Abstract
Study Objectives:
Transgender or gender-nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.
Methods:
This retrospective cross-sectional study utilized a large US-based administrative claims database (deidentified Optum Clinformatics Data Mart Database) to identify youth aged 12–25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.
Results:
This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (odds ratio = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (odds ratio = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (odds ratio = 3.1, 95% confidence interval 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (odds ratio = 0.5, 95% confidence interval 0.4, 0.7) relative to those not on GAT.
Conclusions:
This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.
Citation:
Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. Gender identity and transition: relationships with sleep disorders in US youth. J Clin Sleep Med. 2022;18(11):2553–2559.
Keywords: transgender persons, sleep disorders, gender-affirming therapy
BRIEF SUMMARY
Current Knowledge/Study Rationale: A higher burden of sleep disorders has been suggested in transgender youth relative to cisgender. Beyond gender identity, the impact of gender-affirming therapy on sleep disorders has been rarely explored. The present study examines the impact of gender identity and gender-affirming therapy on sleep disorders in a large sample of US cisgender and transgender youth.
Study Impact: Given the higher prevalence of sleep disorders among transgender or gender-nonconforming in relation to cisgender youth, clinicians should consider screening and testing this population for such disorders. The potential protective effect of gender-affirming therapy on sleep disorders in transgender youth requires further evaluation.
INTRODUCTION
Transgender or gender-nonconforming (TGNC) individuals have a gender identity or expression that differs from their sex assigned at birth or from the typically expected masculine or feminine concepts.1,2 Current reports estimate that 0.5 to 1.3% of the US population identify as TGNC,3 including nearly 150,000 youth aged 13–17 years.4 Most TGNC individuals (91%) seek gender-affirming therapy (GAT),5 a medical intervention that provides mental health support, sex hormones therapy, and gender reassignment surgeries.6 The growing societal acceptance of TGNC identity has significantly increased demand for gender-affirming care and highlighted health disparities in gender minorities.7–10
A third of youth experience sleep disorders, of which the most prevalent, yet mostly underdiagnosed, are insomnia, sleep apnea, circadian rhythm disorders, and parasomnias.11–14 Sleep disorders in youth have shown to negatively influence their physical and mental health as well as cognitive abilities that could disrupt daily activities and development.14–16 Furthermore, TGNC youth are more prone to depression, anxiety, and suicidality in comparison to cisgender individuals.17–19 The high burden of mental health in TGNC has been attributed to gender identity stigma and discrimination20,21 and increases their vulnerability to sleep disorders, as recently shown in studies among college students and US adolescent males.19,22
Reports on sleep disorders among TGNC populations are scarce, though new studies have been emerging in recent years. Still, despite biological plausibility, the impact of GAT on sleep has been rarely reported.23 In young cisgender women, a combination of estrogen and progestin oral therapy impaired their sleep architecture,24 while postmenopause hormone replacement therapy had a protective effect on obstructive sleep apnea (OSA) and insomnia.25,26 However, an increase in OSA risk and severity has been linked to testosterone use in cisgender men.27,28
Current reports on the burden of sleep disorders among TGNC individuals have relied on self-report gender identity and sleep complaints. Furthermore, while GAT has been shown to improve mental health outcomes in TGNC youth,29 its impact on sleep disorders is poorly understood.
Here, we utilize a large national administrative claims database to examine the relationships between TGNC identity and sleep disorders and the role of GAT in sleep disorders among TGNC youth. We hypothesized that sleep disorders would be more prevalent in TGNC relative to cisgender youth and that GAT will alleviate the burden of sleep disorders among TGNC on GAT vs those not on GAT.
METHODS
Data source
The deidentified Optum Clinformatics Data Mart Database was utilized for this retrospective cross-sectional study. A national single private payer administrative claims database, Optum contains medical and outpatient pharmacy data from individuals covered by commercial or Medicare Advantage insurance plans in the United States.30 To be enrolled in a private payer insurance health plan, the beneficiary pays for insurance coverage or is covered by their employer or a spouse who has employer-based coverage that extends to family members. This privately insured sample may represent a slightly more affluent sector of the population, and study findings should be interpreted accordingly. Medical, procedure, and outpatient pharmacy claims from January 1, 2018 to December 31, 2018 (1 full calendar year, the most recently available data at the time of study conception) were used for this analysis. Data were deidentified, and the University of Michigan Institutional Review Board approved this study as nonregulated. The data underlying this article cannot be shared due to restrictions imposed by a Data Use Agreement with Optum Clinformatics.
