Experiences and factors associated with transphobic hate crimes among transgender women in the San Francisco Bay Area: comparisons across race

Transgender (trans) women experience gender-based violence (GBV) throughout their lives, which impedes their access to services and contributes to poor health outcomes and quality of life. To inform policies and health programs, trans women worked with the United States Agency for International Development (USAID)- and President's Emergency Plan for AIDS Relief (PEPFAR)-supported LINKAGES project, the United Nations Development Programme, The University of the West Indies, and local organizations to document experiences of GBV and transphobia in healthcare, education, and police encounters. Trans women conducted 74 structured interviews with other trans women in El Salvador, Trinidad and Tobago, Barbados, and Haiti in 2016. We conducted qualitative applied thematic analysis to understand the nature and consequences of GBV and transphobia and descriptive quantitative analysis to identify the proportion who experienced GBV in each context. A high proportion experienced GBV in education (85.1%), healthcare (82.9%), from police (80.0%), and other state institutions (66.1%). Emotional abuse was the most common in all contexts and included gossiping, insults, and refusal to use their chosen name. Participants also experienced economic, physical, and sexual violence, and other human rights violations based on their gender identity and expression. At school, participants were physically threatened and assaulted, harassed in bathrooms, and denied education. In healthcare, participants were given lower priority and received substandard care. Healthcare workers and police blamed participants for their health and legal problems, and denied them services. From police, participants also experienced physical and sexual assault, theft, extortion for sex or money, and arbitrary arrest and detention. Participants had difficulty obtaining identification documents that matched their gender identity, sometimes being forced to alter their appearance or being denied an identification card. Service providers not only failed to meet the specific needs of trans women but also discriminated against them when they sought services, exacerbating their economic, health, and social vulnerability. Although international and regional resolutions call for the legal protection of transgender people, states do not meet these obligations. To respect, promote, and fulfill trans women's human rights, governments should enact and enforce antidiscrimination and gender-affirming laws and policies. Governments should also sensitize providers to deliver gender-affirming services.

Purpose: Transgender (trans) women of color's HIV vulnerabilities are shaped by social exclusion and intersectional stigma. There is a dearth of tailored HIV prevention interventions with trans women of color in Canada. The objective of the study was to explore trans women of color's HIV prevention priorities and to pilot test an intervention developed from these priorities.Methods: We conducted a qualitative implementation science study to develop HIV intervention strategies with trans women of color in Toronto, Canada. First, we conducted a focus group with trans women of color (n=8) to explore HIV prevention priorities. Second, we held a consultation with trans women of color community leaders (n=2). Findings informed the development of the TRANScending Love (T-Love) arts-based workshop that we pilot tested with three groups of trans women of color (n=18). Workshops were directly followed by focus groups to examine T-Love products and processes.Results: Focus group participants called for researchers to shift the focus away from trans women's bodies and HIV risks to address low self-acceptance produced by intersecting forms of stigma. The community leader consultation articulated the potential for strengths-focused arts-based approaches to address self-worth. T-Love participants described how workshops fostered self-acceptance and built connections between trans women of color.Conclusions: Findings demonstrate the feasibility and acceptability of an arts-based strategy with trans women of color to elicit group-based sharing of journeys to self-acceptance, fostering feelings of solidarity and connection. Providing opportunities for dialogue and reflection about individual and collective strengths may reduce internalized stigma among trans women of color.

