Stirling, Ashley E MSc*; Bridges, Eileen J MD†; Cruz, E Laura MD‡; Mountjoy, Margo L MD§
Over the past 20 years, there has been an emergence of reported incidents of abuse, harassment, and bullying in Canadian sport (M. Holman, unpublished data, 1995).1-3 In 1994, an Edmonton track coach was charged and convicted of engaging in sexual relations with his female adolescent athletes. In 1996, the national cycling team coach was charged with sexual harassment against a number of athletes.3,4 Furthermore, media attention surrounding the conviction of junior hockey coach Graham James and gymnastics coach Don Mathey for the sexual assault of young sport participants, and the 2005 hazing reports among McGill University's football players represent just a few recent examples of public attention on the occurrence of abuse, harassment, and bullying in the Canadian sport environment.
A recent report published by the International Olympic Committee Medical Commission recognized the rights of athletes to enjoy a safe and supportive sport environment. This report stated that everyone in sport shares the responsibility to identify and prevent instances of abuse and harassment to assure the health and safety of each participant in the sport environment.5
It is proposed that as supporters of safe and healthy performance environments, the Canadian sport medicine community plays an important role in maltreatment prevention. As such, it is essential that sport medicine specialists be educated on issues of abuse, harassment, and bullying in sport and be equipped with strategies to intervene if/or when potential cases arise. Therefore, the objective of this document is to review current literature on the problems of abuse, harassment, and bullying in Canadian sport. More specifically, this discussion article seeks to provide the medical community with the knowledge to appropriately identify and address cases of abuse, harassment, and bullying. As well, recommendations are proposed for the potential role of sport medicine professionals in the prevention of abuse, harassment, and bullying in sport.
A recent article published in the British Journal of Sports Medicine proposed a conceptual model of the different categories, constructs, and constituents of maltreatment in sport. The article also included a review of current definitions of each category and subcategory of maltreatment and a comprehensive list of sport-specific examples.6
Abuse is defined as a pattern of physical, sexual, emotional, or negligent ill-treatment by a person in a caregiver capacity (eg, parent, coach) resulting in actual or potential harm to the athlete.6 The 4 major recognized types of abuse include physical abuse, sexual abuse, emotional abuse, and neglect.7 Examples of abuse in sport are provided in Table 1.
Harassment is defined as single or multiple acts of unwanted or coerced behaviors by a person within a prescribed position of authority over the athlete (eg, coach, official, administrator) that have the potential to be harmful. Harassment occurs outside the context of a caregiving relationship.6 It refers to behaviors that are in violation of an individual's human rights. Like abuse, harassment is also considered to be based on an abuse of power and trust.8 Individuals can experience harassment on an individual basis or as a group. Examples of harassment in sport are provided in Table 2.
Bullying is defined as a pattern of physical, verbal, or psychological behaviors between peers (eg, teammates) that have the potential to be harmful.6 Bullying is based on an imbalance of power between peers and includes an absence of provocation.9 Examples of bullying in sport are provided in Table 3.
Finally, it needs to be clarified that both children and adults are vulnerable to experiences of abuse, harassment, and bullying. Much of the research to date on abuse, harassment, and bullying in sport has actually been based on the interviews of adult athletes,10 and quite a few researchers have argued that the unbalanced power dynamic between the coach and athlete in the sport environment, which creates a position of vulnerability to abuse of the athlete, is not limited by the age of the athlete.11 Furthermore, it should be noted that abuse, harassment, and bullying can occur between individuals of the same sex. Both men and women may be perpetrators of abuse, harassment, or bullying, and cases of athlete abuse, harassment, and bullying are experienced by male and female athletes alike.12-14
Early research in Canada on the protection of athletes in sport included criticisms of the highly competitive climate of youth sport,15,16 research on violence and injury prevention in sport,17-19 and concerns for the development of elite athletes.20-22
