Hello everyone!
I’m keeping this intro short so I can get to the good stuff, but here is a quick little explanation of this post:
I just graduated from the University of Utah with an Honor Degree in Ballet and a Minor in Nutrition: Yay! 🙂 🙂
Getting this Honors distinction with my degree meant that I had to fulfill a number of extra coursework requirements. I had to take several additional liberal arts classes, pass Honors Writing and Science, maintain a certain GPA, and complete an Undergraduate Thesis research project in my chosen discipline.
Although undertaking that thesis project is often the most dreaded part of any undergraduate’s Honors journey, finishing mine was one of the proudest moments of my college career. I felt so passionately about my topic, and the end result was 40 whole pages of writing, along with a fully produced creative dance work, an informative poster, and an in-person panel discussion that I curated for my peers at the School of Dance.
When I posted about this project on my instagram story, I got so many responses asking me to share the finished result. Although it will be available to U of U students in the Thesis Archives at the Marriott Library, I wanted to make sure that it reached the widest audience possible. Therefore, I am posting it in two parts on this platform, with the hope and wish that people will use the information here responsibly (please remember that this work is copyrighted and not to be redistributed without express permission from the creator :)).
I won’t say anymore, is the intro to the thesis speaks more eloquently for itself. Therefore, without further ado, I give you –
A Delicate Balance: Raising Hormonal Health Awareness Among Females in the Ballet Community (Part 1 :))
LANGUAGE ACKNOWLEDGEMENT: Throughout this essay I use the word “female” to refer to female-identifying individuals who naturally experience their hormonal cycles in the way that I describe. Those who do not identify as female but have similar biochemistry may benefit in their own way from this discussion. Those who identify as female but do not experience a hormonal cycle in this way may also use thoughts from this discussion to better understand and tune in to their feminine energy. However, this content is not specifically tailored to these populations.
When it comes down to statistics, ballet is a woman-dominated profession. In 2021, 73.4% of professionally practicing dance artists in the United States identified as female.1 This percentage has the potential to be larger when it comes down to the gender ratios of local studios and dance schools. The physically demanding practice of ballet attracts and propels high-performing female athletes to the spotlight.
Dance is not the only athletic discipline where this is the case. In several other sports, the participation, support, and visibility of female competitors is on the rise, and has been for some time.2 Data has shown that the popularity of women’s sports has increased the last 50 years and continues to expand.3 We are beyond proving that we are strong, resilient, physical, and capable of incredible athletic feats.
That being said, it is only recently that studies, theories, and ideas about women’s health, particularly in regards to their hormonal balance as athletes, have begun to surface.4 Despite the plethora of research that has been done on the athletic performance of men, these new ideas are still considered cutting-edge. It is clear that a divide remains, an echo of a social and cultural problem with a deeply rooted patriarchal history that is extensive and complex.
There is something specifically to be said about the way that this patriarchal history of health science manifests for females in the dance community. This new research has demonstrated again and again that athletes with female biochemistry have specific and unique needs when it comes to navigating hormonal wellness. However, as will be thoroughly demonstrated through statistics and anecdote, there is great possibility for growth and expansion on this topic when it comes to application and awareness. Specifically in ballet training, which tends to lag behind the realm of sports science in terms of implementing new information and ideas, there is a lot to be desired when it comes to taking hormonal health into account within the dance studios.
In one project, I cannot tackle the gender inequality of the world, or even the world of sports science. However, I can identify specific problems within my own community, and take steps towards solving them. Upon researching the health challenges facing women in today’s ballet world and observing the patterns of my own environment, I have identified a few specific areas of traditional ballet culture that provide a barrier to the full exploration of the new scientific information that is coming to light. Establishing an environment where hormonal ebbs and flows are more accounted for and accepted, body ideals are more realistic, and important topics are more openly discussed would aid the dance world in not only supporting female health, but maximizing female performance. Part one of this thesis project is devoted to analyzing some of the evidence that supports this view.
Just as dance requires precision and stability, achieving hormonal health, especially as a female athlete, is a delicate balance. However, just as in ballet, the process can be fascinating, empowering, and incredibly rewarding. Based on the enthusiastic feedback that I received from my work, this kind of message is something that dancers are extremely interested and invested in. I hope that these efforts and ideas can be replicated and expanded upon in the future in order to change ballet culture for the better and build more momentum for the amazing, much-needed research that is being done on women’s health.
