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ArticleTitle Sex Hormone Levels in Lesbian, Bisexual, and Heterosexual Women: Systematic Review and Exploratory
Meta-Analysis
Article Sub-Title
Article CopyRight Springer Science+Business Media, LLC, part of Springer Nature
(This will be the copyright line in the final PDF)
Journal Name Archives of Sexual Behavior
Corresponding Author Family Name Meads
Particle
Given Name Catherine
Suffix
Division Faculty of Health, Education, Medicine and Social Care
Organization Anglia Ruskin University
Address East Road, Cambridge, CB1 1PT, UK
Phone
Fax
Email catherine.meads@anglia.ac.uk
URL
ORCID https://orcid.org/0000-0002-2368-0665
Author Family Name Harris
Particle
Given Name Alexandra
Suffix
Division Division of Women’s Health, Women’s Health Academic Centre
Organization King’s College London and King’s Health Partners
Address 10th Floor North Wing, St Thomas’ Hospital Campus, London, SE1 7EH,
UK
Phone
Fax
Email lexie_harris@icloud.com
URL
ORCID
Author Family Name Bewley
Particle
Given Name Susan
Suffix
Division Division of Women’s Health, Women’s Health Academic Centre
Organization King’s College London and King’s Health Partners
Address 10th Floor North Wing, St Thomas’ Hospital Campus, London, SE1 7EH,
UK
Phone
Fax
Email susan.bewley@kcl.ac.uk
URL
ORCID
Schedule
Received 4 September 2018
Revised 7 April 2020
Accepted 11 April 2020
Abstract Lesbian and bisexual women may have different levels of sex hormones compared to heterosexual women.
We systematically reviewed comparative studies measuring any sex hormones. A protocol was
prospectively registered (PROSPERO—CRD42017072436) and searches conducted in six databases. Any
relevant empirical studies published within the last 50 years reporting any circulating sex hormones in
sexual minority women compared to heterosexual women were included, with no language or setting
restrictions. Inclusions, data extraction, and quality assessment were conducted in duplicate. Random-
effects meta-analyses of hormone levels, using standardized-mean-differences (SMD) were conducted
where five or more studies reported results. From 1236 citations, 24 full papers were examined and 14
studies of mixed designs included, 12 in women without known ovarian problems. Hormones were
measured in plasma (n = 9), saliva (n = 4), and urine (n = 2) and included androstenedione, luteinizing
hormone, estradiol, pregnanediol, progesterone, testosterone, and several other hormones. Most studies
were small, biased, and had considerable heterogeneity. Few found statistically significant differences
between groups. All-sample meta-analysis showed increased testosterone in sexual minority women
compared to heterosexual women (n = 9; SMD = 0.90; 95% Confidence interval (CI) 0.22, 1.57, I 2 = 84%).
This was the only difference found. We conclude that the small amount of heterogeneous research, from
50 years to date, suggests little discernable difference in sex hormone levels between lesbian, bisexual, and
heterosexual women excepting possibly higher testosterone. A large-scale primary study would be required
before placing any certainty in the findings or their implications.
Keywords (separated by '-') Lesbian - Bisexual women - Sex hormones - Systematic review - Meta-analysis
Footnote Information Electronic supplementary material The online version of this article (https://doi.org/10.1007/
s10508-020-01717-8) contains supplementary material, which is available to authorized users.
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Vol.:(0123456789)
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Archives of Sexual Behavior
https://doi.org/10.1007/s10508-020-01717-8
ORIGINAL PAPER
Sex Hormone Levels inLesbian, Bisexual, andHeterosexual Women:
Systematic Review andExploratory Meta-Analysis
AlexandraHarris1· SusanBewley1· CatherineMeads2
Received: 4 September 2018 / Revised: 7 April 2020 / Accepted: 11 April 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Lesbian and bisexual women may have different levels of sex hormones compared to heterosexual women. We systemati-
cally reviewed comparative studies measuring any sex hormones. A protocol was prospectively registered (PROSPERO—
CRD42017072436) and searches conducted in six databases. Any relevant empirical studies published within the last 50years
reporting any circulating sex hormones in sexual minority women compared to heterosexual women were included, with no
language or setting restrictions. Inclusions, data extraction, and quality assessment were conducted in duplicate. Random-
effects meta-analyses of hormone levels, using standardized-mean-differences (SMD) were conducted where five or more
studies reported results. From 1236 citations, 24 full papers were examined and 14 studies of mixed designs included, 12 in
women without known ovarian problems. Hormones were measured in plasma (n = 9), saliva (n = 4), and urine (n = 2) and
included androstenedione, luteinizing hormone, estradiol, pregnanediol, progesterone, testosterone, and several other hor-
mones. Most studies were small, biased, and had considerable heterogeneity. Few found statistically significant differences
between groups. All-sample meta-analysis showed increased testosterone in sexual minority women compared to hetero-
sexual women (n = 9; SMD = 0.90; 95% Confidence interval (CI) 0.22, 1.57, I2 = 84%). This was the only difference found.
We conclude that the small amount of heterogeneous research, from 50years to date, suggests little discernable difference in
sex hormone levels between lesbian, bisexual, and heterosexual women excepting possibly higher testosterone. A large-scale
primary study would be required before placing any certainty in the findings or their implications.
Keywords Lesbian· Bisexual women· Sex hormones· Systematic review· Meta-analysis
Introduction
Health research in sexual minority women has shown that they
differ from heterosexual women in prevalence of several physi-
cal conditions (Meads, Martin, Grierson, & Varney, 2018; Rob-
inson, Galloway, Bewley, & Meads, 2017). For example, a sys-
tematic review showed higher rates of chronic pelvic pain and
cervical cancer, and lower rates of uterine cancer in lesbians
and bisexual women compared to heterosexual women, but no
significant difference in rates of polycystic ovarian syndrome,
endometriosis, and fibroids (Robinson etal., 2017). Another
systematic review demonstrated higher rates of asthma but not
cardiovascular disease, despite higher cardiovascular disease
risk profiles in lesbians and bisexual women compared to het-
erosexual women (Meads etal., 2018). It is currently unclear
whether there are higher rates of breast cancer incidence or
not, due to lack of good quality evidence (Meads & Moore,
2013). One study from the US has shown a higher mortal-
ity rate from breast cancer (Cochran & Mays, 2012), but it is
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s1050 8-020-01717 -8) contains
supplementary material, which is available to authorized users.
