Governance and safety in Australian combat sports: a call for a unified framework

Introduction

Combat sports are characterized by one-on-one contests that involve striking, grappling, throwing, and punching (1). Examples of combat sports include boxing, Muay Thai (MT), mixed martial arts (MMA), and Judo.

Research by Kotarska et al., involving 441 participants, demonstrated that participating in combat sports promotes healthy behaviours. The study shows that athletes in combat sports tend to display a greater intensity of health-focused behaviours compared to those in other sports (2). This included improved eating habits and a more proactive approach to health management through preventive measures. Additionally, a systematic review by Ciaccioni, which included seventy cross-sectional and two longitudinal studies, highlighted the psycho-physical benefits of combat sports (3). These benefits included enhanced physical fitness, mental resilience, and overall well-being. These benefits have contributed to the increasing popularity of combat sports globally.

Despite their widespread appeal, combat sports constantly attract media scrutiny, medical debates, and parliamentary inquiries due to their health and safety implications (4). A retrospective study of Australian and New Zealand news archives identified 163 boxing-related fatalities in Australia from 1832 to 2020 (5). Traumatic brain injury (74.2%) and cardiac arrest (6.7%) were the most common causes of death (5). In addition to acute complications combat sport athletes also risk long-term consequences. A study by Bernick et al. reported that concussions occurred in 78% fights. The average number of concussions per minute of fight time was 0.061 (boxers experiencing 0.047 and MMA fighters 0.085) and this is higher than other sports (6). This highlights the risks associated with combat sports and need for comprehensive frameworks to address these risks.

A study conducted by Channon et al., based on 200 hours of shadowing medical professionals and event staff at 45 combat sports events highlighted the lack of medical governance in combat sports (7). The researchers found that medical practices and standards in combat sports are highly inconsistent. Event organizers and promoters lacked understanding of the roles of medical practitioners and rarely check whether the staff they hire are appropriately qualified. The study also found that the venues were frequently ill-equipped to handle basic medical procedures and were not able to support more critical interventions such as resuscitation, which is particularly relevant given the high-risk nature of combat sports (7). Channon et al. also discovered that medical professionals had limited authority in the combat sports setting, with clinical decisions being overruled by non-medical staff during events (7). This finding aligns with a study by Bennett et al., which involved over 250 boxers and MMA athletes that highlighted significant gaps in their understanding of concussion symptoms. It also demonstrated lack of proper concussion identification protocols that heavily relied on self-reporting by athletes (8). Around 40% of fighters admitted returning to training or competition on the same day they sustained a head injury. This failure to follow concussion protocols highlights broader governance issues within combat sports, where oversight, education, and medical regulations are inadequate. In contrast to structured leagues like Rugby League or Australian football, which enforce strict return-to-play protocols and independent medical assessments, combat sports typically rely on self-reporting and inconsistent regulations across different organizations. This fragmented approach leaves athletes vulnerable to preventable long-term neurological damage.

Discussion

The Australian Medical Association (AMA) opposes all forms of combat sports and has called for their removal from the Olympic and Commonwealth Games (9). Their opposition stems mainly from concerns about inadequate medical governance and the long-term health risks, particularly the potential for permanent neurological damage, which they believe outweighs the benefits of engaging in these high-risk sports. This aligns with much of the medical literature emphasising the associated risks. However, combat sports account for over 20% of total Olympic medals and participation is increasing globally (10). Despite AMA opposition, sports medicine professionals are increasingly involved in the care of athletes participating in combat sports (11). This paper argues that a purely oppositional stance by medical bodies has a potential to cause more harm. AlHashmi et al. discuss the issue of “team-doctoring” in combat sports, where athletes often seek medical advice from teammates and coaches due to the lack of dedicated medical support. This results in misinformed management that exacerbates the medical issues (12). In contrast to the AMA’s approach, this paper proposes a unified framework that incorporates harm reduction principles from public health into clinical governance strategies, aiming to mitigate risks for all stakeholders in combat sports.

