Sexually and gender-diverse people in rural South Africa are excluded from the systems intended to support their mental health. Photo: Reuters/Brendan McDermid
“People in the rural areas are very ignorant when it comes to LGBTQIA+ experiences. There’s no support for us. We’re always on our own.”
A psychology student at the University of Venda said this during discussions at the launch of the Practice Guidelines for Psychology Professionals Working with Sexually and Gender-Diverse People. Their words were not spoken in anger but with quiet resignation. They captured a reality that many sexually and gender-diverse people in rural South Africa live every day — exclusion from the very systems intended to support their mental health.
Despite our country’s progressive Constitution, access to mental healthcare that is affirming and inclusive remains deeply unequal. In cities like Johannesburg and Cape Town, there are networks of practitioners, student groups and NGOs that provide some measure of support. In rural provinces such as Limpopo, KwaZulu-Natal, North West and the Eastern Cape, that infrastructure is almost non-existent. LGBTQIA+ people in these areas often have to make do with health systems that do not see them, do not name them and sometimes actively exclude them.
The result is predictable. People avoid clinics and counselling services altogether, fearing judgment or harm. Many professionals have never been trained to understand sexual and gender diversity and fall back on stereotypes, silence or outdated practices. Students studying psychology in rural universities can complete entire degrees without once being taught how to work competently with LGBTQIA+ clients.
This is what systemic erasure looks like. And it has consequences: anxiety, depression, substance use and even suicide. For many LGBTQIA+ people in rural South Africa, silence becomes the only strategy for survival. It is precisely this gap that the African LGBTQIA+ Human Rights Project, working through the Psychological Society of South Africa (PsySSA), seeks to address. While our work extends nationally, we have a special focus on rural and underserved communities, where these gaps are most visible and urgent.
It is against this backdrop that the University of Venda invited us to launch the second edition of the Practice Guidelines for Psychology Professionals Working with Sexually and Gender-Diverse People. On 22 August 2025, more than 100 students, faculty members and practitioners gathered to discuss what affirming care should look like. This gathering was far more than a routine academic event. It resonated deeply as a powerful declaration — even in the heart of rural South Africa, where resources and awareness have often been limited, change is not just possible, it is under way.
Institutions such the University of Venda are courageously breaking the long-standing silence around sexual and gender diversity. They are paving the way for a transformation in how mental healthcare is both taught and practised, fostering an environment where inclusivity and understanding are no longer optional but foundational.
The guidelines are not abstract theory. They provide practical ways for psychologists and counsellors to offer care that respects dignity and identity. They ask professionals to reflect on their own assumptions, to recognise how history and culture shape mental health and to adopt practices that are both inclusive and ethical. In Venda, students and faculty leaned into this challenge with a willingness that gave me hope.
As the conversations unfolded during the event, a profound honesty emerged from the students present. Several admitted they had never encountered LGBTQIA+ issues in their training. One said they would not feel safe coming out to a campus counsellor. Another described the loneliness of knowing there was no language in their community to explain who they are. These are not side notes; they are central to understanding why affirmative care matters so urgently in rural areas. This absence of recognition deepens isolation and reinforces the barriers to accessing mental health support.
The University of Venda’s invitation and openness should remind us that rural institutions are not passive bystanders in this conversation. They are training the next generation of psychologists and counsellors. By creating space for this launch, the university signalled that inclusive practice must become part of that training.
But a single launch is not enough. Affirmative care must be built into the very structure of our health and education systems. The Health Professions Council of South Africa and the Department of Higher Education and Training should embed these guidelines into all psychology and health sciences curricula. Students should graduate prepared to work competently with LGBTQIA+ clients, no matter where they practise. Affirmative practice should not be treated as optional or “specialist knowledge”. It is fundamental to ethical care.
This is not only about professional competence. It is about justice. No person in Limpopo or anywhere else in South Africa should have to choose between seeking help and being themselves. No patient should walk into a clinic fearing that their identity will be treated as a pathology or ignored altogether. And no rural institution should be left out of the national conversation on mental health reform.
When that student said, “We’re always on our own,” they voiced both resignation and resilience. But it should not have to be that way. Affirming mental healthcare is not a privilege for those living in urban centres. It must be the standard across every clinic, every classroom and every counselling room in this country, regardless of geography.
This is a call to action — for institutions, professionals and communities to commit to transforming mental healthcare into a space where every individual can find safety, acceptance and affirmation. True care knows no boundaries of geography; it recognises and honours the dignity of all people, everywhere.
You can read the Practice Guidelines for Psychology Professionals Working with Sexually and Gender-Diverse People here.
Thembisile Dlamini is a clinical psychologist in the Sexuality and Gender Division of the Psychological Society of South Africa, working with the African LGBTQIA+ Human Rights Project.