research paper on female athletes

• Search Menu
• Advance Articles
• Editor's Choice
• Braunwald's Corner
• ESC Guidelines
• EHJ Dialogues
• Issue @ a Glance Podcasts
• CardioPulse
• Weekly Journal Scan
• European Heart Journal Supplements
• Year in Cardiovascular Medicine
• Asia in EHJ
• Most Cited Articles
• ESC Content Collections
• Author Guidelines
• Submission Site
• Why publish with EHJ?
• Open Access Options
• Submit from medRxiv or bioRxiv
• Author Resources
• Self-Archiving Policy
• Read & Publish
• Advertising and Corporate Services
• Advertising
• Reprints and ePrints
• Sponsored Supplements
• Journals Career Network
• About European Heart Journal
• Editorial Board
• About the European Society of Cardiology
• ESC Publications
• War in Ukraine
• ESC Membership
• ESC Journals App
• Developing Countries Initiative
• Dispatch Dates
• Terms and Conditions
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Underrepresentation of female athletes in sports research, biological factors unique to female athletes, gaps in current recommendations, strategies to close sex knowledge gaps in sports research.

• < Previous

The underrepresentation of female athletes in sports research: considerations for cardiovascular health

• Article contents
• Figures & tables
• Supplementary Data

Jie Wei Zhu, Jennifer L Reed, Harriette G C Van Spall, The underrepresentation of female athletes in sports research: considerations for cardiovascular health, European Heart Journal , Volume 43, Issue 17, 1 May 2022, Pages 1609–1611, https://doi.org/10.1093/eurheartj/ehab846

• Permissions Icon Permissions

The proportion of female athletes in competitive sporting events—including the World Championships and Olympic games—has increased to nearly half of all athletes, and competing athletes increasingly include those who are peripartum. While participation in sports is closely implicated in cardiovascular health and disease, females remain underrepresented in recreational and performance sports research. This underrepresentation is marked during pregnancy, a unique biological state with substantial hemodynamic changes that have implications on athletic performance and on any underlying cardiovascular conditions. The evidence to guide recreational and performance sports is derived mainly from research in males, which has limited generalizability in females. This is a call for researchers to include female participants, including consenting pregnant and lactating women, in sports physiology research and for guideline committees to include sex-specific and peripartum-specific cardiovascular recommendations for athletes.

Females are under-enrolled in both recreational and performance sports research, and this parallels the underrepresentation of females in research across health and disease states. 1 When female athletes are included, their sample sizes are frequently smaller than their male counterparts. 2 Among 12 511 386 participants in 5261 manuscripts published in six sport and exercise science journals between 2014 and 2020, females accounted for 34% of the study population; in addition, only 6% of total publications were conducted exclusively on females. The underrepresentation female athletes in research translates to knowledge gaps about sex differences in cardiovascular physiology and sports performance, 2 , 3 and there is limited knowledge to guide policy for training and participation in elite events. There is an urgent need for more females to be included in sports research and for more female-only research, which looks at the effects of sex-specific factors, such as the menstrual cycle, hormonal contraceptive use, pregnancy, and menopause on sports physiology, sports performance, and cardiovascular health. 3 , 4

Findings of sports science research in males do not address the biological factors that are unique to females and impact their cardiovascular health. 5 Females have unique health considerations, including different metabolism of medications, lower haemoglobin levels, and smaller cardiac volumes than males. Females are prone to iron deficiency anaemia related to menstruation and pregnancy. Hormonal fluctuations during different stages of the menstrual cycle may influence training and physical performance. For example, relaxin and oestrogen concentrations peak during the luteal phase of the menstrual cycle and are associated with an increased risk of injuries. 5 Oestrogen and progesterone fluctuations during the menstrual cycle may also affect temperature regulation, central nervous system fatigue, basal metabolism, which all contribute to exercise performance and cardiovascular health. Aesthetic sports and caloric restriction may contribute to energy deficiency, with detrimental consequences on sports performance and cardiovascular health. 5

Given the cardiovascular and cerebrovascular adaptations that occur during stages of pregnancy, recommendations for elite level exercise during the postpartum phase should be informed by evidence for maternal and foetal outcomes. Maternal cardiac output increases to ensure adequate perfusion to the uterus, placenta, and maternal organs. 6 Maternal resting heart rate increases by, on average, 20 b.p.m. and stroke volume increases by ∼40% during gestation. 6 Reversible chamber enlargement has also been observed, with atrial diameters expanding up to 40% secondary to the expanded blood volume of pregnancy. 6 Blood pressure normally decreases during pregnancy due to progesterone, which promotes vascular smooth muscle relaxation and increased nitric oxide. 6 Decreased cerebral blood flow has also been reported with no apparent changes to cerebral autoregulation during pregnancy. 6 These pregnancy-related cardiovascular changes typically resolve after the first 4–12 postpartum weeks. 6

Current guidelines indicate that it is safe for female athletes who were physically active before pregnancy to engage in recreational exercise during and after pregnancy, but recommendations regarding performance sports and knowledge regarding maternal and foetal outcomes are lacking. 6 Inactivity during pregnancy has been associated with excessive weight gain, hypertensive disorders of pregnancy, and gestational diabetes—known risk factors for cardiovascular disease and foetal complications. 7 The intensity and duration of physical activity during pregnancy can influence the degree of change in foetal cardiac autonomic control, but evidence is conflicting. In one study, females engaging in high intensity exercise were found to have foetuses with lower, more variable heart rate. 7 However, studies on resistance training found that increased frequency, intensity, and duration of resistance training were associated with lower rates of foetal complications. 7 The developing foetal cardiovascular system is thought to respond differently to various types of maternal exercise, but there are knowledge gaps pertaining to foetal outcomes that require further research. 7

The impact of elite training on post-partum physiology and lactation remains unclear. Findings from an observational study with 16 post-partum participants showed that females who engaged in vigorous exercise for ≥45 min/day tended to produce higher milk volume and energy output. 8 Another observational study in 41 top competitive athletes reported that elite female athletes can benefit substantially from training at high frequencies (i.e. 6-day exercise routine) during an uncomplicated pregnancy as this approach would facilitate a more rapid return to competitive sports in the post-partum period. 9 However, current research is largely limited to observational studies with small sample sizes and further high-quality studies are needed.

There are several strategies to close the sex-specific knowledge gaps in sports training ( Figure 1 ). First, investigating the cardiovascular physiology and health outcomes of female athletes requires representative inclusion of female athletes in the respective sport. Second, pregnant and lactating females should be included in sports research to close knowledge gaps and guide policy specific to this population. It is also essential to include those at different stages of pregnancy, as each is associated with distinct cardiovascular physiological changes. In addition, there is a need to change the ubiquitous male-directed branding and imagery in peer-reviewed scientific publications on sports physiology or performance sports in favour of gender-equal imagery.

Sex-specific knowledge gaps pertaining to sports performance, implications for cardiovascular health, and strategies to increase the inclusion of female athletes in sports research. CV, cardiovascular; SV, stroke volume; HR, heart rate; SVR, systemic vascular resistance; BP, blood pressure; BMI, body mass index.

Strategies to increase the enrolment of females as research participants should include the recruitment, retention, and advancement of women sports researchers. Recruitment of female participants has been previously associated with trial leadership by women, who are largely underrepresented in leadership in sport and cardiovascular research. 3 , 10 In fact, women accounted for ∼25% of first and <20% of senior authorship positions among >4800 randomized controlled trials published from January 2000 to September 2020 in high-impact sport sciences journals. 5 The underrepresentation of women in research leadership positions may lead to lower prioritization of research questions specific to females and less emphasis on research representativeness.

The critical gaps in knowledge pertaining to elite training in female athletes can only be closed by committing to transformative changes in the way research is conducted. The systematic exclusion of pregnant and post-partum athletes, and the underrepresentation of females in general, must no longer be considered acceptable and efforts must be made at multiple levels to ensure that research participants are representative of the population to which findings apply.

Conflict of interest: The authors hereby declare no conflicts of interest.

Data availability

There are no new data associated with this article.

Van Spall HGC . Exclusion of pregnant and lactating women from COVID-19 vaccine trials: a missed opportunity . Eur Heart J 2021 ; 42 : 2724 – 2726 .

Google Scholar

Michos ED , Van Spall HGC . Increasing representation and diversity in cardiovascular clinical trial populations . Nat Rev Cardiol 2021 ; 18 : 537 – 538 .

Whitelaw S , Sullivan K , Eliya Y et al.  Trial characteristics associated with under-enrolment of females in randomized controlled trials of heart failure with reduced ejection fraction: a systematic review . Eur J Heart Fail 2021 ; 23 : 15 – 24 .

Cowley ES , Olenick AA , McNulty KL , Ross EZ . “Invisible sportswomen”: the sex data gap in sport and exercise science research . Women Sport Phys Act J 2021 ; 29 : 146 – 151 .

Martínez-Rosales E , Hernández-Martínez A , Sola-Rodríguez S , Esteban-Cornejo I , Soriano-Maldonado A . Representation of women in sport sciences research, publications, and editorial leadership positions: are we moving forward? J Sci Med Sport 2021 ; 24 : 1093 – 1097 .

Sanghavi M , Rutherford JD . Cardiovascular physiology of pregnancy . Circulation 2014 ; 130 : 1003 – 1008 .

Beilock SL , Feltz DL , Pivarnik JM . Training patterns of athletes during pregnancy and postpartum . Res Q Exerc Sport 2001 ; 72 : 39 – 46 .

Lovelady CA , Lonnerdal B , Dewey KG . Lactation performance of exercising women . Am J Clin Nutr 1990 ; 52 : 103 – 109 .

Kardel KR . Effects of intense training during and after pregnancy in top-level athletes . Scand J Med Sci Sports 2005 ; 15 : 79 – 86 .

Van Spall HGC , Lala A , Deering TF et al.  ; Global CardioVascular Clinical Trialists (CVCT) Forum and Women As One Scientific Expert Panel . Ending gender inequality in cardiovascular clinical trial leadership: JACC review topic of the week . J Am Coll Cardiol 2021 ; 77 : 2960 – 2972 .

Email alerts

Citing articles via, looking for your next opportunity, affiliations.

• Online ISSN 1522-9645
• Print ISSN 0195-668X
• Copyright © 2024 European Society of Cardiology
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Current Opinion
• Open access
• Published: 12 December 2019

The Challenge of Applying and Undertaking Research in Female Sport

• Stacey Emmonds   ORCID: orcid.org/0000-0002-2167-0113 1 , 2 ,
• Omar Heyward 1 , 3 &
• Ben Jones 1 , 2 , 4 , 5 , 6  

Sports Medicine - Open volume  5 , Article number:  51 ( 2019 ) Cite this article

18k Accesses

105 Citations

90 Altmetric

Metrics details

In recent years there has been an exponential rise in the professionalism and success of female sports. Practitioners (e.g., sport science professionals) aim to apply evidence-informed approaches to optimise athlete performance and well-being. Evidence-informed practices should be derived from research literature. Given the lack of research on elite female athletes, this is challenging at present. This limits the ability to adopt an evidence-informed approach when working in female sports, and as such, we are likely failing to maximize the performance potential of female athletes. This article discusses the challenges of applying an evidence base derived from male athletes to female athletes. A conceptual framework is presented, which depicts the need to question the current (male) evidence base due to the differences of the “female athlete” and the “female sporting environment,” which pose a number of challenges for practitioners working in the field. Until a comparable applied sport science research evidence base is established in female athletes, evidence-informed approaches will remain a challenge for those working in female sport.

There is currently a lack of sport science and sport medicine research conducted on elite female athletes, making it challenging to develop an evidence-informed approach to practice.

Applying evidence developed in male athletes to female athletes may be erroneous.

This article highlights the challenges of applying evidence derived from male athletes and applying it to female athletes and female sporting contexts. It provides considerations of how to apply research to female sport, considering the female athlete and the female sporting environment.

Introduction

In recent years there has been an exponential rise in the professionalism and profile of female sports [ 1 ]. Women’s professional soccer, rugby, and netball leagues now exist in a number of countries. While still acknowledging the disparity in opportunities, salaries, and media exposure between elite male and female athletes [ 1 ], the increased professionalism has afforded female athletes the opportunity to train full time and also access professional sports coaching, sport science, and sports medicine support to help maximize performance potential.

Practitioners (e.g., sport science professionals) aim to apply evidence-informed approaches to accomplish the goal of optimal athlete performance and well-being. Evidence-informed practice is the application of research findings to the real world [ 2 ]. The challenges of applying research to practice in sport have been highlighted in the literature (i.e. the challenge of translating science to the context) [ 2 ]. This is even more challenging when working with female cohorts. While in recent years more female participants are included within the research literature, these studies typically involve recreational athletes [ 3 ], and as such high-performance female athletes are typically underrepresented in the “sports performance” literature. This limits the ability to adopt and apply an evidence-informed approach when working with elite female athletes and as such may mean that we are failing to maximize the performance potential of this cohort.

The purpose of this article is therefore to highlight the challenges of applying evidence developed in a male cohort to a female cohort. Of note, this article will not discuss gender as it is outside the scope of this editorial. The article will provide considerations, supporting the application of evidence into practice, and also support future translational research for female sport.

Considerations when Applying Sports Performance Research to Female Athletes

Scientific research aims to investigate the effects of independent variables (e.g., age, maturation status, a training intervention) on dependent variables (e.g., sprint performance). In sports science disciplines, sex should be controlled given the different biological attributes [ 4 ]. However, sport science practices (e.g., training and recovery protocols, nutritional strategies, injury prevention interventions) in female sport are often underpinned by research conducted in male athletes, given the limited representation of female athletes in the sports performance literature. The underrepresentation is highlighted by a search of “injury” and “rugby” and “female” in the last 10 years of retrieving 196 articles, whereas the same search, replacing “female” for “male,” retrieved 602 articles. A similar trend was also observed for “soccer match demands,” with 13 and 102 articles retrieved for females and males, respectively (Scopus, 19 July 2019). These corroborate recent findings showing that only 35% of participants are female in studies published in the British Journal of Sports Medicine [ 5 ]. The application of evidence derived in male athletes to female athletes is a concern given the known biological differences between the sexes.

Developing an applied sports performance evidence base in female sport is also challenging, given the logistical and methodological context [ 6 ]. Fluctuations in hormone concentrations at different stages of the menstrual cycle may influence performance [ 8 ]. This is in addition to the different biomechanical profiles of female athletes in comparison to male athletes [ 6 ]. These factors may partially account for the lack of efficacy and effectiveness of interventions [ 7 ] when applying findings from sports performance research conducted in male athletes. For example, it is known that estrogen concentrations fluctuate throughout the menstrual cycle and estrogen has measurable effects on muscle function and tendon and ligament strength [ 8 ]. Estrogen and relaxin concentrations have been reported to peak during the luteal phase of the menstrual cycle, potentially increasing anterior cruciate ligament (ACL) injury risk [ 9 ]. Similarly, fluctuations in estrogen and progesterone concentrations during different stages of the menstrual cycle may affect temperature regulation, central nervous system fatigue, substrate metabolism, and overall exercise performance [ 7 ]. Therefore, female athletes may require different performance, nutritional, recovery, and injury prevention strategies in comparison to male athletes.

Contextual factors may also influence the effectiveness and application of sports science interventions in practice. Contextual factors include competition structure, finance allocated to tournaments, access to facilities, or access to expert staff, for example. Sports science and medical provision (e.g., strength and conditioning, physiotherapy, team doctor, nutrition) are often limited for female athletes in comparison to males and must be considered when trying to apply research to practice. For example, the success of a training or injury prevention intervention is not solely determined by the efficacy of the intervention, but it is also influenced by multiple interrelated contextual factors within the target group and in the community [ 10 ]. Specifically, return to play guidelines in sport (i.e., soccer, rugby) are the same for both sexes, yet female athletes have been reported to have higher concussion rates [ 11 ] and present different concussion symptoms [ 12 ]. When considering the return to play from injury, contextual challenges, such as access to appropriate qualified support staff (e.g., physiotherapist, sports science support), in addition to the previously identified biological differences, should be considered when supporting female athletes.

Developing and Applying Sports Science Evidence for Female Athletes

Current sports performance and player well-being strategies in female sport are often underpinned by evidence derived from male athletes or male talent development environments. While there are some good practices that can be derived from a male context, in some instances we may be failing to consider the requirements of the female athlete as highlighted above. When aiming to either develop applied sport science practices, adopt an evidence-informed approach, or undertake future research, the first step is to appraise and evaluate the current available evidence. Acknowledging that limited research studies have investigated female athlete cohorts in comparison to male athletes, this may lead to simply identifying the “best available evidence.” For the practitioner, this may mean that the evidence is useful to support decision-making or indeed the findings may not be suitable to translate into practice, due to inherent differences (e.g., talent development systems in male youth soccer vs. female youth soccer).

In Fig. 1 (adapted from Hanson et al. [ 13 ]), we propose the considerations required when aiming to develop an evidence-based approach to practice in female sport. The figure highlights how it is important that the current evidence base is evaluated against (a) the female athlete and (b) the female sporting environment , in addition to the typical scientific scrutiny applied to published research literature. This can be used to both apply the current evidence into policy and practice and indeed conceive future research projects specific to the needs of the female athletes, which has direct translation into practice.

Considerations required when developing an evidence-based approach to practice in female sport

For example, there is a strong body of research evaluating the match demands of male rugby league [ 14 ], but at present limited research exists evaluating the match demands of female rugby league. Following the considerations presented in Fig. 1 , by establishing that the female athlete (e.g., rugby league player) is different to the male rugby league player (e.g., male vs. female rugby league players 20-m speed; 3.66 ± 0.26 vs. 3.09 ± 0.12 s [ 15 , 16 ]), it is unlikely that the match demands research from male rugby league players can be applied to female cohorts. Furthermore, rugby league is professional in England and Australia for elite males and amateur and semiprofessional for elite females; thus when considering the female sporting environment and it’s context, this further corroborates the conclusion that match demands research form male cohorts have limited application to female cohorts.

Acknowledging that the effective translation of research findings is not solely determined by the efficacy of the intervention [ 13 ], there is a clear need to consider the “context” and “environment” of female sport, acknowledging that what occurs in the male game may not be most appropriate for the environment of females. For example, despite the increased professionalism of female sport, factors, such as insufficient training time and lack of resources and equipment in comparison to male athletes, may limit the ability of practitioners to apply such intervention-based evidence to practice. For example, within this context, professional medical staff may not be present at all training session, or qualified sports science/strength and conditioning practitioners, given the limited funding at present in some female sports.

The application of established research models, considering the female athlete within context, is likely a useful starting point. Bishop [ 17 ] provides a framework for undertaking applied research, progressing from “descriptive research” (e.g., what do they do) to “implementation studies in real sporting settings” (e.g., can we improve current practice). Jones et al. [ 18 ] also proposed a research model, emphasizing the need to co-construct research questions with policy-makers and practitioners to increase the usefulness and adoption of the research findings into practice. Adopting such approaches to research as described by Bishop [ 17 ] and Jones et al. [ 18 ] with considerations for the needs of the female athlete and the context of female sport will increase our understanding of the current context (i.e., physical qualities of players, match characteristics, recovery profiles, etc.), which, for a number of reasons discussed above, may be different to that in male athletes within the same sport. These studies are arguably more valuable at present than more advanced scientific studies (e.g., laboratory-based randomized crossover design studies). The challenge for the researcher is that this may be seen by journal editors and academic hierarchies as lacking “originality,” given the potential methodological repetition of male research in a female cohort. While this may be true for the advancement of scientific methodologies, it is an essential first step in the research process to understand the context of female sport and the female athlete. Even within male cohorts, a call for research reproducibility has been made [ 19 ]; thus the need to replicate studies from male cohorts in female cohorts is required.

