Feasibility and acceptability of a mindful self-compassion intervention for transgender and gender-diverse individuals in Hong Kong: a mixed-method pilot study

Abstract

Purpose

Transgender and gender diverse (TGD) individuals face distinct gender minority stress and body image concerns, leading to emotional and cognitive responses that can contribute to negative mental health outcomes. This study aimed to investigate the feasibility, acceptability, and preliminary effectiveness of a mindful self-compassion (MSC) intervention among TGD individuals in Hong Kong.

Methods

A single-group, six-session MSC intervention was delivered weekly among 17 participants from December 2024 to January 2025, including eight transgender men, six transgender women, and three gender-fluid individuals. The median age was 24 years (IQR: 21–30). Validated measures of internalized stigma, self-esteem, body surveillance, body shame, body appreciation, anxiety disorders, and depression symptoms were administered at pre-and post-intervention. Additionally, semi-structured individual interviews were conducted to understand participants’ experiences and their satisfaction with the intervention.

Results

The Wilcoxon signed-rank test indicated there were significant improvements in self-esteem (p = 0.01), body appreciation (p = 0.01), and self-compassion (p = 0.05) immediately after the intervention. Qualitative findings indicated overall satisfaction with the intervention.

Conclusion

The six-session MSC intervention demonstrated preliminary effectiveness in enhancing self-compassion, internalized stigma, and body image among TGD individuals. Further research with a larger sample size and a longer follow-up period is warranted.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s40359-026-05116-x.

Introduction

In Hong Kong, gender clinic service utilization has increased, with attendances at the Gender Identity Clinic (GIC) rising from 950 in 2019 to 1,131 in 2021 [1]. In societies dominated by cisgender norms, transgender and gender-diverse (TGD) individuals, whose gender identities do not align with their birth-assigned sex [2], frequently face significant obstacles in expressing their gender identity, which could negatively impact their body perception and mental health well-being [3, 4]. Studies reported that TGD individuals experienced higher rates of body image dissatisfaction compared to their cisgender counterparts [3]. Furthermore, a survey of 106 transgender individuals in Hong Kong revealed that 67.0% had contemplated suicide, while 20.8% had attempted suicide, with 87.1% of those attempts occurring in young people aged 15–24 [5].

According to the minority stress model, TGD individuals experience external stressors such as gender-based prejudice, exclusion, and mistreatment stemming from society’s cisnormative attitudes [6]. This oppressive environment may lead TGD individuals to internalize societal gender biases, resulting in low self-esteem, poor body image, and feelings of shame [7]. Furthermore, the objectification theory posits that when individuals perceive themselves as objects evaluated primarily on physical appearance rather than as holistic beings, it could lead them to engage in excessive self-monitoring to conform to societal expectations, increasing their susceptibility to body image issues and psychological disorders [7, 8]. The interaction between gender minority stress and self-objectification within one’s social context could engender a sense of oppression, culminating in a dehumanizing experience for the individual [7, 8].

Self-compassion, which entails exhibiting kindness and understanding towards oneself [9], could serve as a potential mechanism to enhance positive body image and mental health among TGD individuals. This concept encompasses three key elements: self-kindness, common humanity, and mindfulness [9]. By facilitating self-acceptance, including the acceptance of one’s shortcomings and imperfections, self-compassion could potentially increase body image flexibility [9]. Kindness refers to embracing a kind attitude toward oneself rather than self-criticism. Common humanity believes one’s suffering and failure are a part of being human. Mindfulness means developing present awareness and recognizing one’s thoughts and emotional reactions to negative feelings or difficulties. Self-compassion offers a framework for relating to oneself with greater acceptance and less self-criticism. For TGD individuals, who may experience stigma, invalidation, or internal negativity regarding their bodies, self-compassion may foster body image flexibility. By increasing awareness of stigma-related thoughts without judgment, normalizing suffering as part of shared human experiences, and encouraging self-kindness and forgiveness [9–11], self-compassion may enhance emotional regulation and cultivate a more positive relationship with one’s body in this population.

A growing body of evidence supported the effectiveness of self-compassion interventions in improving body image and mental health outcomes among various populations. A systematic review of 23 studies found that compassion-based interventions were effective in reducing body weight shame and improving levels of compassion [12]. Another systematic review and meta-analysis of 56 self-compassion interventions revealed significant moderate effects on depressive symptoms (effect size measured by standard mean difference (SMD) = 0.44) and stress (SMD = 0.43), and a small effect on anxiety symptoms (SMD = 0.36) immediately post-intervention [13].

Mindful self-compassion (MSC) training, developed by Christopher Germer and Kristin Neff, combines mindfulness practices with the concept of self-compassion, promoting the capacity for awareness of suffering and for self-compassionate [14, 15]. The eight-session MSC intervention consisted of eight weekly 2-2.5-hour sessions and a half-day retreat. It included core meditation practices, such as compassionate body scan, self-compassion break, as well as informal practices, such as self-compassion letter writing [15]. The six-session adaptations were also used to improve accessibility and engagement, and they [16–19] have exhibited feasibility and effectiveness in improving self-compassion, self-acceptance, positive body image, and reducing anxiety and depression among various populations [16–20].

