Abstract
Background
Chinese transgender individuals seeking gender-affirming surgery (GAS) face legal, familial, and healthcare barriers, yet data on their psychological characteristics and surgical motivations remain limited. This exploratory study examined personality traits, defense styles, and self-reported motivations in a Chinese clinical sample.
Methods
In this cross-sectional study, 37 transgender individuals (transmasculine participants, n = 25; transfeminine participants, n = 12) completed the Eysenck Personality Questionnaire (EPQ), Defense Style Questionnaire (DSQ), and a self-developed GAS-related questionnaire. EPQ scores were compared with Chinese national normative values in an exploratory manner using Wilcoxon signed-rank tests. Associations between EPQ and DSQ dimensions were examined using Spearman correlations with false discovery rate correction. Findings from the self-developed questionnaire were analyzed descriptively.
Results
In exploratory comparisons with Chinese national norms, participants showed lower Extraversion (p < 0.001), higher Neuroticism (p = 0.012), and higher Lie scores (p < 0.001), while Psychoticism did not differ significantly (p = 0.976). After FDR correction, Neuroticism remained positively associated with immature defenses (ρ = 0.646, FDR-adjusted p < 0.001), middle defenses (ρ = 0.468, FDR-adjusted p = 0.032), and hidden defenses (ρ = 0.428, FDR-adjusted p = 0.043). Descriptive questionnaire findings indicated that common motivations included enhancing self-confidence, changing the gender marker on official identification documents, and increasing social acceptance. Cronbach’s α was 0.82 for the Likert-type domains, with subscale values ranging from 0.78 to 0.85.
Conclusion
This exploratory study provides preliminary insights into personality traits, defense styles, and self-reported motivations among Chinese transgender individuals seeking GAS. The findings contribute context-specific descriptive data to the existing literature and may inform future research using larger, multicenter samples, appropriately matched comparison groups, and validated assessment instruments.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s40359-026-05204-y.
Keywords: Gender identity, Gender-affirming surgery, Psychosocial, Chinese
Introduction
Gender identity (GI) and gender dysphoria (GD) are central concepts in transgender research [1, 2]. GI refers to an individual’s internal and deeply-held sense of their gender, which may or may not align with the sex assigned at birth. In contrast, GD is characterized by a marked incongruence between an individual’s experienced/expressed gender and their sex assigned at birth [3]. Recent years have witnessed a global rise in GD diagnoses, particularly among adolescents and young adults [4]. For instance, German national health insurance data (2013–2022) show that outpatient GD (ICD-10 F64) diagnoses among individuals aged 5–24 increased from approximately 22.5 per 100,000 persons in 2013 to 175.7 in 2022, an almost 8-fold rise, especially among females aged 15–19 [5]. In the United States, the Williams Institute estimates that 0.7% of adults aged 18–24 identify as transgender, a higher rate than in other age groups (0.5%–0.6%) [6]. These demographic trends reflect both greater visibility and increasing demand for gender-affirming medical interventions, including psychosocial support, puberty suppression, hormone therapy, and gender-affirming surgery (GAS).
Although transgender identity is not inherently pathological, GD can be associated with substantial psychological distress when untreated. An emerging research focus is the intersection of GD with neurodevelopmental conditions, especially autism and GD. Approximately 11% of individuals diagnosed with GD also meet criteria for autism [7], and even in autistic and non-autistic gender-diverse individuals, elevated levels of autistic traits are reported [8]. These findings underscore the importance of tailoring interventions to patients’ diverse cognitive and emotional needs.
Among the treatment options, GAS plays a pivotal role in reducing gender incongruence and improving psychological well-being [9, 10]. Large cohort studies report that GAS is associated with significant reductions in anxiety, depression, suicidal ideation, and social isolation, alongside improvements in quality of life and gender congruence. Qualitative studies also report improvements in patient-reported satisfaction and quality of life [11–13]. However, the psychological benefits of surgery are not uniform. The outcomes are often shaped by individual-level factors, including surgical motivation, mental health status [14], and expectation [15]. Yet these have received limited attention in the surgical literature.
In many Asian societies, including China, transgender people are often required to obtain a formal psychiatric diagnosis of gender dysphoria, secure family consent, and navigate complex pre-surgical evaluations before accessing GAS, contributing to significant psychosocial burden and delays in care. Existing epidemiological studies also highlight high prevalence of depression, anxiety, and psychological distress among transgender and gender-diverse adults in China, underscoring the importance of understanding the mental health and personality profiles that shape surgical motivations [16, 17]. Such psychological dimensions are not only clinically relevant but may also reflect broader minority stress processes, wherein social stigma, internalized transphobia, and ongoing threat of discrimination contribute to adverse psychological outcomes and heightened urgency for body-aligned medical interventions [18, 19]. In China, transgender individuals face complex legal, familial, and healthcare barriers to accessing gender-affirming surgery, including mandatory psychiatric evaluation, family consent, and limited clinical resources. Despite growing awareness, empirical data on personality traits, defense mechanisms, and surgical motivations remain scarce. This study addresses this gap by exploring psychosocial factors influencing Chinese transgender individuals’ decision-making regarding surgery, providing culturally contextualized insights that complement existing Western-focused research [20].
