Written by Kirsty Burrows, UK
Category: Sport and Society

Volume 10 | Targeted Topic - Hot Topics in Football Medicine | 2021
Volume 10 - Targeted Topic - Hot Topics in Football Medicine

– Written by Kirsty Burrows, UK




From grassroots to the professional game, football is enjoyed by millions of people around the world. FIFA estimates that there are at least 128 million professional players, and a staggering 5 billion consider themselves football fans1,2.

Football embodies the spirit of a sport which belongs to society - embedded within the psyche of cultures and communities. Its popularity, from grassroots to elite, reflects the beauty and commonality of a game which has the power to intrigue, transcend, unite, and drive change. 

However, football, as with all sport, is a microcosm of society itself. And whilst it has the potential to raise awareness of complex socio-cultural issues and create positive change, these issues may also be magnified or even perpetuated through the sport itself. 

Here we look to highlight several key issues impacting footballer welfare and focus on the positive impacts that tackling these issues in and through football can have on wider society. 



Although the benefits of football participation are wide and varied, it is evident that players'  human rights may be infringed upon as a direct or indirect consequence of playing sport. 

These violations include issues related to the protection of privacy, freedom of expression, prohibition of inhuman or degrading treatment, prohibition of discrimination, and the right to an effective remedy. 

It is the responsibility of all those working in football, at every level and in every capacity, to foster sporting environments which recognise and protect the rights of all players - whether they are children in a local league or elite players on the World Cup stage - and to project these values across the fanbase.  

This understanding is reflected in article three of the FIFA statutes (2019)3 which states that “FIFA is committed to respecting all internationally recognised human rights and shall strive to promote the protection of these rights". These rights are inherent to us all, regardless of nationality, sex, national or ethnic origin, colour, religion, language, or any other status4.

There is often a perception that a rights-based approach to athlete welfare is not compatible with elite sporting success. 

This may be compounded by the hyper-commoditization of players – once defined as “the extraction of economic and performance value to the point where athletes become indistinct and interchangeable”5 – which runs counter to the principle that football players are people first. 

The possibility of substantial financial gains earned by and accessible to the upper echelons of the professional game should not create a pretext for environments where rewards and results are valued above a player’s fundamental rights.  

Evidence demonstrates that a holistic approach to player welfare benefits the well-being of players and can influence the perception of sport as a whole - and its subsequent power to be a vehicle for positive societal change.  

It is important to note that violations of the rights of football players do not stem from one specific aetiology – similarly to considering how the rights of any person may be infringed, it can come down to a myriad of factors. 

In this article we acknowledge the right of all players to train and compete in environments which protect, respect and safeguard the integrity and dignity of others, starting specifically with the requirement to refrain from:

23.3: all forms of physical or mental abuse, all forms of harassment, and all other hostile acts intended to isolate, ostracize, or harm the dignity of a person; and 

23.4: threats, the promise of advantages, coercion and all forms of sexual abuse, harassment and exploitation are particularly prohibited. 


Article 23; FIFA Code of Ethics6






The proactive action to protect people from harm or abuse through appropriate prevention and response measures and promoting their well-being. It means doing everything possible to identify and address risks and to prevent any kind of harm or abuse from happening such as physical, sexual, emotional abuse and neglect, trafficking and exploitation. It also means having appropriate systems in place to adequately address and respond to concerns.


FIFA Guardians7


Harassment and abuse in all its forms is widespread and pervasive. Data demonstrates that across their lifetime, 1 in 3 women are subjected to physical or sexual violence (this does not include sexual harassment)8. These figures led the WHO Director General to comment that 'Violence against women is endemic in every country and culture', noting that this has only been exacerbated by the COVID-19 pandemic9

Research further indicates that at least 1 in 6 men have experienced sexual abuse or assault10, whether in childhood or as adults; and international studies reveal that nearly 3 in 4 children aged 2-4 years regularly suffer physical punishment and/or psychological violence at the hands of parents and caregivers11.