To date, only two published online MSC interventions for TGD adolescents have been reported, both conducted in the U.S. and using single-group designs with eight weekly or biweekly 90-minute sessions. One study (N = 41) reported significant reductions in anxiety and depressive symptoms at the three-month follow-up [21]. Another (N = 35) found reduced suicidal ideation at the two-month follow-up [22]. However, no such interventions have been published outside the U.S., highlighting the need for further research to assess their feasibility and effectiveness in non-Western settings.

Hong Kong represents a unique cultural context for studying self-compassion and MSC. In Chinese societies, influenced by Buddhist philosophies, compassion is often understood as caring for others rather than as individual self-care. The Buddhist notion of “no-self”, for instance, transcends self-centeredness by suggesting that caring for others is inherently a way of caring for oneself [23, 24]. Meanwhile, Hong Kong is shaped by both Chinese collectivist traditions and Western individualism. The collectivist emphasis on interpersonal relationships and social harmony views individual well-being as contingent upon the welfare of the group. In this hybrid cultural context, an individual’s practice of self-compassion may be informed by the norm of caring for others in order to maintain social harmony [24]. Thus, self-compassion may be intertwined with compassion for others, a conceptualization that may differ from a more individualistic understanding prevalent in Western cultures. This cultural distinctiveness underscored the importance of investigating MSC within the Hong Kong context.

Aims

Given the absence of MSC intervention among TGD individuals in non-Western contexts and the culturally unique conceptualization of self-compassion among Chinese populations, the aim of this pilot study was to investigate the feasibility, acceptability, and preliminary effectiveness of a 6-week MSC intervention among TGD individuals in Hong Kong.

Hypotheses

• H1: The MSC intervention would meet predefined feasibility and acceptability criteria.

• H2: The MSC intervention would show preliminary improvements in self-compassion, self-esteem, and body appreciation, and reductions in body objectification (i.e., body surveillance and body shame) and mental health outcomes (i.e., anxiety and depression symptoms) from pre- to post-intervention.

Success criteria for feasibility and acceptability

The success criteria were defined as follows:

1. Feasibility:

   1. Recruitment rate: ≥ 40% of eligible participants would consent to participate.
   2. Session attendance rate: ≥ 50% of participants would attend at least four sessions.
   3. Retention rate: ≥ 70% of participants would complete the outcome assessments at immediate post-intervention.

2. Acceptability

   The intervention acceptability was defined as 70% of participants reporting strongly agree or agree with the intervention across key domains in the questionnaire (e.g., overall satisfaction, session duration, delivery format).

Methods

Study design

This study used a single-group, pre-test and post-test study design. This pilot study followed the Consolidated Standards of Reporting Trials (CONSORT) extension pilot and feasibility guidelines, with the primary aim to assess the feasibility and acceptability of the six-session MSC intervention among TGD individuals. A formal sample size calculation for hypothesis testing was not conducted. A target sample of 15–20 participants was set to provide sufficient data to evaluate feasibility and to inform future pilot RCT.

This study was conducted in accordance with the Declaration of Helsinki. Participants’ voluntary participation, privacy, and confidentiality were assured. This study was approved by the Research Ethics Committee of the Hong Kong Metropolitan University (Ethical approval no.: HE-RGC2024/NHS14).

Participants

Inclusion criteria: 1) aged 18 years or above; 2) self-identified as a TGD individual (an umbrella term for a gender other than that assigned at birth, including transgender man, transgender woman, and gender non-binary people); 3) sufficient comprehension of Cantonese; 4) currently living in Hong Kong; and 5) able to provide informed consent.

Exclusion criteria: 1) currently experiencing psychosis; 2) having an intellectual disability; 3) experiencing current suicidal ideation; 4) participation in a similar study or having received similar services in the past year.

The median age of the 17 participants was 24 years (IQR: 21–30). Most participants were current students (n = 9) and had received or were receiving a university education (n = 15). 14 participants reported a personal monthly income below HK$10,000 (≈ US$1,280). Eight were living in public rental housing. In terms of sexual orientation, the majority were attracted to women (n = 9), and 12 were not in a current intimate relationship. Nine participants identified as having no religion. All participants had received consultations related to gender identity issues. 14 were undergoing gender-affirming hormone treatment, six had received gender-affirming surgery, and four were enrolled in gender-affirming voice therapy (See Table 1 Characteristics of the participants).

Table 1.

