Sex and gender dynamics in health outcomes of partner dance

As populations age globally, activities like dance gain prominence for their ability to prevent age-related health declines (Pessoa et al., 2019;World Health Organization, 2020).Partner dance requires two individuals to synchronize their movements and interpret music together. This activity combines physical, cognitive, and social benefits, and in some cases, improves quality of life (Marie-Sophie et al., 2012). Partner dance can be light, moderate, or vigorous in intensity depending on style, tempo, and format (e.g., slow ballroom dances: 3 Metabolic Equivalent of Tasks (METs) vs. faster styles: 5.5 METs) (Ainsworth et al., 2011), as it meets the thresholds for aerobic exercise only in some circumstances, alongside its cognitive and social demands.The health benefits of partner dance are not universally experienced and are profoundly shaped by sex and gender (Editage, 2019). Sex refers to biological attributes-chromosomal composition (typically XX for females and XY for males), hormonal profiles, and anatomical structures-that influence physiological responses to exercise (Mazure, 2021). Gender, by contrast, encompasses sociocultural constructs, including roles, behaviors, identities, and expectations, which evolve and shape participation in activities like dance (Conger, 2017).Despite this distinction, sex and gender terms are frequently used interchangeably in public conversation and research settings, creating confusion about whether role differences arise from biological capacities or culturally reinforced expectations. To address the inconsistency, standardized research frameworks, such as those from the National Institutes of Health's (NIH) Specialized Centers of Research Excellence (SCORE) on Sex Differences, are essential for improving clarification (Office of Research on Women's Health, 2024). With these inconsistencies in mind, this opinion paper explores how sex and gender influence health outcomes in partner dance. Figure 1 synthesizes key considerations across three stages (Foundation, Bridge, and Goal) and, building on these, offers recommendations for future intervention design, with role switching as a central theme. The following sections examine how sex-based biological responses and gendered roles, expectations, and social dynamics may interact to shape health outcomes in partner dance.Evidence from a recent systematic review consisting of 11 randomized controlled trials and 1412 participants suggests that dance may contribute to cognitive reserve and reduce the risks of age-related cognitive decline; however, intensity was reported on only three trials (moderate intensity or 60-80% of maximum heart rate) (Hewston et al., 2021). This review also identified ballroom dance as the most frequently investigated modality (six studies; 54.5%), while highlighting the absence of direct comparisons between partner dance and other dance forms (Hewston et al., 2021). Partner dance involves a unique combination of physical tasks (stepping, turning, and balancing) with cognitive tasks (pattern recognition, memory, and decision-making) (Abraham et al., 2024;Allen et al., 2017;Hackney & Earhart, 2010;Merom et al., 2016), making it an ideal model for examining sex-based differences in health outcomes. These sex differences stem from physiological variations in males and females that influence responses to exercise.Borrowing from the exercise field, females may derive greater cognitive benefits than males from exercise (Barha et al., 2017). A meta-analysis of aerobic and resistance training (moderate-intensity) indicated enhanced executive functions, attention, working memory, and inhibitory control in older females as compared to older males (Barha et al., 2017). Although these findings come from structured, moderate-intensity exercise rather than partner dance, which reach comparable intensity only in some styles and formats, partner dance provides a relevant context for examining such sex differences. A study of partnered dancing (intensity not reported) provoked improvements in mood (i.e., feeling less depressed and happier) in females than males; however, this study was not designed to examine sex-or gender-specific effects (Lakes et al., 2016). Partner dance may offer a useful context for investigating sex differences in cognitive benefits, as dance-based interventions have been associated with improvements in motor-cognitive dual-task performance, global cognition, and executive function in older adults (Hamacher et al., 2015) (Hewston et al., 2021).One mechanism driving these associations may be related to the neuroprotective effects of estrogen (Enns & Tiidus, 2010;Yu et al., 2022). Because many older female participants are post-menopausal, current circulating estrogen and cumulative lifetime estrogen exposure should be considered separately. Current circulating estrogen can be assessed using sensitive serum assays (Hesson, 2012;Lee et al., 2006;Xu et al., 2007), while cumulative exposure can be estimated from reproductive history and exogenous hormone use (Hesson, 2012;Salliot et al., 2022). Estrogen has been associated with increased neuroplasticity