Chapter 9 264 Figure 9.1. Illustration of effects of OCs and GAHT on cortisol levels. The left panel displays endogenous diurnal cortisol in OC users and naturally cycling women, displaying the reduced CAR and increased level of circulating cortisol in OC users (based on findings in this thesis, Høgsted et al., 2021 and on Hertel et al., 2017). The right panel displays the changes in responsivity of the HPA axis in response to pharmacological suppression and stimulation after three months of masculinizing or feminizing GAHT (based on Fuss et al., 2019). Created using BioRender.com. Emotion processing Use of OCs and GAHT could possibly affect emotion processing, although studies on this topic are still limited. In OC users, studies have found indications of negativity bias, meaning that OC users show attentional biases towards negative stimuli (Hamstra et al., 2015) and impaired emotion recognition (Hamstra et al., 2014, 2015), although results are still inconclusive. Neuroimaging studies have also found reduced amygdala activity and reduced connectivity from the amygdala in response to emotional stimuli in OC users compared to non-users (Engman et al., 2018; Petersen & Cahill, 2015), although again, results are mixed. This shows a possible effect of OCs on the processing of emotions, and further studies are needed to assess how these effects relate to depressive symptoms during OC use. In GAHT users, emotion recognition and emotional biases have not been studied, but there is work examining the recognition of one’s own emotions as well as work in neuroimaging. Reed et al. (2023) examined alexithymia, where people have trouble recognizing, expressing, and describing emotions. The authors found that alexithymia decreased after 4 to 5 months of feminizing GAHT. The authors also examined resting state brain activity, and found that resting state connectivity from the insula to the left middle frontal gyrus increased after feminizing GAHT. Kiyar et al. (2022) examined
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