Short- and Long-Term Clinical Skin Effects of TestosteroneTreatment in Trans Men

Katrien Wierckx, MD,1* Fleur Van de Peer,1* Evelien Verhaeghe, MD, PhD,† David Dedecker,*Eva Van Caenegem, MD,* Kaatje Toye,* Jean Marc Kaufman, MD, PhD,* and Guy T’Sjoen, MD, PhD*‡

*Department of Endocrinology, Ghent University Hospital, Ghent, Belgium; †Department of Dermatology, GhentUniversity Hospital, Ghent, Belgium; ‡Department of Sexology and Gender Problems, Ghent University Hospital, Ghent,Belgium

DOI: 10.1111/jsm.12366

A B S T R A C T

Introduction. Our knowledge concerning the effects of testosterone (T) therapy on the skin of trans men (female-to-male transsexuals) is scarce.Aim. The aim of this study was to evaluate the short- and long-term clinical effects of T treatment on the skin oftrans men.Methods. We conducted a prospective intervention study in 20 hormone naive trans men and a cross-sectional studyin 50 trans men with an average of 10 years on T therapy.Main Outcome Measures. Acne lesions were assessed using the Gradual Acne Grading Scale, hair patterns using theFerriman and Gallwey classification (F&G), and androgenetic alopecia using the Norwood Hamilton Scale.Results. T treatment increased facial and body hair growth. The F&G score increased progressively from a medianvalue of 0.5 at baseline to a value of 12 after 12 months of T administration. After long-term T treatment, all but onetrans man achieved an F&G score indicative of hirsutism in women, with a median value of 24. Only one trans manacquired mild frontotemporal hair loss during the first year of T treatment, whereas 32.7% of trans men had mildfrontotemporal hair loss and 31% had moderate to severe androgenetic alopecia after long-term T therapy. Thepresence and severity of acne increased during the first year of T therapy, and peaked at 6 months. After long-termT treatment, most participants had no or mild acne lesions (93.9%). Dermatological outcome was not demonstrablyrelated to individual serum T or dihydrotestosterone levels.Conclusions. T treatment increased facial and body hair in a time-dependent manner. The prevalence and severityof acne in the majority of trans men peaked 6 months after beginning T therapy. Severe skin problems were absentafter short- and long-term T treatment. Wierckx K, Van de Peer F, Verhaeghe E, Dedecker D, Van Caenegem,E, Toye K, Kaufman JM, and T’Sjoen G. Short- and long-term clinical skin effects of testosterone treatmentin trans men. J Sex Med 2014;11:222–229.

Key Words. Testosterone; Gender Identity Disorder; Skin; Transsexualism; Gender Dysphoria; Female-to-MaleTranssexual

Introduction

A ndrogens and estrogens are known to affectthe skin pilosebaceous unit (PSU), and both

androgen and estrogen receptors are expressedin the sebocytes and hair follicle dermal papilla[1,2]. The biological action of testosterone (T)

on peripheral tissues, such as the scalp, is,in part, affected by its local conversion todihydrotestosterone (DHT) by 5α-reductase (type1 and 2). T can also be converted to estradiol (E2)by the aromatase enzyme, which is also promi-nently present in the PSU [3].

Androgens are required for sexual hair andsebaceous gland development and play a centralrole in stimulation of sebaceous gland growth and1These authors contributed equally to this manuscript.

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differentiation [4,5]. In addition, androgens havebeen shown to increase the size of the hair follicle,the diameter of the hair, and the proportion oftime that terminal hairs spend in the anagen phase[4–6]. The effects of E2 on the PSU unit are lessunderstood but estrogens are known to play animportant role in human hair growth control [7].Furthermore, given that T is aromatized into E2in many tissues, it may be possible that someeffects of T on the PSU unit are mediated by E2.Alternatively, the local balance between E2 andandrogens may determine local E2 and androgenaction [7,8].

Androgen excess in women is associated withimportant dermatological effects, such as acne vul-garis, hirsutism, and androgenetic alopecia [9–11],with potentially important psychological disturb-ing effects [12]. However, androgens are not thesole contributors to the pathogenesis of these dis-orders [4,13], and wide interindividual variabilityin androgen effects has been described. Suscep-tible persons may experience these pathologieswith normal female androgen levels, whereasothers experience no skin problems with markedlyelevated androgen levels [4,13,14].