Personality traits and intra-psychic defense mechanisms represent two major psychological constructs that have been linked to coping, stress responses, and decision-making in diverse clinical populations. The Eysenck Personality Questionnaire (EPQ) provides a robust measure of core personality traits—including Extraversion, Neuroticism, Psychoticism, and Lie—which have been associated with differential stress reactivity and social adaptation [21]. Similarly, defense style questionnaires (DSQ) assess patterns of psychological defenses ranging from mature to immature coping strategies [22]. Prior research suggests that individuals with higher neuroticism or more immature defense styles may be more vulnerable to psychological distress and maladaptive coping, which could shape their motivations to seek medical interventions such as GAS. Although these constructs have been extensively studied in general populations, their application to transgender people seeking GAS—particularly in the Chinese context—remains under-explored.
This study aims to investigate the personality traits, defense styles, and surgical motivations among Chinese individuals seeking GAS, and to clarify how these psychological dimensions relate to each other. By employing non-parametric statistical methods appropriate for small samples, we compared personality profiles with national normative data and examined correlations between personality traits and defense mechanisms. The findings may provide preliminary context for future research on psychosocial characteristics and self-reported motivations among Chinese transgender individuals seeking gender-affirming surgery.
Materials and methods
Participants
Participants were recruited consecutively from individuals presenting to the gender-affirming surgery service between April 2013 and April 2015. A total of 37 individuals seeking GAS at the Department of Plastic and Reconstructive Surgery, Shanghai Changzheng Hospital, were enrolled (Transmasculine participants, n = 25; Transfeminine participants, n = 12; age 19–46 years). Inclusion criteria were: (1) Age ≥ 18 years; (2) Formal GD diagnosis by licensed mental health professionals using DSM-5 criteria, based on structured interviews; (3) Absence of severe or unstable psychiatric comorbidities that would preclude participation or substantially confound psychosocial assessment. During the study period, 85 individuals were contacted, and 60 responded to initial screening. Of these, 50 were assessed for eligibility; 6 were excluded due to comorbid psychiatric disorders, and 7 declined participation. The remaining 37 participants provided written informed consent and were included in the final analysis (Fig. 1).
Fig. 1.
Participant recruitment flowchart. Notes: This flowchart illustrates the participant recruitment and clinical screening process in the study of Chinese transgender individuals seeking gender-affirming surgery or subsequent GAS-related procedures
For terminology, we use “transmasculine participants” to refer to individuals assigned female at birth who sought masculinizing gender-affirming surgery, and “transfeminine participants” to refer to individuals assigned male at birth who sought feminizing gender-affirming surgery. These terms were used to preserve the original analytic grouping while adopting contemporary terminology.
Gender dysphoria (GD) diagnosis and preoperative screening
All participants were formally assessed for gender dysphoria by licensed psychiatrists or clinical psychologists with specialized training in transgender healthcare, following DSM-5 diagnostic criteria [23]. The assessment included:
A structured clinical interview to confirm persistent incongruence between experienced gender and assigned sex at birth, and to assess associated distress or functional impairment.
Evaluation of psychiatric comorbidities, including mood disorders, anxiety disorders, and neurodevelopmental conditions, to determine eligibility for inclusion. Participants with severe comorbid psychiatric conditions were excluded to reduce confounding effects on psychosocial measures, consistent with prior studies reporting high comorbidity rates (~ 50%) in transgender populations.
Review of participants’ medical history, prior hormone therapy, and any prior mental health interventions.
A clinical screening protocol was implemented to document participants’ stage of consideration for gender-affirming surgery, including:
Individuals awaiting surgery or subsequent GAS-related procedures,
Individuals considering GAS or further GAS-related procedures,
Individuals receiving counseling or information sessions regarding surgical options.
A flow diagram illustrating participant recruitment, screening, inclusion/exclusion, and final sample for analysis is provided in Fig. 1. This diagram facilitates transparency regarding sample representativeness and screening decisions.
Psychosocial surveys and psychological tests
Psychological assessments were conducted within the clinical evaluation pathway for gender-affirming surgery. All questionnaires, including the sociodemographic questionnaire, GAS-related questionnaire, Eysenck Personality Questionnaire (EPQ), and Defense Style Questionnaire (DSQ), were administered once in a single pen-and-paper session at the time of clinical assessment. For participants who had not yet undergone core gender-affirming surgery, questionnaires were administered during the preoperative surgical evaluation. For participants who had already undergone one or more core GAS procedures before study enrollment, questionnaires were administered during evaluation for subsequent procedures or during follow-up assessment. Therefore, the questionnaire data reflected participants’ psychological and motivational characteristics at the time of assessment and should not be interpreted as uniformly preceding all surgical procedures.
The authors conducted a survey to collect sociodemographic and treatment-related information. Based on a literature review and clinical experience, two questionnaires were developed for this study and are provided in Supplementary 1.
Sociodemographic Questionnaire: This questionnaire collected information on age, education, religion, residence, employment, marital status, family background, and social activity.
