Sex hormones, insomnia, and sleep quality: subjective sleep in the first year of hormone use 151 results are reported in the supplementary materials). However, it is possible that trans men who experienced more dysphoria because of their chest were more likely to undergo a mastectomy surgery earlier in their transition, so this analysis could likely be biased and was therefore not included in the main results. Secondly, the prevalence of mood disorders in transgender persons who seek gender-affirming care is known to be relatively high: 38% of transgender persons suffer from depressive and anxiety disorders at the time they seek gender-affirming care and almost 70% report a current or lifetime diagnosis of affective disorders (Heylens et al., 2014). This high prevalence has also been linked to transgender people experiencing gender minority stress (Valentine & Shipherd, 2018), which encapsulates the idea that there are specific stressors (such as discrimination and social rejection) and protective factors (such as community support) in transgender people, which can affect their mental health (Breslow et al., 2015). Since depressive- and anxiety disorders, as well as stress, are strongly associated with insomnia and poor sleep, our participants’ mental health could also have affected their sleep. Altogether, in interpreting our study results one should keep in mind that starting GAHT for many transgender people comes with psychological, physical, and social effects (Cocchetti et al., 2022; van Leerdam et al., 2021) and that many transgender persons suffer from depressive- or anxiety disorders which also affect sleep. Changes after GAHT are most likely multifactorial, such that any changes in sleep could be due to biological as well as social or psychological factors. Another possible limitation is that we only used self-reported symptoms of insomnia and sleep quality. We did not use objectively measured sleep data (e.g. actigraphy or sleep EEG). Although one could argue that subjective sleep reports are more meaningful than objective measures, since the diagnosis of insomnia is solely based on subjective symptoms, but the subjectively reported sleep- and wake durations, such as the SOL, TST, and SE are most likely less reliable and can be affected by recall bias. Reported sleep durations and durations of wakefulness during the night have been known to often be under- or overestimated when compared to objective sleep durations (Baker et al., 1999; Ma et al., 2021). In cisgender research participants, many studies show that cisgender women show better sleep using objective measurement methods (e.g. longer sleep duration and more deep sleep) compared to cisgender men (Della Monica et al., 2018), whereas cisgender women are also more likely to experience insomnia (Li et al.,
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