Family planning, motherhood and caring responsibilities

Women athletes can face a compounding effect of physical and psychological stress relating to their fertility and family planning decision-making, particularly as it has been shown that women athletes end their career more often due to family-related reasons than men athletes.29

The desire to have children while still wanting to succeed in their sporting career can be a source of significant stress.30 Concerns about not wanting to ‘let the team down’ by taking time away to have a baby, decisions regarding freezing eggs, issues associated with irregular menstrual cycles, as well as fertility drugs and World Anti-Doping Agency compliance, represent a collective psychosocial stress for a growing number of women athletes that can impact their mental health as well as their fertility.30

Despite improvements being made towards gender equity in the workforce, women still undertake the majority of caring responsibilities for children. Combining motherhood and an elite sporting career is another potential stressor that women athletes may experience. There has been a near-total absence of research regarding the physiological, psychological and social aspects of athletes' postpartum return to sport.31 Some research shows however that the social expectations of motherhood can impede the re-entry of women elite athletes into their sport after having children, with many having to balance and juggle expectations of motherhood with training and competing.32 Some have compared the re-entry process after childbirth to the re-entry after an injury, with both requiring a high level of ‘mental strength’.33 Women athletes can also experience guilt when they return to sport after having children.34

There remains a level of conflict in the literature, however, with studies suggesting that an athletic identity may be incompatible with motherhood, and often results in women athletes’ withdrawal from sport.34 Others have reported that becoming a mother improved well-being as the athletes had something to find worth in beyond their athletic identity or that motherhood helped to expand and re-define their athletic identity.33

Violence against women in sport

Violence against women is common in sport. Studies show that athletes belonging to any minority (in terms of gender, ethnicity, sexuality or disability), as well as those athletes at higher levels of competition, experience greater incidence of violence in sport.22 35 36 Violence can be perpetuated by the athletes themselves (self-harming behaviours); by other people, such as those in positions of authority (eg, coaches), peers, fans and spectators (interpersonal violence, discussed below); or violence can arise from the ‘socioorganisational context of certain sport environments’ (page 228) (institutional violence, discussed below).35

Women athletes with certain profiles may also be at a higher risk, including those with low-self-esteem, eating disorders, and/or an extreme dependence on a coach.22 35 While research into violence in sport remains in its infancy, early studies suggest similar trends in sport to those seen in other institutions (organisational, family units, etc), namely that women experience higher instances of violence relative to their men counterparts.22 While gender is a risk factor for experiencing violence in sport, there are trends in the prevalence of the type of violence experienced by each gender, with boys experiencing more physical violence and girls experiencing more sexual violence.36

Sexual harassment and exploitation

It is not uncommon that women athletes experience sexual harassment and exploitation.37 Cumulatively, the prevalence rates of sexual violence in sport fall somewhere between 1% and 64%.38 However, most studies have used purposeful samples of athletes from specific clubs, rather than the less powerful representative samples. One study using a representative sample of adults from Belgium and Netherlands who had previously participated in sport, indicated that 44% had experienced some form of violence in sport and 14% had specifically experienced sexual abuse. Sexual violence rates were higher in women.36 Other studies from individual countries have shown similar trends. Research with elite Swedish athletes revealed higher proportion of women experiencing sexual abuse in sport (16%) compared with men (4%).39

The mental health impacts of sexual violence, particularly when experienced as a child, are profound. Sexual harassment and abuse are well documented to result in serious and often ongoing mental disorders including clinical depression, post-traumatic stress disorder, obsessive–compulsive behaviours or disorder,40 eating disorders and higher rates of suicidal ideation, suicide attempts and completed suicides.41 Currently, there is not enough being done to protect women athletes from sexual violence. A recent socioecological review study found a lack of multilevel prevention practices within sport, including sexual violence prevention practices to protect children, and minimal programming aimed at preventing perpetration, and noted the need for policy level action, as well as the need for sport organisations to prioritise sexual violence prevention in collaboration with national organisations.42

