Ideals of the Paralympic Movement

As stated in article 30 of the 2006 United Nations Convention on the Rights of Persons with Disabilities, persons with impairment are entitled to take part in cultural life, recreation, leisure and sport on an equal basis.1 In so doing, persons with impairment have a right to the well-documented emotional, physical and social benefits of sport.2–7 The highest level of Para and adapted sport is represented by the Paralympic Movement, the vision of which is ‘to enable Para athletes to achieve sporting excellence and inspire and excite the world’.8 One of the Movement’s missions is to ensure that in Paralympic sport, ‘the spirit of fair play prevails, violence is banned, the health risk of the athletes is managed and fundamental ethical principles are upheld’.9 These ideals serve as a check against unfair practices that harm Para athletes.

Enabling environments that encourage athletes to participate and achieve in sport typically include healthy interpersonal relationships within which equality, respect, integrity and trust prevail.10 In contrast, disabling environments that discourage athletes (Para and other) from participating and achieving in sport are poisoned by fear, distrust and severe power imbalances—the same values that underscore unhealthy interpersonal relationships and the cycle of interpersonal violence.11–15 The ethical principles that govern the Paralympic Movement set a behaviour standard for all Para sport actors—athletes, teammates, coaches, parents and administrators,16 where healthy interpersonal relationships are expected.

Non-accidental harms in Para sport

Both children and adults with impairment are at alarmingly high risk of physical, social, sexual and psychological harassment and abuse at home, and within educational, community and healthcare institutions.17–25 Within sport, this vulnerability has been little studied, and the impact non-accidental harms have on youth and senior Para athletes is less well known.26 27 Scientists at the International Olympic Committee (IOC) estimate that athletes with a physical and/or intellectual impairment may be up to four times more likely to be victimised26; however, there is no comprehensive research on the nature and scope of abuse in these athletes.

Risk factors for abuse in athletes and non-athletes with impairment include general dependency, vulnerable living arrangements (eg, family isolation, stress and separation from the home), social powerlessness, communication skill deficits, diminished ability to protect oneself due to lack of instruction and/or resources and impaired judgement (eg, the inability to detect who is safe to be around), learnt compliance, the reluctance to challenge others, and the misinterpretation of affectionate behaviour.21 28 29 Athletes with impairment may be viewed as ‘safe targets for abuse’, and opportunities for inappropriate touching can arise during routine health interventions and/or drug testing. These are just some of the vulnerabilities facing athletes with impairment.21 28 29 Additional predisposing factors include negative public attitudes towards disability and power imbalance where the athlete relies heavily on others for support.

Power imbalance is a critical concept. As described in figure 1, an unequal distribution of psychological power is the central feature of all abusive relationships in sport.26 While all athletes have regular training, nutrition and recovery needs, athletes with impairment may have an additional layer of personal care needs that could require the active, and at times, hands-on participation of teammates, coaches, trainers, parents and other sport actors.16 26 Furthermore, athletes with intellectual impairment may be at even higher risk of aggression specifically due to communication challenges, fewer meaningful friendships and increased need for help navigating social settings.30–32 Recent safeguarding studies suggest that athletes with higher care needs may be at increased risk of non-accidental harms, compared with athletes with lower care needs.26 27 This may be due to the inherent power imbalance that is introduced as sport actors (eg, athletes, teammates, coaches, parents and administrators)16 assist Para athletes with activities of daily living (eg, transfers, hygiene, dressing, bathing and feeding) and other tasks. This power differential, where the Para athlete is subordinate, may set the stage for abusive relationships to develop when an otherwise innocuous power difference is exploited.26 33–35 To date, no literature review has been done to describe the epidemiology of these abuses in Para athletes.

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Figure 1

Conceptual model of non-accidental harms in sport, highlighting the central role a psychological power imbalance plays for all forms of harassment and abuse. Image reproduced with permission care of Professor Sandra L Kirby. British Journal of Sports Medicine. ED, eating disorders; PTSD, post-traumatic stress disorder; STIs, sexually transmitted infections.