* Catherine Meads
catherine.meads@anglia.ac.uk
Alexandra Harris
lexie_harris@icloud.com
Susan Bewley
susan.bewley@kcl.ac.uk
1 Division ofWomen’s Health, Women’s Health Academic
Centre, King’s College London andKing’s Health Partners,
10th Floor North Wing, St Thomas’ Hospital Campus,
LondonSE17EH, UK
2 Faculty ofHealth, Education, Medicine andSocial Care,
Anglia Ruskin University, East Road, CambridgeCB11PT,
UK
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uncertain whether this is due to higher incidence, poorer access
to treatment, or other factors such as avoidance of screening
and over-diagnosis of low-grade lesions. Emerging evidence of
these different illness rates is somewhat puzzling if there were
indeed no physiological differences between sexual minority
women and heterosexual women. One explanation may lie in
different sex hormone levels.
Female sexual orientation has been investigated for dec-
ades (Balthazart, 2011; James, 2005; Meyer-Bahlburg, 1979;
O’Hanlan, Gordon, & Sullivan, 2018), with no firm conclu-
sions drawn about why women may become heterosexual,
bisexual or lesbian, though there has been a suggestion that
prenatal testosterone levels may influence life-long sexual
orientation (Balthazart, 2011). Potential correlations between
sex hormones and sexual orientation have been approached in
three main ways. There has been investigation of differences
in brain sexual differentiation that may lead to lasting differ-
ences in hormonal regulation (Downey, Ehrhardt, Schiffman,
Dyrenfurth, & Becker, 1987). A second route has been by
investigating organizational effects of any alteration of the
prenatal hormone environment in heterosexual and homo-
sexual people (Balthazart, 2011), for example, by looking at
second and fourth finger ratios (2D:4D ratios). Thirdly, and
of relevance to this project, there has been investigation of
activational effects of sex hormones from measurement of
their levels in post-pubertal homosexual people (Downey
etal., 1987).
Some reviews state that prenatal sex hormones are caus-
ally associated with sexual orientation of “butch” lesbians
(James, 2005; O’Hanlan etal. 2018), but this seems to be an
extrapolation from findings from research about women with
congenital adrenal hyperplasia (Stout, Litvak, Robbins, &
Sandberg, 2010). A number of researchers have investigated
various markers that may be associated with the prenatal
hormonal milieu and sexual orientation, such as handedness
(Lalumière, Blanchard, & Zucker, 2000) or second and fourth
finger ratios (2D:4D ratios) (Swift-Gallant, Johnson, Di Rita,
& Breedlove, 2020), among various other parameters. A more
recent extensive review of sexual orientation controversies
discusses differences in genetic and hormonal pathways and
whether either may have a part to play in causation of sexual
orientation (Bailey etal., 2016). While the role of hormones
in mammalian (including human) sexual differentiation is
clear, its role in sexual orientation is less clear.
Historically, much of the research into the biological basis
of sexual orientation has also failed to consider the place of
bisexual women. Studies have tended to either consider bisexu-
ality as a subset of homosexuality or disregard it entirely. There-
fore, in research studies, bisexual women could fall into either
homosexual or heterosexual groups depending on how they
were perceived by the researcher (Van Wyk & Geist, 1995).
There have been several reviews of sex hormone levels and
female sexuality in adulthood, but no systematic reviews. An
early review by Meyer-Bahlburg (1979) concluded that the
majority of female homosexuals have normal sex hormone
levels after puberty but a third have elevated androgen levels.
It is unclear as to how it was discerned that “a third of the
subjects studied had elevated androgen levels” as many of
the included papers were on transsexuals not lesbians and
the normal levels and cut-off used were not clear. Meyer-
Bahlburg also stated that variation in adult androgen levels
did not affect sexual orientation. Subsequent reviews focused
more on issues of trying to extrapolate results from mammals
to humans (Birke, 1981) or discussed potential confounding
effects of environmental stress (Banks & Gartrell, 1995).
If there is a difference in hormone levels between lesbian,
bisexual, and heterosexual women, it is unclear which hor-
mones would be involved, if there is a hormonal “threshold”
which must be met, and if it applies to all (Balthazart, 2011).
There are two primary sources of sex steroids: ovaries and
adrenal glands and the role of each may vary. It may also
be that any differences in hormones found are incidental,
secondary, or confounding, rather than causative, or affect
subgroups of sexual minority women only, such as those who
look or pass as more “masculine.”
It could also be that lesbian practices (or other factors)
might lead to changes in sex hormone levels. Similarly, higher
levels of chronic stress in society might lead to lower average
hormone levels, including for sex hormones such as luteinizing
hormone (LH), follicle-stimulating hormone (FSH), prolactin,
progesterone and testosterone, and higher levels of estrogen.
Most research in this area is on non-human animals.
This systematic review evaluates all published human
research on sex hormone levels in sexual minority women
compared to heterosexual women.
Method
This systematic review was conducted according to a pro-
spective protocol which was lodged with PROSPERO
(CRD42017072436) in September 2017.
Inclusion Criteria
Studies were eligible using the following inclusion criteria:
(1) Population: sexual minority women self-described as; les-
bian or bisexual, women who described themselves as having
sex with women (WSW), or having sex with women and men
(WSWM); or women co-habiting or married to women, and
who were identified as women at birth, and are not taking
exogenous sex hormones. (2) Exposure: any sex hormones
as reported in included papers, including (but not limited to)
androstenedione, estradiol, luteinizing hormone, pregnanediol,
progesterone, and testosterone; (3) Comparator: heterosexual
women or women self-describing as only having sex with men
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Archives of Sexual Behavior
1 3
or married to men; and who were identified as women at birth,
and are not taking exogenous hormones. (4) Study design:
any comparative studies including randomized controlled tri-
als, experimental studies, cohort studies, case–control stud-
ies, cross-sectional analyses, or secondary studies with data
of interest. Studies had to contain primary data and be peer-
reviewed. Only studies published between 1969 and 2019 were
eligible. There were no restrictions on setting or language.
