BJSM E-edition: #SportsEquity

Dear Readers, This e-edition is concerned with (in)equities in sport. In contrast to equality (giving everyone the same), equity recognises that not everyone began at the same place in society, that the playing field was never level, and that social power imbalances influence different groups’ lived experiences. Some people are born into and face adverse conditions and circumstances, making it more challenging--despite greater effort--to match others’ achievements. Equity advocates for the historically disadvantaged. For equity, what is ‘fair’ is not a question of receiving the same, but considers contextual factors (paraphrased from the Ross Initiative in Sports for Equality), as well as each person’s unique needs (summarised by the Robert Wood Johnson Foundation). Power imbalance is at the heart of all forms of inequity. Inequities in sport include systemic discrimination against marginalised groups, which can foster unethical behaviors such as abuse and harassment. In this issue, we have chosen to present five up-to-the-minute topics actively being debated in sports and exercise medicine circles--but we recognise that there are more (e.g., ageism, etc.). These five topics commonly affect girls and women, those who identify as LGBTQ+, Black, Indigenous, and people of colour, those with physical, developmental or intellectual disabilities, and those at the intersection of more than one of these identities: 1. Interpersonal violence 2. Racism 3. Ableism 4. Sexism 5. Heterosexism and Transphobia

By design, sport, exercise, recreation, and play draw everyone in. Sport allows those on society’s margins to participate equally, build community, and find their strength. It challenges us to engage each other with dignity, honesty, and respect, and it inspires us to try (and to try again) to achieve our highest standards of behaviour and performance. This past year, through the pandemic and during the simultaneous global racial reckoning, athletes, sports teams, and leagues around the world used their platforms to stand up (or kneel) and speak out for equity. There may be no clearer example of how those in sport, regardless of background, identity, and ability, can model social justice advocacy. This e-edition of BJSM continues that trend. By actively seeking out resources that address imbalances and build equity, this and similar work will ultimately liberate global sport to do what it was designed to do: spark joy. Sincerely, Yetsa A. Tuakli-Wosornu, Phathokuhle C. Zondi, Gail Knudson, Yuka Tsukahara, Dikaia Chatziefstathiou, Sean Tweedy, Jane Thornton

Derived from the 15^th century English word ‘disport’ (previously, French ‘desport’), “sport” literally means pleasant pastime. But sport is not always pleasant, nor is it always safe. Interpersonal violence (i.e., abuse, or non-accidental violence), including neglect, and psychological, physical, and sexual harassment and abuse is a disturbing reality for many athletes at all levels. What is worse, many in sport are unaware of, or do not understand athlete abuse. A recent BJSM infographic aims to summarise the issue, and points to some of the current evidence base (Tuakli-Wosornu 2021), while a BBC podcast explores the harrowing experience of English athletes. Kev Murphy of the NWG Exploitation Response Unit summarises related multi-media resources in a blog post. Tuakli-Wosornu YA. Infographic. A guide to understanding athlete abuse. Br J Sports Med. 2021 Jun 18:bjsports-2021-104194. doi: 10.1136/bjsports-2021-104194. Epub ahead of print. PMID: 34144949

A recent Human Rights Watch report highlighted the troubling reality that in some societies, abuse is so culturally ingrained, that parents, coaches, clinicians, teammates, and others consider it a normal and even beneficial part of physical education training. The sweeping report illustrates that physical violence and abuse is an accepted coaching technique with a “long tradition…, often seen as essential to achieving excellence in competition and in personal character.”

Victoria Roberts et al. make similar points: the power, money, and prestige-driven culture of many sport settings (especially elite), which can combine with formal and informal societal norms, is a strong organisational driver of abuse in sport. In her comprehensive 2020 review, she and her colleagues elegantly describe a range of additional antecedent conditions and motivational factors for abuse in sport. Roberts V, Sojo V, Grant F. Organisational factors and non-accidental violence in sport: A systematic review. Sport Management Review. 2020;23(1):8-27.

