Editor's note: Ella Limbach is currently completing her master’s degree in International Sport Development and Politics at the German Sport University Cologne. Her interests include human rights of athletes, labour rights in sport, the intersection of gender, human rights and sport and the working conditions in women’s football. Previously, she graduated from Utrecht University with a LL.M in Public International Law with a specialization in International Human Rights Law. This blog was written during Ella's internship at the Asser Institute where she conducted research for the H.E.R.O. project. The topic of this blog is also the subject of her master's thesis.

Women’s football has experienced exponential growth over the past decade, though the professionalization of the women’s game continues to face barriers that can be tied to the historical exclusion of women from football and insufficient investment on many levels. While attendance records have been broken and media coverage has increased, the rise in attention also highlighted the need for special accommodations for female footballers regarding health and safety at the workplace. Female footballers face gender specific circumstances which can have an impact on their health such as menstruation, anterior cruciate ligament (ACL) injuries and the impact of maternity. As the recent ILO Brief on ‘Professional athletes and the fundamental principles and rights at work' states “gender issues related to [occupational health and safety] risks are often neglected (p. 23).” While it could be argued that from a human rights point of view article 13(c) of the Convention on the Elimination of Discrimination of Women stipulates “the right to participate in […] sports [on an equal basis to men],” reality shows that so far practices of men’s football were simply applied to women’s football without taking into consideration the physiological differences between male and female players and the implications that can have for female players’ health. The ILO Declaration on Fundamental Principles and Rights at Work(ILO Declaration, amended in 2022) includes “a safe and healthy working environment” as one of the fundamental rights at work (Art. 2e). This begs the question whether the scope of the right to occupational health and safety at the workplace includes the consideration of female specific health issues in women’s football.

Scope of the fundamental right to occupational health and safety

 The ILO Declaration also identifies the Convention on Occupational Health and Safety (No. 155, 1981) and the Convention on a Promotional Framework for Occupational Health and Safety (No. 187, 2006) as fundamental frameworks guaranteeing the right to occupational health and safety. In its Brief on ‘Professional athletes and the fundamental principles and rights at work’ the ILO reaffirms that athletes get their right to occupational health and safety through these two conventions. The Occupational Health and Safety Convention “applies to all branches of economic activity (Art. 1),” and as football is a global industry generating billions in revenue, it should be included within the scope of the convention. Article 3 provides that the term health includes physical elements affecting safety at work. Article 4 reads the following: 

1. “Each Member shall, in the light of national conditions and practice, and in consultation with the most representative organisations of employers and workers, formulate, implement and periodically review a coherent national policy on occupational safety, occupational health and the working environment.

2. The aim of the policy shall be to prevent accidents and injury to health arising out of, linked with or occurring in the course of work, by minimising, so far as is reasonably practicable, the causes of hazards inherent in the working environment.” 

Applying this to football, could mean that signatory states of the Occupational Health and Safety Convention shall consult FIFA and their respective national federations, clubs and player unions to mitigate hazards specific to football. Moreover, the employers are obligated to ensure “workplaces, […] equipment and processes under their control are safe and without risk to health (Art. 16(1).” The cost of ensuring safety and health at the workplace shall not be covered by athletes according to article 21. 

The Convention on a Promotional Framework for Occupational Health and Safety emphasizes that “the principle of prevention is accorded the highest priority (Art. 1d).” It also calls for continuous improvement of occupational safety and health in order to prevent injuries (Art. 2). The national policy shall be supported by a national occupational safety and health system which amongst others should include laws and regulations and collective agreements, compliance mechanisms, research and data collection and analysis on occupational injuries and diseases (Art. 4). While maternity is not discussed within the context of the above mentioned conventions, the ILO’s Maternity Protection Convention (No. 183, 2000) protects the health of pregnant or breastfeeding women by ensuring that they are not obliged to perform work which is harmful or poses a risk to the health of the mother or the child (Art. 3). It also stipulates a minimum of 14 weeks maternity leave (Art. 4).

Health concerns specific to women’s football

Female footballers face several barriers that are unique to their experience as women. Generally, there is a lack of education on female physiology and health and how it affects performance. Several risks are specific to women’s football and must be differentiated from the men’s game. Here three different points are assessed: the impact of menstruation on training, performance and injury risk, ACL injuries and maternity. These have already been identified by Martínez-Lagunas, Niessen and Hartmann in 2014 for necessitating specific adaptations to the training of female players due to their difference in physiology compared to men.

