Sexual harassment and abuse occur in all sports and at all levels with an increased risk at the elite level. The physical and psychological consequences of sexual harassment and abuse are significant for the athlete, their team and for the health and integrity of sport in general. The sports medicine health professional has an integral role to play in the prevention of sexual harassment and abuse in sport. This paper provides sport healthcare professionals with a practical guide on prevention strategies and advice on the recognition and management of suspected abuse.
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Sexual harassment and abuse (SHA) occurs in all sports, at all levels.1,–,3 Given the widespread occurrence of SHA within sport,3 ,4 it is vital that all people involved with athletes are made aware of the risk factors and consequences of this abuse. Team doctors and sports physicians are in a pivotal position, given their frequent contact with athletes, to identify these potential risks and consequences. This paper focuses on the team doctor's role in the identification, prevention and treatment of SHA in sport and will begin with an overview of the definition of SHA and the risk factors and consequences of SHA. The paper will then discuss methods directed at the prevention of SHA, including the role the team doctor can play in prevention.
What is sexual harassment and abuse in sport?
The inappropriate sexual encounters experienced through SHA in sport can occur in various forms, including sexual harassment, sexual abuse, gender harassment, hazing and homophobia. Sexual harassment is considered sexualised verbal, non-verbal or physical behaviour. This form of harassment may be intended or unintended and legal or illegal. The underlying aspect of sexual harassment is that it is ‘based upon an abuse of power and trust and that is considered by the victim or a bystander to be unwanted or coerced’ (pp1).5 Brackenridge6 similarly defined sexual harassment as ‘unwanted attention on the basis of sex’ (pp 116) and sexual abuse as ‘groomed or coerced collaboration in sexual and/or genital acts where the victim has been entrapped by the perpetrator’ (pp 116–117). Sexual abuse has also been defined as ‘any sexual interaction with person(s) of any age that is perpetrated against the victim’s will, without consent or in an aggressive, exploitative, manipulative or threatening manner” (pp 3).7 Sexual abuse therefore involves any sexual activity where consent is not or cannot be given. In sport, sexual abuse often involves manipulation and entrapment of the athlete. Gender harassment consists of ‘derogatory treatment of one gender or another that is systematic and repeated but not necessarily sexual in nature’.5 Hazing is considered ‘any activity expected of someone joining a group that humiliates, degrades, abuses or endangers, regardless of the person’s willingness to participate' (page 8)8 and often has sexual components.9 ,10 Homophobia is a ‘form of prejudice and discrimination ranging from passive resentment to active victimisation of lesbian, gay, bisexual and transgendered people’.5 Sexual harassment, sexual abuse, gender harassment and hazing have all been described as stages in a continuum of sexual exploration.6 Homophobia also belongs to this continuum but depends upon what form the homophobia occurs in.11 ,12
Prevalence of sexual harassment and abuse in sport
Research demonstrates that these various forms of SHA (sexual harassment, sexual abuse, gender harassment, hazing and homophobia) occur in all sports2 ,13 and at all levels, including child and youth sports,1 college and university athletes,14 ,15 and elite athletes.3 While exact prevalence rates of SHA in sport have not been systematically determined,16 estimates range widely from 2% to 48%.3 ,4 ,11 ,17,–,19
While SHA occurs in all levels of sport, prevalence of SHA does appear to be higher in elite sport as the higher the athlete is on the sporting talent ladder, the greater the risks of being sexually exploited.3 ,4 In addition, sports where there is early specialisation may also present greater risks of sexual exploitation, especially in sports where intensive talent identification happens around puberty.12 SHA commencing during the ‘stage of imminent achievement’ in sport is posited to occur as athletes have an increased dependence on their coach as they reach their performance goals.20
Perpetrators of sexual harassment and abuse in sport
Often perpetrators of SHA are in positions of power such as coaches and other members of athletes' entourage.21 However, coaches are not the only perpetrators of SHA. In fact, peer athletes actually harass athletes more than coaches,13 as is often seen in the case of hazing.9 ,10 While it is expected and also seen that more males than females are perpetrators of SHA,22 this could be due to the larger percentage of males in positions of power in sport. In fact, it is not solely males who are the perpetrators, as females are also perpetrators of SHA outside23 and within sport.22 For example, a recent study exploring sexual harassment of females in sport, has found that 34% of women had experienced sexual harassment from men and 12% from women.22 SHA also does not solely occur in a heterosexual manner, as there are known examples of homosexual perpetrators of SHA in sport.24 However, it is important to note that sexual orientation is unrelated to SHA within sport and outside.11
Risk factors for sexual harassment and abuse in sport
Contrary to some myths of SHA in sport, there is no evidence that the amount of clothing,2 amount of touching13 or the type of sport are risk factors of SHA.2 There are similar prevalence rates of sexual harassment across sports in which there are different degrees of revealing sports attire.2 However, female athletes who participate in more masculine sports, with the possibility of more clothing, do appear to experience more harassment than women in other sports.2 There is also no known connection between the amount of physical touching in sport and sexual exploitation.13 Lastly, SHA occurs in all sports, individual and team sports2 and so the type of sport is not considered a risk factor of SHA.