Terminology

Once the link between sport, the United Nations Convention on the Rights of the Child and other international human rights initiatives (eg, United Nations Study on Violence against Children) was established,27 36 the body of published, scientific literature dedicated to non-accidental harms in sport expanded significantly.37–39 Accordingly, the terminology experts use to describe non-accidental harms in sport has changed over time and continues to be debated. Scientists have described distinct categories of non-accidental harms including bullying (and cyberbullying), harassment, neglect, physical abuse, emotional abuse and sexual abuse, often with qualifying subcategories including physical, verbal, social, racial, gender, contact and non-contact (eg, non-contact physical abuse, racial harassment or verbal bullying).40

In the absence of universal consensus definitions,41 we use the general umbrella term ‘non-accidental harm(s)’ in this manuscript, meaning ‘volitional acts that result in or have the potential to result in physical injury and/or psychological harm’.10 42 As described in figure 2, ‘maltreatment’, ‘interpersonal violence’, ‘intentional harm(s)’, ‘intentional violence’, ‘intentional injury’, ‘gender-based violence’ and ‘abuse’ have also been used somewhat interchangeably with ‘non-accidental harms’ by other authors in the field to represent all forms of harassment and abuse in sport.43 We chose ‘non-accidental harm(s)’ because we feel this term captures harms that are conscious and readily apparent to others (eg, physical abuse), as well as those that may be unconscious and less readily apparent to others (eg, financial abuse).20 In this manuscript, specific terms such as ‘physical abuse’ and ‘bullying’ will be used when describing data from a specific study, but the umbrella term ‘non-accidental harm(s)’ covers all forms of abuse, including those that have had higher visibility in scientific literature (eg, sexual harassment and abuse) and those that may be lesser known (eg, hazing and neglect).44 45

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Figure 2

Examples of terminology used to describe harassment and abuse in sport settings. Scholars in the field are increasingly using this terminology to describe volitional acts that result in or have the potential to result in physical injury and/or psychological harm.

In addition, we have chosen to use two equivalent and up-to-date terms, ‘Para athlete(s)’ and ‘athletes with impairment’ throughout this manuscript to describe our population of interest.8 46 ‘Para athlete(s)’ is the International Paralympic Committee’s term for all sportspersons with impairment.8 In the same way, ‘athletes with impairment’ describes all sportspersons with impairment, regardless of competition level, and inclusive of youth, recreational, collegiate and elite athletes. ‘Paralympic athletes’ and ‘Paralympians’, in contrast, refer only to athletes who have competed at the Paralympic Games.8

Aim

The aim of this literature review was to summarise the current state of knowledge and the priorities for future research as related to non-accidental harms in athletes with impairment at all levels of competition.

Study characteristics

Eight studies met inclusion criteria (table 3). All were published within the past six years. Of those, two studies employed a qualitative design,51 52 one used quantitative methods53 and five employed a mixed methods study design (eg, combination of in-person or telephone interview and a survey tool).54–58 Four studies were conducted in the USA, while the remainder were conducted in the UK, the Netherlands and Australia. Half of the studies only included young athletes aged 8–25 years.

Total sample size ranged from five participants52 to 6124 participants.54 55 While all studies included Para athletes (1%–100% of total study sample), only five included results and conclusions specific to Para athletes. Half of the studies focused exclusively on Para athletes,51 52 56 57 75% of which focused on young athletes with visual impairment and 25% of which focused on athletes with intellectual and developmental impairment.

Level of competition was summarised as either ‘recreational’ or ‘elite’, based on the definition or categorisation offered in each study. We included school-based, club, community-level, regional-level or national-level Para athletes under the designation ‘recreational’, while ‘elite’ athletes were those who competed internationally. Only one study included elite athletes.53

Of non-accidental harms examined, more than half of the study authors were concerned with bullying and its social implications.51 52 54 56 57 Of note, de Schipper et al 51 investigated verbal abuse among children with visual impairment and used the terms ‘verbal abuse’ and ‘bullying’ interchangeably. Stafford et al,55 Vertommen et al,53 Dane-Staples et al 56 and McHugh and Howard57 examined physical abuse. Only Vertommen et al 53 studied sexual abuse, in addition to psychological and physical.

