Biological and Socio-Cultural Factors Have the Potential to Influence the Health and Performance of Elite Female Athletes: A Cross Sectional Survey of 219 Elite Female Athletes in Aotearoa New Zealand
Open accessAbstract
Health is a pre-requisite for optimal performance yet the parameters which govern health and performance of elite female athletes are little understood. The aim of this study was to quantify the health status of elite female athletes, and understand sociocultural factors influencing that status. The survey addressed demographic, health and athletic performance history, training load, contraceptive use, sport-specific appearance and performance pressures, and communication barriers. Three hundred and fifty-seven elite New Zealand female athletes were recruited to complete an on-line survey. Two hundred and nineteen athletes completed the survey. Oligomenorrhea/amenorrhea had been diagnosed in only 12% of athletes compared with 50% of athletes not on hormonal contraception who reported symptoms consistent with this diagnosis. Stress fractures and iron deficiency were common and associated with oligomenorrhoea/amenorrhea (P = 0.002), disordered eating (P = 0.009) or menorrhagia (P = 0.026). Athletes involved in individual sports (P = 0.047) and with higher training volumes (P < 0.001) were more likely to report a medical illness. Seventy-three percent of athletes felt pressured by their sport to alter their physical appearance to conform to gender ideals with 15% engaging in disordered eating practices. Barriers to communicating female health issues included male coaches and support staff, and lack of quality information pertaining to health. Elite female athletes may fail to reach peak performance due to specific health issues and undiagnosed pathology. Sociocultural factors influence the effectiveness of support of female's health and performance. Organizational and cultural change is required if elite female athletes are to combine optimal health with best performance.
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Athletes are at a greater risk for LEA from sociocultural pressures, such as social media pressures, pressures from coaches/teammates/self to look a certain way, or from the prevailing belief that a lower body weight will result in greater performance outcomes.
“Athletes are at a greater risk for LEA from sociocultural pressures, such as social media pressures, pressures from coaches/teammates/self to look a certain way, or from the prevailing belief that a lower body weight will result in greater performance outcomes [122–125].”
From International society of sports nutrition position stand: nutritional concerns of the female athlete (2023) · cites this paper as [122]
The Results (Appearance- and Performance Related Pressures; Communication and Sources of Information, pages unavailable) document pressure from social media, coaches, peers and athletes themselves, including the belief that being leaner improves performance. They also report dietary restriction to attain an ideal body, and the Introduction links sports requiring low body mass or an idealized appearance with possible energy deficiency. But this survey of elite female athletes does not establish that sociocultural pressures increase the risk of low energy availability among athletes generally. (LLM, conf=0.86)
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Guevara, S. A., Donaldson, A., Keegan, R. J., Appaneal, R. N., Smyth, E. A., Waddington, G. S., Mahony, K. E., Mara, J. K., & Drew, M. K. (2023) · Journal of science and medicine in sport · doi:10.1016/j.jsams.2023.11.003 · Cited by 5 · see citing works
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Castellanos-Mendoza, M. C., Galloway, S. D. R., & Witard, O. C. (2023) · Frontiers in Sports and Active Living · doi:10.3389/fspor.2023.1279534 · Cited by 5 · see citing works
You, W., & Henneberg, M. (2022) · Scientific Reports · doi:10.1038/s41598-022-19633-3 · Cited by 5 · see citing works
Królikowska, A., Prill, R., Patt, T., Kayaalp, M. E., Ostojić, M., & Oleksy, Ł. (2025) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1002/ksa.70257 · Cited by 5 · see citing works
Gibbons, A. E., Thorpe, H., Hemi, K. V., Bruinvels, G., Pedlar, C. R., & Hamilton, B. H. (2025) · International Review for the Sociology of Sport · doi:10.1177/10126902251351181 · Cited by 4 · see citing works
“…decades, sport scientists have examined how sporting participation (and sport-related stressors) can impact the menstrual cycle, as well as how menstruation can impact athletes ’ health, well-being performance (Brown et al., 2021; Bruinvels et al., 2017; Heather et al., 2021; McNulty et al., 2020).”