Characteristics of the participants

ID	Age	Gender identity	Sexual orientation	Education	Religiosity	Occupational status	Personal income (monthly, HKD)	Housing	Current intimate relationship	Gender-affirming treatment received
1	29	Trans woman	Attracted to women	Tertiary	No	Unemployment	<10,000	Private house	No	Consultation; GAHT; voice therapy
2	23	Trans woman	Attracted to women	Tertiary	Atheism	Student	<10,000	Public rental housing	No	Consultation; GAHT
3	27	Trans man	Attracted to men	Tertiary	No	Student	<10,000	Private housing	No	Consultation; GAHT
4	23	Trans man	Attracted to women	Tertiary	No	Student	<10,000	Public rental housing	Yes	Consultation; GAHT; bilateral mastectomy
5	21	Trans woman	Attracted to women	Tertiary	No	Student	<10,000	Public rental housing	No	Consultation
6	23	Trans woman	Pansexual	Tertiary	No	Student, part-time employment and	<10,000	Private housing	No	Consultation; GAHT; voice therapy
7	19	Gender non-binary	Attracted to women	Secondary	Catholicism	Self-employment	<10,000	Private housing	No	Consultation; GAHT
8	24	Gender non-binary	Pansexual	Tertiary	No	Self-employment	10,000-19,000	Public rental housing	Yes	Consultation;
9	30	Trans man	Attracted to women	Tertiary	Buddhism	Full-time employment	10,000-19,000	Public rental housing	No	Consultation; GAHT; bilateral mastectomy; phalloplasty
10	30	Trans man	Attracted to men	Tertiary	No	Full-time employment	>40,000	Private housing	Yes	Consultation; GAHT; bilateral mastectomy
11	27	Trans man	Attracted to women	Tertiary	Christianity	Unemployment	<10,000	Public rental housing	No	Consultation; GAHT; bilateral mastectomy; hysterectomy with bilateral salpingo-oophorectomy
12	19	Gender non-binary	Pansexual	Tertiary	Atheism	Student	<10,000	Student dormitory	Yes	Consultation
13	36	Trans man	Attracted to women	Tertiary	No	Self-employment	<10,000	Private housing	Yes	Consultation; GAHT; bilateral mastectomy
14	21	Trans woman	Pansexual	Tertiary	Christianity	Student	<10,000	Public rental housing	No	Consultation; GAHT; voice therapy
15	24	Trans man	Attracted to women	Tertiary	No	Student	<10,000	Private housing	No	Consultation; GAHT; bilateral mastectomy
16	19	Trans woman	Unknown	Tertiary	Atheism	Student	<10,000	Public rental housing	No	Consultation; GAHT
17	39	Trans woman	Pansexual	Secondary	Christianity	Unemployment	<10,000	Private housing	No	Consultation; GAHT; voice therapy

^#GAHT: Gender affirming hormone therapy

Procedure

From December 2024 to January 2025, convenience and snowball sampling methods were used to recruit participants with support from two local non-governmental organizations (NGOs) (i.e., Gender Empowerment and Quarks). They posted the project posters on their online platforms (e.g., Instagram, Facebook, and Twitter) and in the private TGD WhatsApp group. Interested participants were invited to complete an anonymous initial screening test via Qualtrics^XM (www.qualtrics.com), accessible only to the principal investigator (PI). The participants agreed to provide their email addresses or phone numbers for the research team’s follow-up. The PI then contacted all enrolled participants after the initial screening test and conducted a phone call with them to ensure their eligibility. Those who met the eligibility criteria were subsequently invited to take part in the intervention. After receiving their consent, a research assistant would conduct further follow-up. For enrolled participants who were ineligible, the PI also reached out to them, referring them to NGOs and providing information about mental health hotlines and services.

In total, 35 people enrolled. Of these, six people with recent suicidal ideation who were receiving follow-up care from NGOs or governmental mental health services were excluded. Among the remaining 29 eligible participants, nine had scheduled conflicts, and three could not be contacted. Finally, 17 participants provided written informed consent and participated in the MSC intervention, including seven transgender men, seven transgender women, and three gender-fluid individuals.

All of them completed the baseline and post-intervention assessments (See Fig. 1 CONSORT flow diagram).

Fig. 1.

Flow diagram

Intervention

The intervention was adapted from the established eight-session MSC curriculum [15] and the six-session MSC intervention for breast cancer survivors with negative body image [16]. The eight-session MSC included the following topics: general introduction of self-compassion (week 1), foundation knowledge of mindfulness (week 2), application of self-compassion in various aspects of life (week 3), development of a compassionate inner voice (week 4), the importance of living with core values (week 5), skills to deal with difficulty emotions (week 6), challenging interpersonal relationships (week 7), and relating to positive aspects of oneself and one’s life in appreciation (week 8) [15].

Chen et al. adapted the eight-session MSC into a six-session intervention for breast cancer survivors with negative body image [16]. The content and exercises remained similar to the standard eight-session program, and this six-session format demonstrated effectiveness in self-compassion and negative body image among breast cancer survivors. To further adapt this six-session MSC for the TGD individuals in the present study, adaptations were made in collaboration with a certified MSC trainer and a TGD leader from a local NGO serving the TGD community. Prior to the intervention, the research team and the MSC trainer briefed the TGD leader on key concepts of the MSC intervention. The TGD leader provided guidance on using gender-affirming language and maintaining sensitivity around body image and emotions during the intervention.