Female-to-male transsexual persons (hereinreferred to as trans men) receive T treatment toinduce virilization and suppress menstruation [15].Given the important effects of sex steroids onsebum production and distribution as well as onthe growth of body and scalp hair, dermatologicalchanges during cross-sex hormone treatment areimportant to address. However, to our knowledge,only one study has previously investigated theeffects of T treatment on the skin in trans men.Giltay and Gooren [16] examined the changes ofhair growth and sebum production during the firstyear of cross-sex hormone therapy in 17 transmen, all treated with intramuscular T esters every14 days. However, the short-term dermatologicaleffects of T undecanoate, a long-acting depotpreparation administered every 3 months, havenot been previously addressed in trans men. Inaddition, long-term dermatological outcomes of Ttreatment have not yet been described in thispatient population.

Aim

The aim of the current study is to investigate theshort- and long-term dermatological effects of Ttreatment in a relatively large group of transmen.

Methods

Study Population and Study ProceduresAll trans participants were diagnosed with genderidentity disorder (Diagnostic and StatisticalManual of Mental Disorders-III-R and DSM-IV,302.85) and were treated at the center for Sexologyand Gender Problems at the Ghent UniversityHospital (Ghent, Belgium). Two different studieswere performed.

Prospective Intervention StudyTwenty Caucasian trans men before start of cross-sex hormone therapy and sex reassignment surgery(SRS) were included in this study. All men receivedintramuscular T undecanoate (1,000 mg) (Nebido)every 3 months. Patients were followed and moni-tored every 3 months during the first treatmentyear (Clinical trial number: NCT01072825).

Cross-Sectional StudyThis study included 50 trans men who underwentSRS, including hystero-oophorectomy and mas-tectomy. On average, participants were 8.7 yearsafter SRS (range 9 months–22 years). All startedhormonal therapy at least 2 years before SRS. Themajority of participants were Belgians (n = 48),with one Dutch subject and one Iranian subject.Detailed descriptions of this study population canbe found elsewhere [17,18].

Trans men had been using T treatment for anaverage of 9.9 years, (range 3.2–27.5 years).Current cross-sex hormonal therapy consisted ofintramuscular T treatment with either a mixture ofT esters (T decanoate 100 mg, T isocaproate60 mg, T fenylpropionate 60 mg, and T propio-nate 30 mg/mL) every 2 or 3 weeks (n = 35), Tundecanoate (1,000 mg) every 12 weeks (n = 7), ortransdermal T (50 mg) daily (n = 8). One partici-pant used both oral T undecanoate (40 mg, oncedaily) and T gel (50 mg per 5 g, 50 mg daily). Alltrans men had physiological male T levels.

Exclusion criteria for both studies includedtreatments or disorders affecting sex hormonestatus: untreated hypo- or hyperthyroidism,Cushing syndrome, alcohol abuse, mucoviscidosis,malabsorption, cirrhosis, chronic kidney failure, orcurrent (<2 years) or prolonged use of corticoste-roids, anabolic steroids, and antiandrogens. Bothstudies complied with the recommendations of theDeclaration of Helsinki and were approved by theEthics Committee of the Ghent University Hos-pital. All participants gave their written informedconsent.

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Main Outcome MeasuresMedical HistoryIn both studies, a self-constructed questionnairewas completed with questions pertaining tomedical history, current and past hormonal treat-ment, medication use, and dermatological history.

Degree of Hair GrowthThe degree of hair growth was subjectivelyassessed according to the modified Ferriman andGallwey (F&G) method [19] in which nine sites(lip, chin, chest, upper back, sacroiliac region,upper abdomen, lower abdomen, arm, and medialthigh) are graded according to the following:0 = none, 1 = slight, 2 = moderate, 3 = dense, and4 = very dense. The F&G score has a minimumvalue of 0 and a maximum of 36. Only terminalhair growth is considered in the scoring. A score ofgreater than 8 in an androgen-dependent area wasconsidered indicative of hirsutism.

Androgenetic alopecia was assessed using theNorwood/Hamilton classification [20].

Satisfaction Male Hair PatternSatisfaction with the male hair pattern wasassessed using a five-point Likert scale from veryunsatisfied to very satisfied.

