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Misunderstanding the Female Athlete Triad: Refuting the IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S)
  1. Mary Jane De Souza1,
  2. Nancy I Williams1,
  3. Aurelia Nattiv2,
  4. Elizabeth Joy3,
  5. Madhusmita Misra4,
  6. Anne B Loucks5,
  7. Gordon Matheson6,
  8. Marion P Olmsted7,
  9. Michelle Barrack8,
  10. Rebecca J Mallinson1,
  11. Jenna C Gibbs9,
  12. Marci Goolsby10,
  13. Jeanne F Nichols11,
  14. Barbara Drinkwater12,
  15. Charlotte (Barney) Sanborn13,
  16. Rosemary Agostini14,
  17. Carol L Otis15,
  18. Mimi D Johnson16,
  19. Anne Zeni Hoch17,
  20. Julia M K Alleyne7,
  21. L Tyler Wadsworth18,
  22. Karsten Koehler1,
  23. Jaci VanHeest19,
  24. Paula Harvey7,
  25. Amanda K Weiss Kelly20,
  26. Michael Fredericson21,
  27. George A Brooks22,
  28. Emma O'Donnell7,
  29. Lisa R Callahan23,
  30. Margot Putukian24,
  31. Lauren Costello24,
  32. Suzanne Hecht25,
  33. Mitchell J Rauh26,
  34. Jacalyn McComb27
  1. 1Department of Kinesiology, Pennsylvania State University, University Park, Pennsylvania, USA
  2. 2Division of Sports Medicine and Department of Orthopaedic Surgery, University of California, Los Angeles, California, USA
  3. 3Intermountain Healthcare, Salt Lake City, Utah, USA
  4. 4Massachusetts General Hospital, Boston, Massachusetts, USA
  5. 5Ohio University, Athens, Ohio, USA
  6. 6Stanford University School of Medicine, Stanford, California, USA
  7. 7University of Toronto, Toronto, Ontario, Canada
  8. 8University of California, Northridge, California, USA
  9. 9University of Waterloo, Waterloo, Ontario, Canada
  10. 10Hospital for Special Surgery, New York, New York, USA
  11. 11University of California, San Diego, California, USA
  12. 12Washington, USA
  13. 13Texas Woman's University, Denton, Texas, USA
  14. 14Group Health, Seattle, Washington, USA
  15. 15WTA Tour Player Development, Portland, Oregon, USA
  16. 16University of Washington, Seattle, Washington, USA
  17. 17Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  18. 18Advanced Orthopedics and Sports Medicine, St Louis, Missouri, USA
  19. 19University of Connecticut, Storrs, Connecticut, USA
  20. 20University Hospitals Case Medical Center, Cleveland, Ohio, USA
  21. 21Stanford University, Stanford, California, USA
  22. 22University of California, Berkeley, California, USA
  23. 23Hospital for Special Surgery, New York, New York, USA
  24. 24Princeton University, Princeton, New Jersey, USA
  25. 25University of Minnesota, Minneapolis, Minnesota, USA
  26. 26San Diego State University, San Diego, California, USA
  27. 27Texas Tech University, Lubbock, Texas, USA
  1. Correspondence to Dr Mary Jane De Souza, Women's Health and Exercise Laboratory, 104 Noll Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA; mjd34{at}

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An IOC consensus group has recently introduced a new umbrella term, that is, ‘Relative Energy Deficiency in Sport’ (RED-S) to describe the physiological and pathophysiological effects of energy deficiency in male and female athletes.1 The authors assert that “new terminology is required to more accurately describe the clinical syndrome originally known as the Female Athlete Triad” that is a “more comprehensive, broader term for the overall syndrome, which includes what has so far been called the ‘Female Athlete Triad’.”1 This new terminology (RED-S) is insufficiently supported by scientific research to warrant adoption at this time. The Female Athlete Triad has more than 30 years of published evidence to support its existence in the scientific literature with strong evidence for its clinical sequelae and should remain a focus of scientific inquiry and translation.2–6 Moreover, several major concerns and errors with the IOC consensus statement should give researchers and practitioners great pause before adopting the IOC's new terminology, its theoretical construct and its proposed recommendations for screening and return to play.

As stated by the IOC authors, the science of energy deficiency in the male athlete and in other groups is still in its ‘infancy’.1 In contrast, research on the Triad has been published since the early 1990s4 and, in fact, even earlier. Reports of menstrual and other problems in athletes were becoming prevalent in the literature as early as the 1960s, but particularly in the 1970s and 1980s.7–10 The first symposium related to the topic at the American College of Sports Medicine (ACSM) Annual Meeting was organised by Barbara Drinkwater in 1981 and was entitled ‘Menstrual Irregularities in Female Athletes’. The term ‘Female Athlete Triad’ was introduced at a workshop in 1992.4 The first position stand from the ACSM was published in 1997,2 and …

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