Ballet Culture and Hormonal Health
As mentioned previously, I have identified three major ways that the dance world can progress in terms of being better attuned to hormonal health, backed up with research and observations from my own experiences in this industry. The first is to establish a culture that acknowledges varied chronobiological patterns.
Chronobiology is a field that seeks to understand and interpret cyclical phenomena and physiological rhythms in organisms.5 In our society, we are very aware of how chronobiology applies to us when it comes to the circadian rhythms that govern this rise and fall of the sun and the 24-hour cycle of work days.6 However, although the male hormonal cycle follows this circadian clock, the female hormonal system is programmed to a completely different timeline – the 28-day infradian rhythm.7 In her book, In The Flo, author Alisa Vitti calls for a societal change that allows those with female biochemistry to become more aligned with their inner selves. Over the course of the work, she outlines different stages of productivity, self-care, and play that follow the phases of the menstrual cycle.
Particularly interesting is her chapter on exercise. According to Vitti, most major athletic regimens subscribe to a very patriarchal outlook.8 These regimens, which promote a “go hard or go home” mindset and involve doing a similar routine day in and day out, operate more in-tune to a circadian cycle.9 This method is used by many pre-professional ballet training programs, where dancers take class almost every day and a standard of consistency and excellence is expected of their work on a regular basis. For example, at the Vaganova Ballet Academy, one of the most highly regarded dance schools in the world, the students practice for every day of the week except for Sunday, doing a very similar set of exercises, and linear growth and development is expected to be displayed in their yearly exams.10 A 2022 article in the Journal of Dance Medicine and Science remarked upon how dance training is often not periodized throughout the year (as most other sports are) and is instead ongoing from performance to performance, creating a unique risk factor for symptoms of burnout (one of which is menstrual dysfunction).11
There is no doubt that these training programs produce beautiful dancers. However, training at a high intensity consistently is not necessarily the most productive route for athletic growth and overall health, especially for those with a menstrual cycle. In her book, Vitti imagines a reality where training is more attuned to chronobiological theory. It has been shown that the late luteal phase of the hormonal cycle is a time when the body tires quicker and is more prone to injury, so she suggests slowing down the pace of exercise and allowing rest for the body.12 Conversely, it has been shown that the first half of the menstrual cycle is an ideal time for strength training and increasing cardio capacity, so she suggests increasing exercise intensity in the follicular and ovulatory phases.13 This is consistent with research and anecdotal evidence that demonstrates that workouts are less draining, more productive, less painful and less hazardous when taking this infradian rhythm into account. For example, members of the gold medal-winning US women’s soccer team have been tracking their periods and integrating this advice into their practice routine, based on research that suggests that athletic performance in their sport may worsen during the menstrual phase.14 They report that it has both reduced PMS symptoms and given their training an edge.15
Sabine Krautgasser-Tolman, a sports dietician at the University of Utah, divides the phases up differently for her athletes, thinking of the luteal phase and the follicular phase as the two major components of the cycle, with menstruation as part of the follicular phase and ovulation as a singular point of time (it should be noted that there is no one correct way to go about splitting up a phenomenon, which is in truth just flowing and repeating without regard to our tendency to label and categorize it).16 However, she shares with Vitti the idea that the environment within the body is in a constant state of change, and that respect and attention must be devoted to this fact when taking things like food and exercise into account. In her presentation that she regularly gives to her female athletes, she mentions how hormone levels vary throughout the different phases of the cycle, affecting everything from performance to metabolic demands to nutrition needs to substrate utilization.17 She discusses how hormone ratios can increase resilience to strength training during menstruation, and how things like even the fluctuation of body temperature during the luteal phase can change time to exhaustion during exercise.18 As a dietician, she even has different suggestions for macronutrients to emphasize during different parts of the menstrual cycle in order to stimulate ideal performance. For instance, she recommends a higher intake of fats and proteins during the luteal phase when the fat-bearing estrogen is low and catabolic progesterone peaks, and an increased carbohydrate consumption during the follicular phase when the body is not as efficient at accessing glycogen stores.19 Of course, this is all very new science, and studies are still coming to some conflicting conclusions about these things depending on what is being measured and how to go about properly measuring them. However, there still exists a plethora of evidence that suggests that chronobiology is more than relevant to female athletes, who would greatly benefit from understanding the changes that their bodies are going through on a month-to-month basis.