Acne EvaluationClinical assessments of current acne lesions wereperformed on the face and back of subjects accord-ing to the Global Acne Grading Scale (GAGS)[21]. The GAGS considers six locations on the faceand chest/upper back, with a factor for each loca-tion based roughly on surface area, distribution,and density of PSUs. The borders on the face aredelineated by the hairline, jaw line, and ears. Nomagnifying glass or skin stretching is allowed andgood lighting is taken into account. The chest andupper back have been included because they arecritical in order to assess the severity of the acne.Each of the six locations is graded separately on a0–4 scale, with the most severe lesion within alocation determining the local score. Thesegrading scores are then multiplied by the factor ofeach location (forehead ×2, right cheek ×2, leftcheek ×2, nose ×1, chin ×1, chest and upper back×3). The global score is the summation of allthe local scores (= grades × factors). The globalscores are subdivided into categories: noactive acne lesions (score = 0), mild active acnelesions (score = 1–18), moderate active acnelesions (score = 19–30), severe active acne lesions

(score = 31–38), and very severe acne lesions(score > 39).

Sebum Production and Acne Scar EvaluationIn the cross-sectional study, we additionally evalu-ated sebum production using the Dual TapeSebum Test Kit, Cortex Technology (CudermCorporation, http://www.cortex.dk) 1 hour afterthorough alcohol cleansing. The Sebutape tech-nique provides information about sebaceous glandfunction expressed in a score ranging from 1 to 10:low production of sebum (values 1, 2, or 3), normalproduction of sebum (values 4, 5, 6, or 7), and highproduction of sebum (values 8, 9, or 10). The areain the midline of the forehead was tested becausethis is an area where sebaceous glands are thelargest and most numerous.

In this study, we also assessed acne scarringon the face of subjects according to theÉchelle d’evaluation Clinique des cicatrices d’acné(ECCA) grading scale (min score = 0; maxscore = 540) [22].

Biochemical DeterminationsIn all subjects, venous blood samples wereobtained between 8:00 am and 10:00 am Usingthese blood samples, hematocrit (Sysmex-XE-2100 Hematology Analyzer, Goffin Meyvis, Etten-Leur, the Netherlands), creatinine, and totalcholesterol (Cobas C501 + Modular, Roche Diag-nostics, Mannheim, Germany) were determined inthe serum. Commercial immunoassay kits wereused to determine serum concentrations ofsex hormone-binding globulin (SHBG) (OrionDiagnostica, Espoo, Finland), luteinizinghormone (LH), follicle-stimulating hormone, andestradiol (Modular; Roche Diagnostics, Mann-heim, Germany). Baseline T levels in hormonenaive trans men were determined by using liquidchromatography–mass spectrometry (AB Sciex5500 triple–quadrupole mass spectrometer, ABSciex, Toronto, Canada). T levels within the malerange were determined using immunoassaykits (Modular; Roche Diagnostics, Mannheim,Germany). DHT was measured by LC–MS afterpaper chromatography. The intra- and interassaycoefficients of variation for all assays were ≤10%.

Statistical AnalysesThe normal distribution of all variables was testedusing the Kolmogorov–Smirnov one-sample test.Variables with a normal distribution weredescribed in terms of the mean and standard devia-tion or in the case of non-normal distribution, the

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median (first to third quartiles). Correlationsbetween normally distributed parameters were cal-culated using Pearson’s correlation coefficient andotherwise by Spearman’s correlation coefficient.Analysis of variance tests for repeated measure-ments were used to explore dermatologicalchanges during the first year of T treatment.

We used multiple regression analyses with abso-lute changes in dermatological variables as thedependent variable and absolute changes in endo-crine measurements as the independent variable toinvestigate associations of changes in endocrinemeasurements with dermatological changes.

PASW 21.0 software package (SPSS Inc.,Chicago, IL, USA) was used for all analyses. A Pvalue <0.05 was considered statistically significant;all P values were two tailed.

Results

The general characteristics of the study popula-tions are summarized in Table 1.

Hair Growth and Hair DistributionProspective StudyT treatment increased facial and body hair growthin all subjects. The F&G score increased progres-sively from a median of 0.5 at baseline to 12.0 after12 months of T administration (Table 2). After 6months of T treatment, more than half of theparticipants (53.8%) had scores >8, which indi-cates hirsutism in women. After 12 months, themajority of trans men (80.0%) had scores >8(Figure 1). Wide interindividual variability wasobserved as the absolute increase in F&G scoresranged from 2 to 25.

Cross-Sectional StudyAll but one participant (n = 49) acquired an F&Gscore >8, with a median score of 24 (range 6–34)(Figure 1). The subject with an F&G score of 6had been on T therapy for 43 months.

