By introducing an article on “Menstrual Health” in its Regulations on the Status and Transfer of Players, effective June 1, 2024, FIFA is promoting the well-being of female athletes by guaranteeing paid menstrual leave. As the first international sport federation to add menstrual health to its policies, it acknowledges its impact on performance and sheds light on a topic that has long been taboo and plagued by negative gender stereotypes. This article examines the gradual recognition of the menstrual cycle in professional sports, mainly through athletes breaking the silence by speaking up about the detrimental effects of menstrual silence. Low menstrual health literacy, stemming from a gender science gap, is exacerbated by insufficient menstrual education across sport organizations. FIFA’s initiative could reduce the stigma and normalize menstrual health at all levels of sport.
Introduction
Estelle Nze Minko has won nearly every major title with the French National Handball Team. In 2019, she joined Győri ETO KC, a prominent Hungarian club with five EHF Women’s Champions League titles. Upon joining, she was initially taken aback when the club’s physical therapist asked about the onset of her periods, finding the question violent, even “perverse!”. This prompted her to seek further understanding, leading to the realization that she had never trained according to her menstrual cycle. A year later, she authored an article on Règles Élémentaires’ website, an organization fighting period poverty, stating that although she had been playing at the elite level for over 10 years, this was the first time she had ever been asked about her menstruation.
Her story made it to national media outlets and started an important conversation to break a deeply embedded taboo in France, and in the French language, which is quite rich in euphemisms for menstruation. British or Canadians might find it amusing that “Niagara Falls” or “the British army has landed” are among the top fifteen commonly used expressions for periods.
Menstruation, or period, is a normal biological process that marks the beginning of the menstrual cycle, with up to seven days of bleeding. It initiates the follicular phase, which lasts about 12 days. This is followed by ovulation, lasting approximately 16 to 32 hours, and then the luteal phase, which lasts about 14 days and includes a high hormone phase, during which pre-menstrual syndrome symptoms such as cramps or poor sleep may be experienced. A healthy menstrual cycle lasts between 28 to 35 days, with variations in hormone levels throughout.
A professional female athlete who menstruates must manage her cycle while struggling with structurally challenging working conditions. These conditions include short-term contracts (such as in professional football, where the median contract length is between 1 and 1.5 years) and salaries that show massive disparities compared to their male counterparts.
In a paper written by the International Labor Organization (ILO) for discussion ahead of the 2020 Global Dialogue Forum on Decent Work in the World of Sport, a professional athlete is defined as an individual “who gains income through competitive sport and whose activities are controlled by a sports organization, such as a club or federation.” Therefore, professional female athletes are workers, and their physiology plays a role in their work as the paper goes on to acknowledge that “the sexual and reproductive health of athletes affects men and women differently, but the effects are not always well researched. Some female athletes have been outspoken that menstruation impacts their performance and can increase the likelihood of injury.”
The final report of the Global Dialogue Forum on Decent Work in the World of Sport stated few points of consensus, among which that “All workers, including athletes, regardless of the type of employment relationship, require, as a minimum, to be protected by the fundamental principles and rights at work.” In this documents the ILO recommends the enablement of a sport environment promoting decent work in the world of sport by “generating equal opportunities for all and providing equal conditions of work for female athlete”, including access to social protection coverage in relation to workplace injury benefits and maternity leave. One might have expected the ILO to underline the importance of developing policies that support the reproductive health needs of female athletes, by further “engendering” the right to work by including menstruation. However, this was not reflected in the final document.
A few months later, following a proposal from the professional football players’ association FIFPRO, FIFA updated its Regulations on the Status and Transfer of Players (RSTP) to improve female players’ working conditions. This improvement was achieved by adding a new section on Special Provisions Relating to Female Players, which detailed its parental policy.
Parental policies have been standard for most female workers globally for decades. Their recent adoption by FIFA may seem anachronistic given the progressive values typically associated with sport, but the federation is doing more than just catching up. It is setting a new standard in women’s sports by embarking on what philosopher Camille Froidevaux-Metterie refers to as a battle in the “genital turn” of the feminist movement, which calls for the recognition of aspects of female physiology long considered taboo, such as menstruation and menopause.