Study population
Youth aged 12 to 25 years who had continuous enrollment for the full calendar year 2018 were eligible for this study. This age range was selected as transgender identity is less common among children younger than 12 years of age, while enrollment in their caregiver insurance plan is limited to age 26. To allow the inclusion of young adults prior to their transition to independent insurance plans, age 25 years was determined as the upper limit. The requirement for continuous enrollment during the full calendar year (2018) is common in claims-based research to allow for an adequate time for ascertainment of study variables.31
Exposures: gender identity and GAT
Guided by previous claims-based studies32–34 showing high validity,33 TGNC identity was defined by ≥ 1 claim containing any 1 of the following International Classification of Diseases Tenth Revision Clinical Modification (ICD-10-CM) codes: F64.0, F64.1, F64.2, F64.8, F64.9, and/or Z87.890 (see supplemental material for details). Youth without any claims for TGNC-related diagnoses were classified as cisgender. Within TGNC youth, evidence of affirming care was used to create 2 groups, those who pursued GAT vs those not on GAT. To further divide TGNC youth on GAT into transmasculine or transfeminine subgroups, we utilized outpatient pharmacy claims for medications, Healthcare Common Procedure Coding System (HCPCS) codes (ie, injection of testosterone), and Current Procedural Terminology (CPT) codes (ie, urethroplasty). Specifically, transmasculine was identified by the presence of prescribed medication for testosterone or norethindrone, HCPCS codes for testosterone (J1070, J1071, J1080, J3120, J3121, J3130, J3140, J3145, J3150), or CPT codes indicating surgery for transmasculine transition (19303, 19304, 53420, 53425, 54660, 55175, 55180, 55980, 57110, 96372). Transfeminine was defined as having been prescribed medication for estradiol, progesterone, medroxyprogesterone acetate, spironolactone, histrelin, bicalutamide, finasteride, dutasteride, or leuprolide, HCPCS codes for estradiol (J1000), or CPT codes indicating surgery for transfeminine transition (17380, 19316, 19325, 53430, 54125, 54520, 54690, 55970, 57291, 57335, 56805, 58999). For a complete description of HCPCS and CPT codes, see supplemental material.
Outcome: sleep disorders
We used ICD-10-CM codes to identify 3 separate outcomes of sleep disorders: (1) insomnia (ICD-10-CM: F51.0x and G47.0x), (2) sleep apnea (ICD-10-CM: G47.3x), and (3) other sleep disorders, such as hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders (ICD-10-CM: F51.1x, F51.3, F51.4, F51.5, F51.8, F51.9, G47.4x, G47.5x, G47.8, G47.9). Administrative claims data has been shown to have good accuracy for identifying those sleep disorders, with up to 97.9% positive predictive value and up to 99.3% specificity.35
Covariates
Selection of covariates was guided by causal diagrams based on their relevance to TGNC identity, sleep disorders, and availability and reliability in administrative claims databases. Age, gender (for the cisgender group), race/ethnicity, and region of residence in the United States were included. Relevant mental health disorders were included by ≥ 1 claim for mood affective disorders (ICD-10-CM: F30.x–F39.x) and anxiety disorders (ICD-10-CM: F40.x and F41.x).
Statistical analysis
Descriptive characteristics were summarized for TGNC and cisgender groups and then for transmasculine, transfeminine, and TGNC not on GAT. Unadjusted and age-adjusted logistic regression models were implemented, first for any sleep disorder as an inclusive outcome and then for insomnia, sleep apnea, or any other sleep disorders (hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders) as separate outcomes. We compared the odds of sleep disorders between TGNC and cisgender youth and then within the sample of TGNC youth between those on GAT relative to those not pursuing GAT. Effect estimates were reported as odds ratios (OR) with 95% confidence intervals (CIs). Analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina).
