After decades of neglecting women athletes, sport and exercise medicine is finally catching up

When cyclist Alison Tetrick joined the sport’s professional ranks, she received the perks that come with the job — new bikes and clothing included. But she could never get comfortable on the bike saddles. After several years, Tetrick suffered so much damage to her genital area that she eventually resorted to surgery to trim excess skin from her labia. Tetrick wasn’t alone — the sad truth was that many of her female cycling peers had also required the procedure.

Since Tetrick’s experience about a decade ago, several cycling companies have developed women-specific saddles and cycling shorts, as amateur athlete and journalist Christine Yu writes in her new book “Up to Speed: The Groundbreaking Science of Women Athletes.” But Tetrick’s case is representative of a massive gap in science and exercise medicine, which has long neglected the study of women.

The repercussions of this gap are still playing out today, from sports gear that neglects to take into account physiological differences in women’s bodies to higher rates for injuries like ACL tears and bone stress fractures for women in sports like soccer and running. “Although female athletes constitute approximately 50% of the population, there are distinct knowledge gaps in areas such as sports performance, cardiovascular health, musculoskeletal health, postpartum physiology and lactation research,” the authors of an editorial in the journal BMJ Open Sport & Exercise Medicine wrote this May, calling for greater representation of women as both study participants and as researchers in the field.

The starting point for the research gap can be traced as far back as Hippocrates, according to Rachel E. Gross, author of the 2022 book “Vagina Obscura,” which explores female anatomy through both a scientific and historical lens.

“Hippocrates and other well-known doctors considered the female body an inferior variant of the male body,” Gross told STAT. “Until the 1800s, there were always issues getting enough female bodies to dissect, and there was a fundamental assumption that the female body was ‘lesser,’ and therefore didn’t need rigorous examination.”

This thought process informed science of all kinds going forward. “It’s a paradox,” said Gross. “Science has considered women’s bodies as too different and weird to include in clinical trials, yet not so different that we can’t just extrapolate male data.”

Even as scientists increasingly acknowledge women aren’t just smaller versions of men, there’s a lot of catching up to do. It wasn’t until 1993 that the National Institutes of Health mandated the inclusion of women and minorities in the clinical research it funded. Even since then, researchers have frequently left pregnant women and people of color out of clinical trials.

“Medical research on the female body has focused on reproduction and disease, but left out general health, immunity and pleasure,” said Gross. “It’s not that we don’t have the tools, it’s that we haven’t found it interesting enough or urgent enough.”

Sexist attitudes about women’s bodies have also shaped many of the events in which they compete. Women didn’t play in the World Cup until 1991, while the Olympic marathon wasn’t available to women runners until 1984. At major tennis events, women still only play best-of-three set matches to men’s five. And despite ample criticism, in the National Collegiate Athletic Association, cross-country running courses for women remain at 6k, while men run 10k.

With women athletes still fighting for even playing fields, it’s no wonder that they continue to lack sufficient information to understand how their very biology can impact training, nutrition, health, and ultimately, performance.

“Women’s sports science is really still in its infancy,” said Kathryn Ackerman, director of the Female Athlete Program at Boston Children’s Hospital. “If you look at the research papers between 2016 and 2020, only six percent is focused on female athletes.”

How research gaps hurt female athlete

The birthplace of exercise science is widely considered to be the Harvard Fatigue Lab. Founded in 1927, the lab studied male athletes as they performed experiments like running on treadmills in below-freezing cold chambers and “artificial deserts” where the temperatures could reach up to 115 degrees. Blood draws from Olympic marathoner Clarence DeMar in 1930, for instance, allowed researchers to understand more about endurance during exercise. But women were not included in that research, Yu said — and “where we start matters.”

When the lab closed in 1947, Yu explained, “the male researchers and students dispersed to other institutions and established their own labs, which continued to study male athletes. That legacy continues even today.”

One of the biggest exclusions in women’s sports science to date is the role of hormones, particularly in pubescent, pre- and post-menopausal years. “When reading sports science results, it’s important to know if they controlled for menstrual cycles, or if subjects are on the pill and what that might mean,”  said Boston Children’s Hospital’s Ackerman. “Much of the body of work used to guide women athletes isn’t as sound as it should be.”

With little to go on, women athletes have needed to figure it out themselves, or alongside coaches who don’t have a deep understanding of gender differences, either.

Esther Goldsmith, a sports scientist with ORRECO, a bio-analytics company, and FitrWoman, a period tracking app that allows women to sync their cycle to their training, noticed this gap while pursuing her masters in exercise physiology a decade ago. “We were taught entire modules on how to better athletic performance, but none of it was supported with data on women athletes,” she said. “It’s still underappreciated, but now there’s at least an acknowledgement of the need to push this forward.”

