A wave of legislation marketed to improve conditions for women athletes conflates transgender participation with the enduring marginalization of women in sport. Ensuring supportive, not mutually exclusive, access to sports for students is critical for healthy adolescent development and well within the problem-solving capacity of our society. The 80+ trans-exclusionary bills proposed this year miss the mark, and will fail to advance fair sport.
I began running competitively as a freshman in high school. Right away, my father made a point to have a conversation with me about how he had seen members of his college swim team waste away and lose their potential to anorexia. I didn’t understand that he was warning me of a broader phenomenon, of how destructive the hyperfocus on body image in sports can be. Ten years later, I acknowledged my bulimia for the first time in an open letter about my experience with collegiate running. Dozens of my teammates and I had been coached to lose weight under the flawed yet widely circulated narrative that restrictive diets help preclude injury and enhance performance.
“The stories of abusive coaching and medical malpractice […] are part of a prominent issue in the world of women’s athletics.”
The prevalence of eating disorders that inevitably ensue from this advice is increasingly recognized to contribute to the high rate of athletic injuries among women. Still, multiple accounts across professional and collegiate teams have highlighted coaching practices that continue to push calorie restriction in response to injury or nonlinear performance progression. Professional runner Mary Cain catalyzed this conversation by sharing how her former Nike Oregon Project coach Alberto Salazar weaponized medical misinformation to undermine her athletic talent and commitment, driving her to patterns of self-harm that included an eating disorder. Though Cain was told by the medical and leadership team at Nike that calorie restriction would strengthen her performance, she suffered from multiple bone injuries, menstrual irregularities, anemia, and suicide ideation. Cain’s experience is known as Relative Energy Deficiency in Sport (RED-S) by medical professionals. In the athletic world, it is increasingly identified as abuse.
The stories of abusive coaching and medical malpractice that Cain and I relayed are part of a prominent issue in the world of women’s athletics. They were accompanied by numerous supporting accounts from our respective teammates, yet followed by a lack of accountability within our organizations. My coach was found to be free of wrongdoing in the painful yet unsurprising conclusion of a Title IX investigation, though he ultimately resigned after the team refused to continue training under him. What was shocking, however, was the replacement hire. My university chose Meredith Remigino, a high school coach and attorney that testified in support of a 2020 New Hampshire bill to ban transgender girls from school sports.
Little did we know that my university’s response foreshadowed a nation-wide trend to shift efforts from addressing systemic barriers to healthy, equitable sport for women to narrowing the definition of women that deserve protection. As laws that target tangible inequalities in women’s sports remain few and far between, over eighty bills have been introduced in 2021 with names such as the “Save Women’s Sports Act” or the “Promoting Equality of Athletic Opportunity Act”, claiming to even the playing field for girls by excluding transgender children from participating in school sports. Such regulations are unlikely to meaningfully improve conditions for girls in sport but will come at an enormous cost to the health of transgender children.
Understanding trans-exclusionary sports regulations
“The premise that student athletes would benefit from transgender-exclusionary practices is unsubstantiated, but the cost of exclusion is tangible.”
Policymakers are proposing the exclusion of transgender girls under the premise that they harbor an unfair advantage over other girls, but the severity of this solution is disproportionate to the degree to which transgender children alter the competitive field. Transgender students account for less than 2% of the youth population and are underrepresented in sports: likely a reflection of various psychosocial deterrents to participation, like feeling unsafe at school, body dissatisfaction, and existing exclusionary policies (i.e., to changing facilities). Advocates of trans-exclusionary policies assert that the transgender students who do choose to participate in school sports outcompete other girls, but the accompanying evidence is anecdotal as best. It is also important to keep in mind that despite the hyperfocus on testosterone as a determinant of athletic ability, biological variations are prevalent and often celebrated in athletics.
The premise that student athletes would benefit from transgender-exclusionary practices is unsubstantiated, but the cost of exclusion is tangible. The self-esteem, social skills, and exercise habits built from participating in school sports can improve long-term health outcomes and quality of life. The social connectivity and self-confidence promoted by extracurricular activities are especially critical for transgender children who suffer from elevated rates of depressive symptoms and suicide. Crucially, improved mental health outcomes are consistently reported for transgender youth with supportive families, freedom to socially transition, and access to gender-affirming care. For example, hormone-blocking treatment eases the mental distress that puberty-driven developments (i.e., the growth of breasts, facial hair, vocal cords, and hip positioning) can cause, and that may otherwise require profound surgical and medical measures to reverse.