RESULTS
In this sample of 1,216,044 youth aged 12 to 25 years, 2,652 (0.2%) obtained a diagnosis of TGNC. The TGNC youth were predominately (70.2%) White, with a mean age of 19.3 years (3.6 SD). Mood affective disorders and anxiety were highly prevalent in TGNC (56.1% and 52.8%, respectively) relative to cisgender youth (9.2% and 11.7%, respectively) (Table 1). In further analyses restricted to TGNC youth, we excluded 49 individuals with both transmasculine and transfeminine identifiers.
Table 1.
Demographics and mental health characteristics of transgender or gender-nonconforming and cisgender youth in the United States.
| Transgender or gender-nonconforming (n = 2,652) n (%) | Cisgender (n = 1,213,392) n (%) | |
|---|---|---|
| Age, mean (SD) | 19.3 (3.6) | 18.3 (4.0) |
| 12–14 years | 257 (9.7) | 271,541 (22.4) |
| 15–17 years | 652 (24.6) | 274,414 (22.6) |
| 18–21 years | 893 (33.7) | 339,733 (28.0) |
| 22–25 years | 850 (32.1) | 327,704 (27.0) |
| Gender | ||
| Female | 636,693 (52.5) | |
| Male | 576,665 (47.5) | |
| Race | ||
| White | 1,861 (70.2) | 774,388 (63.8) |
| Black | 123 (4.6) | 83,074 (6.9) |
| Hispanic | 184 (6.9) | 140,636 (11.6) |
| Asian | 53 (2.0) | 50,848 (4.2) |
| Other/unknown | 431 (16.3) | 164,446 (13.6) |
| US region of residence | ||
| West | 741 (27.9) | 261,563 (21.6) |
| Midwest | 747 (28.2) | 330,502 (27.2) |
| South | 896 (33.8) | 507,714 (41.8) |
| Northeast | 268 (10.1) | 113,613 (9.4) |
| Mental health disorders | ||
| Mood affective disorders | 1,490 (56.1) | 111,642 (9.2) |
| Anxiety | 1,400 (52.8) | 142,488 (11.7) |
SD = standard deviation.
Table 2 represents demographic, and mental health characteristics of 2,603 TGNC youth, stratified by GAT and affirmed gender. Over half of TGNC youth pursued GAT, and of those 868 identified as transmasculine and 519 as transfeminine. Lower prevalence of mood affective disorders and anxiety was observed among TGNC youth on GAT (transmasculine and transfeminine) in comparison to those not on GAT.
Table 2.
Demographics and mental health characteristics of transgender or gender-nonconforming youth (n = 2,603) stratified by gender-affirming therapy status and gender.
| Transmasculine (n = 868) n (%) | Transfeminine (n = 519) n (%) | Not on GAT (n = 1,216) n (%) | |
|---|---|---|---|
| Age, mean (SD) | 20.6 (3.0) | 20.7 (2.9) | 17.8 (3.6) |
| 12–14 years | 16 (1.8) | * | 232 (19.1) |
| 15–17 years | 138 (15.9) | 71 (13.7) | 432 (35.5) |
| 18–21 years | 348 (40.1) | 206 (39.7) | 321 (26.4) |
| 22–25 years | 366 (42.2) | 233 (44.9) | 231 (19.0) |
| Race | |||
| White | 575 (66.2) | 375 (72.3) | 878 (72.2) |
| Black | 54 (6.2) | 22 (4.2) | 46 (3.8) |
| Hispanic | 58 (6.7) | 33 (6.4) | 92 (7.6) |
| Asian | 13 (1.5) | * | 28 (2.3) |
| Other/unknown | 168 (19.4) | 79 (15.2) | 172 (14.1) |
| US region of residence | |||
| West | 228 (26.3) | 179 (34.5) | 323 (26.6) |
| Midwest | 230 (26.5) | 107 (20.6) | 397 (32.6) |
| South | 323 (37.2) | 178 (34.3) | 378 (31.1) |
| Northeast | 87 (10.0) | 55 (10.6) | 118 (9.7) |
| Mental health disorders | |||
| Mood affective disorders | 423 (48.7) | 258 (49.7) | 774 (63.7) |
| Anxiety | 397 (45.7) | 229 (44.1) | 730 (60.0) |
*n < 11, data not shown for deidentification purposes. GAT = gender-affirming therapy, SD = standard deviation.
