Throughout the evolution of humanity most of what we have learnt about humans, both culturally and biologically, have represented the lives of men. From understanding how the human body works, to scientific medicine, economics, politics, technology, and even as far as representation in mainstream film, literature and the news, there has been a large gender gap (Cleghorn, 2021; Perez, 2019). Important to note that this failure in the underrepresentation of women is often not deliberate or malicious, but in fact a product of a way of thinking that has been around for hundreds of years (Perez, 2019).
Historically, it was often assumed that the only differences between the sexes were body sizes and the reproductive system, and as a result, medical research followed a male norm. Furthermore, females were often excluded from research due to the complexities around the menstrual cycle (Blair, 2007). For many years, guidelines following this male norm caused real harm to women and it was not until the 1990s that the Society for Women’s Health called for a new strategy to focus on physiological sex differences, disease prevention, diagnosis and treatment (Marts & Keitt, 2004). It is a well-known fact that males typically have different body compositions than females, there are also structural and morphological differences across many organ systems that will affect physiological functioning (Blair, 2007). For example, males have larger lungs and airways, as well as greater lung diffusion capacities and as such, this may affect a female’s maximal capacity for exercise due to limitations in pulmonary capacity (Harms, 2006).
Male-biased research extends further when investigating the use of exercise as a preventative measure for disease. For example, the use of resistance training is not recommended for individuals who have high blood pressure (HTN) largely because it can cause an increase in artery stiffness as well as the fact that aerobic exercise has more beneficial effects on lowering blood pressure compared to resistance training (Sardeli & Chacon-Mikahil, 2016). Research on women who engage in resistance training reported lowered blood pressure and also found that women do not experience the same increase in artery stiffness. These findings have important implications due to the fact that blood pressure differs in males and females as they age, with women experiencing higher blood pressure than their age equivalent male counterparts. So, if the recommendation to avoid resistance training for individuals with HTN was applied to both sexes, females could potentially miss out on interventions that may benefit their overall health and reduce HTN as they age. This highlights the importance of understanding sex differences in more detail before designing exercise treatment programs for individuals with differing health conditions (Collier, 2008).
Historically, women were often excluded from sport as it was thought “that physical effort, like running, jumping and climbing, might damage their reproductive organs and make them unattractive to men” (McCrone, 1988 p. 8). Although society has come a long way since such societal and cultural views were in place, it was only in the recent Tokyo Olympic Games 2021, did we see almost equal ratios of men and women as competitors. It is therefore not surprising that females remain significantly underrepresented in the field of sport and exercise research and as such any scientific conclusions and recommendations may only be applicable to males (Bruinvels et al., 2016; Cowley et al., 2021). Considering that many more females are taking part in sport, we would expect to see an increase in their inclusion in research, however, in the three top Sports and Exercise Journals (British Journal of Sports Medicine, American journal of Sports Medicine and Medicine and Science in Sports and Exercise), a high male bias towards males in research was found, providing further evidence that females remain underrepresented in important scientific explorations of physiology (Costello et al., 2014).
Similar to the high male bias we see elsewhere in the scientific literature, most of the guidelines in relation to sports and exercise have been derived from male participants, making it increasingly harder to adopt an evidence-based approach when working with female athletes. Indeed, a lot of the research evidence may well be applicable to women, however it cannot be assumed that all would apply to female athletes as there are fundamental differences in anatomy, physiology and endocrinology between the sexes (Cowley et al., 2021). Given that in recent years we have seen a rise in numbers of women and girls taking part in physical activity (both recreational and professional/elite), it seems imperative that future research focuses on specific areas of women’s physiological and psychological differences that may influence their health and sporting performance (Cowley et al., 2021; McNulty, 2021). Furthermore, when recommendations related to sports and exercise based on male-participants are applied to women, this may potentially result in missed opportunities for sportswomen to reach both their athletic and performance potential (Elliot-Sale et al., 2021).
One area where research is expanding is the effects of the menstrual cycle on training and exercise, however the research is conflicting and often of low quality due to methodological issues (Janse De Jonge et al., 2019). Furthermore, whether or not sex hormones influence and change female performance is still not well understood (McNulty et al., 2021). A systematic review and meta-analysis of the available data suggested that as oestrogen rises during the late follicular and ovulatory stages of the menstrual cycle, and due to the fact that oestrogen is known for its anabolic effects, it is possible that this may have a positive effect on strength training during this period. Furthermore, exercise performance may be reduced in the early follicular cycle of the menstrual cycle, suggesting that women may get the most benefits out of strength training during their follicular phase. Again, given that research is often conflicting, no formal recommendations can be given for a universal approach to women’s training throughout their menstrual cycle, instead an individualised approach should be taken when supporting female athletes (McNulty et al., 2020).