Whilst there is no conclusive evidence demonstrating that abuse occurs more often in sport than elsewhere, there are factors which may increase risk within sport, including reward structures centering on a win-at-all-costs mentality, the hierarchical nature of sport, lack of protection policies and access to effective remedy, institutional scandal avoidance, and unbalanced gender ratios. 

Whilst it is difficult to obtain precise data related to  the prevalence of harassment and abuse in sport (and there is a dearth of literature examining football specifically), it has been clearly shown to occur in all sports disciplines, at all levels, and worldwide. 

In a study of children and young people’s experiences of participating in organised sport in the UK, 75% of the 6,000 respondents (of which 13% said football was their main sport and 8% said it was their second) reported having experienced emotional harm, 24% sexual harassment, 23% physical harm and 3% sexual abuse13.

A study of elite athletes and coaches in Zambia (of which 23% were footballers) found 78% reported having experienced verbal harassment, 69% sexual harassment, 65% neglect, 30% physical abuse, and 37% sexual abuse14.

In a Canadian study of 1,001 current and retired professional athletes - including footballers - 60% reported having experienced emotional harm, 16% physical harm, 20% sexual harm and 71% neglect15.

It is also important to challenge the notion that harassment and abuse in sport predominantly impacts women and girls. A study by Rhind (2014)16 which reviewed cases of abuse in UK sport (and included football) found that 65% of the victims were male. 

As cases of harassment and abuse in football have continued to come to the forefront of public attention over the past few years, it is important to highlight that more cases being reported within the sport does not point to harassment and abuse being more prevalent in football than in other sports or societal sectors. 

In the face of historical evidence of systemic failures amongst sports organisations to prevent and/or respond effectively and appropriately to athlete maltreatment, disclosures reflect an active demand from players for safe, inclusive sporting cultures which recognise that their rights and well-being are of central importance. 

To better protect and support all players, football organisations must build capacity in both the prevention of and the response to abuse in sport and ensure a trauma-informed, people-centered approach to working with survivors. It is also essential that the interventions put in place (such as organisational policies ensuring access to recourse and remedy, education and training, etc.) are regularly monitored and evaluated. FIFA has recently launched several important programmes to support this, most notably the FIFA Guardians programme7.

That said, football is also a powerful vehicle which can influence the realisation of the rights of children and other vulnerable groups around the world. For many, it represents a safe space - an opportunity for social development programmes and educational initiatives fostering inclusion, community and driving wider social agendas.

Examples of sport for development programmes utilizing football to tackle wider societal issues are many and include the STOP GBV campaign implemented by Sport in Action in Zambia17 which uses community football as a platform to integrate sport and anti-gender-based violence education, and Slum Soccer18, which uses football to foster sustainable development within otherwise marginalised populations in India. 

There are countless opportunities for football to be used as a medium for social development, however these opportunities can only be realised when participation in the sport represents a physical and psychological safe space, centralising both the rights and welfare of participants across all levels of the game. 



As previously noted, harassment and abuse can affect anyone in sport - with elite athletes, children, players with disabilities and LGBTQI+ athletes being amongst those at higher risk19. Similarly, anyone can be a perpetrator, however male-dominated gender ratios in sport have been evidenced to be a risk factor, and studies have indicated that a higher percentage of perpetrators of interpersonal violence in sport are male20.

When considering grassroots participation, women and girls may overwhelmingly face challenges related to access. These have been broadly grouped as 1. practical – such as access to facilities, safe transport, funding, childcare, and personal safety in and around sports and community venues: 2. personal – such as clothing and equipment: 3. social and cultural - including gender constructs, attitudes and prejudices around sexuality, disability, and ethnicity, and 4. drop out due to harassment and abuse21.

This adds to the abundance of reasons why, when looking to cultivate safe and inclusive environments in and through football, it is essential to consider access and opportunity for women and girls from the pitch to the board room of the people’s game.

Women’s football has come a long way since its 12-team 1991 World Cup. With over 200 national teams globally and a planned 32-team World Cup in 2023, the momentum of women's football can neither be denied nor ignored. 

