India’s sports training vision does not understand the female body

When we fail to understand a female athlete’s body, we also extend our patriarchal biases into sports. TNM spoke to a few athletes and doctors to see what transpires in their worlds.
A representative image of a woman playing football
A representative image of a woman playing football
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Popular football club Kerala Blasters recently shut down their women’s football team to raise funds for a fine imposed on their men’s team. Ironic? Not really. Sports, as a discipline, is designed for men, and to exist in it, women have to fight many gender stereotypes. The Blasters women’s football team bearing the brunt of the men’s team’s financial burden is a classic example of how our sporting culture de-prioritises women. But this is not where the problem begins. That the female body is generally misunderstood, has specific consequences for a sportswoman. For a female athlete, the problem begins right with her physiology. Doctors explain that since menstruation forms the crux of the female reality, their hormonal composition changes by the day, warranting pointed interventions at every single step in the way they are trained. But does our sporting vision really care about this?

Dr Sruthi N Kumar, a practising gynaecologist in Kerala says that women’s bodies follow a cyclical pattern anchored on their menstruation, as against the linear body trajectory of men, and that our sports training mechanisms hardly understand this. “This affects everything starting right from anatomy. Let’s look at basic exercises. They are all designed for men, like the simple squat for instance. A man’s squat will look picture-perfect with his spine symmetrically erect, whereas a woman’s picture-perfect looks different because of her anatomy and wider pelvic floor. This differential nature impacts all aspects of sports training including nutrition, fitness, mental health, and medication,” says Dr Sruthi, who is a level-1 cross-fitter herself, and the Director of the SFC Fitness and Martial Arts Centre in Kerala’s Kozhikode.

In a patriarchal society, where women suffer from malnutrition, anaemia, and stigmatised menstruation, female athletes often only have their passion as fuel as is very evident from the lack of institutional will to fund and sustain women's sports. Imagine eating an imbalanced meal, travelling a long distance to a practice ground, braving the male gaze, and exerting despite energy loss just to play a sport. We spoke to a few athletes and doctors to understand what transpires in their worlds.

Nutrition and the female triad

The most critical differentiating aspect for a woman in sports is, of course, her physiology. Most sports are anchored on physical fitness and performance, and nutrition is the founding element to maintaining optimum fitness. 

Femina Raj, a young footballer from Vadakara, completed her degree at St Joseph’s College, where the Kerala Sports Council gives accommodation to select athletes to stay and train along with academics. She says that sports hostelers ate the same food that other students ate, making it difficult for athletes to sustain themselves through long hours of practice. “In the mess, we were given chicken only twice a week, that too with any one meal of the day. We then protested and approached the management, and now, I am told that there is chicken every day with dinner,” she explains. While the lack of adequate protein may be something even male athletes face, what makes the deficit more adverse in females is that their bodies are prone to spiral into what is medically called a ‘female triad’.

Dr Sajesh BS, a physiotherapist who specialises in sports injuries, explains the female triad. “The female triad is a combination of three interrelated conditions – energy deficiency with or without eating disorders, menstrual cycle imbalances, and impaired bone health with or without osteoporosis,” he elaborates. Females in any sport can develop one or more conditions mentioned in the triad if they do not eat right or exercise in tandem with their bodies. Since women’s bodies are cyclical, one condition easily triggers another, leading to loss of muscle, increase in stress injuries, constant fatigue, menstrual abnormalities, mood swings, and loss of bone health, among others. 

The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad, after the first (San Francisco, California, USA) and second (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad, provides guidelines for trainers, physicians, dieticians and other caregivers of female athletes with detailed information about how to diagnose a triad, ways to treat it, as well as recommendations to clear an athlete experiencing a triad for return to play. It says that a screening for the triad must be conducted as part of the pre-participation physical evaluation – this includes collecting information about the menstrual cycle of the athlete, her history of menstrual distress, list of hormone medications or contraceptive medicines taken if any, body image issues if any, bone health impairments or history of stress injuries, eating disorders, and diet pattern. It also recommends bone density tests to evaluate mineral loss as frequently as every two years.