While many myths of the risk factors associated with SHA in sport are unfounded, there are some situations where there are higher risks of SHA in sport.6 ,25 ,26 These include locations where isolation may occur (eg, locker room, coach's car, coach's home, trips away, isolation from other athletes),6 ,11 ,25 during training (eg, playing field) and group events that may involve alcohol or power differentials (eg, team socials, initiations and hazing, year-end events).10
Risk factors can also be broken down into athlete, coach and sport variables.6 ,25 Athlete variables include a poor and distant relationship with parents, being a younger woman, having low self-esteem, a strong talent in their sport and a dedication to their coach.6 ,25 Coach variables include a male coach who is older, has a good reputation in the sport and is trusted by the athletes' parents.6 ,25 ,27 Sport variables include providing many opportunities for trips away from home and limited opportunities for reporting SHA.6 ,11 ,25
While some researchers cite being a woman as an athlete-specific risk factor for SHA,25 there has been limited research investigating gender differences in SHA within sport. It is known that sexual abuse of females is more prevalent outside sport than inside sport.4 In contrast, sexual harassment of females is more prevalent inside sport than outside sport.13 However, this is not the case in all situations outside of sport, as Volkwein-Caplan and colleagues21 found sexual harassment to be slightly more prevalent in academia than in athletics. A thorough understanding of these potential risk factors is important when looking towards prevention of SHA in sport.
Physical and psychological consequences of sexual harassment and abuse in sport
In addition to the above-mentioned risk factors, awareness of the sequelae resulting from SHA can help those around the athlete become more cognisant of the possible occurrence of SHA. As there is very little research on the consequences of SHA in sport, understanding of the impact of SHA can be drawn from research on SHA outside of sport. SHA can have a negative impact on all aspects of the victim's life including physical28 ,29 and psychological consequences.30 ,31 These consequences then may detract from scholastic and employment achievements, including decrease in job performance and satisfaction, poorer marks and more dropped courses.32
Physical consequences and medical presentations of SHA in sport
The physical consequences of SHA in sport, and outside of sport, are often more easily detectable than the psychological consequences as they are more visible. The athlete who has experienced SHA may present with various medical and somatising concerns to the sports physician. Physical reactions may include headaches, lethargy, sleep disturbances, weight fluctuations and poorer general health satisfaction.32,–,35 Irish and colleagues28 conducted a meta-analysis of the literature on the long-term physical health consequences of childhood sexual abuse. They found people who had experienced sexual abuse have poorer health outcomes in the following areas: general health, gastrointestinal health, gynaecological or reproductive health, pain, cardiopulmonary symptoms and obesity.28 In the hazing that is sometimes seen in sports, there can also be extreme physical consequences, such as alcohol poisoning and even death.10
Psychological consequences of SHA in sport
As psychological consequences of SHA are less observable, the detection of these concerns requires awareness that such problems occur in the world of sport and are keen attunement to the possible consequences of SHA. Table 1 outlines the various psychological consequences that may occur as a result of SHA in sport and similarly outside of sport. Some more observable psychological symptoms from SHA may include weight loss/gain,36 bed wetting,37 ,38 increase in fatigue/decreased energy, acting out behaviours causing physical harm33 ,39 and sexually transmitted infections.40 In addition, outward signs of SHA may include risky or self-harm activities or self-abuse may also be observed by the physician (eg, excessive dieting or bingeing, limited condom use).36 ,39 ,41 ,42 There may also be various other social or behavioural problems,23 ,33 ,36 ,39 including the harming of others (eg, pets, bullying of peers, schoolmates or neighbours, and harming family members).43 People who have experienced SHA in sport may also describe poor interpersonal relationships and trust difficulties, such as problems in marriage.23 ,36
Numerous meta-analyses have shown that previous sexual abuse results in increased risk of developing mental health concerns.30 For example, people who have experienced SHA often report experiencing symptoms of clinical depression44,–,47 and have higher rates of suicidal ideation, attempts and completed suicides.23 ,46 In addition to depression, people report increased rates of anxiety and anxiety disorders following SHA. This could include acute and chronic post-traumatic stress disorder44 ,46 involving nightmares and hypervigilance and obsessive–compulsive behaviours and/or disorder.45 ,47 Sexual abuse may also have negative impacts on self-esteem, body image and result in the development of an eating disorder.36 ,44 ,48 ,49 Similarly, the athletes may engage in substance abuse or dependence as a result of the SHA.49 ,50
Sport-specific psychological consequences and medical presentations
In addition to the various medical presentations which sports physicians should be aware of, there are also sport-specific medical presentations that may suggest the possibility of SHA. The athlete who has experienced SHA in sport may demonstrate excessive risk-taking within their sport and outside.43 ,51 The athlete may also engage in various self-harm forms of behaviour that may be manifested in unexplained injuries or eating disorders.49 In order to cope with the abuse, or as a consequence of the abuse, some athletes may also engage in obsessive–compulsive training, potentially leading to symptoms of burn-out. As a result of the athlete's risk-taking, self-harm, and/or excessive training, the physician may notice unexplained injuries that do not make sense or never seen to resolve. Another sport-related presentation the physician may notice is unexpected early sport dropout.