First, menstrual cycle disfunctions are not uncommon for athletes. FIFA has recognised the lack of scientific literature on the health of female athletes and has through reviewing current literature developed the FIFA Female Health Projectaiming to provide educational resources for all stakeholders in women’s football. That can include having infrequent periods, not ovulating, heavy bleeding and pain. These can be tied to disease, genetics, as well as stress which is common in the competitive environment of professional football. Stress can be caused by workload, travel and psychological pressure. In addition, if players experience lower energy levels, they are more prone to injury. There are a number of symptoms women experience during their period such as cramps, fatigue, disturbed sleep and back and leg pain. The impact of nutrition on menstrual health also should be monitored, the same applies to hydration. Therefore, health issues related to menstruation should be taken more seriously in football and women players should receive proper care.

Secondly, women’s football has suffered what many describe as an epidemic concerning the number of players suffering ACL injuries. Injuries arising out of being employed as footballers in general are not uncommon, however the rise in ACL injuries is alarming. ACL tears are twice as likely in women, a higher likelihood also recognised by the ILO in its Brief. About two thirds of ACL injuries occur without physical contact. In addition, ACL injuries take between six to twelve months to recover, which has a large impact on a footballer’s career. Not much research has been done on the topic but a few potential reasons as to why that is the case have been identified by stakeholders in women’s football such as FIFPRO and academics especially within the field of sport medicine. For one, football boots and kits are designed based on the male physique and many female players reported having issues with their shoes. Another possible reason for ACL injuries could be inconsistency of the match calendar experienced by some players. Female players experience underload due to fewer teams, shorter seasons and longer breaks as well as long lasting discrimination of the women’s game which impacts its professionalization. However, at the same time parts of an elite player’s season are characterized by overload where players play a high number of games in a short period of time. For some players the increase in workload and decrease in recovery through a packed competition schedule may also be an issue, though this issue does not exclusively impact women’s football. Nevertheless, on the elite level women face less structured match calendar and more precarious conditions regarding medical treatment and recovery.

Thirdly, female players have to arrange their career with family planning. As FIFPRO reports, many women in football had to leave the sport early because they wish to become mothers and current structures in elite football were not allowing both, being a mother and a professional football player. Childcare support and maternity pay are rarely provided. While FIFA has developed protections of players during and after pregnancy, FIFPRO has recently shown that the regulations have not been implemented by most of FIFA’s member associations. Moreover, pregnant professional players previously reported that medical care throughout their pregnancy especially regarding training and support as to which exercises are beneficial during pregnancy are lacking. Lastly, an early return after pregnancy can also lead to health implications if not monitored.

FIFA’s responsibility to ensure respect for ILO Conventions throughout football

FIFA is the world governing body for football and has committed to respecting internationally recognised human rights throughout its activities. The FIFA Statutes state that “FIFA is committed to respecting all internationally recognised human rights and shall strive to promote the protection of these rights.” Moreover, FIFA published a ‘Human Rights Policy’ in 2017, which refers to the UN Guiding Principles for Business and Human Rights (UNGPs). As highlighted by the UNGPs, internationally recognized human rights include at least some ILO Conventions. Therefore, FIFA following its own commitment to respect and strive to promote human rights, should ensure that throughout football minimum standards of health and safety aligned with ILO requirements are in place. FIFA should, therefore, be deemed to be bound under FIFA law to ensure respect with ILO Conventions throughout its activities (including regulations affecting professional football players). In fact, FIFA has started to include a set of ‘Special Provisions Relating to Female Players’ in their Regulations on the Status and Transfer of Players (RSTP). For example, menstruation and maternity leave. 

Current status of female players health regulations by FIFA 

When looking at the risks specific to female players the question arises how FIFA and national football federations contribute to realizing the right to health and safety at work. FIFA has launched the Women’s Health, Wellbeing, and Performance Project in 2023, consulting 20 experts to investigate the female physiology and women’s health challenges. It covers all three topics and should be available to FIFA stakeholders in full soon. Some of its objectives include increased research, awareness, optimized training and access to screening and monitoring tools. It is yet to be seen whether this project will positively impact players health.

The Special Provisions Relating to Female Players included in the Regulations on the Status and Transfer of Players (RSTP) are also relevant here. Indeed, an article related to menstruation has recently been added to FIFA’s RSTP. It requires a club to respect a player’s needs regarding their menstrual cycle and health (Art. 18quinquies), meaning, if a player receives a medical certificate by her gynaecologist or another medical professional, the player has the right to miss trainings or games due to her menstrual health without consequences for her pay. FIFPRO points out that while this does not differentiate from taking a certificate to excuse them from training or games due to illness, it provides legal certainty that menstruation is covered by sick leave.

