Doubt

In the 2008 Hollywood movie “Doubt,” Meryl Streep plays Sister Aloysius, a hard-nosed school principal, who was plagued with doubt and anguish over her discovery of sexual abuse in a private Catholic school in the Bronx in the 1960s. Despite her doubt, she was relentless in her pursuit of protection for the abused student. As sports medicine physicians, are we, in our role as athlete advocates, acting on our doubts to protect our athletes from the often hidden and secretive threats of nonaccidental violence in sport? The Olympic Charter (2013), which defines the key principles of Olympism, identifies the role of the International Olympic Committee in acting against any form of discrimination and the importance of protection of athlete health (8). The Olympic Movement Medical Code (2009) underscores the necessity that all stakeholders “should take care that sport is practiced without danger to the health of the athletes and with respect for fair play and sports ethics … [and should take] measures necessary to protect the health of participants and to minimize the risks of physical injury and psychological harm” (9). These two fundamental documents illustrate the rationale for athlete protection in sport. As sports medicine physicians, we are educated in the science and clinical application of sport-related injury and illness prevention, recognition, and treatment. We are not well trained or experienced in the underlying science and clinical skill of prevention, identification, and management of nonaccidental violence in sport. What have you done to safeguard your athletes? Are you confident in your skill to manage an athlete who discloses abuse? Nonaccidental Violence in Sport Nonaccidental violence in sport is composed of various forms of maltreatment including sexual, physical, and psychological abuse as well as gender and sexual harassment, hazing, bullying, homophobia, neglect, forced exertion, medical mismanagement, and similar mistreatments. The term violence has been adopted by international athlete welfare advocacy groups, such as Safe Sport International, to emphasize the seriousness of the threats to an athlete’s well-being and to align with the terminology utilized by other recognized organizations such as the World Health Organization and UNICEF (2). These violations are impingements of the UN Declaration of Human Rights (16), rights which also apply to our athletes within the sport. In the sporting context, athletes also have “the right to enjoy a safe and supportive sport environment” (12). Threats There are a range of potential threats which have been identified in the scientific literature that affect athlete health and well-being. These threats can be categorized into three main groups: individual, relational, and organizational. The individual threats from nonaccidental violence in sport include physical injury, age cheating, doping, depression, self-harm, substance abuse, and disordered eating/eating disorders. Threats from nonaccidental violence in sport also can be relational involving more than one individual including sexual harassment, sexual abuse, physical abuse, forced physical exertion, virtual maltreatment, neglect, and bullying. Finally, there are organizational threats to athletes that can take the form of abuse from spectators, discrimination, hazing, medical mismanagement, and unhealthy training programs. Medical mismanagement Surely, everyone reading this commentary is thinking that he or she is not guilty of this form of violence against athletes! As sports physicians, we are in a particularly unique situation as athletes entrust us with the medical management of their health and well-being; at the same time, sports organizations utilize our knowledge and expertise to maximize athletic performance. This dichotomy of dual responsibilities can be incongruent and potentially can negatively influence our decision making. What is disturbing to discover is that medical mismanagement in sport is not rare: examples include the judicious use of injected local anesthetic and glucocorticoid in joints and soft tissue of competing elite athletes, return to play in unsafe situations, and the excessive and often systemic prescription of analgesic medication in the sport setting (15). As team physicians, we often empower physiotherapists or athlete trainers to manage athlete health beyond their scope of practice during travel. We also rely on insufficiently trained coaches to recognize and often manage medical issues in athletes (6). Consequences of Nonaccidental Violence in Sport The consequences of nonaccidental violence in sport can be devastating and are far reaching, affecting athlete health and performance not only during sport but also postretirement from sport. It can negatively affect the athlete’s physical, emotional, mental, and/or relational health. Individuals who have experienced childhood sexual abuse have poorer health outcomes in many domains. Beyond sport, the consequences also can negatively affect the athlete’s scholastic and/or employment success. In addition to the effect on the athlete, nonaccidental violence in sport is detrimental to the moral and ethical integrity of sport as well as the financial viability of sport organizations. The devastation of nonaccidental violence in sport should not be underestimated (13). Prevalence Research in the field of athlete welfare has increased greatly in the past 25 years revealing disturbing prevalence data that demonstrates a range of nonaccidental violence in sport between 2% and 48% (10). There is documentation in the scientific literature that various forms of sexual harassment and abuse occur in all sports, at all levels, and in all ages ranging from the child athlete to the elite level athlete (14). In particular, there is a higher risk of sexual harassment and abuse for the athlete at the elite level (7) and in sports where there is early specialization or where intensive talent identification occurs at or around the age of puberty (3). Another time of high risk for sexual abuse is when the athlete is in the “stage of imminent achievement” where there is an increased dependency on the coach or perpetrator to reach for athlete success (4). Given this prevalence data, are you sure that you are not missing cases? Can you identify the pattern of the subtle signs and symptoms of abuse? When you see a constellation of somatic, behavioral, and psychological presentations, does it trigger your doubt? Do you have a strategy to act on your athlete’s behalf to uncover the violence and stop it? Action Prevention What can a sports physician do to prevent nonaccidental violence in sport? The first step in prevention is to understand the “grooming” process that occurs between the perpetrator and the athlete. Nonaccidental violence in sport occurs when there is an abuse of power in the coach/entourage and athlete relationship. Knowledge of this process facilitates the implementation of effective prevention initiatives. As occurs outside of sport, the perpetrator follows these steps over time to entrap the vulnerable victim (5,11): Step 1: targeting the vulnerable athlete Step 2: building trust and friendship Step 3: developing further control and securing loyalty Step 4: building and securing secrecy Prevention of nonaccidental violence in sport is the responsibility of all involved in sport. All sport organizations have the legal, as well as a moral and ethical, responsibility to protect athlete health and well-being (11). As sports physicians, we should ensure that our sport organization has policies for safeguarding athletes, including written policies for the recruitment and training of all personnel in the athlete’s entourage. Police and background checks should be standard procedures to ensure that a perpetrator in one club or country does not just “move on” to another jurisdiction to repeat the pattern of abuse. These policies should include codes of conduct guiding appropriate behavior and the clear definition of boundaries. In addition, there should be systems and procedures to manage allegations. Educational programs raising awareness of athletes’ rights, threats, and policies and procedures should be mandatory for everyone in the sporting community. Importantly, athletes should have an active voice in the development of these programs and a mechanism of communication with sport authorities that is heard and valued. Disclosure The team physician’s clinical approach to athlete disclosure should include empathetic listening and psychological support as athletes often feel strong feelings of guilt, shame, and fear. The encouragement of disclosure without using leading questions is encouraged. Meticulous record keeping is required for potential future legal utilization. Immediate physical and psychological support should be provided for the athlete, the athlete’s team, and the athlete’s family. Timely reporting to the local legal authorities and/or sport organization as per the procedures described above is recommended to ensure that violence is stopped. Neglecting to report or ignoring the abuse compounds the psychological trauma for the victim. This phenomenon is known as the “bystander effect” (1). In the words of Sister Aloysius when facing the perpetrator in her school, “I will do what needs to be done ….” As sports physicians, we should have no doubt. We have the moral and ethical responsibility as well as the knowledge and means to “do what needs to be done” to ensure that our athletes are protected from both threats and harm, and they are provided with a healthy sport environment where they can flourish to reach their potential athletic goals. The author declares no conflicts of interest and does not have any financial disclosures.

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