Chapter 5 140 was grouped under the term cycle-regulating medication. Feminizing hormones used by transgender women consisted of the anti-androgen cyproterone acetate (CPA; daily dose of 10 to 50 mg), or GnRH analogs, i.e. either the short-acting form (triptorelin 3.75 mg per 4 weeks) or the longacting form (triptorelin 11.25 mg per 12 weeks), combined with estrogens, i.e. either orally administered estradiol valerate (2 mg twice daily), estradiol gel (0.06% 1.5 mg daily) or estradiol patches (100 mcg per 24 hours twice a week). All included trans women used both estrogens and anti-androgens. 2.4. Questionnaires Self-reported symptoms of insomnia and sleep quality were assessed using the ISI (Bastien et al., 2001) and PSQI (Buysse et al., 1989). The ISI scores were assessed at baseline and after 3-, 6-, 9- and 12 months of GAHT, and the PSQI was assessed at baseline and after 12 months of GAHT. The ISI is a seven-item questionnaire that inquires about reported symptoms of insomnia and the daily burden of insomnia in the previous two weeks. Each item ranges from 0 to 4, and items are added together to form a sum score (range 0-28), where a higher score means more severe insomnia symptoms. To estimate the presence of insomnia, the ISI scores can be grouped using the standardized cut-offs: a score of 7 or lower indicates the participant experiences no insomnia, a score between 8 and 14 mild or subclinical insomnia, a score between 15 and 21 moderate or clinical insomnia, and a score over 22 severe clinical insomnia (Bastien et al., 2001). Although the ISI has not been validated in a cohort of transgender persons, it has excellent internal validity (Cronbach’s alpha=0.90; Morin et al., 2011) it is widely used in sleep research to indicate the severity of insomnia symptoms (Manzar et al., 2021). The seven items directly correspond to the symptoms of insomnia as defined by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). The PSQI is a questionnaire that consists of 19 items, and each item can be scored on a range from 0 to 3. It inquires about subjectively reported sleep duration, sleep quality, sleep disturbances, and daytime disturbances due to sleep problems over the past month. It is scored into seven subscores, which are subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Each subscore is calculated from specific items of the questionnaire, and the total sum of the seven components forms the total
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