Professional athletes are increasingly vocal about menstrual health and its implications on performance and injury risk. Incorporating female physiology into sports organization policies is a first step toward breaking the silence, educating stakeholders, changing the culture of sport, and advancing scientific knowledge surrounding menstruation. Tracking and sharing menstrual data seems inevitable and brings with it the challenge of data protection.
FIFA’s menstrual health policy
In June 2024, FIFA made a remarkable change to its RSTP, introducing a section on “Menstrual Health” within its special provisions for female players. Under this new provision, a player is entitled to be absent from training or matches whenever her menstrual health requires it. Additionally, she is entitled to receive her full salary while exercising this right, provided that a medical certificate is issued by her personal gynecologist or specialist medical practitioner.
Theoretically, players could already take medical leave due to any health issue, but the specific inclusion of menstrual leave in the RSTP acknowledges an aspect of women’s health that has long been neglected. This decision was driven by FIFA’s commitment to educating on the female body since 2011 with its guide for players and coaches on Health and Fitness for the Female Football Player. In its guide, FIFA has been striving to educate on menstrual health, particularly focusing on the potential effects of irregular or absent menstruation on health and performance. The guide encourages athletes to track their cycles and to alert doctors in case of abnormalities to prevent bone mineral density loss. Additionally, the guide educates on the female athlete triad (disordered eating, amenorrhea, and osteoporosis), which was the subject of a consensus published by the International Olympic Committee (IOC) Medical and Scientific Commission in 2005 and updated with the consensus statement on Relative Energy Deficiency in Sport (REDs) in 2014.
In 2023, the FIFA Female Health Project was launched with a published report explaining FIFA’s current strategy and recommendations. In its foreword, Sarai Bareman, FIFA Chief Women’s Football Officer, highlighted the “lack of scientific literature on female athletes,” noting that “there is little information about how female hormones affect training stimuli and overall performance.”
FIFA “recognizes the uniqueness of female physiology and is committed to providing women in football with the attention, resources, and knowledge they deserve.” There is a pressing need to incorporate menstrual health considerations into sports as there is a lack of comprehensive studies detailing the specific mechanisms by which the phases of the menstrual cycle may disrupt athletic performance and increase the risk of injury.
FIFA highlights the considerable impact of the menstrual cycle on women’s participation in sport. In fact, a survey conducted this year on 622 French female football players from amateur clubs aged 11 to 18 years revealed that 70% of respondents miss training due to menstrual pain. Additionally, nearly 50% of respondents reported not feeling comfortable discussing their menstrual health with their club staff.
These findings in amateur sports today, if not addressed through research and education, are likely to affect those who advance to the professional level tomorrow. Surveys of professional athletes and their entourage, including coaches, continue to reveal low oral contraception and menstrual cycle literacy.,
In this perspective, the FIFA Female Health Project appears to be one of the most ambitious initiatives in sports focused on women’s health, performance, and well-being. It emphasizes “fundamental anatomical, physiological and hormonal differences between men and women.” As a result, the project aims to normalize this natural biological process, educate at all levels, from grassroots to elite, and support athlete preparation through to retirement.
The cultural change needed to accept menstrual leave in professional sport
In February 2023, Tiger Woods faced backlash for handing a fellow golfer a tampon as a joke after outperforming him at a tournament. The act, captured in photos, was criticized for being sexist and immature, reinforcing negative stereotypes on menstruating women.
Despite female athletes becoming increasingly outspoken about menstruation, the cultural battle to educate about the menstrual cycle, and on menstrual leave, must primarily be led by sports organizations as gender stereotypes are deeply rooted in the entire sports ecosystem, which acts as an echo chamber reflecting broader societal beliefs.
Law scholars have provided original and valuable insights on menstrual leave. In “Menstruation Matters,” Bridget J. Crawford and Emily Gold Waldman examine the intersection of law and menstruation-related policies. They suggest that menstrual leave might be counterproductive, using Japan as an example, where such leave has been implemented since 1947. In Japan, the rate of menstrual leave utilization decreased from 26% in 1965 to under 1% in 2017, primarily due to concerns about workplace discrimination. Similarly, in some provinces in China, recent menstrual policies have caused women to hesitate to take leave for fear of upsetting their employers.