To the Editors: The past decade has seen progress toward getting to zero HIV infections in San Francisco overall. New HIV diagnoses dropped from 521 in 2008 to 197 in 2018, a 62% decrease.1 HIV incidence estimated by a CD4 model2 corroborates a parallel, commensurate drop in incident infections, from a projected 330 in 2013 to 190 in 2017.1 Unfortunately, there is insufficient sample size to estimate HIV incidence separately for smaller populations who may have elevated risk. Directly measured rates of HIV seroconversion observed in longitudinal studies are logistically difficult and costly and therefore rare.3 Limitations of sample size and resources are substantial for estimating or measuring HIV incidence among transgender women (hereafter "trans women"), the population with the highest burden of HIV in San Francisco1,4 and in many parts of the world.5 We report results from the TransNational Study in San Francisco, the primary aims of which are to measure the rate of HIV seroconversion and identify predictors of HIV acquisition among trans women. The present analysis focuses on identifying demographic disparities in HIV risk, particularly testing hypotheses on whether HIV incidence is higher among trans women who are young, members of racial/ethnic minority groups, living in poverty, and homeless based on differences in HIV prevalence and recent trends in new diagnoses in San Francisco.1 Trans women were defined by being assigned male sex at birth and currently identify as other than male gender. Trans women were enrolled into the cohort using a long-chain peer-referral method previously used to accrue a cohort of young trans women in San Francisco6 and men who have sex with men (MSM) in Nanjing, China.7 In brief, initial seeds were identified from diverse social networks and instructed to refer other eligible trans women to the study. Participants were interviewed face-to-face on demographics and risk behaviors and tested for HIV. Trans women who tested negative for HIV and were 18 years or older were eligible. Participants were retested and interviewed at 6, 12, and 18 months. Participants who seroconverted were linked to HIV care. We used an incidence density approach (ie, the number of events divided by the person-time of follow-up) to calculate rates of HIV seroconversion. Incidence rate ratios were used to compare differences in rates among subgroups of trans women assuming a Poisson distribution. When a subgroup had zero seroconversions, we calculated 97.5% one-sided confidence intervals (CI) and compared groups using the Z-test. Referrals to HIV prevention programs, including pre-exposure prophylaxis (PrEP), were offered at each visit. Participants were given $55 for completion of the survey and HIV testing at their initial visit, increasing to $70 for the 18-month visit. Participants were given $20 for each eligible referral to the study. The protocol was approved by the Human Research Protection Program of the University of California San Francisco. Participants provided written informed consent. Of 415 who were HIV negative at enrollment and agreed to follow-up, 377 were seen at their 18-month visit and 8 seroconverted by the time of their 18-month visit (92.6% retention). The 8 seroconversions occurred over 604 person-years (py) of follow-up for an incidence rate of 1.3 per 100 py (95% CI: 0.7 to 2.7) (Table 1).TABLE 1.: HIV Incidence Among Trans Women in a Longitudinal Cohort, San Francisco, 2017–2019Several disparities in HIV incidence rates were noted. Trans women aged 18–24 years had a significantly higher HIV incidence (3.7 per 100 py; 95% CI: 1.2 to 11.6) compared with those aged 25 years and older (1.0 per 100 py; 95% CI: 0.4 to 2.3, P = 0.04). Age categories above 25 years were collapsed because they were similar in magnitude. HIV incidence was significantly higher among Latina/x trans women (2.6 per 100 py; 95% CI: 1.1 to 6.1, P = 0.03) and trans women of color (2.2 per 100 py; 95% CI: 1.1 to 4.3, P = 0.01) compared with white trans women. Trans women who had been incarcerated (2.3 per 100 py; 95% CI: 1.1 to 4.8, P = 0.04) and those without health insurance (5.8 per 100 py; 95% CI: 1.5 to 23.2, P = 0.02) also had significantly elevated HIV incidence. Incidence estimates among trans women for comparison are rare. Twenty years ago, HIV incidence was calculated among trans women in San Francisco in a retrospective cohort, arriving at a rate of 7.8 per 100 py (95% CI: 4.6 to 12.3).8 The estimate suggests a substantial decline to the current level. Serial cross-sectional surveys of trans women in San Francisco show HIV infection sustained at high levels over the past several years.4 We recognize the risk in overinterpreting data based on 8 seroconversions. Small numbers may miss true associations in the population. We also acknowledge potential Hawthorne effects. Multiple risk assessments, HIV testing, and referral to prevention programs, such as PrEP, are likely to dampen HIV incidence, underestimating true rates in the population. Other studies note challenges in measuring HIV incidence among trans women. The iPrEx trial of PrEP efficacy was able to enroll 339 trans women among 2499 total participants across 11 sites.9 The researchers cite difficulties in identifying trans women and determining the preventive effects of PrEP specifically for them. Other studies combine MSM with trans women without being able to separate them for analysis.5 For example, a recent analysis of HIV incidence among key populations in Bangkok across 10 years was unable to distinguish between MSM and trans women.10 We concur with these researchers in the strong need for trans-specific longitudinal studies, including benchmark measures of HIV incidence and randomized controlled trials with incident endpoints. On the other hand, the fact that we were able to find significantly elevated HIV incidence for some groups speaks to the potential magnitude of these effects. Significant correlates of HIV incidence found in our cohort echo concerns emerging from citywide surveillance data.1 Despite decreases overall, new HIV diagnoses have increased for black/African Americans and Latina/x people. Prior studies also found significantly higher incidence and prevalence of HIV among trans women of color.4,8 History of incarceration and lack of health insurance point to structural drivers of continued HIV acquisition among trans women that must be addressed. Structural risks of housing instability, low income, and education are risk factors for sex work and incarceration and are more prevalent among trans women of color.11–13 Instability may also preclude trans women from completing the steps required to enroll in health insurance and establish care in the public health system where biomedical HIV prevention is available. Structural factors disproportionately affecting trans women of color are also tied to poor HIV care outcomes and suboptimal access to HIV prevention use.14,15 Such risks are exacerbated in our city, which has wide disparities in wealth, housing, and employment opportunities.16 Perhaps, the most disheartening finding is the elevated HIV incidence among young trans women. The nearly four-fold higher incidence among transgender youth predicts a continuing high burden of infection for years to come. In an era of intensifying efforts to get to zero HIV infections by 2030,17 any incidence rate above 1 per 100 py is a worrisome reminder that the endgame of eliminating new HIV infections may see diminishing returns as the remaining cases occur among our most marginalized communities.