and hippocampal volume (Barha & Liu-Ambrose, 2018). Thus, lifetime hormonal exposure may be a useful variable to examine in future studies of cognitive responses to exercise and partner dance, particularly in relation to menopausal status and hormone therapy.In contrast, males may achieve greater cardiorespiratory gains than females from intense exercise due to greater oxygen uptake and substrate utilization (Cobbold, 2018).Additionally, males may experience greater muscle hypertrophy and aerobic adaptations such as a larger increase in VO₂ max, cardiac output, and lactate threshold due to higher testosterone levels, which support lean muscle mass development (Landen et al., 2023;Nuzzo, 2023). These sex-related physiological differences may be relevant to physically demanding partner-dance movements, particularly in styles and formats that reach vigorous intensity, although their implications for dance-specific health outcomes remain unclear. Such differences may also influence performance in strength-and power-demanding elements, including lifts in ballroom dance and rapid turns in tango, warranting further investigation into sex-specific physiological responses to partner dance (Hunter et al., 2023).Partner dance also relies heavily on balance and flexibility. Females generally demonstrate better static balance and greater joint flexibility, enhancing aesthetic movement but increasing susceptibility to hypermobility-related injuries such as hip labral strain (Pappas et al., 2011;Steinberg et al., 2016). While males typically show stronger dynamic balance and greater muscular power, supporting lifts and directional control, these processes may elevate the risk of upper-body overuse injuries (Wanke et al., 2013). Importantly, substantial overlap exists between females and males in these characteristics (i.e., balance, flexibility, and power), and individual fitness, training history, and dance experience may also influence intervention outcomes and injury risk. Nonetheless, both sexes experience similar overall physical health benefits from moderate-intensity activities, and dance interventions have demonstrated physical, inflammatory, mood, and neurocognitive benefits in different populations (Borges et al., 2019;Hackney et al., 2020;Lakes et al., 2016).Sex differences may confer distinct health-related risks and benefits during partner dance, whereas gender norms may indirectly shape health outcomes by influencing the dance environment and opportunities for cognitive and social engagement. These norms may also affect cognitive reserve through unequal lifelong access to cognitively stimulating activities, with implications for health disparities.In many traditional partner dance styles, social conventions-often aligned with binary gender norms-assign women take the follower role, interpreting cues with responsiveness, adaptability, and active styling, while men the leader role, where they initiate movements, select figures, and guide the dance's direction (Hackney et al., 2024). Both roles require active cognitive engagement, although following requires continuous sensory integration and adaptive responses to partner cues, whereas leadership may emphasize planning and spatial awareness (Abraham et al., 2024;Den Kulturella Hjärnan, 2014;Foster Vander Elst et al., 2023).However, rigid role assignments may limit cognitive diversity by reinforcing normative gender expectations. For example, women limited to follower roles may have fewer opportunities to develop planning skills, potentially impacting cognitive reserve (Qi et al., 2024).Conversely, men who consistently lead may have fewer opportunities to practice the rapid sensory integration and adaptive responsiveness required of followers. Accordingly, challenging normative role assignments may be an important consideration for maximizing cognitive engagement and health equity in dance-based interventions.Cultural norms strongly shape gendered role expectations in partner dance, influencing who leads, who follows, and how movement qualities are valued (Risner, 2010). Many dance traditions reinforce heteronormative scripts that associate following with feminine responsiveness, shaping cognitive and motor demands placed on each role and leadership with masculine assertiveness (McMains, 2015;Royce, 2008). Cultural expectations may also affect participation patterns and access to cognitively demanding roles, influencing long-term engagement and health outcomes. Integrating cultural context is therefore essential for understanding how gendered movement practices influence equity in dance-based interventions.Gender roles in dance are rapidly evolving, particularly in inclusive activities like queer tango, where individuals choose roles based on identity or comfort (Lucchi Basili & Sacco, 2025). Allowing participants to choose or alternate roles may increase opportunities to engage with different cognitive, motor, and social demands while reducing reliance on traditional gender expectations. More broadly, frameworks centered on joint action emphasizing interpersonal coordination, reciprocal adaptation, and the co-construction of movement between individuals (Sebanz