Following this research, several examinations were conducted throughout the 1990s on the occurrence of abuse, harassment, and bullying in Canadian sport. Based on in-depth interviews with 45 retired high-performance Canadian athletes and a number of documentary and informal sources of data, Donnelly discussed the vulnerability of elite child athletes to inappropriate behaviors within the coach-athlete relationship, such as unwanted rubdowns, sexual advances, domination of the body, and coercion into unnecessary dieting.23 As well, one third of the athletes interviewed reported physical and mental abuse, and many discussed issues with peer violence and bullying.23
In 1995, Parks and Recreation Ontario interviewed and surveyed 138 participants aged 11 to 25 years and reported that 47% of the respondents had experienced harassment in sport in the form of jokes, gestures, or looks that were humiliating, insulting, or offensive.24 A survey of 1100 Canadian Interuniversity Athletic Union varsity athletes reported that 57% of respondents had experienced sexually harassing behaviors (M. Holman, unpublished data, 1995). At the 1995 Canada Winter Games in Alberta, the Canada Games Council questioned athletes on their experiences of harassment in sport. Of those athletes, 50% had reported experiencing at least 1 form of harassment (11% racial, 16% sexual, 18% verbal, and 11% physical). This study was then repeated at the 1997 Canada Games in Manitoba revealing similar results. Forty-seven percent of athlete respondents reported experiencing some form of harassment in sport.24 Furthermore, in 1996, a national-level study on the prevalence of sexual harassment and abuse among Canadian Olympians was conducted. From this study, the researchers reported that of the 266 surveys completed, 19% of the athletes complained of experiencing upsetting sexual comments or advances, 21.8% experienced sexual intercourse with authority figures in sport, and 25% of the respondents reported being insulted, ridiculed, made to feel like a bad person, slapped, hit, or beaten by these authority figures.25
Most recently, a body of literature has begun to emerge on Canadian athletes' experiences of emotional abuse in sport. Based on a series of semistructured interviews with elite and subelite retired athletes, it has been reported that acts of aggression such as hitting and throwing objects either at the athlete or in the presence of the athlete, yelling and shouting at an athlete or group of athletes, belittling, name-calling, degrading, humiliating, or intimidating comments, and the intentional denial of attention and support are often normalized as standard coaching techniques required to produce successful performance in sport.26,27 As well, the significant power of the coach and the enhanced vulnerability of athletes to experiences of sexual and emotional maltreatment in sport have been reported.10,28
In addition to those studies described, several other researchers in Canada have written about the occurrence of athlete abuse and harassment1,29-33 and hazing in sport.34,35 Outside of Canada, a large body of literature has been published outlining the problem of abuse, harassment, and bullying among athletes in countries such as Australia,36 Denmark,37 Israel,38 the Netherlands,39 Norway,40,41 Turkey,42 the United Kingdom,11,12,43-48 and the United States (S. L. Hinkle, unpublished data, 2005).49-61 Furthermore, literature on human rights approaches to abuse is emerging internationally.62-64
Identified risk factors for athlete maltreatment in sport are based exclusively on the empirical literature on sexual abuse and harassment within the coach-athlete relationship. However, it is proposed that although most of these factors should apply to some extent to all forms of maltreatment in the sport, some differences may exist.
Based on the individual accounts of 90 sexually abused female athletes in the United Kingdom, Brackenridge explained that various stakeholders are involved in the occurrence of sexual abuse in sport, including the abusers, children, parents, coaches, social services/police, sport club/organization, and the national coaches' organizations. In her research, Brackenridge (1997)43 categorized trends of risk into the following: (1) coach variables: sex (male), age (older), size/physique (larger), accredited qualifications (good), reputation (high), previous record of sexual abuse (unknown/ ignored), trust of parents (high), commitment to codes of ethics (low), and the like; (2) athlete variables: sex (female), age (younger), size/ physique (smaller), status (high), self-esteem (low), medical problems (med/high), relationship with parents (weak), awareness of sexual abuse (low), devotion to coach (complete), and the like; and (3) sport variables: employment controls (weak), existence of parent and athlete contracts (none), and codes of ethics (weak/none).