It is estimated that 29 million women and girls play football worldwide and FIFA aims to reach 60 million by 202622.

Opportunity for women and girls in football is a multifaceted ecosystem that needs to be addressed at all levels. There is currently a vast under-representation of women among coaches (7%), referees (10%), and executives (9%) across all national football associations23. As an example, in Spain there were 44 UEFA Pro licenses given to women coaches in 2017, and 2,379 were given to men24.

Associations and clubs around the world are also recognising that investments should be made in facilities and in access to medical care. For example, FIFA's Benchmarking Report: Women's Football showed that clubs with better access to higher number and quality facilities outperform other clubs in their league, with 50% of teams with access to a set standard of quality facilities being their league champions in the last 5 years25.

The 2020 FIFPro “Raising Our Game Report“26, which provides an overview of the global women's football industry, issued a call to action for “fair treatment, decent work, equal opportunities and the right to viable career paths as professionals in this industry”, requesting  the establishment of standards for the working conditions of players; global minimum labour standards; global standards for international tournaments and recognition of the professional status of players. 

Methods to challenge the status quo have been practiced around the world. Examples include the US women's team taking legal action, stating the violation of the US Equal Pay Act and Ada Hegerberg, the first recipient of the Ballon d’Or Féminin, refusing to play for her national team in the 2019 World Cup due to disputes over equality27.

Progression and change achieved by associations, clubs, technical staff, and players should, however, be noted.

·       In 2017, Lewes FC became the first professional club to establish the ‘Equality FC’ agenda, which has reaped benefits ever since. Attendance quadrupled and additional sponsorship deals were made based on the club's principles and values28.

·       In August 2019, Stephanie Frapport became the very first women's referee to officiate a major men's European final, the UEFA Super Cup29.

·       Autumn 2021 saw the kick-off of the first fully professional women's football league in Japan. The founding 11 teams of the WE League (Women's Empowerment League) are required to have a stipulated minimum number of players on professional contracts; at least 50% of the staff must be female; and at least one woman on their executive board30.

·       FIFpro, together with Women in Football, also launched ‘Ready to Board’ in 2021 - a programme looking to equip and prepare 12 women for executive roles in professional football31.

Even as we appreciate the advancements made in recent years, we must also acknowledge that there is still much work to be done. As passion and excitement for women’s football continues to grow at all levels, it is imperative that we continue to advocate for access, opportunity, and representation across the entire ecosystem.



Football has many powerful societal benefits including fostering a sense of belonging, solidarity, teamwork, and community. Despite this, it may also reveal deeply embedded discriminatory undertones within society. 

Incidents of racial abuse in football are not uncommon and sadly continue to be on the rise. The latest statistics from Kick it Out reported racial abuse in the professional game had risen by 53% from the 2018/19 season to the 2019/20 season regardless of the impact of COVID-1932. In Italy, statistics from the Observatory on Racism in Football, found that there were 249 racist incidents in stadiums from 2011-2016, and in the 2017-18 season alone there were 60 reported incidents33.

Footballers are not only targeted on the pitch. Social media has given perpetrators a new avenue to reach (and abuse) the biggest names in sport whilst granting them a perceived sense of anonymity. 

Between 17 and 26 June 2020, the Professional Footballers’ Association and Kick It Out, found that 43% of Premier League players had experienced racist abuse on Twitter34. Data collected by the English Premier League to monitor the issue of online harassment against players in 2021 suggested 70% of the profiles of perpetrators belong to people outside of the United Kingdom, demonstrating the international scope of online abuse35.

Whilst efforts are being made to tackle this behaviour (including educational & social campaigns and organisational responses in the form of sanctions), it is important to recognise racial inequality within the wider ecosystem of football itself. 

·       In the UK, football was historically perceived as a white man’s sport and racial chants during football games were not uncommon36. In Brazil, football at its origin was a sport for the elite. Games were played in exclusive clubs, and although admission to these clubs were primarily based on socio-economic status, people of colour were informally banned from these locations37.