GAS-related Questionnaire: This self-developed questionnaire collected information on the development of gender dysphoria, current psychiatric symptoms, histories of and concerns regarding surgical, endocrine, and psychological interventions, family and social support, surgical motivations, risk perception, reproductive planning, and information sources. The questionnaire had two parallel versions: one for participants before undergoing gender-affirming surgery and another for participants who had already completed one or two core GAS procedures. The questionnaire included categorical, multiple-choice, and Likert-type items. Descriptive frequencies reported in Tables 2, 3, 4 and 5 were based mainly on categorical and multiple-choice responses, whereas internal consistency estimates were calculated for Likert-type items within predefined domains.
Table 2.
Psychosocial information of the transgender individuals
| All (N = 37) | Transmasculine participants (N = 25) | Transfeminine participants (N = 12) | |
|---|---|---|---|
| Sex factor | |||
| Sexual attraction exclusively toward individuals with the same sex assigned at birth | 37 (100%) | 25 | 12 |
| Number of romantic relationships * | |||
| 0 | 9 (24.3%) | 6 | 3 |
| 1–5 | 25 (67.6%) | 17 | 8 |
| 6–10 | 1 (2.7%) | 1 | 0 |
| >10 | 2 (5.4%) | 1 | 1 |
| Number of sex partners* | |||
| 0 | 12 (32.4%) | 8 | 4 |
| 1 | 12 (32.4%) | 9 | 3 |
| 2 | 8 (21.6%) | 6 | 2 |
| 3 | 2 (5.4%) | 0 | 2 |
| 4 | 3 (8.1%) | 2 | 1 |
| Family factor | |||
| Family structure | |||
| One-child family | 15 (40.5%) | 10 | 3 |
| Multiple-child family | 22 (59.5%) | 15 | 9 |
| Most influential family member | |||
| Father | 5 (13.5%) | 4 | 1 |
| Mother | 20 (54.1%) | 14 | 6 |
| Siblings | 6 (16.2%) | 2 | 4 |
| None | 6 (16.2%) | 5 | 1 |
| Meaningfulness to have biological children | |||
| Great | 4 (10.8%) | 3 | 1 |
| Moderate | 2 (5.4%) | 1 | 1 |
| A little | 19 (51.4%) | 14 | 5 |
| None | 12 (32.4%) | 7 | 5 |
| Mental health factor | |||
| Time of gender identity incongruence | |||
| Childhood | 26 (70.3%) | 20 | 6 |
| Adolescence | 11 (29.7%) | 5 | 6 |
| Psychological inducement | |||
| From family | 7 (18.9%) | 5 | 2 |
| From society | 4 (10.8%) | 4 | 0 |
| From both | 3 (8.1%) | 1 | 2 |
| None | 23 (62.2%) | 15 | 8 |
| Previous mental problem* | |||
| Anxiety | 23 (62.2%) | 16 | 7 |
| Depression | 13 (35.1%) | 10 | 3 |
| Insomnia | 19 (51.4%) | 13 | 6 |
| Suicide attempt | 14 (37.8%) | 9 | 5 |
| Self-harm | 7 (18.9%) | 4 | 3 |
| Neurosis | 3 (8.1%) | 2 | 1 |
| Social phobia | 2 (5.4%) | 2 | 0 |
| None | 5 (13.5%) | 2 | 3 |
| Impact on daily life | |||
| Great | 17 (45.9%) | 13 | 4 |
| Moderate | 4 (10.8%) | 2 | 2 |
| A little | 5 (13.5%) | 2 | 3 |
| None | 11 (29.7%) | 8 | 3 |
Multi-choice or open-ended question; A denominator of 37 in calculation of all percent values.
Table 3.
Information about psychotherapy of the transgender individuals
| All (N = 37) | Transmasculine participants (N = 25) | Transfeminine participants (N = 12) | |
|---|---|---|---|
| Any knowledge? | |||
| Yes | 32 (86.5%) a | 22 | 10 |
| No | 5 (13.5%) a | 3 | 2 |
| Source of information* | |||
| Internet | 17 (50.0%) a | 14 | 3 |
| Media | 6 (18.8%) a | 3 | 3 |
| Books | 6 (18.8%) a | 6 | 0 |
| Physicians | 2 (6.3%) a | 2 | 1 |
| Family member | 7 (21.9%) a | 5 | 3 |
| Friend | 3 (9.4%) a | 2 | 1 |
| With knowledge, any treatment? | |||
| Yes | 19 (59.4%) b | 12 | 7 |
| No | 13 (35.1%) b | 10 | 3 |
| If treated, any effect on GD? | |||
| None | 19 (100%) c | 12 | 7 |
| If treated, any effect on general mental health? | |||
| Great | 1(5.3%) c | 0 | 1 |
| Moderate | 2(10.5%) c | 2 | 0 |
| A little | 5(26.3%) c | 2 | 3 |
| None | 11(57.9%) c | 8 | 3 |
*Multi-choice or open-ended question; a A denominator of 37; b A denominator of 32; c A denominator of 19
Table 4.