Self-citationAnalysing gender disparities in youth sports coaching: an international survey (FEMCoach project)
Dias, V., Calleja-González, J., López-Ros, V., Font-Lladó, R., Arede, J., Cunha, L., Douka, S., Rosa, B., Pinto, G., & Leite, N. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1560764 · Cited by 4 · see citing works
Schofield, K., Thorpe, H., & Sims, S. T. (2023) · Physiologia · doi:10.3390/physiologia3030033 · Cited by 4 · see citing works
Self-citationStewart, D. G., Allen, J. B., & Kirkland, A. (2023) · International Journal of Sports Science & Coaching · doi:10.1177/17479541231179301 · Cited by 4 · see citing works
“Heather et al. 30 identi fi ed that >10% of elite female athletes had been told by their coach that they needed to lose weight.”
BackgroundLong Noncoding RNA LIFR‐AS1: A New Player in Human Cancers
Bai, Z., Wang, X., & Zhang, Z. (2022) · BioMed Research International · doi:10.1155/2022/1590815 · Cited by 4 · see citing works
“To expand the existing evidence concerning speci fi c gene variants that are involved in the pathogenesis of preterm birth, Frey et al. [52] used multiple genetic models in a cohort of African-American women to identify SNPs associated with spontaneous preterm birth before 37 weeks of gestation.”
‘Between the flags’: women's participation in surf lifesaving sport in Aotearoa New Zealand
Onken, R., Cosgriff, M., & Wheaton, B. (2024) · Sport Education and Society · doi:10.1080/13573322.2024.2366265 · Cited by 3 · see citing works
“…reported that the social pressures for women athletes to look a certain way can have complex negative impacts on their physical and mental health (Heather et al., 2021) and that a dominant belief was that leanness equates to better physical performance, adding complex layers of pressure for…”
Maximising the Usefulness of Wearable Data for Athletes
Sahdra, S. K., Duthie, G. M., Kay, J., & Yacef, K. (2024) · ACM International Joint Conference on Pervasive and Ubiquitous Computing (UbiComp) · doi:10.1145/3675094.3677600 · Cited by 2 · see citing works
Crawford, L., McNulty, K. L., Hicks, K. M., Hall, E. T., & Ansdell, P. (2025) · Women in Sport and Physical Activity Journal · doi:10.1123/wspaj.2024-0137 · Cited by 2 · see citing works
Menstruation in Motion: Understanding Experiences of Menstruation in Sport in Zambia
Zipp, S., & Mwambwa, L. A. (2024) · doi:10.5871/bacad/9780197267578.003.0006 · Cited by 2 · see citing works
Arévalo-Chico, H., Sellés, S., Fernández‐Sáez, J., & Cejuela, R. (2025) · The Journal of Strength and Conditioning Research · doi:10.1519/jsc.0000000000005100 · Cited by 2 · see citing works
Keys to female athlete performance in Paris 2024
Boz, E., Adatepe, E., Çelik, H., Kırkbir, H., Öktem, T., Ünlü, Y., Öz, Ü., & Yilmaz, B. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1718337 · Cited by 1 · see citing works
Nelson, M., Thorpe, H., Wheaton, B., Clarke, G. H., & Sims, S. T. (2026) · Journal of Sport and Social Issues · doi:10.1177/01937235261424379 · Cited by 1 · see citing works
“…improved menstrual health education, destigmatization of menstruation, and efforts to link affected athletes with quali fi ed medical providers such as reproductive health specialists and sports dieticians (Fletcher et al., 2024; Heather et al., 2021; Jakubowska, 2024; McGawley et al., 2023).”
Self-citationThorpe, H., & Shanks, A. (2022) · doi:10.64628/aa.pwq5pvtww · Cited by 1 · see citing works
Self-citationСєногонова, Г. І., & Sienohonova, L. (2022) · EUREKA Life Sciences · doi:10.21303/2504-5695.2022.002299
“It is necessary to understand and take into account the negative objective factors that are the result of deteriorating food quality, modern specifics of living conditions, employment of modern human, the inevitable deterioration of the environment and many other reasons [12].”
BackgroundKhalid, A., Ali, A., & Ahmed, F. (2024) · Journal of Development and Social Sciences · doi:10.47205/jdss.2024(5-i)10
“Surveys across North America, Europe, and developed countries, including South Asia, report a surge in appearance dissatisfaction, ranging from 23% to 56% for females (Heather et al., 2021).”
BackgroundVerma, R., & Gupta, S. (2024) · Research Square · doi:10.21203/rs.3.rs-4782294/v1
Sahdra, S. K., Duthie, G. M., Kay, J., & Yacef, K. (2024) · ACM International Joint Conference on Pervasive and Ubiquitous Computing (UbiComp) · doi:10.1145/3675094.3678362
“Other studies focused on the relationship between physical health and psychological markers in relation to athlete identity and performance such as Ng and Ryba [57], Rapp and Tirabeni [67], Abdullah et al. [2], Heather et al. [39], and Van Ryswyk et al. [78].”