The International Olympic Committee’s statement of consensus on the female athlete triad also addresses this condition in detail. Noting that a coach must be able to identify an ‘at risk’ or symptomatic athlete, the statement also says that physicians, health care providers, and coaches should be aware of risk factors, including body image stereotypes that equate thinness with popularity and success, especially in those sports where leanness or specific weight is important. It also says that many people presume that a thin athlete may not experience a triad, because in our fatphobic culture, thinness is often considered as fitness. But this is the wrong way to go about it because a female triad can occur in athletes of any size. The solution is to ensure adequate nutrition and keep track of dips in energy, and menstrual fluctuations. 

A 2019 study put together by a multi-disciplinary team comprising physiologists, nutritionists, academics, and gynaecologists at the Inspire Institute of Sport (IIS), tracked the menstrual cycles of the athletes training at the Bellary-based IIS centre. The study says that an alarming number of Indian athletes miss their periods and are prone to injuries and bone mineral loss. The pool of respondents included athletes in sports such as athletics, boxing, judo, swimming, and wrestling. 20% of the 51 athletes missed their periods, while 90% were deficient in iron. The research further showed that nutritional deficiencies in women are much higher compared to their male counterparts.

In elite sports and in professional clubs, athletes may have access to personal nutritionists and regular medical screening, but that is not the picture everywhere as Femina mentions. Dr Sajeesh also affirms that the most important causal aspect here is nutrition. “For women, extra care must be taken to include supplements like iron in their diet because they menstruate, as well as calcium and folic acid. Leafy vegetables, nuts, eggs, milk, – all such foods must be taken in balanced proportions to avoid muscle loss. Omega 3 fatty acids are also very crucial for women, which can be gained from including fish in the diet. Additionally, vitamins D and B12 also must be supplemented,” says Dr Sajesh.

Femina says that though their protests have brought chicken to the table once every day for sports hostelers, just having chicken is hardly enough. Most of the time, students eat the food they get thinking that in itself is a big relief, albeit it being insufficient. “There is nobody there we can ask such things to. I don’t know, at least. Sometimes they give us some dates or nuts once or maximum twice a month. I don’t know if they cannot afford to give us good food or if they simply ignore us,” she says.

Dr Sajeesh points out that 1 to 2 grams of protein are required per kilogram of body weight for a person who trains intensely. “250 grams of chicken may hardly have 30 or a maximum of 36 grams of protein. This will result in a deficit, and athletes need more because they burn more and there is monthly drainage of fluids in women. Dehydration is yet another neglected aspect, which for women, is almost doubly adverse in effect. Public sports schools don’t seem to follow these specifications to the dot and when women experience nutrient deficits for a long time, they go into a triad, exacerbating health risks and defeating their hard work,” he says. 

Even at home, most women from marginalised locations cannot afford adequate nutrition. In privileged homes as well, patriarchy often determines who gets the fleshier piece of meat at the dining table, which is not the woman. When women go to institutions that promise sports training and lodging along with food, it is extremely important for those in charge to ensure that their nutritional needs are met keeping in mind all the complexities of their bodies.

Impact of hormones, OCPs, testosterone shots

Kavya, a 23-year-old footballer from Kerala’s Kozhikode, who now works at a gym as a trainer, says that it is access to regular fitness equipment that makes employment at a gym more beneficial for an athlete like her. “At home, I don’t have the required arrangements to maintain my fitness. I can do core exercises, but strength training is not possible. For us women, if we don’t practise or play for even a few days, our form is altered and we have to build from scratch, unlike male bodies. This also makes us easily prone to injuries,” she says. Dr Sruthi explains why this is true.

“Female bodies have lesser muscle mass because of the presence of female hormones – oestrogen and progesterone. While this is true, having lesser muscle mass is not the reason why female athletes are prone to injuries. The hormone profile of women fluctuates by the day, as against men, who have a more or less steady count of testosterone. So when a female athlete trains, or plays a sport, if this fluctuating dynamic of her body is not kept in mind, she will be prone to injuries. Women have a wider pelvic floor and therefore, they are also more prone to alignment injuries, ACL tears, dislocations in the leg, etc.,” she says. 

Methods to increase muscle mass in women can also lead to an absence of menstruation. The absence of a menstrual period for more than three cycles is called amenorrhea, and fitness coach Gaadha Madhav says that this can be because of extreme exercising. “To build extreme muscle mass, like sport a six-pack, the body fat percentage has to go very low. When the body loses such large amounts of fat, it triggers menstrual problems, sometimes leading to the absence of periods in women,” she says, adding that the idealisation of abs and a size zero body in our society also contributes to this dangerous level of fat loss.

