WMA contribution to the report of the Special Rapporteur on violence against women and girls to the UN General Assembly on violence against women and girls in sportWMA contribution to the report of the Special Rapporteur on violence against women and girls to the UN General Assembly on violence against women and girls in sport

WORLD MEDICAL ASSOCIATION
ASSOCIATION MEDICALE MONDIALE
ASOCIACION MEDICA MUNDIAL
CIB Immeuble A “Le Keynes” Website : www.wma.net Postal Address :
13-A Chemin du Levant Telephone : (33) 4 50 40 75 75 CS 5001
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France E-mail address : wma@wma.net France
WMA contribution to the report of the Special Rapporteur on violence against women and
girls to the UN General Assembly on violence against women and girls in sport
1. The World Medical Association (WMA) is the global federation of National Medical
Associations representing millions of physicians worldwide. It aims to ensure the independence
of physicians and the highest possible standards of ethical behavior and care by physicians toward
all people. The WMA provides ethical guidance covering a wide range of subjects, including
health-related human rights, in order to promote and defend the basic rights of patients and
physicians.
2. We thank the Special Rapporteur for the opportunity to provide our inputs on the issue of violence
against women and girls in sport. The WMA has long condemned all forms of violence against
women and girls, denouncing the devastating consequences for women’s health, and more broadly
for the family and society, and advising physicians on how to prevent and combat this scourge1
.
3. With regard to sport in particular, we would like to draw your attention to the World Athletics’
eligibility rules for female classification about which we have the greatest reservations. These
Regulations make participation in competitions by female athletes with differences in sexual
development (DSD) conditional on medical intervention to reduce their natural level of
testosterone in the blood.2
.
4. We strongly contest the validity of these regulations from the point of view of human rights and
medical ethics. By their coercive nature and detrimental impact on women, they contravene
fundamental human rights to health, non-discrimination and the enjoyment of just and favourable
conditions of work. Furthermore, the Regulations promote practices that directly violates the core
ethical values of the medical profession enshrined in the WMA’s universally recognized set of
policies: beneficence, non-maleficence “do no harm’, justice and autonomy3
. As we elaborate
below, we feel they are a form of violence to girls and women in sport which deserves the Special
Rapporteur’s attention in her upcoming report.
Infringement to the freedom to choose and accept work
5. While the Regulations state that “no athlete will be forced” to submit to medical assessment or
interventions, the consequence of such refusal is exclusion from all events.4 Facing a set of forced
choices does not allow athletes to make a truly voluntary decision about whether to undergo
medical assessment and potential intervention which are prerequisites to carrying out their
1
WMA Statement on Violence against Women, WMA Statement on Forced or Coerced Sterilisation, WMA Statement
on Female Genital Mutilation, WMA Statement on Family Violence
2
The Eligibility Regulations for the Female Classification were revised in 2023, further restricting the conditions of
access to competitions to female athletes with differences in sexual development.
3
Declaration of Geneva,– the modern Hippocratic oath, WMA Declaration of Lisbon on the Rights of the Patient, WMA
Declaration of Cordoba on Patient-Physician Relationship, WMA Declaration of Seoul on Professional Autonomy and
Clinical Independence
4
The 2023 version states simply that consent may be revoked, demonstrating continued lack of appreciation for how
‘choice’ is fundamentally constrained, given that revocation of consent removes eligibility: Regulations 2023, r 2.2.
WMA page 2
2
professional activity. This forced choice contravenes the right to work within the meaning of
article 6 of the International Covenant on Economic, Social and Cultural Rights which guarantees
“the right of everyone to the opportunity to gain his living by work which he freely chooses or
accepts”. A female athlete cannot decide freely on her work given the major consequences
on her health of the conditions under which she has access to that work.
6. From the perspective of medical ethics, the conditions required for the informed consent of the
patient are not met, especially in the light of elements of coercion. The WMA Declaration of
Lisbon on the rights of the patients provides that “The patient has the right to self-determination,
to make free decisions regarding himself/herself”.