Female leadership archetypes in sport: an approach based on the 2024 idols barometer
Aparicio-Chueca, P., Ivern, X. M. T. I., & Rodríguez-Rodríguez, S. (2025) · Sport Business and Management An International Journal · doi:10.1108/sbm-07-2025-0184
Resistance Training and Elite Athletes: A Systematic Bibliometric Analysis (2015–2023)
Dinata, W. W., Fitri, M., Mukhtarsyaf, F., & Rifki, M. S. (2026) · Physical Education Theory and Methodology · doi:10.17309/tmfv.2026.1.02
“Recent studies have also highlighted the importance of examining psychosocial and hormonal factors specific to female athletes, as well as the unique needs of disabled athletes (Suchomel et al., 2018; Heather et al., 2021).”
Luguterah, A. W., & Kokoe, J. (2026) · Women in Sport and Physical Activity Journal · doi:10.1123/wspaj.2025-0086
Ausland, Å., Solstad, B. E., Ivarsson, A., Melin, A., Laxdal, A. G., Augustsson, S. R., Radovan, F., Linnér, S., Kjær, J. B., Bjärsholm, D., et al. (2026) · Sports Coaching Review · doi:10.1080/21640629.2026.2659981
Badenhorst, C. E., Kolić, P. V., Romero‐Parra, N., & Sims, S. T. (2026) · Women in Sport and Physical Activity Journal · doi:10.1123/wspaj.2025-0144
Self-citationEkenros, L., Swärdh, E., Rosen, P., & Fridén, C. (2026) · European Journal of Physiotherapy · doi:10.1080/21679169.2026.2693305
Fogarty, N., Catháin, C. Ó., Lane, A., Henry, E., Walsh, D. M. J., & Chéilleachair, N. N. (2026) · Qualitative Research in Sport Exercise and Health · doi:10.1080/2159676x.2026.2708031
Building a Female Athlete Health Literacy Programme within Netball in Aotearoa, New Zealand
Cox, K. A., & Kearney, S. (2026) · Springer eBooks · doi:10.1007/978-981-95-8357-7_22
Nelson, M., Baker, D., MacManus, C., McKenna, M., & Moore, H. (2026) · Springer eBooks · doi:10.1007/978-981-95-8357-7_23
Clarke, A., & Carmichael, M. A. (2026) · Springer eBooks · doi:10.1007/978-981-95-8357-7_18
Embracing the Strength in Cycles: Insights from a Wahine Māori Sports Practitioner on Menstruation
Ogilvy, J. (2026) · Springer eBooks · doi:10.1007/978-981-95-8357-7_10
Carmichael, M. A., Roberts, A. H., Perry, K., & Clarke, A. C. (2026) · European Journal of Sport Science · doi:10.1002/ejsc.70265
“Friedlander et al. 2024; Heather et al. 2021; Mkumbuzi 2024; Majumder et al. 2022).”
- Authors
- Heather, A. K., Thorpe, H., Ogilvie, M., Sims, S. T., Beable, S., Milsom, S., Schofield, K. L., Coleman, L., & Hamilton, B.
- Affiliations
- University of Otago (NZ)
- University of Waikato (NZ)
- Auckland District Health Board (NZ)
- University of Auckland (NZ)
- Auckland University of Technology (NZ)
- Corresponding author
- Hamilton, Bruce
- ORCID
- Venue
- Frontiers in Sports and Active Living
- Publisher
- Frontiers Media SA
- Published
- 2021-02-18
- Volume
- 3
- Pages
- 601420-601420
- ISSN
- 2624-9367 (ISSN-L)
- PMC
- PMC7932044
- OpenAlex
- W3130659097
- Cited by
- 69
- References
- 32
- Citations by year
- 2026: 13 · 2025: 8 · 2024: 22 · 2023: 11 · 2022: 11 · 2021: 4
- FWCI
- 11.82
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Sports and Active Living (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Research Commons (University of Waikato) (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Social Sciences › Psychology › Developmental and Educational Psychology › Sport Psychology and Performance
- Keywords
- elite female athletes, athlete health, athletic performance, amenorrhea, oligomenorrhea, stress fractures, iron deficiency, disordered eating, menorrhagia, hormonal contraception, appearance pressure, gender ideals, training load, individual sports, communication barriers, male coaches, sociocultural factors, New Zealand
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