Information about hormone therapy of the transgender individuals
| All (N = 37) | Transmasculine participants (N = 25) | Transfeminine participants (N = 12) | |
|---|---|---|---|
| Any knowledge? | |||
| Yes | 26 (70.3%) a | 16 | 10 |
| No | 11 (29.7%) a | 9 | 2 |
| Source of information* | |||
| Internet | 16 (61.5%) a | 13 | 3 |
| Books | 7 (26.9%) a | 4 | 3 |
| Physicians | 7 (26.9%) a | 4 | 3 |
| Family member | 3 (11.5%) a | 0 | 3 |
| Friend | 3(11.5%) a | 0 | 3 |
| With knowledge, any treatment? | |||
| Yes | 10 (38.5%) b | 5 | 5 |
| No | 16 (61.5%) b | 11 | 5 |
| If treated, any guide from the physicians? | |||
| Yes | 3 (30.0%) c | 2 | 1 |
| No | 7 (70.0%) c | 3 | 4 |
| Route of administration | |||
| Oral | 7 (70.0%) c | 3 | 4 |
| Intramuscular | 2 (20.0%) c | 1 | 1 |
| Both | 1 (10.0%) c | 1 | 0 |
| If treated, what about the feminizing/masculinizing effect? | |||
| Great | 2 (20.0%) c | 1 | 1 |
| Moderate | 4 (40.0%) c | 2 | 2 |
| A little | 2 (20.0%) c | 1 | 1 |
| None | 2 (20.0%) c | 1 | 1 |
Table 5.
GAS-related information of the transgender individuals
| All (N = 37) | Transmasculine participants (N = 25) | Transfeminine participants (N = 12) | |
|---|---|---|---|
| Family support factor | |||
| Reason for previous objection from family member* | |||
| Worry about potential harm to health | 27 (73.0%) | 21 | 6 |
| Worry about loss of face | 11 (29.7%) | 8 | 3 |
| Production of genetic offspring | 5 (13.5%) | 3 | 2 |
| Affordability | 3 (8.1%) | 2 | 1 |
| Any additional condition for GA? | |||
| Yes | 1 (2.7%) | 1 | 0 |
| No | 36 (97.3%) | 24 | 12 |
| Surgery factor | |||
| Life period at knowing of GAS | |||
| Childhood (4–11 year) | 4 (10.8%) | 4 | 0 |
| Adolescence (12–17 year) | 14 (37.8%) | 9 | 5 |
| Adulthood (≥ 18 year) | 19 (51.4%) | 12 | 7 |
| Source of information about GAS* | |||
| Internet | 23 (62.2%) | 18 | 5 |
| Media | 11 (29.7%) | 7 | 4 |
| Books | 11 (29.7%) | 7 | 4 |
| Physicians | 1 (2.7%) | 1 | 0 |
| Family member | 1 (2.7%) | 1 | 0 |
| Friend | 2 (5.4%) | 1 | 1 |
| Previous core GASs | |||
| Yes | 17 (45.9%) | 12 | 5 |
| No | 20 (54.1%) | 13 | 7 |
| Motive for surgical intervention* | |||
| To enhance self-confidence | 29 (78.4%) | 18 | 11 |
| To change the ID card | 17 (45.9%) | 13 | 4 |
| To increase social acceptance | 14 (37.8%) | 9 | 5 |
| To please the romantic partner | 10 (27.0%) | 6 | 4 |
| Source of information about surgical center* | |||
| Internet | 23 (62.2%) | 17 | 6 |
| Media | 4 (10.8%) | 1 | 3 |
| Books | 3 (8.1%) | 2 | 1 |
| Physicians | 3 (8.1%) | 2 | 1 |
| Family member | 2 (5.4%) | 0 | 2 |
| Friend | 4 (10.8%) | 3 | 1 |
| Preference of core GASs | |||
| Breast first | 20 (54.1%) | 13 | 7 |
| Genitalia first | 17 (45.9%) | 12 | 5 |
| Likely response to surgical failure* | |||
| Blame the surgeon | 4 (10.8%) | 3 | 1 |
| Request for revision | 21 (56.8%) | 14 | 7 |
| Request for compensation | 2 (5.4%) | 1 | 1 |
| Wait-and-see attitude | 8 (21.6%) | 6 | 2 |
| Unsure | 7 (18.9%) | 4 | 3 |
| Gonadal and reproductive planning | |||
| Intention to preserve one or both gonads during anticipated genital GAS involving possible gonadectomy | |||
| One side | 5 (13.5%) | 4 | 1 |
| Both sides | 5 (13.5%) | 4 | 1 |
| None | 27 (73.0%) | 17 | 10 |
| Preservation for health* | 10 (27.0%) | 8 | 2 |
| Intention to store oocytes/sperm | |||
| Yes | 13 (35.1%) | 9 | 4 |
| No | 24 (64.9%) | 16 | 8 |
The item on gonadal preservation referred to participants undergoing or anticipating genital gender-affirming surgery involving possible gonadectomy. It was distinct from gamete cryopreservation
The GAS-related questionnaire was developed through item generation based on literature review and clinical experience, expert content review by clinicians and researchers in transgender healthcare and psychology, and pilot testing in five transgender individuals outside the final analytic sample. Pilot feedback was used to refine item wording, clarity, and cultural appropriateness. Cronbach’s α was 0.82 for the Likert-type domains of the questionnaire, with subscale values ranging from 0.78 to 0.85. However, because the questionnaire was self-developed, its psychometric properties remain limited. No exploratory or confirmatory factor analysis, test-retest reliability assessment, or external validation against established transgender-specific psychosocial instruments was performed. Therefore, construct validity has not been established, and findings based on this questionnaire should be interpreted descriptively and as exploratory rather than as evidence derived from a fully validated psychometric scale. The development and preliminary internal consistency assessment of the GAS-related questionnaire are summarized in Fig. 2.