Introduction Transgender (trans) women of color navigate the intersected identity frames of gender, race, social class and sexuality, whilst facing multiple layers of stigma, discrimination and violence during and following gender affirmation. However, little is known about the ways in which trans women of color negotiate gender affirmation, in the context of the risk of social exclusion and violence. Aim This article discusses the experience and construction of gender transitioning and gender affirmation for trans women of color living in Australia, associated with the risk of social exclusion or violence. Method In-depth interviews and photovoice were conducted with 31 trans women of color, analyzed through theoretical thematic analysis informed by intersectionality theory. Results The following themes were identifed: 1) ‘Gender affirmation: A bittersweet experience’, with three subthemes: ‘Self-empowerment is tempered by family rejection’, ‘Migration facilitates gender affirmation’ and ‘Gender affirmation and social support’; 2) ‘Being a trans woman of color’, subthemes: ‘Bodily agency and passing’, ‘Femininity as pleasure and cultural self-expression’, and ‘Resisting archetypal White hetero-femininity’; 3) ‘Hormones, surgical intervention and navigating the health system’. Conclusion Gender transitioning and gender affirmation involved the intersection of gender, cultural, social class and sexual identities, accomplished through personal agency and with the support of significant others. To ensure that policy and support services meet the needs of trans women of color, it is critical that the voices of such multiply-marginalized women are at the center of leadership, program and policy development.

Background: Transgender women are disproportionately affected by gender-based violence (GBV). However, little is known about how they respond to GBV. Aims: This study aims to understand transgender women’s response to GBV and identify barriers and facilitators in accessing healthcare and legal aid after experiencing the violence. Methods: We conducted a qualitative study between February to March 2020 in Phnom Penh, Cambodia. Data were collected through in-depth interviews with 20 transgender women aged between 21 and 49 who had experienced GBV or knew a peer who had experienced GBV. Thematic analysis was conducted for the coding process, and an inductive approach was used to develop a coding frame. Results: All participants had experienced at least one form of GBV in their lifetime, and most participants had experienced multiple forms of GBV. However, most of them did not seek any services from healthcare providers, law enforcement officers, or assistance for healthcare and legal aid from non-governmental organizations (NGOs). Participants reported the following barriers to access to GBV services: anticipated stigma, the internalized stigma, which resulted in shame and low self-esteem, a lack of knowledge on NGOs’ services that can assist with healthcare and legal aid, the perception that mental health services were unavailable, a lack of social support, enacted stigma by the police, and the perceived healthcare cost. The participants reported social support and knowledge of NGOs’ services as facilitators of access to GBV service. Social media and NGO staff were reported to be preferred sources of information. Participants wanted more effective law enforcement services, comprehensive healthcare catered to the unique transgender women’s needs, and non-discriminating service providers. Discussion: Interventions to address GBV and improve the health outcomes of transgender women should involve creating an enabling environment for help-seeking with the partnership between NGOs and different sectors and building social support.