Satisfaction with the obtained male hairpattern was positively associated with the F&Gscore (r = 0.49, P < 0.001). No associations wereobserved between duration of T therapy, and typeof T therapy, and F&G score (data not shown).

Evaluation of Androgenetic AlopeciaProspective StudyOne subject developed a mild frontotemporal hairloss during the first year of T treatment(Norwood/Hamilton score II).

Cross-Sectional StudyEighteen participants (36.7%) experienced noscalp hair loss (Norwood/Hamilton score I),whereas 32.7% (n = 16) had mild frontotemporalhair loss (Norwood/Hamilton score II). Fifteenparticipants (31%) had moderate to severe alope-cia (Norwood/Hamilton score ≥ III). A significantcorrelation between alopecia and age was observed(r = 0.31, P = 0.03). No associations were observedbetween duration of T therapy, and type of Ttherapy, and alopecia (data not shown).

Table 1 General characteristics of the study populations

Prospective studyBaseline visit(N = 20)

Cross-sectionalstudy (N = 50)

Age (years) 26.6 ± 8.3 37 ± 8.2Age at SRS (years) — 30 ± 8.2Height (cm) 163.7 ± 4.7 165 ± 6.7Weight (kg) 63.9 ± 14.0 67.5 ± 11.5BMI (kg/m2) 23.7 ± 4.5 24.8 ± 3.8Use of hormone

therapy (%)100 100

Current smoking (%) 25.0 28T (ng/dL) 30.3 (20.6–46.5) 631.1 (466.0–1,019.2)DihydroT (ng/dL) 13.1 (9.1–18.7) 64.5 (46.3–117.3)Estradiol (pg/mL) 88.3 (44.6–140) 34.4 (24.7–49.7)SHBG (nmol/L) 67.7 (17.8–84.5) 30.1 (22.5–38.5)LH (U/L) 5 (3.7–8.1) 3.7 (0.2–28.5)Creatinin (mg/dL) 0.8 (0.7–0.8) 0.9 (0.9–1.0)Hematocrit (%) 41.6 ± 3.0 48.8 ± 2.8Total cholesterol

(mg/dL)172.2 ± 29.1 207 ± 35

Data are presented as mean ± SD or median (first to third quartiles) in case ofnon-Gaussian distribution.SD = standard deviation

Table 2 Hormonal and dermatological changes during T therapy for 12 months

Baseline 3 months 6 months 9 months 12 months P *

T (ng/dL) 30.3 (20.6–46.5) 483.1 (364–591) 568.2 (467–711) 650 (406–781) 610.5 (459.3–825.2) <0.001DihydroT (ng/dL) 3.1 (8.2–19.1) — — — 49.4 (35.0–62.8) <0.001Estradiol (pg/mL) 88.3 (44.6–140) 35.8 (32.6–46.9) 38.9 (31.3–48.2) 39.4 (23.6–46.1) 39.7 (7.9–41.9) 0.002SHBG (nmol/L) 67.7 (17.8–84.5) 34.8 (22.7–52.1) 32.3 (21.1–49.2) 35.7 (24.3–52.1) 34.0 (22.6–40.7) 0.001LH (U/L) 5 (3.7–8.1) 3.5 (0.4–8.1) 3 (0.4–7.2) 2.8 (0.4–12) 2.9 (0.1–13.5) nsFSH (U/L) 4.2 (3.0–6.3) 6.0 (1.7–7.1) 5.1 (1.7–7.1) 5.2 (2.6–10.7) 4.7 (1.0–7.8) nsHematocrit (%) 41.6 ± 3.0 43.4 ± 2.9 44.4 ± 2.6 44.2 ± 3.6 45.5 ± 1.9 <0.001

Data are presented as mean ± SD or median (first to third quartiles) in case of non-Gaussian distribution.*ANOVA repeated measures.FSH = follicle stimulating hormone; LH = luteinizing hormone; SHBG = sex hormone-binding globulin; ns = not significant

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Acne EvaluationProspective StudyAt baseline, 35% of the subjects had facial acneand 15% had acne on the back and/or chest. After6 months of androgen administration, facial acnewas present in 82.4% of subjects and in 88.2% ofsubjects on the back and/or chest. After 12 monthsof androgen therapy, facial acne was still present in55% of participants and 50% of participants onthe back and/or chest. The presence of acne as wellas the severity increased during T administration(Figure 2). However, during our observations, themajority of trans men had mild acne lesions, 20%had moderate acne lesions, and none had severe orvery severe acne lesions according to the GAGS.