From the current advice available there seems to be key areas that should be considered when supporting women in sport. First, recommendations for individuals to understand the basic biology of their menstrual cycle is key. Recommendations suggest that women in sports should follow an individualised approach to understanding how their cycle affects them, and a good start is beginning to track their own cycles (McNulty et al., 2020). Second, being aware that hormonal contraception may affect an individual’s performance and training. Similarly, to advice given around menstrual cycles, tracking individual experiences of contraception and how this may affect exercise should remain a priority until further research in this area is explored (Thompson et al., 2020). Third, similar to both the menstrual cycle and the contraceptive pill, breast health and support remains individual to the sportswoman, however 85% of women are still not wearing the correct support. Sports bras have been found to not only influence participation in sports and exercise but also affects performance and training (McNulty, 2021; Research Group in Breast Health, 2021). Fourth, understanding pelvic floor health is important, as active women are more likely to experience urine leaking. Future research is needed to understand how different life phases affect pelvic floor health. Women who exercise who experience these difficulties are advised to seek help from their GP (McNulty, 2021). Fifth, different life phases such as pregnancy, post-partum, peri-menopause and menopause, differences in female specific risks and injuries, as well as psychological differences between men and women are all important areas for future research. Understanding how these specific areas impact on performance and training will further inform evidence-based practice and will also provide fitness professionals and coaches with the information needed to continue providing high quality coaching. It is also important that the female athlete educates herself in order to optimise training and exercise (McNulty, 2021). Lastly, females may benefit from specific nutritional recommendations due to fluctuating hormone levels across their cycle. Individualised approaches to specific caloric, macro and micro nutrient and additional supplements should be recommended and tailored to the individual based on their training goals (Wohlegemuth et al., 2021).
In summary, there is a long road ahead into truly understanding the physical and mental health needs of the female athlete. Given that there is still a paucity of high-quality research on women in sports both recreationally and at an elite level, it seems particularly important that general information, areas for current support, professional guidance and research studies are circulated and made available to coaches, health practitioners and others working in the field of women’s health.
References
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Bruinvels, G., Burden, R. J., McGregor, A. J., Ackerman, K. E., Dooley, M., Richards, T. & Pedlar, C. (2016). Sport, exercise and the menstrual cycle: where is the research? British Journal of Sports Medicine, 0, 1.
Cleghorn, E. (2021). Unwell women – a journey through medicine and myth in a man-made world. The Orion Publishing Group Ltd.
Collier, S.R. (2008). Sex differences in the effects of aerobic and anaerobic exercise on blood pressure and arterial stiffness. Gender Medicine, 5(2),115-23.
Costello, J. T., Bieuzen, F., & Bleakley, C. M. (2014) Where are all the female participants in Sports and Exercise Medicine research? European Journal of Sport Science, 14(8), 847-851
Cowley, E. S., Olenick, A. A., McNulty, K. L., & Ross, E. Z. (2021). “Invisible Sportswomen”: The sex data gap in sport and exercise science research. Women in Sport and Physical Activity Journal, 29(2), 146-151.
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McCrone, K. E. (1988). Playing the game: sport and the physical emancipation of English women. University Press of Kentucky.
McNulty, K. L., Elliot-Sale, K. J., Dolan, E., Swinton, P. A., Ansdell, P., Goodall, S., Thomas, K., & Hicks, K. M. (2020). The effects of menstrual cycle phase on exercise performance in eumenorrheic women: A systematic review and meta-analysis. Sports Medicine, 50, 1813-1827.
McNulty, K. L. (2021). 10 female athlete considerations for performance and training. Period of the Period. https://www.periodoftheperiod.com/post/10-female-athlete-considerations-for-performance-training
McNulty, K. L., Hicks, K. M., & Ansdell, P. (2021). Variation in physiological function within and between menstrual cycles: uncovering the contributing factors. Experimental Physiology, 1-2.
Perez, C. C. (2019). Invisible women: exposing data bias in a world designed for men. Penguin Random House UK.
Research Group On Breast Health (2021). Experts in breast and bra science. University of Plymouth. https://www.port.ac.uk/research/research-centres-and-groups/research-group-in-breast-health#recent%20publication%20highlights
Sardeli, A. V., & Chacon-Mikahil, M. P. T. (2016). Is The Exercise-Induced Increase in Central Arterial Stiffness a Risk Factor for Health? Journal of Archives in Military Medicine, 4(2), 1-5.
Thompson, B., Almarjawi, A., Sculley, D., & Janse de Jonge, X. (2020). The effect of the menstrual cycle and oral contraceptives on acute responses and chronic adaptations to resistance training: A systematic review of the literature. Sports Medicine, 50, 171-185.
Wohlgemuth, K. L. Arieta, L. R., Brewer, G. J., Hoselton, A. L., Gould, L. M., & Smith-Ryan, A. E. (2021). Sex differences and considerations for female specific nutritional strategies: a narrative review. Journal of the International Society of Sports Nutrition, 18(27), 1-20.
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