In summary, all stakeholders need to be cognizant of sexual dimorphism and the disparity in the current sports science literature and consequent challenges of adopting an evidence-informed approach to practice for female athletes. When applying and undertaking research in female sport, the first step is to appraise and evaluate the current available evidence, with consideration for both the female athlete and the female sporting environment . Considering the athlete and the environment allows the researcher and practitioner to consider potential differences to published literature in male cohorts. Due to the dearth in female-specific sport science literature, in most cases there is a clear need to start with descriptive research to understand the current level of performance within female elite sport. Once this is achieved, the next challenge will be exploring in the influence of female physiology and the contextual factors which may limit the effectiveness of interventions with high efficacy. Only when this disparity in applied sport science research is addressed will the full potential of adopting an evidence-informed approach be possible in female sport.

Availability of Data and Materials

Not applicable

Abbreviations

Anterior cruciate ligament

Fink JS. Female athletes, women's sport, and the sport media commercial complex: Have we really “come a long way, baby”? J Sport Manage. 2015; 18 :331–42.

Google Scholar  

Eisenmann J. Translational gap between laboratory and playing field: new era to solve old problems in sports science . Trans J Amer Sport Med . 2017; 2 :37–43.

Wang D, et al. Neuromuscular training effects on the stiffness properties of the knee joint and landing biomechanics of young female recreational athletes . Br J Sports Med. 2017;51:405.

Heidari S, et al. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use . Research Integrity and Peer Review. 2016;1:2.

Article   Google Scholar  

Costello JT, Bieuzen F, Bleakley CM. Where are all the female participants in sports and exercise medicine research? Eur J Sport Sci. 2014; 14 :847–51.

Thompson B, Han A. Methodological recommendations for menstrual cycle research in sports and exercise. Med. Sci. Sports Exerc. 2019.

Bruinvels G, et al. Sport, exercise and the menstrual cycle: where is the research? Br. J. Sports Med . 2017.

Mendiguchia J, et al. Sex differences in proximal control of the knee joint . J Sports Med. 2011;41:541–57.

Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors . Am J Sport Med. 2006; 34 :299–311.

Dale, H., et al., Research alone is not sufficient to prevent sports injury . 2014: p. 682-684.

Comstock RD, et al. An evidence-based discussion of heading the ball and concussions in high school soccer . JAMA Pediatrics. 2015; 169 :830–7.

Bauman S, Ray M, Joseph PP. Gender differences in clinical presentation and recovery of sports related concussion . Br J Sports Med . 2017; 51 :A35.

Hanson D, et al. Research alone is not sufficient to prevent sports injury. Br J Sports Med . 2014.

Glassbrook DJ, et al. The demands of professional rugby league match-play: a meta-analysis. Sports Med . 2019; 5 :24.

Jones B, et al. Physical qualities of international female rugby league players by playing position. J Strength Con Res . 2016; 30 :1333–40.

Dobbin, N., et al., The discriminant validity of standardised testing battery and its ability to differentiate anthropometric and physical characteristics between youth, academy and senior professional rugby league players. Int Journal Sport Physio l, 2019

Bishop D. An applied research model for the sport sciences . Sports Med. 2008;38:253–63.

Jones B, et al. Accessing off-field brains in sport; an applied research model to develop practice. Br J Sports Med . 2019.

Iqbal SA, et al. Reproducible research practices and transparency across the biomedical literature . PLoS Biol . 2016; [Epub ahead of print].

Download references

Acknowledgements

Not applicable.

No funding was received for this project.

Author information

Authors and affiliations.

Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK

Stacey Emmonds, Omar Heyward & Ben Jones

England Performance Unit, Rugby Football League, Red Hall, Leeds, UK

Stacey Emmonds & Ben Jones

Rugby Football Union, Twickenham, London, UK

Omar Heyward

Leeds Rhinos Rugby League Club, Leeds, UK

School of Science and Technology, University of New England, Armidale, New South Wales, Australia

Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town and the Sports Science Institute of South Africa, Cape Town, South Africa

You can also search for this author in PubMed   Google Scholar

Contributions

SE/BJ conceptualized the ideas for the opinion piece. SE/BJ/OH all contributed to writing the opinion piece. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Stacey Emmonds .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors, Stacey Emmonds, Omar Heyward, and Ben Jones, declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Reprints and permissions

About this article

Cite this article.

Emmonds, S., Heyward, O. & Jones, B. The Challenge of Applying and Undertaking Research in Female Sport. Sports Med - Open 5 , 51 (2019). https://doi.org/10.1186/s40798-019-0224-x

Download citation

Received : 05 April 2019

Accepted : 05 November 2019

Published : 12 December 2019

DOI : https://doi.org/10.1186/s40798-019-0224-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• 14 December 2022

How sports science is neglecting female athletes

• Katharine Sanderson 0

Katharine Sanderson is a freelance journalist based in Cornwall, UK.

You can also search for this author in PubMed   Google Scholar

Research on the science of sport is heavily skewed towards male athletes, finds a review of hundreds of sports-medicine studies 1 . The imbalance leaves large gaps in knowledge about female sports and sport-related injuries.

Access options

Access Nature and 54 other Nature Portfolio journals

Get Nature+, our best-value online-access subscription

24,99 € / 30 days

cancel any time

Subscribe to this journal

Receive 51 print issues and online access

185,98 € per year

only 3,65 € per issue

Rent or buy this article

Prices vary by article type

Prices may be subject to local taxes which are calculated during checkout

doi: https://doi.org/10.1038/d41586-022-04460-3

Paul, R. W. et al. Am. J. Sports Med . https://doi.org/10.1177/03635465221131281 (2022).

Article   Google Scholar  

Download references

Reprints and permissions

Related Articles

• Scientific community
• Medical research

Overcoming low vision to prove my abilities under pressure

Career Q&A 28 MAR 24

How a spreadsheet helped me to land my dream job

Career Column 28 MAR 24

The corpse of an exploded star and more — March’s best science images

News 28 MAR 24

First pig kidney transplant in a person: what it means for the future

News 22 MAR 24

Powerful microscopy reveals blood-cell production in bone marrow

News & Views 20 MAR 24

First pig liver transplanted into a person lasts for 10 days

News 20 MAR 24

How to make an old immune system young again

News 27 MAR 24

Depleting myeloid-biased haematopoietic stem cells rejuvenates aged immunity

Article 27 MAR 24

Pregnancy advances your ‘biological’ age — but giving birth turns it back

Tenure-track Assistant Professor in Ecological and Evolutionary Modeling

Tenure-track Assistant Professor in Ecosystem Ecology linked to IceLab’s Center for modeling adaptive mechanisms in living systems under stress

Umeå, Sweden

Umeå University

Faculty Positions in Westlake University

Founded in 2018, Westlake University is a new type of non-profit research-oriented university in Hangzhou, China, supported by public a...

Hangzhou, Zhejiang, China

Westlake University

Postdoctoral Fellowships-Metabolic control of cell growth and senescence

Postdoctoral positions in the team Cell growth control by nutrients at Inst. Necker, Université Paris Cité, Inserm, Paris, France.

Paris, Ile-de-France (FR)

Inserm DR IDF Paris Centre Nord

Zhejiang Provincial Hospital of Chinese Medicine on Open Recruitment of Medical Talents and Postdocs

Director of Clinical Department, Professor, Researcher, Post-doctor

The First Affiliated Hospital of Zhejiang Chinese Medical University

Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Warmly Welcomes Talents Abroad

“Qiushi” Distinguished Scholar, Zhejiang University, including Professor and Physician

No. 3, Qingchun East Road, Hangzhou, Zhejiang (CN)

Sir Run Run Shaw Hospital Affiliated with Zhejiang University School of Medicine

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Reference Manager
• Simple TEXT file

People also looked at

Brief research report article, what about the girls exploring the gender data gap in talent development.

• 1 School of Health and Human Performance, Dublin City University, Dublin, Ireland
• 2 Institute for Sport and Health, University College Dublin, Dublin, Ireland
• 3 Institute of Coaching and Performance, University of Central Lancashire, Preston, United Kingdom

Although there is an extensive literature about talent development, the lack of data pertaining to females is problematic. Indeed, the gender data gap can be seen in practically all domains including sport and exercise medicine. Evidence-based practice is the systematic reviewing of the best evidence in order to make informed choices about practice. Unfortunately, it may be that the data collected in sport is typically about male experiences, and not female; a rather unfortunate omission given that approximately half of the population is made up of women. When female athletes are underrepresented in research there are issues when making inferences about data collected in male dominated research domains to inform practice and policy for female athletes. In parallel, female sport participation is continually increasing worldwide. Recognizing the importance of evidence-based practice in driving policy and practice, and reflecting the gender data gap that is a consistent feature of (almost) all other domains, we were interested in examining whether a gender data gap exists in talent development research. The results suggest that a gender data gap exists in talent development research across all topics. Youth athlete development pathways may be failing to recognize the development requirements of females, particularly where female sports may be borrowing systems that are perceived to work for their male counterparts. In order to ensure robust evidence based practice in female youth sport there is a need to increase the visibility of female athletes in talent development literature.

Introduction

The literature base, and data, about talent development in sport is extensive and includes a range of empirical articles ( Coutinho et al., 2015 ; Forsman et al., 2016 ), theory-driven papers ( Phillips et al., 2010 ; Davids et al., 2013 ), and models of talent development ( Gagné, 2004 ; Bailey and Morley, 2006 ) that are purported to enable researchers, practitioners, and policy makers generate a clear understanding of what is known in order to guide their practice and inform policy decisions. Indeed, across all sport science disciplines there is an understanding of the importance of evidence-based practice in determining the best outcomes for athletes and coaches. Evidence-based practice is the systematic reviewing of the best evidence in order to make informed choices about practice. Unfortunately, it may be (as elsewhere in a data-driven world) that the data collected in sport is typically about male experiences, and not female; a rather unfortunate omission given that approximately half of the population is made up of women ( The World Bank, 2017 )! The gender data gap ( Perez, 2019 ) is important to consider against the growth of womens' and girls' sport in general and the subsequent implementation of female specific talent development pathways (e.g., The Football Association Girls' England Talent Pathway; The FA, 2017 ). If data is used, in the talent development space, to drive decisions about resource allocation, pathway structures, coaching, and competition about female sport, are we sure that it reflects the needs of specific populations?

There has been much recent attention on the gender data gap across domains from medicine ( Vitale et al., 2017 ), to vehicle safety ( Linder et al., 2011 ), and urban design ( Carpio-Pinedo et al., 2019 ). Simply, researchers fail to collect data on women yet the results of research are extrapolated to females without due consideration of the impact of that transfer ( Perez, 2019 ). When women are underrepresented in the data that underpins how decisions are made, when the statistics ignore them, the results can be problematic. For example, women are more likely to be misdiagnosed of a heart attack as they experience different symptoms to men. However, cardiac trials generally use male participants leading to the most common known symptoms of cardiac events to be those experienced by males. Similarly, cars are designed around the body and physical profile of a male, increasing the likelihood of injury to women in collisions. The dangers of not having, and using, robust data on females is far-reaching.

Even when data on females is collected it is not always analyzed appropriately. As such, it is important to collect sex segregated data as “ women are not just men with boobs and tubes, they have their own anatomy and physiology that deserve to be studied with the same intensity ” ( Mcgregor, 2015 ). Of course, in medicine and transportation safety the results of the data gap can be deadly ( Bose et al., 2011 ; Linder et al., 2011 ; Vitale et al., 2017 ). In talent development, while there may not be the same catastrophic repercussions to excluding data on female experiences, failing to account for the experiences of females can result in inefficient talent systems and less than optimal experiences for female athletes. As such, closing the gender data gap requires the need to count female experiences explicitly in all fields. Sport and exercise medicine research has already been reported to significantly under-represent females in current literature, accounting for <40% of the total number of participants ( Costello et al., 2014 ).

The last 20 years has seen large and robust literature emerge exploring various aspects of talent development ( Coutinho et al., 2016 ; Rongen et al., 2018 ; Bennett et al., 2019 ). This research base has focused on a broad range of factors including identifying key aspects of the talent development environment ( Wang et al., 2016 ; Li et al., 2017 ; Gledhill and Harwood, 2019 ), the importance of psycho-behavioral factors ( Höner and Feichtinger, 2016 ; Erikstad et al., 2018a , b ; Tedesqui and Young, 2018 ), physiological ( Arazi et al., 2013 ; Forsman et al., 2016 ; Fornasiero et al., 2018 ; Jones et al., 2018 ), coaching ( Romann et al., 2017 ; Peña-González et al., 2018 ), family ( Domingues and Gonçalves, 2013 ; Elliott et al., 2018 ), and early experiences ( Ford et al., 2009 ; Schorer et al., 2010 ; Coutinho et al., 2015 ) on the trajectory of young athletes. However, if the research-practice divide is to be effectively bridged for all athletes and robust implications for practice offered to practitioners, it is important to critically examine this evidence base and its applicability for both male and female athletes. Published literature such as journal articles present the knowledge base of a given discipline and reflect the discipline's history, trends, and research norms. As such, before research findings can be applied with confidence to particular contexts, it is important to establish that the research reflects that context.

Funding and structures for women's sport is increasing across the world with the establishment of professional leagues in, for example, soccer, hockey, athletics, and talent development pathways and academy structure for young female athletes developing in parallel. Often, the structures designed for female athletes have been “borrowed” from their male counterparts, perhaps without due interrogation of the similarities and differences that may exist between the two cohorts. Recognizing the importance of evidence-based practice in driving policy and practice, and reflecting the gender data gap that is a consistent feature of (almost) all other domains, we were interested in examining whether a gender data gap exists in talent development research. Therefore, the purpose of this paper was 2-fold. Firstly, the aim of this study was to review the peer-reviewed literature in talent development published between 1999 and 2019 to examine whether female athletes were represented in the participant sampling. Building on this, the second part of the paper discusses some reasons why future studies with female athletes are important in order to ensure that the literature is reflective of commonalities and differences in their experiences.

Development of Search Strategy

As scientist-practitioners our aim is to generate practically meaningful knowledge. As such, this study was underpinned by a pragmatic research philosophy ( Giacobbi et al., 2005 ) and this philosophy guided all parts of the research process. This literature search utilized in this study employed review principles similar to conventional systematic reviews in order to ensure that adequate selection of literature based on replicable criteria occurred ( Smith, 2010 ). A list of key words relevant to the aim and theme of the research was created ( Smith, 2010 ) and these search parameters were trialed in a preliminary search on the SPORTDiscus database. During this preliminary search, every 10th result was checked and analyzed for relevance and to consider whether additional keywords should be included. This process was repeated until the most effective search terms were identified (i.e., the terms that returned the most relevant and specific literature in relation to the research question). Irrelevant terms that repeatedly came up in the search results were excluded (i.e., injury). Following this process, the final list of search terms included the following:

“Talent Development” OR “Talent Identification” OR “Talent Selection” OR “Talent” OR “Long Term Development” OR “Specialisation” OR “Relative Age Effect” AND “Youth Sport” OR “Youth Athlete” OR “Young Athlete” OR “Adolescence” AND “Maturation” OR “Growth” AND “Psychology” OR “Mental Skills” NOT “Injury”

In the final literature search two relevant databases, SPORTDiscus and Ovid, were broadly, though not exhaustively, searched using the key words in different combinations to allow for the return of relevant research papers.

Inclusion/Exclusion Criteria

Inclusion and exclusion criteria were employed to create clearly defined boundaries for the literature search ( Smith, 2010 ). The inclusion criteria were, (a) peer reviewed empirical research studies, (b) published from January 1999 until April 2019 (when the formal search was finalized), (c) in English language, (d) have gathered original qualitative or quantitative evidence from young athletes only (under 21 years of age), and not evidence from other stakeholders (e.g., coaches, parents, peers etc.), that facilitate talent development knowledge and understanding, (e) provide information on the age and gender of the research participants, and (f) contain specific reference to either talent/talent development/talent identification/talent specialization, long term development/growth/maturation, or psychological skills/psychological attributes to talent development within the title, abstract or listed key words.

Search Returns

The search process came to a close on the 1st of April 2019 and retrieved 2,873 potentially relevant hits. Duplications were removed and abstracts and titles assessed for relevance. Based on the inclusion/exclusion criteria, 2,498 search returns were excluded and 375 papers kept for full-text retrieval. Most studies were excluded due to duplicates, a lack of definitive relevance to talent development, or their focus on senior (above 21 years of age) elite athletes. After full-text retrieval and review, 312 of the 375 papers met the inclusion criteria. Most studies were excluded due to the inclusion of coaches or parents in the participant group, no clearly defined age or gender of participants as well as inclusion of participants above 21 years. This reference list was examined by an experienced external advisory team. Suggestions from this advisory team included the removal of further studies due to a lack of definitive talent development focus as well as the suggestion for consideration of additional references. These additional studies were considered and 10 papers accessed and reviewed. Following this process an additional two references were added. Following this process, 276 studies met the inclusion criteria and were analyzed for the purpose of this review. Following the PRISMA flow diagram guidelines developed by Moher et al. (2009) , an outline of the detailed overview of the search process, along with the reasons why papers were rejected, can be found in Figure 1 .

Figure 1 . PRISMA flow diagram of study selection.

Data Synthesis

The literature search was used to identify and elicit research papers regarding areas within talent development of athletes under 21 years of age. The aim of the literature search was to examine whether a gender data gap was apparent in talent development research carried out from 1999 to 2019. As a first step, the first author went through an extensive process to check all papers for relevance and identify any alternative and appropriate key words for use within the literature search to ensure accuracy and comprehensiveness. A content analysis was used to extract key information from the data regarding the gender, age and the key words used within each research paper ( Pope et al., 2007 ).

Establishing Trustworthiness

To establish trustworthiness and meet the criteria of validity and credibility, a number of processes were followed ( Creswell and Miller, 2000 ; Sparkes and Smith, 2009 ). Firstly, peer debrief , which involved a consistent review of the research process by an experienced supervisor who offered their support and criticisms, was employed ( Creswell and Miller, 2000 ). Peer debrief took place regularly (i.e., every 2–4 weeks) through meetings and informal discussions. Secondly, an advisory team , comprised of two external researchers who had previously published studies within the explored literature, was established ( Smith, 2010 ). The advisory team was provided with references of included studies, strategies for developing the research question, inclusion and exclusion criteria, and a briefing about the purpose of the literature search. The included papers and research methods employed were approved by the panel and suggestions for additional inclusions provided.

Reflecting the aims of this study, we were particularly interested in examining the participant populations included in the talent development research from 1999 to 2019. Table 1 illustrates the gender breakdown across the selected publications. Of the 276 research papers included in the data synthesis, only 9.42% included a female only population in comparison to 60.14% in a male only population, and 30.43% with both males and females included in the participant group (gender aggregated). This finding clearly indicates that a gender data gap exists in the talent development research from 1999 to 2019. Table 1 also presents the extent to which the gender aggregated research papers report findings on males and females considered together as a single participant group or if the findings were compared between the genders. 77.38% of the 84 gender aggregated papers present results where males and females have been considered separately. Of these, 86.15% illustrate a difference in the results relating to females in comparison to males.

Table 1 . The number and percentage of gender groups (male, female, and gender aggregated; both male and female); and the number and percentage of papers where comparisons are made between genders represented in the research papers included in the literature search data set.

Having established that a gender data gap was apparent, we then reviewed the results to consider whether the data gap was more or less apparent in the literature pertaining to specific topics in talent development (see Table 2 ). Research relating to the relative age effect and maturation of youth athletes was the most represented topic in the literature search (36.96%) and, perhaps surprisingly, research relating to sport specialization (3.26%) was the least evident. Reflecting the purpose of the paper, each topic was then analyzed to examine whether a gender data gap was apparent and this examination found that females were underrepresented across every topic. Females accounted for only 3–17% of the participant groups in the included literature compared to a 38–73% representation for male only groups. Gender aggregated data (male and female participants) was also higher than the female only across all but one topic of the literature search. Physical factors returned 8.82% of studies for gender aggregated groups compared to 17.65% for female only groups. The gender aggregated group also accounted for less studies across all topics compared to the male only group.

Table 2 . The number and percentage of topics and number and percentage separated per participant group represented in the research papers included in the literature search data set.