Cyber abuse against individual athletes

Cyber abuse against individual athletes is not uncommon among women athletes. Iterations of violence can also be perpetuated through the internet. In cyber abuse, comments are written by people directly to athletes on their social media platforms or similar. Cyber abuse (harassment and bullying) has proliferated most prominently at the time when mobile phones were readily connected to the Internet.43 Despite many studies demonstrating the extensive impacts of cyber bullying and harassment on mental health in children and non-athletes, there has been little research into the prevalence of cyber harassment and abuse specifically in sport.44 One prevalent form of cyber abuse towards women athletes is the sexualisation of their bodies. A recent analysis of social media commentary found that more than a quarter of all Facebook posts directed towards sportswomen were sexist (20%), blatantly sexualised women athletes (14%), were belittling of women’s sports (20%), or were otherwise negative in nature with women athletes experiencing three times as many negative comments compared with men athletes (27% vs 9%).45 A notable recent example of the sexualisation of women athletes’ bodies is demonstrated by the derogatory and sexualised comments received by Australian Football League Women’s star, Tayla Harris, following the publication of a photograph of her kicking a football during a game. Harris told RSN radio, ‘The comments I saw were sexual abuse, if you can call it that, because it was repulsive and it made me uncomfortable.’ ‘That is what I would consider sexual abuse on social media.’46 While there are no data available regarding the wider impact of online harassment on mental health outcomes among women athletes, athletes such as Tayla Harris did report that the harassment resulted in fears about safety.46

Overall, the resulting litany of mental health impacts from violence, coupled with the fact that elite and semielite women athletes are more at risk of violence, suggests that there is a need for a greater understanding of the psychosocial stressors associated with instances of violence as well as the development of interventions to address the issue directly.

Family planning, motherhood and caring responsibilities

Family planning, motherhood and caring responsibilities can impact the mental health of women athletes. There is limited family support available for women elite and semielite athletes.33 A recent study of analysis of interviews with 27 UK sportswomen reports that women athletes delay life plans due to a lack of financial well-being and do not feel supported to have children by their club or sports body.47 Women athletes with childcare responsibilities from the National Rugby League Women’s Premiership (Australia and New Zealand) report that they face distinct barriers and organisational policies are yet to account for the distinct needs of this cohort.48 Currently, there is a lack of structured support for elite pregnant athletes in terms of governmental funding/corporate sponsorship, resulting in uncertainty surrounding pregnancy.49 Some sports such as netball and rugby now have pregnancy policies which give players employment certainty throughout pregnancy, as well as a guaranteed opportunity to claim back their spots and some financial support for tours or training. Cricket Australia guarantees a paid carer until the child is 4 years old,31 however, initiatives such as these to support women athletes in managing motherhood and a sporting career are lacking in many sports, and constitute another gender-specific stressor experienced by women elite and semielite athletes. Indeed, recent work has identified the critical importance of organisational culture in women athletes’ experience of motherhood in sport. Athletes have identified a need for role models who became pregnant and returned to elite sport, supportive networks including teammates and coaches. In the absence of a supportive organisational culture, women athletes report worry about disclosing pregnancy due to fear of being viewed as not dedicated to their sport, and therefore, delay disclosing this information until late in pregnancy. In contrast, this work reported that organisations with clear policies and regulations about the financial support for women athletes including eligibility requirements enabled athletes to make informed family planning decisions.50

Disparity of wages

Research shows that in non-athletes, when women earn a lower income compared with their men counterparts, the odds of experiencing depression are 2.43 times higher, and the odds of experiencing anxiety are four times higher than men. Conversely, women earning equivalent or higher incomes compared with their men counterparts report much lower anxiety, even among higher income earners.51 This demonstrates that pay disparity contributes to the onset of mental health problems, however, this is yet to be explored in athletes specifically. Women athletes consistently receive lower wages compared with men athletes. Even in tennis, where the prize money is equal in prestigious tournaments such as Grand Slam events, annual prize money for the top earners in the Women’s Tennis Association is roughly 80 cents to the dollar top male earners in the Association of Tennis Professionals.52 At the FIFA (Fédération Internationale de Football Association) Women’s World Cup in 2019, 24 nations competed for 7.5% of the total prize money awarded at the men’s 2018 World Cup in Russia.53 During the Women’s 2019 World Cup, it was reported that the Australian national women soccer team, the Matildas, would receive $A1 million for reaching the knockout stages and $A4 million if they won the whole tournament. This is in stark contrast to the Australian national men’s soccer team, the Socceroos, who received $A8 million for reaching the knockout stages of their 2018 World Cup.53 Data from women athletes from the National Rugby League Women’s Premiership (Australia and New Zealand) shows that the introduction of player payments is accompanied by increased expectations of the employing clubs however athletes report that the level of remuneration is insufficient to cover training, travel, playing and community commitments.48 A recent analysis of interviews with 27 UK sportswomen reports that women athletes face unique financial challenges resulting from sport practices which limit participation and representation and that financial well-being impacted overall well-being, particularly among women playing team sports.47 This gender disparity in financial security is a global issue that has recently seen a number of Professional Players Associations lobby international sporting federations, such as FIFA, for equal pay. In late 2019, Football Australia forged a landmark deal to close the pay gap between the Matildas and the Socceroos.54 In the USA, the national women’s soccer team sued and recently settled with the country’s soccer federation overpay equity and working conditions, filing a gender discrimination lawsuit to address gender disparities in pay, training and travel conditions, medical treatments and coaching received.55 In acknowledgement of widespread disparity in wages between women and men athletes, Australian sporting chief executives of leading sports organisations have released a plan to advance equal pay for elite women athletes.56