Understanding gender-affirming care is critical context for understanding both the motivation and consequences of recent legislation concerning transgender youth. Of the thirty-five states that have introduced legislation to ban transgender participation in school sports, twenty-three have introduced legislation to ban medical affirmation for transgender youth. For example, Arkansas banned transgender sports participation from kindergarten through college with the “Fairness in Women’s Sports Act”, and quickly followed it with the “Save Adolescents from Experimentation Act” that criminalizes physicians who administer hormone-blocking treatment to transgender youth under the premise that it is understudied and therefore unsafe. This assertion is incorrect, however. Hormone-blockers have been safely administered for decades to treat hormone-sensitive cancers (e.g., prostate and breast cancers), common gynecological disorders (e.g., endometriosis), and women undergoing in vitro fertilization. Just as they have been rigorously assessed for these applications, hormone-blocking treatments have been proven safe for gender-affirming care.
Just one example of how to (really) improve conditions for women in sport
Policymakers introduce measures that threaten the healthy development of transgender youth while bypassing calls to dismantle harmful narratives that continue to damage girls sports. Measures like Title IX have meaningfully strengthened women’s access to sports, but the accompanying benefits falter without adequate education and emphasis on supporting adolescent health and development. Since young athletes may be hesitant to voice mistreatment or lack the vocabulary to identify abuse, the responsibility to foster evidence- and empathy- driven practices falls predominantly on those with administrative, leadership, and narrative power in the sports world. The underrepresentation of women across these positions facilitates medical neglect and misinformation that continues to damage the health and athletic potential of women, from primary school to professional careers.
“Coaches that dismiss the importance of reproductive function and fueling are ill-equipped to support the health of their athletes.”
This phenomenon is illustrated by RED-S, the components of which (menstrual dysregulation, disordered eating, low bone mineral density) are estimated to affect up to 60% of women in sport. Such symptoms are especially prevalent across women’s sports because they magnify two societal aspects that are especially damaging to women: 1) the normalization of body-shaming, and 2) the disregard for reproductive health as a critical component of overall health. Reproductive and metabolic hormones work together to regulate menstrual and bone health, and the production of these hormones can be disrupted by the combination of high volume training and deficient calorie intake. As a result, red blood cells – which are produced in the bone marrow – circulate oxygen less efficiently through the bloodstream to negatively impact endurance.
Coaches that dismiss the importance of reproductive function and fueling are ill-equipped to support the health of their athletes. And even coaches that do not prescribe weight loss, but shy away from understanding the prevalence of body dysmorphia in sports, can fail to prevent, identify, or encourage recovery from eating disorders amongst their athletes. For instance, 20% of surveyed Division I women athletes reported an eating disorder while 30% reported body dissatisfaction, yet in a separate survey, less than half of coaches agreed with the statement that eating disorders are a problem in athletics. It is important to note that the mortality rate of eating disorders is surpassed only by that of opioid addiction among mental illnesses. Are coaches that fail to seek out relevant education, or let personal biases override the available science, qualified to play such a large role in the life of students? How can athletes that, as a consequence, struggle with their mental and physiological health be expected to perform? Until representative and evidence-based practices become a cornerstone of organized sports, the full athletic potential of women will continue to be stymied.
Damaging narratives on reproductive health and nutrition influence young athletes as well. For girls in sports where leanness is exalted, developmental milestones like the initial onset of periods (menarche) have been reported to be accompanied by shame and even resistance. While competing in high school track & field, I saw how desperation to maintain a “lighter and faster” pre-pubescent body can catalyze eating disorders and even delay menarche. This approach can force an early peak in performance, but is impossible to sustain. The same girls that I saw overtrained and under-fueled as freshman were the same ones that I saw quit running by senior year. More broadly, only one of the last 40 national champions of girls high school cross country has gone on to qualify for the Olympics. Are these patterns a reflection of these athletes’ talent or commitment? Whose responsibility is it to defend the longterm health and potential of student athletes?
The path forward is clear
There are opportunities to improve conditions for girls in sports. Addressing gaps in education and oversight would combat the prevalence of misinformation and abusive tactics. Increasing the representation of women in leadership positions and media coverage will reduce social stigma and the rate at which girls quit sports. Instead, recent legislative efforts focus on excluding instead of empowering women athletes.
Who stands to benefit from recent pushes for trans-exclusionary policy? Portraying women as the beneficiary of these regulations is an effective tactic because women are so evidently disadvantaged in sport. This comparative disadvantage is shaped by the historical and institutional marginalization of female athletes, not the composition of the competitive field. If policymakers want to protect women in sports, the path forward is clear: promote, pay, and showcase us equitably. Address the prevalence of abuse. Celebrate and support our development. And most importantly: stop using women as a smokescreen to marginalize other women.
Written by Yuki Hebner.
Edited by Holly Hake and Melis Cakar.
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