Dr Deepti, a practising gynaecologist from Thiruvananthapuram also confirms this. Additionally, she says that severe physical stress in female athletes may lead to a lack of ovulation because their brain does not secrete enough chemicals that stimulate ovulation, owing to their extreme physical exertion. “These chemicals are secreted from the brain, precisely the pituitary gland. Physical exertion affects brain activity and sometimes suppresses ovulation, leading to irregular periods or lack of periods altogether,” she says, citing that the key is to understand each athlete’s subjective chemical composition and regulate training accordingly, along with regular medical monitoring.

Dr Ashley Tomy, who specialises in sports medicine, says that many female athletes often take additional testosterone – a male hormone that is found in lower levels in the female body – to help with muscle power. “Testosterone catalyses muscle building and gives muscles the power to explode when there is a high-stakes sports performance. This is found in men, definitely, because it is a male hormone, This is why men have more physical power and muscle mass. While many sportswomen take testosterone, there is no informed supervision on how to wash it out and allow the body to rest. This leads to accumulation of it, leading to problems like developing cysts in the ovaries (Polycystic Ovarian Syndrome), back pain, menstrual distress, loss of fertility, etc.,” he explains. 

Many female athletes use progesterone-based hormone medication to delay their period when they have intensive training or important matches, altering their menstrual cycle. Femina says that she has seen her fellow players use these medicines, and while some of them are scared of the impact on their bodies, some are unaware. 

Dr Sruthi says that the content of a hormone medication to delay a menstrual cycle is progesterone. “While it is a steroid and sex hormone that is already present in the body, administering it externally alters the body’s natural cycle, exerting stress on the ovaries. This is not advisable, and such medicines should strictly not be taken frequently,” she explains. She also clarifies that all hormone medications are prescription drugs, and only emergency contraceptives can be accessed over the counter. “Many athletes are constantly worried about not getting pregnant, and the mind space lost to this itself is tortuous,” she further adds.

When asked about Oral Contraceptive Pills (OCP), she says that though they may not have severe side effects, they are generally not prescribed to women who have migraines, kidney diseases, or liver malfunctions. “Even for those who take OCPs, we do not let them use it for long periods of time. Usually, we give it for say six months and then give it a break before resuming. This is to allow the body’s hormonal cycle to also function on its own, without the stimulation of the OCPs. Otherwise, it becomes stressful for the reproductive system,” she adds.

Dr Deepti says OCPs are not only used for contraception but also to regulate menstruation by supplying hormones that may be suppressed in athletes due to physical exertion or pathological reasons like ovarian cysts. “OCPs are a very convenient method of contraception compared to inserting intra-uterine (IU) contraceptive devices. Additionally, they regulate periods, and prevent any kind of pregnancy, even if it is one that develops in the fallopian tubes. IU devices only protect against pregnancies within the uterus,” she says.

How does a sportswoman manage menstruation and pregnancy? 

Female bodies are also devalued and considered a bad bet after childbirth, adding to the mental pressure about pregnancy as Dr Sruthi mentions. Aparna Balan, a national champion and international medalist in badminton, who recently received the GV Raja Award for the Best Sportsperson in Kerala from Chief Minister Pinarayi Vijayan, says that while Kerala is a state which is more conducive for women in sports compared to other places when it comes to breaking stereotypes about female bodies, the mechanism needs improvement. “For example, when I returned to the game after childbirth, I did not have sponsors, though I was training and ready for matches. Even those who were sponsoring me until then stopped their contributions. I had to spend my own money to go to tournaments, buy equipment, etc. People don’t really get the female body and this reflects in how few resources come to us, undermining all the progress we have made so far in our career,” she says.

Experts point out that this is just another myth stemming from a lack of understanding on how to train a woman’s body during and after pregnancy. When asked about physical fitness and pregnancy management, Dr Sruthi says that most coaches do not train athletes throughout pregnancy and post-delivery, partly because they may not be aware of how to, and partly because in our social psychology, pregnancy is treated as a ‘period of rest’. “When people don’t understand something, they choose to not address it. This is why the bodies of female athletes are underestimated after childbirth. In the absence of other medical complications, a pregnant woman can train, and even lift weights. But all this must happen under close supervision of a coach or medical practitioner. A pregnant athlete who has regularly been training can keep her workouts going. For an otherwise healthy pregnancy, workouts do not increase any risks. But the woman must take care not to do acts that make her prone to losing balance or get hit on the abdomen,” she adds.