A large proportion of the female population all over the world, particularly in developing countries, experience some form of gender-based violence (GBV) during their life. Early marriage, a form of GBV, is particularly highly prevalent in rural Upper Egypt. The aim of the current study was to assess the knowledge, attitudes and practices (KAP) of adolescents in Upper Egypt on domestic GBV, with a focus on early girls' marriage. The study was a cross-sectional descriptive household survey targeting 400 randomly selected adolescent boys and girls aged 11-16 years from five villages of Minya Governorate in Upper Egypt. The proportion of interviewed adolescents who could identify certain practices as forms of GBV was relatively low: the identified practices were mainly deprivation of work (9.0%), deprivation of inheritance (3.3%), arbitrary neglect and desertion (2.8%), and preventing from visiting relatives (0.5%). Abusive sexual behavior was not identified by any of the study participants as a form of domestic GBV. A total of 112 boys (56.0%) reported that they have been perpetrators in domestic GBV events at least once and 118 girls (59.0%) reported that they have been actual victims of domestic GBV. An overall 65.6% of study participants could correctly identify the legal age of marriage as 18 years, yet only 22.0% identified earlier ages of marriage as a form of domestic GBV. The vast majority of girls and boys reported that they would not agree to get married before the age of 18 years (91.0 and 87.0%, respectively). Adolescents in Upper Egypt demonstrated a less than satisfactory knowledge about the forms of GBV. Although early girls' marriage was not universally recognized by adolescents as a form of domestic GBV, they demonstrated satisfactory knowledge about the legal age of marriage, as well as a tendency to abandon the practice. Establishing a community-based awareness program for adolescents of both sexes about GBV with a focus on early girls' marriage is highly recommended.

Hate crimes (or bias crimes) are crimes motivated by an offenders’ personal bias against a particular social group. Modern hate crimes legislation developed out of civil rights protections based on race, religion, and national origin; however, the acts that constitute a hate crime have expanded over time, as have the groups protected by hate crimes legislation. Anti-LGBT hate crimes, in which victims are targeted based on their sexual orientation or gender identity. LGBT people are highly overrepresented as victims of hate crimes given the number of LGBT people in the population, and this is especially true of hate crimes against transgender women. Despite the frequency of these crimes, the legal framework for addressing them varies widely across the United States. Many states do not have specific legislation that addresses anti-LGBT hate crimes, while others have legislation that mandates data collection on those crimes but does not enhance civil or criminal penalties for them, and some offer enhanced civil and/or criminal penalties. Even in states that do have legislation to address these types of hate crimes, some states only address hate crimes based on sexual orientation but not those based on gender identity. The Matthew Shepard and James Byrd Jr. Hate Crimes Prevention Act gives the federal government the authority to prosecute those crimes regardless of jurisdiction; however, this power has been used in a limited capacity. Hate crimes are distinct from other crimes that are not motivated by bias. For example, thrill seeking, retaliation, or the desire to harm or punish members of a particular social group often motivates perpetrators of hate crimes; these motivations often result in hate crimes being more violent than other similar crimes. The difference in the motivation of offenders also has significant consequences for victims, both physically and mentally. Victims of hate crimes are more likely to require medical attention than victims of non-bias crimes. Likewise, victims of hate crimes, and especially anti-LGBT hate crimes, often experience negative psychological outcomes, such as PTSD, depression, or anxiety as a result of being victimized for being a member of an already marginalized social group.

Purpose: The purpose of our study was to examine the effects of mental distress (depression, anxiety, and post-traumatic stress disorder [PTSD]), incarceration, and hate crime on stimulant use (methamphetamine, crack, and cocaine) among transgender women. Methods: We conducted a secondary analysis of longitudinal data collected from 2016 to 2018 with 429 transgender women in the San Francisco Bay Area. Generalized estimating equation log-binomial regressions were used to calculate relative risks of stimulant use associated with mental distress, incarceration, and hate crime. Results: At baseline, transgender women experienced transphobic hate crime (46.4%), incarceration (53.0%), mental distress (69.2%), and stimulant use (28.4%). Transgender women who used stimulants reported lower education (45.1%, χ2 = 14.3, p = 0.001) and significantly more had been incarcerated (62.3%, χ2 = 5.9, p = 0.015), and reported diagnoses of depression (67.8%, χ2 = 6.1, p = 0.014), anxiety (62.8%, χ2 = 4.3, p = 0.039), and PTSD (43.8%, χ2 = 6.7, p = 0.010). Longitudinal multivariate analysis found that depression (adjusted relative risk [aRR] = 1.46, 95% confidence interval [CI] 1.09-1.95), anxiety (aRR = 1.42, 95% CI = 1.05-1.93), and PTSD (aRR = 1.38, 95% CI = 1.02-1.87) were associated with methamphetamine use but not with crack or cocaine use. Incarceration was associated with methamphetamine use and crack use, whereas experiencing hate crime was associated with crack use. Conclusions: Mental distress, incarceration, and hate crime were key exposures of stimulant use among transgender women. Intervention targets for reducing stimulant use should consider working upstream by addressing underlying stressors impacting mental health for transgender women, including laws to protect transgender women from hate crime and to reduce their disproportionate representation in the criminal justice system.