Of course, nobody is asking ballet schools and companies to track the periods of all their female dancers and arrange their classes and shows accordingly. Even Vitti concedes that this is often not possible, acknowledging that professional athletes may not be able to reschedule their tournaments and training.20 However, there are things that can be changed in the environment of dance studios to allow students to pay attention to their bodies and the infradian rhythms in their lives with more ease. For one, dancers can be encouraged to abide by a more sustainable cross-training regimen that supports whatever phase of the cycle that they are in. They should be told to include all macronutrients in their diet and be informed on how and when to consume these nutrients to reach optimal performance. Days off to rest, as well as training days that require the modification of athletic effort, should be better understood by those in charge, so dancers do not have anxiety or fear over losing status or position in their organization if they think coming to work or school would do them more harm than good. As Vitti states at the end of her chapter, syncing life to your cycle is not meant to prevent women from doing what they love, but rather to maximize their experiences to make going after their dreams as easeful and pain-free as possible.21 These suggestions could not only increase the hormonal health of the performers in question, but allow for a more functional, empowered population, ready to utilize their studio time to their full advantage and minimize their chances of injury, unpleasant PMS symptoms, and burnout.
But what if a dancer’s menstrual cycle is absent altogether? I struggled with this very thing as a young dancer. At age nineteen, I had to contend with the fact that I had not yet had my menarche (or first period), which is an extremely large indicator of female health. It was a long and difficult journey to get to where I am today in terms of hormonal function. Unfortunately, there are many young artists out there who have similar issues, and it is a problem that can be linked back to ballet culture and standards in many cases.
There are several reasons why someone can have a menstrual cycle that is absent or missing, such as pregnancy, ovarian failure, or thyroid dysfunction.22 Anyone who is experiencing this problem should be tested for all of them. However, a common cause of this issue (called amenorrhea) in dancers is a condition named Relative Energy Deficiency in Sport (or RED-S).
In 2018, a consensus statement on the topic by the American Olympics defined RED-S as “impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.”23 Before it was called RED-S, it was described as the “Female Athlete Triad.”24 The “triad” of ailments in question are three common signs of RED-S in those with a menstrual cycle – loss of the menses, disordered eating, and decreased bone density.25 The name has since been modified to RED-S to include all genders and to make the symptoms and causes of the condition more clear, among other reasons.26 However, the terms are often used interchangeably in the field of sports medicine. Since I have chosen to focus on female athletes in particular, both titles will be utilized in this discussion.
Here is where ballet culture and ideals come into play in propagating this issue. RED-S is a particularly large problem in sports where a lean physique and low body weight is emphasized.27 This is because one of the main and most worrying symptoms of RED-S- the loss of menstrual function – has been directly linked to low BMI, as well as a large deficit in caloric intake versus energy expenditure.28
According to a 2014 study published by the International Society of Sports Nutrition, a large percentage of menstrual disturbances in young female dancers and athletes could be remedied through a personalized nutritional intervention, which often included an increase in caloric intake and a bit of weight gain.29 However, researchers found a lot of resistance to their intervention in athletes who practiced sports in which “silhouette was of vital importance.”30 They mentioned the dancers in particular as being problematic participants, as they feared that their status in their training program would be at risk if there happened to be an increase in their weight.31
This finding points to a significant concern in ballet, one that anyone familiar with the art form knows well. As evidenced by the dancers referenced in this study, there still exists a permeating expectation of a certain “ballet physique” that aspiring artists feel pressured to maintain. Many dancers feel that, in order to be successful, they must be lean, and resist the suggestion of weight gain. I would say that this sentiment was very true and relatable to me in my struggle with amenorrhea. I wanted to be healthy and to get better, but this desire was hampered by the fear that peers, mentors, and future employers would see me differently if my appearance started to change. I had a lot of restrictive eating practices at that time that were holding me back from recovery, and I had a lot of fear attached to letting them go.
