Examining Sex-Based Inequities in Pediatric Sports Medicine Research: A Systematic Review

Inequalities in the inclusion of male and female athletes have been documented in the sports medicine literature. However, the extent to which this phenomenon exists in studies of pediatric athletes remains poorly defined. The purpose of this study is to characterize the inclusion of male versus female athletes in pediatric sports medicine.

All articles published from 2020 to 2024 in 12 top interdisciplinary sports medicine journals were manually reviewed, and results were reported following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols. Inclusion criteria were: (1) full-text original research study, (2) isolated athletes, and (3) isolated a pediatric patient population. Exclusion criteria were: (1) editorial or review article, (2) case report with only one subject, and (3) cadaveric study. Data were collected to characterize study design, inclusion, and outcomes of interest. Statistical analysis was performed using the asymptotic χ2 (Pearson) test as the default. To examine absolute inequality in the inclusion of male and female athletes, mean differences (MDs) were calculated from linear regression models for continuous outcomes.

Across 409 included studies, 30% enrolled only male athletes, 10% enrolled only female athletes, and 60% included both male and female athletes. The median inclusion was 61% male and 39% female (mean 64% and 36%, respectively). Among 234 studies that focused on a single sport, 48.7% included only males, 15.4% included only females, and 35.9% included both males and females (P<0.001). Using MDs from linear regression, female athletes were shown to be underrepresented in study designs representing a higher level of evidence that analyzed variables such as patient-reported outcomes, injury, reinjury, or return to play. No difference in inclusion was seen in studies of mental health outcomes.

Females are underrepresented in studies of youth athletes, particularly in single-sport studies and study designs with a higher level of evidence.

Given that there are known differences in sex-related outcomes, future research should prioritize equity in the inclusion of male and female athletes.

Level IV-systematic review.