Gender nonconformity or variance is when a person’s gender identity differs from cultural norms (1). In the DSM-5, “gender dysphoria” (GD) refers to distress from the mismatch between experienced and assigned gender. Persistent gender dysphoria can result in mental health disorders such as depression and anxiety (2–5). Research indicates that the prevalence of Axis I comorbidity ranges from 14.3% to 39% for current cases and from 5.3% to 71% for lifetime cases (2–5). Recent extensive clinical studies have identified depression as the most prevalent diagnosis (6). This high prevalence has also been confirmed in recent systematic reviews of transgender populations in China (7, 8). This significant link between gender dysphoria and psychiatric disorders is crucial, as psychiatric comorbidity is a key negative prognostic factor for gender-affirming treatment outcomes (9, 10).

Gender-affirming hormone therapy and surgeries can help feminize or masculinize the body by altering primary and/or secondary sex characteristics. Individualized management is crucial since the intensity, type, and sequence of intervention may vary for each person (11). Studies on gender-affirming treatments, including hormones and surgeries, have concentrated on mental health issues such as anxiety and depression (12) and quality of life (13). Overall, studies indicate that these treatments are linked to improved mental health, quality of life, and psychological functioning (14). Social functioning studies show positive impacts of these treatments on transgender individuals’ social relationships and support systems, with benefits including reduced harassment (15, 16). Standardized assessment tools were lacking in most studies on mental health issues in individuals with Gender Dysphoria (GD), which hindered reliable comparisons (3, 5, 11).

Sociocultural context profoundly moderates the impact of gender dysphoria (17). Specific Chinese cultural values often amplify this burden in conservative Asian societies like Hong Kong. Collectivism, filial piety, and the emphasis on family lineage can frame gender nonconformity as a source of profound family shame and a failure of familial duty (18, 19). The complex relationship of these factors and contrasting societal attitudes leaves the generalizability of Western-based findings to a Hong Kong Chinese environment unclear. Furthermore, the local service context has evolved significantly. Historically, Hong Kong had scattered transgender medical services until the establishment of the centralized, multidisciplinary Gender Identity Disorder (GID) Clinic in October 2016.

This clinic, which is the setting for our study, serves as the sole public provider for adults with gender dysphoria. The team includes psychiatrists, endocrinologists, plastic and reconstructive surgeons, urologists, clinical psychologists, and other allied health professionals, offering a full range of assessments and treatments in accordance with the 7th version of the WPATH Standards of Care. While a prior local thesis used standardized tools (20), it was conducted over a decade ago under the previous service model and DSM-IV ‘GID’ criteria. A distinct research gap exists for a contemporary investigation using standardized diagnostic instruments to assess the mental comorbidities and psychosocial functioning of patients under this novel service model.

The present study has two main objectives. Our primary, descriptive objective is to investigate the prevalence of psychiatric comorbidities in Chinese individuals with GD at the Hong Kong GID clinic using standardized diagnostic tools. Our secondary, exploratory objective is to assess the associations between different gender-affirming treatment stages and psychosocial measures (including depressive symptoms, anxiety, self-esteem, and quality of life). Based on the preponderance of existing literature (14, 21), we expected to find that individuals in more advanced treatment stages would report better psychosocial functioning.

In this observational cross-sectional study, patients attending the GID clinic at a psychiatric center of a local hospital between October 2017 and August 2018 were consecutively recruited. Figure 1 details the full participant recruitment and screening process. Inclusion criteria included being aged 18 or older, of Chinese ethnicity, meeting DSM-5 diagnostic criteria for gender dysphoria as assessed by specialist psychiatrists at the GID clinic and being capable of providing informed consent. The diagnosis was confirmed by a psychiatry specialist after a minimum of three assessment sessions. Exclusion criteria included inability to communicate in Chinese, significant hearing impairment, and significant cognitive deficit (e.g., moderate or severe mental retardation and dementia).

This study, the first at the centralized GID clinic in Hong Kong to use standardized clinical assessments to examine mental health issues in Chinese adult GD patients across different gender-affirming treatment stages, highlights a complex psychiatric profile. Our findings show a high lifetime prevalence of Axis I psychiatric disorders, yet a point prevalence comparable to that of the general Hong Kong population. Gender-affirming treatment (GAT) was significantly associated with better self-esteem and psychological quality of life. However, its association with depressive symptoms was weak, and no significant link was found for anxiety. This discrepancy implies that persistent sociocultural stressors in the local context may moderate the complex relationship between GAT and mental health.

Our finding of a 46.1% lifetime prevalence of Axis I disorders, with depression being the most common (39.3%), is consistent with international data that confirm a high prevalence of depression among transgender populations (6, 7). This high lifetime burden can be understood through the Gender Minority Stress Model (23), which posits that transgender people face unique stressors, such as discrimination and internalized stigma, that contribute to adverse psychological outcomes (24).

In sharp contrast, the 12.4–percentage point prevalence in our sample was not significantly different from the 13.3% prevalence of common mental disorders found in a large local epidemiological study (25). This discrepancy between high lifetime and lower point prevalence could be due to several factors. It may reflect a selection bias, where individuals with better baseline mental health are more likely to seek and remain in specialized care. Conversely, this finding may also suggest a protective association of being engaged in the specialized GID clinic, which provides validation, psychiatric support, and a pathway to transition. This interpretation aligns with existing evidence demonstrating that access to gender-affirming care, including surgeries, is associated with improved mental health (21).

