Women and Equalities Committee
Oral evidence: Sexism and inequalities in sport, HC 1346
Wednesday 14 June 2023
Ordered by the House of Commons to be published on 14 June 2023.
Members present: Caroline Nokes (Chair); Jackie Doyle-Price; Kim Johnson; Ms Anum Qaisar; Bell Ribeiro-Addy.
Questions 1 - 52
Witnesses
I. Janet Birkmyre, Track Racing Cyclist; Shaunagh Brown, Recently Retired Professional Rugby Player; Mathilda Hodgkins Byrne, GB Rower; Eboni Usoro-Brown, Recently Retired England Netball Player.
II. Baz Moffat, Chief Executive, The Well HQ; Dr Louise Newson, GP and Founder, The Menopause Charity; Kate Seary, Director, Kyniska Advocacy; Lisa West, Head of Policy, Partnerships and Public Affairs, Women in Sport.
Witnesses: Janet Birkmyre, Shaunagh Brown, Mathilda Hodgkins Byrne and Eboni Usoro-Brown.
Chair: Good afternoon and welcome to the Women and Equalities Committee and one of our oral evidence sessions into sexism and equality in sport, with a particular focus today on women’s health and physiology. Members of the Committee will ask witnesses questions in turn. If at any point you wish to come in on a question that you have not been asked, please either raise your hand or indicate in some way. Remote witnesses, please feel free to do that via raising your hand physically or using the button that allows you to do that. We will come to you; please do not panic. It might take a moment to find the right opportunity.
Q1 Kim Johnson: Good afternoon, panel. I have a couple of questions about support for sport injuries and sports-related illnesses. I know that you all come from different fields. Research has shown that coaching methods in women’s football are not keeping up with the increasing demands of the sport, putting women at increased risk of injury, particularly ACL. Are coaches, doctors and physios in your sport sufficiently aware of the specific risks of injury to and the needs of women?
Shaunagh Brown: The short answer is that it depends on who you have in your team. It depends on which doctor and which physio. I have been exposed to physios who know a lot more about my female body than I do, including male physios. Equally, there have been things when I have had to let them realise, “Actually, I am on my period at the moment, so those readings are off because I am on my period and that’s right”. The short answer is that it depends on who you have and from which team. If someone is standing in as well, they are not as informed.
Kim Johnson: There is not a consistent approach. Mathilda, do you have any different experience from your sports field?
Mathilda Hodgkins Byrne: We do not train at all with women’s health in consideration. The current mindset is that you train until you break, and that breaking and injury is part of the training programme.
Q2 Chair: Is there any differential between women’s rowing and men’s rowing when it comes to the quote you used, “train until you break”?
Mathilda Hodgkins Byrne: Yes, we have two different head coaches. I have been part of the women’s squad since 2016 and I know we have more fatigue issues and more rib injuries. A significant proportion will spend the time rehabbing compared to the men’s squad.
Q3 Chair: What about the way you are treated? Would there be more accommodation for male teams rather than female teams?
Mathilda Hodgkins Byrne: No, they are the same.
Chair: Everybody trains until they break.
Mathilda Hodgkins Byrne: Yes. The men can pull out first and their training programme is not as hard. We are not on the same training programme. The men’s training programme is a slightly lighter programme than the women’s programme.
Q4 Kim Johnson: Eboni, would you like to comment on that question about the support you get in terms of women’s sport and injuries?
Eboni Usoro-Brown: It is quite disheartening to hear Shaunagh and Mathilda. Netball has taken steps in that regard. I was part of the England programme for nearly 17 years, having started there when I was a 17‑year‑old and progressing to being 34. During that time, the majority of the time that I was in the squad there was a physio called Ros Cooke, who did a PhD or some extensive research into ACL injuries. Given the nature of netball—short, sharp movement—it was one of the most common injuries that we experienced.
From there, she developed a set of testing and prehab measures that we all had to start to complete prior to training, each and every training session. That continued for the last 10 years. We all have prehab programmes that we have to complete beforehand in terms of prevention of injury. They were all tailored individually to specific needs. They are developed after fitness testing, strength and conditioning testing or physio screening that you have at the start of every single year. It is monitored closely throughout the year, in collaboration with the strength and conditioning coach themselves.
There are still steps to be taken in how we progress that model. I definitely think that, especially over the last few years that I was in the England programme, although ACLs happened, they were less common compared to when that programme was initially implemented.
Janet Birkmyre: I am in a very different situation, because I have not come from a squad set-up. Cycling is a great sport for the body and lends itself very much to whole-life sport because it is quite an easy way to train. The injuries that come from cycling tend to come from the gym more. I know we will touch on this when we talk about the life stage experience that I am going to bring to this Committee. Training in the gym has specific issues around joint health and back health that are probably a little more prevalent in women as they start to reduce their hormone levels. I am not sure how relevant that is or how much of that you want at this stage.
Q5 Kim Johnson: Shaunagh, you said that the approach is very different and that there is an inconsistent approach. What additional or improved support would you like to see help prevent injuries in your particular sport?
Shaunagh Brown: It would be based in the research into why we are rehabbing this way, why we are asked to do this activity and why we are using this training programme. You will find that a lot of it has come from men—for example, concussion protocols. For me, it does not sound right that male and female concussion protocols are exactly the same. It is just because so often we are treated as small men, as opposed to having completely different needs as women. It is where it has all come from.
There is no base at the moment. It is changing slowly the more that people are looking into it and researching it, even with things such as dissertations. I learned a lot more from people who are at university now and in the last year or two, because they are the ones doing the research into it. They are the ones looking into how the menstruation cycle affects your training or how taking a hormonal versus non-hormonal pill affects your training.
Unfortunately, they are almost not established enough as students to then pass that information on to governing bodies and be trusted enough. In that case, the governing bodies are listening to what is seen as more proper, I guess, but that research is based on men.
Q6 Kim Johnson: Are there any particular universities that you are aware of that are doing some of this research at the moment?
Shaunagh Brown: It is not general universities. It will be individuals and people I know and trust, because I know them personally and know how they operate as individuals. No, it is not particular universities.
Q7 Kim Johnson: Janet, are sportswomen and their coaches sufficiently aware of the risks of relative energy deficiency in sport—RED-S—and how to manage them?
Janet Birkmyre: In my experience, it is a very individual answer. My particular coach is very aware of it. It is something that he raises for me regularly. Probably most sports have a degree of body consciousness and therefore you have this dichotomy between looking right and fuelling correctly for your sessions. My experience has been really good, but I think that that is the exception rather than the rule. My coach comes with nutritional qualifications that make him stand out, but of course I choose my coach and pay for him personally. It is a very different set-up from perhaps a squad.
Mathilda Hodgkins Byrne: RED-S is very common in rowing. Over my time of being there, it seemed more abnormal if you had a regular period. It is at times considered that you are not training hard enough if you maintain having one.
Shaunagh Brown: I would suggest that parts of rugby training are not as intensely monitored as the likes of track cycling and rowing. It is a squad effort and somethings I think that there are almost too many of us for them to monitor us that closely. They do not scrutinise us as much.
Eboni Usoro-Brown: I do not know about the other girls, but in netball we use PDMS, which is a daily monitoring app that comes through the EIS. I am not sure whether it is universal, but I know that in netball, on a daily basis, we are meant to log our periods—as and when it is your time of the month. The sports science staff can see in and around when you are having your periods and whether it is irregular. You are encouraged, if it has been irregular, to notice signs in order to go and see the doctor. That is one of the ways that they have been, seemingly, in tune—trying to monitor that, alongside performance results.
Shaunagh Brown: In rugby, the English rugby union has used the PDMS app before. We no longer use it. I am not sure of the actual reason, whether it is budget or other reasons. Nothing was done, so they were just monitoring it. They told us they were monitoring it. We would fill it out every morning before 7 am. You had to do it or you were not allowed to train, but then nothing seemed to change at all. It was disheartening to the point where people did not fill it in.
Chair: Eboni, how long has netball been using that app?
Eboni Usoro-Brown: It is probably over 15 years.
Chair: Okay, so a long time. Shaunagh, for what period of time was rugby using it?
Shaunagh Brown: I was only in the set-up for seven years—probably five. We stopped using it about two years ago, so I would only have about a three‑year experience. I do not know how long they were using it previously. I think that it was to do with player feedback as well and the fact that nothing was done, and they were asking, “So why are we filling it in?”
Part of me thinks that it is now about this research piece that had not been done 25 or 35 years ago, as with men. Maybe they are not going to action some of it now, because it is about them looking at other things around us. We were never informed as to what was done with that data. It might be for good reasons because it is going to affect the girls and women in 10 years’ time.
Chair: It was never used.
Shaunagh Brown: Yes, exactly, for us.
Mathilda Hodgkins Byrne: We started using it with covid. It became the way to get into the training centre. We still fill it in and I know that mine is currently monitored, but that is because I am still on maternity. To the best of my knowledge, no one else’s is monitored.