Studies were excluded if: the sexual orientation and/or behav-
ior of women were not clear; there was no comparison with
heterosexual women; there were no outcomes of interest; or
if they were opinions, editorials, conference abstracts, or case
reports. Although not specified in the protocol, studies would
have been excluded if all participants were taking exogenous
hormones (e.g., transgender women who were born male and
were taking estrogen supplements).
Search Strategy, Study Selection, andData
Extraction
Searches were conducted by one reviewer (AH) and checked
by another (CM). Search terms and appropriate synonyms
(as MeSH terms and text words) were developed based on
population and exposures. Six databases (platforms) were
searched—British Nursing Index (Ovid), Cochrane Central
(Cochrane Library), Medline (PubMed), Embase (Ovid),
PsycInfo (Ovid), and Science Citation Index (Web of Sci-
ence). The same search terms were used for each database
but adapted where necessary. A full table of search terms can
be found in Online Supplement Appendix1. Searches were
conducted up to June 2018, and redone using the same search
terms and databases in May 2019. There were no language
restrictions. All titles found by the above search were assessed
for inclusion and abstracts read. Reference lists of relevant
reviews and accepted studies were also hand-searched to
identify any relevant papers not found by database search-
ing. We also checked studies on lesbian health used in other
projects because titles and abstracts may not have mentioned
the measurement of relevant sex hormones. If any titles and
abstracts had relevant information or there was uncertainty,
the full study was read and either accepted for the systematic
review or rejected based on the above inclusion and exclusion
criteria. Full-text assessment to determine inclusion in the
systematic review was carried out by both reviewers (AH,
CM). Any disagreements were resolved by discussion. A
standard form was devised prior to data extraction and qual-
ity scoring, based on the content of the papers and the aims
of the review. Data were extracted by one reviewer (AH) and
checked by another (CM). No authors were contacted about
data discrepancies.
Quality Assessments
Studies were appraised for selection, performance, attrition,
and detection biases (CM), and reported in the categories of
risk of bias, study design issues, and whether the study would
be representative of the general population. There is no single
validated checklist that would be appropriate for all of the
studies due to the diverse study designs so a formal quality
assessment tool could not be used.
Data Analysis
Results for plasma, saliva, and urinary analyses were tabu-
lated separately by the different hormones measured. Results
for women with medical conditions were assessed separately
to those without conditions. Meta-analysis was conducted,
using RevMan version 5.3, on hormone levels where five or
more studies reported results in a similar way. Where mul-
tiple sexual minority subgroups were present, the same het-
erosexual women comparator was used. Heterogeneity was
assessed using the I2 test, using established thresholds. Sub-
group analysis was performed where relevant, according to
sample type (blood, saliva, urine), and presence or absence of
contraceptive pill use, inclusion of postmenopausal women,
and sample taken in the post-luteal phase.
Results
From 1236 citations, 104 abstracts were selected, of which
24 full papers were available and were read. Fourteen stud-
ies were included in the narrative synthesis and nine in the
meta-analyses. See Online Supplement Fig.1 (PRISMA
flowchart) and Online Supplement Table1 (excluded stud-
ies with reasons).
Study Characteristics
The 14 studies were published between 1970 and 2016, and
are detailed in Table1. Study designs used were case–control
(n = 6), cross sectional (n = 6) and cohort (n = 2), see Online
Supplement Table2 (quality assessment of included studies).
Studies were all published in English and originated from:
USA (n = 6), UK (n = 5), Taiwan (n = 1), Canada (n = 1) and
the Netherlands (n = 1). Funding sources were wide ranging,
although four had no details on study funding. Recruitment
methods varied with most studies occurring outside of the
healthcare environment (n = 12), but one was performed in
a gynecology outpatient clinic (Agrawal etal., 2004) and
one in two fertility clinics (Chen etal., 2014). Participants
were recruited by a variety of methods, including advertising,
word of mouth, or consecutive patients; and in some studies a
combination was used. Two early studies gave no recruitment
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Table 1 Characteristics of Included Studies
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Agrawal (2004)
UK
Lesbian women
n = 254
Consecutive recruit-
ing of women who
attended The London
Women’s Clinic and
Hallam Medical
Centre for ovulation
induction between
November 2001 and
January 2003
Self-identification
of orientation and
history of sexual
behavior discussed in
interviews,
Heterosexual women
n = 364
Recruitment same as
lesbian women
Plasma
Androstenedione
DHEAS
FSH
LH
Estradiol
Testosterone
Age range:
20–45years old
(mean 35.4)
(Timing of veni-
puncture on early
follicular phase,
i.e., days 2–3 of
menstrual cycle.
