A new study challenges the popular claim that medical interventions improve trans-identifying people’s mental health. Rather, the study argues, nonmedical factors like social support and coping style are far more important determinants of these individuals’ mental-health outcomes.
For years, doctors and medical associations have argued that patients with gender-related distress, including children, suffer from depression and suicidality and need access to “gender-affirming care” to relieve it. They presented this view as the scientific consensus, and that view has shaped policy debates about how readily these interventions should be offered and under what—if any—safeguards.
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The mental-health case for medical transition relies on observational clinic studies that measure patients’ psychological distress before and after treatment. Many of these studies follow small samples for short periods, often less than two years. When these studies report improvements in patients’ symptom scores or well-being measures after medical transition, the design often cannot tell whether the medical intervention drove the difference, since other things typically occur alongside treatment. That is one reason systematic evidence reviews have repeatedly judged the certainty of this evidence as low and the findings as inconsistent.
A new retrospective follow-up study from Hong Kong, published in Frontiers in Psychiatry earlier this month, addresses those problems. The authors argue that much of the earlier literature leans too heavily on group averages and does not adequately account for basic determinants of mental health, such as social support and coping style. Instead of treating those variables as background, the Hong Kong researchers measured them directly and included them in the same longitudinal models as treatment status. Their aim was to see whether hormone use or surgery still predicted changes in depression and anxiety once support and coping strategies were considered.
The study followed adults seen at Hong Kong’s public Gender Identity Clinic. The proctors assembled the original 394-participant cohort in 2019 and 2020 and collected follow-up data between October 2023 and June 2024. After accounting for deaths, loss to follow-up, and participants who discontinued hormones, the final sample included 178 people.
Of that sample, nearly half were “female-to-male,” nearly half “male-to-female,” and a small fraction identified as “non-binary.” The median age was 36, and most were not in a romantic relationship. Over a quarter had psychiatric comorbidities, one in four were taking psychotropic medication, and more than one in three were in active care with a psychologist.
Participants completed standardized questionnaires on depression, anxiety, and stress (the DASS-21) and on perceived social support and coping strategies. “Social support,” the authors explain, refers to the “perception that help will be available when needed,” while “coping” refers to personal efforts to manage stressors or emotional challenges. The study distinguishes between “facilitative coping,” which includes active coping, planning, positive reframing, and seeking emotional or practical support; and “avoidant coping,” which includes disengagement, self-blame, and substance use.
The authors emphasize that coping style is an important determinant of mental health. They cite prior research linking avoidant coping with worse outcomes in trans-identified populations. “Avoidant coping,” they write, “is consistently associated with worse mental health, including anxiety . . . and depression.” By contrast, facilitative coping, such as cognitive reframing—similar to methods used in cognitive behavioral therapy—is associated with improvement.
The study divided participants into three main groups: those who had not had surgery, those who underwent surgery during the study period, and those who had already had surgery by the time the study began. A secondary analysis divided participants by hormone status and duration of use, noting that the full effects of hormones can take years to develop.
What makes this study distinct is not only its size and duration but its design. The authors tracked changes over time, while controlling for social support, coping, and other background factors. Put simply, the question was: Accounting for these other influences, do hormones or surgeries still predict better mental-health outcomes?
The answer was no. Neither surgery nor cross-sex hormones significantly reduced depression, anxiety, or stress once coping and social support were included in the statistical models. Instead, it was those psychosocial factors that proved the strongest predictors of patients’ mental health. Facilitative coping and both types of social support—meaning support from family and from friends or a significant other—were associated with fewer depressive symptoms. Avoidant coping, by contrast, was strongly linked to higher depression and anxiety.
As the authors summarize, “gender-affirming treatments did not reduce depressive or anxiety symptoms significantly, after controlling for coping and social support.”
While the authors found that participants who received hormones or surgery reported greater “gender congruence”—a perceived alignment between patients’ “gender identity” and their bodies—this did not translate into improved mood. The authors note that “mental wellbeing did not improve despite greater gender congruence,” consistent with earlier studies that found the same pattern.
The Hong Kong study’s longer timeframe also allowed for a clearer picture than short-term research. The group that underwent surgery during the study period showed reduced depression in raw averages, while the groups that had already had surgery or had none showed increases. But this apparent benefit vanished once social support and coping were factored in, suggesting that mood improvement reflected the concurrent rise in family support rather than the surgery itself.
The findings speak to a deeper misunderstanding about the nature of gender-related distress. The prevailing public narrative casts trans-identifying people as a biologically defined minority group, harmed by stigma and in need of medical affirmation. The research, however, does not convincingly establish transgender identity as a distinct biological condition.
Another interpretation is that many trans-identifying individuals are experiencing psychological distress—often alongside sex-atypical traits or same-sex attraction—and have been taught to understand that distress through the framework of “gender identity.” From this perspective, gender identity is not a fixed trait to be affirmed but a belief to be examined. Transition then becomes a way of externalizing inner conflict rather than resolving it.
The Hong Kong study lends support to this view. In that cohort, the factors most strongly associated with better mental health were not hormones or surgery but ordinary determinants of well-being, such as healthier coping strategies and stronger social support.
For many individuals, immersion in online or activist communities centered on grievance and identity may instead entrench distress. More than half of participants in the cohort reported active involvement with the transgender community. Recovery, the findings suggest, is more likely to follow from disengaging from those environments, finding purpose, and pursuing reality-based therapeutic approaches.
The new Hong Kong study adds to a growing body of evidence suggesting that medical transition does not resolve the psychological problems that lead people to seek it. Instead, the paper points toward addressing those problems directly—not medicalizing distress under the banner of “gender affirmation.”
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