et al., 2006) offer a complementary lens for conceptualizing these more fluid role dynamics. By challenging heteronormative standards, inclusive partner dance settings promote equity and broaden cognitive engagement, aligning with global calls for gender-sensitive health interventions (World Bank, 2024).Role switching in partner dance might build cognitive reserve by engaging diverse cognitive processes (Hackney et al., 2024), but this is a theoretical pathway that requires direct investigation in partner dance interventions. Switching between follower and leader roles may require dancers to integrate different combinations of planning, sensory processing, spatial awareness, and partner cues; whether this translates into measurable cognitive or psychosocial benefits remains an important research question. Historically, women have faced barriers to education and professional advancement, which limit cognitive reserve. Although the precise reason for women's higher Alzheimer's rates remains unknown (Moutinho, 2025), cognitive reserve has been associated with lifestyle activities and other cognitively stimulating experiences (Qi et al., 2024), suggesting that gendered differences in lifelong opportunities may warrant further investigation. Contemporary shifts, with increased participation of women in higher education and professional spheres, may reduce these disparities, but further research is needed.Despite the growing recognition of partner dance as a multifaceted health intervention, significant gaps in literature hinder its optimization for diverse populations (Fong Yan et al., 2024;Kattenstroth et al., 2013). The evidence base includes relatively few studies designed to examine sex-or gender-specific effects, and many findings are extrapolated from general exercise or broader dance research. Additionally, heterogeneity in dance styles, participant populations, and outcome measures limits comparability across studies, and the overreliance on self-reported or indirect measures weakens causal inferences (Delattre et al., 2024;Noetel et al., 2024). Addressing these limitations requires more rigorous, targeted research to clarify how biological and sociocultural factors shape the health effects of partner dance across diverse populations.Current research often fails to disaggregate data by sex or analyze sex differences, obscuring how biological variability may shape health outcomes (Barha et al., 2017;Nuzzo, 2023). For example, previous work has rarely explored how menstrual cycles or menopausal status affect sex-and gender-based responses to exercise, limiting the development of tailored interventions (Sims & Heather, 2018). The limited research available suggests that hormonal fluctuations across the menstrual cycle can influence exercise performance, vascular endothelial responses, and physiological mechanisms underlying cardiopulmonary and neuromuscular function (Ghniem et al., 2025;Heinrich & Behringer, 2023;Hicks et al., 2023;Wen et al., 2025). Future partner-dance studies should therefore record relevant hormonal or reproductive characteristics when appropriate rather than assuming that age or sex alone captures hormonal status. Similarly, gender analyses are underdeveloped, with minimal research examining how traditional role assignments-such as women following and men leading -impact cognitive reserve or psychosocial benefits across genders (Hackney et al., 2024). Researchers should record role allocation and experience and, where appropriate, compare fixed-role and role-switching protocols to determine whether role flexibility influences cognitive load. It is currently unknown whether learning roles sequentially rather than simultaneously reduces cognitive load for beginners. Finally, research focusing specifically on health outcomes and role preferences of non-binary and transgender dancers remains critically underexplored (Jones et al., 2019).It is important to note that the studies reviewed here operationalize "partner dance" across distinct contexts, including clinical rehabilitation programs for specific populations and unstructured social/ballroom dancing, which may influence participant demographics, adherence, and outcomes. This heterogeneity underscores the need for standardized definitions in future research, which should integrate guidelines (e.g., NIH SCORE) on sex/gender equity, measure sex and gender separately without assuming binary chromosomal categories, and foster interdisciplinary collaboration to maximize the potential of partner dance as an inclusive public health tool for diverse populations. Partner dance offers a unique lens for examining sex (biological) and gender (socially constructed) dynamics in health outcomes, with traditional follower-leader roles often reflecting heteronormative gender expectations. Inclusive practices like same-sex partnerships and roleswitching promote equity and can maximize intervention benefits. Role-switching and inclusive practices may jointly shape physical, cognitive, and psychosocial benefits, typically targeted through separate exercise programs, positioning partner dance as a uniquely engaging intervention with beneficial outcomes across domains.