Finally, we examined the data to identify trends within talent development research published from 1999 to 2019. Table 3 highlights the growth of this particular area of research in more recent years. 38.41% of the included literature were published from 2016 to 2019 compared to only 7.61% of the studies published between 2007 and 2009. Only 5.80% of the papers included in the literature search were published between 1999 and 2006. Table 3 also highlights the gender breakdown of the published papers by year and presents a clear underrepresentation of research papers with female only populations. Although attention on topics pertaining to talent development has increased year-on-year, the gender data gap has remained consistent.

Table 3 . The number and percentage of publications by year and number and percentage separated per participant group represented in the research papers included in the literature search data set.

The gender data gap represents an unequal representation of females across numerous domains in a world driven by data ( Perez, 2019 ). Although there has been considerable growth in research relating to talent development in recent years, females are underrepresented in this data. Given that research should underpin advancements in real world practice in sport and youth athlete development, this gender data gap may have significant implications. Gender differences play an important role in the development of young athletes and there are notable differences between males and females in this regard; for example, physical ( Batterham and Birch, 1996 ; Cramer et al., 2002 ; Weber et al., 2006 ; Bradley et al., 2014 ; Clarke et al., 2014 ), and cognitive ( Crocker and Graham, 1995 ; Phillipe and Seiler, 2005 ; Murcia et al., 2008 ) differences between males and females are well-documented. Table 2 illustrates that the gender data gap is apparent across these important constructs. This becomes problematic when applying current findings to female development pathways and practices since gender can potentially influence youth athlete development. For example, the aerobic fitness evolution of young females progresses at slower rates to their male counterparts ( Fornasiero et al., 2018 ). Furthermore, youth female athletes perceive their environment as a more task oriented climate ( Murcia et al., 2008 ) and have a more long-term development focus than males ( Li et al., 2018 ). Similarly, relative age effects are less pronounced in female sports, potentially due to maturational differences between females and males ( Romann et al., 2018 ). As such, if data is to be used to inform talent development practice, there is a need for caution when making inferences about female athletes from male dominated research studies. Though beyond the scope of this review, we additionally recognize the complexity of these issues and the need for research to evolve further to adequately and appropriately represent individuals of all gender identities, whether they identify as men, women, or other. However, in this context we have delimited the analysis to male/female to reflect the categorization of competitive sport.

This literature search highlighted an underrepresentation of female data across all topics of talent development research and questions the extent to which the research as it stands can be extrapolated with confidence to female talent pathways. For example, there is less evidence on females in research specific to talent identification, physical and psychological development. Despite the dearth of female based talent development literature, there is continued growth worldwide of female sport, with sports participation amongst girls and women at an all-time high, female athletes are participating in record numbers ( Fink, 2015 ). Research pertaining to male athletes cannot be assumed to relate to female athletes and the implications of applying such research findings to female sport are vast, creating talent pathways likely to be unreflective of female athlete needs.

Based on the evidence presented here, it can be hypothesized that current talent development pathways and systems for female athletes have been designed and developed based on male data. As such, talent development systems and structures for female athletes appear to lack a robust evidence base and may instead be the product of experience, gut feel, and tradition largely adopted from male athlete experiences. Simply, there is clearly a need for evidence of the experiences, requirements, and reflections of female athletes on the talent development pathway across all topics of talent development—physical, psycho-behavioral, talent identification etc. and a greater visibility of female athletes in the literature. The lack of data for females in talent development undermines the ability to understand the experiences of women and girls in sport and the constraints and opportunities they experience. Furthermore, this paper presents clear evidence that data collection in talent development is distorted by gender biases and how this negatively impacts the ability to design appropriate policies, structures, and systems for female athletes. In addition to the gender data gap, we would also argue that having no data, or poor data on issues that affect female athletes in particular is a significant issue; some issues (e.g., maturation, puberty, pregnancy, menstruation) clearly impact female athletes differently than their male counterparts and gender data would help us understand this better. In sum, there is a clear need for unbiased data in order to design talent development policies and practices—the gender data gap means that we only have a partial snapshot of the experiences and requirements of females in this space. Rigorous gender data will also allow sports to make informed decisions for females in sport and track the efficacy of talent development interventions.

Data Availability

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

OC, AM, and DP contributed to the design and implementation of the research and contributed to the final version of the manuscript. OC performed the data collection and analysis.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Arazi, H., Faraji, H., and Mehrtash, M. (2013). Anthropometric and physiological profile of iranian junior elite gymnasts. Facta Univ. 11, 35–41.

Google Scholar

Bailey, R., and Morley, D. (2006). Towards a model of talent development in physical education. Sport Educ. Soc. 11, 211–230. doi: 10.1080/13573320600813366

CrossRef Full Text | Google Scholar

Batterham, A. M., and Birch, K. M. (1996). Allometry of anaerobic performance: a gender comparison. Can. J. Appl. Physiol. 21, 48–62. doi: 10.1139/h96-005

PubMed Abstract | CrossRef Full Text | Google Scholar

Bennett, K. J. M., Vaeyens, R., and Fransen, J. (2019). Creating a framework for talent identification and development in emerging football nations. Sci. Med. Football 3, 36–42. doi: 10.1080/24733938.2018.1489141

Bose, D., Segui-Gomez, M., and Crandall, J. R. (2011). Vulnerability of female drivers involved in motor vehicle crashes: an analysis of US population at risk. Am. J. Public Health 101, 2368–2373. doi: 10.2105/AJPH.2011.300275

Bradley, P. S., Dellal, A., Mohr, M., Castellano, J., and Wilkie, A. (2014). Gender differences in match performance characteristics of soccer players competing in the uefa champions league. Hum. Mov. Sci. 33, 159–71. doi: 10.1016/j.humov.2013.07.024

Carpio-Pinedo, J., De Gregorio Hurtado, S., and Sanchez De Madariaga, I. (2019). Gender mainstreaming in urban planning: the potential of geographic information systems and open data sources. Plan. Theory Pract. 20, 221–240. doi: 10.1080/14649357.2019.1598567

Clarke, A. C., Presland, J., Rattray, B., and Pyne, D. B. (2014). Critical velocity as a measure of aerobic fitness in women's rugby sevens. J. Sci. Med. Sport 17, 144–148. doi: 10.1016/j.jsams.2013.03.008

Costello, J. T., Bieuzen, F., and Bleakley, C. M. (2014). Where are all the female participants in sports and exercise medicine research? Eur. J. Sport Sci. 14, 847–851. doi: 10.1080/17461391.2014.911354

Coutinho, P., Mesquita, I., and Fonseca, A. M. (2016). Talent development in sport: a critical review of pathways to expert performance. Int. J. Sports Sci. Coach. 11, 279–293. doi: 10.1177/1747954116637499

Coutinho, P., Mesquita, I., Fonseca, A. M., and Côte, J. (2015). Expertise development in volleyball: the role of early sport activities and players' age and height. Kinesiology 47, 215–225.

Cramer, J. T., Housh, T. J., Weir, J. E., Johnson, G. O., Ebersole, K. T., Perry, S. R., et al. (2002). Power output, mechanomyographic, and electromyographic responses to maximal, concentric, isokinetic muscle actions in men and women. J. Strength Condition. Res. 16, 399–408. doi: 10.1519/00124278-200208000-00010

Creswell, J., and Miller, D. (2000). Determining validity in qualitative inquiry. Theory Pract. 39, 124–130. doi: 10.1207/s15430421tip3903_2

Crocker, P. R. E., and Graham, T. R. (1995). Coping by competitive athletes with performance stress: gender differences and relationships with affect. Sport Psychol. 9, 325–338. doi: 10.1123/tsp.9.3.325

Davids, K., Araujo, D., Vilar, L., Renshaw, I., and Pinder, R. (2013). An ecological dynamics approach to skill acquisition: implications for development of talent in sport. Talent Dev. Excell. 5, 21–34.

Domingues, M., and Gonçalves, C. E. (2013). The role of parents in talented youth sport. does context matter? Polish J. Sport Tour. 20, 117–122. doi: 10.2478/pjst-2013-0011

Elliott, S., Drummond, M. J. N., and Knight, C. (2018). The experiences of being a talented youth athlete: lessons for parents. J. Appl. Sport Psychol. 30, 437–455. doi: 10.1080/10413200.2017.1382019

Erikstad, M. K., Høigaard, R., Johansen, B. T., Kandala, N.-B., and Haugen, T. (2018a). Childhood football play and practice in relation to self-regulation and national team selection; a study of norwegian elite youth players. J. Sports Sci. 36, 2304–2310. doi: 10.1080/02640414.2018.1449563

Erikstad, M. K., Martin, L. J., Haugen, T., and Høigaard, R. (2018b). Group cohesion, needs satisfaction, and self-regulated learning: a one-year prospective study of elite youth soccer players' perceptions of their club team. Psychol. Sport Exerc. 39, 171–178. doi: 10.1016/j.psychsport.2018.08.013

Fink, J. S. (2015). Female Athletes, Women's Sport, And The Sport Media Commercial Complex: Have We Really “Come A Long Way, Baby?”. Sport Management Review , 18, 331–342. doi: 10.1016/j.smr.2014.05.001

Ford, P., Ward, P., Hodges, N., and Williams, A. M. (2009). The role of deliberate practice and play in career progression in sport: the early engagement Hypothesis. High Ability Stud. 20, 65–75. doi: 10.1080/13598130902860721

Fornasiero, A., Savoldelli, A., Modena, R., Boccia, G., Pellegrini, B., and Schena, F. (2018). Physiological and anthropometric characteristics of top-level youth cross-country cyclists. J. Sports Sci. 36, 901–906. doi: 10.1080/02640414.2017.1346271

Forsman, H., Blomqvist, M., Davids, K., Liukkonen, J., and Konttinen, N. (2016). Identifying technical, physiological, tactical and psychological characteristics that contribute to career progression in soccer. Int. J. Sports Sci. Coach. 11, 505–513. doi: 10.1177/1747954116655051

Gagné, F. (2004). Transforming gifts into talents: the DMGT as a developmental theory. High Ability Stud. 15, 119–147. doi: 10.1080/1359813042000314682

Giacobbi, P. R. Jr., Poczwardowski, A., and Hager, P. (2005). A pragmatic research philosophy for applied sport psychology. Sport Psychol. 19, 18–31. doi: 10.1123/tsp.19.1.18

Gledhill, A., and Harwood, C. (2019). Toward an understanding of players' perceptions of talent development environments in Uk female football. J. Appl. Sport Psychol. 31, 105–115. doi: 10.1080/10413200.2017.1410254

Höner, O., and Feichtinger, P. (2016). Psychological talent predictors in early adolescence and their empirical relationship with current and future performance in soccer. Psychol. Sport Exerc. 25, 17–26. doi: 10.1016/j.psychsport.2016.03.004

Jones, B., Weaving, D., Tee, J., Darrall-Jones, J., Weakley, J., Phibbs, P., et al. (2018). Bigger, stronger, faster, fitter: the differences in physical qualities of school and academy rugby union players. J. Sports Sci. 36, 2399–2404. doi: 10.1080/02640414.2018.1458589

Li, C., Martindale, R., Wu, Y., and Si, G. (2018). Psychometric properties of the talent development environment questionnaire with chinese talented athletes. J. Sports Sci. 36, 79–85. doi: 10.1080/02640414.2017.1282619

Li, C. I., Wang, C. K. J., and Pyun, D. Y. (2017). The roles of the talent development environment on athlete burnout: a qualitative study. Int. J. Sport Psychol. 48, 143–164. doi: 10.7352/IJSP2016.47.143

Linder, A., Svenson, M., Carlsson, A., Lemmen, P., Chang, F., Schmidtt, K., et al. (2011). “Evarid - Anthropometric and biomechanical specification of a finite element dummy model of an average female for rear impact testing,” in The 22nd International Technical Conference on the Enhanced Safety of Vehicles (ESV) (Washington, DC: Swedish National Road And Transport Research Institute), 11.

Mcgregor, A. (2015). Why Medicine Often Has Dangerous Side Effects For Women [Video File]. Retrieved from: https://Www.Ted.Com/Talks/Alyson_Mcgregor_Why_Medicine_Often_Has_Dangerous_Side_Effects_For_Women (accessed May 5, 2019).

Moher, D., Liberati, A., Tetzlaff, J., and Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. Ann. Int. Med. 151, 264–269. doi: 10.7326/0003-4819-151-4-200908180-00135

Murcia, J. A. M., Gimeno, E. C., and Coll, D. G. (2008). Relationship among goal orientations, motivational climate, and flow in adolescent athletes: differences by gender. Span. J. Psychol. 11, 181–191. doi: 10.1017/S1138741600004224

Peña-González, I., Fernández-Fernández, J., Moya-Ramón, M., and Cervell, Ó. E. (2018). Relative age effect, biological maturation, and coaches' efficacy expectations in young male soccer players. Res. Q. Exerc. Sport 89, 373–379. doi: 10.1080/02701367.2018.1486003

Perez, C. C. (2019). Invisible Women: Exposing Data Bias in a World Designed for Men. London: Chatto & Windus.

Phillipe, R. A., and Seiler, R. (2005). Sex differences on use of associative and dissociative cognitive strategies among male and female athletes. Percept. Motorskills 101, 440–444. doi: 10.2466/pms.101.2.440-444

Phillips, E., Davids, K., Renshaw, I., and Portus, M. (2010). Expert performance in sport and the dynamics of talent development. Sports Med. 40, 271–283. doi: 10.2165/11319430-000000000-00000

Pope, C., Mays, N., and Popay, J. (2007). Synthesizing Qualitative and Quantitative Health Research: A Guide to Methods. Maidenhead: Open University Press.

Romann, M., Javet, M., and Fuchslocher, J. (2017). Coaches' eye as a valid method to assess biological maturation in youth elite soccer. Talent Dev. Excell. 9, 3–13.

Romann, M., Rössler, R., Javet, M., and Faude, O. (2018). Relative age effects in swiss talent development - a nationwide analysis of all sports. J. Sports Sci. 36, 2025–2031. doi: 10.1080/02640414.2018.1432964

Rongen, F., Mckenna, J., Cobley, S., and Till, K. (2018). Are youth sport talent identification and development systems necessary and healthy? Sports Med. Open 4, 18–18. doi: 10.1186/s40798-018-0135-2

Schorer, J., Baker, J., Lotz, S., and Büsch, D. (2010). Influence of early environmental constraints on achievement motivation in talented young handball players. Int. J. Sport Psychol. 41, 42–57.

Smith, M. (2010). Research Methods in Sport . London: Learning Matters.

Sparkes, A., and Smith, B. (2009). Judging the quality of qualitative inquiry: criteriology and relativism in action. Psychol. Sport Exerc. 10, 491–497. doi: 10.1016/j.psychsport.2009.02.006

Tedesqui, R. A. B., and Young, B. W. (2018). Comparing the contribution of conscientiousness, self-control, and grit to key criteria of sport expertise development. Psychol. Sport Exerc. 34, 110–118. doi: 10.1016/j.psychsport.2017.10.002

The FA (2017). Talent Pathway . Available online at: http://Www.Thefa.Com/Womens-Girls-Football/England-Talent-Pathway (accessed April 30, 2019).

The World Bank (2017). Population, Female (% Of Total) . Available online at: https://Data.Worldbank.Org/Indicator/Sp.Pop.Totl.Fe.Zs (accessed April 30, 2019).

Vitale, C., Fini, M., Spoletini, I., Lainscak, M., Seferovic, P., and Rosana, G. M. C. (2017). Under-representation of elderly and women in clinical trials. Int. J. Cardiol. 232, 216–221. doi: 10.1016/j.ijcard.2017.01.018

Wang, C. K. J., Pyun, D. Y, Chunxiao, L., and Lee, M. S. (2016). Talent development environment and achievement goal adoption among korean and singaporean athletes: does perceived competence matter? Int. J. Sports Sci. Coach. 11, 496–504. doi: 10.1177/1747954116654779

Weber, C. L., Chia, M., and Inbar, O. (2006). Gender differences in anaerobic power of the arms and legs – a scaling issue. Med. Sci. Sports Exerc. 38, 1–9. doi: 10.1249/01.mss.0000179902.31527.2c

Keywords: female athlete, youth athlete, gender gap, evidence-base, talent

Citation: Curran O, MacNamara A and Passmore D (2019) What About the Girls? Exploring the Gender Data Gap in Talent Development. Front. Sports Act. Living 1:3. doi: 10.3389/fspor.2019.00003

Received: 14 May 2019; Accepted: 28 June 2019; Published: 11 July 2019.

Reviewed by:

Copyright © 2019 Curran, MacNamara and Passmore. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Aine MacNamara, amacnamara1@uclan.ac.uk

• >", "name": "top-nav-watch", "type": "link"}}' href="https://watch.outsideonline.com">Watch
• >", "name": "top-nav-learn", "type": "link"}}' href="https://learn.outsideonline.com">Learn
• >", "name": "top-nav-podcasts", "type": "link"}}' href="https://www.outsideonline.com/podcast-directory/">Podcasts
• >", "name": "top-nav-maps", "type": "link"}}' href="https://www.gaiagps.com">Maps
• >", "name": "top-nav-events", "type": "link"}}' href="https://www.athletereg.com/events">Events
• >", "name": "top-nav-shop", "type": "link"}}' href="https://shop.outsideonline.com">Shop
• >", "name": "top-nav-buysell", "type": "link"}}' href="https://www.pinkbike.com/buysell">BuySell
• >", "name": "top-nav-outside", "type": "link"}}' href="https://www.outsideonline.com/outsideplus">Outside+

Become a Member

Get access to more than 30 brands, premium video, exclusive content, events, mapping, and more.

Already have an account? >", "name": "mega-signin", "type": "link"}}' class="u-color--red-dark u-font--xs u-text-transform--upper u-font-weight--bold">Sign In

Outside watch, outside learn.