The authors also discuss Italy’s proposal to offer up to three days of paid menstrual leave per month in 2017, which was ultimately abandoned due to concerns about its potential negative impact on women’s employability. The authors explain that while tax exemptions on menstrual hygiene products are widely supported, the fact that menstruation is experienced differently by women raises “greater skepticism” about the real need for menstrual leave. They argue that to address menstrual equity in the workplace, a menstrual leave policy would be the least viable solution. They assert that gender-neutral policies are more favorable, especially from a legal standpoint, as they avoid the risk of sex discrimination, do not perpetuate gender stereotypes like perceived weakness, and protect the privacy of women’s health.
Another perspective on law and menstruation was published by Sydney Colussi, Elizabeth Hill, and Marian Baird. Through a critical feminist lens, they analyzed two international conventions, namely the International Covenant on Economic, Social and Cultural Rights (1976) and the Convention on the Elimination of All Forms of Discrimination Against Women (1981). They point out that international law has “engendered” the right to work by acknowledging the reproductive body but has limited this to pregnancy and parenthood. They argue that to fully engender the right to work, menstruation and menopause should be recognized as equally important aspects of the reproductive body. They consider paid menstrual and menopause leaves as counterproductive if gender stereotypes are not addressed, as it could reinforce the sexist idea that women do not belong in the workplace. Additionally, they mention that treating these leaves as sick leave would medicalize innate bodily functions, thus undermining progress in women’s rights.
In fact, several athletes’ testimonies support their argument, as sports federations tend to medicalize innate biological processes. For example, Clarisse Agbégnénou, the most decorated woman in the history of French judo, revealed that when she announced her pregnancy to the French Judo Federation in 2022, it was “complicated” as she had to “remind them that pregnancy is not a disease.”
Therefore, without initiating a cultural change to combat gender stereotypes in their sport, federations risk unintentionally reinforcing negative stereotypes around female physiology. This change must occur at all levels of their organizations and involve all stakeholders. Simply implementing menstrual leave, without addressing the underlying gender biases, could perpetuate the very stereotypes these policies aim to dismantle.
The struggle of menstruating athletes: employees versus entrepreneurs
Considering menstrual health, while a significant advancement in team sports, may not be applicable in the same way to individual sports. For example, in a team, it is possible to rotate players, allowing those who may experience painful periods to rest or adjust their playing time.
When experiencing menstrual pain, an individual sport athlete faces the dilemma of either competing through the pain or withdrawing from a competition she has prepared for years. The solution is not simple, as illustrated by British middle- and long-distance runner Eilish McColgan, who responded to a man criticizing her for complaining about getting her period during competition, saying, “As if I could simply call up the Olympic Games and ask them to move my event to the following week to fit my cycle.”
Sport governing bodies are used to implementing policies regarding athletes’ health to ensure their safety and well-being as it is one of their missions and roles under the Olympic Charter. For instance, many federations have adopted concussion protocols that prevent athletes from competing if they do not meet specific health criteria. Recently, the International Federation of Sport Climbing has announced its intention to combat REDs, which can manifest through disruptions in the menstrual cycle. Its REDs policy restricts participation of affected athletes in any competition, including the Olympics.
This type of solution could work perfectly in settings where professional athletes have access to paid medical leave to recover. But what about sports where athletes are considered independent contractors?
Tennis, for example, presents particularly challenging working conditions, with 80% of the top 1,000 ranked players struggling to earn a livelihood. Unlike sports where athletes have employment contracts, golf or tennis players are more like solo entrepreneurs. They manage and bear the financial burdens of their staff as independent contractors rather than employees. These financial pressures restrain athletes from taking necessary time off in order to sustain their income and improve their rankings. Consequently, female athletes classified as contractors are compelled to mitigate any health concerns to continue competing.