No participants had
previous exposure
to androgens or
androgen elevating
substances or used
hormonal therapy in
the last year)
Acne
BMI
Hirsutism
Oligo-/amenor-rhea
Ovarian volume
PCOS
Polycystic ovaries
No information
Chen (2014)
Taiwan
Lesbians with PCOS
n = 8
Recruited by medical
history questionnaire
at Gynecology Out-
patients Department
of Taipei Medical
University Hospital
Self-reporting and
description of sexual
history over past
2years on question-
naires
Heterosexual women
with PCOS n = 89
Recruitment same as
for lesbian women
Plasma Fasting: Andros-
tenedione
FAI
FSH
LH
LH/FSH ratio
Estradiol
Total testosterone
(Hyperandrogenism:
tT elevated and A
(> 2.4ng/mL))
Age range:
20–35years old
(Timing regarding
menstrual cycle
not specified). (No
participants were
taking OCP or expe-
riencing menopausal
symptoms at time of
venipuncture, or had
ever been diagnosed
with Cushing’s
syndrome, androgen-
secreting tumors, or
congenital adrenal
hyperplasia)
Acne
BMI
Hirsutism
Hyperandrogenism
Oligomen-norrhoea
PCOS
Joint grant from Taipei
Medical University
and Taipei Medical
University Hospital
and also by the Min-
istry of Science and
Technology, Executive
Yuan and Taipei Vet-
erans General Hospital
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Table 1 (continued)
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Dancey (1990)
UK
Lesbians (n = 30) sepa-
rated into 3 catego-
ries: Primary lesbians
(n = 10), intermediate
lesbians
(n = 10), secondary
lesbians (n = 10)#
Recruitment by
response to advertise-
ments: Letters left
in women’s clubs,
pubs, and bookshops.
Adverts in women’s
magazines. Women
who responded
were given letters to
give to their female
friends
Self-definition as les-
bian/heterosexual.
Primary emotional/
sexual attractions
fulfilled by women
(lesbians) or men
(heterosexuals).
Corroborated by score
on SOM question-
naire
Heterosexual women
n = 10
Recruitment same as
for lesbians
Plasma
Androstenedione
Estradiol
Progesterone
Testosterone Testoster-
one/progesterone ratio
(Luteal phase
testosterone: 0.5–
2.5nmol/L)
Age range: 21–41
(mean 28.4 ± 4.96)
(Timing of venipunc-
ture on luteal phase,
i.e., days 4–9 after
ovulation). No par-
ticipants were taking
hormonal prepara-
tions)
– Grant from the Central
Research Fund Com-
mittee, University of
London
Diamond and
Wallen (2011)
USA
Lesbian women
n = 5
Bisexual women
n = 7
Part of larger longitudi-
nal study to study
sexual identity
development. Initial
sampling at lesbian,
gay, and bisexual
community events,
youth groups, and
classes on gender
and sexuality issues
taught at local col-
leges and universities
Self-reporting in
interviews and online
diary throughout
longitudinal study
Non-lesbian and non-
bisexual women who
either identified as
heterosexual or did
not claim to have
a sexual identity.
These women had
previously identified
as lesbian or bisexual
at the start of the
longitudinal study.
n = 8
Recruiting the same
as for lesbian and
bisexual women
Salivary estradiol Mean age = 30years.
(Timing of sample col-
lection started 9days
after first day of
menstrual period and
consistent time of
day. No participants
were pregnant, breast
feeding, or taking
OCP at the time of
sample collection)
– Grant from National
Institutes of Child
Health and Human
Development. Univer-
sity of Utah Research
Committee grant
Author Proof
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Archives of Sexual Behavior
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Table 1 (continued)
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Downey (1987)
USA
Homosexual women
n = 7
Recruitment by adver-
tisement within a uni-
versity community
Kinsey scale score
based on partner
preference of sexual
fantasies and behav-
ior during previous
12months
Heterosexual women
n = 7
recruitment same
as for homosexual
women
Plasma
androstenedione
testosterone
Age range: 19–29
(Timing of venipunc-
ture on days 1–3
of menstrual cycle
and between 8 and
9am on each day.
Matching of homo-
sexual and hetero-
sexual participants
according to: age,
height, weight, level
of education, and
whether or not they
had a live in partner.
No participants had
irregular menstrual
cycles, had used
OCP in the previous
year, or been exposed
to diethylstilbestrol
prenatally)
– BRSG grant of the
Research Foundation
for Mental Hygiene;
USPHS NIMH
Research Scientist
Development Award;
Research Center
Grants
Gartrell (1977)
USA
Homosexual women
n = 21
Recruitment: referred
by local “homophile
organizations”
Sexual behavior
included only
same-sex partners
(homosexuals) or
opposite sex partners
(heterosexuals) for
the preceding year
Heterosexual women
n = 19
No details of recruit-
ment
Plasma
testosterone
Age range homosexual
women: 21–35;
heterosexual women:
21–33.
(Timing of venipunc-
ture on days 1–3 of
menstrual cycle and
at 8am each day. No
participants were
taking OCP or had
menstrual irregulari-
ties)
– No details
Author Proof
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Archives of Sexual Behavior
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Table 1 (continued)
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Gladue (1991)
USA
Lesbians
n = 16
Recruited using
newspaper ads, post-
ers, referrals from
friends and previous
volunteers
Categorized by Kinsey
scale using informa-
tion from question-
naires and interview
data.
Only included if exclu-
sive lifelong (since
puberty) homosexual
or heterosexual
history
Heterosexual women
(n = 16)
Recruitment same as
lesbians women
Plasma
Estradiol
Testosterone (free and
total)
(Reference range not
given but states results
are in normal limits)
Age range: lesbians
21–32; heterosexual
women: 27–21
(Timing of venipunc-
ture on day 6 of
menstrual cycle and
between 1–4pm on
1day. No partici-
pants used OCP or
had known endocrine
abnormalities)
– Harry Frank Guggen-
heim Foundation;
National Science
Foundation Experi-
mental Program to
Stimulate Competitive
Research; Achieving
Science Excellence
in North Dakota
Project, National
Science Foundation
Research Experiences
for Under-graduates
Program
Gooren (1986)
Netherlands
Homosexual women
n = 6
No details of recruit-
ment
Self-reporting of
orientation.
Lesbians had a
life-long history of
exclusive or near
exclusive homosex-
ual orientation
Heterosexual women
(n = 6)
No details of recruit-
ment
Plasma
LH, Estradiol
Testosterone
Age range: homosex-
ual women: 24–32;
heterosexual women:
22–27.