During the first year of androgen treatment,50% of trans men used one or more topicalproduct (benzoyl peroxide [5% gel] [n = 6],adapalene [0.1%], and benzoyl peroxide [2.5%] gel[n = 6], or over the counter topical products[n = 4]). Three subjects used oral antibioticsduring the course of the study to treat acne.

Cross-Sectional StudyParticipants had a median total GAGS of 3.0(range 0–24) (Figure 2C). According to this scale,the majority (63.3%) had mild acne lesions. Threeparticipants (6%) had moderate acne scores, and15 participants (30.6%) had no active acne lesions.Younger participants had more acne lesions(P = 0.05). The majority of participants (65%) hadno acne scars, according to the ECCA gradingscale. The mean score was 12.55 (standard devia-tion 25.4; range 0–115).

Sebum Production Evaluation in theCross-Sectional StudySebum production was performed using theSebutape technique on the forehead in 40 trans

men. A median value of 2.0 was observed with arange from 1 to 9. Twenty-five participants (62.5%)had a low sebum production 1 hour after alcoholcleansing; however, up to 95% of all participants(n = 38) had low to normal sebum production(value of 1–6). Only two subjects showed elevatedlevels of sebum production. No significant associa-tions were found between sebum production andacne lesions, duration of hormonal therapy, andtype of hormonal therapy (data not shown).

Associations Between Dermatological Outcome andSex SteroidsProspective StudyNo associations were observed between absolutechanges in F&G scores, male pattern baldness,acne lesions, and absolute changes in LH, T,DHT, E2, or SHBG (data not shown).

Cross-Sectional StudyNo significant associations were found betweenF&G scores, male pattern baldness, sebum pro-duction, acne lesions, and LH, T, DHT, E2, orSHBG apart from a positive association betweenF&G scores and E2 (linear regression; β = 3.19;P = 0.03).

Conclusions

This study investigated the short- and long-termdermatological effects of T treatment in transmen. We observed that the majority of trans menacquired an F&G score indicative of hirsutism inbiological women during the first year of Ttherapy. These findings corroborate those fromGiltay and Gooren [16]. As expected, long-term Tadministration further increased F&G scores. Allbut one participant achieved an F&G score >8,

Figure 1 Ferriman and Gallwey(F&G) scores during T treatment.Data are presented as the medianF&G score; error bars represent 95%confidence intervals. Long-term Ttreatment represents median F&Gscores from the cross-sectionalstudy. P value results from ANOVA

repeated measures analyses.

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with wide interindividual variability. Our results,therefore, suggest that substantial changes in hairgrowth and hair distribution occur during the firstyear of T treatment. However, slower but impor-tant increases in hair growth can be expected after.Moreover, the further increase in F&G scorescontributes to increased patient satisfactionbecause it was strongly associated with theobtained male hair pattern.

With respect to the dermatological side effectsof androgen therapy, we observed that the pres-ence and severity of acne lesions increased duringT treatment. However, most men developed onlymild acne and none suffered from severe or verysevere acne according to the GAGS. However, thefact that half of our participants began usingtopical agents or oral antibiotics during our studyperiod shows that, although mild and moderate,these acne lesions are clinically significant.

Similar to the observation of Giltay and Gooren[16], we found that most acne lesions occurredwithin the first 6–9 months of treatment, with adecrease at 12 months. These results may berelated to the acne treatment used by several of ourpatients. Alternatively, it may indicate that theinitial increase in sebum production and the asso-ciated acne lesions resulting from male T levels inbiological females attenuate over time. Indeed, ourlong-term observations also show markedly lowermedian acne scores compared with scores duringthe first year of treatment. Furthermore, afterlong-term T therapy, the vast majority of transmen had no or mild acne scars, suggesting that thelong-term dermatological side effects related toacne are relatively rare in this specific patientpopulation.

It was also found that the risk of developingandrogenetic alopecia was low during the first year

Figure 2 Acne scores during Ttreatment. Data are presented as themedian score; error bars representstandard error. Long-term T treat-ment represents the median scorefrom the cross-sectional study. Pvalue results from ANOVA repeatedmeasures analyses.