• >", "name": "mega-backpacker-link", "type": "link"}}' href="https://www.backpacker.com/">Backpacker
• >", "name": "mega-climbing-link", "type": "link"}}' href="https://www.climbing.com/">Climbing
• >", "name": "mega-flyfilmtour-link", "type": "link"}}' href="https://flyfilmtour.com/">Fly Fishing Film Tour
• >", "name": "mega-gaiagps-link", "type": "link"}}' href="https://www.gaiagps.com/">Gaia GPS
• >", "name": "mega-npt-link", "type": "link"}}' href="https://www.nationalparktrips.com/">National Park Trips
• >", "name": "mega-outsideonline-link", "type": "link"}}' href="https://www.outsideonline.com/">Outside
• >", "name": "mega-outsideio-link", "type": "link"}}' href="https://www.outside.io/">Outside.io
• >", "name": "mega-outsidetv-link", "type": "link"}}' href="https://watch.outsideonline.com">Outside Watch
• >", "name": "mega-ski-link", "type": "link"}}' href="https://www.skimag.com/">Ski
• >", "name": "mega-warrenmiller-link", "type": "link"}}' href="https://warrenmiller.com/">Warren Miller Entertainment

Healthy Living

• >", "name": "mega-ce-link", "type": "link"}}' href="https://www.cleaneatingmag.com/">Clean Eating
• >", "name": "mega-oxy-link", "type": "link"}}' href="https://www.oxygenmag.com/">Oxygen
• >", "name": "mega-vt-link", "type": "link"}}' href="https://www.vegetariantimes.com/">Vegetarian Times
• >", "name": "mega-yj-link", "type": "link"}}' href="https://www.yogajournal.com/">Yoga Journal
• >", "name": "mega-beta-link", "type": "link"}}' href="https://www.betamtb.com/">Beta
• >", "name": "mega-pinkbike-link", "type": "link"}}' href="https://www.pinkbike.com/">Pinkbike
• >", "name": "mega-roll-link", "type": "link"}}' href="https://www.rollmassif.com/">Roll Massif
• >", "name": "mega-trailforks-link", "type": "link"}}' href="https://www.trailforks.com/">Trailforks
• >", "name": "mega-trail-link", "type": "link"}}' href="https://trailrunnermag.com/">Trail Runner
• >", "name": "mega-tri-link", "type": "link"}}' href="https://www.triathlete.com/">Triathlete
• >", "name": "mega-vn-link", "type": "link"}}' href="https://velo.outsideonline.com/">Velo
• >", "name": "mega-wr-link", "type": "link"}}' href="https://www.womensrunning.com/">Women's Running
• >", "name": "mega-athletereg-link", "type": "link"}}' href="https://www.athletereg.com/">athleteReg
• >", "name": "mega-bicycleretailer-link", "type": "link"}}' href="https://www.bicycleretailer.com/">Bicycle Retailer & Industry News
• >", "name": "mega-cairn-link", "type": "link"}}' href="https://www.getcairn.com/">Cairn
• >", "name": "mega-finisherpix-link", "type": "link"}}' href="https://www.finisherpix.com/">FinisherPix
• >", "name": "mega-idea-link", "type": "link"}}' href="https://www.ideafit.com/">Idea
• >", "name": "mega-nastar-link", "type": "link"}}' href="https://www.nastar.com/">NASTAR
• >", "name": "mega-shop-link", "type": "link"}}' href="https://www.outsideinc.com/outside-books/">Outside Books
• >", "name": "mega-veloswap-link", "type": "link"}}' href="https://www.veloswap.com/">VeloSwap
• >", "name": "mega-backpacker-link-accordion", "type": "link"}}' href="https://www.backpacker.com/">Backpacker
• >", "name": "mega-climbing-link-accordion", "type": "link"}}' href="https://www.climbing.com/">Climbing
• >", "name": "mega-flyfilmtour-link-accordion", "type": "link"}}' href="https://flyfilmtour.com/">Fly Fishing Film Tour
• >", "name": "mega-gaiagps-link-accordion", "type": "link"}}' href="https://www.gaiagps.com/">Gaia GPS
• >", "name": "mega-npt-link-accordion", "type": "link"}}' href="https://www.nationalparktrips.com/">National Park Trips
• >", "name": "mega-outsideonline-link-accordion", "type": "link"}}' href="https://www.outsideonline.com/">Outside
• >", "name": "mega-outsidetv-link-accordion", "type": "link"}}' href="https://watch.outsideonline.com">Watch
• >", "name": "mega-ski-link-accordion", "type": "link"}}' href="https://www.skimag.com/">Ski
• >", "name": "mega-warrenmiller-link-accordion", "type": "link"}}' href="https://warrenmiller.com/">Warren Miller Entertainment
• >", "name": "mega-ce-link-accordion", "type": "link"}}' href="https://www.cleaneatingmag.com/">Clean Eating
• >", "name": "mega-oxy-link-accordion", "type": "link"}}' href="https://www.oxygenmag.com/">Oxygen
• >", "name": "mega-vt-link-accordion", "type": "link"}}' href="https://www.vegetariantimes.com/">Vegetarian Times
• >", "name": "mega-yj-link-accordion", "type": "link"}}' href="https://www.yogajournal.com/">Yoga Journal
• >", "name": "mega-beta-link-accordion", "type": "link"}}' href="https://www.betamtb.com/">Beta
• >", "name": "mega-roll-link-accordion", "type": "link"}}' href="https://www.rollmassif.com/">Roll Massif
• >", "name": "mega-trail-link-accordion", "type": "link"}}' href="https://trailrunnermag.com/">Trail Runner
• >", "name": "mega-tri-link-accordion", "type": "link"}}' href="https://www.triathlete.com/">Triathlete
• >", "name": "mega-vn-link-accordion", "type": "link"}}' href="https://velo.outsideonline.com/">Velo
• >", "name": "mega-wr-link-accordion", "type": "link"}}' href="https://www.womensrunning.com/">Women's Running
• >", "name": "mega-athletereg-link-accordion", "type": "link"}}' href="https://www.athletereg.com/">athleteReg
• >", "name": "mega-bicycleretailer-link-accordion", "type": "link"}}' href="https://www.bicycleretailer.com/">Bicycle Retailer & Industry News
• >", "name": "mega-finisherpix-link-accordion", "type": "link"}}' href="https://www.finisherpix.com/">FinisherPix
• >", "name": "mega-idea-link-accordion", "type": "link"}}' href="https://www.ideafit.com/">Idea
• >", "name": "mega-nastar-link-accordion", "type": "link"}}' href="https://www.nastar.com/">NASTAR
• >", "name": "mega-shop-link-accordion", "type": "link"}}' href="https://shop.outsideonline.com/">Outside Shop
• >", "name": "mega-vp-link-accordion", "type": "link"}}' href="https://www.velopress.com/">VeloPress
• >", "name": "mega-veloswap-link-accordion", "type": "link"}}' href="https://www.veloswap.com/">VeloSwap

NEW! YOUR LOCAL RUNNING DROP

Get after it with nearby recommendations just for you.

New Research Is Changing the Game for Female Athletes

Fresh discoveries could usher in a new era of unprecedented female performance..

New perk! Get after it with local recommendations just for you. Discover nearby events, routes out your door, and hidden gems when you >","name":"in-content-cta","type":"link"}}'>sign up for the Local Running Drop .

Despite more than a century of inquiry into human endurance, research is still frustratingly scant on how women’s bodies adapt and peak. But that’s starting to change, and fresh discoveries could usher in a new era of unprecedented female performance.

On the first viciously hot summer day, when my husband and I launch into a set of half-mile repeats, I finish each interval a few steps behind him.

It’s weird—and maddening—because (sorry, honey) I can best him in every other season.

Don’t you feel like you’re going to die? I say, my heart hammering and my vision blurring around the edges.

Not really, he says calmly before beginning again.

For years, I assumed that the heat just messed with my head; that I was underperforming because “I hate this” mental muck had sucked my legs down with it. But I assumed wrong. It turns out there’s more to it than a lack of mental fortitude; my gender could play a role in how I respond to the heat.

The Gender Chasm

How big of an issue is this? In 2014, a review published in The European Journal of Sports Science looked at 1,382 peer-reviewed studies from sports science and sports medicine journals. It found that, on average, women made up just 39 percent of study subjects. In 2016, Bethany Brookshire, a writer for Science News, built on the 2014 review by tallying the number of studies that included women in two major academic journals: Medicine and Science in Sports and Exercise and the American Journal of Sports Medicine. She found that 42 percent of the study subjects were women, which seems like an improvement. But she also found that, while 27 percent of studies were done only with men, just four percent of the research was female-specific.

To get an understanding of why women have traditionally been left out, some historical context helps. “Much of exercise science got its dawn from research interests specific to improving military readiness,” says Chris Lockwood, an exercise physiologist who has worked on dozens of published research papers and has navigated the crazy world of funding for years. Since traditionally soldiers—especially those in combat roles who needed supreme fitness—were men, using men as subjects just made sense. “But the military—at least the U.S. Armed Services—is no longer the predominant funding source behind endurance-specific research in the U.S.,” adds Lockwood. Now researchers piece together funding from public and private grants, and sports institutions and brands themselves, like Gatorade and the NFL. Even if research was still primarily aimed at military preparedness, women now serve in combat roles and are permeating even the most physically demanding sectors, like the Army Rangers and the Marine Infantry units. Research should reflect that fact.

And then there are the logistical issues of using women as study subjects. Lockwood points out that endurance science research can be awkwardly intimate. “Most exercise studies will require exercise and body composition assessments. For body comp testing, the subject is nearly naked,” he says. Also, tests can spanhours and hours, especially if you’re eating then doing a time trial. Lockwood argues that if you want to add more women to your study, offering free childcare might be necessary. Finally, there’s that pesky period problem.

In a 2017 editorial published in the British Medical Journal , the authors wrote that mainly women have been excluded from research because they’re seen as “more physiologically variable.” In other words, scientists have figured out how to replace heart valves with robotic technology, but figuring out how to navigate women’s monthly cycles while designing a study is still, to this day, deemed too difficult a problem to bear.

Plus, many researchers simply assumed that women were similar enough that it didn’t matter. Or that since men were the ones performing at the highest levels, research on them was somehow more important.

Anecdotally, Sims has been well aware of the fact that women-only research is hard to get approved and funded. “I’ve heard several times in my career, ‘Why do you want to study women, we don’t know enough about men!’” she says, adding that she’s currently fighting for money to do research on a group of female Olympians, while the same exact research has already been funded for their male counterparts.

But those arguments are ignorant at best. Women are participating in endurance sports in record numbers. The 2015 RunningUSA Runner’s Survey found that women make up a whopping 62.4 percent of the running public. And according to USA Triathlon, there are now more female membership holders than in any other point in the sport’s history. Furthermore, 44 percent of collegiate athletes—the Guinea pig pool researchers tend to draw from—are women. If a researcher isn’t studying a sex-specific subject but chooses a group of men for their test, it’s not because the researcher couldn’t find any women willing to help.

The Culture of Weakness

If there is an area where women are overrepresented in sports research, it’s in papers on the female athlete triad. This is a condition where an energy deficiency causes changes to hormone levels. If left untreated, it can result in lowered bone density and a notable drop in performance. It’s a serious and important issue that female athletes need to be aware of, but it’s been studied disproportionately more than any other subject related to female athletes—there are 19,800 hits when you search the term on Google Scholar—and the result of that deluge of triad research has deeply colored our view of female endurance athletes.

Sims explains it like this: “When you think about the term ‘male athlete,’ most often you think of images or words that convey strength, power, speed, and leanness. But when you think of the term ‘female athlete,’ most often the idea of the triad, anemia, infertility, poor recovery, eating disorders comes up. It’s the dogma of male athletes being fit, strong, and ready to compete, where female athletes are sick.”

Here’s the real rub, though. Although the condition has been known as the female athlete triad for years, men are susceptible to the condition too. However, “It’s more difficult to detect in males,” explains Dr. Michael Fredericson, M.D., the team physician for Stanford Intercollegiate Athletics. With women, there’s a clear physical cue when energy demands aren’t being met for a prolonged period of time: They lose their periods. For men, though, the symptoms can be subtle, like a loss of libido or the loss of a morning erection. Those can be embarrassing things to ask a doctor about. Add to this the fact that men are less likely to go to the doctor anyway, and it’s no wonder the condition is being diagnosed much more frequently in women than in men.

Just like in women, a long-term energy deficiency in men translates to long-term consequences including decreases in bone density and increased risk for stress fractures. Numerous studies have shown that competitive male cyclists often show decreased bone density compared to their non-cycling peers—not simply because cycling is a non-weight- bearing sport—so this problem is real. The condition is now known to be common enough in men that the International Olympic Committee put forth a paper in 2014 suggesting that the female athlete triad be renamed RED-S, for Relative Energy Deficiency in Sports. Still, major media outlets regularly publish handwringing features about the “female athlete triad,” managing to ignore an entire sector of the population and fueling further gender norms about women being the weaker sex, all at one time.

The Research That Made It

For every researcher reluctant to recruit women for their work, there’s a researcher fighting for dollars and journal space for women-centric studies. So, we actually know quite a bit about how those of us with two X chromosomes differ from those with an X and a Y. In 2016, Sims published an entire book on this topic, entitled Roar: How to match your food and fitness to your female physiology for optimum performance, great health and a strong, lean body for life . We asked her to walk us through the biggest ways women endurance athletes split from their male peers. First up, something I knew anecdotally from running with my husband: Women take longer to acclimate to hot weather.

A 2014 study in the Scandinavian Journal of Medicine and Science in Sports found that women didn’t respond particularly well to short term heat acclimatization (five days), but did better after 10 days. They may also underperform on hot days if in a “high hormone” time (like the days right before their period), writes Sims in Roar. “Progesterone elevates your core temperature, so you’ll feel hotter to begin with. On top of that, lower blood volume during high-hormone days means it’s harder for your body to sweat and cool yourself.”

Next: Women’s cycles matter. Max V02 won’t change during a period, and neither will lactate threshold. In fact, during menstruation, women are actually hormonally in a good place to perform well (though they may have some GI issues). The highest estrogen and progesterone days of a cycle, which fall about five days before a period, are when things get toughest. The body won’t process carbs as efficiently and will have more trouble repairing muscle. Sims advocates for eating especially well during these days and reaching for foods that contain extra leucine and other amino acids.

On the topic of food, women need carbs. Sims writes that women on low-carb diets actually produce more cortisol, a stress hormone that can inhibit muscle repair, than men. She says that while women may see the men in their lives get shredded on a keto diet, women are more likely to just feel lousy and see a dip in performance.

Also: Women kick ass at long distance races and races at altitude. We’re seeing more and more women take the overall wins at ultras. (Remember when Chrissie Wellington took second overall at her first ultra last June?) This is due in part to women’s enhanced ability to metabolize fat. But their ability to pace well comes into play too. A study done by the organization RunRepeat found that women were 18.6 percent better at running the same pace at both the beginning and the end of a marathon. At altitude, men’s bodies gobble up carbohydrates while women seem to be able to better use fat for fuel, thus giving them an advantage—especially if it’s a long effort. If a woman wants to best her male friends, she should challenge them to Leadville or another high-mountain ultra.

Closing The Gap

There are still things we don’t know about female athletes, and that’s frustrating. But Sims says a new crop of researchers—including more women than ever—are pushing for more gender equity. That means female athletes can look forward to a future where researchers don’t shy away from the complexity of the menstrual cycle, but rather help women learn how to wield it for maximum training effect. And when that happens, we may witness an exciting surge in new women’s endurance records. “If we were to train and recover our female athletes in accordance to their natural physiology,” Sims says, “we would most likely see huge gains in the outcomes of female athletes.”

Popular on Triathlete

Join Outside+ to get access to exclusive content, 1,000s of training plans, and more.

• Clean Eating
• Vegetarian Times
• Yoga Journal
• Fly Fishing Film Tour
• National Park Trips
• Warren Miller
• Fastest Known Time
• Trail Runner
• Women's Running
• Bicycle Retailer & Industry News
• FinisherPix
• Outside Events Cycling Series
• Outside Shop

© 2024 Outside Interactive, Inc

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

•  We're Hiring!
•  Help Center

Female Athletes

• Most Cited Papers
• Most Downloaded Papers
• Newest Papers
• Save to Library
• Representation of Female Athletes in Tabloid Press Follow Following
• Single Leg Drop Landing Follow Following
• Kinematic and Kinetic Variables Follow Following
• Proximal Tibia Anterior Shear Force Follow Following
• Women's Sport Follow Following
• Soccer Follow Following
• Women's Boxing Follow Following
• Elections Follow Following
• Football (soccer) Follow Following
• Gender Portrayal in Media Follow Following

Enter the email address you signed up with and we'll email you a reset link.

• Academia.edu Publishing
•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

FIFA Launches the Women’s Health, Wellbeing, and Performance Project: Empowering Women in Sports

Project has been in gestation for the last two years

The initiative recognises the uniqueness of female physiology

More than 20 global experts have collaborated with FIFA to address crucial challenges in women’s health

FIFA, in collaboration with leading experts from around the globe, has today proudly unveiled the FIFA Women’s Health, Wellbeing, and Performance project. Over the past two years, this pioneering initiative of FIFA's Women’s Football Division has been dedicated to addressing crucial challenges in women's health within the realm of sports, with a vision to elevate women's participation, education, and performance to new horizons. In the current landscape of women’s health in sports, the urgency to develop this area is evident. The FIFA Women’s Health, Wellbeing, and Performance project is firmly committed to dismantling barriers that have previously impeded the realisation of women's full potential in sports.

Sarai Bareman, FIFA Chief Women’s Football Officer: "We are excited about our new initiative, which is dedicated to enhancing the holistic development of every female footballer. "Our goal is to prioritize the health, well-being, and performance of these athletes, while also advancing the understanding and engagement of women and girls in football across all levels of the game. This initiative reflects our commitment to creating a thriving and inclusive environment for women's football, fostering growth, and expanding opportunities for all."

The project's core objectives encompass:

1. Addressing Education Gaps The lack of education and awareness surrounding women's physiology, health, wellbeing, and performance is a persistent issue. This project strives to educate, empower, and equip women with the knowledge they need to excel. 2. Empowering through Knowledge Fostering a profound understanding of female physiology to liberate women from constraints rooted in training paradigms designed for male athletes. 3. Combating Puberty-Related Dropout Acknowledging the unique challenges adolescent female athletes face and offering support structures to ensure their continued participation. 4. Optimising training amid Hormonal Changes Recognising the impact of hormonal fluctuations on performance and devising tailored training methodologies to empower female athletes to reach their peak potential. 5. Breaking Barriers and Taboos Confronting societal, cultural, and health-related barriers that have limited women’s involvement in sports, paving the way for inclusivity. 6. Enhancing Coach Education Integrating women’s health and well-being education into coaching curricula to equip coaches with the necessary understanding to guide female players. 7. Promoting Access to Screening and Monitoring Tools Providing essential resources for screening and monitoring to enhance female athletes' wellbeing and performance. 8. Championing Research and Resources Bridging the research and resource gap for female players, ensuring they have access to evidence-based support. 9. Creating Awareness and Education Raising awareness and educating stakeholders about women’s health, wellbeing, and performance to foster a more inclusive environment.

The Menstrual Cycle's Impact on Performance: A Focus on Evidence

Dr Dawn Scott, a leading expert, emphasises the significance of this initiative: "For too long, we have applied research on white male players and used the evidence to train female players. This project is the starting point to educate and empower players, coaches, and support staff on how to optimally train women as women, ensuring health, wellbeing, and performance of female players."

The project's evidence-based approach underscores the significant impact of the menstrual cycle on women’s participation and performance: • 95% of players experience daily menstrual cycle symptoms. • 1 in 3 players have adjusted training due to symptoms. • 66% feel symptoms affect their performance. • 90% of players do not communicate menstrual cycle issues with coaches. • 41% of players have encountered heavy bleeding. • 85% perceive insufficient menstrual cycle knowledge. • 42-47.1% of athletes use hormonal contraception, and 45% use analgesics for menstrual symptoms.

Three Pillars for Transformation

The project operates under three interconnected pillars: 1. Awareness: Sharing best practices, fostering understanding, and providing a learning platform for health, wellbeing, and performance in sports. 2. Research: Encouraging knowledge expansion and exchange through research to inform decisions and advance the professionalisation of women's sports. 3. Education: Developing resources and educational frameworks to cultivate improved environments for growth and performance among coaches, players, and multidisciplinary teams.

"By learning more about the individualized response to hormonal changes across the female lifecycle and training women as women, we can truly unlock the full potential of female athletes" added Dr. Georgie Bruinvels, another leading expert involved in the project. The FIFA Women’s Health, Wellbeing, and Performance project is poised to drive transformative change by addressing complex topics such as, supporting players through pregnancy and understanding the menstrual cycle's impact. The initiative recognises the uniqueness of female physiology and is committed to providing women in football with the attention, resources, and knowledge they deserve.

• Patient Care
• Career Opportunities
• Ways to Donate
• Advocacy Information
• I’m just browsing
• (888) 584-7888
• Pay My Bill
• Make a Gift
• Our Hospitals
• For Patients
• For Healthcare Providers
• Clinical Trials

• ACL Injuries in Female Athletes

Understanding ACL Injuries in Female Athletes: Risk Factors, Treatment and Prevention

Publish Date: 03/16/2024

The anterior cruciate ligament, or ACL, serves an important role in maintaining stability of the knee during physical activities. Despite its strength, the ACL is susceptible to injuries, particularly among female athletes.

We spoke with Mary K. Mulcahey, MD, FAAOS, FAOA - the division director of Sports Medicine at Loyola Medicine and Director of the Women's Sports Medicine program - to learn how female athletes can prevent ACL injuries.

"The anterior cruciate ligament is in the center of the knee and is absolutely critical to stability of the knee. We don’t need the ACL to be able to walk straight; however, it is essential for any side-to-side movement," says Dr. Mulcahey.

What is the ACL and why is it important?