Participants received a group-based, face-to-face MSC intervention comprising six consecutive weekly sessions, each lasting 90 min. Each session included an introduction, sharing personal experience of self-compassion, guided exercises, group discussions, and home practice. All six sessions were conducted in a classroom of the researcher’s university during six consecutive Saturdays from December 2024 to January 2025.

The content of the intervention was as follows:

• Session 1 introduced self-compassion concepts and their importance for mental health. Participants engaged in compassionate meditation and reflective writing on “How do I treat a friend?” Home Practice: Journal of self-criticism moments and reframe them with self-compassion.

• Session 2 presented the scientific evidence on the association between self-compassion and physiological outcomes and provided mindfulness practices and self-compassion skills. Participants were guided to observe their thoughts without judgment. Self-compassion skills, such as touch and breaks, were taught. Home Practice: Daily mindfulness practice.

• Session 3 explored the impact of self-compassion components and self-criticism. Participants practiced compassionate experiences of self-talk and shared self-kindness. Home Practice: Integrate self-compassionate thoughts into daily routines and reflect on experiences.

• Session 4 deepened self-compassion in a supportive environment. Activities included body scanning, foot meditation, compassionate breathing, and mindful walking. Home Practice: Write a self-compassion letter to oneself.

• Session 5 addressed self-compassion, which involved caring for oneself and others. The session highlighted the importance of addressing difficulties with self-compassion and developing the ability to offer compassion to others while maintaining emotional boundaries. Guided practices, including compassionate listening, giving and receiving compassion, and calm compassion exercises, were practiced. Home Practice: Practice compassionate listening daily.

• Session 6 explored personal core values and their alignment with self-compassion. Participants shared experiences and insights from the course. Strategies for continued self-compassion practice were introduced.

Please see the supplementary document for a more detailed description of the intervention.

The intervention was delivered by a certified MSC trainer and facilitated by the first author. Each participant HK$50 (≈ US$ 6.38) in cash for attending each session of the MSC intervention, covering transportation costs, with a maximum of HK$ 300 (≈ US$ 38.29).

Data collection

Participants’ demographic information, including age, gender assigned at birth, gender identity, sexual orientation, education, occupation, marital status, religion, personal monthly income, type of housing, and history of gender-affirming treatments, was collected at baseline (T₀).

The feasibility outcomes were collected using screening logs and study registers. The acceptability of the intervention was collected after the intervention (T₁). The secondary outcome measurements, including self-compassion, internalized stigma, self-esteem, body objectification, body appreciation, anxiety, and depression, were collected at baseline (T₀) and immediate post-intervention (T₁). Details of the quantitative measurements were listed below.

Quantitative measurements

Primary outcomes

The primary outcomes were the feasibility and acceptability of the MSC intervention. The feasibility was assessed using the recruitment rate (i.e., the number of recruited participants among eligible participants), the attendance rate (i.e., the number of sessions attended divided by the total number of sessions), and the retention rate (i.e., the number of participants who completed the outcome measurements after the MSC intervention).

The acceptability of the MSC intervention was evaluated using a 10-item questionnaire with a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), including perceptions of the frequency and number of the workshop sessions, the delivery mode, and overall satisfaction. The details of the items are shown in Table 2.

Table 2.

Acceptability of the workshop

Items	Strongly disagree /disagree	Neutral	Strongly agree/agree
1. The frequency of the workshop (once a week) is suitable for me.	0 (0.0%)	4 (23.5%)	13 (76.5%)
2. The duration of each class (90 minutes each) is suitable for me.	3 (17.6%)	2 (11.8%)	12 (70.6%)
3. The duration of the workshop (6 weeks) is suitable for me.	3 (17.6%)	5 (29.4%)	9 (52.9%)
4. I prefer to attend in-person workshops.	1 (5.9%)	4 (23.5%)	12 (70.6%)
5. I prefer to attend workshops in a small group format.	1 (5.9%)	5 (29.4%)	11 (64.7%)
6. I can apply what I learn in the workshop to cope with stress and challenges in life.	0 (0.0%)	6 (35.3%)	11 (64.7%)
7. I would recommend this workshop to other TGD friends.	0 (0.0%)	5 (29.4%)	12 (70.6%)
8. I am satisfied with the instructor’s explanations.	2 (11.8%)	2 (11.8%)	13 (76.5%)
9. I am satisfied with the arrangements made by the research team.	1 (5.9%)	1 (5.9%)	15 (88.2%)
10. Overall, I am satisfied with this workshop.	2 (11.8%)	1 (5.9%)	14 (82.4%)

Secondary outcomes

Self-compassion

Self-compassion was measured using the short version of the self-compassion scale, consisting of 12 items across six subscales: self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification [25]. Each item was rated on a 5-point Likert scale (1 = almost never, 5 = almost always), with higher scores indicating greater self-compassion. The scale has demonstrated good internal consistency in Chinese sexual minorities (Cronbach’s alpha = 0.87) [26].