Girls and women, who are routinely discriminated against in sports generally (see Sexism heading below), are at greater risk. Elite, child, disabled, sexual and gender minority, and racialised athletes also have increased risk, as reviewed by Yetsa Tuakli-Wosornu and team in 2020. Athletes can be made even more susceptible to interpersonal violence by their ambiguous relationship to sport institutions—neither employees nor workers, they often cannot benefit from standard labour protections (Roberts and Sojo, 2020). What many in sport may not realise: first, all forms of abuse violate the universal human rights of sport participants. Secondly, a holistic, wrap-around approach is needed to shift the culture towards an ethic of care—not just perpetrator sanctions, as Gretchen Kerr and colleagues explore. The clear and accessible safeguarding recommendations for sport organisations, from Margo Mountjoy and co-authors, may help. Public health, human rights, medical, ethics, legal, sports performance, and other expertise must come together to boost abuse prevention, response, remedy, and healing in sport. Mountjoy, M., Rhind, D. J., Tiivas, A., & Leglise, M. (2015). Safeguarding the child athlete in sport: a review, a framework and recommendations for the IOC youth athlete development model. British journal of sports medicine, 49(13), 883–886. https://doi.org/10.1136/bjsports-2015-094619

Finally, Sports and Exercise Medicine (SEM) clinicians have a particular duty of care to “connect with patients in new and vulnerable ways,” described in this courageous patient’s call to action. Beyond an entertaining pastime, sport can be a life-saving antidote to the chaos of life. Better safeguards aimed at shifting the culture towards an ethos of care and well-being, can help bring ‘sport’ back to its original meaning. Helping athletes affected by sexual violence: my challenge to the sports and exercise medicine community. Br J Sports Med. 2021 Feb;55(3):177-178. doi: 10.1136/bjsports-2020-103301. Epub 2020 Nov 5. PMID: 33153977

*Terminology varies. The terminology we use here was determined by expert panel consensus, and with reference to three sources: 1. Terminology Guidelines for the Protection of Children from Sexual Exploitation and Sexual Abuse Adopted by the Interagency Working Group in Luxembourg, 28 January 2016; available at http://luxembourgguidelines.org/english-version/; 2. Mercy JA, Hillis SD, Butchart A, et al. Interpersonal Violence: Global Impact and Paths to Prevention. In: Mock CN, Nugent R, Kobusingye O, et al., editors. Injury Prevention and Environmental Health. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Oct 27. Chapter 5; 3. Mountjoy M, Brackenridge C, Arrington M, Blauwet C, Carska-Sheppard A, Fasting K, et al. International Olympic Committee consensus statement: harassment and abuse (non-accidental).

While many may want to believe that sport does not see colour, the pressing reality is that race and racism continue to influence the experiences and opportunities of people of colour involved in sport – both on and off the field of play. At the community/recreational level, the built environment itself often reflects this bias, with marginalized populations often residing in environments which have underdeveloped recreational facilities or poor access to natural and safe environments that facilitate spontaneous physical activity. As Meredith Sones and her colleagues wrote in their 2019 editorial, “achieving spatial equity in access to infrastructure does not guarantee social equity” however, community design does play an important role in enabling access to infrastructure and programmes that support physical activity and other healthy behaviour. At the elite level, the relative increase in participation and performance of elite athletes of colour represents only surface-level inclusion, beneath which sits layers of injustice and inequity that need to be hurdled, dodged, or simply stomached in their journey to success. As Love et al. underline, athletes of colour encounter racism in various ways: abuse hurled by fans, exclusion from key roles or opportunities, racial stereotypes that result in over- or under-representation in particular positions within teams, and stingingly biased media representations (Love et al., 2019).  Over the years, many athletes have taken a stand to highlight this inequity, challenge the status quo and initiate change to promote social justice. Professionals, administrators, and support personnel involved in sport experience similar racial prejudice which translates to a lack of diversity and obvious inequity in leadership and administration structures of elite sport (Love et al., 2019). Phatokuhle Zondi and Ashley Austin’s insightful manuscript on systemic racism in SEM further demonstrates that prejudice on the basis of race and ethnicity is also pervasive at an individual level in the form of racial slurs, racist jokes, and the exclusion of particular individuals, informed by the persistent belief that some racial and ethnic groups are superior to others. In a recent editorial, Katherine Marino and colleagues outline how this bias may be conscious or unconscious, providing eight meaningful steps that should be undertaken by individuals to confront unconscious bias and initiate change in their immediate circles. Represented in the infographic below, some of these actions include acknowledging your own bias, empowering diverse voices, practicing inclusivity, and leading by example. At a systemic level, racial inequity and bias embedded in SEM policy, institutional practice, and cultural norms have perpetuated non-inclusive leadership structures, poor representation of minority groups in academia, and a paucity of population-specific research (Mkhumbuzi and Zondi, 2021), with implications on clinical practice and ultimately athlete care and wellbeing. Marino KR, Vishnubala D, Ahmed OH, Zondi PC, Whittaker JL, Shafik A, Le CY, Chatterjee D, Odulaja A, Jones NE, Thornton JS. Embrace your discomfort: leadership and unconscious bias in sport and exercise medicine. Br J Sports Med. 2021 Mar;55(6):303-304 In order to adequately address these challenges in sport and, more specifically in SEM, Blake (2020) astutely suggests that we should be as rigorous in our approach to racism as we are to injury prevention strategies. Adopting the principles of the Translating Research into Injury Prevention Practice (TRIPP) framework, effective reform will require that we measure and evaluate the extent of racism in sport and SEM; identify etiology and mechanisms that reinforce the presence and impact of this inequity; develop preventative measures and policies; implement a context sensitive intervention; and finally, evaluate the effectiveness of these interventions in addressing racism and enabling diversity, equality and inclusion. We cannot tire or take a break in our efforts to challenge racism. We must rally until we win the game, set and match against all forms of racial prejudice. In each of the articles referenced above, there is a clear cry and call to action: Representation matters. We are each accountable. The time for social justice is now.

