General discussion 273 Figure 9.4. Illustration of the healthy user bias in retrospective or population research involving long-time OC users. In this scenario, the healthy user bias creates an underrepresentation of users with OC-related side effects. Created using Biorender.com. 3.3. Changes before and during GAHT use In Chapters 3, 5, 6, and 7 we used data from the RESTED and ENIGI studies, in which we prospectively followed transgender persons starting GAHT to examine changes in sleep and mood. The prospective design is an important strength, but these studies have other limitations. Firstly, previous studies have shown that transgender persons report significant stress with regard to access to care (Harry-Hernandez et al., 2020). The stress about access to gender-affirming care most likely also applies for the context in the Netherlands: wait times for gender-affirming care in the Netherlands are as long as 2 to 3 years, and many transgender people have trouble accessing care. In this context, the timing of measurements regarding well-being in this process is essential: the comparison of transgender persons who are on the waitlist for genderaffirming care with transgender persons already using GAHT might be biased by the waitlisted participants’ stress about gender-affirming care. Our studies examined sleep and depression right before, or at the start of GAHT use, and compared these with the participant’s own measurements after 3 and 12 months. We therefore expect that our study findings are less biased
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