The COVID-19 pandemic significantly affected elite athletes, leading to increased mental health issues such as stress, anxiety, and depression. Sex differences in mental health may exist among athletes during the COVID-19 crisis. This study aimed to perform a systematic review and meta-analysis to examine sex differences in mental health symptoms among elite athletes during the COVID-19 pandemic. We systematically searched the databases including Pubmed, EMBASE, and manually checked previous systematic reviews for relevant studies in March 2024. Authors were also contacted for sex-specific data. Studies were included if they compared mental health symptoms between male and female elite athletes during the COVID-19 pandemic. We used a random-effects model to summarize the rate ratio (RR) between female and male athletes across studies. Risk of bias in studies was assessed using a 9-item tool. We included 18 studies in this review. The results indicated that female athletes reported higher levels of anxiety (RR 1.24, 95% CI = 1.08 to 1.43) and depression (RR 1.36, 95% CI = 1.15 to 1.61) than male athletes during the pandemic. They also had a higher risk of stress or distress (RR 1.27, 95% CI = 0.99 to 1.63) than their male counterparts. No significant differences were found regarding alcohol use or misuse between female and male athletes (RR 1.01, 95% CI = 0.75 to 1.37). Limited evidence was available for eating disorders, gambling, substance use, and sleep problems. In conclusion, female and male athletes differed in mental health symptoms during the COVID-19 pandemic. Female athletes were more likely to report anxiety, depression, and distress. Incorporating mental health resources may be particularly important for women`s sports, which have smaller financial margins and greater career uncertainty than men`s sports.
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