Fig. 2.
GAS-Related questionnaire development, content review, pilot testing, and internal consistency. Notes: This flowchart summarizes the development, expert content review, pilot testing, and preliminary internal consistency assessment of the self-developed GAS-related questionnaire. Items were generated based on literature review and clinical experience, refined after expert review and pilot testing in five transgender individuals outside the final analytic sample. Internal consistency was acceptable, with Cronbach’s α = 0.82 for the Likert-type domains of the questionnaire and 0.78–0.85 for subscales. As full psychometric validation was not performed, the questionnaire should be interpreted as an exploratory descriptive instrument
The item regarding preservation of testes/ovaries was asked in the context of genital gender-affirming surgery involving possible gonadectomy. This item assessed whether participants wished to retain one or both gonads for perceived long-term health reasons. This was distinct from the separate item on gamete cryopreservation.
Eysenck Personality Questionnaire (EPQ): The 88-item adult version was used to assess Extraversion, Neuroticism, Psychoticism, and Lie scales. The Chinese version has demonstrated satisfactory reliability and validity and was used to describe participants’ personality characteristics in relation to Chinese national normative data.
Defense Style Questionnaire (DSQ): The DSQ was used to assess defense-related dimensions, including immature, mature, middle, and hidden defense dimensions. Scoring followed Andrews et al. Each defense style score was calculated as the mean of its corresponding items, yielding a value from 1.0 to 9.0 that reflected the individual’s predominant style of psychological defense at the time of assessment.
Sexual orientation was assessed by self-report. In this study, “heterosexual” was interpreted in relation to the participant’s experienced/affirmed gender. The questionnaire also recorded the sex assigned at birth of the person(s) to whom participants reported sexual attraction; therefore, the term “sex assigned at birth” was used instead of “genotypic sex,” as no genetic or chromosomal testing was performed.
Analytic strategies
Survey data from transmasculine and transfeminine participants were summarized descriptively in Tables 1, 2, 3, 4, 5, 6 and 7. Categorical variables were reported as counts and percentages. Continuous variables were summarized using medians and interquartile ranges where appropriate, and EPQ domain scores were additionally presented as mean ± SD to match the format of the Chinese national normative data. Due to the small and imbalanced sample size, no between-group inferential comparisons between transmasculine and transfeminine participants were performed.
Table 1.
Sociodemographic information of the transgender individuals
| All (N = 37) | Transmasculine participants (N = 25) | Transfeminine participants (N = 12) | |
|---|---|---|---|
| Nationality | |||
| Han | 35 (94.6%) | 24 | 11 |
| Non-Han | 2 (5.4%) | 1 | 1 |
| Religion | |||
| Buddhism | 3 (8.1%) | 2 | 1 |
| None | 34 (91.9%) | 23 | 11 |
| Residence | |||
| Rural | 15 (40.5%) | 8 | 7 |
| Urban | 22 (59.5%) | 17 | 5 |
| Marital status | |||
| Unmarried | 30 (81.0%) | 20 | 10 |
| Married | 4 (10.8%) | 2 | 2 |
| Divorced | 2 (5.4%) | 2 | 0 |
| Parenthood (biological children) | 1 (2.7%) | 1 | 0 |
| Education | |||
| Elementary school | 3 (8.1%) | 1 | 2 |
| Junior school | 7 (18.9%) | 4 | 3 |
| Senior school | 8 (21.6%) | 5 | 3 |
| University | 19 (51.3%) | 15 | 4 |
| Employment | |||
| Student | 4 (10.8%) | 2 | 2 |
| Employed | 23 (62.2%) | 16 | 7 |
| Unemployed | 10 (27.0%) | 7 | 3 |
A denominator of 37 in calculation of all percent values
Table 6.
Comparison of EPQ domains between transgender participants and national norms
| Group | Extraversion | Neuroticism | Psychoticism | Lie | |
|---|---|---|---|---|---|
| Transgender participants (n = 37) | 6.95 ± 3.305 | 11.139 ± 3.750 | 10.955 ± 4.605 | 14.150 ± 3.695 | |
| National sample (n = 2517) [26] | 9.806 ± 3.293 | 9.300 ± 4.315 | 10.333 ± 5.575 | 9.944 ± 3.913 | |
| Wilcoxon Statistic | 47.00 | 187.00 | 349.0 | 46.0 | |
| Standardized mean difference | -0.87 | 0.43 | 0.11 | 1.08 | |
| p value | < 0.001*** | 0.012** | 0.976 | < 0.001*** | |
National normative values were derived from the Chinese EPQ national norm sample (n = 2517) [26]. Values are presented as mean ± SD unless otherwise specified. The national normative sample was not individually matched to the present sample by age, sex assigned at birth, education, or other demographic variables. EPQ scores of the study participants were compared with national normative values using Wilcoxon single-sample signed-rank tests. **P < 0.01; ***P < 0.001
Table 7.