A key finding is the 36% prevalence of personality disorders, with avoidant personality disorder (Cluster C) being the most common (16.9%). This contrasts with most Western studies, which typically find Cluster B disorders to be more prevalent (4, 26–28). This finding may indicate a culturally specific expression of minority stress. Established literature shows that avoidant coping is a common and detrimental mediator between minority stress and depression (24). This phenomenon is especially pronounced and driven by the internalized sense of ‘shamefulness’ (18) associated with violating cultural norms in Hong Kong. We propose that this chronic, pervasive use of avoidant coping, in response to chronic societal rejection, can become a rigid and dysfunctional pattern that manifests in our clinical sample as a full Avoidant Personality Disorder.

Regarding the role of GAT, our results were mixed. The finding that both the HT and AS groups were associated with significantly higher self-esteem and psychological quality of life (compared to the BT group) is a key positive finding. This finding is consistent with a robust international consensus (29–34) and supports the hypothesis of a profound, positive association between medical affirmation and core well-being.

However, the association with mood and anxiety was less clear. The link with reduced depressive symptoms in the HT group was only marginally significant (p=0.049) and should be interpreted with caution, especially given the study’s cross-sectional design and limited sample size. Furthermore, there was no association with anxiety symptoms. The regression model for anxiety (BAI) was not statistically significant and had very limited explanatory power (Adjusted R² = 0.052), indicating that the included variables do not adequately explain the variance in anxiety scores in our sample. This discrepancy does not necessarily contradict Western literature (16, 29, 31, 35, 36); rather, it likely highlights the overwhelming power of the local social context. As a recent scoping review confirms, transgender individuals in Hong Kong face persistent and severe discrimination in employment, education, and public accommodation, as well as high rates of social rejection (37). This chronic, unresolved societal stress may diminish or override the expected mental health improvements from medical treatment alone. Our findings suggest that in a conservative environment, GAT is an important factor associated with better self-esteem and life quality, but it may not be sufficient to overcome the daily psychological impact of societal stigma and discrimination.

This interpretation is further reinforced by our regression models. Perceived social support emerged as the variable strongly associated with better mental health across multiple domains, correlating with lower depressive symptoms, higher self-esteem, and improved quality of life. The critical role of social support found in our study is consistent with a vast body of international research that has specifically linked it to reduced depressive symptoms (38) and enhanced quality of life (39) in transgender populations. These findings strongly suggest that for transgender individuals in Hong Kong, social and familial acceptance is not a peripheral issue but rather a factor critically linked to psychological well-being.

Our study has several limitations. First, a primary limitation is the absence of a matched cisgender control group. It should be noted that our study’s objectives were to investigate the prevalence of psychiatric comorbidities and explore the psychosocial impact of gender-affirming treatments within our specific clinical population, rather than to conduct a comparative analysis against the general population. Nonetheless, we acknowledge that this design choice limits the interpretability of our prevalence data. Without a control group, we cannot definitively conclude whether the high rates of psychiatric comorbidities observed are specific to gender dysphoria or to what extent they may be reflective of general minority stress or other factors prevalent in clinical populations in Hong Kong. Future research employing a matched cisgender control group (ideally sampling from both general and clinical populations) would be essential to contextualize these rates and to disentangle the effects of gender dysphoria from other contributing stressors.

Second, the cross-sectional design cannot establish causality or temporal relationships, potentially leading to a misinterpretation of results. It’s plausible that higher self-esteem and psychological quality of life could influence one’s advocacy for gender-affirming treatments rather than being solely outcomes of such treatments. Additionally, comparing subjects at different treatment stages may not capture changes in individuals over time. Longitudinal studies have consistently shown a positive link between hormone therapy and psychological well-being, unlike cross-sectional studies (35).

Finally, our sample selectiveness and small sample size pose further limitations. While our study considered various covariates, such as age, gender identity, sexual orientation, personality disorders, and perceived social support, the cross-sectional ‘stage’ groups were heterogeneous, which reflects the real-world clinical population and limits interpretation. For instance, in the HT group, 43.3% of subjects (n=13) had been on hormone therapy for less than 12 months. This variable duration—which for some may be insufficient to achieve maximal expected psychological effects—may have diluted the observed associations for this group. Similarly, the AS group was not stratified by surgery type and included individuals with both upper-only procedures (n=7) and genital procedures (n=24). Our limited sample size restricted further stratification of these groups or the inclusion of other potential determinants (e.g., family dynamics, body satisfaction) in the regression models, limiting the depth of analysis.

This study, the first standardized psychiatric assessment of Chinese adults at Hong Kong’s GID clinic, found a high lifetime prevalence of psychiatric comorbidities, with depressive disorders and avoidant personality disorders being the most prevalent. Our findings show gender-affirming treatment is associated with higher self-esteem and better psychological quality of life. Conversely, perceived social support was associated with a wider range of favorable psychosocial measures, including reduced depressive symptoms. These findings highlight the clinical importance of screening for these common comorbidities, recognizing that illnesses such as avoidant personality disorder might require culturally informed therapy approaches, and emphasizing the importance of mobilizing psychosocial support. From a policy perspective, our data suggest that in addition to medical GAT access, broader anti-discrimination measures are essential to fully address the psychological impact of societal stigma. Future longitudinal research is warranted to confirm these associations.