(Timing of venipunc-
ture on day 3–5 of
menstrual cycle
between 8.30 and
10am. No partici-
pants had used hor-
monal preparations
in 15months before
the study began)
– No details
Author Proof
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Archives of Sexual Behavior
1 3
Table 1 (continued)
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Griffiths (1974)
UK
Lesbian women:
n = 36
Recruited through les-
bian organizations
Self-identification as
lesbian and member
of lesbian organiza-
tion
“Normal” subjects
from a previous
study for estradiol,
estriol and estrone4
n = not given
Urinary 17-oxosteroids
Epitestosterone Estra-
diol, Estriol Estrone
Prenanediol Pregnan-
etriol Testosterone
(Reference ranges:
pregnanediol: 6.2–15.6
(luteal) pregnanetriol:
0.3–8.9 17-Oxos-
teroids: 17.4–55.9
(µmol/24)5 epites-
tosterone: 6.9–61.8
testosterone: 3.5-41.3
(nmol/24h)6)
Lesbians age range:
22–55
(Comparator popula-
tion of an “appro-
priate age group”
Timing of sam-
pling in relation to
menstrual cycle was
noted for lesbian
subjects. Comparator
population samples
taken at “appropriate
stage” of menstrual
cycle. Use of OCP
was noted and taken
into account when
reporting results)
– Endowment fund of St.
Thomas Hospital
Juster (2016)
Canada
Lesbian women
n = 8
Bisexual women
n = 13
Recruited as part of
a broader research
program. Separate
advertisements
according to sexual
orientation
Self-identification
of orientation by
responding to one of
three separate adverts
asking for hetero-
sexual, bisexual or
lesbian participants
and in telephone con-
sultation.
Corroborated using
Klein Sexual Orien-
tation Scale
Heterosexual women
n = 20
Recruitment the same
as for lesbian and
bisexual women
Salivary fasting estradiol
Progesterone Testos-
terone (Saliva)
Plasma fasting DHEAS
(DHEAS range:
1.2–10.4µmol/l)
Age range: 18–45
(Timing of sample
collection between
12 noon and 7pm
each day, phase of
menstrual cycle not
stated. Use of oral
contraceptive use and
phase of menstrual
cycle was considered
in analysis)
Blood pressure
BMI
Cholesterol level
Insulin level
Triglyceride level
Canadian Institutes of
Health Research.
RP Juster Doctoral
Scholarship from The
Institute of Aging of
Canadian Institutes of
Health Research
Loraine (1970)
UK
Lesbians
n = 4
No information on
recruitment
Self-reporting of ori-
entation and sexual
behavior
Heterosexual women
n = not given
Members of laboratory
staff who did not
admit to homosexual
inclinations
Urinary Epitestosterone
FSH, LH
Estradiol
Estriol, Estrone
Pregnanediol
Testosterone
Lesbians age range:
20–23 (age not given
for controls).
(Samples taken
throughout menstrual
cycle)
– No information
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Archives of Sexual Behavior
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Table 1 (continued)
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Neave (1999)
UK
Lesbian women
n = 14
Recruited through
homophile organiza-
tions and friendship
networks
Self-reporting and
score on question-
naire derived from
sell scale of sexual
orientation
Heterosexual women
n = 14
Recruited from North-
umbria University
student population
and in the com-
munity matched to
lesbian women in
terms of education
level and age
Salivary Testosterone Age range: Lesbi-
ans: 19–43 (mean
26); Heterosexual
women: 20–43
(mean 31),
(Timing of sample col-
lection according to
menstrual cycle and
consistent time of
day. No participants
were taking hormone
influencing drugs
(including OCP), had
abnormal menstrual
cycles, or had medi-
cal conditions affect-
ing hormone level)
– University of Northum-
bria Small Research
Grants Scheme
Singh (1999)
USA
Lesbian women
(n = 33) separated
into “butch” (n = 17)
and “femme” (n = 16)
categories according
to score on personal
history questionnaire.
Recruited by “Snow-
ball”/networking
technique to find
friends/acquaintances
of researchers who
then recruited more
participants by word
of mouth
Self-identification as
lesbian or hetero-
sexual
Heterosexual women
n = 11
Same as for lesbian
women
Salivary Fasting:
Testosterone
Age range: 25–45
(Timing of sample
collection at 7–9am
each day, phase of
menstrual cycle not
stated. No par-
ticipants were taking
OCP or had known
ovarian problem)
BMI
Age at menarche
National Science Foun-
dation Grant
Author Proof
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Archives of Sexual Behavior
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Table 1 (continued)
References Population recruitment Determination of
sexual orientation
Comparator recruit-
ment
Hormones measured
method (reference
ranges)
Age range (moderators
controlled for)
Conditions related
to hormones levels
measured
Funding
Smith (2011)
USA
Lesbian women
(n = 114)
Recruitment using
participants of the
ESTHER Project
who agreed to be
contacted about
further studies.
Recruited to original
study by local
advertisement and
community events
Self-identified as
non-heterosexual
and reported only
or primarily having
emotional, physi-
cal, and romantic
attraction toward
women within the
past 5years or were
in relationships with
only or primarily
women within the
past 5years
Heterosexual women
(n = 97)
Self-identified as
heterosexual/straight
and only had male
partners since the
age of 18
Plasma Fasting:
Androstenedione
Testosterone
(Biochemical hyper-
androgensism:
tT 3.4ng/mL and
A > 2.4ng/mL)
Age range: 35–45
(Venipuncture phase
of menstrual cycle
not stated. No
participants were
using OCP at time
of venipuncture, dis-
played menopausal
symptoms, or had a
previous diagnosis of
Cushing’s syndrome,
androgen-secreting
tumors, congenital
adrenal hyperplasia)
Acne
BMI
Hirsutism
Infertility
PCOS
Oligo-menorrhea
ESTHER Project
funded by National
Lung, Blood and
Heart Association.