Risk of bias

Most studies satisfactorily met less than half of the criteria on the seven-item Cochrane risk of bias tool (table 1). According to CEBM criteria, six articles met Level 4 level of evidence, while Dane-Stales et al 56 and Vertommen et al,53 met Level 3 due to the presence of a control arm and large effect size, respectively.

Risk stratification by impairment status and demographics

Assessed using a low-threshold measure (eg, at least one experience), self-reported prevalence estimates of non-accidental harms in Para athletes were remarkably high in the Vertommen et al 53 study. Nearly half (49.7%) of Para athletes (n=185) reported psychological abuse, while 32.4% reported physical violence and 33.5% reported sexual abuse. Furthermore, in the same study, athletes who had participated in ‘disabled sport’ as children had 2.90 increased odds of sexual abuse (99% CI 1.84 to 4.59; p<0.001), 3.23 increased odds of physical abuse (99% CI 2.02 to 5.15; p<0.001) and 1.31 increased odds of psychological abuse (99% CI 0.87 to 1.99; p=0.09) compared with athletes who had not participated in ‘disabled sport’.53

We found no differences in prevalence or type of non-accidental harms based on age, gender, sport, skill or competition level, in all studies included in this analysis. Of the five studies that included results specific to Para athletes, there were no reported age-level, gender-level, sport-level, skill-level or competition-level related differences in the prevalence or type of non-accidental harms athletes with impairment experienced. Haegele et al 52 did describe increased perceived risk of bullying in an active, visually impaired child due to his strong academic skills, but this theme did not apply to the remaining study participants. McPherson et al 58 suggested that a younger age may place Para athletes at increased risk of non-accidental harms. Stafford et al 54 55 described a competition-level trend for all athletes studied: as recreational athletes rose through the competitive ranks, frequency of physical abuse decreased, while frequency of emotional abuse increased. Similarly, Vertommen et al reported a significant increase in the odds of psychological, physical and sexual abuse with increasing sport level, for all athletes in the analysis. In the multivariate analysis using recreational-level athletes as the reference group, the ORs of psychological, physical and sexual abuse were 1.05, 1.26 and 1.22 for local-level athletes but 2.32, 3.18 and 3.07 for international-level athletes, respectively (p=0.00–0.13). Unfortunately, although 6% of total study sample in the Stafford et al analyses and 5% of total study sample in the Vertommen et al analysis reportedly had an impairment, trends specific to this subset of athletes were not clarified by the authors. It remains unclear whether these patterns apply to Para athletes, specifically.

Bullying behaviours

Bullying behaviours by peer athletes were reported most commonly, though coaches and teachers were also described.57 58 In one study, athletes (as opposed to non-athletes) with impairment tended to internalise the pain associated with bullying through self-blame.56 McHugh et al reported that 80% of parents surveyed about intellectually and developmentally impaired athletes’ risk of bullying, ‘felt that the desire for friendship placed [their] child with [intellectual impairment] at greater risk for bullying, compared to children without intellectual [impairments]’.57 Reasons cited were: ‘[parents] felt their child would not complain about being bullied or cyberbullied if telling placed them at risk for losing a friend’.57 Among 49 visually impaired study participants (athletes and non-athletes), 41 indicated having been bullied in their life, primarily in low-supervision areas during the elementary and middle school years. Verbal attacks were the most common.52 56

Para athletes’ physical and/or intellectual impairments did not hinder them from becoming bullies themselves. The ‘bully-victim’ role was described by multiple authors and seemed more common among athletes with impairment when compared with non-athletes with impairment.51 52 56 In Dane-Staples’ analysis, compared with non-athletes, athletes were less likely to be bullied but were more likely to respond to bullying aggressively rather than passively. In the analysis, 76.6% of athlete participants reported experiencing bullying in their lives compared with 94.7% of non-athlete participants. Forty-three percent of athletes reported fighting back physically. In contrast, a full 77.8% of non-athletes did not retaliate.56 One athlete stated it plainly: ‘[I] initiated fights… became a bully’. Among one cohort of Para athletes studied, about half adopted a victim-only role and the other half adopted a bully-victim role.56 In another cohort, four out of six reported being bullied (victim-only roles), and one described experiencing sport drop-out as a consequence of bullying. She recounted her experience of bullying: ‘Like “you can’t see” and stuff like that. And they said my eyes were creepy, and I was young… When kids do that to me today, now I’m older, I don’t really take it that seriously, but when I was younger I did’.51 In all studies, no Para athlete adopted the bully-only role.