Eboni Usoro-Brown: Ours has definitely evolved. In that 15-year period that we have used PDMS, they have refined the survey and the questions that got asked every day. I think that that is, similarly, because initially it was not monitored. Then the player collective raised our concerns and that is when it became more of a tool for our sports science team. We had similar experiences of filling it out just for the sake of filling it out. I can definitely say that, especially in the last three to four years, having used PDMS, I felt that the sports science team took notice of it and adapted programmes where necessary because of it.
Q8 Ms Qaisar: Thank you so much for joining us today. I want to talk about periods. Are periods still seen as taboo? I am going to break this down. It is not just in terms of periods when you are bleeding during your menstrual cycle but also the period symptoms. Of course, it is not just when you bleed. It is beforehand: the stomach cramps, the aches and the pains. This is an open-ended question for everyone.
Shaunagh Brown: For me, it has been a taboo in the past. It is only in the last year, I would say, that we have started speaking about it as a squad of rugby players and as a staffing group, to the point where you can almost make jokes about it. A lot of our staff are men, but they would also then talk about periods. It was becoming more and more socially acceptable for men to talk about periods, rather than this awkward subject that everyone stayed away from.
I have been out coaching in the Cayman Islands for the last four months and I got to the point where periods are not taboo, so I would talk about it normally and so I never raised it as an issue. There was a session in particular that we had with a group of 25 women and girls. The person leading the session literally mentioned the word “period” and people’s faces still turned; that is women and girls who it is affecting.
It is about recognising that we are in a better place, for my team in particular. I cannot speak for other teams and definitely not for other sports. There is still a lot of work to be done even to get people to accept and realise that it is a thing. Actually, it can be a thing that helps us, if used correctly. It is still very much a mixed reaction. I am sure that other sports can be very different.
Q9 Ms Qaisar: Are you able to have conversations about how periods impact participation and performance?
Shaunagh Brown: It is becoming more and more normal to talk about that. There is also the trust element, in terms of speaking to a coach and saying, “I am not in a good place for this type of session today and maybe I need to step away. Maybe I need to dial back”. It has taken a long time to get to that. It would have previously been automatically assumed, “You are just lazy” or “You just cannot be bothered today”.
It is about understanding that so many people are different. I am very pro-women in everything I have done and will continue to do, but I have never had any issues with my period. I was one of those people who thought that the girls who did not want to do PE because of their period were just lazy and did not want to do it, because we have never spoken about how severely some people have an issue. It is literally to the point that some cannot get out of bed. I am talking to a grown adult about that who plays rugby for England. She is obviously not lazy or trying to get out of the session. It is becoming more and more normal to talk about it and understand that people are different and that we can talk about it with each other.
Mathilda Hodgkins Byrne: In my experience, again, not having a period is more the norm. I am pretty certain that no one would feel that they could back out of a session because of a period, no matter how uncomfortable they were. My sister did a lot of research on how we treat it compared to the New Zealand team. I know that they changed the way they programme the girls and have actually got significantly better results as a result. We have been trying to push to do that. I hope that that coming into PDMS is the start of it. At the moment, we just train through as normal.
Q10 Ms Qaisar: What were the differences between you and the New Zealand team?
Mathilda Hodgkins Byrne: They will train around their cycle. They will do different sessions depending on where they are in their cycle. I know that for us, from what I have heard, the risk of injury is significantly higher when you are on your period, so therefore the chance of damaging your back when doing heavy squats is higher. We still carry on as normal, whereas the New Zealand team would not do that. They would change the lifts they were doing, the weight they were lifting—all the intensity sessions.
Q11 Ms Qaisar: Is there a call or appetite for this kind of session? That sounds to me as if it would be more inclusive.
Mathilda Hodgkins Byrne: They have got results off it. If they are going to get results off it, it is very easy for everyone to get on the bandwagon with it. It is one of those things where you do not want to say, “I am uncomfortable; that is why I cannot do the session”, because you will get called soft, until that culture changes and you realise that we can train more effectively around it. That has to come from the coaches, which it does not in rowing.
Q12 Ms Qaisar: Does that culture stem from male coaches or female colleagues?
Mathilda Hodgkins Byrne: In my entire time in rowing, I have had two female coaches. Currently, all the staff are male, so there are very few women in the building.
Shaunagh Brown: A slight part of that as well is that you want to be picked. You want to be selected. You do not want to be the one who says, “I cannot quite train today because my tummy is not right”, so you go through it; otherwise you do not get selected.
Eboni Usoro-Brown: It is probably one of those things that are not taboo in netball compared to rowing or rugby. For a long time, netball’s unique selling point was that it was a majority female game, run by women. Given the fact that we are all experiencing it, I would not say that it is taboo, but it is not necessarily spoken about.
It was only in the last couple of years where they adapted PDMS, informed us about regularities and irregularities in terms of periods and encouraged us to go and see the doctor. I would not necessarily say it was taboo, but it was not necessarily spoken about. I know that peers of mine who had been experiencing cramps or having challenges in and around their cycle most of the time just took paracetamol and got on with it. There was probably a lack of education in and around it, rather than it necessarily being taboo itself.
I know that, in the last couple of months, England Netball has launched its NETBALLHer campaign through its social media channels and online. It is tackling the subjects of periods, fertility and menopause. It is trying to reach out to not only the elite group of athletes but grassroots level. It is trying to see that, for those athletes who are young women between the ages of 14 and 21, where there is probably the biggest dropout rate in sport, it is not a hindrance.
It has also partnered with period pants companies, allowing the conversation to be broadened as to not necessarily what the solutions are but what the aids are that can assist in those periods of time to make sure that you can continue to play netball in this particular regard, and sport in general. I do not necessarily think that it has been taboo, but I do not think that it has been a conversation. From what I see at the moment, England Netball is making efforts to make it part of a conversation and inviting people to the table to talk about it.
Janet Birkmyre: I was reflecting on what I would say for this panel and I threw back my mind to 2000. Was it 1999 or 2000? I took part in a round‑the-world yacht race and I remember at the time looking at the medical set that we took away with us. The yacht race was away for nine months. The longest legs between ports were maybe four weeks at a time, but the race itself took up to 10 months. I remember being mildly amused to find that there was a pregnancy test on board, but at no time did anyone mention periods, cycles or challenges that would be specific to women.
Sport generally is really quite misogynist. There is a prevalence of men in it. There are some wonderfully enlightened people and the conversations that we are starting to have around menopause and women’s hormones more generally now are opening that conversation up. I take every opportunity I can to have that conversation. For young girls in sport now, this idea that not having a cycle is normal is just terrible.
Q13 Ms Qaisar: This is a slightly intrusive question, so I am not going to come to each of you. I will allow you to come in and answer if you want. Does anybody want to tell us and describe how it has been having periods and a menstrual cycle during your sporting activities? How has that affected and impacted your performance and participation?
Shaunagh Brown: As I said earlier, I have never had a problem with my periods, but almost entirely, I would suggest, because I have been on the pill from the age of 16.
Janet Birkmyre: Yes, same here.
Eboni Usoro-Brown: Same here.
Shaunagh Brown: That was more of a social decision, but then I realised later that people make that decision for performance reasons. As long as it is your own informed choice and you are not forced into it, for performance reasons is absolutely fine, but, again, that was not spoken about. It is like, if you are on the pill, it is for sexual or social reasons and therefore you are a bad person. It is being able to have the informed choice that there is a lot of choice out there and you can affect your period, for good or for ill, by taking it or not taking it.
I have been listening to how normal it is to not have a period; I have never experienced that. Going out on a limb here, in terms of the structure of a lot of rugby players—men and women—we have a lot more meat on us. You have a lot of muscle and we do not. Even having a period or not having a period is associated with training styles and intensity. We do not go at that sort of intensity.
Mathilda Hodgkins Byrne: I went on the pill in 2015 and I think I came off two years later. Since then I had three periods, was diagnosed with RED-S and subsequently got told that I was infertile. Subsequently, I became pregnant, having had a break post the games. For me, I did not train, but got diagnosed, but then nothing was done once I had the diagnosis because it was normal to not have a period.
Janet Birkmyre: This idea of going on the pill for supposedly social reasons—convenience or contraception—is rather masking perhaps a coping strategy on behalf of women to deal with it. That is what I did on the round-the-world yacht race, for sure; I took the pill nonstop. That took away the whole issue of having a period while at sea, in very close confines, with mostly men. The heads had no little bins in them. There was absolutely no privacy and the pill was the way forward for sure.
Q14 Ms Qaisar: We have spoken quite a bit about male coaches. I want to gain a little bit of an understanding of how much support you would receive from your coaches. How much awareness do they have around periods and the menstrual cycle? I always laugh when I have conversations with some men who do not realise that it is not just day one of your period; it is actually the week before when you start having symptoms.
Shaunagh Brown: Generally, men are not interested, to the point where we had sessions as a squad about training around your period, maximising when you can and what to not do when you are at highest risk of injury, and the male coaches were not in the room. It is not a physical rugby session, but it is still seen as a rugby meeting and everybody should be in the room, but the male coaches were not. Because I am that kind of person, I questioned that afterwards with some of the other staff. There were very poor excuses that they could not be there and yet they are at every single other session.
There are one or two men who are good at listening and actively wanting to know more, reading about it and being bought books around female health. They have to get over a stigma of reading a book called “The Female Body Bible”. Some people say, “That is a bit weird. You are a man”. There are very good men out there, but not enough who want to know more and just accept that we are not small men. We are very different.