Women in sport leadership roles

The relationship between a lack of representative leadership and mental health in women athletes has not been well explored. It would be useful for future research to explore if the systematic barriers in career opportunities for women in sport influence the mental health and well-being of women athletes. Notwithstanding the growing number of women and girls participating in sport, women continue to be underrepresented in sport leadership positions.57 A recent narrative review reports that women continue to be under-represented in leadership positions in sport across the world.58 Even where gender equity policies do exist, tangible actions to pursue or create gender equity are more limited.58 In a recent study assessing gender equality in 56 Canadian universities from 2010 to 2017, gender inequality was found in both employment in leadership positions and the opportunity for women athletes to participate as an athlete, resulting from a lack of implementation of gender equity policies.59

In Canada, only 9 of the 54 national teams have women head coaches (16%); and at the 2016 Olympic Games there were only 6% women coaches, down from 19% at the London 2012 Olympics.60 Likewise, the Australian national team at the 2016 Olympics was represented by 9% women coaches, down from 12% at the 2012 Olympic Games.61

In addition to coaching, the organisational demography of leadership positions within national Olympic governing bodies is also highly skewed to male leaders.57 While there is limited research on the impediments to women athletes assuming leadership roles in sport, global business giants such as Ernst & Young have recognised the unique potential of elite women athletes to become exceptional leaders after retirement from playing competitive sport.62 Sporting organisations such as the Australian Institute of Sport have recently launched intensive leadership development programmes to further address the under-representation of women in sport leadership positions.61 These programmes shine a light on systemic imbalances, promote new pathway opportunities into sport leadership and have the potential to create valuable new role models. In turn, this may have a positive impact on the mental health and well-being of women athletes.

Sex verification

Women are routinely subjected to sex verification testing in sport, which is not conducted on athletes competing in the men’s category. Between 1968 and 1999, the IOC required all women competing in the Olympic games to undergo genetic testing as part of its sex verification policy, under the assumption that there was a need to prevent men from impersonating women and competing in women-only events.63 In 2011, the IOC adopted a new policy on female hyperandrogenism, which established an upper hormonal limit of testosterone for athletes eligible to compete in women sporting events63 However, a study of postcompetition hormonal levels between men and women elite athletes showed considerable overlap between the sexes, and that 16.5% of men athletes had low testosterone levels, whereas 13.7% of women athletes had high levels,64 indicating no clear separation between the testosterone levels of men and women elite athletes.64 Since this time, excluding women athletes on the basis of a serum testosterone levels has been considered unethical and ceased to occur during the 2016 Rio Olympics.65 Presently, the IOC and the International Association of Athletics Federations have set upper limits on acceptable testosterone levels for women to compete, which some authors have argued is based on flawed scientific foundation, which is a complex issue and beyond the scope of the current review, for further information on the scientific debate, see Roger et al.1 The recently released ‘IOC Framework on Fairness, Inclusion and Non-discrimination on the Basis of Gender Identify and Sex Variations,’ states that where sports organisations choose to establish eligibility criteria in order to determine the participation conditions for men’s and women’s categories for specific contests in high-level organised sports competitions, that the criteria should be established and applied in a manner that respects the principles included in the Framework. These principles are inclusion, prevention of harm, non-discrimination, fairness, no presumption of advantage, primacy of health and bodily autonomy (which states that Athletes should never be pressured by an International Federation, sports organisation, or any other party to undergo medically unnecessary procedures or treatment to meet eligibility criteria).66

Research that has addressed sex testing from regulatory67 and sociological68 standpoints has highlighted the potential impact on athletes undergoing the testing or who are under suspicion of having high testosterone. Bekker and Kolanyane-Kesupile and Bekker and Posbergh highlight that sports organisational policy can be a mechanism for unintentional and intentional organisational violence that leads to poor mental health outcomes for athletes.69 70 These authors state that requiring women to unnecessarily take medications to lower their testosterone levels is problematic from an ethical and medical standpoint and if a form of institutional violence and systemic discrimination.70