Age-adjusted logistic regression models showed 4-fold increased odds of any sleep disorder in TGNC youth compared with cisgender individuals (OR = 4.3, 95% CI 3.8, 4.9). Specifically, increased odds of insomnia (OR = 5.4, 95% CI 4.7, 6.2), sleep apnea (OR = 3.0, 95% CI 2.3, 4.0), and other sleep disorders (OR = 3.1, 95% CI 2.5, 3.9) were observed in TGNC vs cisgender youth (Table 3).
Table 3.
Associations between transgender or gender-nonconforming identity and sleep disorders in a US youth sample.
| TGNC (n = 2,652) % (n) | Cisgender (n = 1,213,392) % (n) | Unadjusted OR OR (95% CI) | P | Age adjusted OR OR (95% CI) | P | |
|---|---|---|---|---|---|---|
| Any sleep disorder | 297 (11.2) | 32,649 (2.7) | 4.6 (4.0, 5.2) | <.001 | 4.3 (3.8, 4.9) | <.001 |
| Insomnia | 221 (8.3) | 18,570 (1.5) | 5.9 (5.1, 6.7) | <.001 | 5.4 (4.7, 6.2) | <.001 |
| Sleep apnea | 48 (1.8) | 6,958 (0.6) | 3.2 (2.4, 4.3) | <.001 | 3.0 (2.3, 4.0) | <.001 |
| Other sleep disorders† | 76 (2.9) | 11,195 (0.9) | 3.0 (2.5, 4.0) | <.001 | 3.1 (2.5, 3.9) | <.001 |
†Other sleep disorders: hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders. CI = confidence interval, OR = odds ratio, TGNC = transgender or gender-nonconforming.
In a sample restricted to TGNC youth, age-adjusted analyses showed decreased odds of any sleep disorder in individuals on GAT (OR = 0.5, 95% CI 0.4, 0.7) relative to those not on GAT. Analyses of specific sleep disorders produced similar results for insomnia (OR = 0.5, 95% CI 0.4, 0.7) and other sleep disorders (OR = 0.5, 95% CI 0.3, 0.9) in TGNC on GAT in comparison to those not on GAT. However, the influence of GAT on sleep apnea in the TGNC youth was not significant (Table 4).
Table 4.
Associations of gender-affirming therapy and sleep disorders in transgender or gender-nonconforming youth (n = 2,603).
| Prevalence n (%) | Unadjusted OR OR (95% CI) | P | Age adjusted OR OR (95% CI) | P | |
|---|---|---|---|---|---|
| Any sleep disorder | |||||
| TGNC not on GAT (n = 1,216) | 178 (14.6) | Reference | Reference | ||
| TGNC on GAT (n = 1,387) | 112 (8.1) | 0.5 (0.4, 0.7) | <.001 | 0.5 (0.4, 0.7) | <.001 |
| Insomnia | |||||
| TGNC not on GAT (n = 1,216) | 135 (11.1) | Reference | Reference | ||
| TGNC on GAT (n = 1,387) | 80 (5.8) | 0.5 (0.4, 0.7) | <.001 | 0.5 (0.4, 0.7) | <.001 |
| Sleep apnea | |||||
| TGNC not on GAT (n = 1,216) | 22 (1.8) | Reference | Reference | ||
| TGNC on GAT (n = 1,387) | 23 (1.7) | 0.9 (0.5, 1.7) | .768 | 0.7 (0.4, 1.2) | .193 |
| Other sleep disorders† | |||||
| TGNC not on GAT (n = 1,216) | 51 (4.2) | Reference | Reference | ||
| TGNC on GAT (n = 1,387) | 24 (1.7) | 0.4 (0.2, 0.7) | <.001 | 0.5 (0.3, 0.9) | .019 |
†Other sleep disorders: hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders. CI = confidence interval, GAT = gender-affirming therapy, OR = odds ratio, TGNC = transgender or gender-nonconforming.