Q15 Ms Qaisar: It sounds as if the onus is put on women to deal with their problem themselves, rather than men being willing to learn and understand how the menstrual cycle impacts you as women and how that impacts your performance.
Eboni Usoro-Brown: My experience is completely different. I have never ever had a male coach. I have had one assistant male coach and that was when I was playing out in Australia and New Zealand. Over there, similarly, it is quite taboo in terms of having periods. We had a female coach who made him come and sit in the room when we were having a talk about periods and how to maintain your own individual welfare.
I can sense the education point of view in and around male and female coaches. They are worlds apart. It is definitely at the centre and focus of a female coach’s mind—in and around those subjects of periods, fertility, menopause, and managing and coping with those challenges. In netball, from even the elite level to the grassroots level, I do not think that you will see many male coaches. That might be a reason why it is much more accepted and assistance is given within the sport.
Q16 Ms Qaisar: We have spoken a lot about how this has impacted you. I am really curious to learn about what you think should happen in the future. As female athletes, you are trailblazers. There are young women and girls looking at the four of you and being inspired by you. What would you like to see that has changed in order to help more young women and girls into sport, and to not be worried about their periods and menstrual cycle?
Mathilda Hodgkins Byrne: For me, if there was some evidence that, if you trained around it successfully, you would be faster—in elite sport, that would make the biggest difference. I completely agree: you do not want to back out because you need to be selected. If there was evidence to say that if you trained cleverly, you would be faster, it would become the norm. The only way—certainly in rowing, in my opinion—is to make it scientific. If younger people were able to look up at the elite sportspeople and be like, “They train cleverly and for them talking about periods, dealing with them and bringing them into their daily life is the norm”, it would help normalise it downwards to younger people.
Eboni Usoro-Brown: I support that. It is backed by science and with education programmes, especially at the junior and grassroots levels. Nothing is necessarily normal, but there should be an understanding of what is normal, what could be deemed as irregular and what the mechanisms are to assist you, whether it is the contraception pill or monitoring your cycle, throughout your elite training development years or even at the top level.
There should be more education for athletes around what they should expect and avenues by which they can raise the alarm, if they have concerns, and know that they will not be judged or deselected within their particular sport. Education programmes should be mandatory across the board and not just a one-off. They should be reiterated, even if it was on a yearly or two‑yearly programme, as we have with drugs education.
Shaunagh Brown: It would be the support from a younger age. More and more sports now, especially the elite clubs, have girls in their programmes from a lot younger. That should be put into them from the beginning: “Yes, we talk about it here. This is what we do”. Yes, they are at an age where maybe they do not want to talk about it, but they should be allowed to get through that, with the coaches and governing bodies actively drawing it out. Exactly like Eboni says, we have to sit through a drugs and gambling awareness programme every year within rugby. Why not do the same in and around the periods?
Janet Birkmyre: There are two quick ones from me. One is in terms of education. I started doing the British Cycling level 2 coaching. There are all sorts of wonderful modules in there about safeguarding, but absolutely nothing about female health or the menstrual cycle. It has to go down the levels from the national squads all the way through to every coach who is going to be in contact with a female athlete.
You asked what we need to happen. Going back to a job I had not long out of university—I worked for Tampax for a while. At the time, we sponsored a nurse lecture service that went out to schools and educated girls and boys in the same room together about the changes that their bodies would go through. The conversation was normalised by the fact that it was very simple biology, but it was about letting people know what the changes would be in their bodies and starting that conversation in a very informal way. I do not think that it still happens now, but I remember it being incredibly powerful.
Q17 Chair: Shaunagh, can I take you back to something you said about the information programmes around periods and that there were no male coaches in the room? You challenged that afterwards. Do you think that anything changed as a result of you saying something?
Shaunagh Brown: No. I do not think it even went further than the member of staff I asked. I do not think she then said, “Why were you not there?” Certainly in rugby, the coaches are the top of the hierarchy. There is nobody there to question them, so, essentially, sometimes I feel like they do what they want.
Q18 Chair: Janet, you made a comment about how level 2 coaching included nothing about the menstrual cycle. This is a question for anybody who wants to make a comment on it. As we see more and more girls playing rugby, playing football and taking part in sports—I hate to say this, but I am going to say it—that are traditionally male, would it be fair to say that the lower down the coaching ranks you go, the much more likely it is to be a female coach? Are more women coming into coaching at the same rate as we are seeing more girls taking part? I am getting a shaking head there from Eboni.
Eboni Usoro-Brown: I am only saying that because we have one of those problems in netball where new coaches are few and far between. We have a lot of old heads, but there is a lack of mentoring programmes and support for new coaches coming into the sport. After our 2018 Commonwealth games gold win, participation levels absolutely soared. There are more and more girls tuning in and coming to play netball, but there are not the coaches there to support them in the teams, so they fall by the wayside if they are not lucky enough to be on a pathway.
Shaunagh Brown: There are more coming into the game at the lower, grassroots level, particularly because of the female syndrome we have where we think we are not good enough. We think that we are only good enough to teach kids how to do things and not good enough to teach adults how to do things. Women are left there in the grassroots, even when they know a lot more than they think they do. Therefore, it is then thought that, “We have women here, but they do not want to progress.”
You are not realising that you are making it hard for them to progress because you are not making adaptations around progression. You are not making it easy for them to progress. You are not telling them that they are good enough. Slyly, you are always saying, “You have the minis this week. You have the under-16s next year. You have the under-eights the year after that” and not saying, “You are good enough to develop yourself as a coach, whether you are male or female. You are good enough as a coach to come through.”
Q19 Bell Ribeiro-Addy: I want to ask some questions on support for pregnant women and mothers. Thinking about what you were saying before, Mathilda, it is really interesting just how much people will tell us that they know about women’s bodies and they just do not. That is probably because we do not put a lot of research and development into looking into women’s bodies.
In some of the information that we have put together as a Committee, we found that a BBC elite sportswomen’s survey that was published in 2020 said that 58% of sportswomen did not feel supported by their club or governing body to have a baby and continue to compete. Almost half said that they delayed starting a family because of their sporting career. Mathilda and Eboni, were those two considerations for you before you started your families?
Mathilda Hodgkins Byrne: Freddie was not planned.
Eboni Usoro-Brown: Savannah was planned. After the 2019 world cup, I thought that, to be fair, I was kind of retired or considering retiring. Netball is not an Olympic sport, so our highlights are the Commonwealth games and the Netball World Cup. It was the start of the first year of the four-year cycle. I had just got married the year before, and my husband and I definitely wanted to start a family and thought that that would be a great year in which to do it.
I was lucky, having had a female coach who had recently given birth herself and was very passionate about women’s health and welfare. It was really positive. I was part of the Team Bath netball squad, and the first athlete from that Team Bath netball squad to get pregnant and consider having a baby while still wanting to play. I felt very supported by the club and the university at the time. Fortunately, rather than ask me to decide, as I was the captain of the team at the time, they found me a role to help support the new captain. They adapted my role in terms of helping with hospitality and the commercial elements in and around the club.
I was asked to come to every single training session to be involved and have input. I think that I said to them that I wanted to return after having Savannah. It was really important at that time that the coach—it was my first time being pregnant and I did not necessarily know what the expectations were—ensured that I had a pelvic floor health consultant, who I saw prenatally and postnatally. Prenatally, they developed a programme so I could still do some strength and conditioning training under supervision and under guidance from the pelvic floor health consultant, but very much at my own pace.
Nothing was pushed. There was no expectation from the club as to when I was expected to return after having Savannah. That was managed through me giving birth but also afterwards. I was not allowed to return to training or to the court until the pelvic floor health consultant had signed me off. I was not allowed to run until, I think, 12 weeks after I had given birth. It was very gradual.
Obviously covid came in 2020 and the season got suspended in the March before I had Savannah anyway, so, ironically, I did not really miss any of the season. I still felt supported in that time, through that journey, as my body changed significantly. When I had to come back again, I saw a sports psychologist in terms of management of body image and how I would rebuild that foundation. Also, there were the conversations with the squad around the time about, “This is where Eboni is at. Her programme might look a little different to yours, but she is still very much a part of it. She will be adapted and progressively reintroduced to the squad as and when appropriate”.
When the season came round, I played half, I think, in the first match. That was just due to my own progression; it was not an expectation for me to do it. It was very much coach-led in that regard. Without her guidance, I would not have known about those support systems that could be available. I am very grateful that I was able to receive them. I know from having talked to peers around other clubs in the netball fraternity that that is not the same in every other club. There are other netball athletes who have had children and have not received the same support at all.
I would definitely use the Team Bath template that I had as a template that could be rolled out to other clubs. I found it really advantageous. We made the final with the Team Bath squad that season, but then I also made it back into the England squad for the Commonwealth games in the following year. Without that foundation, I do not think that I would have found myself back in an England dress. For many, the consideration has always been, “If you choose to have a baby at that point in time, you are retired”, rather than necessarily that you can return to elite sport and perform on the world stage once again.
Q20 Bell Ribeiro-Addy: We would definitely call Bath’s support pioneering in this instance.