This situation presents a structural issue that could be resolved through negotiations to establish minimum compensation standards, safeguarding the well-being of athletes unable to work due to their menstruation. The ILO underscores that professional athletes, including those not directly employed by their club or sport organization, have a fundamental right to organize and negotiate Collective Bargaining Agreements (CBAs). Such agreements are essential for advancing protection standards and fostering a constructive platform for social dialogue to improve athletes’ working conditions. Based on the Occupational Safety and Health Convention, 1981 (No. 155), and the Promotional Framework for Occupational Safety and Health Convention, 2006 (No. 187), the ILO asserts that “athletes should not be required to shoulder the costs of measures required to protect their health and safety.”
The cost of menstruation silence
Without greater visibility, particularly on prime-time television, which remains the “central bank of attention,” female athlete may continue to suffer a wider gap on too many fronts: pay, visibility and research. In fact, only 8.8% of studies are exclusively focused on female athletes, compared to the 70.7% focused on male-only athletes. In addition, available scientific studies on the impact of menstrual cycle suffer methodological differences preventing a clear understanding of its implications for athletes’ health. Performance parameters in athletes can vary during the menstrual cycle, but the evidence is inconsistent regarding the nature and extent of these variations.
Tunisian tennis player Ons Jabeur regularly speaks about the financial struggles she faced when she was not ranked among the top 10 of the Women’s Tennis Association (WTA), noting that nobody would listen to her during those times. This led her to join the executive committee of the newly created Professional Tennis Players Association (PTPA) in January 2023. The PTPA is pushing for change in the “bureaucratic” structure of tennis, which allows only a few players to financially break even.
However, Jabeur goes further by explaining that the structure of the sport is mentally taxing on female athletes, influencing their decisions about delaying maternity due to financial concerns, period anxiety due to dress codes, and the management of period pain, as they have no other choice but to continue playing. In an interview with The Guardian, she stated, “I cannot tell you how many times I played on the first day of my period and how I was suffering and crying in pain. I have lost matches because of it.”
Now-retired judoka Frédérique Jossinet told Le Monde that she experienced period anxiety throughout her career due to fear of blood leaking on her white kimono. Moreover, the fear of menstrual blood leaking onto white shorts has been shown to negatively affect performance. This concern has led several football teams to adopt darker-colored shorts. As of Wimbledon, known for its all-white dress code, it made changes in 2023, now permitting solid, mid-to-dark-colored undershorts, provided they are not longer than the outer shorts or skirts. Allowing women to influence change in direction of their sport’s organization uniforms is an important cultural shift in an ecosystem still policing the bodies of female athletes.
The rights gained by women in the general population tend to be implemented decades later for women in professional sports, as they are often not recognized as workers with rights. Even minimal protections enshrined in international law, such as maternity rights, are only now being recognized and adapted to professional sports (e.g., the WTA’s return to competition ranking policy after maternity leave in 2019 or FIFA’s minimum maternity leave in its 2021 RSTP).
As noted by the ILO, the autonomy of sport “exposes the sector to regulatory gaps and the risk of exploitation.” These risks are mitigated by numerous factors, including membership in a players’ association. For instance, FIFPRO was the driving force behind the FIFA RSTP parental policies of 2021 and 2024, which is yet to be implemented at the national level by most of FIFA’s member associations.
Menstrual cycle tracking and data privacy
The FIFA Female Health Project calls for “individualized and proactive” tracking of the menstrual cycle but does not recommend any specific method. As most athletes track their cycles through mobile applications and wearables, and may share personal health data with some of their club staff, it raises questions about data privacy.
In collaboration with FIFA, FIFPRO published a “Charter of Player Data Rights” in 2022 to establish standards for the protection of professional footballers’ data. The Charter outlines several rights for players regarding their personal data: being informed about data collection and use, accessing their data, and revoking consent at any time. Additional to the right to restrict data processing, ensure data portability, correct inaccurate data, file complaints, and request data erasure.
Therefore, even if the Charter provides clear direction for the desired strategy in protecting players’ data within football, players’ associations have yet to negotiate CBAs that protect athletes’ health data. If wearables and tracking apps could facilitate the emergence of a “menstrual consciousness” among professional athletes, it may come at the cost of data security.
To protect athletes’ data, one interesting example is the CBA between the NBA and the National Basketball Players Association (NBPA) which includes a section on wearables, introduced in 2017 with a “Wearables Committee” consisting of three representatives from each organization. This committee reviews requests and authorizes device use based on criteria like data security. In the current CBA, effective through the 2029-2030 seasons, an NBA team can request a player to voluntarily wear an approved device, provided the team gives a written confidential explanation of the tracked data, its meaning, and the benefits for the player.