Ableism can be defined as stereotyping prejudice, discrimination, or social oppression of people with disabilities. “Para athletes” are athletes with disabilities who compete in sports governed by the International Paralympic Committee or its member organisations. While all Para athletes challenge society’s ableist attitudes, those who arguably pose the most direct challenge are Para athletes with high support needs (PAHSN)--those who cannot mobilise without aids and require physical assistance with fundamental tasks of daily living such as dressing and bathing. The notion that people with high support needs should not undertake physically demanding exercise is fundamentally ableist and is surprisingly prevalent, even among health professionals. A recent publication on sport and exercise for people with cerebral palsy (CP) advised that those most severely affected--level IV and V of the Gross Motor Function Classification System (GMFCS)--would be unable to perform activities of greater than 1.0 MET and would “… struggle performing structured exercise programs”. For perspective, 1.0 MET is the metabolic cost of quiet sitting. These statements run contrary to scientific evidence and are worrying because they are inherently self-reinforcing: the less patients are encouraged to physically exert themselves, the more deconditioned they become. Sean Tweedy’s Queensland University team recently introduced the world to three (2M, 1F) early-career PAHSN with severe CP who enrolled in ParaSTART, a competitive swimming program, at 15-16 years of age. None had any prior sporting experience and all were deconditioned. It’s four years since the intervention began and all participants are still training, regularly completing 3-4x30min sessions of moderate (3-6METs) or vigorous (6-9METs) training and all have achieved significant increases in maximum swimming distance and velocity. Participant reflections reinforce the notion that, prior to their engagement in ParaSTART, the low expectations of some trained teachers and healthcare professionals had contributed to their deconditioned state. The physical intensity at which our ParaSTART swimmers train is well captured in 25m double arm backstroke effort (RPE = 8/10) completed as part of the Main Set in this swimmers 250m training session. PAHSN also challenge ableist perspectives of “elite athletic performance”. For example, many in the media and public use the “Would-they-beat-an-average-nondisabled-person?” test to evaluate whether a Para athlete performance is elite. The Mind-Changer Workout produced in the lead up to the Rio Paralympic Games is an exemplar: hidden cameras filmed a range of Para athletes outperforming and impressing non-disabled people by running faster or lifting more weight. However, this test is invalid for PAHSN as the following example from the sport of Para swimming illustrates. In Para swimming the most disabled Para swimmers – e.g., those with no use of their legs, trunk, hands and minimal use of their shoulders – compete in Class S1 and there is little doubt that the worlds best S1 swimmers would be slower over 50m than most people who train regularly for fitness in a swimming squad. These highly trained PAHSN challenge us to develop new ways of thinking about elite athletic performance that will help society to appreciate human achievement in the context of severe impairment. In doing this we can come to a more complete understanding of the human condition. Unfortunately S1 women don’t have an event on the Tokyo 2020 program and a recent IPC decision means that the Paris 2024 program will have no S1 events at all (male or female) and no S2 female events. Conversely Paris will feature 12 events for male and female S10 athletes (those Para swimmers with minimal disability) These events for the most disabled swimmers were removed because they did not meet the IPC’s so-called “Event Viability Rule” which requires that, inter alia, an individual medal events must include >10 athletes from > 4 countries. The Event Viability Rule exemplifies the important difference between equality and equity, which is explained succinctly by this Inclusive Sport Design blogpost: https://inclusivesportdesign.com/tutorials/equality-equity-and-the-role-of-fairness-in-inclusive-sport/. Specifically, while the Rule applies equally to all Para swimmers, S1 to S10, it is not equitable because swimmers in lower classes face significantly greater barriers to participation. For example, while an S10 athlete will be able to train with a nondisabled squad with a coach who requires little or no specialist knowledge and use facilities that don’t feature disability access, most S1/S2 athletes will need individualised sessions with a coach who has considerable specialist knowledge and who works in facilities with accessible parking, change rooms and pool entry. Furthermore, the need for motorised wheelchairs and/or personal carers make international travel more difficult and more expensive for PAHSN. As a consequence, participation rates are lower. The Event Viability Rule clearly needs to change, not only for the sake of equity, but the long-term legitimacy of the Paralympic Games.