Eboni Usoro-Brown: Yes, I think so. I would definitely say so in terms of how I came back as an athlete and what I was able to achieve thereafter. It was very coach-led. Anna Stembridge was the coach at the time. She was an ex‑England coach. It was her vision and knowledge of who I was as a person and what was needed that allowed that programme to be put in place, alongside the support and funding from the University of Bath.
Q21 Bell Ribeiro-Addy: You have described a bit about the programme and how it worked. Are there any other parts of the programme that was put together for you that were very helpful?
Eboni Usoro-Brown: There was strength and conditioning. Weights were modified. Cardiovascular was in and around swimming and walking.
I saw the sports psychologist as my body changed and, as a female athlete, I had to manage that. After giving birth, I talked to the sports psychologist about my experience and my birth journey, which was luckily very positive, but also having to manage what my expectations were for myself now that my body had changed, and how I could prepare and focus going into match days and the competitive mode given that these changes had happened.
Also, similarly, there was nutritional support to assist as my body was adapting. I was breastfeeding at the time for the first six months, so it was about managing the changes in my body with relaxing, and about how I could fuel myself better to prevent injury, developing a prehab programme from a strengthening and conditioning perspective, but also developing that cardiovascular element in a safe way. It was not rushing my body and allowing it time to heal, but also preparing for performance later on.
Q22 Bell Ribeiro-Addy: It sounds like they put a lot forward. You have already said that you would recommend it to other clubs. Was there anything else that could have been done to support you?
Eboni Usoro-Brown: It is one of those things that are really trial and error at the time. In hindsight now, I felt ready and supported. One thing we will probably touch on a little later is more education in and around it. I always thought that you had to retire in order to start a family. There were not very many positive examples for me, especially in my own sport, of people having babies, coming back, still excelling and being selected for those elite squads.
As we have talked about before, it is the education piece, informing those younger athletes that, with the right programme and funding in place, it is possible. The education as a younger athlete is something I would welcome. Even for current athletes, now and today, there is that education piece as to what they might need to do—even freezing their eggs if they are delaying starting a family—in order to make sure they progress that.
Q23 Bell Ribeiro-Addy: Mathilda, I know that you are working your way back to elite-level international rowing after having your baby just last year. Can you describe the support that you had during and after your pregnancy from your team?
Mathilda Hodgkins Byrne: The minute I said I was pregnant, they had to reach out to the EIS. I think it is Esme, who programmed Laura Kenny and Jess Ennis-Hill, who was then giving guidelines of what I could and could not do. When I was pregnant, the support team I had were brilliant.
I was straight away removed from the main programme. That would be my biggest criticism. Currently, I am not part of the squad. I am in limbo, being a development athlete, but, at the same time, if I do not hit certain scores this summer, I will now be cut, without the full support of being back in the team.
I delayed telling the coaches that I was pregnant until the UK Sport pregnancy policy had come out. That was the first time that they had had one and that came out in November 2021.
Bell Ribeiro-Addy: You felt under pressure because you thought you might be discriminated against.
Mathilda Hodgkins Byrne: That I would lose my funding was my concern. My biggest criticism of the pregnancy document is that it only goes to nine months post-partum. I know that in some sports it is possible to return. In cycling, they are world champions after seven months. In rowing, I am not allowed to race this summer, but there is no security for me or my funding. At the moment, I am being treated as a development athlete or an athlete who has been injured or ill, rather than someone who has had a baby.
My support team have been brilliant, but the support team does not include the coaches or management. Bath sounds like it was great with the fact that it was your coach. Like we mentioned earlier, the coaches are the hierarchy. Unless they are on board and supporting, it is very easy to feel alienated and pushed to the side a bit. That is my experience a bit more at the moment.
Shaunagh Brown: I have not had a baby yet. I hope to someday. Part of that decision is around sport. I am at an age now where I am too old to have a baby and come back, but, equally, maybe I have another year or two in rugby. That is my personal position.
The reason I wanted to come in is that it is all a guessing game. It sounds like Eboni has had a great experience in terms of the support around her and the specialists. With women I know—not just in rugby but in other sports—that nobody has a clue, and that is even the case in some workplaces. I have been a firefighter previously. As soon as you say the words that you are pregnant, it is like there is something wrong with you and you cannot even walk up the stairs of a fire truck—in one instance that I knew of.
Some of it comes from good will, as in you want to look after someone. You do not want them to risk any sort of issues with baby. Some people need an extra hand around them, but it is just a guessing game. The majority of people involved do not have a clue what to do with you. It is literally like, “We do not really know what to do with you, so we are just going to take you out of everything”. Sometimes I see it as, “We want to protect ourselves as an organisation and, if you get hurt, we do not want to be blamed”. That is so much of it as I see it. So many people just do not know what to do with you and so do nothing with you.
Bell Ribeiro-Addy: Most of you answered this question as well. I was going to ask whether, in your experience, attitudes towards pregnancy and maternity have become more supportive, but it does not sound like they have, so I am going to leave it there.
Q24 Chair: Mathilda and Shaunagh, you both said that pregnancy is seen as an illness, not as a condition.
Shaunagh Brown: I would caveat that. Now England Rugby has what sounds like an incredible maternity policy, where you are completely supported. You cannot be cut from having a contract. Once the baby is born, you are entitled to have the baby with you at any training camps and a plus-one to look after the baby for up to a year, I believe.
England Rugby has gone above and beyond now. I would argue that it is too late, of course, but I would always want more. No matter what you give me, I would always want more. England Rugby is currently in a good place. It sounds like it is in a much better place than so many other sports.
Eboni Usoro-Brown: In a similar vein to that, England Netball did not have a policy beforehand and I think that it still does not have one now. For instance, for the Commonwealth games last year, I was able to bring Savannah into training camp with me and my mum. It facilitated them being there in terms of having a bigger room and having Savannah on camp. I was able to train—the training camp was two and a half weeks—with Savannah there, so I was not separated.
It is definitely developing policies where you can either bring your child to camp or, potentially, take them on tour, especially in that first year, to ensure that there is not that separation in the early years of life for the child, but also from an emotional and psychological point of view for the female athlete. There is still more to be done. We are not at the levels of the male cricketers bring their whole family with them, or being able to financially support that the whole way, but efforts are being made and steps are being taken, especially in netball, to see what that space now looks like moving forward.
Mathilda Hodgkins Byrne: If I go on training camps, I will be able to bring Freddie with me, but I have to pay for it, which therefore means per training camp it is going to be about £5,000. From that point of view, it takes a huge toll on the family. My biggest wish with this going forwards is that there could be a globalised policy of the protection, so that you are no longer treated as an injured athlete or cast aside.
I agree: I have been sent the rugby policy and it is great, but certainly in my sport you cannot come back within a year. A year in my sport is not long enough; security should probably go to 18 months, so I would not now, in my position, be wondering if I am still going to be funded come November. If there was some security around that, that would have a huge impact. I think that that would encourage more people to have babies, because the financial impact you are potentially going to end up with is too much of a toss-up. You cannot risk it.
Q25 Chair: Janet, I am going to turn to you now with some questions about midlife and the menopause. Specifically, I know that you have spoken previously about poor clinical advice and the impact that that has had. Can you explain to us what was lacking?
Janet Birkmyre: This is a conversation that dates back to before some very high-profile documentaries. I think that a lot of the thinking has changed and the education is different.
There are a couple of things that bother me. My sister was diagnosed with breast cancer. I started having menopausal symptoms. I have got away quite lightly, but for those who have it coming there is the lack of sleep, the lack of mental resilience and the joint pains. You have to put it all together. There is no clear diagnosis for menopause. Even if you were to have blood hormone levels monitored, it is a retrospective diagnosis, if you like. I was put on antidepressants to control the hot flushes when I could in fact have been taking HRT. For me at least, now that I am taking it, HRT is a much better solution.
The other issue that I have been quite vocal on is the ability of women to supplement all three of the sex hormones: oestrogen, progesterone and testosterone. Testosterone is seen in the world of sport as an entirely male hormone. It is almost never linked with women and yet we have more circulating testosterone than men at times. We have less in total and therefore a drop in testosterone affects us more.
The effects are quite hard to quantify. Again, you are talking about mental health, resilience, future health around osteoporosis, cognition, heart disease and dementia. I would clearly be sanctioned if I took testosterone, even at a very low level, when I think that that is stopping me from enjoying the best health that I could enjoy right now and in the future.
Q26 Chair: Can I take you back to menopause? I will come back to the testosterone issue in a moment. Is there improved knowledge among coaches now?
Janet Birkmyre: It is a really difficult one. My coach is enlightened, but the first time we had a conversation he brought his wife into the room as a chaperone, if you like, to encourage me to be open and confident in speaking. It worth saying—I made a note of this—that he is a British Cycling coach. He does a lot of work with paracycling and is a lead coach out in Aigle sometimes. He is at a reasonable level, but I think that he is the exception rather than the rule.
In my experience, men in cycling shy away from any conversations about women’s health and hormones. I have possibly been lucky. I have also caused the conversation because it is something I feel very strongly about.
