This document presents the recommendations developed by the IOC Medical and Scientific Commission and several international federations (IF) on the protection of athletes competing in the heat. It is based on a working group, meetings, field experience and a Delphi process. The first section presents recommendations for event organisers to monitor environmental conditions before and during an event; to provide sufficient ice, shading and cooling; and to work with the IF to remove regulatory and logistical limitations. The second section summarises recommendations that are directly associated with athletes’ behaviours, which include the role and methods for heat acclimation; the management of hydration; and adaptation to the warm-up and clothing. The third section explains the specific medical management of exertional heat stroke (EHS) from the field of play triage to the prehospital management in a dedicated heat deck, complementing the usual medical services. The fourth section provides an example for developing an environmental heat risk analysis for sport competitions across all IFs. In summary, while EHS is one of the leading life-threatening conditions for athletes, it is preventable and treatable with the proper risk mitigation and medical response. The protection of athletes competing in the heat involves the close cooperation of the local organising committee, the national and international federations, the athletes and their entourages and the medical team.

The influence of advanced footwear technology (thickness of light midsole foam and rigid plate) on distance running performances was analyzed during an 8-year period. Analysis of variance was used to measure effects of time, gender, shoe technology, and East African origin on male and female top 20 or top 100 seasonal best times in 10-kilometer races, half-marathons, and marathons. In both genders and three distance-running events, seasonal best times significantly decreased from 2017, which coincided with the introduction of the advanced footwear technology in distance running. This performance improvement was of similar magnitude in both East African and non-East African elite runners. In female elite athletes, the magnitudes (from 1.7 to 2.3%) of the decrease in seasonal best times between 2016 and 2019 were significantly higher than in their male counterparts (from 0.6 to 1.5%). Analyses of variance confirmed that the adoption of the advanced footwear technology significantly improved the top 20 seasonal best times in female half marathons and marathons and male marathons, with the improvements being more pronounced in females and in long-distance running events. The adoption of this new shoe technology improved female marathon time by ~2 min and 10 s, which represents a significant increase in performance (1.7%).

Purpose: To determine associations between thermal responses, medical events, performance, heat acclimation and health status during a World Athletics Championships in hot-humid conditions.Methods: From 305 marathon and race-walk starters, 83 completed a preparticipation questionnaire on health and acclimation. Core (T_core; ingestible pill) and skin (T_skin; thermal camera) temperatures were measured in-competition in 56 and 107 athletes, respectively. 70 in-race medical events were analysed retrospectively. Performance (% personal best) and did not finish (DNF) were extracted from official results.Results: Peak T_coreduring competition reached 39.6°C±0.6°C (maximum 41.1°C). T_skindecreased from 32.2°C±1.3°C to 31.0°C±1.4°C during the races (p<0.001). T_corewas not related to DNF (25% of starters) or medical events (p≥0.150), whereas T_skin, T_skinrate of decrease and T_core-to-T_skingradient were (p≤0.029). A third of the athletes reported symptoms in the 10 days preceding the event, mainly insomnia, diarrhoea and stomach pain, with diarrhoea (9% of athletes) increasing the risk of in-race medical events (71% vs 17%, p<0.001). Athletes (63%) who performed 5–30 days heat acclimation before the competition: ranked better (18±13 vs 28±13, p=0.009), displayed a lower peak T_core(39.4°C±0.4°C vs 39.8°C±0.7°C, p=0.044) and larger in-race decrease in T_skin(−1.4°C±1.0°C vs −0.9°C±1.2°C, p=0.060), than non-acclimated athletes. Although not significant, they also showed lower DNF (19% vs 30%, p=0.273) and medical events (19% vs 32%, p=0.179).Conclusion: T_skin, T_skinrate of decrease and T_core-to-T_skingradient were important indicators of heat tolerance. While heat-acclimated athletes ranked better, recent diarrhoea represented a significant risk factor for DNF and in-race medical events.

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.

To examine prevalence of verbal, physical, and sexual abuses in young elite athletes, a cross sectional questionnaire-based survey was conducted during the World Athletics under 20 World Championships. This questionnaire aimed at distinguishing between abuses perpetrated in the context of Athletics from those which were unrelated to Athletics. Four hundred and eighty athletes (52.3%, male) from North America, South America, Europe, Africa, Asia, and Oceania took part in the electronic anonymous survey. Outside Athletics setting, no gender difference was found for the prevalence of verbal, physical, and sexual abuses. However, 45 males (18% of the male population) and 34 females (15% of the female population) athletes reported sexual abuse. Asian athletes reported a slightly higher rate of sexual abuse; three quarters of them being non-touching abuses. Inside Athletics setting, no gender difference was found for the prevalence of verbal, physical, and non-touching sexual abuses. However, 58 males (23%) and 47 females (21%) reported verbal abuses. Thirty-one males (12%) and 20 females (9%) reported physical abuses, whereas 30 males (12%) and 17 females (7%) reported sexual abuses. Physical abuses were slightly more frequent in Asia and in Africa and less frequent in South America. Sexual abuses inside Athletics also differed over regions, and were unexpectedly twice more frequent than expected in Asia and slightly less frequent than expected in Europe. Friends and partners were identified as the more frequent (>50%) abusers outside or inside the Athletics settings, whereas outside Athletics and inside Athletics, coaches were identified as sexual abuse perpetrators in 8 and 25% of cases, respectively. The prevalence of verbal, physical, or sexual abuses is high but consistent with what has been reported in United Kingdom, Norway, Canada, and Sweden at national level in recreational or elite athletes. Sexual abuse, including touching or penetrative abuses, occurred significantly more often in male athletes when compared to female athletes. This finding invites healthcare and social workers, and policymakers to also consider the risk of sexual abuse of young male athletes in Athletics. These results also call for longitudinal studies on young elite athletes.