Internalized stigma

The internalized stigma was measured using the Chinese version of the 9-item self-stigma scale [27], which assesses the cognitive, affective, and behavioral components of internalized stigma. Each item was rated on a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree), with higher scores indicating greater internalized stigma. This scale has demonstrated excellent reliability in Chinese sexual minorities (Cronbach’s alpha ranged = 0.92) [27].

Self-esteem

Self-esteem was measured using the 10-item Rosenberg Self-esteem Scale (RES) [28]. Each item was assessed on a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree), with higher scores indicating greater self-esteem. The RES had demonstrated good reliability in Chinese transgender women (Cronbach’s alpha = 0.81) [29].

Body objectification

Body objectification was measured using the 14-item Objectified Body Consciousness Scale (OBCS), which consisted of two subscales: body surveillance and body shame. Each item was rated on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree), with higher scores indicating greater body surveillance or body shame. The OBCS has demonstrated acceptable to good reliability in Chinese people (Cronbach’s α = 0.80–0.81 for body surveillance, and 0.70 for body shame) [30].

Body appreciation

Body appreciation was measured using the 10-item Chinese version of the Body Appreciation Scale (BAS-2). Each item was rated on a 5-point Likert scale, ranging from 1 (never) to 5 (always), with higher scores indicating greater body appreciation. The scale has good reliability in the Chinese population (Cronbach’s α = 0.89) [31].

Anxiety

Anxiety was measured using the 7-item Generalized Anxiety Disorder Scale (GAD-7) [32]. Each item was rated on a 4-point Likert scale (0 = not at all, 3 = nearly every day), with higher scores indicating greater anxiety. The scale has demonstrated excellent reliability in the Chinese population (Cronbach’s α = 0.922) [33].

Depression

Depression was measured using the Chinese version of the 9-item Patient Health Questionnaire (PHQ-9). Each item was rated on a 4-point Likert scale (0 = not at all, 3 = nearly every day), with higher scores indicating greater depression. The scale has demonstrated good reliability in the Chinese population (Cronbach’s α = 0.82) [34].

Qualitative interview

Within two weeks of completing the six-session MSC intervention, semi-structured individual interviews were conducted with 13 participants to evaluate their overall experiences of the intervention in a meeting room at a university in Hong Kong or via Zoom, whichever was convenient for the participants.

The semi-structured interview guide was developed by the PI, a qualitative researcher with training in nursing, public health, sexuality education, and sexuality counseling. Interview questions focused on participants’ overall experiences of the intervention, their perceived benefits and limitations, and recommendations for further improvement. Example questions included: “How is your overall experience of the intervention?” “Which part of the MSC training did you find useful? How did you incorporate them in your life?” and “Which parts were not useful or should be removed?” The average interview duration was 72 min. Participants who took part in the individual interview received HK$200 in cash as compensation for their time.

Data analysis

Quantitative data analysis

SPSS statistical package (version 25) was used to analyze quantitative data. The Kolmogorov-Smirnov normality test was performed prior to data analysis to examine the normality of the distribution of the continuous data. Descriptive analysis was used to describe the characteristics of the participants, and feasibility and acceptability measures. The Wilcoxon signed-rank test was used to assess within-participant pre-post changes in outcome measures. The effect size (r) was calculated using the formula r = Z/√N, with 0.1, 0.3, and 0.5 representing small, medium, and large effect sizes [35]. A p-value of < 0.05 was considered statistically significant.

Qualitative data analysis

Inductive thematic analysis, guided by the six-phase framework of Braun and Clarke (2006, 2022) [36, 37], was used to analyze the qualitative data. Audio recordings of the interviews were transcribed verbatim following each session. To ensure data-driven interpretations and to clarify how findings were derived, the following steps were taken: (1) Familiarization: Two researchers (HXM and YJM) immersed themselves in the data by reading the transcripts and field notes several times to obtain an overall picture. (2) Initial coding: The two researchers independently coded the data line-by-line, staying close to participants’ own words to ensure the coding was grounded in the data. (3) Theme development: These initial codes were subsequently sorted, compared, and grouped into potential themes. This was an iterative process, with researchers constantly returning to the original transcript to ensure the emerging themes remained grounded in participants’ accounts. (4) Consensus coding: The two researchers compared their coding decisions and themes, and resolved any discrepancies through discussions with the research team. (5) Reporting: Supporting verbatim quotes were presented to illustrate the findings. NVivo software was used to support the coding process. Strategies, such as member checking, peer debriefing, and maintaining an audit trail, were used to ensure the trustworthiness of the data analysis results.

Results

Quantitative data

Acceptability

Participants’ acceptability of the workshop is presented in Table 2. The predefined acceptability criterion of at least 70% agreement was met for most domains, including overall satisfaction, which was endorsed by 82.4% of the participants. Moreover, over 70% agreed or strongly agreed with the frequency and duration of each session, the face-to-face delivery format, the instructors’ explanations and the research team’s arrangement, and would recommend the MSC training to their friends. However, satisfaction with the overall workshop duration of six weeks was lower, with only 52.9% endorsing this item, which did not meet the 70% criterion. Additionally, 64.7% preferred attending the workshop in small groups and felt they could apply what they learned in their daily lives, and this domain was also fell below the 70% criterion.