Authors did offer reasons for the bully-victim phenomenon: generally, athletes enjoy higher social status than non-athletes, but persons with impairment suffer lower social status than able-bodied persons. Athletes with impairment can therefore leverage sport to build self-confidence, improve self-esteem and increase social status, leveling the social playing field just enough to reduce the likelihood of becoming passive victims of non-accidental harms, such as bullying.56 Another potential reason for the bully-victim observation is distrust. In one study, impaired study participants interviewed expressed distrust towards those in positions of authority (eg, teachers and coaches) to successfully deter bullying behaviours after prior attempts to report bullying went unanswered. Without support, Para athletes felt as though they were left to fend for themselves and resorted to hitting back, as a way to minimise future bullying.51 52 56 As explained, ‘occasionally, I hit back if assaulted, which limited assaults from others; because I was a good fighter and it was embarrassing for others to lose to the little blind girl’.56

Adults (eg, teachers and coaches) instigated emotional abuse and discrimination as well. McPherson’s analysis painted vivid images: one young athlete recalled being told by an instructor to give up because she was worthless, and another described the psychological damage her coach inflicted as ‘irreparable’: her once-energetic and positive outlook on life replaced by a sad shell of herself with no self-confidence.58 Another young athlete described how, despite being a healthy body weight, she was publicly described by an authority figure as having a huge tire around her waist, causing humiliation, deep shame and an eating disorder.58 Additionally, two young male athletes reported suicide attempts as a result of emotional harm inflicted during sport by adults, consistent with a first-person analysis from Dane-Staples’ report.56 58

Social exclusion was also reported. In one analysis, four out of six athletes with impairment said that they felt excluded during physical education at school, and one girl specifically shared how classmates excluded her from team games in physical education class.51 Similarly, one young boy stated that he felt ‘more left out in physical education than in other classes’.52

Physical and sexual harassment and abuse

Four studies covered physical harm.53 55 56 58 Compared with 11.3% prevalence among all participants (n=4043), the reported prevalence of physical harm was 32.4% among athletes with impairment (n=185) in Vertommen’s cohort.53 The most commonly described physically harmful behaviour was excessive, intense training or continuing to train while physically injured or exhausted.55 58 Greater than one-third of McPherson’s cohort reported playing their sport when they should have been resting.58 Nearly 13% reported that this was a regular occurrence: ‘a lot of people would train injured…[leading] to further injury or slower recovery time’.58 Other forms of physical harm described included being shoved, punched, having something thrown at them and being knocked down.55 58 One respondent described his coach telling him to do a handstand and them deliberately pushing him over.58 Another recalled his coach throwing an object at him after failing to live up to his coach’s performance standards.58

Sexual harms were higher in Para athletes, when compared with the broader study population in Vertommen’s analysis: of all study participants (n=4043), 14.3% had experienced sexual violence at least once, while for Para athletes (n=185), prevalence was 33.5%. Furthermore, in the multivariate analysis, Para athletes had 2.9 increased odds of experiencing sexual violence compared with able-bodied athletes (99% CI 1.84 to 4.59; p<0.001).