Q27 Chair: Turning back to testosterone, anti-doping rules and the arguments that the governing bodies are making against the use of testosterone by menopausal women, what could change and what needs to change?
Janet Birkmyre: There are a couple of things on menopause. The first, and I suppose most urgent, one would be for women who have been forced into early menopause through surgical procedures or ill health—ovarian cancer, for example. We are talking about young women now whose ability to produce testosterone in their ovaries is almost completely removed from them.
A man in a similar situation who had, let us say, testicular cancer and was having his testicles removed would be able to supplement with testosterone. A woman who has had the ability removed, or has lost the ability to produce her own testosterone at a very young age and has been forced into menopause surgically, will not have that ability. There is no therapeutic use exemption available to a woman at any time, for any circumstances, for testosterone.
Q28 Chair: Where does that rule come from? Is there a blanket rule across all sports that women can never have a therapeutic exemption?
Janet Birkmyre: That is correct, yes. There are no circumstances by which a woman can apply for a TUE for testosterone. I completely get that it is a drug that has been horribly abused and we are opening a can of worms here. The fact that it is available to men but not to women shows you just how far this conversation has to go to acknowledge that testosterone is a hormone that is present in the female body.
Q29 Chair: Presumably, in order for men to be able to use a therapeutic exemption for testosterone, there has to be some testing level at which it is acceptable and above which it would be unacceptable. Could the same sort of testing regime be applied to women?
Janet Birkmyre: I do not see any reason why not. It is not cheap. I suppose, if it is elite women who would be covered by their sporting body federation if they wanted to keep that individual in the sport. It is done by means of blood tests and that is certainly a method by which women could be administered the drug. I know you are going to pick up with Dr Louise Newson later; she has some strong feelings on this.
It clearly needs to be prescribed by medical practitioners who are doing so in the right way, at the right levels, with the right checks and balances. I am not suggesting a free-for-all here. If we could at least acknowledge that testosterone is a female hormone, that would be a massive step in the right direction.
Q30 Chair: Did any of the other athletes have a view on the use of testosterone therapeutically for women?
Shaunagh Brown: It will be the first time that I have heard the suggestion. After hearing Janet speaking about it and the reasoning why, especially if it is available for men who now do not have the ability to produce it, why should it not be used to an acceptable level? I will not go into the debate.
Q31 Chair: No, I am not asking you to. I just wondered whether any of you were going to scream, “No, no way”.
Mathilda Hodgkins Byrne: No, not if it is for a medical reason. We all know the stuff that happened in East Germany and countries such as that surgically forcing women into menopause. That sounds ridiculous, but you can definitely see it happening in certain countries. It would have to be policed very closely. In a medical situation, it should be allowed. You can take insulin. I know that they are different hormones, but you have TUEs for insulin and other hormones.
Chair: Men are allowed the exemption.
Q32 Jackie Doyle-Price: Shaunagh, you have mentioned a few times during your evidence that women are treated like small men. I have been reflecting on the evidence. Certainly Eboni’s experience in what is a more female-dominated sport seems to be that the rules are set with women in mind. I would like any of you to reflect on whether, with sports that are characteristically more male-dominated, the rules and governing are basically men and non-men.
Mathilda Hodgkins Byrne: I think so. Rowing is my experience of that. It has been a male-dominated sports. One of the biggest British competitions is Henley Royal. In 2012, that was the first time a junior girls’ event had even been brought in. Only in the last couple of years have they brought in more women’s events; otherwise women had to do Henley Women’s and it was a segregated event.
Q33 Jackie Doyle-Price: I was struck by your evidence particularly. You are expected to train in exactly the same way as the men, despite physiologically having challenges that simply cannot be met. Would you go as far to say that that framework is itself massively discriminatory?
Mathilda Hodgkins Byrne: Yes, because we are not men.
Jackie Doyle-Price: I put it in those terms because it feels like women and the peculiar needs of women are completely invisible in this space. It is about the men’s attitude rather than women. That is how I put it.
Shaunagh Brown: Equally, training programmes across the board are just training programmes. There is more looking after people of a different age and potentially different weight categories than there is of a gender category. I am heavy for a woman. I am 16 stone and I would be expected to train like a 16-stone man. If I was a lot lighter, I would probably have a different training programme. If I was weaker or stronger, I would have a different training programme. If I was exactly the same person but a man, I would probably have the same training plan and sessions.
Mathilda Hodgkins Byrne: I would have a lighter training programme.
Eboni Usoro-Brown: It is probably for us also to understand where this needs to rank on the list of priorities for national governing bodies. Even in netball, the C-suites are very much focused on performance and results because that impacts funding. It is about how it is placed, where it ranks in terms of the emphasis put on athlete wellbeing in among those decisions, how much attention is given to that and how much mandatory attention needs to be given to that from grassroots to elite levels.
It might be discriminatory, but, when they have targets to hit, sometimes the viewpoint becomes skewed. It depends on how much we want to make that change and make sure that change is compulsory and mandatory, rather than just an afterthought, so we do not have to have this conversation again and again, and 10 years’ down the line there is no change.
Jackie Doyle-Price: I am even more horrified now by the way you have just put that. It is seeing our sportswomen as economic units and not as people with needs. I get the point you are making completely.
Chair: I was more shocked by the afterthought comment. Can I thank all four of you for your evidence this afternoon? If, at any point, there is something that you have not told us that you want to impart, please feel free to send it in writing to the Committee. We would be delighted to hear anything additional from you. Can I thank Shaunagh Brown, Mathilda Hodgkins Byrne, Janet Birkmyre and Eboni Usoro-Brown for your evidence? You have been really helpful this afternoon. Thank you very much.
Witnesses: Baz Moffat, Dr Louise Newson, Kate Seary and Lisa West.
Chair: Good afternoon and welcome to the second panel of this afternoon’s evidence session about women in sport. We have with us Baz Moffat, chief exec of The Well HQ; Lisa West, head of policy, partnerships and public affairs at Women in Sport; Kate Seary, director of Kyniska Advocacy; and Dr Louise Newson, GP and founder of The Menopause Charity. Lisa is the only witness by Zoom. As you will have heard from the previous session, the Committee members will come to each of you in turn with questions.
Q34 Jackie Doyle-Price: This first question is for Baz and Louise. We have heard that there are much higher dropout rates from sport post puberty among girls than boys. Could you perhaps give some thoughts as to what is driving that, and whether we need to take action to close that gap in participation?
Baz Moffat: It is multifactorial, obviously. There is not one solution, but we know that 70% of girls will not be playing sport by the end of puberty, which is a huge statistic. It is double the number of boys in that age group. We can track it back to the age of five, where there is what we call a gender play gap. Girls move a lot less than boys. All of us can observe that when we are out in the parks and the playgrounds. The boys are doing rough and tumble, and playing around. They are learning how to move their bodies, but girls are just not moving as much.
Within the primary system, sport is all about fun, enjoyment and just getting involved. They enter into the senior school system. We have these girls who cannot move their bodies. Then they hit puberty and their bodies do not feel great. The girls who love sport will carry on doing sport, but there is a massive group for whom the barrier to dropping out of sport is very low. Their breasts grow; they get periods; they cannot move their bodies; they are not given opportunities in sports that they want to do; they are asked to wear skirts and all of that.
There are lots of different reasons for that dropout rate but, reflecting on what everyone said in that first panel, there is also no standard education about girls and women for anybody working with girls and women. PE teachers have no education about girls going through puberty, and that is massive as well.
Dr Newson: It is really interesting. Just so that you know, I am a GP and a menopause specialist, but I am also very interested in female hormones throughout all ages. If you look at the incidence of PMDD, it is thought to affect about 15% of women. PMDD is pre-menstrual dysphoric disorder. For those people, it is very extreme, but a lot of women and girls get a dip just two or three days before their period. From research, we know that people are less likely to exercise. They are less likely to engage in homework. There are even more prison offences in the time before the period. Physiologically, we know that that is when our hormone levels drop. Our oestrogen and progesterone drop as well.
There are lots of hormonal changes going on. Any of us who have had teenage children, me included, know how hormones can affect us. Also, our hormones have receptors in our muscles, our bones, and obviously our brains as well. If you are not motivated and your muscles are not working so well, they are not putting it together and thinking of their hormones,, but that will make a difference. Obviously, there are the behavioural changes as well.
While the menopause obviously affects all women, about 3% of people under the age of 40 have an early menopause. My youngest patient with early menopause was 14. Her ovaries did not develop. She was sitting in double maths with such severe vaginal dryness and brain fog that she did not know what was going on. I know that is quite extreme, but there are women who have hormonal changes.
Also, I worry about the contraceptive pill, because we know it blocks the natural testosterone in women. You might know that it increases a hormone called SHBG, which blocks our freely available testosterone. No research has been done, because very little research is done on any women or hormones, but I wonder and look at a lot of women on the contraceptive pill who have reduced libido. It is not such a problem because they have a higher libido than older women, but they have this “can’t be bothered” attitude and put on a bit of weight. They are just not as interested in things. I would love to do research into how many of those are testosterone-deficient.
It is so easy to blame areas of deprivation, poor parenting or poor diet, but it is a cycle that these people are getting into. As we know, behaviours that you have when you are younger usually carry on as you get older. There are a lot of mental and physical health problems. I cannot answer how many of those are due to hormones because we do not have evidence, but we know that there is variation throughout the month of the menstrual cycle.