The ACL connects the thigh bone (femur) to the shin bone (tibia), playing a major role in ensuring that our knees can withstand the demands of daily activities, especially in sports.

During athletic events, the ACL not only supports the knee during high-speed maneuvers but also aids in precise movements, like jumping, pivoting, and landing safely. Unfortunately, despite its crucial role, the ACL is prone to injuries, particularly in sports that involve cutting and pivoting and sudden changes in direction, such as basketball, soccer, and volleyball.

ACL injuries are not only common, but also exhibit a notable gender disparity. Research indicates that female athletes are significantly more likely to suffer from ACL injuries than their male counterparts. This increased risk is attributed to a combination of anatomical, hormonal, and biomechanical differences.

"Without the ACL, the knee doesn't function normally. It's so important for stability. If the ACL is not functioning properly, there is additional stress on other structures in the knee, such as the medial meniscus," says Dr. Mulcahey.

Why are female athletes at a higher risk for ACL injuries?

In the world of sports, female athletes face a unique set of challenges, particularly when it comes to injuries. Women are at a higher risk for ACL injuries because of various biological and physical factors.

"ACL tears are 2-8 times more common in female than male athletes due to a combination of non-modifiable and modifiable risk factors.  Non-modifiable risk factors, things we cannot change, include gender-related differences in knee anatomy, like the size of the ACL and hormonal fluctuations during the menstrual cycle," says Dr. Mulcahey.

"However, there are risk factors that we can control, like hamstring and quadriceps strength, as well as how female athletes are landing during their sport."

There are many reasons why the risk of ACL injuries is higher for females .

How to prevent ACL injuries in women

Preventing ACL injuries in female athletes requires a multifaceted approach that starts with the foundational support system: coaches and parents. These key figures play a crucial role in instilling practices and behaviors that can significantly reduce the risk of ACL injuries.

Coaches and parents are on the front lines of prevention. They can encourage athletes to participate in injury prevention programs and ensure they are performing exercises correctly. By fostering an environment that prioritizes safety, proper technique, and strength training, coaches and parents can help female athletes build resilience against ACL injuries.

Implementing the following prevention strategies can set female athletes up for success.

Training and conditioning programs : Specialized training programs that focus on improving strength, flexibility, and balance are essential. These programs should include exercises that strengthen the muscles around the knees, hips, and core.

Proper techniques : Coaches should emphasize the importance of landing softly with knees slightly bent and hips back, reducing the force on the ACL.

Strength training : Targeted strength training, especially for the quadriceps and hamstrings, can provide the knee with more stability. Coaches and athletic trainers should include exercises that balance the strength of these muscle groups, as imbalances can increase the risk of injury.

Neuromuscular training : This involves exercises that improve the coordination and control of leg muscles, teaching the body to respond more effectively to the demands of sports.

Footwear and orthotic support : The right footwear can make a significant difference in reducing ACL injury risk. Athletic shoes that provide adequate support and fit the sport's specific demands can help in maintaining proper leg alignment and stability. In some cases, custom orthotics might be recommended to correct biomechanical imbalances.

"A key consideration to keep in mind for athletes, coaches and parents when creating or participating in injury prevention programs is that they shouldn't focus on just one type of exercise, but rather categories of exercises. There is strengthening, balance, core and lower extremity exercises and then progressions within each of those categories," says Dr. Mulcahey.

How to treat an ACL injury

When an ACL injury occurs, understanding the available treatment options is critical for a smooth and effective recovery. Treatment can vary depending on the severity of the injury, the athlete's age, activity level, and personal goals.

Immediately after an injury, the R.I.C.E. (Rest, Ice, Compression, and Elevation) method is a fundamental first step. Resting prevents further damage, ice reduces swelling, compression helps minimize inflammation, and elevation lowers swelling by reducing blood flow to the injured area.

Thankfully, not all ACL injuries require surgery. For less severe injuries or for individuals who engage in low-impact activities, physical therapy focused on strengthening the muscles around the knee to compensate for the torn ligament may be enough. Bracing may also be used to stabilize the knee during recovery.

In cases where the ACL is completely torn or if the individual wishes to return to high-impact sports, ACL reconstruction surgery is often recommended. This procedure involves replacing the torn ligament with a graft taken from another tendon in the patient's body or from a donor.

Physical therapy is an important component of recovery following injury and surgery.  A comprehensive rehabilitation program is tailored to each patient’s needs, focusing on gradually rebuilding strength, flexibility, and stability in the knee. Physical therapists guide patients through various exercises and provide milestones to track progress.

When to see a doctor for an ACL tear

An ACL injury can range from a mild sprain to a complete tear, and understanding the signs that warrant a visit to the doctor can help ensure timely and appropriate care.

The moment an ACL injury occurs, it often comes with a distinct popping sound, followed by immediate pain and swelling in the knee. The joint may feel unstable or like it can't support your weight. If you experience these symptoms, particularly after a twisting motion or impact during sports, it's a sign to see a physician or orthopedic surgeon.

Early diagnosis is key to preventing further damage and starting the path to recovery. A doctor can assess the extent of the injury through a physical examination and imaging tests like x-rays and an MRI. When you visit a doctor, they will ask about how the injury occurred, symptoms you’ve experienced, and your medical history.

It's perfectly fine to ask about the full range of treatment options, the pros and cons of operative versus non-operative treatment, the expected timeline for recovery, and any potential complications. Inquire about what you can do to aid in your recovery and any lifestyle modifications that might be necessary. Remember, being proactive about your health is the first step toward healing.

The Women's Sports Medicine program at Loyola Medicine focuses on injury prevention and treatment for female athletes, as well as maintaining a high level of athletic performance.

Mary K. Mulcahey, MD, is an orthopaedic surgeon, division director of Sports Medicine, and Director of the Women's Sports Medicine program at Loyola Medicine . Dr. Mulcahey offers individualized, patient-centered care for both men and women.  Her extensive knowledge of non-operative and operative management of orthopaedic and musculoskeletal conditions is reflected in her thorough explanation of injuries and treatment options.

Book an appointment today to see Dr. Mulcahey by  self-scheduling an in-person or virtual appointment  using myLoyola.

How to Schedule a Loyola Appointment

You can easily self-schedule an appointment online today with one of Loyola Medicine's expert primary and specialty care providers!

Self-schedule an Appointment

Follow Us on Social Media

Join our Mailing List!

Stay up to date with the latest news, health tips and more from Loyola Medicine!

Women's Sports Medicine Program

Whether you're a recreational runner, high school athlete or professional athlete, our team of physicians help women of all ages and fitness levels stay active, without injury.

Media Center 3/27/2024 3:00:00 PM Corbin McGuire

Women in the Olympic Games

Olympic pipeline of college sports helping more women reach team usa.

Women's participation in the Olympics will come full circle at the 2024 Olympic Games in Paris, hosting for the third time in history. 

Paris' first Olympics occurred in 1900 and marked the first time that women were allowed to compete in the Olympics. At the 1900 Games, 22 of 997 total athletes were women.  The 2024 Paris Games will mark the first Olympics to achieve full gender parity. Out of the 10,500 athletes participating in the Games, 5,250 will be men and 5,250 women. The 2020 Tokyo Games were previously the most gender-balanced to date, with 47.8% of all athletes being women. At the 1964 Tokyo Games, women accounted for only 13% of all athletes. 

Team USA has followed a similar climb in gender parity, marked in large part by the impact of Title IX becoming law in 1972. Since 1972, Team USA has seen a 310% increase in female participation on summer U.S. Olympic rosters. In 1972, women athletes from 38 colleges and universities were on the U.S. Olympic team roster. At the 2020 Games, that number was 112 schools. 

As opportunities for women in college sports continue to increase, the collegiate pipeline to Team USA continues to strengthen. Learn more about NCAA women in the Olympics below. 

Most decorated NCAA athletes

Team USA's most decorated women — Jenny Thompson, Dara Torres and Natalie Coughlin — share two things in common: They all won 12 Olympic medals in swimming, and they all swam in college. 

Among women with NCAA ties, Thompson, a Stanford graduate, tallied the most gold medals for Team USA. Thompson collected eight gold, three silver and one bronze medal across four Olympics. Thompson also earned 19 individual and relay NCAA titles while at Stanford, along with leading the program to four straight NCAA team championships from 1992-95. 

Torres, a Florida alum, won four gold, four silver and four bronze medals across five Olympics. In 2008, Torres became the oldest swimmer to earn a place on the U.S. Olympic team at age 41. At Florida, she earned 28 All-America honors. 

Coughlin swam collegiately at California for three years before beginning an Olympic career that included three gold medals, four silvers and five bronzes. In college, she won 11 NCAA titles individually and one relay title, as well. 

NCAA to Team USA 

At the 2020 Games, 70% of Team USA's women (233 of 331) had NCAA ties, the latest in an upward trend for participation by women. The 2012 London Games marked the first time a U.S. Olympic team had more women overall than men (six more). At the Rio de Janeiro Games, the U.S. Olympic roster had 27 more women than men, and in Tokyo, that number nearly doubled to 51 more women than men. At the Sydney Olympics in 2000, 181 women with NCAA ties competed for Team USA. That number increased to 212 at the Beijing Olympics in 2008 and hit 215 in Rio de Janeiro in 2016. 

Powerhouse pipelines

Curious which schools produce the most women Olympians for Team USA? Since 2000, UCLA leads the way with 66 athletes, followed by Stanford (61 athletes) and North Carolina (40 athletes).

Keeping it 100

While college sports are a major pipeline for a number of women's sports, athletes with NCAA ties made up 100% of eight Team USA rosters in Tokyo: water polo, indoor volleyball, beach volleyball, softball, rowing, basketball, 3x3 basketball and diving. 

Notably, Team USA won gold medals in Tokyo in women's water polo, basketball, indoor volleyball, 3x3 basketball and beach volleyball (April Ross and Alix Klineman). Team USA also won a silver medal in softball, while former Nevada standout Krysta Palmer captured a bronze in the 3-meter diving competition.  

Gold standard

South Carolina women's basketball head coach Dawn Staley is a legend for what she's done in the college game as a coach and a player, but her accomplishments for Team USA are equally impressive. Staley is the second woman ever to win a gold medal for Team USA as a player, an assistant coach and a head coach, following in the footsteps of former Old Dominion player Anne Donovan. Staley won gold medals in 1996, 2000 and 2004 on the court, and coached Team USA to a gold at the 2020 Tokyo Games. She also served as an assistant when the U.S. won gold in 2008 and 2016.

At the college level, Staley has won a pair of NCAA titles on the sidelines at South Carolina, and her undefeated 2024 team entered the NCAA tournament as the No. 1 overall seed. 

Thanks for visiting !

The use of software that blocks ads hinders our ability to serve you the content you came here to enjoy.

We ask that you consider turning off your ad blocker so we can deliver you the best experience possible while you are here.

Thank you for your support!

open I am a

• Future Student
• Current Student
• Newly Admitted Student
• Parent/Guardian
• Faculty / Staff Member

open Colleges

• Arts and Letters
• Fowler College of Business
• Engineering
• Graduate Studies
• Health and Human Services
• SDSU Library
• Professional Studies and Fine Arts
• Weber Honors College

open Other Locations

• SDSU Georgia
• SDSU Global Campus
• SDSU Imperial Valley
• SDSU Mission Valley

SDSU’s Henrietta Goodwin Scholars examine treatment of Black female athletes in media

A group of friends in the HGS program use SDSU Student Symposium to increase research interest and skills among underrepresented student groups.

• Share on Facebook
• Share on Twitter
• Share on LinkedIn
• Share via Email

Brenna Barnes , a first-year marketing major from San Antonio, has always questioned why Black female athletes are often scrutinized for their looks, sexuality and behavior more than their counterparts of other races and ethnicities. San Diego State University gave her a chance to look more deeply and learn important skills at the same time.

She and a group of friends in the Henrietta Goodwin Scholars (HGS) , a program that supports Black students as they transition to college and throughout their time at SDSU, studied the examples of the media and social media portrayal of athletes such as tennis legend Serena Williams , WNBA star Britney Griner , track and field star Sha'Carri Richardson and Louisiana State University basketball star Angel Reese . 

Barnes’ group, along with seven other groups from the HGS program, presented their findings at the SDSU Student Symposium, a public forum where more than 650 students from both undergraduate and graduate levels presented research, scholarship and creative activities to the SDSU and greater San Diego communities. 

The event, held March 1, included more than 500 posters, talks, exhibits and performances. Upward of 450 volunteers from SDSU and the community judged and moderated the presentations. More than 90 students and teams were honored for their excellence and earned cash prizes; 10 who received the President's Award will represent SDSU at the California State University system-wide student research competition on April 26-27.

This was the first time the symposium had a session dedicated to HGS scholars. The program’s students and leaders said incorporating the symposium fits seamlessly with HGS’ mission to guide first-year students by providing academic and student services designed to support overall success.

The HGS sophomore cohort, HGS 2.0, presented at the Black Resource Center’s Black Research Symposium on March 22. 

“One of the goals of the HGS program is to support and encourage the continued growth and success of students, including exposure to graduate studies and career exploration,” said Rachael Stewart , the Black Resource Center’s Charles Bell faculty scholar, who serves as the HGS program director. “This research experience provided an opportunity for my students to understand the relevance of research in their daily lives and how to apply research in their academic and career journeys. 

“Additionally, it fostered the development of their critical thinking, problem-solving, and decision-making skills that will stick with them for the rest of their lives,” Stewart said. 

The HGS session of the symposium was initially suggested by SDSU librarian Ashley Wilson , who wanted to encourage more black students to present at the event without feeling out of place. 

“When I suggested an HGS session, I thought that would be a way to welcome a cohort of African American students in a way that wouldn’t overwhelm them,” Wilson said. “I also suggested we invite Dr. Rachael Stewart to moderate the session for her students.”

She and Stewart worked together to encourage the students in the cohort to present. 

“At the end of the session, I was pleased to see so many Black students as presenters and the audience,” Wilson said. “I hope having more students of color, particularly Black students, participate in S3 will help them feel included in the conversation.”

Stewart concurred, calling the student presentations a success. 

“The day was fantastic. The room was filled with the whole HGS class, and there was a camaraderie in the support the cohort provided to their peers as they presented,” Stewart said. “I was emotional as we started the day. To see this idea come to fruition after having graduated from SDSU with an educational leadership doctorate degree was a full-circle moment. I couldn't be more proud of my students.”

Malaika Mwangi , a first-year biology major and interdisciplinary studies minor from Waverly, Iowa, was part of an HGS group whose research project studied the effect of drug use among U.S. college students. She said the experience gave the students exposure to undergraduate research, an area where students of color are often underrepresented.

“I think it's important for students of color to participate in undergraduate research because it is a great way to establish representation in the field,” Mwangi said. “A lot of times, research being conducted does not consider minorities or specific ethnic groups and then generalizations are made that do not apply to people of color. By encouraging students of color to participate in research, there is more representation of our people not only in experimental studies but also as researchers in varying fields.”

Mwangi said undergraduate research will prove critical toward her career goal of becoming a doctor. 

“Research is vital to the medical field  — no pun intended. Starting early will provide me with the proper experience to be successful in my future career,”she said.

One of the eight HGS groups received the Dean’s Award, a $250 prize awarded to 16 groups deemed the top presentation in each college. 

The winning group for Fowler College of Business was Barnes’ presentation on the close examination of Black female athletes appearance, sexuality and behavior. 

“I was super shocked,” said Barnes, who wants to pursue sports marketing as a career. “But I was extremely grateful and honored that our group received the recognition. I think it was a great idea for HGS to participate in the symposium, and I’m hoping that future scholars will have this opportunity.”

Campus News

• Recap: 16th annual San Diego Festival of Science and Engineering
• SDSU Associated Students wins sustainability leadership award

• Aztecs' Jaedon LeDee excels on the court and in the classroom
• Combat to campus: Elisa East picked to lead SDSU’s MVP program

• SDSU Women’s Fund champions equity in athletics, academics
• SDSU announces $5 million Black Resource Center naming gift

Mobile Menu Overlay

The White House 1600 Pennsylvania Ave NW Washington, DC 20500

FACT SHEET: President   Biden Issues Executive Order and Announces New Actions to Advance Women’s Health Research and   Innovation

In his State of the Union address, President Biden laid out his vision for transforming women’s health research and improving women’s lives all across America. The President called on Congress to make a bold, transformative investment of $12 billion in new funding for women’s health research. This investment would be used to create a Fund for Women’s Health Research at the National Institutes of Health (NIH) to advance a cutting-edge, interdisciplinary research agenda and to establish a new nationwide network of research centers of excellence and innovation in women’s health—which would serve as a national gold standard for women’s health research across the lifespan.

It is long past time to ensure women get the answers they need when it comes to their health—from cardiovascular disease to autoimmune diseases to menopause-related conditions. To pioneer the next generation of discoveries, the President and the First Lady launched the first-ever White House Initiative on Women’s Health Research , which aims to fundamentally change how we approach and fund women’s health research in the United States.

Today, President Biden is signing a new Executive Order that will direct the most comprehensive set of executive actions ever taken to expand and improve research on women’s health. These directives will ensure women’s health is integrated and prioritized across the federal research portfolio and budget, and will galvanize new research on a wide range of topics, including women’s midlife health.

The President and First Lady are also announcing more than twenty new actions and commitments by federal agencies, including through the U.S. Department of Health and Human Services (HHS), the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the National Science Foundation (NSF). This includes the launch of a new NIH-wide effort that will direct key investments of $200 million in Fiscal Year 2025 to fund new, interdisciplinary women’s health research—a first step towards the transformative central Fund on Women’s Health that the President has called on Congress to invest in. These actions also build on the First Lady’s announcement last month of the Advanced Research Projects Agency for Health (ARPA-H) Sprint for Women’s Health , which committed $100 million towards transformative research and development in women’s health.

Today, the President is issuing an Executive Order that will:

• Integrate Women’s Health Across the Federal Research Portfolio . The Executive Order directs the Initiative’s constituent agencies to develop and strengthen research and data standards on women’s health across all relevant research and funding opportunities, with the goal of helping ensure that the Administration is better leveraging every dollar of federal funding for health research to improve women’s health. These actions will build on the NIH’s current policy to ensure that research it funds considers women’s health in the development of study design and in data collection and analysis. Agencies will take action to ensure women’s health is being considered at every step in the research process—from the applications that prospective grantees submit to the way that they report on grant implementation.
• Prioritize Investments in Women’s Health Research . The Executive Order directs the Initiative’s constituent agencies to prioritize funding for women’s health research and encourage innovation in women’s health, including through ARPA-H and multi-agency initiatives such as the Small Business Innovation Research Program and the Small Business Technology Transfer Program. These entities are dedicated to high-impact research and innovation, including through the support of early-stage small businesses and entrepreneurs engaged in research and innovation. The Executive Order further directs HHS and NSF to study ways to leverage artificial intelligence to advance women’s health research. These additional investments—across a wide range of agencies—will support innovation and open new doors to breakthroughs in women’s health.
• Galvanize New Research on Women’s Midlife Health .  To narrow research gaps on diseases and conditions associated with women’s midlife health or that are more likely to occur after menopause, such as rheumatoid arthritis, heart attack, and osteoporosis, the President is directing HHS to: expand data collection efforts related to women’s midlife health; launch a comprehensive research agenda that will guide future investments in menopause-related research; identify ways to improve management of menopause-related issues and the clinical care that women receive; and develop new resources to help women better understand their options for menopause-related symptoms prevention and treatment. The Executive Order also directs the DoD and VA to study and take steps to improve the treatment of, and research related to, menopause for Service women and women veterans.
• Assess Unmet Needs to Support Women’s Health Research . The Executive Order directs the Office of Management and Budget and the Gender Policy Council to lead a robust effort to assess gaps in federal funding for women’s health research and identify changes—whether statutory, regulatory, or budgetary—that are needed to maximally support the broad scope of women’s health research across the federal government. Agencies will also be required to report annually on their investments in women’s health research, as well as progress towards their efforts to improve women’s health.

