Scope of the review

In its early phases, work on safeguarding focused on practices within sport. As the field has grown, its remit has broadened to encompass a much wider conception of the ways in which sport may foster harm and abuse. Brackenridge and Rhind19 have recently identified research and advocacy as focusing on three key domains: safeguarding in, around (eg, associated with a major sporting event or child trafficking), and through sport (eg, educating children about sex and relationships, or teaching life skills through a sport-based programme). The scope of this review is limited to the safeguarding of athletes ‘in’ sport.

This review focuses on athletes under the age of 18, which is in line with the definition of a child used within the United Nations’ Convention on the Rights of the Child.20 All competitive levels are considered from initial participation within a recreational context, through training to compete, and on to the elite level.

Review of the scientific literature on child protection in sport

Research interest in the safeguarding of child athletes from violence in sport has increased over recent years. A key trend has been the broadening of this body of work in terms of three important considerations: who is involved in the violence, the context in terms of where it occurs, and what forms of it are studied.

Who: Research has demonstrated that anyone can be a perpetrator of violence in sport including coaches, parents and peers.21 Traditionally, research focused on the coach as the perpetrator and the athlete as the victim. Recent research has revealed that in a significant number of cases the perpetrator is a peer athlete. Indeed, for some forms of violence, such as bullying and hazing, peers are most often the perpetrators.21 Although some athletes may be more vulnerable, these safeguarding concerns are relevant to all athletes, irrespective of their personal characteristics, such as gender and age. Raakman et al22 have highlighted the need to also consider indirect abuse which occurs when children witness the abuse of others within the sport context.

Where: Research indicates that preventing violence is important for all sports.23 The context in which the violence can take place has expanded beyond the environment of training or competition. Recent research has highlighted that athletes are subject to online abuse via social media.24 Furthermore, it is important to recognise that child athletes may disclose to someone within sport negative experiences which take place outside of sport.21 As a result, sport organisations need to be prepared to provide the appropriate advice and support.

What: Perhaps the most significant broadening in terms of scope has taken place with regards to the range of safeguarding concerns that have been studied. This body of research attempts to better define violence in sport by clarifying unacceptable behaviours which harms athletes. The forms of violence can be grouped with reference to their focus at the individual, relational or organisational level (table 1). In terms of the individual athlete, participating in sport can be associated with a range of safeguarding concerns regarding an athlete's health and well-being. These include depression, self-harm and disordered eating.21 Acts of omission, such as neglect, or failure to take action to prevent injury from training/competing are also individual threats that can be as harmful as acts of commission.

There are a range of potential threats or forms of violence to child athletes which concern the critical relationships which are developed with other key individuals in sport. Sexual abuse and harassment in sport were the first relational threats to children identified in the literature.25 ,26 Studies have reported prevalence rates of sexual abuse between 2% and 22%.27 Physical abuse includes the infliction of physical injury, whether through contact (eg, hitting an athlete) or non-contact (eg, forced physical exertion).28 Emotional abuse may be the most prevalent safeguarding concern within youth sport.29 ,30 Indeed, Alexander's, et al18 study highlighted that of a sample of over 6000 young people in the UK; 75% had experienced emotional abuse within organised youth sport. Athletes’ needs can also be neglected in terms of their physical, educational, psychological or social development.28

The nature of violence to the child athlete expands beyond relational abuse to include organisational threats. These include systems which promote over-training,31 the endorsement of abusive hazing rituals,32 the use of selection procedures which promote competing with an injury,33 and age cheating.8 Age cheating refers to the athlete's legal documents being altered to officially change the date of birth to enable an athlete who is either too young, or too old for an age category sport, to compete unethically. It has been reported in both gymnastics and football at the elite level.8

The use of systematic doping is another serious threat to the child athlete. Historical examples include systematic institutionalised doping as seen in the former East German regimen in sports, such as athletics and swimming in the 1970s and 1980s. In some weight category sport cultures, it is an accepted and often imposed behavioural expectation to ‘make weight at all costs’. Examples of this form of violence in youth athletes have also occurred at the elite level. For example, during the 2010 Singapore Summer Youth Olympic Games (ages 14–18 years), there were two antidoping rule violations for diuretics used to reduce weight in order to make a weight category in wrestling.34 In the 2014 Nanjing Summer Youth Olympic Games, one antidoping rule violation was reported also for a diuretic in the weight category sport of Taekwondo.35 Finally, in the 2014 Glasgow Commonwealth Games, there was another diuretic antidoping rule violation for a 16-year-old weight lifter.36 Doping can also be categorised as a relational form of violence if the junior athlete is forced into the act of doping within a power structure by either a coach, a member of the athlete entourage, or a senior team mate.

