A systematic review found a high prevalence of mental health problems among transgender and gender non-conforming (TGNC) individuals living in China and that there was limited access or use of gender-affirming or mental health care. These findings were published in The Lancet Public Health.
The authors of this review, which comprised 30 studies, sought to consolidate research about the impact on mental health among TGNC individuals living in China.
Most transgender youth in China experience parental abuse or neglect (92.8%) and abuse or bullying at school (76.6%). This trend has, in part, been attributed to the strong traditional Chinese values of the family unit, which contributes to discrimination and ostracization.
Although there is gender discrimination legislation in China, it remains unclear whether these regulations include TGNC individuals and in China, individuals are not eligible to change their legal name until after they undergo gender-affirming surgery.
To undergo gender-affirming surgery, patients are responsible for most of the costs and the procedure remains costly. Patients are only eligible to undergo gender-affirming surgery once they obtain a medical diagnosis of gender dysphoria. In addition, 79.4% of the TGNC population has a desire for gender-affirming hormone therapy but 71.5% thought it was hard to obtain. Among those who were using hormone therapy, 61.8% used their medications without professional monitoring.
Anxiety was reported at a rate of 28.5%-51.0% among TGNC individuals. Transgender women and those who wanted but had no access to gender-affirming hormone therapy had higher anxiety scores. Symptoms of anxiety were associated with increased risk for sexualized drug use and lower rates of pre-exposure prophylaxis for HIV.
The rate of depression among TGNC individuals was reported as ranging between 32.0%-54.5%. Factors associated with depression included low self-efficacy, low self-esteem, and negative impacts from childhood maltreatment and school bullying. Individuals with a recent depressive episode or with major depressive disorder were positively associated with suicidal ideation.
Among the TGNC population, 11.1%-25.7% have attempted suicide and 8.2%-14.8% of youth had made a suicide plan in the last month. Suicidal behaviors were more common among transgender women than men, specifically for suicidal ideation (60.7% vs 51.5%), suicide attempt (20.7% vs 11.0%), and seeking mental health support (34.4% vs 20.6%).
For individuals who accessed professional mental health care, 68.4% indicated the care was helpful and 91% went on to seek gender-affirming services. Counseling and psychotherapy services were more likely to be sought by individuals who had been verbally harassed, experienced discrimination, and been rejected for treatment by a medical professional. Transgender women who were sex workers had a low rate of using mental health services and had high unmet needs.
This review had some limitations. Due to the availability of the existing research, the researchers summarized the information as opposed to synthesizing the data into a quasi meta-analysis. Also, the fact that only 30 articles were eligible for this particular review indicates that further research is needed. In addition, the majority of those studies had focused on those aged 18 to 29 years old.
In order to improve mental health of TGNC individuals living in China, a multipronged approach is needed to target discrimination and maltreatment in the family unit, at school, in the community, and the health care setting. Specifically for health care needs, much improvement could be achieved by standardizing guidelines for TGNC health care, as no such guidelines currently exist in China.
Lin Y, Xie H, Huang Z, et al The mental health of transgender and gender non-conforming people in China: a systematic review. Lancet Public Health. 2021;6(12):e954-e969. doi:10.1016/S2468-2667(21)00236-X