Sexual orientation, gender-orientation, and disability have also been previously identified factors of vulnerability to harassment in sport.65 Additionally, other factors of risk identified in the literature include athletic maturation of the athlete, parents' trust of the coach, sport type, and the subculture of sport itself. Brackenridge and Kirby explained that the risk for sexual abuse in sport is dependent on the athletic maturation of the athlete. It was suggested that athletes are most vulnerable to sexual abuse during their peak athletic maturation, the period in which they have the most at stake in terms of their careers. This is referred to as the stage of imminent achievement. It is then proposed that the risk for sexual abuse is highest among athletes in sports where the stage of imminent achievement coincides with age of sexual maturity, such as gymnastics and figure skating.11
In 1998, Brackenridge examined the role of parents in preventing sexual abuse in sport and reported that parents often trust coaches uncritically, which places young athletes in a position of vulnerability. It was reported that less than 45% of the parents surveyed knew of the coach's qualifications, and 80% were unaware of whether the coach was bound by a code of ethics.44
Examination of the prevalence of sexual harassment across 56 different Norwegian sport disciplines was conducted by Fasting, Brackenridge, and Sundgot-Borgen. A total of 572 female athletes, aged 15 to 39 years, who qualified for the Norwegian national team at either the junior or senior level completed a questionnaire that included an 11-item list of sexual harassment descriptions. In this study, it was reported that female athletes who participate in traditionally masculine sports, such as basketball, football, and ice hockey, experience more sexual harassment than female athletes in other historically more feminine sports.41
As well, the culture of sport itself has been discussed as a factor of risk to abuse. Bringer et al46(p229) reviewed aspects of sporting subculture that make experiences of sexual exploitation in sport “‘part of the game' and something ‘you just put up with.’” According to Bringer et al, the risk for sexual abuse in sport is increased by the unquestioned power of coach, single-minded pursuit of excellence, normalization/ambiguity of sexually harassing or abusive behaviors, the morally good image of sport and desire to maintain such an image, and the often apolitical standpoint of many voluntary sport organizations. Martin56 surveyed 134 Division II tennis players asking them to identify 20 perceived sexually abusive behaviors in sport and reported that the behaviors ranked by the athletes as appropriate were contrary to the researchers’ expectations, also demonstrating the ambiguity of appropriate and inappropriate behaviors in sport as a risk for abuse. Further supporting the culture of sport itself as variable of risk, Krauchek and Ranson66 proposed that sexual harassment and abuse of girls and women in sport exist as a means of upholding masculine hegemony in the face of increasing participation and challenge by women. Brackenridge45 then categorized sport or situational variables of risk into normative variables that relate to the culture of the activity or sport organization; constitutive variables that are strictly embedded within the culture of sport; and other variables including age relations, specific locations, sport specificity/subcultural norms.
The risk for abuse in sport is further enhanced by the general reluctance to report inappropriate coaching behaviors. A series of focus groups were conducted with 19 male coaches about their perceptions of appropriateness with regard to coach-athlete sexual relations. This study reported that in general, the coaches perceived a higher standard of appropriateness in the coach-athlete relationship for themselves than the standards by which they would judge other coaches. Furthermore, it was indicated by participants of this study that they would be reluctant to intervene if they considered a peer coach to be acting inappropriately.67
SIGNS AND SYMPTOMS
There are many long-term negative consequences that have been correlated with experiences of abuse, harassment, and bullying. Mullen et al68 reported increased rates of psychopathology, sexual difficulties, low self-esteem, and interpersonal problems associated with all forms of abuse. Other reported negative consequences of abuse, harassment, and bullying include depression, anxiety, debilitating developmental effects, emotional instability, physical self-abuse, eating disorders, substance abuse, attachment problems, dependency, aggression/violence, delinquency/criminality, impaired moral reasoning, overly compliant behaviors, failure to thrive, and inability to develop positive relationships with others.69-72
Specific consequences of abuse and violence identified in the sport environment include obsessive and compulsive behaviors with respect to excessive training, eating disorders, self-injurious behaviors/engagement in excessive risk for accidents and injury, and burnout.63
Aside from recognizing the long-term debilitating effects of abuse, harassment, and bullying, Matthews identified several signs and symptoms that may be used as potential indicators. Applications of these signs in the sport environment are listed in Table 4. However, Matthews73(p154) warns, “It's important to note that these symptoms are all nonspecific, meaning they could result from a number of causes - not just child abuse. Children who are under stress from a variety of sources … may show similar symptoms.”
Medical professionals are responsible for caring for the health and welfare of young persons in sport. The health of the athlete must prevail over other competition, economic, legal, or political interests,5 and thus, it is proposed that medical professionals play an integral role in the prevention and intervention of abuse, harassment, and bullying in sport.
To date no empirical evaluations have been published on the effectiveness of strategies used by medical professionals in response to issues of maltreatment. As such, in generating these guidelines for the ways in which sport medicine professionals should address cases of abuse, harassment, and/or bullying, information has been developed from previously published suggestions for how responsible adults should address suspected cases of abuse,73 combined with expert opinion on the specific strategies for medical professionals within the sport environment.
WHAT SHOULD I DO IF AN ATHLETE DISCLOSES AN EXPERIENCE OF ABUSE, HARASSMENT, OR BULLYING?
1. Listen carefully and calmly. The athlete needs to know that he/she is being heard. You will need to remember the details of the conversation for future investigation. After your conversation, create a detailed written record.