Q35 Jackie Doyle-Price: I am pleased that you mentioned the contraceptive pill, because we have heard evidence from the athletes just now, and we heard reference to people going on the pill to be able to manage their menstrual cycle so that it did not interfere with their sport. Does that worry you?
Dr Newson: Yes, it does worry me. I do not want to teach you simplistic medicine, but just to recap, the contraceptive pill contains synthetic hormones. They have been chemically modified and do not fit nicely on to our hormone receptors on our cells. The natural hormones are a lot safer, as is HRT, because it has the same hormones in.
I do not know the statistic, but people missing school or work because of heavy periods is so common. Obviously, it is all “normalised” for women, but it is a real issue. Having the contraceptive pill can help, but we also have things such as Jaydess and Kyleena, which are very small contraceptive coils—like the Mirena but smaller—so they can be given to people and it means they do not have periods. For example, one of my daughters, who is 20, uses that as contraception, but it also means she does not have periods, which is absolutely wonderful.
We should be looking at other ways. We get so worried about pregnancy, which is absolutely the right thing to do, but we forget what else is going on. We know there are lots of different types of contraceptives. Some people need two, three or four types to try. We have the implants now, but they are just giving a chemical menopause, of course. They are stopping ovulation, so they are stopping the hormones associated with it.
I feel that in 2023 we should be thinking beyond the box. It is not just about whether women need contraception. How are these hormones affecting their bodies? We all know that it is so easy. Once you exercise, you feel so much better, but what if you do not have the motivation? You could tell me every day to exercise, but, when I was perimenopausal—sorry, I just could not. I could not get off the sofa and I had such bad muscle and joint pain.
We need to be thinking about whether there are causes. I am not saying that all causes are due to hormones, but we seem to be forgetting that hormones are really important for all ages, including for boys and men, of course. Especially when we are thinking about exercise and we know the figures on obesity—it can all be linked.
Q36 Jackie Doyle-Price: Absolutely, and it occurs to me that, if we are losing so many women—they are participating at lower rates to start with, but then, at the onset of puberty, they withdraw even more—the long-term impact for their wellbeing is quite significant. I sit here as somebody who is very overweight, but used to be stick thin because I was a good cross-country runner until I hit 14. I have no doubt that my physical wellbeing would be much better if I had carried on playing active sport.
Dr Newson: It is very interesting. I spoke to a patient yesterday who had put on about two stone when she went on the contraceptive pill when she was 14, and she had never lost it. I wonder if that is a testosterone effect. How much has that made a difference?
Testosterone is such an interesting hormone. It is the most biologically active hormone we have as women. It is a neurotransmitter. It affects the way our brain works and everything, yet we are just ignored. Even from the menopause, we are told it is just for libido, but it helps our metabolism, as do our other hormones. All our hormones work together with our stress hormone and our happy hormone. Our bodies are very cleverly designed. Once people start to increase weight, it can be a slippery slope, so it is so important that we look at it all together.
Especially when you look at areas of deprivation, there is so much about fertility. They are just given the implants and the progestogen-only injections. We know they carry a slightly increased risk of osteoporosis. Everyone says that does not matter because they will regain their bone strength when they are off the contraceptive, but that is because they are affecting and blocking our hormones, so what about their brains? Are they not performing as well at school? Are they not doing exercise because they just want to sit and vegetate in front of the television because they do not have their hormones? I am happy to be proven wrong, but we have not done anything to take this conversation forward for these poor women.
Jackie Doyle-Price: Thank you. That is interesting.
Baz Moffat: We do a lot of work in schools and with young women. Often, it is seen as a quick fix. It is seen as the catch-all for any issues that women have with their menstrual cycle.
As Shaunagh said, the choice is social and sexual, and that is right, but often people who do not have a period are put on the pill; people who have problematic periods are put on the pill; people who have spotty backs are put on the pill, because it is a short conversation and because that is how they have been trained.
We do not have the resilience and the tools to explore the various other ways that we can help a woman manage her menstrual cycle symptoms. That is the bit we need to be doing so that women can benefit from those hormones that Louise was just talking about there.
Q37 Jackie Doyle-Price: I am going to have to move on, although we could spend all day talking about the contraceptive pill. If I could now turn to Lisa and Kate, to what extent do you think that the barriers to participation are about girls going through puberty feeling challenged by their body image?
Kate Seary: It is 100% an issue of a lack of knowledge and education, as Baz touched on just then. If our women athletes had the knowledge that, when they hit puberty, they might see a performance drop or they might start to struggle with things, but we are going to work through it and have this training plan to help us get through it, and that with a little bit of patience they will get back to being able to perform in the way they were able to, that would be huge. Education is definitely a part of that.
The report that we just released showed that 74% of athletes do not think they look like an athlete, so no one thinks they look like an athlete. I would like to meet someone who thinks that they do. Yes, we have an endemic of young women and girls who do not believe that they are athletes. They do not believe that they are able to participate in that sport. They do not think they look like they fit in. They are restricting their food intake and they are taking themselves out of that part of society completely.
As we have just discussed, that has huge wellbeing impacts later in life. We have a huge job to do in informing women and girls that, if they move their bodies, they are athletes. That is the message that we need to send.
Jackie Doyle-Price: Do you think that the taboos around periods are contributing to that too?
Kate Seary: Yes, 100%. It is getting better. There have been some great campaigns such as Baz’s and the “Let’s call it what it is: period” campaign. These campaigns are really helping, but what we learned from the previous panel is about consistency between and within sports. The support that there is for the menstrual cycle is worlds apart depending on which sport you choose to fall in love with. That is where we need to get everyone on a level playing field so that, whatever sport you go into, whatever school you go into and wherever you are having your PE lessons, there is the same support and knowledge there about the menstrual cycle and performance sport.
Lisa West: I am going to drill a little further into what Baz was talking about earlier in terms of how early it starts. We often talk about how girls hit teenage years and they all go, as if it is like this magical “poof” that they all disappear, but of course this is built over years. We have been looking at the primary-age girls, understanding and digging more into the gender stereotyping that we know is very much prevalent and affects girls’ enjoyment and involvement in sport and physical activity.
Gender stereotyping starts right at the beginning. We have talked a lot about testosterone, but when we put it in the boys they have this testosterone surge at six months old. All of a sudden, we see this increased physicality. From that point, boys are 6% stronger and faster than girls. Therefore, as we have heard, the way we then play with them and the physicality they generate means that, when they come into primary school, there is a real gap in fundamental skills between boys and girls.
We are then taking these little girls who we have told that they do not belong in sport, and we are putting them into schools where we are treating everyone the same. We have mixed sport. They are all participating together. We perpetuate these stereotypes through primary school. We know that only 38% of girls are enjoying sport in primary school. That is really low. We also know that those girls with good object control skills are 20% more likely to be taking part in sport as teenagers than those without. We are doing a lot of damage early on.
Absolutely, puberty is a huge disruptor for girls, but we cannot underestimate everything that has gone before. If we just look at puberty and try to solve the problems there, we are missing the fact that we have already lost them. We see their resilience and confidence decline through primary. We have to look at this as the bigger package. At Women in Sport, we concentrate on looking at all the social factors around women and girls, understanding how that plays out in sport.
Q38 Jackie Doyle-Price: Is it to do with what games are played at school?
Lisa West: It is, absolutely. We see this very real gap again in team sport versus individual sport. There is a gap of about 22% difference between boys and girls playing team sport, so 22% fewer girls playing team sport. it's really interesting the work that we did around primary girls, because we talked to families a lot. Ultimately, when they are young, of course that is where the influence is very heavily. Parents without a doubt want to do the best by their kids, but we see that for those parents who do understand that sport is important for girls, which is only about 30%, mostly the activities that they are choosing for their girls are then dance, gymnastics and other sports that are very aesthetic.
You mentioned body image. Of course, then you hit puberty, and those are sports where you are in a leotard or they are early-specialism sports, and so the body image becomes huge for them at that point. They are not in the sports where they have teams around them, where they have peers that they can bounce off, so they can understand what each other are going through. They are in individual sports that are heavily focused on what they look like. We just cannot be channelling them there if we want them to be continuing—not that they are not great, of course; I do not want to give that message.
Q39 Jackie Doyle-Price: What you are telling us is that there is sexism in sport from the age of five.
Lisa West: Six months, yes. It starts from the point that they are in primary school. There is already a problem.
Q40 Jackie Doyle-Price: I have limited time, so I am going to quickly move on to this next set of questions, which are about the injuries or poor health experiences that women involved in sport would go through. We find a disproportionate prevalence of injuries for women playing team sports. The discussion we have just had was about whether governing bodies are just using the rules set for men’s sport and then applying them to non-men—i.e. women. Is that failure to make bespoke rules sexist?
Baz Moffat: It is, but I would argue not intentionally. We have designed a male-shaped system because the men were there first and there were only men involved with it. If you look at the professional sports such as rugby, cricket or football, we have now just put women into that system. We are only recently having the conversation about girls and women being different from men.
