Chapter 5 154 sleep quality. This possible association between hormone fluctuations, irrespective of hormone type, and sleep, might also explain why this study found temporary effects of GAHT on insomnia, but no lasting effects after 12 months of GAHT. It is common for transgender hormone users to change the dosages and forms of GAHT administration (e.g. transdermal, oral or intramuscular) after starting GAHT in order to find a form that is easiest to use and produces minimal side effects, so future research could further examine whether different forms of GAHT have different effects on sleep. There are a number of demographic factors we did not further explore in this study. Previous research has shown that subjective sleep quality and insomnia symptoms differ across age groups and with groups with lower or higher BMIs (Chan et al., 2018; Stewart et al., 2006). In our study we included mainly (young) adults, hence further research should investigate effects of GAHT on sleep in transgender adolescents and older transgender people to study whether these groups show different outcomes, either because of different forms of GAHT, as seen in adolescents using puberty suppressants, or because of longer endogenous hormone exposure and the effect of ageing, as seen in older GAHT users. However, as participants’ BMI also showed no confounding effects in our sample on the main outcomes variables. However, as the use of GAHT can increase BMI (Klaver et al., 2017), future research should address whether participants who show strong changes in BMI after GAHT use are more at risk for poor sleep quality or sleep disorders such as insomnia or sleep apnea. In summary, this study shows that transgender persons report poor sleep quality before GAHT, and that no clinically significant changes in insomnia or sleep quality occur after starting gender-affirming hormone use. However, there was a moderate reduction in sleep onset latency in trans women and marginal reduction sleep efficiency in trans men. Furthermore, we see that trans women who experience hot flashes report more insomnia symptoms than those who do not. Future studies on different hormone protocols, such as differences between CPA and GnRH analogs in trans women, could provide more insight into the underlying hormonal mechanisms affecting sleep quality. Considering the possible changes in sleep-wake duration after GAHT use, further studies should focus on the objective measurement of sleep during GAHT and on possible underlying mechanisms.
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