Singapore's Yip Pin Xiu is looking to defend her title in Tokyo (ⒸREUTERS/Jason O'Brien, available at https://www.paralympic.org/feature/defending-champion-yip-pin-xiu-ready-test-tokyo)

Defined as prejudice, stereotyping, or discrimination–typically against women–on the basis of sex, sexism remains a major issue within SEM. Gender bias – a preference toward one gender over another – manifests across the field from study participant recruitment to implementation strategies to research funding. While this section deals primarily with sexism and gender bias against women, we acknowledge that sexism may also extend to individuals identifying as men and/or with differences in sex development (DSD)/intersex. As Nonhlanlha Mkumbuzi and colleagues note, gender bias in sport is even more pronounced in lower-resourced settings or regions such as Africa. When individuals who identify as women are underrepresented in research studies as participants, the resulting data gap may have serious implications (Patel et al., 2021). Incomplete information may negatively impact performance, injury or illness prevention and management, and overall health. There is an unknown and unacceptable risk of failure when targeting interventions based on male athlete evidence are targeted at female athletes; the consequences could also prove costly both clinically and financially. When Joanne Parsons and colleagues adopted a gendered environmental approach to investigate why anterior cruciate ligament (ACL) injury rates have decreased in boys and men but have remained unchanged in girls and women, they found that injury risk factors are influenced by societal and cultural considerations. For example, while resistance training is a protective factor against ACL injury, its social acceptability is lower in girls and women and therefore may not be performed. Girls and women also do not have access to the equipment needed to perform such training. Studies such as these dispel the myth that strictly biological explanations and solutions will improve outcomes for girls and women. Parsons JL, Coen SE, Bekker S. Anterior cruciate ligament injury: towards a gendered environmental approach. Br J Sports Med. 2021 Mar 10:bjsports-2020-103173. doi: 10.1136/bjsports-2020-103173. Epub ahead of print. PMID: 33692033

The risk of atrial fibrillation in male endurance athletes is well-established, but rates in female athletes are largely unknown or not reported (BJSM). Cardiac adaptations may differ in the female athlete, including differences in cardiac remodelling and myocardial fibrosis, and rates and outcomes of atrial fibrillation. These differences may affect prevention, treatment, and even informed decisions about sport participation from the patient perspective. A prior BJSM e-edition on female athlete health addresses other considerations unique to this population. Gender bias can also manifest as a tendency to overestimate the qualifications of men and underestimate the qualifications of women, reflected in leadership positions and inherent in “manels” (men only or male-predominant panels) (Bekker et al., 2018). To build a more equitable SEM community, we must pay attention to our own biases and dismantle the structures that hold women back. Bekker S, Ahmed OH, Bakare U, et al. We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine. Br J Sports Med. 2018 Oct;52(20):1287-1289. doi: 10.1136/bjsports-2018-099084. Epub 2018 Mar 17. PMID: 29550755

