Female bodies have long been seen as vessels through which a child is carried to term. Due to this fact, prior to the 1970s, individuals with female reproductive systems were excluded from clinical research. In fact, in 1977 the United States Food and Drug Administration (USFDA) recommended that women be purposefully excluded from clinical trials, to protect the children they were potentially bearing (1). The recommendation extended beyond hopeful mothers and encompassed those who were not hoping to conceive, those who did not have sex with someone capable of impregnating them, and those who could not get pregnant. It wasn’t until 10 years later that the downfalls of excluding close to half the population had come to light. Following a 1985 report on the potential limitations of excluding women from research, the National Institute of Health (NIH) encouraged researchers to include women as study participants (1). Although the performative attempt by the NIH to include women seemed good enough, a 1990 investigation by the General Accounting Office (GAO) uncovered how ineffective the policy truly was. The GAO established that the policy was not well communicated, nor understood by researchers; the enforcement in grant reviews were inconsistent; the policy only applied to research outside of the scientist’s primary focus; and that implementation was relatively weak (2). It wasn’t until 3 years after the release of this report that the inclusion of female participants in clinical research became law. Although it is now required that those assigned female at birth take part in clinical research, women still only represent little more than 40% of clinical participants (3).
Although the inclusion of participants in clinical settings is far from acceptable, research on the same population in sports is abysmal. Only 6% of participants in sports science research are women (4). Despite the fact that female participation in sports has increased close to 900% since the passage of Title IX, the US law mandating equal opportunity for women in sport, little progress has been made on understanding their specific physiology (4). In fact, Ellen Casey, MD, CAQSM, FACSM, the co-director of the Penn Center for Female Athletes, noted how difficult the lack of knowledge has made training for athletes and coaches. In a 2017 article, Casey was quoted saying “Female athletes are already discussing the impact of periods on performance with their teammates, coaches, [and] trainers. Unfortunately, there is not enough research in this area, which means there are lots of questions and not enough answers” (5). This results in coaches and athletes making decisions regarding training that are largely based on recommendations designed on men.
Given the business-sided nature of research, it is no surprise that academics would choose not to include females as part of their studies. First and foremost, women researchers are likely to receive less funding for their studies than men. In fact, in 2019 The New York Times reported that when men are listed on grant applications, funding increases by close to $40,000 (6). Additionally, less than 30% of the global scientists are women (7). Because most research questions stem from personal interest, men are likely to research problems surrounding men, and women are likely to research questions concerning women. Therefore, the underfunding and underrepresentation of women in research leads to less focus on the progression of knowledge surrounding female health.
Aside from the lack of interest in the topic, the sheer complexity of female physiology has driven many researchers away from female health. Fluctuations in hormones create physiologic differences relating to temperature, metabolism, fatigue, recovery, hydration, etc. that are inconsistent throughout the month. Not only do these introduce a myriad of confounding variables that need to be carefully controlled, but they can clutter the data and make it more costly to analyze, both with regard to time and money. As such, many researchers have opted to simply treat women as if they are just smaller versions of their easier-to-study participants (aka men). However, as noted earlier, this creates a large knowledge gap as to how to navigate the countless physiologic variables that differentiate those assigned male at birth to those assigned female at birth.
Lastly, individuals with female reproductive organs are less likely to participate in sport as compared to their male counterparts. In 2019, sport participation for men was close to 7% higher than that for women, with the largest gap falling on children between the ages of 10-14 (8). The Women’s Sport Foundation reports that by age 14 girls are 2-times more likely to drop out of sports as compared to boys (9). Although the stigma surrounding the masculinity of sports scares many girls away, some additional cited reasons for this discrepancy include lack of access and lack of quality facilities and equipment. For high school activities alone, girls have 1.3 million fewer opportunities than boys to participate. When they are able to compete, they are often faced with less quality equipment, less funding for uniforms, and often come second to boys teams in terms of practice field scheduling and coaching focus (9). Given these unfortunate facts, sports scientists are less likely to invest their time, money, and brainpower into investigating female athletes.
Aside from the laboratory-based findings that have continually left women behind, sports science devices are often designed by and for men. A simple Google search of “Wearable Tracking Watches for Women” will result in a variety of well-known companies marketing their devices, just prettier and smaller, along with fertility tracking watches. While fertility tracking is undoubtedly important for couples trying to conceive, it’s hard to comprehend that it is the only device designed by and for women.
Many male-dominated companies have made attempts to include women in their devices through new menstrual tracking programs; however, little has been done to account for unique physiologic differences otherwise. Recovery scores that are so common among health tracking devices often consider heart rate, heart rate variability (HRV), respiratory rate, sleep quality, temperature, and pulse oximeter data (SpO2) (10). Cyclical fluctuations in hormones, as is seen in females, such as estrogen and progesterone, lead to changes in several of these variables. For example, heart rate variability (HRV) lowers during the luteal phase, showing more sympathetic activity (11). Additional differences in HRV have been established. For example, females have shown to have a significantly lower HRV than male counterparts, despite increased vagal input (12). Additionally, progesterone has been shown to increase core temperature by up to 0.7°C, while estrogen has temperature-lowering effects (13). Lastly, PMS-related symptoms, including menstrual cramping, often limit quality sleep in individuals. Additionally, the duration of time spent in stage 2 and REM sleep seem to change throughout the Luteal and Follicular phases (14). Such fluctuations in commonly relied-on biometrics should be taken into consideration when designing wearable tech, yet it appears as though they are left out of the algorithms.
In addition to the lack of inclusion of female physiology into many sports’ specific devices, female tracking apps often subscribe to patriarchal tropes. In the app store, fertility and period tracking apps are grouped together. Synonymizing female and fertility health suggests that women should be vigilant about their health for the sake of their fetus, not for themselves. In fact, a 2016 investigation into 20 accurate, free apps available in the Apple store found that 80% mentioned conception, and 50% mentioned contraception (15). Aside from placing female health solely on the premise of conceiving a child, focusing on pregnancy assumes that women are having sex, let alone having sex with the intent or capability of conceiving a child. Thus, period tracking apps often alienate transgender men, queer individuals, and sterile and/or women uninterested in having children.
It cannot be denied that many individuals may well use period tracking apps in hopes of conceiving a child. However, despite the apparent central design of such apps being pregnancy, many do not know how to respond once that goal is met. For example, despite the fact that someone is quite literally growing new life, some apps continually pester users about lack of exercise and poor sleep. Such notifications have reportedly made subscribers feel judged or guilty for not continuing on with life as usual, according to a 2019 ABC Science article (16). Regardless, there are few guidelines regarding exercise programming during pregnancy. Traditional recommendations suggest low intensity, low impact exercises, such as walking or water aerobics. However, little research has been done surrounding the pregnant athlete; i.e., someone who participates in more high-intensity training (17). Therefore, active mothers-to-be are left questioning whether they can continue with their training as usual, or whether to detrain for the sake of their fetus.
Aside from the central focus on conception of a child, such tracking apps are often flooded with societal messages regarding the frailness of women. However, prior to delving into such a discussion, it is important to note that these images of female health often stem from the male designers behind such companies. Though the femtech industry is rapidly growing, less than 10% of funding is provided to female founders (18). As such, women are often left using apps that are designed from a male perspective. Often using pink hues and full of flowers, such designs leave the impression that a period is not so much of a clinical signal, as it is a cute monthly activity. Additionally, many apps track mood as an imperative symptom of one’s period, sometimes allowing partners to be alerted when PMS is nearby. While emotional state is hardly an insignificant side effect of pre-menstruation, it seems clinically irrelevant to alert others that you may be more vulnerable than usual. In a 2014 Atlantic article, Heather Rivers, creator of Monthly Info, jokingly impersonated the designers of such apps saying, “we men don’t like to be blindsided by your hormonal impulses, so we need to track you” (19).
Though there seems to be an endless number of apps targeted at menstrual tracking, there are relatively few that are designed for the female athlete specifically. A simple search for “female athlete” in the app store returns four results: one for tracking recovery and performance (Wild AI), and three miscellaneous ones (volleyball stickers, encouraging youth participation in sport, and a fitness program). Broadening the search to include “female fitness” returns endless programs for women focused on achieving a certain bodily aesthetic. Though the lack of performance-driven apps is discouraging, the view of fitness for women as a purely extracurricular activity is unsurprising. Female athletes have repeatedly been undervalued and overlooked. For example, despite continually outperforming their male counterparts, the US Women’s National Soccer Team did not receive equal pay until earlier this year. Additionally, despite indications that women may outperform men in ultra-endurance events, other women’s sports are often shortened. For example, in tennis men play to the best of 5 sets, while women play best of 3. Though it is often thought that female athletes are in need of modifications because of their frailty, the female body has proven otherwise. Increased reliance on fat oxidation, an increased number of fatigue-resistant muscle fibers, and enhanced neuromuscular activity contraindicates the need for the adapted duration, intensity, and/or volume of exercise for female athletes (20). Further, men’s sports are frequently given better media coverage on better platforms, leaving women’s sports to poor time slots on less-visited channels. Additionally, these athletes' narratives continue to be centered around their femininity. An article published in 2008 in the Western Journal of Communication analyzed the socially constructed view of the female athlete. The article noted that in order to be granted access to the athlete realm, women must conduct themselves with some sort of masculinity (21). Further, identifying as both a woman and an athlete is constructed as mutually exclusive. The article further discussed how such societally accepted views of female athletes are often intertwined with athlete identities of themselves. Therefore, it is unsurprising that apps targeted at women who participate in sport are more common than those that view the woman as an athlete themselves.
Though it has been nearly 50 years since the passage of Title IX, encouraging equal participation in sport, the female athlete has been continually excluded when understanding sport. From a lack of inclusion in sports-related research to the continued frail construct of the female athlete, those assigned female at birth are continually downplayed as powerful beings. The solution to such a disproportionate knowledge base in female sport is multifaceted. Societal constructs need to view women as more than their gender, tracking devices need to account for physiologic differences that need to be backed by female-specific research, and the menstrual cycle needs to be viewed as more than a monthly inconvenience. Athletes that are assigned female at birth are amazing beings capable of much more than bearing a child, it’s time the world view them that way.
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