Today, agencies are also announcing new actions they are taking to promote women’s health research , as part of their ongoing efforts through the White House Initiative on Women’s Health Research. Agencies are announcing actions to:

Prioritize and Increase Investments in Women’s Health Research

• Launch an NIH-Cross Cutting Effort to Transform Women’s Health Throughout the Lifespan. NIH is launching an NIH-wide effort to close gaps in women’s health research across the lifespan. This effort—which will initially be supported by $200 million from NIH beginning in FY 2025—will allow NIH to catalyze interdisciplinary research, particularly on issues that cut across the traditional mandates of the institutes and centers at NIH. It will also allow NIH to launch ambitious, multi-faceted research projects such as research on the impact of perimenopause and menopause on heart health, brain health and bone health. In addition, the President’s FY25 Budget Request would double current funding for the NIH Office of Research on Women’s Health to support new and existing initiatives that emphasize women’s health research.

This coordinated, NIH-wide effort will be co-chaired by the NIH Office of the Director, the Office of Research on Women’s Health, and the institute directors from the National Institute on Aging; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Institute on Arthritis, Musculoskeletal and Skin Diseases.

• Invest in Research on a Wide Range of Women’s Health Issues. The bipartisan Congressionally Directed Medical Research Program (CDMRP), led out of DoD, funds research on women’s health encompassing a range of diseases and conditions that affect women uniquely, disproportionately, or differently from men. While the programs and topic areas directed by Congress differ each year, CDMRP has consistently funded research to advance women’s health since its creation in 1993. In Fiscal Year 2022, DoD implemented nearly $490 million in CDMRP investments towards women’s health research projects ranging from breast and ovarian cancer to lupus to orthotics and prosthetics in women.  In Fiscal Year 2023, DoD anticipates implementing approximately $500 million in CDMRP funding for women’s health research, including in endometriosis, rheumatoid arthritis, and chronic fatigue.
• Call for New Proposals on Emerging Women’s Health Issues . Today, NSF is calling for new research and education proposals to advance discoveries and innovations related to women’s health. To promote multidisciplinary solutions to women’s health disparities, NSF invites applications that would improve women’s health through a wide range of disciplines—from computational research to engineering biomechanics. This is the first time that NSF has broadly called for novel and transformative research that is focused entirely on women’s health topics, and proposals will be considered on an ongoing basis.
• Increase Research on How Environmental Factors Affect Women’s Health. The Environmental Protection Agency (EPA) is updating its grant solicitations and contracts to ensure that applicants prioritize, as appropriate, the consideration of women’s exposures and health outcomes. These changes will help ensure that women’s health is better accounted for across EPA’s research portfolio and increase our knowledge of women’s environmental health—from endocrine disruption to toxic exposure.
• Create a Dedicated, One-Stop Shop for NIH Funding Opportunities on Women’s Health. Researchers are often unaware of existing opportunities to apply for federal funding. To help close this gap, NIH is issuing a new Notice of Special Interest that identifies current, open funding opportunities related to women’s health research across a wide range of health conditions and all Institutes, Centers, and Offices. The NIH Office of Research on Women’s Health will build on this new Notice by creating a dedicated one-stop shop on open funding opportunities related to women’s health research. This will make it easier for researchers and institutions to find and apply for funding—instead of having to search across each of NIH’s 27 institutes for funding opportunities.

Foster Innovation and Discovery in Women’s Health

• Accelerate Transformative Research and Development in Women’s Health. ARPA-H’s Sprint for Women’s Health launched in February 2024 commits $100 million to transformative research and development in women’s health. ARPA-H is soliciting ideas for novel groundbreaking research and development to address women’s health, as well as opportunities to accelerate and scale tools, products, and platforms with the potential for commercialization to improve women’s health outcomes.
• Support Private Sector Innovation Through Additional Federal Investments in Women’s Health Research. The NIH’s competitive Small Business Innovation Research Program and the Small Business Technology Transfer Program is committing to further increasing—by 50 percent—its investments in supporting innovators and early-stage small businesses engaged in research and development on women’s health. These programs will solicit new proposals on promising women’s health innovation and make evidence-based investments that bridge the gap between performance of basic science and commercialization of resulting innovations. This commitment for additional funds builds on the investments the Administration has already made to increase innovation in women’s health through small businesses, including by increasing investments by sevenfold between Fiscal Year 2021 and Fiscal Year 2023.
• Advance Initiatives to Protect and Promote the Health of Women. The Food and Drug Administration (FDA) seeks to advance efforts to help address gaps in research and availability of products for diseases and conditions that primarily impact women, or for which scientific considerations may be different for women, and is committed to research and regulatory initiatives that facilitate the development of safe and effective medical products for women. FDA also plans to issue guidance for industry that relates to the inclusion of women in clinical trials and conduct outreach to stakeholders to discuss opportunities to advance women’s health across the lifespan. And FDA’s Office of Women’s Health will update FDA’s framework for women’s health research and seek to fund research with an emphasis on bridging gaps in knowledge on important women’s health topics, including sex differences and conditions that uniquely or disproportionately impact women.
• Use Biomarkers to Improve the Health of Women Through Early Detection and Treatment of Conditions, such as Endometriosis. NIH will launch a new initiative dedicated to research on biomarker discovery and validation to help improve our ability to prevent, diagnose, and treat conditions that affect women uniquely, including endometriosis. This NIH initiative will accelerate our ability to identify new pathways for diagnosis and treatment by encouraging multi-sector collaboration and synergistic research that will speed the transfer of knowledge from bench to bedside.
• Leverage Engineering Research to Improve Women’s Health . The NSF Engineering Research Visioning Alliance (ERVA) is convening national experts to identify high-impact research opportunities in engineering that can improve women’s health. ERVA’s Transforming Women’s Health Outcomes Through Engineering visioning event will be held in June 2024, and will bring together experts from across engineering—including those in microfluidics, computational modeling, artificial intelligence/imaging, and diagnostic technologies and devices—to evaluate the landscape for new applications in women’s health. Following this event, ERVA will issue a report and roadmap on critical areas where engineering research can impact women’s health across the lifespan.
• Drive Engineering Innovations in Women’s Health Discovery . NSF awardees at Texas A&M University will hold a conference in summer 2024 to collectively identify challenges and opportunities in improving women’s health through engineering. Biomedical engineers and scientists will explore and identify how various types of engineering tools, including biomechanics and immuno-engineering, can be applied to women’s health and spark promising new research directions.

Expand and Leverage Data Collection and Analysis Related to Women’s Health

• Help Standardize Data to Support Research on Women’s Health. NIH is launching an effort to identify and develop new common data elements related to women’s health that will help researchers share and combine datasets, promote interoperability, and improve the accuracy of datasets when it comes to women’s health. NIH will initiate this process by convening data and scientific experts across the federal government to solicit feedback on the need to develop new NIH-endorsed common data elements—which are widely used in both research and clinical settings. By advancing new tools to capture more data about women’s health, NIH will give researchers and clinicians the tools they need to enable more meaningful data collection, analysis, and reporting and comprehensively improve our knowledge of women’s health.
• Reflect Women’s Health Needs in National Coverage Determinations. The Centers for Medicare & Medicaid Services (CMS) will strengthen its review process, including through Coverage with Evidence Development guidance, to ensure that new medical services and technologies work well in women, as applicable, before being covered nationally through the Medicare program. This will help ensure that Medicare funds are used for treatments with a sufficient evidence base to show that they actually work in women, who make up more than half of the Medicare population.
• Leverage Data and Quality Measures to Advance Women’s Health Research. The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) are building on existing datasets to improve the collection, analysis, and reporting of information on women’s health. The CDC is expanding the collection of key quality measures across a woman’s lifespan, including to understand the link between pregnancy and post-partum hypertension and heart disease, and plans to release the Million Hearts Hypertension in Pregnancy Change Package. This resource will feature a menu of evidence-informed strategies by which clinicians can change care processes. Each strategy includes tested tools and resources to support related clinical quality improvement. HRSA is modernizing its Uniform Data System in ways that will improve the ability to assess how women are being served through HRSA-funded health centers. By improving the ability to analyze data on key clinical quality measures, CDC and HRSA can help close gaps in women’s health care access and identify new opportunities for high-impact research.  

Strengthen Coordination, Infrastructure, and Training to Support Women’s Health Research

• Launch New Joint Collaborative to Improve Women’s Health Research for Service Members and Veterans. DoD and VA are launching a new Women’s Health Research collaborative to explore opportunities that further promote joint efforts to advance women’s health research and improve evidence-based care for Service members and veterans. The collaborative will increase coordination with the goal of helping improve care across the lifespan for women in the military and women veterans. The Departments will further advance research on key women’s health issues and develop a roadmap to close pressing research gaps, including those specifically affecting Service women and women veterans.
• Coordinate Research to Advance the Health of Women in the Military. DoD will invest $10 million, contingent on available funds, in the Military Women’s Health Research Partnership. This Partnership is led by the Uniformed Services University and advances and coordinates women’s health research across the Department. The Partnership is supporting research in a wide range of health issues affecting women in the military, including cancers, mental and behavioral health, and the unique health care needs of Active Duty Service Women. In addition, the Uniformed Services University established a dedicated Director of Military Women’s Health Research Program, a role that is responsible for identifying research gaps, fostering collaboration, and coordinating and aligning a unified approach to address the evolving needs of Active Duty Service Women.
• Support EPA-Wide Research and Dissemination of Data on Women’s Health. EPA is establishing a Women’s Health Community of Practice to coordinate research and data dissemination. EPA also plans to direct the Board of Scientific Counselors to identify ways to advance EPA’s research with specific consideration of the intersection of environmental factors and women’s health, including maternal health.
• Expand Fellowship Training in Women’s Health Research. CDC, in collaboration with the CDC Foundation and American Board of Obstetrics and Gynecology, is expanding training in women’s health research and public health surveillance to OBGYNs, nurses and advanced practice nurses. Through fellowships and public health experiences with CDC, these clinicians will gain public health research skills to improve the health of women and children exposed to or affected by infectious diseases, mental health and substance use disorders. CDC will invite early career clinicians to train in public health and policy to become future leaders in women’s health research.

Improve Women’s Health Across the Lifespan

• Create a Comprehensive Research Agenda on Menopause. To help women get the answers they need about menopause, NIH will launch its first-ever Pathways to Prevention series on menopause and the treatment of menopausal symptoms. Pathways to Prevention is an independent, evidence-based process to synthesize the current state of the evidence, identify gaps in existing research, and develop a roadmap that can be used to help guide the field forward. The report, once completed, will help guide innovation and investments in menopause-related research and care across the federal government and research community.
• Improve Primary Care and Preventive Services for Women . The Agency for Healthcare Research and Quality (AHRQ) will issue a Notice of Intent to publish a funding opportunity announcement for research to advance the science of primary care, which will include a focus on women’s health. Through this funding opportunity, AHRQ will build evidence about key elements of primary care that influence patient outcomes and advance health equity—focusing on women of color—such as care coordination, continuity of care, comprehensiveness of care, person-centered care, and trust. The results from the funding opportunity will shed light on vital targets for improvements in the delivery of primary healthcare across a woman’s lifespan, including women’s health preventive services, prevention and management of multiple chronic diseases, perinatal care, transition from pediatric to adult care, sexual and reproductive health, and care of older adults.
• Promote the Health of American Indian and Alaska Native Women. The Indian Health Service is launching a series of engagements, including focus groups, to better understand tribal beliefs related to menopause in American Indian and Alaska Native Women. This series will inform new opportunities to expand culturally informed patient care and research as well as the development of new resources and educational materials.
• Connect Research to Real-World Outcomes to Improve Women’s Mental and Behavioral Health. The Substance Abuse and Mental Health Services Administration (SAMHSA) is supporting a range of health care providers to address the unique needs of women with or at risk for mental health and substance use disorders. Building on its current efforts to provide technical assistance through various initiatives , SAMHSA intends, contingent on available funds, to launch a new comprehensive Women’s Behavioral Health Technical Assistance Center. This center will identify and improve the implementation of best practices in women’s behavioral health across the life span; identify and fill critical gaps in knowledge of and resources for women’s behavioral health; and provide learning opportunities, training, and technical assistance for healthcare providers.
• Support Research on Maternal Health Outcomes. USDA will fund research to help recognize early warning signs of maternal morbidity and mortality in recipients of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and anticipates awarding up to $5 million in Fiscal Year 2023 to support maternal health research through WIC. In addition, research being conducted through the Agricultural Research Service’s Human Nutrition Research Centers is focusing on women’s health across the lifespan, including the nutritional needs of pregnant and breastfeeding women and older adults.

Stay Connected

We'll be in touch with the latest information on how President Biden and his administration are working for the American people, as well as ways you can get involved and help our country build back better.

Opt in to send and receive text messages from President Biden.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage

Emma n. hilton.

1 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK

Tommy R. Lundberg

2 Department of Laboratory Medicine/ANA Futura, Division of Clinical Physiology, Karolinska Institutet, Alfred Nobles Allé 8B, Huddinge, 141 52 Stockholm, Sweden

3 Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden

Associated Data

Available upon request.

Males enjoy physical performance advantages over females within competitive sport. The sex-based segregation into male and female sporting categories does not account for transgender persons who experience incongruence between their biological sex and their experienced gender identity. Accordingly, the International Olympic Committee (IOC) determined criteria by which a transgender woman may be eligible to compete in the female category, requiring total serum testosterone levels to be suppressed below 10 nmol/L for at least 12 months prior to and during competition. Whether this regulation removes the male performance advantage has not been scrutinized. Here, we review how differences in biological characteristics between biological males and females affect sporting performance and assess whether evidence exists to support the assumption that testosterone suppression in transgender women removes the male performance advantage and thus delivers fair and safe competition. We report that the performance gap between males and females becomes significant at puberty and often amounts to 10–50% depending on sport. The performance gap is more pronounced in sporting activities relying on muscle mass and explosive strength, particularly in the upper body. Longitudinal studies examining the effects of testosterone suppression on muscle mass and strength in transgender women consistently show very modest changes, where the loss of lean body mass, muscle area and strength typically amounts to approximately 5% after 12 months of treatment. Thus, the muscular advantage enjoyed by transgender women is only minimally reduced when testosterone is suppressed. Sports organizations should consider this evidence when reassessing current policies regarding participation of transgender women in the female category of sport.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-020-01389-3.

Introduction

Sporting performance is strongly influenced by a range of physiological factors, including muscle force and power-producing capacity, anthropometric characteristics, cardiorespiratory capacity and metabolic factors [ 1 , 2 ]. Many of these physiological factors differ significantly between biological males and females as a result of genetic differences and androgen-directed development of secondary sex characteristics [ 3 , 4 ]. This confers large sporting performance advantages on biological males over females [ 5 ].

When comparing athletes who compete directly against one another, such as elite or comparable levels of school-aged athletes, the physiological advantages conferred by biological sex appear, on assessment of performance data, insurmountable. Further, in sports where contact, collision or combat are important for gameplay, widely different physiological attributes may create safety and athlete welfare concerns, necessitating not only segregation of sport into male and female categories, but also, for example, into weight and age classes. Thus, to ensure that both men and women can enjoy sport in terms of fairness, safety and inclusivity, most sports are divided, in the first instance, into male and female categories.

Segregating sports by biological sex does not account for transgender persons who experience incongruence between their biological sex and their experienced gender identity, and whose legal sex may be different to that recorded at birth [ 6 , 7 ]. More specifically, transgender women (observed at birth as biologically male but identifying as women) may, before or after cross-hormone treatment, wish to compete in the female category. This has raised concerns about fairness and safety within female competition, and the issue of how to fairly and safely accommodate transgender persons in sport has been subject to much discussion [ 6 – 13 ].

The current International Olympic Committee (IOC) policy [ 14 ] on transgender athletes states that “it is necessary to ensure insofar as possible that trans athletes are not excluded from the opportunity to participate in sporting competition”. Yet the policy also states that “the overriding sporting objective is and remains the guarantee of fair competition”. As these goals may be seen as conflicting if male performance advantages are carried through to competition in the female category, the IOC concludes that “restrictions on participation are appropriate to the extent that they are necessary and proportionate to the achievement of that objective”.

Accordingly, the IOC determined criteria by which transgender women may be eligible to compete in the female category. These include a solemn declaration that her gender identity is female and the maintenance of total serum testosterone levels below 10 nmol/L for at least 12 months prior to competing and during competition [ 14 ]. Whilst the scientific basis for this testosterone threshold was not openly communicated by the IOC, it is surmised that the IOC believed this testosterone criterion sufficient to reduce the sporting advantages of biological males over females and deliver fair and safe competition within the female category.

Several studies have examined the effects of testosterone suppression on the changing biology, physiology and performance markers of transgender women. In this review, we aim to assess whether evidence exists to support the assumption that testosterone suppression in transgender women removes these advantages. To achieve this aim, we first review the differences in biological characteristics between biological males and females, and examine how those differences affect sporting performance. We then evaluate the studies that have measured elements of performance and physical capacity following testosterone suppression in untrained transgender women, and discuss the relevance of these findings to the supposition of fairness and safety (i.e. removal of the male performance advantage) as per current sporting guidelines.

The Biological Basis for Sporting Performance Advantages in Males

The physical divergence between males and females begins during early embryogenesis, when bipotential gonads are triggered to differentiate into testes or ovaries, the tissues that will produce sperm in males and ova in females, respectively [ 15 ]. Gonad differentiation into testes or ovaries determines, via the specific hormone milieu each generates, downstream in utero reproductive anatomy development [ 16 ], producing male or female body plans. We note that in rare instances, differences in sex development (DSDs) occur and the typical progression of male or female development is disrupted [ 17 ]. The categorisation of such athletes is beyond the scope of this review, and the impact of individual DSDs on sporting performance must be considered on their own merits.

In early childhood, prior to puberty, sporting participation prioritises team play and the development of fundamental motor and social skills, and is sometimes mixed sex. Athletic performance differences between males and females prior to puberty are often considered inconsequential or relatively small [ 18 ]. Nonetheless, pre-puberty performance differences are not unequivocally negligible, and could be mediated, to some extent, by genetic factors and/or activation of the hypothalamic–pituitary–gonadal axis during the neonatal period, sometimes referred to as “minipuberty”. For example, some 6500 genes are differentially expressed between males and females [ 19 ] with an estimated 3000 sex-specific differences in skeletal muscle likely to influence composition and function beyond the effects of androgenisation [ 3 ], while increased testosterone during minipuberty in males aged 1–6 months may be correlated with higher growth velocity and an “imprinting effect” on BMI and bodyweight [ 20 , 21 ]. An extensive review of fitness data from over 85,000 Australian children aged 9–17 years old showed that, compared with 9-year-old females, 9-year-old males were faster over short sprints (9.8%) and 1 mile (16.6%), could jump 9.5% further from a standing start (a test of explosive power), could complete 33% more push-ups in 30 s and had 13.8% stronger grip [ 22 ]. Male advantage of a similar magnitude was detected in a study of Greek children, where, compared with 6-year-old females, 6-year-old males completed 16.6% more shuttle runs in a given time and could jump 9.7% further from a standing position [ 23 ]. In terms of aerobic capacity, 6- to 7-year-old males have been shown to have a higher absolute and relative (to body mass) V O 2max than 6- to 7-year-old females [ 24 ]. Nonetheless, while some biological sex differences, probably genetic in origin, are measurable and affect performance pre-puberty, we consider the effect of androgenizing puberty more influential on performance, and have focused our analysis on musculoskeletal differences hereafter.

Secondary sex characteristics that develop during puberty have evolved under sexual selection pressures to improve reproductive fitness and thus generate anatomical divergence beyond the reproductive system, leading to adult body types that are measurably different between sexes. This phenomenon is known as sex dimorphism. During puberty, testes-derived testosterone levels increase 20-fold in males, but remain low in females, resulting in circulating testosterone concentrations at least 15 times higher in males than in females of any age [ 4 , 25 ]. Testosterone in males induces changes in muscle mass, strength, anthropometric variables and hemoglobin levels [ 4 ], as part of the range of sexually dimorphic characteristics observed in humans.