PCOS study funded
by ESTHER Project,
Lambda Founda-
tion and Lesbian
Health Fund (Gay
and Lesbian Medical
Association)
Key: #Primary lesbians: Never had heterosexual experiences or interest, scored less than 20 on the heterosexual component of SOM. Intermediate lesbians: Prior heterosexual experience or
interest and scored less than 20 on the heterosexual part of the SOM. Secondary Lesbians: Prior heterosexual experience or interest and scored more than 20 on the heterosexual part of the SOM
(Dancey etal. 1990)
Hormones: A: androstenedione; DHEAS: dehydroepiandrosterone sulfate; E2: estradiol; FAI: free androgen index (testosterone/sex hormone-binding globulin x100); FSH: follicle-stimulating
hormone; L2: luteinizing hormone; P: progesterone; T: testosterone; fT: free testosterone, tT: total testosterone
Abbreviations: ESTHER—BMI—body mass index, BRSG—Biomedical Research support Grant, Epidemiologic Study of Health Risk. Nmol—nanomoles, OCP—oral contraceptive pill,
PCO—polycystic ovaries, PCOS—polycystic ovary syndrome, SOM—sexual orientation method, µmol—micromoles, USPHS NIMH—United States Public Health Service National Institute
for Mental Health
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Archives of Sexual Behavior
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details (Gooren, 1986; Loraine, Ismail, Adamopoulos, &
Dove, 1970). The number of sexual minority women included
in the primary studies ranged from 4 (Loraine etal., 1970)
to 254 (Agrawal etal., 2004). Participants were all within
adult reproductive age range (15–45) except one early study,
which included participants up to 55years old (Griffiths etal.,
1974), without clarification of numbers related to menopausal
status. Sexual minority status was determined by self-report-
ing of: self-identified orientation, history of sexual behavior,
and/or feelings of sexual attraction. Five studies also used a
numerical scale of sexual orientation or sexual preference
(Dancey, 1990; Downey etal., 1987; Gladue, 1991; Juster
etal., 2016; Neave, Menaged, & Weightman, 1999). Six stud-
ies specified a length of time participants must have identified
as lesbian or bisexual (Chen etal., 2014; Downey etal., 1987;
Gartrell, Loriaux, & Chase, 1977; Gladue, 1991; Gooren,
1986; Smith etal., 2011. The minimum time requirement
given was 12months (Downey etal., 1987; Gartrell etal.
1977) and the maximum was exclusive life-long orientation
(Gladue, 1991; Gooren, 1986). In one study, lesbians were
divided into subgroups according to sexual history (primary,
intermediate, and secondary lesbians) (Dancey, 1990) and
in one study (Singh, Vidaurri, Zambarano, & Dabbs, 1999)
the sexual minority women participants were divided into
“butch” and “femme.” Only two of the 14 studies included
bisexual women (Diamond & Wallen, 2011; Juster etal.,
2016), with one grouping them with lesbian women (Juster
etal., 2016) and the other reporting results for bisexual
women separately (Diamond & Wallen, 2011). Heterosexual
women were the comparator group in 12 studies, one study
used a comparator population of women who did not identify
as lesbian or bisexual (Diamond & Wallen, 2011), and one
study used reference ranges from textbooks and results from
a previous study (Griffiths etal., 1974).
In one study, self-reported information and blood test
results were examined by a reproductive endocrinologist
(Griffiths etal., 1974). Hormones were measured in plasma
(n = 9), saliva (n = 4), and urine (n = 2), one study reported
both plasma and salivary hormone results (Juster etal., 2016).
Hormones measured included 17-oxosteroids (n = 1), andros-
tenedione (n = 5), DHEAS (n = 2), epitestosterone (n = 2),
FSH (n = 2), LH (n = 3), estriol (n = 2), estrone (n = 2), estra-
diol (n = 10), pregnanediol (n = 2), pregnanetriol (n = 1), pro-
gesterone (n = 4), prolactin (n = 2), and testosterone (n = 15).
There were 15 results for testosterone because one paper
reported results separately for “butch” and “femme” women
(Singh etal., 1999). Timing of hormone sampling was con-
trolled for in some studies by time of day (n = 8) (Diamond
& Wallen, 2011; Downey etal., 1987; Gartrell etal. 1977;
Gladue, 1991; Juster etal., 2016; Loraine etal., 1970; Neave,
Menaged, & Weightman, 1999; Singh etal., 1999) and by
point in menstrual cycle (n = 9) (Agrawal etal., 2004; Dancey,
1990; Diamond & Wallen, 2011; Downey etal., 1987; Gartrell
etal. 1977; Gladue, 1991; Gooren, 1986; Griffiths etal., 1974;
Neave, Menaged, & Weightman, 1999). Some studies noted a
medical history of menstrual/endocrine abnormalities (n = 7)
(Chen etal. 2014; Downey etal., 1987; Gartrell etal. 1977;
Gladue, 1991; Neave, Menaged, & Weightman, 1999; Singh
etal., 1999; Smith etal., 2011). Current use of hormonal prep-
arations (e.g., contraceptive pill) was specifically excluded
for participants in all studies except one (Juster etal., 2016)
and not mentioned in two early studies (Griffiths etal., 1974;
Loraine etal., 1970). Hormone levels in polycystic ovarian
syndrome (PCOS) patients were measured in three studies
(Agrawal etal., 2004; Chen etal., 2014; Smith etal. 2011). All
of the participants in Chen etal., (2014) had PCOS but fewer
than 10% of the participants in Smith etal. (2011) had PCOS
(13/211). The study by Agrawal etal., (2004) gave hormone
levels for women with normal ovaries separately from those
with PCO and PCOS, but the results were not reported sepa-
rately in Smith etal., (2011). Five studies provided reference
ranges for one or more hormone (Chen etal., 2014; Dancey,
1990; Griffiths etal., 1974; Juster etal., 2016; Smith etal.,
2011). Numerical results are presented separately for plasma
(n = 9) (see Online Supplement Table3), saliva (n = 4) (see
Online Supplement Table4), and urine hormones (n = 2) (see
Online Supplement Table5).
Findings inHealthy Women
Direction of difference in hormone levels in sexual minor-
ity women compared to heterosexual women without known
ovarian problems, measured in more than one study are shown
in Table2. The two early studies measuring estrone (Griffiths
etal., 1974; Loraine etal., 1970) showed significant reductions
in sexual minority women compared to heterosexual women.