A recent Human Rights Watch report states that human rights violations related to sex verification in sport have taken place under the veneer of evidence-based policies of sport governing bodies, and these include violations of athlete privacy and dignity and coercion to undergo medical interventions. This report notes that the practices have significant mental health impacts on women athletes, including suicide attempts, feelings of shame, self-questioning, shame and withdrawal from sport.71

Media coverage

The impact of the general portrayal of women in sport in mainstream media on the mental health of women athletes is undetermined and a valuable area for future research. What is known is that media and tpublic relations are crucial elements that shape public knowledge about, and understanding of, sports and athletes. Those who write about sports are often those who shape public opinion about important issues in sport. A wide body of research demonstrates that mass media coverage of women in sport is greatly underrepresented.23–26 A recent systematic review of the coverage of women sport at the Olympic Games showed a lack of fairness in the amount of media coverage women’s sports received, coupled with gender differentiation in the representation of women’s sport.72 In fact, coverage for women in sport in the USA has declined over the last 30 years, in 2010 less than 5% of all broadcast sport media pertained to women athletes.73 Similarly in Australia, coverage of men playing sport comprises 81% of television (TV) sports news coverage, compared with women playing sport at 8.7%, this percentage was a decline from a decade earlier of 11%.74 More recently in Australia, however, overcoming barriers to engagement of women playing sport has become a priority. A free-to-air broadcasting strategy was developed and executed as public survey shows that 48% of people acknowledged they would watch more women playing sport if it was accessible on free-to-air TV or free online.75 In North America, the total sport media coverage of women playing sport is 2%,76 despite women making up 40% of all sport participants.77 Furthermore, women athletes who participate in sports considered to be ‘feminine-appropriate,’ such as gymnastics, figure skating and tennis generally receive more media coverage than women athletes participating in traditionally ‘masculine’ team sports, such as ice hockey or rugby.25 78 There is however some research indicating a shift in coverage of women playing sport. One recent study reports that the 2015 FIFA Women’s World Cup received a significant amount of English newspaper coverage that was largely positive, which may indicate moving towards a new age of media coverage of women playing sport in the UK towards greater gender equality.79

When women athletes do receive media coverage, this can often be ambivalent coverage, of which the impact on mental health outcomes among women athletes is currently unknown. Ambivalent coverage is that which diminishes the sporting achievements of athletes by shifting focus away from their athletic success by pairing positive statements with statements focusing on faults or aspects unrelated to sport that undermine athleticism.80 It is a well-documented sport media pattern which marginalises and trivialises women athletes.80 81 An analysis of articles published by ESPN.com and ESPNW.com found that 59% of articles published about women athletes were ambivalently framed, while only 11% of articles published about men athletes were ambivalently framed.82 A recent example is the tennis player Eugenie Bouchard being asked to ‘twirl’ (to spin around in a circle) on court in 2015 by the male presenter conducting her on-court interview at the Australian Open.83 These are overt examples of redirection away from the athlete’s performance and, in this particular example, also an example of sexualisation of the athlete’s physique and femininity, entirely unrelated to the sport (a form of violence). The impact of ambivalent coverage on mental health outcomes among women athletes has not been studied, however, it is reasonable to propose that published diminishment of sporting achievements is likely to result in psychological distress for women athletes.

Sexualisation in the mainstream media

When women are represented in sport, how the media chooses to portray athletes can have a profound effect on the collective response to them. For example, images which focus on depicting women athletes’ athletic intensity and performance can legitimise them as role models for adolescent girls.84 However, a plethora of research shows that women are more often portrayed in a sexualised manner by the media, with reports focusing on their physical characteristics, questioning their femininity, or even blatantly depicting them as sex objects.23 78

Findings consistently indicate that although sexualised women athletes are often rated as more attractive, desirable or sexual, they are also seen as less capable, as having less athletic ability, having lower intelligence and as having less self-respect than non-sexualised women athletes.85 The sexualised portrayal of women athletes can have substantial social and economic outcomes in terms of the general acceptance of women athletes in society and their marketability as elite athletes.86

On a society level, after viewing sexualised images of women athletes, girls, women and men make objectified appraisals of the athletes and themselves, as well a critique of women’s status in society.84 In general, just the viewing of sexualised images results in higher levels of body dissatisfaction, greater self-objectification, greater support of sexist beliefs and of adversarial sexual beliefs, and greater tolerance of sexual violence towards women.87 Thus, the sexualisation of women athletes can harm not only the athletes themselves but also have wide reaching detrimental effects within the community. As such, the sexualised portrayal of women in the media can be conceptualised as a form of institutional violence, as it provides a culture in which sexualisation of women’s bodies is normalised and provides an environment in which sexual abuse can also be normalised.