Harm reduction is a public health strategy aimed at minimizing the negative effects of risky behaviours. It was originally developed to address substance abuse and these strategies have since been successfully applied to reduce morbidity and mortality across a wide range of public health issues. Harm reduction practices are already used to help athletes. This includes initiatives like providing condoms to athletes for promoting sexual health and ensuring the availability of sunscreen to protect against sun damage. Harm reduction is particularly effective in combat sports because the impact of combat extends beyond the confines of the sporting event. It has broader social implications that influence athletes, event organizers, and the wider community. Adopting harm reduction approach in unified structured governance framework would shift the focus away from punitive measures or calls to ban combat sports altogether. Instead, it would prioritize addressing the underlying social and health issues by fostering safer environments and improving medical oversight. This approach has already been embraced in other sports. For example, drug use policies in Australian football where the focus has moved from strict punitive actions to strategies aimed at reducing harm, ensuring athletes’ health is safeguarded and maintaining confidentiality while maintaining the integrity and sustainability of the sport (13). These strategies include providing education on substance use and offering support for athletes struggling with addiction (14). Similarly, in combat sports, a harm reduction model could balance the inherent risks associated with sport and athlete well-being. Harm reduction is the right approach for combat sports because it acknowledges the responsibility of policymakers to develop public health measures that reduce the associated harm to all athletes, promoters and medical practitioners.

The Australian Commission on Safety and Quality in Healthcare defines clinical governance as a framework of structures and responsibilities among stakeholders to ensure optimal clinical outcomes (15). Key principles of the Australian Clinical Governance Framework include establishing appropriate governance and leadership structures, implementing effective safety and quality systems, maintaining high workforce standards, and fostering a culture of continuous improvement (15). Combat sports will benefit from integrating these practices in a unified framework.

Governance and leadership

Appropriate clinical oversight and leadership structures are central to effective clinical governance. Combat sports that are recognised by the International Olympic Committee (IOC), such as boxing, lead the way with mature governance structures. These governance structures are available publically on the Boxing Australia’s website (16). They adopt a federation-style organizational structure that includes representation from association members from each Australian state (17). This leadership structure is supported by a board of Directors that is elected by members. They also have a range of management and operational staff with specified governance responsibilities. They also have publicly identified standing committees that focus on medical services, athlete welfare and performance related policies. These committees help comply with the national clinical governance standards by informed decision-making, fostering accountability, and prioritizing participant safety and well-being. Strategic planning is central to effective governance. Boxing Australia has a clear strategic plan that articulates the organization’s values, mission, and vision. It also outlines strategic priorities accompanied by specific objectives designed to achieve these goals, ensuring alignment and accountability across all levels of the organization.

Boxing Australia’s governance framework is further supported by a publically available constitution, which provides clarity and structure to its operations. They also have a publically available board charter, code of conduct and delegation regulation. This comprehensive approach ensures that Boxing Australia maintains transparency and accountability in achieving its objectives of supporting its athletes, coaches, and broader community. Other sports, such as Judo Australia (18), Australian Taekwondo, Wrestling Australia (19), and the Australian Karate Federation (20), have similarly established governance frameworks to oversee safety, athlete welfare, and competitive standards.

In contrast, sports like MMA and MT lack cohesive, overarching national governance bodies. The regional regulations in these sports, such as the Combat Sports Commission in Western Australia (21) and the Combat Sports Authority in New South Wales (22), provide some oversight, but these bodies are limited in scope and expertise. They vary in pre-athletic screening, required medical equipment, and facilities at competition venues. Additionally, they have different requirements for fundamentals such as the minimum age for pregnancy testing and the frequency of infectious disease testing (21,22). Governance structures and strategic plans are not publicly accessible. Additionally, there is limited information on medical representation in leadership roles. When details are available, they vary by state. For example, the Western Australian employs an occupational physician, while New South Wales employs a general surgeon to lead clinical governance roles. A more unified and standardized governance approach, leadership structures and clinical governance standards would help enhance athlete safety and help with long-term development of combat sports.

Safety and quality systems

Australian states and territories have enacted various regulations to address safety concerns in combat sports (4,5). This includes Boxing and Martial Arts Act 2000 (SA), Combat Sports Regulations 2004 (WA), and Combat Sports Act 2013 (NSW). Despite these efforts, significant gaps remain in standardizing clinical governance across different sports. Effective safety and quality systems require robust policies, comprehensive risk management, consistent incident reporting, and a strong commitment to open disclosure. Concussion is a prime example where safety and quality systems are failing in combat sports. Combat sports do not have consistent publicly available policies. Head strikes are a common occurrence in combat sports. However, several combat sports lack written consensus statements specifically addressing the management of athletes who have suffered a concussion or their return to competition (23). Fighters are unlikely to voluntarily quit due to the competitive nature of the sport. Ringside medical staffs are not allowed to examine athletes during the contest using standardized assessment tools. Therefore, it is crucial for referees, physicians, and ringside personnel to be trained to identify visual signs of concussion and stop fights promptly.