Feasibility

Regarding H1, all predefined feasibility criteria were achieved. Of the 35 people enrolled, 17 eligible TGD participants took part in the MSC training, resulting in a 48.6% recruitment rate (meeting the predefined ≥ 40% criterion). The average attendance rate was 74.5%, equivalent to an average attendance rate of 4.5 (SD: 1.7) sessions out of six sessions. Although only two participants attended the first session, nine attended at least five sessions (52.9%, meeting the ≥ 50% criterion), and seven completed all six sessions. All the participants completed the baseline and the post-test questionnaire, achieving a 100.0% retention rate (meeting the ≥ 70% criterion).

Preliminary effectiveness

Regarding H2, preliminary effectiveness was partially supported. The Wilcoxon signed-rank test revealed statistically significant improvements in self-compassion (Z = -2.32, p = 0.02), self-esteem (Z = -2.82, p = 0.01), body appreciation (Z = -2.09, p = 0.04), along with a significant decrease in internalized stigma (Z = -2.49, p = 0.01) and body shame (Z = -1.98, p = 0.05) upon completion of the training. No significant changes were observed for body surveillance, anxiety, and depression. The effect sizes were large for self-compassion (r = 0.6), self-esteem (r = 0.7), internalized stigma (r = 0.6), body shame (r = 0.5) and body appreciation (r = 0.5), medium for body surveillance (r = 0.4) and depression (r = 0.4), and small for anxiety (r = 0.2) (See Table 3).

Table 3.

Comparison of pre and post outcome measurements by the Wilcoxon signed-rank test (N = 17)

Outcome measurement	Baseline median (IQR)	Post-test median (IQR)	Z	p value	Effect size  r
SCS	29.00 (26.00-38.00)	36.00 (28.00-43.00)	-2.322	0.020*	0.6
SSS	21.00 (19.00-25.00)	20.00 (18.00-23.00)	-2.493	0.013*	0.6
RES	15.00 (11.00-20.00)	19.00 (15.00-22.00)	-2.817	0.005*	0.7
OBCS-Body surveillance	35.00 (31.00-43.00)	36.00 (29.00-38.00)	-1.738	0.082	0.4
OBCS-Body shame	25.00 (19.00-31.00)	22.00 (19.00-28.00)	-1.980	0.048*	0.5
BAS-2	27.00 (23.00-30.00)	31.00 (27.00-34.00)	-2.085	0.037*	0.5
GAD-7	8.00 (2.00-10.00)	6.00 (4.00-10.00)	-0.958	0.338	0.2
PHQ-9	9.00 (5.00-16.00)	7.00 (3.00-9.00)	-1.708	0.088	0.4

IQR Interquartile range, SCS Self-compassion scale, RES Rosenberg Self-esteem Scale, SSS Self-stigma scale, OBCS Objectified Body Consciousness Scale, BAS-2 Body appreciation scale, GAD-7 Generalized Anxiety Disorder Scale, PHQ-9 Patient Health Questionnaire

 *p < 0.05

Qualitative data

Acceptability of the MSC training

Thematic analysis identified four themes from semi-structured individual interviews: (1) Redefine the self: From isolation to shared humanity. (2) The promise and limits of social connection. (3) Adapting the intervention for greater flexibility and impact. (4) Sustaining impact through peer-led support networks.

Theme 1: redefine the self: from isolation to shared humanity

Participants described a shift from feelings of isolation to feeling a sense of collective belonging. By meeting with others with similar experiences and examining the concept of common humanity, several participants reframed their personal struggles as collective experiences within the TGD community. The process reduced self-criticism and encouraged the development of relationships with others. One participant shared:

Meeting others with similar experiences helped me feel less lonely. Recognizing our common humanity, a core element of self-compassion, helped me see that I am not an alien. The gender identity issues, body image, mental health, and family relationship issues I struggle with are also concerns for other TGD friends, and that made me feel connected.” (#1, trans woman, 29y).

Participants also developed a new relationship with their emotions, learning to acknowledge them rather than suppress them. They valued the training program that offered a specific environment conducive to both self-reflection and the cultivation of self-compassion. One participant commented:

I am grateful for the chance to slow down, to reflect, and to be kind to myself (#9, trans man, 30y).

Many participants highlighted the experiential exercises and group discussions as helping them apply self-compassion skills into their daily lives, such as breathing exercises, mindfulness practices, and compassionate self-touch. For example:

The training is highly practical. It was the first time during my transition that I used compassionate self-touch. It gave me a feeling of companionship. Rather than seeking external validation, I have cultivated internal sovereignty and kindness to myself (#8, gender non-binary, 24y).

