Systematic Review with Meta-analysis of Laboratory-Based Exercise Performance Tests in Transgender Women

This review compared laboratory-based exercise test performance between transgender women (TW) and cisgender women (CW) and/or men (CM). Data sources included SPORTDiscus and PubMed from inception to 2025. Standardized mean differences with 95% confidence intervals were calculated and pooled effects were subsequently assessed. Fourteen studies met the inclusion criteria. Aerobic performance measures included peak oxygen consumption (V̇O2peak) and lactate threshold (LT). Muscle strength and explosiveness measures included handgrip strength, knee extension torque, Wingate peak and mean cycling power output (PPO and MPO), push-up performance, and countermovement jump (CMJ) power. A total of 259 TW (33.1±8.2 years) were included, all of whom had undergone gender-affirming hormone therapy for at least 12 months. Comparator groups included 248 CW (33.5±9.4 years) and 325 CM (34.5±8.9 years). No significant differences were observed between TW and CW in handgrip strength normalized to height2, CMJ power/body mass (BM), knee extension torque (absolute or relative to BM), Wingate PPO/BM and MPO, push-up performance, and LT. TW demonstrated significantly higher absolute V̇O2peak, g=0.65 [0.40, 0.89], and absolute handgrip strength, g=0.97 [0.45, 1.48] than CW while exhibiting lower V̇O2peak relative to BM, g= -0.34 [-0.67, -0.00]. TW scored significantly lower than CM across multiple exercise tests, including V̇O2peak, g= -1.81 [-2.42, -1.20] and for CMJ height g= -1.92 [-2.81, -1.23]. Based on limited evidence, exercise performance in TW has been interpreted as more comparable to CW than to CM; however, given the low-to-moderate inconsistencies in the reviewed studies, more high-quality data are needed to assess this conclusion.