There were mixed results in epitestosterone (n = 2), DHEAS
(n = 2), LH (n = 3), estriol (n = 2), and progesterone (n = 4), and
no significant difference in levels between sexual minority and
heterosexual women in androstenedione (n = 5), FSH (n = 2),
and pregnanediol (n = 2) (see Table2). There were also no dif-
ferences seen in the single studies that measured 17-oxosteroids
(Griffiths etal., 1974), pregnanetriol (Griffiths etal., 1974), and
prolactin (Agrawal etal., 2004) in women without known ovar-
ian problems. The one study measuring testosterone in “butch”
and “femme” lesbians (Singh etal., 1999) showed a significant
increase for the “butch” lesbians compared to “femme” lesbians
and compared to heterosexual women, but no significant dif-
ference between “femme” lesbians and heterosexual women
(of any appearance).
Exploratory meta-analyses in testosterone and estradiol
in women without known ovarian problems were conducted.
For testosterone, there was a significant increase in sexual
minority women overall (n = 9, SMD = + 0.90; 95% CI +0.22
to +1.57, I2 = 84%) (see Fig.1) compared to heterosexual
AQ1
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Archives of Sexual Behavior
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women, but no significant increase in the plasma testoster-
one subgroup results. For estradiol, there was no significant
difference overall [n = 7, SMD = − 0.03 (95% CI − 0.24 to
+ 0.18, I2 = 0%)] or in any subgroup by sampling type (see
Fig.2).
Table 2 Hormone Levels, Showing Statistically Significantly Increased (r), Decreased (t), Same Levels (s), or Not Measured (…) in Sexual
Minority Women Compared to Heterosexual Women Without Known Ovarian Problems
References Andros-
tenedi-
one
DHEAS Epites-
toster-
one
Estriol Estrone Estradiol FSH LH Pregnanediol Progesterone Testosterone
Agrawal (2004) … s… … … s s s … … s
Dancey (1990)p s… … … … s… … … s s
Dancey (1990)i s… … … … s… … … s s
Dancey (1990)b s… … … … s… … … s s
Diamond and Wallen (2011) … … … … … s… … … … …
Downey (1987)s… … … … … … … … … s
Gartrell (1977) … … … … … … … … … … r
Gladue (1991) … … … … … s… … … … s
Gooren (1986) … … … … … s…s… … s
Griffiths (1974) … … s s t s … … s…s
Juster (2016) … r… … … s… … … r r
Loraine (1970) … … r t t t s r s …r
Neave (1999) … … … … … … … … … … s
Singh (1999) (“butch”) … … … … … … … … … … r
Singh (1999) (“femme”) … … … … … … … … … … s
Smith etal. (2011)s… … … … … … … … … s
Fig. 1 Random effects subgroup meta-analysis of testosterone levels by sample method in lesbians and heterosexual women with no known
ovarian or endocrine problem
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Subgroup analysis of the testosterone meta-analysis remov-
ing the study using luteal sampling (Dancey, 1990) increased
the overall SMD to + 1.19 (95% CI + 0.47 to + 1.91). Subgroup
analysis removing the study explicitly including participants
using the contraceptive pill (Juster etal., 2016) decreased the
overall SMD to + 0.63 (95% CI + 0.08 to + 1.18). Adding in
results for bisexual women (Dancey, 1990) decreased the over-
all SMD slightly to + 0.82 (95% CI + 0.19 to + 1.45).
All of the subgroup analyses for the estrogen meta-analy-
sis made very little difference to the overall result. The only
study enrolling participants over the age of 50 (who may have
been menopausal) (Griffiths etal., 1974) did not contribute
to either meta-analysis.
Results inWomen withPolycystic Ovary Syndrome
Three studies included women with PCOS (Agrawal etal.,
2004; Chen etal., 2014; Smith etal. 2011). As Smith etal.
(2011) did not give results for sexual minority women with
PCOS separately to those without PCOS, and there were fewer
than 10% of women with PCOS, their results are given in the
section above. Agrawal etal. (2004) gave results separately for
women with PCOS and all participants in Chen etal. (2014)
had PCOS. For sexual minority women with PCOS, there
were statistically significantly lower levels of estradiol in one
study (Chen etal., 2014) but not in the other (Agrawal etal.,
2004), and higher levels of testosterone, androstenedione, and
free androgen index in one study (Agrawal etal., 2004), but
not in the other (Chen etal., 2014), compared to heterosexual
women. There were no significant differences found in lev-
els of DHEAS (Agrawal etal., 2004), FSH (Agrawal etal.,
2004; Chen etal., 2014), LH (Agrawal etal., 2004; Chen etal.,
2014), and prolactin (Agrawal etal., 2004).
Discussion
Main Findings
There has been disappointingly little research into sex hor-
mone levels in sexual minority women. Our findings suggest
little discernible difference in plasma hormone levels between
sexual minority and heterosexual women except for possibly
higher testosterone levels, and only when combining blood,
saliva and urine results across studies which were small with
considerable variation in methods of hormonal data collec-
tion. If there are higher rates of testosterone in sexual minority
women, the current evidence is not sufficient to determine
whether this is in a subset or not. Also, the testosterone levels
may be an incidental finding rather than causative of health
differences. There were inconsistent results in women with
PCOS.