With respect to how training is adjusted when an athlete is menstruating, Priya PV, a former footballer who is currently the head coach of the India women’s under-17 team, feels that if women athletes get proper training from a young age, they can be taught to manage their menstrual pain. Dr Sruthi explains how pain management happens through exercise. “If a person exercises or trains regularly, their menstrual pain will be lesser. This is because exercising releases a chemical called endorphin, which reduces the body’s sensation of pain,” she points out. She also says that if a woman experiences severe menstrual cramps despite exercise, then there is usually a pathological reason like endometriosis (lining of the uterus growing outside the uterus), cysts, or other conditions. 

Endometriosis and cysts in the ovaries often present with high-intensity pain. But Gaadha, who suffered both, says that in women who exercise regularly, this may be difficult to figure out. “I would just pop a painkiller and work out and I had a lesser sensation of pain compared to what women would usually feel when they have endometriosis. This is because I lift weights and train regularly. So it had to really get worse for me to see a doctor. Even my cyst was one that was blood-filled, and it would move about when I had period cramps, because when you cramp, your uterine muscles contract. But otherwise, it would simply sit intact and I thought the pain during periods was regular period cramp,” she adds.

Any pain that cannot be managed with a simple painkiller, or any pain that persists, must be investigated, and abnormalities can be diagnosed through ultrasound scans. But women’s pain, especially related to menstruation, is considered normal and seldom examined. When an athlete goes from tournament to tournament, it is easy to brush aside cramps, leading to pathological problems being undiagnosed until they get worse.

Citing that if an athlete wants rest she must be able to avail it, Priya says that how much pain tolerance an athlete has is subjective and the coach must be able to understand this. “It is important to believe a woman when she says she is in severe pain instead of positioning her pain as a weakness. This also, in turn, helps in diagnosing menstrual health problems early on. Since athletes spend the most time with coaches, we must assume this responsibility,” she says.

Femina remarks that such sensitivity towards menstruating athletes comes mostly from female coaches. “In group practices, just because one person is menstruating, nobody alters the workouts. If we are unable to move, we sit it out. Some women jog on the side or stretch on their own. If we sit out, we lose a day’s training, which is treated as our personal loss,” she says. 

How sports play up the mental fears of women

For women, mental wellness is deeply connected with their socio-political marginalisation. In a high-performance career like sports, the focus is always to outdo a potential competitor through an explosive display of physical power and skill. Sports initially started off as a preparation for war and has always been a man’s arena. It was only after frequent wars ended that it became an activity for leisure or competition. When a woman lands in professional sports which looks at her abilities and her body through a systemic male gaze, her mental fears only play up. But there is seldom space for any healing. 

In 2021, top Indian wrestler Vinesh Phogat, who is also currently among the protesters in the alleged sexual harassment charges against India’s Wrestling Federation Chief Brij Bhushan, had revealed that she was diagnosed with depression in 2019. Citing the example of international gymnast Simone Biles who pulled out of events because of bad mental health, Vinesh said that one could not even imagine such a thing in India. She also wrote about the breakdown she went through after having lost at the Olympic stage in Tokyo in 2020, saying, “My body is not broken, but I am truly broken.”

In the First Information Reports registered on April 28, 2023, based on the complaints of six wrestlers, the complainant athletes mention mental trauma owing to sexual advances by Brij Bhushan. This explains how physically embodying the female identity is in itself an added layer of stress in a culture that sexualises women, demanding them to compromise their dignity in return for their hard work to be rewarded. 

Priya, who deals with young female footballers who are under 17, says that coaches must have a gender-sensitive approach, especially while training young women in sports, because the anxieties of being a woman remain, even if they are top performers.“Though many sports coaching courses, including the mandatory Diploma in Sports Coaching by Netaji Subhas National Institute of Sports, recognised by the Indian government have modules in psychology, generic psychology training alone does not cut it when dealing with female athletes who often fight their families to take up a sporting career and look up to coaches to instill confidence,” she says. 

