'#BeTheChange': the responsibility of sports medicine in protecting athletes from harassment and abuse in sport.

Mahatma Gandhi was an Indian lawyer who became famous for employing non-violent measures to influence change to improve civil rights and liberties. ‘Be the change you wish to see in the world’ is one of Gandhi’s quotes that exemplifies his approach to inspiring change in attitude and behaviour at the individual level. As sports medicine physicians, we should be motivated to action by these words while sport faces one of the most severe threats to athlete health and well-being; harassment and abuse.

Safe sport is defined as an athletic environment that is respectful, equitable and free from any form of harassment and abuse. There are four forms of harassment and abuse in sport: psychological, physical, sexual, and neglect. Harassment and abuse occur across all sports, and at all levels, with increasing risk at the elite level, for child athletes, athletes with a disability and those who identify as LGBTQ+ (lesbian/gay/bisexual/trans-sexual/queer+).1 Prominent cases of harassment and abuse worldwide have shocked sports politicians, the media and advocacy groups to action. Some of the many examples include (i) the Human Rights Watch report on the practice of Taibatsu (corporal punishment) in youth sport in Japan2; (ii) Operation Hydrant (multi-divisional police investigation) in British football involving 849 victims from 340 football clubs, and 300 alleged suspects3; (iii) allegations of systemic sexual abuse in women’s basketball in Mali, Africa4 and (iv) the sexual abuse of 256 gymnasts by Dr Larry Nassar in the USA.5

The prevalence of harassment and abuse is difficult to quantify due to severe under-reporting. However, several studies have revealed alarming results that we cannot neglect. For example, a survey including 6124 youth athletes (aged 18–22 years) in Great Britain showed a prevalence of 29% for sexual harassment and 3% for sexual abuse prior to the age of 16.6 Another study showed that 75% of athletes experienced psychological abuse and 25% physical abuse before they turned 16 years.7 A retrospective survey of 4000 athletes in the Netherlands and Belgium identified that during their youth athletic career, 44% had experienced harassment and abuse (14% sexual, 11% physical, 33% psychological abuse).8

Harassment and abuse impact athlete health

The impacts of harassment and abuse on athletes’ health and well-being are extensive, can be severe and last long after the abuse has ended. Figure 1 illustrates the forms, the mechanisms and the impact of harassment and abuse on the athlete.

Figure 1

The International Olympic Committee model demonstrates the continuum of harassment and abuse in sport and the resulting athlete and organisational impacts.1 EDs, Eating Disorders; PTSD, Post Traumatic Stress Disorder; STI, Sexually Transmitted Infections.

The mental health impacts of harassment and abuse vary depending on the type of abuse, the duration and the circumstances. Reported mental health symptoms resulting from harassment and abuse include avoidance, dependence, low self-esteem, low self-worth and poor concentration. The mental health disorders attributed to experiencing harassment and abuse are depression, anxiety, post-traumatic stress disorder, disordered eating, eating disorders, substance misuse, self-harm, and even suicide.9

The physical impacts of abuse include injuries, self-harm, psychosomatic illnesses, unwanted pregnancies and sexually transmitted infections. Harassment and abuse can negatively affect athletic performance and cause premature drop-out from the sport. Victims of harassment and abuse have been shown to have an increased willingness to cheat in sport and participate in doping.1

What is the responsibility of sports medicine physicians?

Various professional guidelines regulate our responsibilities and actions towards athlete health and protection. One such ethical framework is the Declaration of Geneva adopted by the World Medical Association, which states, ‘As a member of the medical profession, the health and well-being of my patient will be my first consideration’.10 Sports medicine physicians also have an overarching ethical code of conduct developed by the International Olympic Committee, which outlines athletes’ rights as patients and provides guidelines for the ethical behaviour of sports medicine physicians within the context of elite sport. The Olympic Movement Medical Code (2016) states:

The Olympic movement … encourages all stakeholders to take measures to ensure that sport is practised to minimise harm to the health of the athletes … to protect the health of participants by minimising the risks of physical injury, illness and psychological harm … [2.1.4] For the benefit of all concerned, measures to safeguard the health of the athletes and to minimise the risks of physical injury and psychological harm.11

From the above, we can only conclude that it is our strong obligation as sports medicine physicians to support the health and well-being of our athletes as patients in our care, and to consider the significant health impacts of harassment and abuse, the prevention of harassment and abuse, and understand that the support of athlete victims is our individual and collective responsibility.

#BeTheChange: the call to action

Sports medicine physicians should have the clinical competence to recognise the signs and symptoms of abuse, to manage disclosures of athlete allegations, to be knowledgeable of reporting obligations and mechanisms, and to support the athlete in their recovery as a member of a multidisciplinary team (ie, sports medicine, sports psychiatry, specialist as required).12 Sports medicine physicians should also be trained in the principles and skills of trauma-informed care to prevent re-traumatisation of athlete victims of harassment and abuse.13 These core clinical competencies should be embedded in the sports medicine fellowship training curriculum.14 Finally, we must understand and acknowledge that sports medicine physicians cannot bring effective change if the ecosystem in sports does not recognise the place they have in helping athletes thrive. The CanMEDS Framework, developed by the Royal College of Physicians and Surgeons of Canada, identifies the roles and desired attributes physicians require to effectively meet the community’s healthcare needs. Many of these roles are applicable to sports medicine to guide the care of our ‘community’ of athletes in the context of harassment and abuse (see figure 2).15

Figure 2

A framework to guide sports medicine physician’s behaviours and actions modified from the CanMEDS Framework.15 Copyright 2015 The Royal College of Physicians and Surgeons of Canada. https://wwwroyalcollegeca/rcsite/canmeds/canmeds-framework-e. Reproduced with permission.

Given the assertion that sports medicine physicians have the responsibility to safeguard athletes from the health impacts of harassment and abuse and the alarming prevalence, it is apparent that there is an urgent need for action by sports medicine, both individually and as a collective group. We must ‘be the change’ to strive for a safe sporting environment free from harassment and abuse.