Of course, ballet is an aesthetic art form, and requires a certain look and level of skill onstage. However, no aesthetic should come at the expense of an artist’s health. As stated in its definition, Relative Energy Deficiency in Sport comes with all sorts of ramifications, some of which have been linked to a loss of menses in a cause-and-effect relationship (such as infertility and osteoporosis).32 What if, instead of body shape, more leaders in the dance community emphasized athletic ability, performance quality, and health? What if the dancers that we saw on main stages represented many examples of what a healthy woman could look like, not just one? Then, maybe, dancers who do have issues with maintaining a menstrual cycle and balancing their energy expenditure would be more willing to make beneficial lifestyle adjustments, and there would be a shift towards better hormonal health in the community overall.
That being said, even if body and training standards were relaxed in the ballet community, there is one more missing piece to the puzzle to encouraging a more hormonally balanced population. Ultimately, in my own journey towards menstrual health, I was able to gain my menarche through a combination of my own research endeavors and a global pandemic that gave me the time and space to rest, refuel, and heal. However, there was nobody within my dance community that found it important to provide me with any of the crucial information about exercise, caloric intake, and hormonal balance that I was able to seek out on my own. This, it seems, is the crux of the issue. Dancers, dance educators, and even health support teams that operate within the ballet community demonstrate a marked lack of understanding and awareness when it comes to hormonal issues. For example, a 2019 survey study conducted by the Journal of Pediatric and Adolescent Gynecology demonstrated that dancers tend to be particularly oblivious about the condition of RED-S as compared to other lightweight athletes. It was discovered that “a higher proportion of runners than figure skaters and dancers had high knowledge of the triad (16% vs 6% vs 5%, P <.01).”33 It was also found that “dancers vs figure skaters and runners had nearly twice the odds of triad risk.”34 These statistics quantify the ways in which health education in dance is lacking, and suggest a correlation between knowledge and incidence of the ailment.
Knowledge of menstruation-related conditions in health professionals has also been shown to be strangely absent. A 2015 survey of multispecialty physicians at three separate institutions found that approximately one third of the physicians had heard of the Female Athlete Triad, while approximately one half of them were comfortable treating or referring a patient with symptoms.35 A key point of the ensuing discussion is that “it is likely that many females are not diagnosed and subsequently treated for the Triad given the high number of physician responders who were unable to properly identify the Triad in a clinical setting.”36 If the healthcare professionals that dancers might be going to for help are not aware and comfortable treating a major hormonal issue, that in and of itself is a significant knowledge gap that should not be overlooked.
The solution to this problem is clear – dancers, teachers, and health professionals alike need to be educated better. We need to bring awareness into medical residencies and dance teacher trainings, have discussions with dance students that are open, honest, and sincere, and create safe spaces in our communities that allow this to be a topic that is interesting and important, rather than uncomfortable and taboo. This is easier said than done, certainly, but there have been efforts made out there. For example, Allison DeBona, principal of the Ballet West Park City Campus, has recently integrated “Wellness Wednesdays” into the training of her dancers (“Dancing Through the Menstrual Cycle” was the subject of one of the installments).37 I believe that this is an admirable endeavor, and would love to see it integrated more into ballet schools across the country and the world. Education is the first step towards opening the door to the changes that need to be made, and creating space for dialogue is vital to this process.
It is true that, in our patriarchal world, the topic of hormonal health according to female biochemistry is still rarely breached. It is also true that in places where this knowledge is most relevant and useful – such as in a traditional ballet training environment – a permeating culture, fraught with outdated expectations, often stands in the way to unlocking the true potential of this information. Relaxing stringent, linear training expectations, doing away with unhealthy body ideals, and allowing for more open, honest educational opportunities for aspiring artists, could go a long way in making hormonal health more of a priority in our community. I truly believe that everyone in this field – regardless of gender or status – could grow stronger together if we gave more attention to these issues and devoted more time and energy towards finding our personal balance and “flow”.
Thank you all for reading! Stay tuned next week for part 2!
Citations (A full Works Cited will be published with Part 2):
1 “Ballet Dancer Statistics By Gender,” Zippia, Accessed April 7 2023, https://www.zippia.com/ballet-dancer-jobs/demographics/.
2 Lindsey Douglas, “The Rise of Women’s Sports: Identifying and Maximizing the Opportunity,” The Nielsen Company, (2018): 4.
3 Douglas, “The Rise of Women’s Sports,” 4.
4 G Bruinvels et al., “Sport, exercise and the menstrual cycle: where is the research?” British Journal of Sports Medicine, 51 (2017): 487.
