 1:32:57

What would you like to see changing in terms of transgender rights and gender-affirming healthcare?

Prof Elma de Vries: 1:33:04

What I would love to see is that it is part of every health professional curriculum, whether it is nurses, doctors, psychologists, physiotherapists. Everyone needs to understand how to be affirming towards anyone who comes, because it's a vulnerable human being who seeks care, and if they can be seen and recognised for who they are, whether what they bring is a gender identity issue or whether it's... People bring so many different things to us.

Prof Elma de Vries: 1:33:41

And if we can just see them, that's what I want to be part of all health professions tr aining. C aring, seeing the human being, a s part of training everywhere. And then it would be great if for, specifically for medical students, they can also understand a bit more about gender- affirming hormone care, so that one day... I t took a long time before ARVs became available at every clinic. I worked through the time, and you probably did as well, before ARVs. Eish, it was heartbreaking. And then there were these people in Khayelitsha who started prescribing ARVs. And there was Hermann Reuter in Lusikisiki who started prescribing ARVs and we initially thought, oh, but this is such a specialist thing, you need to know exactly what you're doing.

Prof Elma de Vries: 1:34:33

And we had this debate at the time in terms of health systems. Do we go for quantity of treating fewer people very well, or do we go for quantity and make ARVs broadly accessible? And now, even with nurse prescribing, and it's not always perfect, but a lot more people have access. And what transgender people would like to see is that they're able to access their hormones as part of the primary package of care at the clinic. And that is where we want to go to, and that's how we wrote it in the guidelines, that hormone treatment is not rocket science. Postmenopausal women use the same estradiol. Men with hypogonadism use the same testosterone. You don't need a specialist to prescribe this. Where we want to go is where it is freely accessible at primary care level.

Dr Maria Christodoulou: 1:35:28

I guess what the issues highlight is the intersectionality of all of these things. It isn't just about knowledge of hormones, it's about the destigmatising, it's about the questioning of assumptions and stereotypes and the role of the doctor, and it's so difficult to isolate one thing as the issue that's getting in the way of these things being done differently.

Prof Elma de Vries: 1:35:47

And there's also some parallels for me. The HIV Clinician Society also published guidelines on people who inject drugs with a harm reduction approach, and it's the same thing of can you see the human being and how you can help them have a more meaningful life without judging them, because judging them just drives them away.

Dr Maria Christodoulou: 1:36:09

Well, and that's the thing, who defines what a meaningful life is? And if we're imposing our ideas of a meaningful life on our patients, we're in trouble or they're in trouble. Sjoe Elme, I'm aware that there's so much we still haven't talked about, but if you were to think about the person listening to this conversation and if there was only one thing that you wanted them to take away at the end of our conversation, what would that be? What would you hope that people have heard today about you?

Prof Elma de Vries: 1:36:41

About me? I guess I'm a dreamer and I'm dreaming of a world where people are allowed to be their beautiful, authentic selves. I wish for that world where I'm not judged or put in a box and I wish that for all the people around me, that people can see the beauty. And I just get very sad when there's so much harm being done because people are not seen as equal. In all the wars we have, the enemy is seen as less than human and then it's justifiable to... The unspeakable atrocity, and sometimes that breaks ones heart. But I need to be... The legacy that I'm carrying is being a bittereinder and carrying on and caring.

Dr Maria Christodoulou: 1:37:42

So what helps you to carry on and care?

Prof Elma de Vries: 1:37:44

It's difficult to define, but it's a heart thing. For me, it's an attitude of waking up in the morning and saying to myself be kind. Be kind to me. I'm an imperfect human being, but I'm trying to do what I can, and be kind to the people I encounter.

Dr Maria Christodoulou: 1:38:02

I love that and I think what I remind myself of often is that when I get into that space of the system or the institution, it's actually comprised of people like you and me.

Prof Elma de Vries: 1:38:14

Ja.

Dr Maria Christodoulou: 1:38:15

And that's what I remind myself of when things feel a bit overwhelming.

Prof Elma de Vries: 1:38:21

I think part of my learning and growing is reading and just learning from other people's journey. So, When Breath Becomes Air.' [Dr Maria Christodoulou] Oh yes, Paul Kalanithi. [Prof Elma de Vries] Wow. That was amazing for me. Wh ere he talks about, in medicine, that it is holy with an H and then wholly impossible with a W. That human interaction can sometimes be such a burden that you feel crushed by it. And beautiful words, and I think often it's poetry that keeps me going. There's such inspirational poetry that just helps one recalibrate and pause for a moment and think wow.

Dr Maria Christodoulou: 1:39:20

You also spoke about nature earlier.