Fig. 2 Random effects subgroup meta-analysis of estradiol levels by sample method in lesbians and heterosexual women with no known ovarian
or endocrine problem
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Strengths andLimitations
Strengths included protocol preregistration in the PROSPERO
database, careful presentation of numerical results, inclusion
of global data from a variety of sources, and a search for any
relevant studies from the last 50years. Methods of hormone
assays have changed over time but each study used the same
methods for all of their participant groups. Therefore, as we
looked for relative differences between groups within each
study and used standardized mean differences in the meta-
analyses, absolute differences in measurement methods across
studies will not impact on the results. However, we cannot
be certain that each of the studies measured hormones in the
same part of the menstrual cycle in each participant. Where
studies had relatively large samples, hopefully these differ-
ences would cancel each other, but in small sample sizes,
there may be consistent differences because of this. It would
be uncertain as to which direction these differences would
lie. Also, participants in most of the studies were not explic-
itly asked whether they had PCOS or even congenital adre-
nal hyperplasia (CAH), both of which can affect testosterone
levels. Participants in some studies were split into subgroups
of sexual minority status, such as primary, intermediate, or
secondary lesbians (for definitions see Online Supplement
Table2) (Dancey, 1990) or “butch” and “femme” (Singh etal.
1999), with little justification, and results presented sepa-
rately, thereby diluting the main effect of sexual minority vs
heterosexual women. Therefore, we cannot tell from the small
amount of studies so far whether the slightly higher testoster-
one levels found in the all-sample meta-analysis would apply
to all lesbians and bisexual women or to a subgroup. It is
uncertain as to how any subgroups would be defined.
Interpretation
There have been no recent systematic reviews of sex hormone
levels in sexual minority women. Other studies are consistent
with some of the findings, for example Pearcey, Docherty,
& Dabbs (1996) found that when measured in butch/femme
pairs, “butch” lesbians had higher testosterone levels than
their partners who rated themselves as more “femme,” which
is similar to the findings in one of our included studies (Singh
etal. 1999). However, when combined results for all “butch”
partners were compared to all “femme” partners, no sig-
nificant differences were seen, suggesting that the relative
rather than absolute difference is more important, or that the
sample size was too small to determine absolute differences
in testosterone levels. The heterogeneity of findings was of
particular importance in the testosterone findings, where there
was some statistically significant evidence of a relationship
between androgens and sexual orientation. However, the prob-
lem is that there are a number of endocrine conditions that
might affect levels of androgens (such as CAH, PCOS, and
oral contraceptive or menstrual regulation use), and thus it
would be crucial that these variables are controlled for, which
was not consistently the case. In the aforementioned study
by Singh etal. (1999) participants were not explicitly asked
whether they had PCOS or even CAH. They were not asked
whether they had congenital androgen insensitivity syndrome
(CAIS), a condition that effectively makes androgen action
impossible, regardless of androgen levels. Thus, the composi-
tion of the sample in relation to endocrine factors that would
affect androgen levels is unknown. Similarly, in Smith etal.
(2011), which did include women with PCOS, these results
were not presented separately as they made up only 10% of
the sample, thus confounding any relationship between tes-
tosterone and sexual minority status.
Implications forPolicymakers
If the tentative finding of higher levels of testosterone in
sexual minority women were confirmed, higher rates of
conditions associated with higher testosterone levels such
as PCOS might be expected to be observed, although a recent
systematic review has not demonstrated this (Robinson etal.,
2017). Therefore, any clinical implications remain currently
unclear. Also, finding a difference tells us nothing about the
direction of causality. Testosterone levels in the blood can
be raised indirectly by stress and there has been much work
around minority stress in sexual minorities (Meyer, 2003).
Thus, it is unclear if our tentative finding of higher testos-
terone levels is because of minority stress, another cause, or
merely an incidental finding. More clarity is required before
any implications for health in sexual minority women can
be discussed.
Implications forResearch
There has been very little research into sex hormone levels in
sexual minority women so far and most previous studies have
had small sample sizes. In the 40years since its publication,
research seems not to have progressed much further than
the Meyer-Bahlburg (1979) review. There also appears to be
very little information on variations of androgen and estrogen
receptor sensitivity. A large, well-conducted study is needed
to establish sex hormone levels in sexual minority women
compared to heterosexual women so that potential influences
on the health of sexual minority women can be estimated.
This could also measure variations of androgen and estrogen
receptor sensitivity. Using an online two group sample size
calculator, at 95% CI (alpha of 0.05), beta of 2 and power of
80%, and means and SDs taken from the testosterone Forest
plot (mean 17.4, SD 6.27 lesbian, mean 14.7 heterosexual
group), we estimate that a single study which could look at
all hormone profiles should have 170 participants, 85 in each
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Archives of Sexual Behavior
1 3
group, which is fewer than in the Forest plot, but much larger
than all of the included studies.
It may be possible to use cohort data, for example from the
Avon Longitudinal Study of Parents and Children (ALSPAC)
study, to investigate links between sex hormone and receptor
sensitivity levels and sexual orientation. This large cohort
study enrolled participants before birth, recorded adolescents’
sexual orientation at age 15years, and collected blood sam-
ples at various ages, including at age 24. Regarding PCOS and
other rarer conditions, some questions can only be answered
by case–control studies or registry data, which would be
feasible if they recorded sexual orientation. An important
implication for future research is that sexual orientation,
sexual behavior, and cohabitation status should be routinely
recorded as part of data collection in research studies, along-
side medical records, to allow more large scale interpretation
of hormone levels, disease patterns, and potential confounders
including stress levels.
Conclusion
Our findings suggest little discernible difference in hormone
levels between sexual minority women and heterosexual
women except for possibly higher testosterone levels, but a
large-scale primary study would be needed to increase the
certainty of this finding or its refutation. The paucity of pri-
mary studies may relate to a lack of interest, lack of funding,
or stigmatization of the topic. Some included studies focused
on identity and some on behavior. However, while identity and
behavior are overlapping categories, they must be distinguished
in research by recording and presenting both.
Acknowledgements We thank Miss Melanie Davies for comments on
an earlier draft. We thank the anonymous peer reviewers and Editor on
Chief for their comments.
Funding The study arose from an initial project undertaken during a
part-funded B.Sc. at King’s College London (AH) but was otherwise
unfunded. The authors had no financial support for this work. There
were no financial relationships with any organizations that might have
an interest in the submitted work in the previous three years and there
were no other relationships or activities that could appear to have influ-
enced the submitted work.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval This article does not contain any studies with human
participants performed by any of the authors as it’s a systematic review.
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