In her work with Orreco, Goldsmith is studying blood biomarkers to understand hormone levels throughout menstrual cycles and how they can impact women athletes. The group has launched the Female Athlete Program, which is geared to help women athletes work proactively with their cycles to sustain peak performance. This might include advice on nutrition, hydration, and how to lower injury and illness risks at various points of a cycle. For instance, some research has indicated that women athletes are more susceptible to muscle and tendon injury during ovulation. “As we learn, we’re also educating women athletes from youth on up to high-performance elite athletes,” she said.

There’s also a gap in understanding female anatomy, including breasts, when it comes to athletic performance. “There’s no muscle structure or bone in breast tissue, and it has a very complex movement pattern,” said Yu. “It really does impact how women experience physical activity, yet we didn’t invent sports bras until the 1970s.”

When gear like sports bras are developed without research-based insights into women’s bodies, they don’t provide the amount of control women need to fully participate in sports. Yu’s book points to the fact that, over the course of a marathon, an ill-fitting sports bra can cause a woman’s steps to shorten, translating to a performance dip. A 2020 study, meanwhile, found that 44% of 540 female athletes reported experiencing exercise-induced breast pain during training and competition, negatively impacting their performance.

This lack of understanding of female anatomy has long contributed to horror stories like Tetrick’s, where gear makers applied a “shrink it and pink it” approach.

Yu points to several sports where women’s gear either comes in a smaller version of men’s, or only at entry level or slightly better. From women’s soccer cleats to downhill skis, running shoes and more, the gear women have had available to them has often been ill-fitting and not supportive of anatomical differences, such as the fact that women’s wider pelvises tend to put more strain on their knees.

Making strides toward gender equality

Part of the solution to these issues lies in more research that’s specifically focused on women in sports. A 2021 study of sports-related concussions in high school females over a 20-year period, for instance, found that female athletes experience concussions at rates nearly twice as high as males in comparable sports. They also are more likely to suffer recurrent concussions than males. While researchers are still trying to understand why this is the case, such knowledge can inform treatment both on the field and after.

Providing women athletes with informed, holistic health care is also necessary. When Ackerman first began work as a sports medicine physician, she noticed a pattern. “I had young athletes coming to see me with issues like eating disorders, multiple stress fractures, gastrointestinal issues and mental health concerns,” she says. “They had to see different doctors for each concern, and there was no interdisciplinary approach to their issues.”

Ackerman’s boss was a forward-thinking male orthopedic surgeon, and when she approached him about the idea of centralized care for women athletes, he supported her vision. In 2013, Ackerman opened the Female Athlete Program and today offers holistic care to female athletes. The center provides a comprehensive care approach, assessing exercise habits, hormone balances, nutritional needs and athletic background. There’s so much demand for the program that Ackerman is actively recruiting clinicians to keep up.

Ackerman also leads the biannual Female Athlete Conference, where interdisciplinary researchers and clinicians from all over the globe convene to present and learn from each other. “My hope is that together with the center, we can develop trusted guidelines for women athletes and their coaches to inform and better our understanding of women’s bodies and performance,” Ackerman said.

Work like Ackerman’s and other similar clinics, like the FASTR program run by Emily Kraus at Stanford Children’s Orthopedic and Sports Medicine Center, are helping push the understanding of women athletes and how to coach and treat them.

The danger of gender essentialism in research

While sports science is evolving and including more women — as it should — there’s also a danger in “over-correcting” or oversimplifying binary gender results. As more trans athletes take to the fields, it’s also essential to consider their needs and preferences. This is the concern of Kathryn B. H. Clancy, professor of anthropology at the University of Illinois and author of “Period: The Real Story of Menstruation.”

“There’s long been a misconception that cycles don’t matter, and it’s important that we’re starting to understand that they do,” said Clancy. “But we also need a middle-ground response, one that doesn’t take it to the other end and suggests cycles are everything when it comes to exercise.”

Yu agrees. “I do worry there’s a potential to oversimplify matters and boil things down to only hormones, as if they are the only thing that matters,” she said. “But we are not just our hormones, or how they act in a laboratory setting or defined methodological parameters of a single study.”

Goldsmith, too, worries about the misinformation pipeline and trend to oversimplify the message. “If you want to change your events or races around your menstrual cycle to help your performance, do so,” she said. “But it’s not always a realistic option and everyone is different. It’s more about understanding how to manage your own symptoms throughout your cycle.”

Likewise, making gear specific to women — while a welcome and overdue advance — comes with minefields. Gender-specific products aren’t always the answer, and in some cases, they may be unnecessary. Yu connected with bicycle maker Specialized for her book. The brand revealed that while it has revolutionized saddle design for women’s bodies, the science didn’t support its former line of women’s specific bike frames — so they discontinued it.

But as researchers push forward with more inclusive studies and younger women athletes expect more from their coaches, gear, and performance, experts in exercise science see reason for optimism.

“Female bodies have already smashed so many myths and assumptions in the scientific world and I only see that continuing,” said Gross. “The key is asking what the female body can do, not what makes it different. We haven’t even approached that full potential yet.”