Psychological consequences of SHA may also include the athlete losing self-confidence and having poorer performance consistency, which not surprisingly negatively affects their athletic performance.25 ,48 This poorer athletic performance may also be due to decrease in concentration, as athletes who have experienced SHA noted decreased concentration when their abuser was present, such as on the sporting field.48 Due to the SHA and relationship with this perpetrator, athletes often experience trust issues with people associated with their abuse and sport (eg, coaches, peers, athlete entourage, officials, volunteers, authority figures: parents, teachers and others).48 For example, in qualitative interviews with athletes, many noted this abuse affected their relationship with their coaches and how they interacted with this particular coach.48 As athletes are no longer feeling confident in their sporting abilities, may have poorer performance, and have lost trust in people associated with sport, they may consider dropping out of their sport.10 ,25 ,48
How does it happen? Understanding the coach–athlete relationship
A more in-depth understanding of how the development of a coach–athlete relationship may lead towards SHA can help in improving prevention and earlier identification of this abuse. This relationship development has been labelled a ‘grooming’ process for sexual abuse.6 12 25 52–54 While there are various definitions for the term ‘grooming’, it can be used to describe any strategy a perpetrator uses to coerce a person to engage in sexual interactions with them.24 As Brackenridge6 stated:
Sexually abusive coaches spend a long time … grooming their athletes. This process is a crucial precursor to sexual approaches and involves building trust, gradually pushing back the boundaries of acceptable behaviour and slowly violating more and more personal space through verbal familiarity, emotional blackmailing and physical touching. (page 122)
Often there are early signs in the relationship between the coach and athlete of the potential for abuse to occur which are important to outline. There are four key components of the coach–athlete relationship that may increase the potential for SHA: (i) Targeting the victim. (ii) Building trust and friendship. (iii) Developing control and loyalty. (iv) Building and securing secrecy. The points are discussed below:
Initially, the victim might be targeted as the coach finds a potentially vulnerable athlete and begins a friendship with this athlete. Brackenridge6 found these athletes are often vulnerable as they are more isolated on the sports team, have a poor relationship with their parents and/or have few friends.
Through this friendship the coach builds a more trusting relationship by making the athlete feel special by the giving of rewards or gifts. With the provision of these rewards, the coach can later say, ‘you have to do this (sexual activity), because of I have (given you this reward)…’ These rewards can also serve to increase an athlete's feelings of cooperation with the coach.25
The coaches may then develop further control and loyalty often through refusing the athlete access to significant others, friends and supports. This may include restricting access to the athlete's parents as a way of checking the athlete's commitment. For example, in qualitative interviews with athletes who had experienced sexual abuse, the athletes spoke how developing a strong sense of dependence on the coach lead to increased cooperation with the coaches' sexual behaviours.25
After the abuse has begun, the coach may continue to build and secure secrecy by ensuring the consequences of the sexual boundaries. The coach may use statements such as ‘you owe me’ or ‘it is our little secret.’
The gradual nature of this entrapment serves to increased secrecy, security for the abuser and cooperation of the athlete.25 Through the grooming process, the athlete is often rendered powerless to speak up against the perpetrator, or even to seek help. The athletes thus often become silenced and are unable to say no or tell someone about the abuse. In order to help prevent SHA in sport and to support athletes in speaking out about this abuse, it is vital to have a good understanding of the coach–athlete relationship and the potential for SHA within this relationship.
The team doctor's role in prevention
Athlete protection policy, codes of conduct and boundaries
Prevention strategies include the adoption of athlete protection policy statements in every sport organisation. These policies should be associated with codes of conduct/practice, educational and training programmes, complaint and support mechanisms, and monitoring and evaluation systems.5 All people involved in sport (such as team doctors) have a duty of care to ensure that each sport organisation has an effective athlete protection policy. An athlete protection policy is a ‘statement of intent that demonstrates a commitment to create a safe and mutually respectful environment’ (pp 2).5 This policy should include what is needed to promote the well-being and rights of the athletes. It also allows the sporting organisation to take action, and possible disciplinary measures, when an abuse allegation is made.