Infringement of the right of everyone to the enjoyment of the highest attainable standard of
physical and mental health.
7. The right to the highest attainable standard of physical and mental health is enshrined in the
International Covenant on Economic, Social and Cultural Rights. It is an inclusive right,
extending beyond healthcare to the underlying determinants of health, and States must abstain
from enforcing discriminatory practices relating to women’s health status and needs.5
8. A medical intervention to reduce and maintain athletes’ natural level of testosterone in the blood
is, in general, only appropriate when it is not coerced, where there is a medical need, and with
attention to minimal invasiveness and side effects. The principle of beneficence enshrined in the
WMA Declaration of Geneva is explicit in this respect, stating that the “health and well-being” of
patients is the primary consideration of physicians. The WMA has therefore consistently opposed
the World Athletics’ rules: “The mere existence of a condition caused by a difference in sex
development, in a person who has not expressed a desire to change that condition, does not
constitute a medical indication for treatment. Medical treatment solely to alter athletic
performance is unethical”6
.
9. In addition, the side effects of these medical interventions constitute risks that cannot be balanced
against any health benefit because their purpose is compliance with sports eligibility rules. These
include diuretic effects that cause excessive thirst and urination, electrolyte imbalance, liver
toxicity, disruption of metabolism, inhibited steroid production, cortisol deficiency, headache,
fatigue and nausea (for pharmacological interventions such as hormonal contraceptives or GnRH
contraceptives),7
as well as compromised bone strength, chronic weakness, depression, diabetes,
and sterilization (in the case of surgical interventions such as gonadectomy).8
In sum, WMA
assesses these interventions as causing only harm.
10. Causing (or risking to cause) such harm, here coerced and for no reason related to health or well-
being, constitutes a violation of the human right to health and of the medical ethical principles of
beneficence and non-maleficence.
5
CESCR, ‘General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12)’ (11 August 2000,
E/C.12/2000/4).
6
WMA Declaration on Principles of Health Care in Sports Medicine
7
Human Rights Watch, n Error! Bookmark not defined. at 63-67, 82; Rebecca Jordan Young et al, ‘Sex, Health and
Athletes’ [2014] Vol. 348 BMJ 348, 349.
8
Letter from Special Rapporteur on the right to enjoyment of the highest attainable standard of physical and mental
health et al to IAAF (18 September 2018)
.
WMA page 3
3
Infringement of the principles of non-discrimination and social justice
11. The International Covenant on Civil and Political Rights entrenches the principle of non-
discrimination and the right to the equal protection of the law. Equally, the WMA’s Declaration
of Geneva recognizes the principle of non-discrimination and justice by requiring physicians not
to permit considerations such as age, disease, disability, ethnic origin, nationality, gender, sexual
orientation or social standing to come in the way of their duty to their patients. This duty of
physicians relates to the right of patients to appropriate medical care without discrimination.9
12. If the World Athletics Regulations involve the surveillance of all women, those whose gender
presentation does not match dominant stereotypes of femininity will be under particular scrutiny,
and therefore investigated and stigmatized. As noted by United Nations human rights experts, the
Regulations’ surveillance of all women, and the selection of a subset of women to investigate,
reinforces negative stereotypes and stigma around race, sex, and gender identity and subjective
expectations around which bodies are appropriate.10
13. Because of the natural variation in sex development, some women’s athletes are therefore directly
discriminated against, having to undergo a long-term and heavy medical intervention to be
allowed to practice their chosen work in sport. What’s more, assessing testosterone levels requires
a series of intrusive and often offensive examinations and interrogations violating their privacy,
bodily integrity and autonomy. Through these coercive medical interventions, the Regulations
openly deny women’s rights, their dignity, their physical integrity and autonomy, in
particular through denials of their right to control their own bodies, including the right to
make their own decisions about health and contraception.