In further analyses, we found significant protective associations between GAT modality (transfeminine or transmasculine) and insomnia, relative to TGNC not on GAT. Protective relationships were also found between transmasculine therapy and other sleep disorders (hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders) but not for sleep apnea. We were unable to estimate the associations in the transfeminine group, given a small number of participants with sleep apnea (data not shown).
DISCUSSION
In a large national administrative claims database of 1,216,044 US youth, 0.2% obtained a TGNC diagnosis, and over half pursued GAT. In TGNC youth, we found a 4-fold increase in odds of sleep disorders relative to cisgender youth. GAT was associated with 50% lower odds of sleep disorders. These findings highlight the burden of sleep disorders in TGNC youth and suggest a protective role for GAT on sleep disorders in TGNC youth.
Sleep health has been rarely examined in transgender youth. Poor sleep has been reported by North American college students who identified as sexual and gender minorities.19,36 In particular, TGNC college students were 3 times more likely to report insomnia symptoms than their cisgender peers.19 A nationally representative sample of US high school students found that more of a third of girls and boys in sexual minority groups reported very short sleep (≤ 5 hours) in comparison to < 20% of heterosexual students.37 This report highlighted a 5-fold increase in odds of insomnia among TGNC relative to cisgender youth.
In contrast to sleep disorders, well-being and mood in TGNC populations have been studied frequently. Reports on TGNC youth and adults estimated a high prevalence of depression and anxiety symptoms, ranging from 31–62%. Concordant with prior findings, we found that 50% of TGNC youth are impacted by mood affective disorders and anxiety. In the general population, associations between mental health and insomnia have been consistently reported as strong and bidirectional.38,39 Indeed, concurrent to sleep disorders, mood and anxiety disorders are disproportionally high in TGNC relative to cisgender individuals.40 Potential pathways that link TGNC identity, mood disorders, and sleep suggest that mental health is likely a mediator in the association between TGNC identity and insomnia. We hypothesized that TGNC identity precedes mental health disorders and that both influence insomnia diagnosis. Thus, mood affective disorders and anxiety were considered as mediators of the relationship between TGNC identity and insomnia and were not included in the regression models to avoid overadjustment.41
Gender identity has also been associated with sleep apnea in TGNC individuals, perhaps as a result of gender-affirming hormone use, as suggested in a case series of TGNC individuals who used gender-affirming hormones.23 Findings of positive associations between testosterone and OSA risk in cismen and negative associations between estrogen and OSA risk in postmenopausal ciswomen support this possibility.25,27
Beyond insomnia and sleep apnea, other sleep disorders, ie hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders, were associated with 3-fold increased odds among TGNC vs cisgender youth, although the nature of these associations is less clear. We were unable to pursue analyses of individual sleep disorders given their low proportion among TGNC youth included in this sample.
To examine whether GAT for TGNC youth is associated with sleep disorders, we created 2 TGNC subgroups by GAT status. Our findings show lower proportion of any sleep disorder among TGNC youth on GAT vs those not on GAT, likely attributed to decreased odds of insomnia. The TGNC group on GAT had 50% lower odds of insomnia relative to those not on GAT. We hypothesized that gender transition could improve mental health, which, in turn, decreases the proportion of insomnia. Indeed, gender-affirming hormone use was associated with lower odds of depression in TGNC individuals,29 although the impact of gender reassignment surgeries on mood disorders was inconclusive.40 GAT may decrease odds of insomnia by improving gender dysphoria, poor mood, and minority stress. A qualitative study showed that 35% of TGNC individuals reported poor sleep due to physically feeling uncomfortable with their body,42 while GAT improved their mood.43 The minority stress theory states that prejudice and discrimination could increase the risk of chronic psychosocial stressors that can lead to poor health in individuals with a minority identity.44,45 Thus, stress experienced by TGNC people is likely related to their identification as a sexual minority group and leads to impaired mental health.36,46 These negative experiences can increase arousal, vigilance, distress, and physiological reactivity that disrupt sleep.47 Overall, GAT could improve gender dysphoria, mood, minority stress, psychosocial outcomes, and social connectedness48–50 that positively influence insomnia.51–53 Alternatively, rather than GAT improving mental health, it is plausible that those receiving GAT may have better mental health prior to initiation of transition and therefore are likely to seek further management for TGNC such as GAT.