Elaborating on how she herself tries to identify mental distress in students, Priya says that she closely observes their body language. “I look for signs of distress like frequent loss of attention, isolation from peers, lack of appetite, and general body language. If I feel something is off, I try to speak to them and reassure them, or rope in a trusted family member if necessary,” she says, adding that coaches cannot absolve themselves of this responsibility. 

Stressing the importance of looking at mental health as a gendered problem, Dr Sajesh explains that he meets many female athletes who experience performance anxieties after they develop an injury. “Women feel tensed about their career, opportunities, and how they would navigate things like childbirth if they don’t peak by mid-20s. They are constantly told they don’t have time, and hence, when they have the slightest injury, though they recover, they are mentally very affected. Their bodies are also constantly policed for size, choice of clothes, etc. All of this adds up to stress,” he says.

Physiology also plays an extensive role in determining the mental wellness of a woman. Any imbalance in menstruation can trigger mood swings and problems like Premenstrual Syndrome (PMS) or Premenstrual Dysphoric Disorder (PMDD), which is an aggravated form of PMS, causing extreme irritability, sadness, mood oscillations, hopelessness, and fatigue before the onset of the menstrual period.

Dr Deepti says that hormone medicines to alter menstruation, as well as OCPs can cause mood swings in women. “In the case of OCPs, it is when you use them for a very long period, say more than a year without break, that these problems become pronounced. They make the person feel emotionally vulnerable, triggering nausea, binge eating, and bloating,” she says. “Menstruation itself is a process involving a gamut of emotional ups and downs. When external medication is supplied, the effects cumulate in some people, and performance pressure does not help either,” she adds.

Dr Sruthi says that though pre-menstrual moods usually resolve as the period starts, some women experience it more severely than others, disrupting their daily activities. “While most women experience this, for an athlete, they cannot afford to fall back to nurse their minds because sports is often not that forgiving. Sometimes, exercise helps alleviate mood swings to an extent, but if the athlete feels stressed to the point of being suicidal or inflicting self-torture through extreme exhaustion, the trainer should immediately intervene and refer her for medical assistance. This needs the trainer to also actively look out for sings,” she adds.

Access to practice grounds

If an athlete manages to bypass nutrition and mental health and decides to go practice at a ground, access becomes a big barrier. In Kerala, it is not that hard to find a ground to play at, but we often see very few women in such spaces. While lack of access to practice spaces may be common to all sportspersons from marginalised identities, what makes it more pointed for women is the additional lack of safety they experience. 

Femina says that except at government practice grounds, there are no security guards appointed for supervision. “If we are playing in the Kerala state team, then of course, there is a team manager, guards to oversee our practice, etc. But take the case of Sevens football for example. We are often invited by small clubs in villages to play tournaments. In such cases, they would pay us and we would go play. While we practice late in the evening, or after the match as we pack up and leave, nobody accompanies us. There is a feeling of being unsafe, but that is how it functions mostly,” she says.

When asked about whether she feels safe accessing the beach or nearby grounds for individual practice by herself, she says that by now, like most other women, she has learned to ignore those who ogle or comment. “If I don't find a way to keep up with practice, it is my loss. So I try to focus on the practice. Not that I feel good about it all the time, but what else can be done?”, she asks.

What this does is that it plays up their anxieties as women. Sports training does not happen in isolation, and if nutrition, mental health, and physiology form the internal part of embodying the female identity, social marginalisation is the external element that triggers all elements into distress. This layer is also where conversations about institutional accountability and reform should happen.

Priya points out how barring a few, there are not many hostel or lodging facilities available for female athletes. Accessing a ground is one thing, but being able to feel safe in that space is another, which for a woman, is extremely non-negotiable. “We have repeatedly asked the Kerala Sports Council for more hostels, but as of now, the situation remains unchanged,” Priya says.

When asked if she still feels hopeful of pursuing football, Femina says she would like to keep trying. “Even to apply for a job, we should be able to show how many medals we won. But if this is the situation when it comes to training, food, and how unseen we feel, how can we perform at all?”, she asks.

When we fail to understand a female athlete’s body, we also extend our patriarchal biases into sports as a field that boasts of fraternity and a sense of spirited justice. From the accounts of these athletes and doctors, it appears that our sporting culture and policy measures need to make many more interventions to accommodate the needs of changing bodies and anxious minds of sportswomen.

This reporting is made possible with support from Report for the World, an initiative of The GroundTruth Project.

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