UH Publishes Study of Association Between Testosterone Therapy and Sleep Apnea in Transmasculine Individuals

Innovations in Pulmonology, Critical Care & -Sleep Medicine | Fall 2025

Ambrose Chiang, MD

University Hospitals sleep specialist Ambrose Chiang, MD recently worked with three Case Western Reserve University School Medicine students to publish a retrospective population-based cohort study in the International Journal of Transgender Health evaluating whether testosterone therapy is linked to a higher risk of obstructive and central sleep apnea (OSA and CSA) in transmasculine individuals.

The students — Anastasia Christ, Matthew Loria and Tomasz Tabernacki — utilized TriNetX, a U.S. electronic health record database of over 120 million subjects, to identify 22,745 transmasculine individuals diagnosed with gender incongruence and documented testosterone use, excluding those with a prior sleep apnea diagnosis.

Examining a 20-year period from 2004 to 2024, the researchers found that the overall risk of sleep apnea was significantly higher in transmasculine individuals than in cisgender females and males. OSA risk was also elevated compared to cisgender females and males, and CSA risk was substantially higher than in cisgender females and mildly higher than in cisgender males.

“These three highly motivated medical students initiated the project, which represents the first well-run, population-based study to demonstrate an association between testosterone therapy and sleep apnea risk for transmasculine individuals,” says Dr. Chiang, a senior staff physician within the University Hospitals Division of Pulmonary, Critical Care and Sleep Medicine and a Clinical Professor at School of Medicine.

Known Sex-differentiated Risks of Sleep Apnea

“Sex differences in sleep apnea risk have been acknowledged for a number of years,” Dr. Chiang says. “For example, OSA is more common in cisgender males than in premenopausal cisgender females.” However, he notes that the relationship between sleep apnea and testosterone supplementation requires additional study.

Exogenous testosterone is commonly used by transmasculine individuals to promote the masculinization of physical traits, including increased muscle mass, decreased fat mass and a deeper voice, helping them align with their gender identity. The effects of this testosterone supplementation may differ between transmasculine individuals and hypogonadal cisgender males.

“The relationship between sleep apnea and testosterone supplementation is complex,” Dr. Chiang says. “Our previous understanding of the transmasculine population was largely based on observational case studies, which suggested an association between testosterone use and the emergence of sleep-disordered breathing in individuals assigned female at birth, indicating a potentially higher risk for sleep apnea. Before this project, there has not been a population-based analysis that has demonstrated statistically significant evidence of increased risk of sleep apnea in this specific patient group.”

The Importance of Close Patient Surveillance

Untreated sleep apnea poses a risk of comorbidities, including adverse cardiovascular outcomes, metabolic dysfunction and neurocognitive impairment such as memory problems, depression and daytime sleepiness.

“Patients and physicians may be unaware that testosterone therapy can increase the risk of sleep apnea in this patient population,” Dr. Chiang says. “It is imperative that clinicians who follow transmasculine individuals on testosterone have heightened diagnostic vigilance and educate them on the symptoms and potential development of sleep apnea.”   

Emerging sleep technologies — from consumer smartwatches like the Apple Watch and Samsung Galaxy Watch to clinical-grade home sleep testing wearables — now offer continuous monitoring of sleep physiologic metrics. For transmasculine individuals, these innovations could lead to earlier detection of sleep apnea and improved health outcomes.

“By monitoring patients’ sleep over an extended period, we can better understand when most transmasculine individuals taking testosterone develop sleep apnea and how testosterone therapy alters sleep dynamics over time,” Dr. Chiang says. “Longitudinal studies utilizing leading-edge technology could provide key insights into the relationship between testosterone therapy and sleep apnea, enabling us to better treat transmasculine patients and improve their quality of life.”

Next Steps

Dr. Chiang emphasizes that further research is needed to discern the underlying mechanisms of sleep apnea in connection with testosterone therapy. “Sleep apnea has a lot to do with upper airway anatomy and respiratory control,” he says. “Future investigations should examine how testosterone impacts CSA pathophysiology, OSA endotypes and upper airway anatomy.”

For more information, contact Dr. Chiang at Ambrose.Chiang@UHhospitals.org.

Contributing Expert:
Ambrose Chiang, MD
Senior staff physician
Division of Pulmonary, Critical Care and Sleep Medicine
University Hospitals Cleveland Medical Center
Clinical Professor
Case Western Reserve University School of Medicine
Division of Sleep Medicine
Louis Stokes Cleveland VA Medical Center