This has – thankfully – rapidly changed, and football has been shown to be an important platform for community integration.  However, a recent Belgian study highlighted a continued clear under-representation of minority groups within football's governing organisations including coaches, technical staff, governance, and leadership positions38. This finding is supported by the 2017 Sport People’s Think Tank report which found that in 2017 people from ethnic minority backgrounds held only 4.6% of senior coaching positions in elite English football, despite accounting for 14% of the British population39.

Addressing racism in football will take more than legal, judicial, and disciplinary measures. Whilst these are necessary and should be applied consistently, properly addressing racism in football requires continued vigilance from every individual involved in the sport, from the tops of football organisations to fans watching at home. Diversity and inclusion strategies which recognises, and counters historical, social, and cultural prejudice must be embedded across all levels of the sport.


“Tackling racism in football involves confronting institutional racism, systemic prejudice, toxic behaviours and unconscious biases across society for change within and beyond sport.”34



When looking at the welfare of football players, it is crucial to discuss the intersectionality with mental health and well-being and the importance of caring for mental health with the same consideration as physical health. 

In a study on mental health in elite footballers, Gouttebarge (2018) found a 4-week prevalence of symptoms of common mental disorders in elite football players ranging from 9% for adverse alcohol use to 38% for anxiety/depression, and the 12-month incidence ranged from 12% for distress to 37% for anxiety/depression40.

In recent years, we have seen many footballers speak up about the mental health challenges they faced both during their sporting careers and following their transition out of elite competition.  

The stressors in today's game are wide and varied, and include biological, psychological, social, sport-specific and career-related stressors40, and yet conversations concerning mental health and well-being are often shrouded in stigma, with players encountering a number of barriers to help seeking, including: 

·       Lack of problem awareness

·       Scared of what might happen

·       Impacts on ability to play or train

·       Difficulty or unwillingness to express emotion

·       Not sure who to reach out to

·       Accessibility to support 

·       Belief that it would not help41.

Athletes experience mental health symptoms and disorders at similar levels to wider society41, and normalising conversations around mental health, recognising its importance to well-being and supporting help-seeking through established pathways to care will not only benefit football players, but also send an important and positive message to those for whom players are an important role model. 

If we are to propagate a holistic approach to athlete welfare, we must recognise that mental and physical well-being are two halves of a whole. 



Whilst efforts are being made to ensure that football is a safe and inclusive sport which provides equal access and opportunity and in doing so demonstrates a commitment to wider social agendas, it is clear that further attention must be paid towards the protection and promotion of footballer welfare.

The issues discussed here demonstrate the need for a transcultural approach which recognizes the inter-related experiences of players who experience harassment, abuse, and discrimination – be it by gender, race, or any other protected characteristic - along with the mental, physical, and psychosocial well-being of football players.

A commitment to diversity and inclusion – from the pitch, across all functional areas, and reflected centrally in the leadership – would positively impact all key topics discussed in this article, as would ensuring that footballers have mechanisms to make their voices heard and are represented at the decision-making level of organisations. 

Only by taking a holistic, rights-based approach to fostering a culture which protects and promotes the physical and psychological well-being of football players across the entire football ecosystem can we influence social and cultural change and help to protect not only the physical and emotional integrity of players, but the values of the sport itself. 


Whilst this article has provided an overview of some of the 'hot topics' currently impacting footballer welfare, they are by no means the only issues of note. Other topics including labour, economic exploitation, freedom of expression, specific considerations and protections for children, LGBTQI+ footballers and those with disabilities, and the rise of eSport and the implications for gamer welfare, warrant further discussion.  


Acknowledgements: Carrie Raukar-Herman, Tessa Jansen and Matthew Walker, Sports Rights Solutions 


Kirsty Burrows M.D., F.E.B.S.M.

Managing Director

Sports Rights Solutions

London,  United Kingdom







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Volume 10 | Targeted Topic - Hot Topics in Football Medicine | 2021
Volume 10 - Targeted Topic - Hot Topics in Football Medicine

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