2. Do not speak poorly about the perpetrator. The perpetrator can be a person that the victim truly cares for. Some victims may feel the need to protect their abusers, and any threats against this person may lessen the athlete's willingness to report and/or allow for further investigation of the issue.
3. Encourage the individual. You should encourage the athlete to tell you as much as he/she feels comfortable sharing. The goal is to get enough information to guide the person in the direction of more specific care and support.
4. Avoid asking specific questions. Specific questions can mislead the athlete's account and impede future investigations.
5. Assure the athlete that the maltreatment is not his/her fault. Tell the athlete that you are glad that he/she told you about the maltreatment. There is often a culture of silence around experiences of abuse, harassment, or bullying. Especially in sport, where mental toughness is ingrained in many young athletes, individuals may feel that they are weak in asking for help. The athlete needs to be assured that the maltreatment is not his/her fault and that you are aware of the courage it has taken him/her to come forward.
6. Report. Mandated reporting laws vary between provinces, but in general, all persons and all professionals who have reasonable grounds to suspect that a child (individual younger than 16 years) is or may be in need of protection must report. In the case of suspected child abuse or harassment, duty to report exceeds patient client confidentiality. Reports must be made directly to local child protection services. For suspected cases of bullying, or abuse/harassment of nonchild athletes, if a physician has general concerns about athlete maltreatment, then he/she should inform the sport body that there are concerns without violating patient confidentiality and allow the sport governing body to address the issue. For concern over specific cases of maltreatment of an adult athlete, the physician should encourage the adult athlete to report his/her case of maltreatment to local authorities and/or the sport governing body. The athlete will need to have additional support and encouragement if any investigation develops.
7. Make a referral. Once you have taken the appropriate steps to report the maltreatment to the authorities, you should refer the athlete to a therapist or relevant health expert. Even if the symptoms of the maltreatment are not evident, it is best to err on the side of caution. There are several long-term consequences that can occur as a result of experiences of athlete abuse, harassment, or bullying.
WHAT SHOULD I DO IF I SUSPECT A CASE OF ABUSE, HARASSMENT, OR BULLYING IN SPORT, BUT I AM NOT SURE?
1. Look for signs and symptoms. Medical professionals are in a unique position where they may be able to recognize early signs of abuse, harassment, or bullying and have the ability to intervene accordingly. See Table 4.
2. Report. It is imperative that all suspected cases of athlete abuse or harassment be reported directly to the authorities. Suspected cases of abuse/harassment of a child athlete (an athlete younger than 16 years) must be reported directly to local child protection services. Concerns for bullying or suspected cases of abuse or harassment of an adult athlete should be reported to the highest level of the sport organization without violating patient confidentiality.
AS A MEDICAL PROFESSIONAL, HOW CAN I HELP PROTECT ATHLETES FROM FUTURE CASES OF ABUSE, HARASSMENT, AND BULLYING?
1. Maintain focus on the well-being of the athlete. The primary role of the sport medicine community is to care for the long-term health and welfare of individuals in sport. This should include attention to the physical, psychological, social, and spiritual health of the athlete, and this focus must take precedence over performance interests.
2. Educate. The sport medicine community has an extended responsibility to educate individuals in leadership positions on their position of trust/power and their need to assure the long-term well-being of the individuals within their care. Physicians can encourage participation of coaches, parents, and athletes in prevention workshops. Through their own practice, medical professionals can promote and exemplify equitable, respectful, and ethical leadership. As well, sport medicine professionals may educate the media to be responsive to the ways in which Sport Medicine has taken a proactive and progressive role in eliminating abuse, harassment, and bullying in sport.
3. Ensure that the sport organization has in place a policy for athlete protection. In order for an athlete protection policy to be most effective, it should include codes of practice, education and training, complaint and support mechanisms, and monitoring and evaluation systems. The policy should state the commitment of the organization to create a safe and mutually respectful environment. The establishment of athlete protection policies can help to minimize opportunities for maltreatment and manage potential unfounded allegations.
4. Foster strong partnerships with parents/caregivers in the prevention of athlete maltreatment.
5. Promote and support scientific research on these issues.
WHAT CAN I DO TO PROTECT MYSELF FROM UNWARRANTED ALLEGATIONS OF ABUSE, HARASSMENT, OR BULLYING?
1. Respect the professional boundaries involved with the physician-athlete relationship.
2. Ensure that your sport organization has preventative policies and codes of conduct in place.
3. Maintain accurate and timely records of physician/athlete encounters.
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