The relationships between GAT and sleep apnea have been suggested in a small case series report that included 2 transmasculine individuals, 1 youth and 1 adult. In this report, testosterone use was associated with the development of OSA in both transmasculine individuals, and resolution of OSA was linked to estrogen and androgen blocker use in a transfeminine adult.23 These observations are consistent with findings in cisgender populations where testosterone replacement therapy worsened OSA in men with hypogonadism, whereas hormone replacement therapy was protective in postmenopausal women.25,27
The present study sought to examine associations between GAT and sleep apnea; however, analyses were hindered by the small number of TGNC individuals with sleep apnea. The role of GAT on sleep apnea is biologically plausible, as sex hormones influence ventilation in part through the serotonin system.54 Progesterone, and to a lesser degree estrogen, stimulate the ventilatory drive.55 The effect of testosterone on ventilation is less understood, and available data are conflicting.56,57 Upper airway collapse is a major risk factor for OSA. Estrogen and progesterone increase upper airway dilator muscle activity, decreasing the risk for airway collapse.58 Testosterone may increase the risk of OSA, but the physiology is less clear.59,60 The aforementioned findings are possible mechanisms of GAT––particularly gender-affirming hormones––for modifying the risk of sleep apnea. In cisgender men with hypogonadism and postmenopausal women the effects on sleep apnea risk have been reported within weeks of starting hormone therapy25,27; therefore, the 1-year period of continuous insurance enrolment of this study would suffice to develop sleep complaints.
The odds of other sleep disorders (hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorders) were 50% lower in TGNC youth on GAT relative to those not on GAT. However, the nature of the suggested protective effect of GAT on hypersomnolence, parasomnia, circadian rhythm, and sleep movement disorder is less known.
This study has several strengths. First, the utilization of a real-world, nationally large administrative claims database increases the generalizability of these findings. Second, administrative claims data have high accuracy for identifying sleep disorders. Third, the use of ICD-10-CM codes allowed us to distinguish specific disorders. Limitations include a cross-sectional study design that does not support temporal examinations. The Optum Clinformatics Data Mart Database may not represent all US regions and population and a 1-year study period may not identify all TGNC on GAT. Body mass index may contribute to sleep disorders onset; however, it is not available in administrative claims data. Another limitation is the ICD-10-CM code G47.3x that corresponds to all sleep apnea types. Finally, despite the high validity of ICD-10-CM codes to identify TGNC individuals, the sensitivity and specificity of claims-based algorithms for TGNC youth and sleep disorders are unknown.
To address current gaps, future studies should employ a longitudinal design to estimate the burden of sleep disorders prior to and following GAT in the TGNC population.
CONCLUSIONS
In a large sample of US youth, we report increased odds of sleep disorders among TGNC in comparison to cisgender individuals. GAT showed a protective effect on sleep disorders among TGNC youth. Associations between GAT and sleep apnea were inconclusive.
DISCLOSURE STATEMENT
All authors have seen and approved the manuscript. Work for this study was performed at the University of Michigan, Ann Arbor. Dr. Gavidia was supported by a T32 grant from the NINDS (NIH/NINDS T32 NS007222); Dr. Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund; Dr. Selkie was supported by a K23 grant from the NICHD (NIH/NICHD K23 HD093815-03); Dr. Dunietz was supported by a Mentored Research Scientist Development Award from the NHLBI (K01 HL144914). The authors report no conflicts of interest.
ABBREVIATIONS
- CI
confidence interval
- CPT
Current Procedural Terminology
- GAT
gender-affirming therapy
- HCPCS
Healthcare Common Procedure Coding System
- ICD-10-CM
Classification of Diseases Tenth Revision Clinical Modification
- OR
odds ratio
- OSA
obstructive sleep apnea
- TGNC
transgender or gender-nonconforming
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