While research and support on ACL prevention and treatment has been lacking overall, FIFPRO, the Professional Footballer Association England, Nike and Leeds Beckett University have launched a project aiming to reduce ACL injuries in women’s football, the findings of which they will also make available to FIFA. The study will run for three years and examine players of the Women’s Super League which is England’s top-tier women’s football league. They will also track players workload, travel and appearances. From the findings best practice will be identified. 

Finally, FIFA, with support of FIFPRO, established maternity regulations in 2021 which are included in the RSTP (Art. 18quater). These must be implemented by member associations in their national regulations. Female players are now granted a minimum of 14 weeks of maternity leave, including eight weeks after childbirth, two more weeks as required by the ILO Convention. In its latest advocacy, FIFPRO advocated for 10 weeks after childbirth. Additionally, players receive two thirds of their salary during maternity leave. The FIFA RSTP also give players the autonomy to decide when to stop playing while pregnant, as long as it not considered a risk to the health of both player and child, with clubs having to accept the player’s decision. During their pregnancy clubs must also provide the opportunity for players to do alternative work. As of 2024, the RSTP include adoption leave of eight weeks, if the child is under two years old, and family leave for non-childbearing parents of eight weeks (Art. 18(7)). They now also included a postpartum plan and the obligation of clubs to provide adequate ongoing medical support. After already engaging heavily with the topic, FIFPRO recently published a guide on supporting players during pregnancy and in returning to play which was developed “with football players who actually experienced motherhood while they were professionals and with doctors and physiotherapists specialised in maternity in professional sport.” While the RSTPs include a postpartum plan to be agreed between player and club without including recommendations, the question remains in how far the best practices identified in the guide will be transposed by FIFA in the next RSTPs.

The implementation of the rights enshrined in the FIFA RSTP by national federations is still lacking, however. For example, the case of Sara Björk Gunnarsdóttir against her former club Olympique Lyonnais shows that clubs are not necessarily upholding the provisions related to maternity protection. The dispute arose because Lyon failed to continue paying Gunnarsdóttir’s salary during her pregnancy in contravention with FIFA’s maternity regulations, but in line with French law. Gunnarsdóttir won the case before the FIFA Dispute Resolution Chamber. However, (financial) sanctions for non-compliance are often insufficient and not effective in providing incentives for clubs to adhere to the rules, and in the worst case could even lead to national football federations allocating less resources to women’s football, thus also impacting the adherence with the RSTP. There is also a risk of double standards, between national and international players, as rules and regulations may apply differently to them. 

Conclusions and the way forward

The right to health and safety is a fundamental right at work therefore it should also apply to professional female footballers. ILO conventions impose primary duties onto signatories of the Conventions and while FIFA is a Swiss association and thus not directly bound by ILO Conventions, it can be argued that because of its commitments to uphold internationally recognized human rights in line with the UNGPs it should adhere to ILO conventions. In addition to FIFA’s responsibility through its own commitments and as the global regulator of football there are several other duty bearers that play a relevant role. Because member states should consult with representatives of employers one could argue that national football federations and clubs, in their role as employers of players, and the states in which they are located have a shared responsibility to fulfil the right to occupational health and safety at the work for female footballers. Consequently, because the ILO requires that employers create a safe working environment minimizing causes of hazards, having adjusted training programs and doing the necessary research and studies on the health and safety of female footballers will be a necessity for clubs and federations. To provide a practical example, developing football boots adapted to female physicality might be an obligation under article 16(1) of the Occupational Health and Safety Convention.

As has been outlined above, there is no question on whether menstruation, ACL injuries and maternity affect the health and wellbeing of female athletes at the workplace and thus fall under the ILO’s scope of the fundamental right to occupational health and safety at the workplace. While FIFA has begun to work on including female specific health issues in their regulations, the national implementation of the relevant provisions is still lacking efficiency. Thus, more active pursuit of national football associations and club’s adherence should be high on FIFA’s to do list. Moreover, FIFPRO must be credited with a lot of work regarding the implementation of these rights. As the global football players union, it represents the workers in this case and thus it can be seen as a positive step that FIFA is to a certain extent implementing their recommendations. Though it is clear that FIFA needs to take greater responsibility as long as serious issues, such as extensive workload and the impact on players health, continue to be highlighted by FIFPRO without meaningful action by FIFA. Overall, a way forward would include establishing effective mechanisms to ensure that relevant provisions of the RSTP are universally implemented and ultimately stronger sanctions for breaching these provisions.