Safety and quality systems are also inadequate in weight management and cutting within combat sports. Combat sports classify athletes by body weight to ensure fair competition. To meet weight requirements, athletes often engage in unsafe practices such as extreme calorie restriction, dehydration, and vomiting (24). These methods can have severe consequences, negatively impacting both physical and mental health (10). Performance-enhancing drugs (PEDs) use also remains a significant safety challenge in combat sports. Certain combat sports in Australia, like boxing, jiu-jitsu, and MT, adhere to the Australian National Anti-Doping Policy, while others, such as MMA, do not (25).

To address these gaps, there is a need for a unified national framework incorporating harm reduction public health principles. This will help ensure consistency in clinical governance and safety standards across all combat sports. This framework should provide evidence-based recommendations on routine activities like return to sport after concussion, frequency of testing for blood-borne infections and uniform age criteria for urinalysis in female athletes. Policies promoting safe weight management practices must be prioritized, including mandatory education programs on nutrition, hydration, and the risks of extreme weight-cutting methods. Furthermore, implementing mandatory adherence to the Australian National Anti-Doping Policy across all combat sports is essential to combat the use of PEDs (26). Transparent incident reporting systems, combined with comprehensive risk management strategies and open disclosure practices, can further enhance athlete safety and promote public trust in the governance of combat sports.

Workforce standards

Medical practitioners play a vital role in combat sports. They are responsible for conducting pre and post-contest medical clearance. They need to assess for injuries on ring-side within a short period of time. Unlike collision sports such as rugby league and soccer, where medical professionals must have advanced first-aid training and life support certification, combat sports have no specific credentialing requirements for medical practitioners. Credentialing for combat sports practitioners should include expertise in sports medicine, combat sport specific injuries, and knowledge of PEDs. Additionally, regular assessment of leadership and decision-making skills for medical practitioners is crucial to ensure optimal outcomes in managing the complex demands from other ring side event staff (27).

Credentialing should involve a structured process that evaluates sports specific qualifications and experience of practitioners involved in combat sports. Medical practitioners should demonstrate a solid foundation in sports medicine, including the prevention, diagnosis, treatment, and rehabilitation of sports-related injuries relevant to combat sports. Ringside medical practitioners must be capable of responding to critical situations, such as cardiac arrest, intra cranial injuries and respiratory distress. Credentialing should confirm their expertise in advanced life support and trauma care to ensure readiness for emergencies. This approach has already proven beneficial for general practitioners working in community settings (28). Accreditation through recognized bodies such as sports medicine colleges or universities will ensure basic competency in this area.

Additionally, practitioners should be knowledgeable about the physiological and psychological effects of PEDs, their potential for misuse, and the associated health risks. Credentialing should include training on anti-doping regulations, testing protocols, and ethical considerations regarding PED use in sports. Practitioners must also be equipped to counsel athletes on the dangers of PEDs and offer guidance on alternative, safer performance optimization strategies (29).

Lastly, combat sports athletes face unique mental health challenges, such as competition pressures, weight management stress, and the psychological effects of injury. Credentialing should include training to recognize and address these mental health issues, with the ability to provide appropriate referrals to mental health professionals when necessary. This comprehensive credentialing process ensures that medical practitioners are fully prepared to safeguard the health and well-being of combat sports athletes.

Conclusions

By implementing harm reduction measures, combat sports organizations can create environments that prioritize athlete safety, ensure the presence of appropriately trained medical professionals, and foster a culture focused on minimizing health risks for combat athletes. This approach is essential not only for managing injuries but also for preventing more severe and long-term health complications. Key strategies to support this include mandating the credentialing of medical personnel involved in combat sports, ensuring they possess sport-specific expertise. This ensures that doctors are trained in combat-related injuries, managing PEDs, and addressing mental health issues commonly faced by athletes in high-risk sports. Additionally, combat sports organizations must develop and implement comprehensive national guidelines that address crucial areas such as concussion management, weight-cutting practices, and injury care protocols. These guidelines should align with international best practices across different contact sports. Regular audits and evaluations are also essential to monitor compliance with clinical governance standards, ensuring continued safety improvements. By implementing these steps, governance bodies can protect athlete health while upholding the integrity and sustainability of the sport. This will help combat sports organizations showcase the benefits of combat sports and support their growth.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-10/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-10/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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