Bullying

In Para sport, bullying seems to surface on multiple levels and in multiple ways. Initially, bullying can be a barrier to sports participation for children with impairment.51 68 69 Once enrolled in sport, athletes with impairment can use sport as a buffer against negative stereotypes associated with disability, thus as a buffer against bullying and other forms of non-accidental harms. An important finding from this review includes the bully-victim role observed in athletes with impairment but not in non-athletes with impairment. Those with clear and visible impairments tend to be bully-victims more often (as opposed to victims-only),51 70 and athletes with impairment (compared with non-athletes) tend to internalise the pain associated with bullying through self-blame.56 This review makes it clear that ‘traditional’ physical, verbal and emotional bullying may be common among athletes with impairment. In the digital age, Para athletes with intellectual and developmental impairment may also be at particularly high risk of cyberbullying via social media and personal electronic devices.57 It is important for scientists to continue to explore exactly how peer aggression manifests itself among Para athletes at all levels, since navigating the bully-only, victim-only or bully-victim roles appears to be commonplace in this group.65 71–73

Priorities for future research

This literature review offers a window into the characteristics of victims and instigators of non-accidental harms in Para sport, describes a limited range of abuse behaviours among Para sport actors (eg, athletes, teammates, coaches and administrators)16 and highlights a potentially unique feature, the bully-victim role, within Para sport. Of course, complex ethical considerations make non-accidental harms research challenging, particularly when the data collection process can cause additional psychological harm to research participants.55 74 Furthermore, sport organisations are still refining best practices for confidential, supportive and actionable disclosure of abuse.74–76 Nevertheless, descriptive epidemiological data must be strengthened in order to shed light on Para athletes’ experience of non-accidental harms and provide direction to sport organisations’ safeguarding practices and procedures.77

Data describing the prevalence of non-accidental harms, and stratified by age, gender, sport, competition level and impairment status, need to be clarified. A number of studies in the current review did report data stratified by these categories for all athletes in the study population. For example, authors reported higher prevalence of physical violence among male athletes, compared with female athletes, and higher prevalence of sexual violence among female athletes, compared with male athletes. Increased prevalence of physical abuse was reported among younger, recreational athletes compared with older, elite athletes, but psychological abuse was more prevalent among older, elite athletes compared with younger, recreational athletes. Authors reported greater frequency of abuse by peers in team sports as compared with individual sports and greater frequency of abuse by coaches in individual sports as compared with team sports.53–55 58 Unlike in able-bodied sport, where demographic data have been associated with an athlete’s susceptibility to various types of non-accidental harms,78–80 the literature has not yet proven that similar trends exist in Para athletes, specifically.

Age-related vulnerability to non-accidental harms should be explicitly explored in Para athletes. The vulnerability of younger athletes to non-accidental harms has been described elsewhere and is attributed to young athletes being treated as athletes first and children second, as well as to the high regard in which children generally hold coaches and senior teammates.81 We do know that sports performance is positively correlated with young Para athletes’ feelings of empowerment and self-worth.56 However, it is unclear if and how previously described social concepts in youth sport, such as young athletes being treated as athletes first and children second, and young athletes holding authority figures in high regard, play out in Para sport.

Limitations

We acknowledge several limitations. There were a small number of studies available for inclusion, a small number of study participants in those studies and a generally low quality of evidence in the studies reviewed. The paucity of data placed the possibility of presenting quantified summary statistics out of reach. In addition, the studies were heterogeneous in design, making data pooling difficult. Moreover, because the studies reviewed did not use consensus definitions of non-accidental harms, and by and large did not include elite Para athletes, it was difficult to draw any conclusions that are generalisable to all Para athletes. Many studies included Para athletes but did not clarify impairment type or conclusions specific to this specific subset of the study population. Very few studies investigated physical and sexual harms, while none examined financial abuse, neglect, hazing or other types of non-accidental harms. Sexual harassment and abuse is one of the more well-known types of non-accidental harms in sport, but this review reveals a dearth of literature related to sexual harassment and abuse in Para sport. Finally, the majority of analyses focused on athletes with visual impairments and did not explore the experience of athletes with different types of impairments.

Overall, we were unsurprised by the small number of records and participants emerging from this review. Para sport is relatively new in the world of competitive sport, and Para athletes continue to be under-represented in the general sport literature. In addition, a recent review of non-accidental harms in sport by the senior author illuminates many pockets of issues and study populations needing research attention, Para sport being one.82