5 Alisa Vitti, In The Flo (New York, United States: HarperOne, 2020), 40.
6 Vitti, In The Flo, 40.
7 Vitti, 41.
8 Vitti, 133.
9 Vitti, 133.
10 Jaden Grimm, “A Day in My Life at the Vagonova Ballet Academy” Jaden Grimm (blog), December 27, 2019, https://www.jadengrimm.com/post/a-day-in-the-life-vaganova-ballet-academy.
11 Jana S. Dewet, Africa Eileen, and Venter Ranel, “Recovery-Stress States of Professional Ballet Dancers During Different Phases of a Ballet Season,” Journal of Dance Medicine & Science, 26, no.1 (February 2022): 9.
12 Vitti, In The Flo, 140.
13 Vitti, 140.
14 Gabby Landsverk, “The World Cup-Winning US Women’s Soccer Team Tracked Their Periods for Peak Performance, and Evidence Shows Everyday Athletes Can Benefit from Doing the Same,” Insider, July 25, 2019, https://www.insider.com/world-cup-winning-uswnt-period-tracking-how-to-improve-performance-20197#:~:text=After%20the%20U.S.%20Women’s%20National,can%20help%20or%20hinder%20workouts.
15 Landsverk, “World Cup Winning Women’s Soccer Team.”
16 Sabine Krautgasser-Tolman, email message to author, March 24, 2023.
17 Sabine Krautgasser-Tolman and Madeleine Hutchison, “Nutrition Through Your Menstrual Cycle,” March 31, 2023, Marriott Center for Dance at the University of Utah, Salt Lake City, Utah, 39:45, https://youtu.be/MwJss0nJIm8.
18 Krautgasser-Tolman and Hutchison, “Nutrition Through Your Menstrual Cycle.”
19 Krautgasser-Tolman and Hutchison, “Nutrition Through Your Menstrual Cycle.”
20 Vitti, In The Flo, 146.
21 Vitti, In the Flo, 146.
22 Karolina Łagowska, Karina Kapczuk, and Jan Jeszka, “Nine–month Nutritional Intervention Improves Restoration of Menses in Young Female Athletes and Ballet Dancers,” Journal of the International Society of Sports Nutrition 11, no. 1 (December 2014): 2.
23 Margo Mountjoy et al.,”International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (red-s): 2018 Update,” International Journal of Sport Nutrition & Exercise Metabolism 28, no. 4 (2018): 317.
24 Kimberly K Yeager et al., “The Female Athlete Triad: Disordered Eating, Amenorrhea, Osteoporosis,” Medicine and Science in Sports and Exercise 25, no. 7 (1993): 775.
25 Yeager et al., “The Female Athlete Triad,” 775.
26 Margo Mountjoy et al.,”International Olympic Committee (IOC) Consensus Statement,” 317.
27 Andrea Stracciolini et al., “Body Mass Index and Menstrual Patterns in Dancers,” Clinical Pediatrics, 56, no. 1 (2017): 51.
28Stracciolini et al., “Body Mass Index,” 51.
29 Łagowska et al., “Nutritional Intervention Improves Restoration of Menses,” 1.
30 Łagowska et al., “Nutritional Intervention Improves Restoration of Menses,” 8.
31 Łagowska et al., “Nutritional Intervention Improves Restoration of Menses,” 8.
32 Stacciolini et al., “BMI and Menstrual Patterns in Dancers,” 50.
33 Marina Tosi et al., “The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters, Dancers, and Runners,” Journal of Pediatric & Adolescent Gynecology, 32, no. 2 (2019): 165.
34 Tosi et al., “The Female Athlete Triad: A Comparison of Knowledge,” 165.
35 Emily J Curry et al., “Female Athlete Triad Awareness Among Multispecialty Physicians,” Sports Medicine – Open 1, no. 1 (2015): 1.
36 Curry et al., “Female Athlete Triad Awareness Among Multispecialty Physicians,” 4.
37 Allison DeBona (@allidebona), “Tonight we launch WELLNESS WEDNESDAYS at the @bw_academy Park City campus…” Instagram, September 14, 2022, https://www.instagram.com/p/CifS3O1L5Kl/?hl=en.
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