# Gender Identity Milestones and Hormone Utilization in Transgender Men and Women in China

## TL;DR

This study explores how transgender men and women in China develop their gender identity and use hormone therapy, finding differences in timing and access challenges.

## Contribution

The study provides new insights into gender identity milestones and GAHT utilization patterns among transgender individuals in China.

## Key findings

- Transgender men recognized gender incongruence earlier than transgender women but started hormone therapy later.
- Transgender women progressed faster toward medical affirmation and had higher rates of early GAHT initiation.
- Despite improved access to GAHT services, challenges in medical accessibility and social acceptance persist in China.

## Abstract

What are the characteristics of gender identity development and gender-affirming hormone therapy (GAHT) utilization among Chinese transgender men and women?

This cross-sectional study of 1462 transgender men and 2834 transgender women found that while transgender men began gender identity explorations earlier, transgender women progressed faster toward medical affirmation. Although access to qualified GAHT services has improved in China, challenges persist in medical accessibility and social acceptance.

These findings emphasize the need for early, individualized care for transgender youths and underscore the importance of expanding accessible and patient-centered transgender health care services in China.

This cross-sectional study investigates gender identity development and its association with use of gender-affirming hormone therapy among transgender individuals in China.

Little is known about how gender identity develops and how it affects gender-affirming hormone therapy (GAHT) utilization among transgender people in China.

To investigate gender identity development among Chinese transgender men (TM) and transgender women (TW) and to explore how identity-related factors are associated with GAHT utilization.

This cross-sectional study is based on the latest Chinese Transgender Health Survey targeting the transgender population in China conducted from May to December in 2021. Data analysis was completed in December 2024. Participants were recruited online via snowball sampling.

The primary outcomes are the timing of gender identity development milestones (first perception of gender incongruence, confirmation, disclosure, and initiating GAHT) and GAHT utilization status. Multivariable binary logistic regression identified factors associated with GAHT-related behaviors and feedback.

A total of 4296 transgender people (1462 TM [34.0%] and 2834 TW [66.0%]; median [IQR] age, 21 [18-24] years) were included in the final analysis. The age distribution of first perceived gender incongruence exhibited a bimodal pattern, with peak occurrences at ages 5 to 6 and at 12 years. The median (IQR) ages at gender identity development milestones were all younger for TM than for TW: 6 (4-10) years vs 9 (6-12) years for perception, 14 (11-16) years vs 15 (12-17) years for confirmation, and 16 (14-19) years vs 17 (15-20) years for disclosure, whereas the age of initiating GAHT was older in TM than in TW (median [IQR] age, 19 [17-22] years vs 18 [16-21] years). The demand for GAHT (3759 participants [87.5%]), usage (2247 participants [52.3%]), and the rate of valid prescriptions among hormone users (339 participants [15.1%]) have all increased significantly compared with 2017. Being a TW and without a college education were associated with starting GAHT before age 16 years, while being a TM, having family disclosure of gender identity, and having official prescriptions were associated with positive feedback on GAHT.

In this cross-sectional study of Chinese TM and TW, gender identity development differed by gender, with TM recognizing incongruence earlier and TW progressing faster in initiating GAHT. Both groups showed strong demand for GAHT. Despite recent improvements in GAHT service accessibility, challenges persist in medical accessibility. These findings highlight the need for personalized support for transgender youths and underscore the importance of improving formal transgender health care services in China to enhance the well-being of this population.