NBA players have full access to all data collected from approved wearable devices. Team staff can also access this data, but only for player health, performance, and on-court strategic purposes. According to the CBA, this data cannot be used for other purposes, including contract negotiations or player transactions. If a team violates this rule, a grievance arbitrator can impose a fine of up to 250,000 US dollars.
For professional female athletes, establishing a “FemTech Committee” in CBAs would be a significant step towards safeguarding data privacy by selecting menstrual tracking apps and wearables that protects athletes, given that female health data can be criminalized in certain jurisdictions (for example, some tracking apps ask about a past abortion).
While recognizing the usefulness of female mobile health apps, researchers from King’s College London and University College London examined the 20 most downloaded applications on the UK and USA Google Play Stores.[52] They found inconsistencies and conflicts in the information provided across privacy policies, data safety, and app interfaces. In the post-Roe v. Wade world, the researchers highlighted that the policies of 13 of the studied apps permit user data to be accessed by law enforcement, security authorities, or regulatory agencies upon request or subpoena. These applications, which act as a form of “intimate surveillance” pose significant risks through the oversharing of information. Additionally, when consent is given to a tracking app, it can transfer data to third parties, leading to “cascading consent,” where users unknowingly allow further data sharing. The researchers also found that these apps cross-reference user data with browsing information from search engines, increasing the risk of “de-anonymization.”
In a work context without clear guidelines on data usage, there are concerns about the protection of personal health data and the potential for misuse. It could negatively impact women’s rights at work, such as in non-selection decisions and discrimination.
The IOC Medical and Scientific Commission published a paper in 2023 extending the IOC consensus statement on methods for collecting epidemiological data on injury and illness in sport to include ten domains affecting female athletes’ health throughout their lifespan including menstrual and gynecological health.
The Commission recommends that, given the sensitivity of the data collected, it is essential to ensure that the data is only used for the purposes agreed upon during the consent process. It also advises that data-collecting tools owned by third parties be examined to determine ownership and usage rights, with this information communicated to athletes to ensure informed consent. Additionally, it stresses that the data security of these platforms must comply with the data protection laws of the jurisdictions in which they operate.
Conclusion
Early June 2024, singer and comedian Farideh published a TikTok video of her new song “Female Body”, a satire making fun of the ignorance surrounding the female physiology. The video went viral, garnering millions of views and transforming the comments section into a global discussion forum among women on the repercussions of the gender science gap on their health.
From menarche to menopause, half of humanity experiences nearly 400 menstrual cycles over the course of a lifetime. Millennia of stigma and stereotypes of a normal biological process led to the current situation in which women and girls have a low literacy of their cycle, including elite female athletes.
International organizations are increasingly advocating for menstrual health, framed as a human rights issue. In 2022, the High Commissioner for Human Rights acknowledged a “menstrual movement” and recognized menstrual health as an essential part of reproductive rights. In addition, the World Health Organization called for addressing menstruation from a health and human rights perspective rather than as a hygiene issue.
In sports, the IOC, the supreme authority of the Olympic Movement, states in its Charter that its role and mission along with international federations and national Olympic committees is “to encourage and support measures relating to the medical care and health of athletes.” The institution remains gender-neutral in its Charter, leaving the door open for its members to implement their own health policies.
In that regard, FIFA is trailblazing in sports by adding gender-specific policies to its RSTP, including “Menstrual Health,” which secures paid menstrual leave for professional football players. It is supported by a clear vision, outlined in the FIFA Female Health Project: to inform, research, educate, disseminate knowledge, and ultimately change the culture of football. Increased research and education on female physiology, along with cycle tracking, could change the working conditions of professional female athletes by improving their health, well-being, and performance, provided that menstrual health data is protected. It could also reduce the stigma and normalize menstrual health at all levels of sport.
McColgan, E. (2022, August 19). ‘Why is menstruation still a taboo subject?’. BBC Sports
https://www.bbc.com/sport/athletics/61752427