Over the past decade, the landscape of transgender healthcare has undergone considerable evolution, reflecting broader societal recognition of gender diversity and the necessity of gender-affirming interventions. Central to this development are treatments designed to align a transgender individual’s physical characteristics with their genuine gender identity. These treatments typically include gender-affirming hormone therapy (GAHT) and gender-affirmation surgeries, both integral in alleviating gender dysphoria and enhancing well-being. Yet, recent research emerging from China unveils a striking complexity in transgender individuals’ intentions toward these treatments and their mental health correlates. This study, encompassing a substantial participant base, sheds light on nuanced patterns that challenge simplistic interpretations of treatment outcomes and call for highly personalized clinical approaches.
The Chinese Transgender Health Survey sampled 7,576 participants, whose mean age hovered just above 21 years. A surprising finding was that approximately one-third outright expressed no intention to pursue gender-affirming treatments. This alone disrupts common assumptions that every transgender person inevitably seeks medical transition. Instead, the survey delineates four distinct groups based on their treatment status and intentions: those with no treatment intention, those intending to start treatment but who have not yet done so, those currently undergoing hormone therapy, and finally those who have undergone gender-affirmation surgery.
Delving deeper, the group comprising individuals who had completed gender-affirmation surgery reported the highest levels of gender dysphoria. This counterintuitive finding suggests that surgical intervention does not invariably equate with diminished distress related to gender incongruence. Instead, it calls attention to the complexity of dysphoria itself—its persistence or transformation after surgical procedures. Numerous explanations may underlie this pattern: timing of assessment post-surgery, ongoing psychosocial stressors, or a selection effect whereby individuals with more severe dysphoria are more likely to pursue surgery in the first place.
Conversely, participants currently undergoing gender-affirming hormone therapy displayed the most pronounced symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), as well as heightened risk for self-harm and suicidality. This cluster’s elevated mental health challenges signal that the hormone therapy phase might be a critical period of vulnerability within the broader gender affirmation trajectory. Potential contributors include the psychosocial upheaval during early medical transition, side effects of hormones, or societal discrimination triggering or exacerbating psychological distress.
The intermediate group—individuals intending to start treatment but who have not yet initiated hormone therapy or surgery—fell between the no-treatment and treatment groups across many mental health indices. This gradient suggests that the anticipation or planning stage of transition itself harbors distinct psychological challenges. These might involve hope, uncertainty, fear, and societal pressures, each contributing variably to mental well-being.
Sociodemographic factors emerged as differential modulators of mental health outcomes across these groups. Education level, in particular, showed complex interactions, influencing mental health in disparate ways depending on treatment status. For instance, higher education might foster greater access to information, social support, or healthcare resources, but it could also raise awareness of potential risks or deepen existential concerns. This mosaic effect underscores the inadequacy of one-size-fits-all models in transgender healthcare, emphasizing the necessity for clinicians to consider diverse life contexts and personal narratives.
Importantly, the study’s multivariate regression models caution against simplistic causal interpretations. The observed mental health disparities among groups do not inherently reflect the direct effects of gender-affirming treatments themselves. Factors such as pre-existing psychological distress, social stigma, and healthcare accessibility intricately weave into the observed patterns. This distinction matters critically, especially in policy and public discourse, wherein misattributions can fuel harmful misconceptions about the efficacy or safety of gender-affirming interventions.
Expanding on this, the clinical implication is clear: gender-affirming care must be highly individualized. Mental health professionals and endocrinologists should collaboratively tailor interventions, closely monitoring psychological symptoms and adapting care plans responsively. Some patients may need intensified mental health supports during hormone therapy initiation; others might require extended follow-up post-surgery to address persistent dysphoria or emergent challenges.
The Chinese context offers a unique vantage point for this research due to distinct cultural, social, and healthcare system factors shaping transgender experiences. Social stigma toward transgender identities remains significant in many areas, potentially exacerbating mental health burdens irrespective of medical treatment. Moreover, access to specialized gender clinics and psychological services is unevenly distributed, complicating individuals’ transition experiences. Although the findings may resonate globally, regional nuance remains vital in interpreting and applying these insights.
From a methodological perspective, recruiting over seven thousand transgender participants and stratifying them into meaningful treatment intention categories marks a robust and ambitious effort to capture real-world diversity. The study’s average participant age around 21.6 years highlights the prominence of young adults navigating their gender identity amidst pivotal developmental and societal pressures.
The intersection of gender dysphoria with anxiety, depression, PTSD, self-harm, and suicide risk within the hormone therapy group invites further exploration into the biopsychosocial mechanisms at play. Hormonal changes can modulate mood and behavior via neuroendocrine pathways, but concomitant psychosocial stress—ranging from family rejection to discrimination—likely exerts profound exacerbating effects. Untangling these interwoven factors is key to enhancing supportive care during this vulnerable stage.
Significantly, the study reframes prevailing narratives that narrowly view gender-affirming treatments as uniformly ameliorative for mental health. Instead, it situates gender affirmation within a complex matrix of subjective experiences, social determinants, and temporal phases in treatment. Such a perspective resists reductive assumptions and mandates longitudinal, nuanced inquiry moving forward.
Overall, this research contributes to a growing body of evidence advocating for a biopsychosocial model of transgender healthcare. This model integrates medical intervention, mental health support, social advocacy, and personalized care plans attuned to individuals’ motivations and contexts. Recognizing the heterogeneous pathways transgender people undertake respects their autonomy and optimizes health equity.
Future research endeavors must continue to dissect how sociodemographic variables, stigma-related stressors, healthcare accessibility, and treatment timing interact to shape outcomes. Additionally, expanding the geographic and cultural scope of such studies will enrich understanding of universal versus context-specific factors influencing transgender mental health.
In conclusion, these findings emphasize that intentions and choices concerning gender-affirming treatments manifest complex associations with mental health, urging clinicians, researchers, and policymakers toward compassionate, individualized approaches. Such strategies not only acknowledge the multifaceted nature of gender dysphoria but also elevate transgender voices in the co-design of healthcare paradigms that resonate with their lived realities.
Subject of Research:
Associations between gender-affirming treatment intentions and mental health outcomes among transgender individuals.
Article Title:
Investigating the association between gender-affirming treatment intentions and choices on mental health among transgender individuals.
Article References:
Li, J., Cui, X., Zheng, Q. et al. Investigating the association between gender-affirming treatment intentions and choices on mental health among transgender individuals. Nat. Mental Health (2025). https://doi.org/10.1038/s44220-025-00434-2
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