Sex hormones, insomnia, and sleep quality: subjective sleep in the first year of hormone use 149 4. Discussion This is the first study to prospectively examine changes in self-reported insomnia and sleep quality during GAHT use in transgender people. Our findings show that before starting GAHT, transgender persons report more poor sleep than insomnia. Overall, the findings show no significant changes in sleep quality and insomnia after 12 months of GAHT. There is a temporary small improvement in symptoms of insomnia after starting GAHT in both trans men and trans women, but the results show no difference in insomnia symptoms and sleep quality after 12 months. Although the subjectively reported total sleep time does not show significant changes after 12 months of GAHT in both groups, trans men report falling asleep 9 minutes earlier and trans women report an estimated 2.8% decrease in sleep efficiency after 12 months of GAHT. Since a SOL lower than 30 minutes is seen as healthy (M. Ohayon et al., 2017), the 9-minute decrease in trans women could be considered clinically significant. The decrease in SE in the trans men is small compared to the wide range of SE that is considered healthy: An SE higher than 85% is regarded as healthy sleep in adults, and higher than 75% is healthy sleep in young adults (M. Ohayon et al., 2017). A decrease of 2.8% in SE, as seen in trans men, can therefore not be deemed a clinically significant change in SE. Trans women who report hot flashes also report more insomnia symptoms than trans women without hot flashes after 6- and 9 months of GAHT, showing clinically significant but temporary associations between hot flashes and insomnia. In trans women we expected an increase in reported insomnia symptoms and worse sleep quality after feminizing GAHT, in line with insomnia prevalence in cisgender women. Although we found no overall changes in sleep quality or insomnia in trans women, this group did show a shorter SOL after 12 months. The decrease in SOL may be related to the use of CPA as anti-androgen, since 85% of participating trans women used this at the start of GAHT. CPA is a progestogen with strong anti-androgenic properties, but it can also potently affect both progesterone receptors and glucocorticoid receptors (Kuhl, 2005). Previous studies found that administration of progesterone in cisgender men resulted in feelings of fatigue (Söderpalm et al., 2004), indicating a possible sedative effect of progestogens in a group who naturally have very low progesterone. However, these findings could not be confirmed with objective sleep measures by using sleep
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