I was on the British rowing team a very long time ago now. It was just as National Lottery funding came in. At that stage, it was all about us wanting the same. We wanted the same amount of sponsorship. We wanted the same amount of coaching. We wanted the same quality of boats. We wanted to stay in the same hotels or quality of hotels as the men. At no point did we ever want to be different, because we wanted to have the same equality. We have now realised that that is not enough, and so we have shifted that conversation.
Within the context of injury, depending on what research paper you read, women are between five and eight times more likely to get an ACL injury at the knee. You know what is going on at Arsenal, the England football team and in other sports as well. The list of risk factors for women is a lot longer than the list of risk factors for men. That is anatomical and physiological, but there is also sexism at play.
There are no football boots designed for the female foot. Women are often put on secondary playing surfaces. Coaches are often of a lesser quality in the women’s game and they are not as experienced. In the men’s game, if boys are in the football academies or sports teams, they would have been exposed to strength and conditioning coaches and nutritionists from a very young age. You have to be pretty elite and advanced to get any exposure to that as a woman. That is also massively contributing to the increase in injury rates in women.
Q41 Jackie Doyle-Price: You would think there would be a market for football boots designed for women.
Baz Moffat: You would. There are pink and purple ones and narrower ones, which are marketed as women’s football boots. In fact, a major brand came on last week and came up with a £250 boot. It is a unisex boot, but it is taking into account the female biomechanics, so we are getting there. There is one brand in the world called Ida that does a football boot designed for women, but it is not a £30 or £40 Decathlon product. It is brilliant, but it is not a mass-market product.
Q42 Jackie Doyle-Price: Louise, do you have any thoughts on that? Is the fact that we are getting these differential levels of injuries evidence of sexism in how sport is managed?
Dr Newson: It is really interesting. Yes, why are we not looking at anything that has a gender difference? Why are we not exploring that? There is so much—dare I use the word?—medical gaslighting and misogyny in medicine. We are very formulaic. I say “we” as the medical profession, although I would like to think I am not so formulaic. We look at the things that are in front of us.
I have worked part-time as an academic as well as a GP, so it has given me some time to reflect. The problem with many healthcare professionals is that you do what is in front of you and you go to the next patient and the next patient. That is absolutely the right thing to do when you are busy, but you learn by pattern recognition. If there is something that is more common in women than men or girls than boys, what is the difference? Is it a chromosomal difference or a hormonal difference? Is it that they are exercising less and are just not used to it? There are all sorts of things, but we need to explore and have a look rather than just doing a knee-jerk, “Right, we will just treat that condition because that has happened now”.
I am not aware of any really good-quality research looking at why there is a difference. This is so important, especially when, hearing everyone talk, we are thinking about mental health as well as physical health. They should not be seen in isolation. We all know how mental health problems are worse in very young children but also in teenagers. We have to look at the two together, the bigger picture and what is happening.
How, as medics, are we failing these people? A lot of my work is about preventing disease. We can prevent disease by not being overweight, by exercising and, for those who need it, by rebalancing their hormones. These are very simple and not very exciting tools for a lot of people, but is that not better if we are going to save the health economy, not just in the UK but globally? Any gender difference is a red flag, and the same would be true if there was something more common in boys or men. We should be looking at that and thinking about why this is happening.
Q43 Jackie Doyle-Price: Kate, could I ask you about the risk factors for RED-S? We heard a little bit about that earlier this afternoon. What symptoms should we be looking for in girls and women? Why are they particularly prone to it?
Kate Seary: For those who do not know what RED-S is, it is called relative energy deficiency in sport. It is where, either intentionally or unintentionally, athletes are under-fuelling. That can cause lots of bone and tendon injuries but also mental health issues and then, in worse cases, fertility issues too. We find it in men and women, but mostly in aesthetic sports or endurance sports.
Our most recent report found that over 50% of athletes have at least two symptoms of RED-S, and this links to what we were talking about earlier. It is all about body image and this stereotype that lighter is faster or thinner is going to perform better. We know that that is not true. The issues that we are talking about are very much linked. There is a huge risk there that we are causing insane damage to our athletes, and it is really prevalent.
Q44 Jackie Doyle-Price: I had never heard of that condition until this afternoon, and yet I know of somebody who was an international athlete who displayed exactly that. She was a gymnast, so her calorie intake was hugely important. The moment she retired at the age of 18, she just shot up, so her calorie intake was actually having the effect of delaying the onset of puberty. That is quite an extreme example, but how common is that?
Kate Seary: It is extremely common. As I said, 51% have at least two RED-S symptoms. From our report, 20% have five or more symptoms of RED-S. Anecdotally, I am a middle-distance runner. I do not know another female middle-distance runner who could say they have a 100% healthy relationship with food. It runs that deep.
Every single female athlete I have trained with throughout my life has worried about the calories they are eating. Our report said 91% of female athletes worry about calorie intake, which is really scary, quite frankly. The athletes who are then restricting their food intake are suffering 36% more RED-S symptoms. That comes from this notion that what we see as an athlete is a very thin, toned white woman. That is what society tells us, and that is not changing quickly enough.
Again, it also comes down to coach education. We know that 51% of athletes have had comments about their bodies that have made them feel uncomfortable in a sporting context. Those athletes are four times more likely to be restricting their food intake. As I said, those athletes who are restricting their food intake are suffering 36% more RED-S symptoms. It really comes from how we are talking to our athletes and the image of athletes we are putting out there into the world. It is not inclusive in any way, and the mental and physical health of our athletes is suffering as a result.
Q45 Jackie Doyle-Price: It sounds like we need to raise awareness. Lisa, do you have any observations on RED-S, but also on any health conditions that you want to particularly highlight where there is a gender difference?
Lisa West: There is nothing that I would add to what has been said, particularly around injury. The only point that I would put in there is around leadership. We know that, if we have women in decision-making positions with a greater understanding about everything that we are talking about across all sessions, we have a better culture in our organisations and we have better decision-making processes as well. We know that, if we look across the top 20 sports by participation, less than a quarter in the roles of CEO, chair or performance director are women. We just do not have enough women making decisions who are helping to make sure that this stuff is being profiled and dealt with properly.
Q46 Jackie Doyle-Price: Louise, we are having this conversation in the context of elite athletes, but would you say that RED-S would also be a problem for the non-elite participants as well? Would you see any evidence of that?
Dr Newson: Yes, I worry about eating disorders. I really worry about that, because there are a lot of athletes for whom periods are an inconvenience. They do not all want to take the contraceptive pill. Many of you might know that, if our bodyweight goes beyond a certain threshold, our bodies are very clever. They do not want us to be pregnant when we are malnourished and underweight so for a lot of female athletes—eating disorders can occur in boys, of course—their ovaries switch off. That is great for some of these people because they think, “No periods—isn’t that great?”
As you might know, without the hormones, there is an increased risk of osteoporosis. I have seen a lot of young people with osteoporosis. The longer a woman goes without hormones, the greater the risk of heart disease and dementia. Cardiovascular disease and dementia are the most common killers of women globally. I have seen athletes who have had stress fractures, low-impact fractures and osteoporosis.
What they do not know is that they can have their hormones back without having periods. This is really important, because I see it more and more often. I pick up people who had an eating disorder 10 years ago, and they experience the effects of low hormones. No one told them, or they just asked, “Did you take the pill?” Obviously, as I have just said, if you take the contraceptive pill, it blocks your testosterone. It might make you feel worse. Eating disorders can reoccur during the perimenopause and menopause, so they often come back to haunt people at a time when they are feeling worse mentally as well.
You are absolutely right about education. It is not about how we look; it is about what we are eating. We only need to look at all the ultra-processed foods. This needs to be addressed as a priority. It is so easy and cheap to eat badly. That is affecting cardiovascular health and mental health for these people, which will feed into this conversation.
Kate Seary: I wanted to add some stats that back up what was just said about the misinformation around periods: 36% ignore missed periods because they thought it was normal for an active person; and 30% had GPs tell them that it was incredibly normal to miss a period. Interestingly, we asked the athletes whether they took contraception or whether they had a natural menstrual cycle. Some people ticked both: they were on a hormonal contraceptive but also having a natural period. There is an education piece around that. Even when athletes are on a hormonal contraceptive, they do not understand their periods enough.
Jackie Doyle-Price: They do not understand that hormones are not sweeties.
Q47 Chair: Lisa, you painted a pretty bleak picture of sexism in the way we relate to women in sport from the age of six months old. That is quite depressing, is it not?
In my questions, I want to know about sport and women in midlife. If we are doing badly at age five, how are doing at 45? Have the reports that Women in Sport has done around that made a difference? Has that meant that gyms or sports clubs are more welcoming to women now?
Lisa West: We talk about the cumulative impact. We talk about the gender stereotyping that happens when girls are young, and that plays out through life. For women in midlife, we know that menopause happens there, but there is also so much else going on in that period of life. We know that that is when women are likely to be caring. We have sandwich carers who might have young or older kids.
If you then look in particular within the work we have done in south Asian communities, women are even more likely to be in caring roles there. We have to think about the different cultural backgrounds in this and how they are even more affected. In midlife, we saw that the cultural element played out much more significantly.