Together, these accounts suggested that opportunities for shared reflection and skills practice might help participants develop a more adaptive and compassionate relationship with themselves.

Theme 2: the promise and limits of social connection

The participants commonly reported that the training program provided them with an invaluable opportunity to connect with other TGD individuals, which they felt reduced feelings of loneliness and isolation and increased a sense of safety in social situations. One participant who enjoyed the mindful walking stated:

Walking mindfully with the group acted like a psychological shield, protecting against the feelings of being watched by others. (#1, trans woman, 29y)

While the vast majority praised the face-to-face format for fostering community, two participants identified it as a challenge, particularly in relation to self-consciousness and hyper-vigilance during social interactions. One participant who was in the early transition felt “out of place”, while another, who had completed their transition, described feelings of shame and discomfort at being visibly part of a TGD group. For example:

I thought I was passed after conducting the gender affirming surgery, and would be treated as a “cisgender” person. When I walked into the room and saw other TGD individuals who looked like me, I felt so pitiful about them and myself. (#5, trans woman, 21y)

These contrasting accounts indicated that while peer connection was experienced as beneficial by the majority, group visibility could also intensify discomfort for some, highlighting the need for flexibility in delivery and additional psychological safety strategies.

Theme 3: adapting intervention for greater flexibility and impact

While participants generally expressed satisfaction with the intervention, they also identified important areas for improvement to better meet the needs of TGD individuals. A central request was to include more TGD-specific content, such as issues related to body image and gender identity. As one participant stated,

The training on self-reflection and self-kindness is valuable, but I believe we need content that directly addresses our specific challenges (#10, trans man, 30y).

The majority of the participants agreed that an in-person training session was more beneficial than other forms, offering enhanced engagement and a stronger connection. Nevertheless, a few participants commented that some TGD individuals may experience multiple mental health conditions, such as the comorbidity of autism and gender dysphoria, internalized stigma, and depression, which could complicate social interactions. Moreover, the physical presence of others, especially within a marginalized group, could be overstimulating. They suggested that an online format or blended training mode could improve accessibility and psychological safety. As one participant said,

I find in-person interactions exhausting because of my social anxiety. An online format might be more flexible and accessible, allowing me to engage in a space where I feel safe. (#3, trans man, 27y)

Furthermore, many participants commented on the session structure and timing. Some felt that the 90-minute training sessions did not allow sufficient time for in-depth group discussions and suggested fewer, longer duration sessions to support deeper reflection and exchange. As one participant remarked,

We need more time to dive into these topics. We can reduce the number of sessions while extending each session to allow for richer conversations and deeper understanding. (#10, trans man, 30y)

Taken together, these accounts suggested that increasing TGD-specific content and offering flexible delivery and session structure may enhance fit and accessibility across participants with varying needs and comfort levels.

Theme 4: sustaining impact through peer-led support networks

Participants described a desire for continued support after the intervention, particularly because self-compassion practices sometimes brought difficult emotions and long-standing challenges to the surface. Some participants suggested that structured opportunities for post-session or post-program debriefing could help them process these experiences. A participant suggested:

Following the training, some participants may need time for “de-briefing”. It would be beneficial to engage in discussions or debriefing with peers after the exercises (#6, trans woman, 23y).

Participants also described peer support as potentially valuable because peers were perceived as more likely to understand TGD-specific experiences. Building on this, some participants proposed integrating peers into the training program or extending the training to peers or frontline workers to broaden support within the community. As one participant proposed,

If there were a peer involved in the training, or if they received training themselves - perhaps through a simple component like writing a compassion letter from a friend’s perspective or engaging in compassionate gestures - it could have a significant impact. (#11, trans man, 27y)

These accounts indicated that peer-led or peer-augmented components could help sustain intervention gains and strengthen ongoing community-based support beyond the workshop.

Discussion

To the best of our knowledge, this is the first MSC intervention to examine the feasibility, acceptability, and preliminary effectiveness of the MSC intervention on self-compassion, body image, and mental health among TGD individuals in Hong Kong. Findings from this pilot study demonstrated feasibility among TGD individuals in Hong Kong, as demonstrated by the attendance rate (74.5%) and completion rate (100.0%). Additionally, qualitative data revealed that participants found the program helpful, highlighting the potential of MSC training for this marginalized population.

The findings suggested that the MSC intervention was generally well received by participants, as evidenced by an attendance rate of 74.5% and a 100% completion rate for outcome assessments. The face-to-face format allowed meaningful interactions and a sense of community, which was particularly valuable for this population. However, the recruitment rate was 48.6%, while meeting this study’s a priori criteria of 40%, highlighting challenges in engaging TGD individuals in research. Around 25.7% of potential participants cited scheduling conflicts with the intervention sessions, suggesting structural barriers. Qualitatively, participants noted that while face-to-face format sessions facilitated a sense of community, they also highlighted that such an approach might limit participation among individuals with difficulties in social interaction, co-morbidities, or constraints on their time due to transportation or other logistical issues. Future research may explore more flexible delivery modes, such as online or asynchronous options, to enhance accessibility.