Other professionals (eg, physicians or teachers) have codes of conduct and explicitly stated boundaries when interacting with those with less power (patients or students). Likewise, those in positions of power in sport (coaches, administrative staff, physicians, etc) should also have codes of conduct and boundaries. These codes of conduct can be integrated into an athlete protection policy and provide standards of behaviour for people to follow which further implement this policy. Codes of conduct for interaction with athletes must include a clear and explicit statement of the boundaries within various relationships: ‘The code of conduct should specify standards of what is acceptable and unacceptable in terms of both physical contact with athletes/children and issues of dependency and control’ (pp 72).25 These codes of conduct should include and be available to all people who are involved in the sport including coaches, administration staff, volunteers, parents and the athletes themselves. Some codes of conduct/practice for coaches and other people involved in sport have been created including those developed by the US Olympic Committee,55 the Coaching Association of Canada56 and the National Association of Sports Officials.57
While often not explicitly stated in codes of conduct, in order to prevent SHA in sport, the following details should be included in future codes of conduct for coaches and all administration staff: never be alone in a room with an athlete, never share a hotel room at an event, never drive an athlete home after practice and never see an athlete socially. Codes of conduct for team physicians and any other adults in an athlete's environment, should include clear guidelines for the physicians' specific roles, responsibilities, relationship boundaries and appropriate professional boundaries.58 It is essential that each member of the entourage and any other authority figure, stay within the boundaries of a professional relationship with the athlete.
Prevention of SHA: leadership from the International Olympic Committee
The International Olympic Committee (IOC) developed a consensus statement of sexual harassment and abuse in sport. This statement focuses on understanding and preventing SHA and discussed some implications for sport psychology.59 This document serves as an educational tool for team physicians and sport organisations to learn about SHA in sport. For the Youth Olympic Games in 2010, the IOC developed an educational animation for the youth athlete to raise awareness of the athlete's rights in the prevention of SHA. This animation can be used by team physicians and sport organisations in educating the youth athlete in this subject area.
Phase 2 of the IOC sexual harassment and abuse in sport prevention project focuses on athlete protection. Based on models of best practice, an IOC online animation tool was developed for youth athletes to raise awareness of SHA. An additional interactive online educational tool for adult athletes, coaches and sports organisations will be available in late 2011. The goal of this tool is to increase knowledge of the right to safe sports and to develop skills to detect and respond to risks. Team physicians and sport organisations can use these tools to raise awareness and educate about SHA in sport. These resources are appropriately based on past quantitative and qualitative research that has been discussed earlier in this paper and can be accessed from the IOC website (www.olympic.org/sha).
Clinical approach to disclosure
If the sports physician thinks there may be the possibility of SHA, it is important to understand that this athlete may experience immense feelings of shame, guilt and fear.25 Therefore, physicians should focus on actively and empathetically listening to and psychologically supporting the patient/athlete. It is also important to acknowledge his/her courage in speaking about this abuse and to assure the athlete that this experience is not their fault. It is important to simultaneously encourage disclosure and yet avoid any leading questions. To facilitate this disclosure and to demonstrate trust in the athlete, the sport doctor should not denigrate the perpetrator.
At all points in this process, the physician must ensure accurate record completion. In order to stop the SHA, physicians have a duty to report the abuse to the specific authorities depending on the legal statutes in the particular country/jurisdiction. The abuse should also be reported through the reporting mechanism in the sport organisation that is established as outlined in the policies mentioned in the previous sections. Ignoring the abuse or neglecting to act to stop the abuse has been shown to serve to increase the psychological sequelae resulting from the SHA. This concept is known as the ‘bystander’ effect.60 ,61
A team doctor can play a major role in the prevention and early detection of SHA in sport. Through an indepth understanding and awareness of the risk factors of SHA, possible relationship signs pointing to future SHA, and the physical and psychological consequences of SHA, team doctors may be better equipped to identify SHA within their patients/athletes. Through this increase in knowledge it is hoped that team doctors will be able to assist in decreasing the frequency or longevity of SHA in sport. They may also be able to assist athletes who have experienced SHA to engage in appropriate supports following this abuse to minimise any resultant physical or psychological sequelae.
The authors specially thank the North York General Hospital Foundation and Dr Thomas Ungar for their support and assistance in writing this paper.
Funding The North York General Hospital Foundation supported assistance for the writing of the current paper.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed