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The association between adversity and hair cortisol levels in humans: A meta-analysis
Open accessAbstract
Adverse life events are associated with a constellation of negative health outcomes. Theory and research suggest that the hypothalamic-pituitary-adrenal (HPA) axis acts as one mechanism connecting adverse experiences with negative health outcomes. However, this relation is complicated by the potential for adversity to be associated with both hyperactivity and hypoactivity of the HPA axis, as assessed in both animal and human studies. Over the past decade, methodological advances have enabled the sampling of cortisol stored in hair, which provides a marker of HPA axis activity over a several-month period. The present meta-analysis included 28 studies to assess the strength and direction of the relation between adverse experiences and hair cortisol levels. Analyses were conducted using multilevel modeling (MLM) to quantify the magnitude of effects and mixture modeling to identify distinct subgroups of studies. Results of MLM analyses indicated that the overall effect size was small but significant d = 0.213, 95% CI [0.034, 0.397]. There was also significant between-study variance (τ = 0.155, 95% CI [0.065, 0.367]). Mixture modeling to identify distinct classes of studies based on effect size and direction resulted in a 2-class model: The first class included four studies with an overall negative and moderate effect size (d = -0.478, 95% CI [-0.639, -0.318]), and the second class included the remaining 24 studies with an overall positive and significant, albeit small, effect size (d = 0.141, 95% CI [0.084, 0.199]). Moderator analyses indicated that the strength and direction of the association between adversity and hair cortisol were moderated by features of the adversity exposure (e.g., type of adversity, timing of adversity), characteristics of the samples (e.g., clinical status, racial distribution), and features of the publication (e.g., publication type, geographic region of study). The findings refine our understanding of the long-term impact of adversity on dysregulation of the HPA axis, particularly as reflected in hair cortisol measures.
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“Inflammatory factors such as cortisol and C-reactive protein (CRP) are associated with breast cancer progression18 and psychological problems.19”
From The Effect of Mindfulness-Based Stress Reduction Group Counseling on Psychological and Inflammatory Responses of the Women With Breast Cancer (2020) · cites this paper as [19]
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Vergara‐Lopez, C., Bublitz, M. H., Mercado, N., Ziobrowski, H. N., Gomez, A., & Stroud, L. R. (2021) · Stress · doi:10.1080/10253890.2021.1998445 · Cited by 5
“Lastly, it is important to note that other methods exist for examining stable individual differences in HPA-axis function such as measuring cortisol in hair (Khoury et al., 2019) or examining genetic influences (Gerritsen et al., 2017).”
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Panisch, L. S., Murphy, H. R., Wu, Q., Brunner, J., Duberstein, Z. T., Arnold, M. S., Best, M., Barrett, E. S., Miller, R. K., Qiu, X., et al. (2023) · Psychosomatic Medicine · doi:10.1097/psy.0000000000001218 · Cited by 6
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“…of the adversity (e.g. type of adversity, timing of adversity), the characteristics of the samples (e.g. clinical status, racial distribution), and the characteristics of the publication (e.g. type of publication, geographic region of study) that moderated the association (Khoury et al., 2019).”
BackgroundParental Stress and Scalp Hair Cortisol in Excessively Crying Infants: A Case Control Study
de Kruijff, I., Tromp, E., den Berg, M. P. L., Vlieger, A. M., Benninga, M. A., de Rijke, Y. B., & van den Akker, E. L. T. (2021) · Children · doi:10.3390/children8080662 · Cited by 4
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“Meta-analytic evidence further supports a positive association between various adverse experiences (e.g., natural disasters, maltreatment, trauma) and hair cortisol [17].”
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Changes in hair cortisol during retirement transition: the Finnish retirement and aging study
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“The HPA axis is a complex system and both hyper-an hypoactivity of the HPA axis has been reported in long-term stress and adversity [14,15].”
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Hair stress hormones in individuals with a recent suicide attempt experiencing a depressive episode
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“However, as indicated in a meta-analysis, the association between hair cortisol and childhood abuse (or other types of maltreatment) is heterogeneous (Sch ¨ ar et al., 2022) and dependent on other moderators such as study population, timing of adversity, measurements, etc. (Khoury et al., 2019).”
Panneh, M., Beattie, T., Ding, Q., Kabuti, R., Champions, T. M. F. S., Ngurukiri, P., Kungu, M., Abramsky, T., Pollock, J., Beksinska, A., et al. (2026) · PLOS Global Public Health · doi:10.1371/journal.pgph.0005013 · Cited by 1
“Recent empirical studies suggest that stressful life events can harm the functioning of the hypothalamic-pituitary-adrenal (HPA) axis, which may serve as a pathway linking stressful life experiences and negative health outcomes [20].”
Petrowski, K., Renner, V., Herhaus, B., Conrad, R., & Kirschbaum, C. (2026) · Scientific Reports · doi:10.1038/s41598-026-50934-z
“Another limitation is that early adversity was not assessed or controlled for, although it has been shown to influence hair cortisol concentration 29 and should therefore be addressed in future studies.”
Association of internet addiction symptoms with hair cortisol and hair testosterone concentrations
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Efeitos do estresse gerado pelo isolamento social e pela discriminação na saúde mental
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Ayçiçek, S., & Ayçiçek, B. (2026) · Frontiers in Endocrinology · doi:10.3389/fendo.2026.1859428
“In reproductive medicine, elevated hair cortisol levels have been associated with poorer assisted reproductive technology outcomes, underscoring the relevance of chronic stress assessment (26).”
Khoury, J. E., Giles, L., Pattison, M., Tulipan, T., Allen, V., Campbell-Yeo, M. L., & Perrot, T. S. (2026) · Developmental Psychobiology · doi:10.1002/dev.70180
“Chronically low/blunted HPA activity has also been associated with chronic experiences of stress, trauma, and early adversity (Khoury et al. 2019 ).”
Self-citationKhoury, J. E., Zhang, J., Campbell-Yeo, M. L., Allen, V. M., Perrot, T. S., & Raha, S. (2026) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2026.107967
Self-citationBennett, N., Adams, S. W., Chung, J. S., Terry, J., Shorey, S., Herrick, D. B., Bederson, M., & Harris, O. A. (2026) · Brain Injury · doi:10.1080/02699052.2026.2697350
“These changes may disrupt hormone synthesis and secretion, contributing to increased vulnerability to ongoing and future stress reactions and impaired physiological adaptations to stressors (30–32).”
Sharif, H. A., Mohammed, I. N., Hossain, M. I., Heilbronner, U., Schulze, T. G., Kizilhan, J. I., & Hautzinger, M. (2026) · BJPsych Open · doi:10.1192/bjo.2026.12096
“12,13 Therefore, further research is needed to clarify whether hair cortisol and cortisone are associated with psychological symptom severity among trauma-exposed populations.”
Biomarkers of stress across biological systems: conceptual and measurement perspectives
Weiss, S. J., El-Refaay, S. M. M., Keeton, V. F., Longoria, K., Adynski, H., & Leung, C. Y. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1895140
Metadata
- Authors
- Khoury, J. E., Bosquet Enlow, M., Plamondon, A., & Lyons-Ruth, K.
- Affiliations
- Harvard University (US)
- University of Toronto (CA)
- Corresponding author
- Khoury, Jennifer E.
- ORCID
- Khoury, Jennifer E.
- Venue
- Psychoneuroendocrinology
- Publisher
- Elsevier BV
- Published
- 2019-05
- Volume
- 103
- Pages
- 104-117
- ISSN
- 0306-4530 (ISSN-L)
- PMC
- PMC6450779
- OpenAlex
- W2910167098
- Cited by
- 170
- References
- 106
- Citations by year
- 2026: 15 · 2025: 19 · 2024: 20 · 2023: 26 · 2022: 27 · 2021: 35 · 2020: 23 · 2019: 4
- FWCI
- 2.58
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Psychoneuroendocrinology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD079484)
- Topics
- Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Keywords
- adversity, life events, hair cortisol, HPA axis dysregulation, hypothalamic-pituitary-adrenal axis, chronic stress, cortisol biomarkers
- MeSH terms
- Adverse Childhood Experiences, Female, Hair, Humans, Hydrocortisone, Hypothalamo-Hypophyseal System, Male, Pituitary-Adrenal System, Stress, Psychological
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