Medical mismanagement is another organisational threat for the child athlete. In particular, the excessive and often systematic use of analgesic medication by team physicians in elite youth football is reported.37 Additionally, almost 25% of youth athletes have admitted to misuse of their prescribed medication (pain, stimulant, sleep, antianxiety),38 and 13–68% have admitted to anabolic androgenic steroid abuse in the sport context.39 Provision of insufficient medical coverage during training and competition, by relying on insufficiently trained coaches to manage medical issues, is another organisational threat to the child athlete.40 With the commodification of sport, and therefore athletes, there are some new integrity threats, such as match fixing, trafficking of athletes, and gene doping41 to add to cheating through the use of systematic organisationally endorsed performance-enhancing drugs.

Identification of research gaps

Despite this growing body of evidence, there remains clear scope for research in this domain. Studies are required to quantify the prevalence of the various forms of violence as well as the ways in which abusive practices are developed and maintained. While the potential impact of these safeguarding concerns for the individual and the organisation is acknowledged,5 research is required to determine the extent of this impact for the athlete (eg, performance and well-being) and the organisation (eg, reputation). There is also merit in adopting an organisational approach which moves beyond the perpetrator and the victim to reveal how the culture of an organisation can facilitate or prevent violence. There is a need for systematic research which explores the efficacy and effectiveness of strategies which could protect and promote the well-being of child athletes. Additionally, objective evidence from a cost/value analysis of prevention initiatives would be useful data to encourage sport governing bodies of the need to take action on these problems.

Safeguarding recommendations for sport organisations

As recognition of the potential threats or forms of violence faced by child athletes has broadened, so too has the understanding of how these risks can be minimised. Sport organisations have a moral, ethical and legal duty to adopt programmes to protect children's health and well-being in sport.5 Understanding that sport is a ‘business’ which thrives on tension and action on the field of play to engage media interest, potential barriers in the sport community to adopt frameworks to prevent violence in sport may exist. Clearly defining inappropriate violent behaviours in sport as outlined in table 1 can help mitigate or overcome these barriers to facilitate the adoption of safeguards in sport.

The recent formalisation and internationalisation of safeguarding in sport has made the issue increasingly significant for organisations that work with child athletes. The work has been driven by the International Safeguarding Children in Sport Founders Group.42 Working with more than 50 organisations, the group developed the International Safeguards for Children in Sport. These safeguards set out the actions that all organisations working in sport should have in place to ensure children are safe from harm. They have been informed by research with a diverse range of perspectives from different countries and stakeholder groups. The eight safeguards are:

1. Developing your policy

2. Procedures for responding to safeguarding concerns

3. Advice and support

4. Minimising risks to children

5. Guidelines for behaviour

6. Recruiting, training and communicating

7. Working with partners

8. Monitoring and evaluating

Over a year-long piloting phase, data were collected from a range of sources including interviews with the safeguarding lead of each organisation, online group discussions and feedback from the Founder Members Group. Based on this data, eight key pillars were identified which underpin the successful implementation of the safeguards; they have been given the acronym ‘CHILDREN’ (table 2).

Therefore, while the International Safeguards for Children in Sport present a framework which can guide organisations, the impact of these measures will be influenced by the extent to which they are tailored to the local context. This can be facilitated through building a system based on the pillars outlined above.42

In addition to the International Safeguards for Children in Sport framework, sports organisations should adopt and implement the Olympic Movement Medical Code which serves to guide the behaviours of healthcare providers in the care of athletes in the sport context (http://www.olympic.org/PageFiles/61597/Olympic_Movement_Medical_Code_eng.pdf).7 Relationships between athletes and healthcare providers are outlined here, including best practices on informed consent, confidentiality and privacy. Also, best practices with respect to athlete health protection and promotion during training and competition are clearly defined. With respect to the child athlete in particular, the Olympic Movement Medical Code addresses the unique characteristics of the child athlete who, unlike the adult athlete, has variable stages of growth, maturation and psychosocial development which pose distinct physical, psychological and social health risks if not respected in the sport context. The vulnerability of the child athlete to adult pressures in the sport milieu are also identified7Health care providers should oppose any sports or physical activity that is not appropriate to the stage of growth, development, general condition of health, and level of training of children. They should act in the best interest of the health of children or adolescents, without regard to any other interests or pressures from the entourage (eg, coach, management, family, etc.) or other athletes.

In the organisation of multisport events for the child athlete, sport organisations should encourage multidisciplinary collaboration to effectively implement event-safeguarding principles. Specifically, partnering safeguarding organisations with team physicians and field-of-play healthcare professionals will enable closer surveillance and identification of concerning injury patterns or evidence of violence (acts of either omission or commission) and more effective management of allegations.

Finally, to further safeguard children in sport against the threats of performance-enhancing drugs, sports organisations should adopt and adapt the rules and principles outlined in the World Anti-Doping Association Code.43