In a contemporaneous editorial, Kristian Thorborg and colleagues examined gender bias within their own Danish sport medicine system, recognized similar issues and recommended three action steps for others planning to do the same. This includes the use of quotas, transparent calls for topics and publications relevant to women and authored by women, and addressing the presence of manels head-on. Gender bias affects training opportunities within SEM as well. As the first female president of the Australasian College of Sport and Exercise Physicians (ACSEP), Dr. Louise Tulloh outlines several challenges as well as the deliberate action ACSEP has taken to improve their metrics on gender parity. She provides several action steps to improve gender balance for others to follow suit. Tulloh L. They call us fellows: the challenge of gender bias in the Australasian College of Sport and Exercise Physicians. Br J Sports Med. 2019 Nov;53(22):1391-1392. doi: 10.1136/bjsports-2019-101619. Epub 2019 Oct 14. PMID: 31611188 For appreciable change to take root, we must consider the athlete, context and the environment in data collection and analysis. We must also recognize gender bias as a structural problem across SEM. As Thorborg et al. point out: “we can’t keep providing sports medicine content and insight that only addresses half the population.” Researchers and practitioners in SEM have a duty to ensure all athletes and active individuals are fairly reflected across research and do their part not just to remove the barriers holding women back within SEM, but actively promote and advocate for female voices to be heard at all levels from grass roots to leadership positions. We all win as a result.

In their recent review on the evidence of LGBTQ+ discrimination and exclusion in sport, Erik Denison et al. found that few initiatives have been focused on the needs of these communities. They identified two main gaps in the literature; 1) Investigating and identifying effective methods to overcome resistance by government policy makers and sport managers to engage in LGBTQ+ sport diversity, and 2) Research focused on identifying practical, pragmatic, and scalable solutions to stop the discrimination and exclusion of LGBTQ+ people in sport (Denison et al., 2021). Out on the Fields provides a comprehensive timeline on detailed information and statistics about the experiences of gay, lesbian, bisexual as well as trans and gender diverse people in sporting environments and the lack of action by sports leaders to address the issues faced by these communities. The Sport Inclusion Task Force is a recently formed coalition to end LGBTQI2S+ bias in sport through education for and promotion of LGBTQI2S+ inclusion in Canadian sport. The performance-enhancing effect of testosterone is the main reason for the binary categories in sport (Handelsman et al., 2018). To allow transwomen athletes to compete at elite levels, World Athletics (formerly the International Association of Athletic Federations) and the International Olympic Committee (IOC) created guidelines requiring female athletes to demonstrate suppression of testosterone levels to less than 5 –10 nmol/L for at least 12 months prior to competing in women’s events. This year, Harper et al. and Hilton & Lundberg reported that although hemoglobin levels in transgender women decreased after 4 months on gender-affirming hormone therapy (GAHT), biological muscle mass and strength, conferred by an androgenic puberty, is only minimally reduced when testosterone is suppressed as per current sporting guidelines for transgender athletes. One limitation of both articles is that the samples include individuals who may or may not be physically active at all. This limitation is partly addressed in a 2021 manuscript by Roberts et al., as the sample consists of very physically active and fit people, United States Air Force members, and, therefore closer, to elite athletes. Fitness test results and medical records were compared pre- and post-hormone initiation of 29 transmen and 46 transwomen women with the average performance of all ciswomen and cismen under the age of 30 between 2004 and 2014. Rate of hormone associated changes in body composition and athletic performance were also measured. Although the 15–31% athletic advantage that transwomen displayed over their cis women counterparts prior to starting GAHT declined with feminising therapy, transwomen still had a 9% faster mean run speed after the 1-year period of testosterone suppression that is recommended by World Athletics for inclusion in women’s events (Roberts et al., 2021). Harper J, O'Donnell E, Khorashad B, McDermott H, Witcomb G. How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation. British journal of sports medicine. 2021;55