Equity360: Gender, Race, and Ethnicity—Title IX Turns 50: Women Athletes Are Still Fighting Against Gender Disparities in Sports

No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance.

— Title IX, Education Amendments Act (1972)

Four years after the passage of Title IX, during my first year as an undergraduate at Yale University, my rowing teammates and I participated in what might have been the first stand for gender equity in college athletics [20]. Unlike the men’s crew team, the women’s rowing team did not have adequate equipment or proper shower facilities for women at our school’s boathouse. Our team was saddled with a small trailer with four showerheads that only sprayed cold water [20]. The men, of course, used the showers (and its hot water) inside the boathouse. After every practice, the men’s team would hit the showers, while our team packed onto the bus and waited for them so we could get back to school in time for dinner at the last open dining hall and thereafter for a proper shower. The 30-minute bus ride back to campus after practice left us cold and wet, while the men were warm and dry. Multiple requests to address the issue had not been acted upon by the university.

After some discussion among the team, we decided to act. Lead by our captain, Chris Ernst, 19 of us protested in the women’s athletic director’s office. We stripped to display the words, “Title IX,” written across our bare chests and backs while Chris read a statement which began with, “These are the bodies that Yale is exploiting” [20]. Our story was picked up by the New York Times [12], embarrassing the university into action. One year later, an addition was built to the boathouse with facilities for women [20]. Several of us went on to represent the United States at the elite level. At the 1979 World Rowing Championships, I stroked the US National Team 8-oared boat to a bronze medal; in 1980, I was selected to the US Olympic Team.

We have come a long way since our protest. In the 50 years since the passage of Title IX, we’ve seen a dramatic increase in the opportunities for girls and young women to play sports. In 2018-2019, participation among young women in US high school sports (3.4 million) inched closer to that of young men (4.5 million) [11]. Moreover, the opportunity for girls to participate in sports has increased from approximately 24% to 43% between 1973 and 2018 [17] in the United States. When I was in high school, there were no sports teams for girls in my district.

Sociocultural learning experiences are some of the most important benefits that millions of girls now participating in sports receive. Girls who play sports are more likely to get better grades, have higher levels of confidence and self-esteem, have a more positive body image, and higher states of psychological well-being [18]. Research suggests lifelong benefits as well. Adult women impacted by Title IX have reported higher levels of physical activity and lower BMI [6]. Women who had greater athletic opportunities as teenagers have babies who are healthier at birth [16]. If I held the title of “Queen of the Universe,” all children would participate in sports beginning in middle school and extending through college.

Athletics can impact professional career decisions as well. While exposure to orthopaedics during medical school heavily influences career choice [4, 13], medical students who are athletes are more likely to enter orthopaedics. In a 2015 survey of women orthopaedic surgeons, 85% responded that they played sports in college or high school, and 46% noted that this influenced their career decision [10]. We have not seen a dramatic increase in gender diversity in our specialty despite the increase in athletic participation by girls and young women, and, embarrassingly, orthopaedic surgery remains the surgical specialty with the lowest percentage of women. Perhaps promoting athletic participation for girls and young women will increase the number of women exposed to orthopaedics through their medical care, potentially stimulating their interest.

While Title IX dramatically improved access to sports for girls and women, we are far from claiming equal treatment. A recent glaring example of Title IX inequity occurred in March when the deficiency of equipment in the women’s weight room at the 2021 NCAA basketball tournament (among other disparities) went viral on social media. This inequity resulted in the NCAA President agreeing to an independent review of disparities and a commitment to ensure that “all student-athletes are equally supported” at NCAA events [14]. Like so many, I was shocked at the images from the NCAA weight room, taking me back 45 years to that small trailer with cold-water showers. Now 50 years after the passage of Title IX, how can such a disparity still be allowed to happen?