Broadly, males are bigger and stronger than females. It follows that, within competitive sport, males enjoy significant performance advantages over females, predicated on the superior physical capacity developed during puberty in response to testosterone. Thus, the biological effects of elevated pubertal testosterone are primarily responsible for driving the divergence of athletic performances between males and females [ 4 ]. It is acknowledged that this divergence has been compounded historically by a lag in the cultural acceptance of, and financial provision for, females in sport that may have had implications for the rate of improvement in athletic performance in females. Yet, since the 1990s, the difference in performance records between males and females has been relatively stable, suggesting that biological differences created by androgenization explain most of the male advantage, and are insurmountable [ 5 , 26 , 27 ].

Table ​ Table1 1 outlines physical attributes that are major parameters underpinning the male performance advantage [ 28 – 38 ]. Males have: larger and denser muscle mass, and stiffer connective tissue, with associated capacity to exert greater muscular force more rapidly and efficiently; reduced fat mass, and different distribution of body fat and lean muscle mass, which increases power to weight ratios and upper to lower limb strength in sports where this may be a crucial determinant of success; longer and larger skeletal structure, which creates advantages in sports where levers influence force application, where longer limb/digit length is favorable, and where height, mass and proportions are directly responsible for performance capacity; superior cardiovascular and respiratory function, with larger blood and heart volumes, higher hemoglobin concentration, greater cross-sectional area of the trachea and lower oxygen cost of respiration [ 3 , 4 , 39 , 40 ]. Of course, different sports select for different physiological characteristics—an advantage in one discipline may be neutral or even a disadvantage in another—but examination of a variety of record and performance metrics in any discipline reveals there are few sporting disciplines where males do not possess performance advantage over females as a result of the physiological characteristics affected by testosterone.

Selected physical difference between untrained/moderately trained males and females. Female levels are set as the reference value

Sports Performance Differences Between Males and Females

An overview of elite adult athletes.

A comparison of adult elite male and female achievements in sporting activities can quantify the extent of the male performance advantage. We searched publicly available sports federation databases and/or tournament/competition records to identify sporting metrics in various events and disciplines, and calculated the performance of males relative to females. Although not an exhaustive list, examples of performance gaps in a range of sports with various durations, physiological performance determinants, skill components and force requirements are shown in Fig.  1 .

The male performance advantage over females across various selected sporting disciplines. The female level is set to 100%. In sport events with multiple disciplines, the male value has been averaged across disciplines, and the error bars represent the range of the advantage. The metrics were compiled from publicly available sports federation databases and/or tournament/competition records. MTB mountain bike

The smallest performance gaps were seen in rowing, swimming and running (11–13%), with low variation across individual events within each of those categories. The performance gap increases to an average of 16% in track cycling, with higher variation across events (from 9% in the 4000 m team pursuit to 24% in the flying 500 m time trial). The average performance gap is 18% in jumping events (long jump, high jump and triple jump). Performance differences larger than 20% are generally present when considering sports and activities that involve extensive upper body contributions. The gap between fastest recorded tennis serve is 20%, while the gaps between fastest recorded baseball pitches and field hockey drag flicks exceed 50%.

Sports performance relies to some degree on the magnitude, speed and repeatability of force application, and, with respect to the speed of force production (power), vertical jump performance is on average 33% greater in elite men than women, with differences ranging from 27.8% for endurance sports to in excess of 40% for precision and combat sports [ 41 ]. Because implement mass differs, direct comparisons are not possible in throwing events in track and field athletics. However, the performance gap is known to be substantial, and throwing represents the widest sex difference in motor performance from an early age [ 42 ]. In Olympic javelin throwers, this is manifested in differences in the peak linear velocities of the shoulder, wrist, elbow and hand, all of which are 13–21% higher for male athletes compared with females [ 43 ].

The increasing performance gap between males and females as upper body strength becomes more critical for performance is likely explained to a large extent by the observation that males have disproportionately greater strength in their upper compared to lower body, while females show the inverse [ 44 , 45 ]. This different distribution of strength compounds the general advantage of increased muscle mass in upper body dominant disciplines. Males also have longer arms than females, which allows greater torque production from the arm lever when, for example, throwing a ball, punching or pushing.

Olympic Weightlifting

In Olympic weightlifting, where weight categories differ between males and females, the performance gap is between 31 and 37% across the range of competitive body weights between 1998 and 2020 (Fig.  1 ). It is important to note that at all weight categories below the top/open category, performances are produced within weight categories with an upper limit, where strength can be correlated with “fighting weight”, and we focused our analysis of performance gaps in these categories.

To explore strength–mass relationships further, we compared Olympic weightlifting data between equivalent weight categories which, to some extent, limit athlete height, to examine the hypothesis that male performance advantage may be largely (or even wholly) mediated by increased height and lever-derived advantages (Table ​ (Table2). 2 ). Between 1998 and 2018, a 69 kg category was common to both males and females, with the male record holder (69 kg, 1.68 m) lifting a combined weight 30.1% heavier than the female record holder (69 kg, 1.64 m). Weight category changes in 2019 removed the common 69 kg category and created a common 55 kg category. The current male record holder (55 kg, 1.52 m) lifts 29.5% heavier than the female record holder (55 kg, 1.52 m). These comparisons demonstrate that males are approximately 30% stronger than females of equivalent stature and mass. However, importantly, male vs. female weightlifting performance gaps increase with increasing bodyweight. For example, in the top/open weight category of Olympic weightlifting, in the absence of weight (and associated height) limits, maximum male lifting strength exceeds female lifting strength by nearly 40%. This is further manifested in powerlifting, where the male record (total of squat, bench press and deadlift) is 65% higher than the female record in the open weight category of the World Open Classic Records. Further analysis of Olympic weightlifting data shows that the 55-kg male record holder is 6.5% stronger than the 69-kg female record holder (294 kg vs 276 kg), and that the 69-kg male record is 3.2% higher than the record held in the female open category by a 108-kg female (359 kg vs 348 kg). This Olympic weightlifting analysis reveals key differences between male and female strength capacity. It shows that, even after adjustment for mass, biological males are significantly stronger (30%) than females, and that females who are 60% heavier than males do not overcome these strength deficits.

Olympic weightlifting data between equivalent male–female and top/open weight categories

F female, M male

Perspectives on Elite Athlete Performance Differences

Figure  1 illustrates the performance gap between adult elite males and adult elite females across various sporting disciplines and activities. The translation of these advantages, assessed as the performance difference between the very best males and very best females, are significant when extended and applied to larger populations. In running events, for example, where the male–female gap is approximately 11%, it follows that many thousands of males are faster than the very best females. For example, approximately 10,000 males have personal best times that are faster than the current Olympic 100 m female champion (World Athletics, personal communication, July 2019). This has also been described elsewhere [ 46 , 47 ], and illustrates the true effect of an 11% typical difference on population comparisons between males and females. This is further apparent upon examination of selected junior male records, which surpass adult elite female performances by the age of 14–15 years (Table ​ (Table3), 3 ), demonstrating superior male athletic performance over elite females within a few years of the onset of puberty.

Selected junior male records in comparison with adult elite female records

Time format: minutes:seconds.hundredths of a second

These data overwhelmingly confirm that testosterone-driven puberty, as the driving force of development of male secondary sex characteristics, underpins sporting advantages that are so large no female could reasonably hope to succeed without sex segregation in most sporting competitions. To ensure, in light of these analyses, that female athletes can be included in sporting competitions in a fair and safe manner, most sports have a female category the purpose of which is the protection of both fairness and, in some sports, safety/welfare of athletes who do not benefit from the physiological changes induced by male levels of testosterone from puberty onwards.

Performance Differences in Non-elite Individuals

The male performance advantages described above in athletic cohorts are similar in magnitude in untrained people. Even when expressed relative to fat-free weight, V O 2max is 12–15% higher in males than in females [ 48 ]. Records of lower-limb muscle strength reveal a consistent 50% difference in peak torque between males and females across the lifespan [ 31 ]. Hubal et al. [ 49 ] tested 342 women and 243 men for isometric (maximal voluntary contraction) and dynamic strength (one-repetition maximum; 1RM) of the elbow flexor muscles and performed magnetic resonance imaging (MRI) of the biceps brachii to determine cross-sectional area. The males had 57% greater muscle size, 109% greater isometric strength, and 89% greater 1RM strength than age-matched females. This reinforces the finding in athletic cohorts that sex differences in muscle size and strength are more pronounced in the upper body.

Recently, sexual dimorphism in arm force and power was investigated in a punch motion in moderately-trained individuals [ 50 ]. The power produced during a punch was 162% greater in males than in females, and the least powerful man produced more power than the most powerful woman. This highlights that sex differences in parameters such as mass, strength and speed may combine to produce even larger sex differences in sport-specific actions, which often are a product of how various physical capacities combine. For example, power production is the product of force and velocity, and momentum is defined as mass multiplied by velocity. The momentum and kinetic energy that can be transferred to another object, such as during a tackle or punch in collision and combat sports are, therefore, dictated by: the mass; force to accelerate that mass, and; resultant velocity attained by that mass. As there is a male advantage for each of these factors, the net result is likely synergistic in a sport-specific action, such as a tackle or a throw, that widely surpasses the sum of individual magnitudes of advantage in isolated fitness variables. Indeed, already at 17 years of age, the average male throws a ball further than 99% of 17-year-old females [ 51 ], despite no single variable (arm length, muscle mass etc.) reaching this numerical advantage. Similarly, punch power is 162% greater in men than women even though no single parameter that produces punching actions achieves this magnitude of difference [ 50 ].

Is the Male Performance Advantage Lost when Testosterone is Suppressed in Transgender Women?

The current IOC criteria for inclusion of transgender women in female sports categories require testosterone suppression below 10 nmol/L for 12 months prior to and during competition. Given the IOC’s stated position that the “overriding sporting objective is and remains the guarantee of fair competition” [ 14 ] , it is reasonable to assume that the rationale for this requirement is that it reduces the male performance advantages described previously to an acceptable degree, thus permitting fair and safe competition. To determine whether this medical intervention is sufficient to remove (or reduce) the male performance advantage, which we described above, we performed a systematic search of the scientific literature addressing anthropometric and muscle characteristics of transgender women. Search terms and filtering of peer-reviewed data are given in Supplementary Table S1.

Anthropometrics

Given its importance for the general health of the transgender population, there are multiple studies of bone health, and reviews of these data. To summarise, transgender women often have low baseline (pre-intervention) bone mineral density (BMD), attributed to low levels of physical activity, especially weight-bearing exercise, and low vitamin D levels [ 52 , 53 ]. However, transgender women generally maintain bone mass over the course of at least 24 months of testosterone suppression. There may even be small but significant increases in BMD at the lumbar spine [ 54 , 55 ]. Some retrieved studies present data pertaining to maintained BMD in transgender women after many years of testosterone suppression. One such study concluded that “BMD is preserved over a median of 12.5 years” [ 56 ]. In support, no increase in fracture rates was observed over 12 months of testosterone suppression [ 54 ]. Current advice, including that from the International Society for Clinical Densitometry, is that transgender women, in the absence of other risk factors, do not require monitoring of BMD [ 52 , 57 ]. This is explicable under current standard treatment regimes, given the established positive effect of estrogen, rather than testosterone, on bone turnover in males [ 58 ].

Given the maintenance of BMD and the lack of a plausible biological mechanism by which testosterone suppression might affect skeletal measurements such as bone length and hip width, we conclude that height and skeletal parameters remain unaltered in transgender women, and that sporting advantage conferred by skeletal size and bone density would be retained despite testosterone reductions compliant with the IOC’s current guidelines. This is of particular relevance to sports where height, limb length and handspan are key (e.g. basketball, volleyball, handball) and where high movement efficiency is advantageous. Male bone geometry and density may also provide protection against some sport-related injuries—for example, males have a lower incidence of knee injuries, often attributed to low quadriceps ( Q ) angle conferred by a narrow pelvic girdle [ 59 , 60 ].

Muscle and Strength Metrics

As discussed earlier, muscle mass and strength are key parameters underpinning male performance advantages. Strength differences range between 30 and 100%, depending upon the cohort studied and the task used to assess strength. Thus, given the important contribution made by strength to performance, we sought studies that have assessed strength and muscle/lean body mass changes in transgender women after testosterone reduction. Studies retrieved in our literature search covered both longitudinal and cross-sectional analyses. Given the superior power of the former study type, we will focus on these.

The pioneer work by Gooren and colleagues, published in part in 1999 [ 61 ] and in full in 2004 [ 62 ], reported the effects of 1 and 3 years of testosterone suppression and estrogen supplementation in 19 transgender women (age 18–37 years). After the first year of therapy, testosterone levels were reduced to 1 nmol/L, well within typical female reference ranges, and remained low throughout the study course. As determined by MRI, thigh muscle area had decreased by − 9% from baseline measurement. After 3 years, thigh muscle area had decreased by a further − 3% from baseline measurement (total loss of − 12% over 3 years of treatment). However, when compared with the baseline measurement of thigh muscle area in transgender men (who are born female and experience female puberty), transgender women retained significantly higher thigh muscle size. The final thigh muscle area, after three years of testosterone suppression, was 13% larger in transwomen than in the transmen at baseline ( p  < 0.05). The authors concluded that testosterone suppression in transgender women does not reverse muscle size to female levels.

Including Gooren and Bunck [ 62 ], 12 longitudinal studies [ 53 , 63 – 73 ] have examined the effects of testosterone suppression on lean body mass or muscle size in transgender women. The collective evidence from these studies suggests that 12 months, which is the most commonly examined intervention period, of testosterone suppression to female-typical reference levels results in a modest (approximately − 5%) loss of lean body mass or muscle size (Table ​ (Table4). 4 ). No study has reported muscle loss exceeding the − 12% found by Gooren and Bunck after 3 years of therapy. Notably, studies have found very consistent changes in lean body mass (using dual-energy X-ray absorptiometry) after 12 months of treatment, where the change has always been between − 3 and − 5% on average, with slightly greater reductions in the arm compared with the leg region [ 68 ]. Thus, given the large baseline differences in muscle mass between males and females (Table ​ (Table1; 1 ; approximately 40%), the reduction achieved by 12 months of testosterone suppression can reasonably be assessed as small relative to the initial superior mass. We, therefore, conclude that the muscle mass advantage males possess over females, and the performance implications thereof, are not removed by the currently studied durations (4 months, 1, 2 and 3 years) of testosterone suppression in transgender women. In sports where muscle mass is important for performance, inclusion is therefore only possible if a large imbalance in fairness, and potentially safety in some sports, is to be tolerated.

Longitudinal studies of muscle and strength changes in adult transgender women undergoing cross-sex hormone therapy

Studies reporting measures of lean mass, muscle volume, muscle area or strength are included. Muscle/strength data are calculated in reference to baseline cohort data and, where reported, reference female (or transgender men before treatment) cohort data. Tack et al. [ 72 ] was not included in the table since some of the participants had not completed full puberty at treatment initiation. van Caenegem et al. [ 76 ] reports reference female values measured in a separately-published, parallel cohort of transgender men

N number of participants, TW transgender women, Yr year, Mo month, T testosterone, E estrogen. ± Standard deviation (unless otherwise indicated in text), LBM lean body mass, ALM appendicular lean mass

To provide more detailed information on not only gross body composition but also thigh muscle volume and contractile density, Wiik et al. [ 71 ] recently carried out a comprehensive battery of MRI and computed tomography (CT) examinations before and after 12 months of successful testosterone suppression and estrogen supplementation in 11 transgender women. Thigh volume (both anterior and posterior thigh) and quadriceps cross-sectional area decreased − 4 and − 5%, respectively, after the 12-month period, supporting previous results of modest effects of testosterone suppression on muscle mass (see Table ​ Table4). 4 ). The more novel measure of radiological attenuation of the quadriceps muscle, a valid proxy of contractile density [ 74 , 75 ], showed no significant change in transgender women after 12 months of treatment, whereas the parallel group of transgender men demonstrated a + 6% increase in contractile density with testosterone supplementation.

As indicated earlier (e.g. Table ​ Table1), 1 ), the difference in muscle strength between males and females is often more pronounced than the difference in muscle mass. Unfortunately, few studies have examined the effects of testosterone suppression on muscle strength or other proxies of performance in transgender individuals. The first such study was published online approximately 1 year prior to the release of the current IOC policy. In this study, as well as reporting changes in muscle size, van Caenegem et al. [ 53 ] reported that hand-grip strength was reduced from baseline measurements by − 7% and − 9% after 12 and 24 months, respectively, of cross-hormone treatment in transgender women. Comparison with data in a separately-published, parallel cohort of transgender men [ 76 ] demonstrated a retained hand-grip strength advantage after 2 years of 23% over female baseline measurements (a calculated average of baseline data obtained from control females and transgender men).

In a recent multicenter study [ 70 ], examination of 249 transgender women revealed a decrease of − 4% in grip strength after 12 months of cross-hormone treatment, with no variation between different testosterone level, age or BMI tertiles (all transgender women studied were within female reference ranges for testosterone). Despite this modest reduction in strength, transgender women retained a 17% grip strength advantage over transgender men measured at baseline. The authors noted that handgrip strength in transgender women was in approximately the 25th percentile for males but was over the 90th percentile for females, both before and after hormone treatment. This emphasizes that the strength advantage for males over females is inherently large. In another study exploring handgrip strength, albeit in late puberty adolescents, Tack et al. noted no change in grip strength after hormonal treatment (average duration 11 months) of 21 transgender girls [ 72 ].

Although grip strength provides an excellent proxy measurement for general strength in a broad population, specific assessment within different muscle groups is more valuable in a sports-specific framework. Wiik et al., [ 71 ] having determined that thigh muscle mass reduces only modestly, and that no significant changes in contractile density occur with 12 months of testosterone suppression, provided, for the first time, data for isokinetic strength measurements of both knee extension and knee flexion. They reported that muscle strength after 12 months of testosterone suppression was comparable to baseline strength. As a result, transgender women remained about 50% stronger than both the group of transgender men at baseline and a reference group of females. The authors suggested that small neural learning effects during repeated testing may explain the apparent lack of small reductions in strength that had been measured in other studies [ 71 ].

These longitudinal data comprise a clear pattern of very modest to negligible changes in muscle mass and strength in transgender women suppressing testosterone for at least 12 months. Muscle mass and strength are key physical parameters that constitute a significant, if not majority, portion of the male performance advantage, most notably in those sports where upper body strength, overall strength, and muscle mass are crucial determinants of performance. Thus, our analysis strongly suggests that the reduction in testosterone levels required by many sports federation transgender policies is insufficient to remove or reduce the male advantage, in terms of muscle mass and strength, by any meaningful degree. The relatively consistent finding of a minor (approximately − 5%) muscle loss after the first year of treatment is also in line with studies on androgen-deprivation therapy in males with prostate cancer, where the annual loss of lean body mass has been reported to range between − 2 and − 4% [ 77 ].

Although less powerful than longitudinal studies, we identified one major cross-sectional study that measured muscle mass and strength in transgender women. In this study, 23 transgender women and 46 healthy age- and height-matched control males were compared [ 78 ]. The transgender women were recruited at least 3 years after sex reassignment surgery, and the mean duration of cross-hormone treatment was 8 years. The results showed that transgender women had 17% less lean mass and 25% lower peak quadriceps muscle strength than the control males [ 78 ]. This cross-sectional comparison suggests that prolonged testosterone suppression, well beyond the time period mandated by sports federations substantially reduces muscle mass and strength in transgender women. However, the typical gap in lean mass and strength between males and females at baseline (Table ​ (Table1) 1 ) exceeds the reductions reported in this study [ 78 ]. The final average lean body mass of the transgender women was 51.2 kg, which puts them in the 90th percentile for women [ 79 ]. Similarly, the final grip strength was 41 kg, 25% higher than the female reference value [ 80 ]. Collectively, this implies a retained physical advantage even after 8 years of testosterone suppression. Furthermore, given that cohorts of transgender women often have slightly lower baseline measurements of muscle and strength than control males [ 53 ], and baseline measurements were unavailable for the transgender women of this cohort, the above calculations using control males reference values may be an overestimate of actual loss of muscle mass and strength, emphasizing both the need for caution when analyzing cross-sectional data in the absence of baseline assessment and the superior power of longitudinal studies quantifying within-subject changes.