Correlations between the EPQ and DSQ variables
| Variable | Immature defense | Mature defense | Middle defense | Hidden defense | ||||
|---|---|---|---|---|---|---|---|---|
| ρ | p | ρ | p | ρ | p | ρ | p | |
| Extraversion | -0.342 | 0.122 | 0.075 | 0.750 | -0.119 | 0.603 | 0.127 | 0.301 |
| Neuroticism | 0.646*** | < 0.001 | 0.298 | 0.167 | 0.468* | 0.032 | 0.428* | 0.043 |
| Psychoticism | 0.117 | 0.603 | 0.298 | 0.168 | 0.062 | 0.750 | 0.127 | 0.603 |
| Lie | 0.261 | 0.238 | 0.054 | 0.750 | 0.229 | 0.301 | 0.358 | 0.116 |
Values are Spearman correlation coefficients (ρ) and FDR-adjusted p values. Benjamini-Hochberg FDR correction was applied for multiple comparisons. FDR-adjusted p < 0.05 was considered statistically significant. *FDR-adjusted p < 0.05; **FDR-adjusted p < 0.01; ***FDR-adjusted p < 0.001
The Chinese EPQ national normative dataset was derived from the revised Chinese version of the EPQ reported by Gong, which included 2,517 participants and provided aggregate normative means and standard deviations for the EPQ domains. Only published summary-level normative values were available for the present study. Individual-level normative data, detailed demographic distributions, and subgroup-specific values matched to the present cohort were not available. Therefore, adjustment or matching by age, sex assigned at birth, education, recruitment period, or other demographic variables could not be performed. The national norms were used only as a broad contextual reference, and all comparisons with these norms were interpreted as exploratory and descriptive.
EPQ domain scores were compared with Chinese national normative means using Wilcoxon single-sample signed-rank tests, which are appropriate for small samples and non-normal data. Four EPQ domains were compared with national normative values. Standardized mean differences were calculated as descriptive effect sizes using the difference between the study sample mean and the national normative mean divided by the pooled standard deviation. The direction of the standardized mean difference indicated whether the study sample scored higher or lower than the national normative value. These effect sizes were used to describe the magnitude of differences and were not interpreted as confirmatory evidence because the comparison was exploratory and unmatched.
Spearman correlation coefficients (ρ) were calculated to examine associations between EPQ dimensions and DSQ defense dimensions. Sixteen EPQ–DSQ correlations were tested, corresponding to four EPQ dimensions and four DSQ defense dimensions. Benjamini-Hochberg false discovery rate (FDR) correction was applied across these 16 correlation tests to account for multiple comparisons. FDR-adjusted p values were reported for correlation analyses. For Spearman correlation analyses, the correlation coefficients themselves were interpreted as effect sizes, with larger absolute values indicating stronger associations.
All analyses were performed using SPSS version 21.0. Statistical significance was set at a two-tailed P < 0.05. For correlation analyses, FDR-adjusted p < 0.05 was considered statistically significant.
Results
Sociodemographic profile
From April 2013 to April 2015, 37 participants met the inclusion criteria, provided written informed consent, and were included in the final analysis. The final sample included 25 transmasculine participants (67.6%) and 12 transfeminine participants (32.4%), aged 19–46 years (mean = 28.8, SD = 6.7). A total of 19 participants (51.3%) had a college degree or above, and 23 (62.2%) were employed. Of the 6 participants (16.2%) with a history of marriage, only 1 (2.7%) had biological children (Table 1).
Psychosocial characteristics
All participants reported heterosexual orientation, defined in relation to their experienced/affirmed gender. In the questionnaire, this corresponded to exclusive attraction to individuals with the same sex assigned at birth as the participant. More than 90% reported five or fewer romantic relationships, of whom about one third reported having one sex partner, and one third reported having no partners. About half of the participants identified their mother as the most influential family member during growth, and about 80% considered having biological children to be of little or no significance. About two thirds of the participants reported childhood onset of gender identity incongruence, and about one third reported adolescence onset. About two fifths of the participants reported experiencing psychological pressure, with 7 (18.9%) attributing it to family, 4 (10.8%) to societal sources, and 3 (8.1%) to both. Approximately 90% of the participants reported a range of self-reported mental health symptoms or histories, with anxiety (62.2%) and insomnia (51.4%) being the most common complaints. The most severe psychological symptoms reported were suicide attempts and self-harm, affecting 37.8% and 18.9% of the participants, respectively (Table 2).
Experiences with psychotherapy
A total of 32 (86.5%) participants reported awareness of psychotherapy. The most prominent source of information was the Internet, followed by books and media. Among the 19 participants who had received psychotherapy, all reported no improvement in GD-related symptoms, and only 3 (15.8%) noted any meaningful benefit to their overall mental health (Table 3).
Experiences with hormone therapy
A total of 26 (70.3%) participants reported awareness of hormone therapy. The most prominent source of information was the Internet (61.5%), followed by books (26.9%) and physicians (26.9%). Among the 10 participants who had used hormones, 7 had self-administered oral hormones, 3 had consulted healthcare professionals. Notably, 6 participants reported perceived feminizing or masculinizing effects (Table 4).
Family concerns and information sources regarding GAS
Among the 37 participants, 17 (45.9%) had undergone one or more core gender-affirming surgeries (GAS). The primary concern reported by family members was the potential harm of surgery to physical health. About one third of the participants indicated that their families also worried about social stigma—specifically, the concept of “loss of face”. Only one participant reported being pressured to leave their hometown to alleviate social stress on their families. Additionally, 5 (13.5%) participants stated that their families expressed concern about the inability to provide genetic offspring.
Roughly half of the participants reported that they had not known of GAS until adulthood. The internet (62.2%) was the most frequently cited source of information, regarding both GAS procedures and available surgical centers.
Motivations, risk perception, and reproductive planning
Most participants (78.4%) reported that their primary motivation for seeking GAS was to enhance self-confidence. The next most commonly cited reason was the urge to change the gender marker on official identification documents such as the ID card (45.9%).
Most participants reported revision-oriented or wait-and-see responses: 21 participants (56.8%) indicated that they would request revision surgery, and 8 participants (21.6%) reported that they would adopt a wait-and-see attitude. However, 4 (10.8%) participants reported they would blame the surgeon, and 2 (5.4%) said they would request financial compensation in the event of an unsatisfactory outcome.
In the context of anticipated or planned genital GAS involving possible gonadectomy, 10 participants (27.0%) expressed an intention to preserve one or both gonads, primarily because they believed gonadal preservation might protect long-term health. Separately, 13 participants (35.1%) expressed interest in storing gametes, including oocytes or sperm, for potential future reproductive use. (Table 5). Because these findings were derived from a self-developed GAS-related questionnaire without factor analysis or external validation, they should be interpreted as descriptive summaries of item-level responses rather than evidence of validated latent motivational constructs.
Exploratory comparison of EPQ domain scores between study participants and national norms
The comparison of EPQ domain scores between participants and Chinese national norms is shown in Table 6; Fig. 3. Because the national normative sample was not individually matched to the present cohort by age, sex assigned at birth, education, or other demographic variables, these analyses were interpreted as exploratory contextual comparisons rather than matched case-control comparisons.
Fig. 3.
Comparison of EPQ domain scores between transgender participants and national norms. Notes: Bars represent mean EPQ scores, and error bars indicate standard deviations. Blue bars indicate transgender participants, and orange bars indicate the Chinese national normative sample. Significance levels were derived from Wilcoxon single-sample signed-rank tests comparing participant scores with national normative values. These comparisons were exploratory because the national normative sample was not individually matched to the present cohort. **P < 0.01; ***P < 0.001; ns, not significant
Participants showed significantly lower Extraversion scores than the national norm (6.95 ± 3.31 vs. 9.81 ± 3.29; Wilcoxon signed-rank test, p < 0.001; standardized mean difference [SMD] = − 0.87) and significantly higher Neuroticism scores (11.14 ± 3.75 vs. 9.30 ± 4.32; p = 0.012; SMD = 0.43). Psychoticism scores did not differ significantly from the national norm (10.96 ± 4.61 vs. 10.33 ± 5.58; p = 0.976; SMD = 0.11). Lie scores were significantly higher than the national norm (14.15 ± 3.70 vs. 9.94 ± 3.91; p < 0.001; SMD = 1.08), suggesting a greater tendency toward socially desirable responding or impression management (Table 6; Fig. 3).
Correlations between EPQ and DSQ scores
Spearman correlation analyses were performed to examine associations between EPQ domains and DSQ defense dimensions. Sixteen EPQ–DSQ correlations were tested, and Benjamini-Hochberg FDR correction was applied across these tests. The p values reported in Table 7 are FDR-adjusted p values, and Spearman correlation coefficients were interpreted as effect sizes.
After FDR correction, Neuroticism remained positively associated with immature defenses (ρ = 0.646, FDR-adjusted p < 0.001), middle defenses (ρ = 0.468, FDR-adjusted p = 0.032), and hidden defenses (ρ = 0.428, FDR-adjusted p = 0.043). Other EPQ–DSQ associations were not statistically significant after FDR correction. In particular, the association between Lie scores and hidden defenses did not remain significant after adjustment (ρ = 0.358, FDR-adjusted p = 0.116) (Table 7).
Discussion
This study provides preliminary insights into the psychological profiles and surgical motivations of Chinese transgender individuals seeking gender-affirming surgery (GAS). Drawing on personality assessments (EPQ) and defense style evaluations (DSQ), the present findings reveal lower Extraversion, higher Neuroticism, and elevated Lie scores in exploratory comparisons with national norms, while Psychoticism did not differ significantly. These findings suggest a profile characterized by reduced social extraversion, greater emotional reactivity, and increased socially desirable responding in this clinically screened sample. Because most psychosocial and motivational variables were self-reported, elevated Lie scores also suggest that responses may have been influenced by social desirability bias. This should be considered when interpreting participants’ reported motivations, symptoms, and expectations.
The elevated Neuroticism scores observed in our cohort align with existing evidence documenting high levels of psychological distress among transgender and gender-diverse people globally and within China. In the context of minority stress, chronic exposure to stigma, discrimination, family pressure, and barriers to gender-affirming care may contribute to heightened emotional vulnerability [24].
The correlation analyses further showed that Neuroticism was positively associated with immature, middle, and hidden defense styles after FDR correction. Within a context of pervasive stigma and limited systemic support for transgender individuals, impression management may serve as a protective strategy to maintain social acceptance or reduce interpersonal conflict [17]. These findings suggest that participants with higher emotional vulnerability may rely more heavily on less adaptive or less openly expressed coping strategies. In contrast, although Lie scores were elevated relative to national norms, their association with hidden defenses did not remain statistically significant after FDR correction. Therefore, elevated Lie scores may reflect socially desirable responding or impression management in a stigmatizing social context, but the present data do not support a statistically robust association between Lie scores and hidden defense styles.
The significant correlations between personality traits and defense styles further support the notion that psychological responses in this population are multifaceted. Specifically, individuals with higher Neuroticism tended to utilize more immature defense styles, which have been associated with externalizing stress and psychological discomfort. These associations indicate that personality traits and defense styles may be related in this small sample. However, the present cross-sectional data cannot determine whether these psychological characteristics influence surgical decision-making, expectations, or postoperative adjustment.
The current findings also underscore the broader structural and systemic context in China that may shape psychological outcomes and motivations for GAS. Transgender individuals in China encounter multiple barriers to accessing gender-affirming treatments, including lack of accessible health information, restrictive eligibility criteria, and family and societal stigma. Reports by Amnesty International and empirical studies from Chinese contexts highlight these barriers and note that limited pathways to care can lead to unsafe self-treatment practices, including unregulated hormone use or dangerous surgical attempts outside clinical settings [25]. Such systemic obstacles may exacerbate psychological distress and increase the urgency with which individuals pursue available medical interventions, potentially independent of measured personality traits.
Several limitations should be emphasized. First, the sample size was small and drawn from a single surgical center, limiting statistical power and generalizability. Second, the cross-sectional design prevents causal inference regarding the relationships among personality traits, defense styles, and surgical motivations. Third, comparisons with national EPQ norms were exploratory because only published summary-level normative values were available, and the normative sample was not individually matched to the present cohort by age, sex assigned at birth, education, recruitment period, or other demographic variables. Fourth, the GAS-related questionnaire was self-developed and underwent expert content review, pilot testing, and internal consistency assessment, but full psychometric validation was not performed. In particular, no exploratory or confirmatory factor analysis, test-retest reliability assessment, or external validation against established transgender-specific psychosocial instruments was conducted. Therefore, questionnaire-based findings should be interpreted only as descriptive item-level data. Within these limitations, the present findings should be viewed as preliminary and hypothesis-generating. They may help describe psychosocial characteristics and self-reported motivations in this small clinical sample, but they do not establish clinical screening criteria, predictive value, or intervention effects. Future multicenter and longitudinal studies using validated transgender-specific psychosocial instruments are needed to determine whether these exploratory patterns are reproducible.
In conclusion, this exploratory cross-sectional study provides preliminary descriptive data on personality traits, defense styles, and self-reported motivations among Chinese transgender individuals seeking gender-affirming surgery. The findings suggest possible patterns of lower Extraversion, higher Neuroticism, higher Lie scores, and associations between Neuroticism and less mature or less openly expressed defense styles. However, because of the small single-center sample, cross-sectional design, unmatched national norm comparison, and limited validation of the self-developed GAS-related questionnaire, these results should be interpreted cautiously. They should not be considered definitive, predictive, or directly clinically applicable. Larger multicenter and longitudinal studies using validated transgender-specific psychosocial instruments are required to confirm these preliminary observations.
Supplementary Information
Acknowledgements
None.
Authors' contributions
HJ, XHZ, XW and HW designed the study. QJ, LL and XW collected data. QHX and XW analyzed the data. QHX wrote the manuscript. XW revised the manuscript. All the authors read and approved the final manuscript.
Funding
This work was supported by the Medical Discipline Construction Project of Pudong Health Committee of Shanghai [grant numbers: No. PWYts2021-07]. This work is financially supported by National Natural Science Fund of China (Grant numbers: 31400883). East Hospital affiliated with Tongji University introduced a talent research startup fund (Grant Nos.: DFRC2019008, DFRC2022020).
Data availability
Data are available upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and all participants signed an informed consent form and volunteered to participate. This study was approved by the research ethics committee of Shanghai Changzheng Hospital.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Hua Jiang, Email: dosjh@126.com.
Xiaohai Zhu, Email: drzxh@qq.com.
Hui Wang, Email: pathology2000@163.com.
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Supplementary Materials
Data Availability Statement
Data are available upon reasonable request.