Inequities at multiple levels continue. In March of 2017 the U.S. Women’s Hockey team threatened to boycott the world championships in protest over grossly disparate policies for the women’s team versus those of the men’s squad. The men flew business class, the women flew coach; the men had individual hotel rooms, the women shared their room with a teammate; the men were allowed to bring a guest to the world championships with transportation costs covered, the women were not permitted any guests [9]. While USA Hockey, the national governing body, initially stated that the boycotting athletes would be replaced, an agreement was reached that provided significantly more support to the women. Kudos to the National Hockey League for quietly providing some financial support to USA Hockey to help fund the agreement [21].

These disparities happen because someone permits them to. The public outcry over the NCAA and US Hockey debacles supported the resulting positive changes. It is our collective responsibility to support a level playing field for all athletes.

To support this level playing field, decision makers need to be committed to fairness. Title IX may have turned 50, but there are plenty of issues that remain, including enacting policies and guidance related to transgender student athletes and improving how schools handle the reporting of sexual assault on college campuses.

Transgender athletes

The controversy regarding biological males who identify as women and seek to compete in girl’s or women’s events has come to the forefront. How should the playing field be leveled for these individuals to allow them the benefit of sports while not creating a competitive disadvantage for biologically female athletes?

In June, the U.S. Department of Education stated that transgender students were protected under Title IX and that it is currently in the process of developing guidance related to this position, reversing policy enacted in the previous administration. However, numerous states have introduced legislation that would ban transgender students from competing in sports based on their biological sex at birth [15]. The Women’s Sports Policy Working Group [19], composed of sports legends such as Donna De Varona, Martina Navratilova, Donna Lopiano PhD, and my 1980 Olympic teammate Nancy Hogshead-Maker JD, propose that beginning in high school, transgender women must suppress testosterone for at least 1 year before competing against biological females to promote a more level biological playing field [3]. Policy decisions related to this highly emotional topic must be guided by science to ensure that biological females are not significantly disadvantaged by biological males who identify as women.

Title IX Complaint Failures

In 2014, a former Michigan State University student filed a Title IX complaint against physician Larry Nassar, describing how Nassar massaged her breasts and vaginal area during a medical examination. The Title IX investigation at that time found no wrongdoing by Nassar who returned to his position and continued his molestation of young women athletes. He was eventually convicted of rape in 2018 and must serve up to 175 years in prison [7].

In April 2021, seven women filed a federal class-action lawsuit against Louisiana State University and its leadership alleging that the defendants conspired to keep them quiet and “deprive them of their constitutional and federal rights in order to protect the reputation and income of LSU athletics” [2].

In July 2021, 12 women sued Liberty University, claiming they were victims of sexual assault or other sexual misconduct and that the university failed to help them when they went to campus police. Some plaintiffs claimed they were “urged not to file reports, or fined for honor code violations after reporting an alleged incident” [5].

In September 2021, former University of San Francisco (USF) female students turned to social media to allege predatory behavior from the USF men’s soccer team. The posts described a culture of misconduct on the team that spanned 20 years—that’s three coaches, four athletic directors, and two school presidents. The former students accused the school of not taking their accusations seriously [1].

Under Title IX, “when a student experiences sexual violence and notifies their school, the school is obligated to take measures to ensure that the student feels safe on campus and is able to fully access their education in the wake of violence” [8].

But these highly publicized systematic failures in the reporting and handling of sexual violence cases only make it more difficult for survivors of sexual assault to come forward. Although schools generally offer guidance and encouragement to report incidents to their respective Title IX offices on their websites, based on these high-profile cases, how can survivors feel that their education would not be disrupted? How can they feel confident that their stories will be heard, taken seriously, and fully investigated by their school?

For all the good Title IX has accomplished in its first 50 years of existence, there is still serious work to be done to achieve its vision. Alleged unequal treatment must be identified and investigated. Action must follow to right those confirmed wrongs. To do less would mean our failure, as a society, as parents, and as physicians, to promote equal opportunity for all.