How and when gender identity takes shape is one of the central questions in research on gender dysphoria. A new study based on data from the largest Chinese national survey on transgender health, published in JAMA Network Open, maps for the first time the ages at which people perceive, confirm and disclose their identity, and how that journey relates to the use of gender-affirming hormones.
A national survey with almost 4,300 people
The team at Peking University analysed the responses of 4,296 transgender people — 1,462 transgender men and 2,834 transgender women — collected in the second Chinese National Survey on Transgender Health, carried out in 2021. The median age of the participants was 21 years. It is the largest and most current sample of its kind in China.
Two peaks in the age at which incongruence is perceived
One of the most striking findings is that the age at which people say they first perceived that their identity did not match their birth sex follows a pattern with two peaks: one around the age of 5-6 years and another around 12 years, just as puberty arrives. The authors interpret the first peak as the moment when inner identity clashes with the stereotypes imposed at school, and the second as the stage when the bodily changes of puberty intensify distress.
Transgender men perceive it earlier; transgender women move earlier towards treatment
The results show clear differences between the two groups. Transgender men reported a median age of perception of incongruence of 6 years, compared with 9 years among transgender women. However, it was transgender women who started gender-affirming hormone treatment at an earlier median age (18 years versus 19). In other words, transgender men recognise their identity earlier, but transgender women progress earlier towards medical affirmation.
Demand for hormones grows, but medical access remains scarce
Demand for gender-affirming hormone therapy is very high: 87.5% of the participants wanted to receive it, and 52.3% had already used it at some point, percentages far above those of the 2017 survey. Even so, only 15.1% of those using hormones obtained them with a prescription from a qualified doctor. Of those who self-medicated, 78.5% cited the complexity of the procedures, and 14% had started using hormones before the age of 16, a practice discouraged by most clinical guidelines.
Why it matters
The study stresses that gender dysphoria is perceived, in many cases, at very early ages, long before adolescence. The authors conclude that early and personalised support is needed, especially for children who recognise the incongruence early, as well as wider access to formal, supervised medical services in order to reduce self-medication.
Source: Wang Y, Chang X, Hong T, Liu Y. Gender Identity Milestones and Hormone Utilization in Transgender Men and Women in China. JAMA Network Open. 2026;9(1):e2552440. doi:10.1001/jamanetworkopen.2025.52440.
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