Endurance Performance and Cardiovascular Parameters

No controlled longitudinal study has explored the effects of testosterone suppression on endurance-based performance. Sex differences in endurance performance are generally smaller than for events relying more on muscle mass and explosive strength. Using an age grading model designed to normalize times for masters/veteran categories, Harper [ 81 ] analyzed self-selected and self-reported race times for eight transgender women runners of various age categories who had, over an average 7 year period (range 1–29 years), competed in sub-elite middle and long distance races within both the male and female categories. The age-graded scores for these eight runners were the same in both categories, suggesting that cross-hormone treatment reduced running performance by approximately the size of the typical male advantage. However, factors affecting performances in the interim, including training and injury, were uncontrolled for periods of years to decades and there were uncertainties regarding which race times were self-reported vs. which race times were actually reported and verified, and factors such as standardization of race course and weather conditions were unaccounted for. Furthermore, one runner improved substantially post-transition, which was attributed to improved training [ 81 ]. This demonstrates that performance decrease after transition is not inevitable if training practices are improved. Unfortunately, no study to date has followed up these preliminary self-reports in a more controlled setting, so it is impossible to make any firm conclusions from this data set alone.

Circulating hemoglobin levels are androgen-dependent [ 82 ] and typically reported as 12% higher in males compared with females [ 4 ]. Hemoglobin levels appear to decrease by 11–14% with cross-hormone therapy in transgender women [ 62 , 71 ], and indeed comparably sized reductions have been reported in athletes with DSDs where those athletes are sensitive to and been required to reduce testosterone [ 47 , 83 ]. Oxygen-carrying capacity in transgender women is most likely reduced with testosterone suppression, with a concomitant performance penalty estimated at 2–5% for the female athletic population [ 83 ]. Furthermore, there is a robust relationship between hemoglobin mass and V O 2max [ 84 , 85 ] and reduction in hemoglobin is generally associated with reduced aerobic capacity [ 86 , 87 ]. However, hemoglobin mass is not the only parameter contributing to V O 2max , where central factors such as total blood volume, heart size and contractility, and peripheral factors such as capillary supply and mitochondrial content also plays a role in the final oxygen uptake [ 88 ]. Thus, while a reduction in hemoglobin is strongly predicted to impact aerobic capacity and reduce endurance performance in transgender women, it is unlikely to completely close the baseline gap in aerobic capacity between males and females.

The typical increase in body fat noted in transgender women [ 89 , 90 ] may also be a disadvantage for sporting activities (e.g. running) where body weight (or fat distribution) presents a marginal disadvantage. Whether this body composition change negatively affects performance results in transgender women endurance athletes remains unknown. It is unclear to what extent the expected increase in body fat could be offset by nutritional and exercise countermeasures, as individual variation is likely to be present. For example, in the Wiik et al. study [ 71 ], 3 out of the 11 transgender women were completely resistant to the marked increase in total adipose tissue noted at the group level. This inter-individual response to treatment represents yet another challenge for sports governing bodies who most likely, given the many obstacles with case-by-case assessments, will form policies based on average effect sizes.

Altogether, the effects of testosterone suppression on performance markers for endurance athletes remain insufficiently explored. While the negative effect on hemoglobin concentration is well documented, the effects on V O 2max , left ventricular size, stroke volume, blood volume, cardiac output lactate threshold, and exercise economy, all of which are important determinants of endurance performance, remain unknown. However, given the plausible disadvantages with testosterone suppression mentioned in this section, together with the more marginal male advantage in endurance-based sports, the balance between inclusion and fairness is likely closer to equilibrium in weight-bearing endurance-based sports compared with strength-based sports where the male advantage is still substantial.

The data presented here demonstrate that superior anthropometric, muscle mass and strength parameters achieved by males at puberty, and underpinning a considerable portion of the male performance advantage over females, are not removed by the current regimen of testosterone suppression permitting participation of transgender women in female sports categories. Rather, it appears that the male performance advantage remains substantial. Currently, there is no consensus on an acceptable degree of residual advantage held by transgender women that would be tolerable in the female category of sport. There is significant dispute over this issue, especially since the physiological determinants of performance vary across different sporting disciplines. However, given the IOC position that fair competition is the overriding sporting objective [ 14 ], any residual advantage carried by transgender women raises obvious concerns about fair and safe competition in the numerous sports where muscle mass, strength and power are key performance determinants.

Perspectives on Athletic Status of Transgender Women

Whilst available evidence is strong and convincing that strength, skeletal- and muscle-mass derived advantages will largely remain after cross-hormone therapy in transgender women, it is acknowledged that the findings presented here are from healthy adults with regular or even low physical activity levels [ 91 ], and not highly trained athletes. Thus, further research is required in athletic transgender populations.

However, despite the current absence of empirical evidence in athletic transgender women, it is possible to evaluate potential outcomes in athletic transgender women compared with untrained cohorts. The first possibility is that athletic transgender women will experience similar reductions (approximately − 5%) in muscle mass and strength as untrained transgender women, and will thus retain significant advantages over a comparison group of females. As a result of higher baseline characteristics in these variables, the retained advantage may indeed be even larger. A second possibility is that by virtue of greater muscle mass and strength at baseline, pre-trained transgender women will experience larger relative decreases in muscle mass and strength if they converge with untrained transgender women, particularly if training is halted during transition. Finally, training before and during the period of testosterone suppression may attenuate the anticipated reductions, such that relative decreases in muscle mass and strength will be smaller or non-existent in transgender women who undergo training, compared to untrained (and non-training) controls.

It is well established that resistance training counteracts substantial muscle loss during atrophy conditions that are far more severe than testosterone suppression. For example, resistance exercise every third day during 90-days bed rest was sufficient to completely offset the 20% reduction in knee extensor muscle size noted in the resting control subjects [ 92 ]. More relevant to the question of transgender women, however, is to examine training effects in studies where testosterone has been suppressed in biological males. Kvorning et al. investigated, in a randomized placebo-controlled trial, how suppression of endogenous testosterone for 12 weeks influenced muscle hypertrophy and strength gains during a training program (3 days/week) that took place during the last 8 weeks of the 3-month suppression period [ 93 ]. Despite testosterone suppression to female levels of 2 nmol/L, there was a significant + 4% increase in leg lean mass and a + 2% increase in total lean body mass, and a measurable though insignificant increase in isometric knee extension strength. Moreover, in select exercises used during the training program, 10RM leg press and bench press increased + 32% and + 17%, respectively. While some of the training adaptations were lower than in the placebo group, this study demonstrates that training during a period of testosterone suppression not only counteracts muscle loss, but can actually increase muscle mass and strength.

Males with prostate cancer undergoing androgen deprivation therapy provide a second avenue to examine training effects during testosterone suppression. Testosterone levels are typically reduced to castrate levels, and the loss of lean mass has typically ranged between − 2 and − 4% per year [ 77 ], consistent with the findings described previously in transgender women. A recent meta-analysis concluded that exercise interventions including resistance exercise were generally effective for maintaining muscle mass and increasing muscle strength in prostate cancer patients undergoing androgen deprivation therapy [ 94 ]. It is important to emphasize that the efficacy of the different training programs may vary. For example, a 12-week training study of prostate cancer patients undergoing androgen deprivation therapy included drop-sets to combine heavy loads and high volume while eliciting near-maximal efforts in each set [ 95 ]. This strategy resulted in significantly increased lean body mass (+ 3%), thigh muscle volume (+ 6%), knee extensor 1RM strength (+ 28%) and leg press muscle endurance (+ 110%).

In addition to the described effects of training during testosterone suppression, the effect of training prior to testosterone suppression may also contribute to the attenuation of any muscle mass and strength losses, via a molecular mechanism referred to as ‘muscle memory’ [ 96 ]. Specifically, it has been suggested that myonuclei acquired by skeletal muscle cells during training are maintained during subsequent atrophy conditions [ 97 ]. Even though this model of muscle memory has been challenged recently [ 98 ], it may facilitate an improved training response upon retraining [ 99 ]. Mechanistically, the negative effects of testosterone suppression on muscle mass are likely related to reduced levels of resting protein synthesis [ 100 ], which, together with protein breakdown, determines the net protein balance of skeletal muscle. However, testosterone may not be required to elicit a robust muscle protein synthesis response to resistance exercise [ 100 ]. Indeed, relative increases in muscle mass in men and women from resistance training are comparable, despite marked differences in testosterone levels [ 101 ], and the acute rise in testosterone apparent during resistance exercise does not predict muscle hypertrophy nor strength gains [ 102 ]. This suggests that even though testosterone is important for muscle mass, especially during puberty, the maintenance of muscle mass through resistance training is not crucially dependent on circulating testosterone levels.

Thus, in well-controlled studies in biological males who train while undergoing testosterone reduction, training is protective of, and may even enhance, muscle mass and strength attributes. Considering transgender women athletes who train during testosterone suppression, it is plausible to conclude that any losses will be similar to or even smaller in magnitude than documented in the longitudinal studies described in this review. Furthermore, pre-trained transgender women are likely to have greater muscle mass at baseline than untrained transgender women; it is possible that even with the same, rather than smaller, relative decreases in muscle mass and strength, the magnitude of retained advantage will be greater. In contrast, if pre-trained transgender women undergo testosterone suppression while refraining from intense training, it appears likely that muscle mass and strength will be lost at either the same or greater rate than untrained individuals, although there is no rationale to expect a weaker endpoint state. The degree of change in athletic transgender women is influenced by the athlete’s baseline resistance-training status, the efficacy of the implemented program and other factors such as genetic make-up and nutritional habits, but we argue that it is implausible that athletic transgender women would achieve final muscle mass and strength metrics that are on par with reference females at comparable athletic level.

The Focus on Muscle Mass and Strength

We acknowledge that changes in muscle mass are not always correlated in magnitude to changes in strength measurements because muscle mass (or total mass) is not the only contributor to strength [ 103 ]. Indeed, the importance of the nervous system, e.g. muscle agonist activation (recruitment and firing frequency) and antagonist co-activation, for muscle strength must be acknowledged [ 104 ]. In addition, factors such as fiber types, biomechanical levers, pennation angle, fascicle length and tendon/extracellular matrix composition may all influence the ability to develop muscular force [ 105 ]. While there is currently limited to no information on how these factors are influenced by testosterone suppression, the impact seems to be minute, given the modest changes noted in muscle strength during cross-hormone treatment.

It is possible that estrogen replacement may affect the sensitivity of muscle to anabolic signaling and have a protective effect on muscle mass [ 106 ] explaining, in part, the modest change in muscle mass with testosterone suppression and accompanying cross-hormone treatment. Indeed, this is supported by research conducted on estrogen replacement therapy in other targeted populations [ 107 , 108 ] and in several different animal models, including mice after gonadectomy [ 109 ] and ovariectomy [ 110 ].

In terms of other performance proxies relevant to sports performance, there is no research evaluating the effects of transgender hormone treatment on factors such as agility, jumping or sprint performance, competition strength performance (e.g. bench press), or discipline-specific performance. Other factors that may impact sports performance, known to be affected by testosterone and some of them measurably different between males and females, include visuospatial abilities, aggressiveness, coordination and flexibility.

Testosterone-Based Criteria for Inclusion of Transgender Women in Female Sports

The appropriate testosterone limit for participation of transgender women in the female category has been a matter of debate recently, where sports federations such as World Athletics recently lowered the eligibility criterion of free circulating testosterone (measured by means of liquid chromatography coupled with mass spectrometry) to < 5 nmol/L. This was based, at least in part, on a thorough review by Handelsman et al. [ 4 ], where the authors concluded that, given the nonoverlapping distribution of circulating testosterone between males and females, and making an allowance for females with mild hyperandrogenism (e.g. with polycystic ovary syndrome), the appropriate testosterone limit should be 5 rather than 10 nmol/L.

From the longitudinal muscle mass/strength studies summarised here, however, it is apparent that most therapeutic interventions result in almost complete suppression of testosterone levels, certainly well below 5 nmol/L (Table ​ (Table4). 4 ). Thus, with regard to transgender women athletes, we question whether current circulating testosterone level cut-off can be a meaningful decisive factor, when in fact not even suppression down to around 1 nmol/L removes the anthropometric and muscle mass/strength advantage in any significant way.

In terms of duration of testosterone suppression, it may be argued that although 12 months of treatment is not sufficient to remove the male advantage, perhaps extending the time frame of suppression would generate greater parity with female metrics. However, based on the studies reviewed here, evidence is lacking that this would diminish the male advantage to a tolerable degree. On the contrary, it appears that the net loss of lean mass and grip strength is not substantially decreased at year 2 or 3 of cross-hormone treatment (Table ​ (Table4), 4 ), nor evident in cohorts after an average 8 years after transition. This indicates that a plateau or a new steady state is reached within the first or second year of treatment, a phenomenon also noted in transgender men, where the increase in muscle mass seems to stabilise between the first and the second year of testosterone treatment [ 111 ].

Conclusions

We have shown that under testosterone suppression regimes typically used in clinical settings, and which comfortably exceed the requirements of sports federations for inclusion of transgender women in female sports categories by reducing testosterone levels to well below the upper tolerated limit, evidence for loss of the male performance advantage, established by testosterone at puberty and translating in elite athletes to a 10–50% performance advantage, is lacking. Rather, the data show that strength, lean body mass, muscle size and bone density are only trivially affected. The reductions observed in muscle mass, size, and strength are very small compared to the baseline differences between males and females in these variables, and thus, there are major performance and safety implications in sports where these attributes are competitively significant. These data significantly undermine the delivery of fairness and safety presumed by the criteria set out in transgender inclusion policies, particularly given the stated prioritization of fairness as an overriding objective (for the IOC). If those policies are intended to preserve fairness, inclusion and the safety of biologically female athletes, sporting organizations may need to reassess their policies regarding inclusion of transgender women.

From a medical-ethical point of view, it may be questioned as to whether a requirement to lower testosterone below a certain level to ensure sporting participation can be justified at all. If the advantage persists to a large degree, as evidence suggests, then a stated objective of targeting a certain testosterone level to be eligible will not achieve its objective and may drive medical practice that an individual may not want or require, without achieving its intended benefit.

The research conducted so far has studied untrained transgender women. Thus, while this research is important to understand the isolated effects of testosterone suppression, it is still uncertain how transgender women athletes, perhaps undergoing advanced training regimens to counteract the muscle loss during the therapy, would respond. It is also important to recognize that performance in most sports may be influenced by factors outside muscle mass and strength, and the balance between inclusion, safety and fairness therefore differs between sports. While there is certainly a need for more focused research on this topic, including more comprehensive performance tests in transgender women athletes and studies on training capacity of transgender women undergoing hormone therapy, it is still important to recognize that the biological factors underpinning athletic performance are unequivocally established. It is, therefore, possible to make strong inferences and discuss potential performance implications despite the lack of direct sport-specific studies in athletes. Finally, since athlete safety could arguably be described as the immediate priority above considerations of fairness and inclusion, proper risk assessment should be conducted within respective sports that continue to include transgender women in the female category.

If transgender women are restricted within or excluded from the female category of sport, the important question is whether or not this exclusion (or conditional exclusion) is necessary and proportionate to the goal of ensuring fair, safe and meaningful competition. Regardless of what the future will bring in terms of revised transgender policies, it is clear that different sports differ vastly in terms of physiological determinants of success, which may create safety considerations and may alter the importance of retained performance advantages. Thus, we argue against universal guidelines for transgender athletes in sport and instead propose that each individual sports federation evaluate their own conditions for inclusivity, fairness and safety.

Below is the link to the electronic supplementary material.

Compliance with Ethical Standards

None. Open access funding provided by Karolinska Institutet.

Emma N Hilton and Tommy R Lundberg declare that they have no conflict of interest with the content of this review.

Both authors (ENH and TRL) were involved in the conception and design of this paper, and both authors drafted, revised and approved the final version of the paper.

Not applicable.

Advertisement

Supported by

Use of Abortion Pills Has Risen Significantly Post Roe, Research Shows

By Pam Belluck

Pam Belluck has been reporting about reproductive health for over a decade.

• Share full article

On the eve of oral arguments in a Supreme Court case that could affect future access to abortion pills, new research shows the fast-growing use of medication abortion nationally and the many ways women have obtained access to the method since Roe v. Wade was overturned in June 2022.

The Details

A study, published on Monday in the medical journal JAMA , found that the number of abortions using pills obtained outside the formal health system soared in the six months after the national right to abortion was overturned. Another report, published last week by the Guttmacher Institute , a research organization that supports abortion rights, found that medication abortions now account for nearly two-thirds of all abortions provided by the country’s formal health system, which includes clinics and telemedicine abortion services.

The JAMA study evaluated data from overseas telemedicine organizations, online vendors and networks of community volunteers that generally obtain pills from outside the United States. Before Roe was overturned, these avenues provided abortion pills to about 1,400 women per month, but in the six months afterward, the average jumped to 5,900 per month, the study reported.

Overall, the study found that while abortions in the formal health care system declined by about 32,000 from July through December 2022, much of that decline was offset by about 26,000 medication abortions from pills provided by sources outside the formal health system.

“We see what we see elsewhere in the world in the U.S. — that when anti-abortion laws go into effect, oftentimes outside of the formal health care setting is where people look, and the locus of care gets shifted,” said Dr. Abigail Aiken, who is an associate professor at the University of Texas at Austin and the lead author of the JAMA study.

The co-authors were a statistics professor at the university; the founder of Aid Access, a Europe-based organization that helped pioneer telemedicine abortion in the United States; and a leader of Plan C, an organization that provides consumers with information about medication abortion. Before publication, the study went through the rigorous peer review process required by a major medical journal.

The telemedicine organizations in the study evaluated prospective patients using written medical questionnaires, issued prescriptions from doctors who were typically in Europe and had pills shipped from pharmacies in India, generally charging about $100. Community networks typically asked for some information about the pregnancy and either delivered or mailed pills with detailed instructions, often for free.

Online vendors, which supplied a small percentage of the pills in the study and charged between $39 and $470, generally did not ask for women’s medical history and shipped the pills with the least detailed instructions. Vendors in the study were vetted by Plan C and found to be providing genuine abortion pills, Dr. Aiken said.

The Guttmacher report, focusing on the formal health care system, included data from clinics and telemedicine abortion services within the United States that provided abortion to patients who lived in or traveled to states with legal abortion between January and December 2023.

It found that pills accounted for 63 percent of those abortions, up from 53 percent in 2020. The total number of abortions in the report was over a million for the first time in more than a decade.

Why This Matters

Overall, the new reports suggest how rapidly the provision of abortion has adjusted amid post-Roe abortion bans in 14 states and tight restrictions in others.

The numbers may be an undercount and do not reflect the most recent shift: shield laws in six states allowing abortion providers to prescribe and mail pills to tens of thousands of women in states with bans without requiring them to travel. Since last summer, for example, Aid Access has stopped shipping medication from overseas and operating outside the formal health system; it is instead mailing pills to states with bans from within the United States with the protection of shield laws.

What’s Next

In the case that will be argued before the Supreme Court on Tuesday, the plaintiffs, who oppose abortion, are suing the Food and Drug Administration, seeking to block or drastically limit the availability of mifepristone, the first pill in the two-drug medication abortion regimen.

The JAMA study suggests that such a ruling could prompt more women to use avenues outside the formal American health care system, such as pills from other countries.

“There’s so many unknowns about what will happen with the decision,” Dr. Aiken said.

She added: “It’s possible that a decision by the Supreme Court in favor of the plaintiffs could have a knock-on effect where more people are looking to access outside the formal health care setting, either because they’re worried that access is going away or they’re having more trouble accessing the medications.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck