Transgender and nonbinary people assigned female at birth face an elevated cardiovascular risk. For years, suspicion has focused on the testosterone used in gender-affirming treatment. But there is another variable rarely measured in the clinic: the chronic stress of belonging to a gender minority. A new study published in the American Journal of Physiology-Heart and Circulatory Physiology has pitted the two hypotheses against each other and found that they act in opposite directions.
A design that separates hormones and stress
The team, led from McGill University (Canada), recruited 24 transgender and nonbinary adults assigned female at birth: twelve currently using testosterone and twelve who had not started it. Each participant had their blood pressure measured at rest and during two acute stress tests: a physical one (the cold pressor test, a hand in ice water) and a psychological one (the Stroop test, naming the colour of words written in another colour).
Gender minority stress was quantified with a composite score of seven validated psychosocial scales, and total testosterone was measured in blood by radioimmunoassay. The question was clear: which of the two forces is actually associated with the blood pressure response?
At rest, no difference
The first finding is partly reassuring: resting blood pressure was almost identical between testosterone users and non-users (115 vs 115 mmHg systolic; 68 vs 68 diastolic). Living with the treatment did not translate, in this sample, into a higher baseline pressure.
Psychological stress changes everything
The differences appeared during the psychological test. The greater the gender minority stress reported by the person, the more blunted their blood pressure response to the mental challenge: the association was negative and significant for both systolic and diastolic pressure. In contrast, higher testosterone levels were associated with larger blood pressure responses to that same stress.
What stands out is the specificity: neither variable was associated with resting blood pressure or with the response to cold (a physical stimulus). The effect only emerged under mental stress, the kind that most resembles real situations of discrimination or rejection.
What a dampened response means
A blunted cardiovascular response is not neutral: the literature links it to poorer autonomic regulation and higher long-term cardiovascular risk. The authors stress that minority stress and hormones are not competing for first place as a risk factor: they add up, and both deserve measurement. “These data highlight the importance of integrating both physiological and psychological factors when examining cardiovascular risk,” they conclude.
Limits of the study
The sample is small (24 people, half on treatment) and the cross-sectional design cannot establish causation, only associations. Other risk markers or full treatment history were not assessed. Even so, the work opens a practical avenue: if social stress leaves a trace on the cardiovascular response measured in the laboratory, transgender and nonbinary people could benefit from cardiovascular follow-up that considers not only hormones, but also the social context in which they live.
Source: Gender Minority Stress, Testosterone, and Blood Pressure Responses to Stress in Transgender and Nonbinary Adults. Turino Miranda K et al. American Journal of Physiology-Heart and Circulatory Physiology (online publication, 8 September 2026; article ajpheart.00548.2026). DOI: 10.1152/ajpheart.00548.2026.
Publication reference: American Journal of Physiology-Heart and Circulatory Physiology.
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