Prof Elma de Vries: 1:39:22

Yes.

Dr Maria Christodoulou: 1:39:24

One of the questions on my list that I haven't asked is, how do you take care of yourself in the midst of all these difficult situations that you find yourself in?

Prof Elma de Vries: 1:39:33

I've learned and I think especially during COVID there was a lot of teaching on self-care, and I've learned that it's important to be deliberate about it. So one needs to have boundaries, and end of last week there were a lot of unanswered emails, but we went off to Hogsback for the weekend and looked at beautiful trees and waterfalls and hiked and you breathe in that forest air. It's rejuvenating for me to be in nature and then you come back and you manage to carry on. I need to sleep enough, I need to get regular exercise, the usual things. Eat healthy, have human interaction and one is so blessed with amazing friends and nowadays, friends all over, it's not just in Gqeberha.

Dr Maria Christodoulou: 1:40:29

Reminds me of something that author and sacred activist Andrew Harvey said about how important it is, particularly in the times that we live in now, to cultivate joy, and he describes what he calls the seven flames of joy, but they include time in nature, time with loved ones, time spent drawing inspiration from the great poets and artists and musicians. R eally just consciously prioritising the things that nourish you so that you can be an activist in the world, so that you can stay aligned and connected to what's important. How about you, Amy? Anything you'd like to ask Elma?

Amy Kaye: 1:41:06

I just want to say that I'm so grateful that your first thousand days were so good and that you became this wonderful, caring human.

Amy Kaye: 1:41:17

You know you mentioned at one point that you didn't feel like you were making enough of a contribution, but I just think you have contributed so much and you've changed so many lives.

Amy Kaye: 1:41:28

You've changed South Africa. You've changed South Africa essentially in the last few years what you've managed to accomplish, also as a rural doctor, but you've changed South Africa. You will change so many South Africans' lives in the future because of the work that you're doing, and thank you for your deep empathy and thank you for caring so much about people that are not always seen and are not always cared about. And I'm not quite sure why I'm getting so emotional, but I am, which is a good sign. I know that this conversation is going to help somebody somewhere that really needed to hear this conversation. I think this conversation is going to save more than one life, because I think there are a lot of people in the world that really feel alone and really don't feel seen and need to know that there are options and that there is support and that there are people like you in the world that are looking out for them. So thank you very much. [Prof Elma de Vries] Thank you.

Dr Maria Christodoulou: 1:42:28

I'm reminded of something that a listener of the podcast sent me the other day.

Dr Maria Christodoulou: 1:42:32

I'm actually going to quickly call it up so that I can read it, because it feels important. F eels very relevant in terms of what Amy's also just said.

Dr Maria Christodoulou: 1:42:40

She said that, if my interviews are an indicator, the world is brimming with incredible healers, and that she's so grateful that I'm shining a light on them.

Dr Maria Christodoulou: 1:42:52

And so I want to thank you, too, for being willing to share your story on this platform, but also for the shining light that you are in the world and for the work that you are doing, and for your commitment to equitable healthcare at a level beyond what most people even conceive of when they say those words, and for your humility, I think. F or your willingness to question your own assumptions and to reflect on the way that your ancestry has shaped who you are in the world, but also the legacy that they have given you that allows you to do this work in the world and to be a bittereinder in how you do that work. I'd like to take a moment to just honour those ancestors, but also honour the courage that it takes to transform the legacy left by our ancestors, because I think that's what the world needs, that's what South Africa needs, and thank you for being a forerunner in that regard.

Prof Elma de Vries: 1:43:45

I will accept those kind words with humility.

Dr Maria Christodoulou: 1:43:49

Anything else before we say goodbye.

Prof Elma de Vries: 1:43:51

This has been wonderful. It's a privilege to get the opportunity to tell some of one's story. So thank you, both of you.

Dr Maria Christodoulou: 1:44:01

Such a pleasure. I'm aware that there are many stories that have remained untold today and that there are many, many aspects of your personal experiences that we could have dived into, but I also trust that we shared what needed to be shared for today and that perhaps there will come a time when there is an opportunity for further conversation. But thank you. Thank you for sharing your story, thank you for the work you do and thank you for the time that you've given us today. I really appreciate it, and may you continue to find the joy and inspiration to be as passionate and dedicated an activist as you are in the world. Thank you. I'm Dr Maria Christodoulou and you've been listening to the Awakening Doctor podcast. If you enjoyed this conversation, please share it with your friends, f ollow Awakening Doctor on Instagram, Facebook and Spotify, and go to Apple Podcasts to subscribe, rate and give us a good review. Thank you so much for listening.