Infringement of the right of everyone to the enjoyment of just and favourable conditions of
work
14. The International Covenant on Economic, Social and Cultural Rights recognizes “the right of
everyone to the enjoyment of just and favourable conditions of work which ensure, in particular:
(b) Safe and healthy working conditions”11
. We do not see anything “just” or fair in discriminating
a person on the grounds of her natural physiology. Likewise, we do not recognize any “favorable”
or satisfactory working conditions in imposing heavy medical examinations and interventions
(not to mention the important side-effects of the intervention) to allow a person to practice her
profession.
15. To the contrary, the constrained working conditions have a significant impact on the mental
and physical health of athletes. Particularly coercive conditions arise where athletes, their
families, national federations and the team of agents, promoters, and sponsors supporting them,
depend on their sporting career for their livelihood and economic stability. This has been shown
to be the case insofar as the Regulations disproportionately affect athletes from under-resourced
nations.12
This concern is more pronounced under the 2023 Regulations: while athletes previously
could switch to unlisted events, they are now excluded from all events.
9
WMA Declaration of Lisbon on the Rights of the Patient
10
Letter from Special Rapporteur on the right to health, n Error! Bookmark not defined..
11
Article 7 ICESCR
12
See Human Rights Watch, ‘They’re Chasing Us Away From Sport – Human Rights Violations in Sex Testing of Elite
Women Athletes’ [2020] 58, 93-97 . Maybe add: “Gender Battle – The Abandoned Women of Sport,” ARD
Network (2019), https://www.imdb.com/title/tt12044874/.
WMA page 4
4
16. The “safe and healthy working conditions” a fundamental aspect of the right to just and favourable
conditions of work, is closely related to other Covenant rights, in particular the right to the highest
attainable level of physical and mental health13
. As explained above, the medical intervention
imposed by the World Athletic Regulations constitutes a definite risk to the health of the female
athlete, depriving her from safe and healthy working conditions.
Infringement to the patient-physician relationship
17. The very nature of the physicians’ obligations under the World Athletic Regulations is corrupted
from the outset, confronting them with an ethical dilemma: either they comply with the
regulations and provide medical care to athletes for the purposes of athletic performance, at the
risk of compromising the patient’s health and well-being; or they oppose the regulations in
accordance with the ethical values of their profession and find themselves in conflict with their
athletics federation and at risk of losing their position.
18. By asking physicians to act deliberately in breach of their ethical duties to athletes, the
Regulations hamper the trustworthy patient-physician relationship. The WMA sees in the patient-
physician relationship “the fundamental core of any medical action centred on a person” which
must be protected at any time “from interference from governments, other agents and institutional
administrations in the practice of medicine”14
.
19. This protection is essential because it is intrinsically linked to the patients’ rights, autonomy and
dignity. Likewise, “in order to carry out his or her ethical obligations, the sports medicine
physician’s authority must be fully recognized and upheld, particularly when it concerns the
health and safety of the athlete. Concern for the athlete’s health and safety must override the
interests of any third party”15
.
Conclusion
20. The World Athletic Regulations institute a coercive system in which certain female athletes are
confined because of their natural physiological variations, resulting in a succession of harsh
violations of their fundamental rights relating to health, non-discrimination and work, as well as
the principles of medical ethics. Taken as a whole, we consider this system to be a form of blatant
violence against women, within the meaning of the United Nations Declaration on the Elimination
of Violence against Women16
. As physicians, we are particularly outraged by this established
pattern of human rights abuses. There can be no justification for such degrading treatment
affecting the health, dignity and integrity of a person. We therefore urge the Special
Rapporteur to address this issue in her report and to clearly recognize the invalidity of the
World Athletic Regulations from the point of view of human rights and medical ethics.
26/03/2024
13
General comment No. 23 (2016) on the right to just and favourable conditions of work, article 7 of the International
Covenant on Economic, Social and Cultural Rights
14
WMA Declaration of Cordoba on Patient-Physician Relationship – WMA – The World Medical Association
15
WMA’s Declaration on the Principles of Health Care for Sports Medicine
16
Article 1: “any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological
harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether
occurring in public or in private life”.