The findings from this study highlighted the potential benefits of MSC interventions in addressing the unique challenges faced by TGD individuals, such as internalized stigma and body image concerns. The observed medium to large effect sizes in measures of internalized stigma, self-esteem, and body appreciation were consistent with a review that found self-compassion interventions yielded small to moderate effects on reducing body dissatisfaction compared to control groups in both eating disorder and general population samples [38]. Additionally, meta-analyses of cross-sectional studies have indicated that self-compassion is associated with lower levels of internalized stigma in sexual and gender minority populations. These results suggest the need for further exploration of MSC as a therapeutic approach to supporting self-esteem and positive body image within the TGD community. Additional research is needed to replicate these findings and explore the mechanisms through which self-compassion interventions can enhance the well-being of TGD individuals.

Contrary to the previous systematic reviews indicating that self-compassion-related interventions lead to significant improvements in mental health outcomes across diverse populations [39], our study did not observe significant improvements in anxiety and depressive symptoms. This discrepancy might be attributed to several factors. First, the small sample size (N = 17) may have limited our ability to detect statistically significant changes, particularly for anxiety, which showed only a small effect size (r = 0.2). Second, self-compassion interventions, such as MSC, may have a delayed effect on mental health, as cultivating self-compassion can be a gradual process. It is possible that the duration of our intervention may have been insufficient to capture the long-term benefits [40, 41]. Third, our qualitative data suggested a more nuanced explanation. For two participants, the intervention acted as a forced confrontation with being a part of the community, eliciting shame through social comparison. This internal hierarchy may have temporarily heightened distress, consistent with literature documenting intra-community stigma among TGD individuals [42]. These findings suggest that MSC intervention for TGD individuals may not be a linear process of feeling better, but rather a complex journey of processing long-standing stigma that may require longer follow-up. Further research with a larger sample size, longer follow-up periods, and rigorous study designs, such as RCT, is needed to better understand the effectiveness of the MSC intervention on mental health.

Implications

This pilot investigation has implications for the development and implementation of MSC training initiatives specifically tailored for TGD individuals, particularly in non-Western contexts such as Hong Kong. The findings suggest that MSC interventions could play a vital role in addressing internalized stigma and body image concerns that are prevalent among TGD individuals. Mental health practitioners should consider integrating MSC techniques into their practice to help TGD clients cultivate self-acceptance and resilience.

Moreover, implementing a train-the-trainer strategy among peers could be an effective approach to promoting mental health within the TGD community. This strategy not only empowers individuals but also fosters community support, creating a safe environment where TGD individuals can share their experiences and resources. NGOs can play a vital role in facilitating this process.

In addition, our study underscores the need for recognition of TGD individuals’ mental health needs within healthcare systems. Policymakers and mental health organizations should prioritize the development of inclusive mental health programs that incorporate evidence-based practices like MSC. By enhancing access to these interventions, we can improve the overall well-being of TGD individuals and reduce health disparities within this population.

Strengths and limitations

TGD individuals represent a population that is often marginalized and faces substantial barriers in their gender identity journey. They grapple with complex issues, such as discrimination, prejudice, internalized stigma, low self-esteem, body image concerns, and mental health challenges. Our study provided valuable insights that can inform the development of more tailored interventions to address the unique needs of this population. Also, the mixed-methods design allowed for a comprehensive understanding of both quantitative and qualitative outcomes and the experiences of the participants, providing rich contextual data that informs further intervention refinement.

However, several limitations of the study merit consideration. First, the relatively small sample size may have constrained the statistical power to detect significant differences, particularly in mental health outcomes. Second, the study design focused on a single post-intervention assessment, which may not fully capture the long-term effects of the mindful self-compassion intervention. Third, the absence of a control group limits the ability to determine the effectiveness of the intervention.

Conclusion

In conclusion, the present study provided encouraging evidence for the potential of MSC interventions to enhance self-compassion, self-esteem, and body appreciation, while also reducing internalized stigma and body shame among TGD individuals in Hong Kong. Future research with larger sample sizes, longer follow-up durations, and RCT designs is recommended to evaluate the long-term impacts of the intervention. Additionally, self-compassion-based interventions customized to the specific needs of the TGD population should be considered. Exploring more flexible delivery modes, such as fully online, hybrid, or asynchronous models, for these interventions is also advised to increase their accessibility and adaptability.

Authors’ contributions

HXM: Conceptualization, Data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing-original draft, writing-review and editing.YJM: Conceptualization, formal analysis, writing-review, and editing.JBH: Writing-review and editing.SG: Writing-review and editing.JYHW: Writing-review and editing.

Funding

This work was supported by the Hong Kong Metropolitan University R&D Fund (Project reference no.: PFDS/2024/25).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of the Hong Kong Metropolitan University (Ethical approval no.: HE-RGC2024/NHS14). Written informed consent was obtained from all study participants.

Consent for publication

All participants provided their written consent for publication.

Competing interests

The authors declare no competing interests.