Improving Adolescent and Young Adult Health Through Knowledge and Action on Gender-Based Violence.

BackgroundTranswomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda.MethodsThis participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding.ResultsAt the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities.ConclusionThe effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.

It is urgent to develop efficacious HIV prevention programs to curb the reported extremely high HIV prevalence and incidence among transgender women (male-to-female transgender persons) who reside in large cities in the USA. This study aimed to describe unprotected receptive anal sex (URAS) and unprotected insertive anal sex (UIAS) among high-risk transgender women in relation to partner types, psychosocial factors, and background variables. Based on purposive sampling from the targeted communities and AIDS service organizations in San Francisco and Oakland, a total of 573 transgender women who had a history of sex work were recruited and individually interviewed using a structured survey questionnaire. Significant correlates with URAS with primary, casual, and commercial sex partners were found (e.g., needs for social support, frequency of social support received, exposure to transphobia, self-esteem, economic pressure, norms toward practicing healthy behaviors, and self-efficacy toward practicing safe sex). Multiple logistic regression analyses revealed that transgender women who had engaged in URAS with commercial partners were more likely to have higher levels of transphobia or lower levels of the norms or self-efficacy to practice safe sex. Among the participants who did not have vaginoplasty (preoperative transgender women), 16.4% had engaged in insertive anal sex (IAS) with commercial partners in the past 30 days. The participants who were HIV positive and had engaged in IAS were more likely to be African-American or Caucasians, coinfected with sexually transmitted infections, or identified themselves as homosexual. Practices of IAS among transgender women have not been thoroughly investigated in relation to sexual and gender identity. UIAS with homosexual and bisexual men in addition to URAS may be a cause for high HIV incidence among transgender women. An HIV prevention intervention study must be developed and evaluated, which aims to reduce HIV-positive and -negative transgender women's URAS and UIAS.

IntroductionTransgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria.MethodsIn‐depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services.Results and discussionThree main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender‐inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender‐inclusive and gender‐affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender‐inclusive CSO clinics.ConclusionsThis study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender‐inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender‐affirming HIV services.

Disparities in depression and anxiety at the intersection of race and gender identity in a large community health sample

Implementation Strategies for Creating Inclusive, All-Women HIV Care Environments: Perspectives From Trans and Cis Women.

Little is known about how gender identity develops and how it affects gender-affirming hormone therapy (GAHT) utilization among transgender people in China. To investigate gender identity development among Chinese transgender men (TM) and transgender women (TW) and to explore how identity-related factors are associated with GAHT utilization. This cross-sectional study is based on the latest Chinese Transgender Health Survey targeting the transgender population in China conducted from May to December in 2021. Data analysis was completed in December 2024. Participants were recruited online via snowball sampling. The primary outcomes are the timing of gender identity development milestones (first perception of gender incongruence, confirmation, disclosure, and initiating GAHT) and GAHT utilization status. Multivariable binary logistic regression identified factors associated with GAHT-related behaviors and feedback. A total of 4296 transgender people (1462 TM [34.0%] and 2834 TW [66.0%]; median [IQR] age, 21 [18-24] years) were included in the final analysis. The age distribution of first perceived gender incongruence exhibited a bimodal pattern, with peak occurrences at ages 5 to 6 and at 12 years. The median (IQR) ages at gender identity development milestones were all younger for TM than for TW: 6 (4-10) years vs 9 (6-12) years for perception, 14 (11-16) years vs 15 (12-17) years for confirmation, and 16 (14-19) years vs 17 (15-20) years for disclosure, whereas the age of initiating GAHT was older in TM than in TW (median [IQR] age, 19 [17-22] years vs 18 [16-21] years). The demand for GAHT (3759 participants [87.5%]), usage (2247 participants [52.3%]), and the rate of valid prescriptions among hormone users (339 participants [15.1%]) have all increased significantly compared with 2017. Being a TW and without a college education were associated with starting GAHT before age 16 years, while being a TM, having family disclosure of gender identity, and having official prescriptions were associated with positive feedback on GAHT. In this cross-sectional study of Chinese TM and TW, gender identity development differed by gender, with TM recognizing incongruence earlier and TW progressing faster in initiating GAHT. Both groups showed strong demand for GAHT. Despite recent improvements in GAHT service accessibility, challenges persist in medical accessibility. These findings highlight the need for personalized support for transgender youths and underscore the importance of improving formal transgender health care services in China to enhance the well-being of this population.