Sports Psychiatry. Women’s mental health in elite sports – we are missing the complexity

Heuss Sabina^1*, Schneeberger Andres Ricardo^2,3*, Claussen Malte Christian^2,4,5
1 Institute for Competitiveness and Communication, School of Business, FHNW University of Applied Sciences and Arts North­western Switzerland, Olten, Switzerland
² Psychiatric Services Grisons, Chur, Switzerland
³ Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences, Bronx, USA
⁴ Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Zurich, Switzerland
⁵ Private Clinic Wyss AG, Münchenbuchsee, Switzerland

* Shared autorship

In competitive sports, mental health and well-being is of great significance [1]. This applies to the active phase, as well as the time after the career. Mental disorders are common in competitive sports [2]. Physical and psychological well-being and performance in sports relate to each other [2]: Emotional strains and illnesses in sport may have an influence on the performance, may increase the risk for injuries and may lengthen rehabilitation. Injuries have an influence on the performance, too, and are strains and risks for mental health. The requirements in elite sports call for a safe and sound judgement and handling with strains and risks for mental health, as well as in diagnosis and treatment on illness [1].
General and sport specific factors together may increase the risk of mental health symptoms and disorders in competitive sports [2]. Female and male athletes have a greater overall risk of eating disorders compared with their non-athletic counterparts [2]. Trauma-related mental health disorders are also common in competitive sports [2]. Harassment and abuse (non-accidental violence) are in addition to specific mental health issues important problems in competitive sports and risks for mental health.
Sports medicine has focused mainly on the interactions of female physiology and elite sports. While for example, the female athlete triad, also referred to as relative energy deficiency syndrome RED-S, a medical condition observed in physically active females involving three components: 1) low energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone density [3], has been extensively examined, other specific aspects of female health in elite sports have been neglected. Moreover, the extend of the neglect far exceeds the purely medical approach of female athletes. Women compared to men in elite sports experience varied disadvantages not limited to their health. In order to analyze female health and specifically female mental health we need to include other aspects and obstacles women encounter in the sports world. Female athletes are often victims of stereotyping in the sports industry, not only being exposed to excessive sexism, discrimination, and disrespect toward female athletes, but also suffering from structural and financial inequalities such as a lack of airtime on television [4]. These disparities set the stage for distal and proximal stress affecting women and elite sports and impacting their health. While some research addresses specific aspects of mental health issues related to women, often focusing on eating disorders [2], there continues to be a lack of studies addressing the complex interactions of culture, gender and stress.
While women are not a numeric minority within the human race, they are a minority based on power differential in a male dominated (sports) world. The current media attention on sexual abuse in different industries has brought this discrimination to light and underscores the fact that women are subjected to complex stress phenomena. In addition, women in elite sports often combine different minority statuses, being from diverse ethnic, racial and cultural background and having diverse sexual orientations and gender identities.
Sex and gender in medicine have notably increased as a research and publication topic and have contributed to the improvement and safety of patient treatment [5,6]. Unfortunately, this development is not to be found in the sport psychiatry research. As has been described in the introduction of this article, athletes have a prevalence of mental health disorders. Therefore, psychiatry needs to play a role in prevention, detection and treatment of mental health disorders of athletes. Again, sex and gender must be included in the evaluation as divergent factors.
In addition to the physical differences between male and female athletes that will result in different psychiatric considerations, the cultural background of female background must also be respected. Women in sport have a strong cultural and political implication. Role and gender expectation regarding sport are equally formative as race and social class expectations and form the context by which women will be measured and assessed in a society [7].
The work surrounding is of great significance for the mental and physical well-being of athletes and has a significant influence on their performance. Problems and obstacles of women in competitive sports are also, if not mainly a structural problem. While almost two third of female athletes are confident they can take on a leading position in sports, only 50% of male interviewees think that women are up to the job [8]. The study states, that women must first prove themselves before they are recognised, women are not respected equally by their environment as men and in many sports clubs in which men hold a leading position, this position is often only passed on to men. This leads to the fact that the majority of female athlete are managed by men in sports clubs and structures led by men [8].
This paper’s goal was to draw attention on the difficulties of women in competitive sport. First, gender medicine (and in this case gender psychiatry) needs to be applied when discussing issues concerning competitive sports and women. Second, the societal impact on women in competitive sports and the cultural perception of women in sports need to be considered when studying mental well-being of women in sports. Thirdly, it is crucial to include structural settings of sports in the analysis of mental well-being of women in competitive sports.

Corresponding author

Dr. Sabina Heuss
Institute for Competitiveness and
Communication, School of Business,
FHNW University of Applied
Sciences and Arts Northwestern
Switzerland, Olten, Switzerland
sabina.heuss@fhnw.ch

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