The profile of menopause in particular has definitely been helping, but the issue of invisible women that we have talked about for a while has not gone away. Sport, fitness and leisure is still not good enough at understanding women in this life stage and what they need.
We know that a lot of women in that stage have less than 35 minutes a day of time to themselves, by the time they have been to work and looked after everyone they are looking after. If we look at the Government recommendation for physical activity for health, they barely have enough time to get that in in that time. They are incredibly time-poor.
We have to think differently in our offer for women in this stage of life. Yes, menopause is obviously a huge part of that, but we need to look more broadly. We need to look at policies around women’s health that take into account more than just specifically looking at women while they are in the menopause. Of course, perimenopause and menopause is such a long period. We have to think of it quite holistically.
Q48 Chair: What could more be done? What should we be doing? If we are time-poor and we feel pushed out anyway, what actions can sports clubs take to make those doors more open to women?
Lisa West: We talk about support from society as a whole and, particularly from men, a greater understanding of the experiences that women are having. We often make jokes about the marriages we have saved from just helping men understand the experiences of women in midlife, but it is really important.
We talk about it from the perspective of healthcare and everything that has been talked about in terms of HRT and services, as well as opportunities to participate. When we are talking about increasing participation across sports and in sports clubs, we are talking about how we get kids in. We are not thinking about this huge group of people who are sat there and probably had a hideous experience of sport growing up. My generation was maybe the start of the tipping, but I still would not say I enjoyed PE. Certainly, my mum had a hideous time in PE.
We are taking people who have had a bad experience of sport and physical activity, and then we are saying, “It is really good for you. Off you go. You are going through the menopause; go and be active”. We are just not giving them the messages that they need to hear. We are telling them why they should do it as opposed to talking to them in a way that says, “I understand the experiences you have had and why physical activity is not inherent in your daily life. How do we therefore create something that works for you?” We are just hitting them with “you should” rather than helping them understand what they might need themselves.
Baz Moffat: Also, the sports system is designed on a hierarchy from kids at grassroots right up to the national teams, but then that is it. As a coach, you start off and you will get stuck at a certain time. That is where you might be happy, or you will be on this hierarchy, but then we forget about that massive cohort post those at the top of their tree, whatever that might be.
We have been doing some work within the fitness industry educating personal trainers and fitness instructors about women going through menopause. Most personal trainers and sports coaches are men and, especially in the world of fitness, they are mostly younger.
As we know, there is a huge benefit for midlife women to be doing strength training and impact work, but they might have bodies that have not moved, bodies that are overweight or pelvic floors that are leaking. Then they have coaches who do not know how to train them with that body, so they are more likely to get injured or just be embarrassed by being asked to do something that they cannot necessarily do. It is about educating those people who are supporting those midlife women as to how we can train them well so that they get strong, resilient bodies.
Within the sports teams, open-water swimming, age-group triathlon, Pilates and walking are doing a good job of appealing to sportswomen. If you are a netballer or hockey player and you still want to play and be competitive, you are hanging on to that competitive team. There are not those competitive, challenging situations that midlife women want to be in, but within the context of their lives when sport cannot be their all and everything.
Q49 Chair: Louise, can I turn to you? There were some questions earlier about the use of testosterone, perhaps in women who had had early menopause, and whether that could help them stay competitive in sport. Do you have any comments about why there could be arguments against the use of testosterone, or how it can be used and regulated to make sure there is fairness?
Dr Newson: There are two issues here that I would not mind discussing. The first is the conversation about midlife, which is very important. Lots of things go on. Not that any woman is average, but the average age of the menopause in the UK is 51. In some areas and ethnicities it is a lot younger. Our hormones, both oestrogen and testosterone, are very important for our brain function, but also our muscle and bone function. Very common symptoms of the menopause are joint pain, muscle stiffness, reduced motivation, mental health issues, and weight gain because of the metabolic changes that occur.
What I get quite concerned about is that there is lots of education about the menopause saying, “You will expect to do this. You will feel like this. You will not be able to exercise in the same way”. That is because you do not have hormones. We need to address that. We have NICE guidance, which is seven years old now, showing us that the majority of women benefit from HRT. We know only about 16% of menopausal women take HRT. In areas of deprivation, it is as low as 2%. We need to be thinking about why we are not giving treatment to women. That is a crucial thing, and that is just HRT hormones with oestrogen.
With testosterone, it is a massive gender inequality subject because we have higher levels of testosterone than oestrogen in our bodies when we are younger. It is not a menopause-depleted hormone; it is age-related. If you look at the graphs, it gradually reduces from the mid-20s onwards. Obviously, it is a lot lower when we are older, but it is really important because it is a very biologically active hormone. It is the most biologically active hormone we have, and we have receptors in cells all over our body, especially in our brains.
We are told by NICE guidance, which is how we work out of my clinic, that, if someone has reduced sexual desire despite being on HRT, we can consider testosterone. It is still off licence, so it is not licensed for women. That does not mean it is not safe. We prescribe either the gel, which is licensed for men, of course, in lower doses, or there is a private cream available that is licensed for women in Australia. It is not licensed over here, but it is very safe. We prescribe a very small dose, and we monitor testosterone levels very closely.
One of the problems is that it is not just about libido. Any of you will know that libido, in men and women, is not just as simple as a hormone. We have just presented a series at an international conference. Because we have testosterone receptors all over our body, many women, not only at our clinic, are describing that their mood, energy, concentration, stamina, ability to build muscle and to sleep can improve. Not sleeping, as you know, is a form of torture. This improvement is no surprise, given the way our hormones work physiologically.
Obviously, I have a lot of patients. We have a massive clinical experience. We see around 4,000 menopausal and perimenopausal women a month through my clinic. They are all underserved by the NHS; that is why they come. We give testosterone to those with reduced libido and monitor their blood levels very closely, but there are a lot of women, especially professional sportspeople, who have to choose between their career or taking testosterone.
This is where I have a real issue, because it is a natural hormone. Men are allowed a medical exemption certificate if they take testosterone for medical purposes, whereas women cannot. Women can take HRT, but you can have all the oestrogen you like; it is not going to stimulate your testosterone receptors or replace the missing testosterone. There is a real gender inequality here that I very strongly feel should not be happening.
Q50 Chair: Thank you very much for that. Are there arguments against its use?
Dr Newson: There is a bit of a discussion because people think it is a placebo. As you know—I am very transparent—I work in a private clinic. It is a very large private clinic, but I do not work with pharmaceutical companies. I do no paid work with pharma. I do not have any other interests, and a lot of our profit goes to research and the free Balance app, as I am sure many of you realise. People are saying it is placebo, but, again, that is a bit of medical gaslighting. It is very derogatory to women to think that we are taking something that is a placebo when we know it has biologically active effects.
People are concerned about theoretical risks. If you took too much testosterone, of course there could be a risk of virilisation—hair growth or voice changes. They are all reported, but we have about 10,000 women on testosterone, and I have never seen those side effects at all. We monitor their levels and they are in a normal physiological range.
The most common side effect is that people can get some hair growth on the site of application, which is usually the thigh. Most women do not worry about a bit of hair on their thigh when they have their brain back. A lot of people tell me that they can go back to work; they can function; they can sleep; they can exercise because they have some testosterone. Paying for it privately costs about £1 a day. That is a very good investment for future health.
Some studies have shown that there is a lower risk of cardiovascular disease and osteoporosis. There is probably a lower risk of dementia, but the studies just have not been done. We are trying desperately. We have just applied for a bid with Cardiff University to do a proper randomised control study on testosterone, because it has not been done.
We cannot ignore the fact that we have this hormone that is in our body with testosterone receptors all over our body. We would not do this with any other hormone, so it seems so bizarre that we are trying to do everything we can to deny it. I cannot quite understand the reason, other than gender inequality.
Q51 Chair: Can I just ask a quick question about the equality of testosterone and what challenges there are? You said it is off licence in the UK. There is an Australian version that is licensed for women in Australia but not here. What are the challenges in getting a testosterone product in the UK that is licensed for women?
Dr Newson: There used to be a testosterone patch that was licensed for women called Intrinsa. The company that made it just stopped making the patch, and then the MHRA withdrew the licence. There was no safety issue at all in that. It was licensed for young women. Young women with early menopause have their ovaries removed. Of course, their testosterone is going to be depleted.
I know the manufacturers of Androfeme have tried several times, and they have just put in another application, but they have been told there is going to be a delay of over a year before even looking at it. I am not sure why. It might be a cost thing, because there are 14 million menopausal women, and probably quite a lot of those are testosterone-deficient. About 25% of women have reduced libido and HSDD—hypoactive sexual desire disorder. Even if you are only looking at libido, that is still an issue.
Q52 Chair: Can I interrupt you, Louise? We have a Division Bell here and I am going to have to bring the meeting to a close. In a quick answer, can testosterone for female athletes be performance enhancing in a regulated dose that would help them cope with menopause symptoms?
Dr Newson: No, it would take them back to where they should be. It would not enhance their performance in a supraphysiological way.
Chair: Thank you very much. Apologies for having to call this to a very abrupt halt, but we have a Division in the House. Can I thank all the witnesses for their evidence today? If there is anything you wish to add in writing, please do so.