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of T administration. However, as expected, withlonger T exposure, the prevalence of androgeneticalopecia increased. The prevalence of moderate orsevere androgenetic alopecia after a mean T treat-ment period of 10 years in trans men between theages of 18 and 50 (25%) was significantly lowercompared with the general population, in whichapproximately 42% of males aged between 18 and50 years suffer from this condition [23]. It is likelythat shorter exposure times of T may explain theseobservations and that further increases can beexpected with longer durations of T administra-tion. Another possible explanation might be thatthe age at which T exposure is commenced mayplay a significant role in the pathogenesis of andro-genetic alopecia. Alternatively, because aromataselevels in the frontal hair follicles from women werefound to be approximately six times higher thanthose in men, it is possible that natal women areless prone to develop androgenetic alopecia due todifferences in local T and E2 ratios [24]. However,whether this is the case in trans men after long-term T treatment remains unknown.

As expected, we observed no associationsbetween serum T or DHT and dermatologicaloutcome considering the single-point measure-ments of T in these men, the differences in types ofT administration, and the variable timing of sam-pling in relation to the last T dosing in our cross-sectional study. Furthermore, most studies havedescribed a wide interindividual variability andobserved only weak or no association between Tand DHT levels and acne or hirsutism scores[14,16]. The variability in PSU responsiveness toandrogens may be related, in part, to variations inandrogen metabolism; for example, variations in5α reductase activity, 3β-hydroxysteroid dehydro-genase activity, aromatase activity, or differences inandrogen receptor sensitivity [14,25].

Interestingly, a positive relationship wasobserved between E2 and F&G score in our cross-sectional study. One explanation could be thatgiven the variability of T levels due to single-pointmeasurements of T, the differences in the types ofT administration and the variable timing of sam-pling in relation to the last T dosing, E2 may be amore stable marker of T exposure in trans men.

Some limitations of our study need to beaddressed. First, we used the modified F&Gmethod to evaluate hair growth and hair distribu-tion. This method has some limitations, such as itssubjective nature, the failure to account for afocally high score, and the lack of consideration ofother androgen sensitive areas (for example, side-

burns and buttocks) [26]. Objective tools are avail-able to examine hair growth and distribution, suchas determining the density of terminal hairs bydirect counting [27] or photography [28].However, these techniques are predominantlyuseful for assessing hair growth rates and theextent of terminal hair density in a specific bodyarea. They are considered much less useful toassess the extent of total body hair or face terminalhair density [29], which was the main aim of ourstudy.

Second, the cross-sectional design of our long-term follow-up study implies that no causal rela-tionships can be drawn. A long-term prospectivestudy is preferable. Nevertheless, because this isthe first study addressing long-term dermatologi-cal outcomes in trans men, our findings add valu-able information.

In conclusion, T treatment time dependentlyincreased facial and body hair. The prevalence andseverity of acne in the majority of trans menpeaked at 6 months after beginning T therapy.However, severe skin problems were absent aftershort- and long-term T treatments. Dermatologi-cal outcome was not demonstrably related to indi-vidual serum T or DHT. The observed significantassociation with E2 remains to be established.

Corresponding Author: Katrien Wierckx, MD,Department of Endocrinology, Ghent University Hos-pital, De Pintelaan 185, 9000 Ghent, Belgium. Tel:+32 9 332 19 66; Fax: 0032 9 332 38 86; E-mail:katrien.wierckx@ugent.be

Conflict of Interest: The authors report no conflicts ofinterest.

Statement of Authorship

Category 1(a) Conception and Design

Katrien Wierckx; Guy T’Sjoen; Evelien Verhaeghe(b) Acquisition of Data

Katrien Wierckx; Eva Van Caenegem; Fleur Van dePeer; David Dedecker; Kaatje Toye

(c) Analysis and Interpretation of DataKatrien Wierckx; Evelien Verhaeghe; Guy T’Sjoen;Jean Marc Kaufman

Category 2(a) Drafting the Article

Katrien Wierckx; Fleur Van de Peer; Guy T’Sjoen(b) Revising It for Intellectual Content

Katrien Wierckx; Fleur Van de Peer; DavidDedecker; Evelien Verhaeghe; Kaatje Toye; EvaVan Caenegem; Jean Marc Kaufman; Guy T’Sjoen

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Category 3(a) Final Approval of the Completed Article

Katrien Wierckx; Fleur Van de Peer; DavidDedecker; Evelien Verhaeghe; Kaatje Toye; EvaVan Caenegem; Jean Marc Kaufman; Guy T’Sjoen

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