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Despite constituting approximately 50% of the population, women specifically are under-represented in sport and exercise medicine (SEM) and they often experience a negative bias. Our authorship group has recognised this issue based on evidence from recent studies, personal experiences and the experiences of the wider SEM community. We understand that this is a complex issue. Through this editorial, we aim to briefly highlight the issue of insufficient representation of women in SEM, discuss some of the impacts of this inadequate inclusion and other negative aspects experienced and suggest steps that we can all take to address female under-representation to improve the field of SEM
Female under-representation in SEM
Sex and gender bias in SEM settings are evident in multiple ways. Systematic reviews demonstrated that female athletes are under-represented in sports and exercise research.1 2 International Olympic Committee consensus statements identified the need for increased representation and inclusion of authors from different genders, ethnicities, skill sets and levels of experience.3 Female first and last authorship on scientific publications is less than 25%,4 5 they hold less than 25% of leadership roles in editorial boards in sports sciences, and they are also under-represented in leadership in primary care sport medicine.6 7 Women account for less than 20% of team doctors in both collegiate and professional sports, with the highest percentage (31%) in the Women’s National Basketball Association.8 At conferences, all-male conference panels and keynote speakers are still common.9 10
How does it affect the field, and what other adverse consequences do women in SEM face?
Under-representation of female participants, clinicians and researchers in SEM can have detrimental effects for the field and women within it.
Although female athletes constitute approximately 50% of the population, there are distinct knowledge gaps in areas such as sport performance, cardiovascular health, musculoskeletal health, postpartum physiology and lactation research.11 It is crucial to foster diversity in both participant cohorts and research teams.12 This includes designing experimental studies with female-specific physiological considerations and creating evidence-based exercise-related guidelines tailored for sportswomen.13 There is also a need for separate analyses to account for different causal mechanisms for injuries or health issues in men and women. Sex-specific exercise training recommendations can help improve adherence and physiological responses in clinical populations.14 However, women remain under-enrolled in both recreational and performance sports research, mirroring the under-representation of women across health and disease states.15 Addressing this issue is vital to support performance and safe sport for women.
Harassment at the workplace can lead to unhealthy work environments, mental health challenges and poor job satisfaction for female practitioners.14 This may contribute to women leaving their positions early or seeking work in other areas. Moreover, the workload and work culture may differ for female and male clinicians and researchers. Higher suicide mortality rates are observed among female physicians compared with male physicians.16 Work stressors have been identified as a risk factor for suicide among female physicians.17 Female sportmedicine physicians experience disrespect and have their judgement questioned more often than male sport medicine physicians. They have also reported experiencing sexual harassment.18
Reduced sports participation
Encouraging sports participation and actively striving to keep all children and adolescents, irrespective of their sex or gender, engaged in sports is crucial for promoting health throughout life.19 Sports dropout is a major concern among specifically female adolescents. Role models may play a role in ameliorating this.20 21
Addressing female under-representation
At peak sport medicine bodies, academic researchers and training institutions, there are a number of ways we can address female under-representation and its consequences. In table 1, we describe the following strategies: (a) build a culture of awareness, excellence and inclusivity, (b) promote female inclusion in sport medicine, (c) enhance female inclusion in research, publications and conferences, (d) recognise the benefits of greater diversity, (e) enhance the use of enabling technology, (f) distribute work equally, (g) implement anonymous reporting platforms and expert commentary to address bias in SEM settings. By incorporating these strategies, we can work towards creating a more diverse and inclusive environment in the field of sport medicine that benefits everyone involved.
Portugal is an example of a country that has achieved parity between men and women in research, with women representing 50% of published researchers.22 Women are highly represented among first authors, indicating greater equality and representation for early-career researchers. Unlike other comparable nations, women researchers in Portugal are likely to continue publishing over time and remain engaged in research.
It is important that we acknowledge the under-representation and work to break the cycle of gender bias through role models. The lack of female role models in SEM can perpetuate the cycle of gender bias. Breaking this cycle is essential to ensure that future generations do not perceive gender bias as normal and continue to pass it down to new practitioners joining the field. In the future, gender equity should be normal.
Like many disciplines, there is an evident under-representation of women and potential negative bias in SEM, research and occupations at all levels. There are great benefits to achieving gender equity in SEM. We believe that we can ensure that the brightest minds from all backgrounds can contribute to the advancement of science and enhance not only the sports medicine community but also society at large by acknowledging and addressing this under-representation.
Follow the hashtag #WomenInSTEM
See BJSM blog August 2022 https://blogs.bmj.com/bjsm/2022/08/22/gender-bias-in-sports-medicine/
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Contributors NA and DLB are credited with creating the first draft of this paper. All other authors contributed to the development and refinement of the manuscript. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Sonia Cheng and Ana Morais Azevedo provided feedback on this paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests NA, DLB, DGR are senior editorial board members, KF, PE, DR-V, OHA, MJ, LU, JB-P, CGF, CO, NT, TM, LSPP, SH, BH, RM, MB are associate editors, and EV is the editor-in-chief of BMJ Open Sports & Exercise Medicine.
Provenance and peer review Commissioned; internally peer reviewed.