So we're going to take a hard pivot, and we're going to talk about advocacy in yet another way. I know we've heard that word a lot in this meeting. I've certainly heard it almost daily, and I'm happy to see that our organization is making this a priority. Let's see. It's a left click. Okay. So I like this word cloud because it gives us a couple of different ways of thinking about advocacy and the ways that it applies to the different things that we're doing. Certainly one of the ways that we want to advocate is for our patients, and in this case specifically what I'm going to talk about is for our athletes. We've talked about the definition of advocacy, but we also want to talk about the definition of sexual abuse and how these two things have been tied together and how we want to advocate for our athletes so that they don't have to undergo any of these types of events. It was very public, very painful for a lot of people when this occurred, and I think more so when we realized this was amongst our own ranks. In many cases have been cases of physicians or health care workers. So this concept is not new. We applied this to concussions several years ago and continue to apply this, and I think that's another aspect of it, where we didn't quite know how to define it. We knew concussions, if you lost consciousness, were a concussion, but these little bell ringers, et cetera, we weren't really sure what the effect was going to be. So we started looking at it. We started raising awareness about it, and we started stating long-term goals to commit to reduce these types of injuries. And I think we need to approach this in a similar way. That's my alarm. Stop. Sorry. I apologize. But we can do more, and if any of you saw this, this was in 2019, a very tearful comment by Simone Biles, who's very topical, the Olympics are about to happen, and she's still talking about this. Of course she is. If you look at the last sentence in this, you literally had one job, and you couldn't protect us. That's something we need to think about. We do need to protect them. And I think when she calls us out to do that, we need to ask her what she means, her and others. So we need to name the problem. How does this happen? We've talked about bias. We'll talk about it a little bit more. There's blind spot bias, which is this tendency to believe that I'm not biased, I recognize this problem, and I think that Rick, where you talked about this, we are all biased, and we need to recognize and own that. Playing the odds. You know, we tend to think that the worst scenario couldn't possibly be what's happening. We want to assume that it's the more benign process that's occurring. Omission bias. We tend to not want to get involved, especially if it's easier to not get involved, and who knows what the repercussions may be if we do. I think this is hopefully less common now, but attributing the error to the victim. I think that's part of what Me Too speak up and some of these other movements are talking about is it's never the victim's fault. So don't attribute that error. We all have conflicts of interest when we talk about this. I know when we're team physicians, especially depending on the team, what's at stake, it's very difficult sometimes to put your athlete first. Am I going to repair this meniscus in this athlete even though they could go back and play in this championship game sooner if I didn't? You have to be on the athlete's side. And we don't want to throw a wrench in this machine. I don't want to be the one to say this guy can't go back in, but maybe I'm going to have to be that person. So how does this happen? There are all sorts of risk factors that lead to this. We know in sports there's always a hierarchy. There are always people that are put in a place of position of power. There's close contact between the staff, meaning all of us, the athletic trainers, the massage therapists, and the athletes. There's a lot of power imbalance that we all recognize and we see commonly. We accept that the athletes are going to be separated from their peers and their support groups in a lot of these instances, and especially in certain types of camps or developmental academies where they're really brought outside of their comfort zone. We know that there are secrets, right? I hate that word. I think that word is full of negative connotations versus privacy, versus confidentiality, versus the things that our athletes do need from us. Oftentimes, I would say all of us have probably experienced this where you share rooms on trips. Maybe that's not appropriate, but it's common. And we condone sometimes these relationships between members of maybe different ages, different power structures within these situations. And there are athletes that are sexualized by the way that they compete or what they wear or how they're asked to perform, certainly in some of the performing sports such as gymnastics and dance, figure skating, et cetera. There's also a lot of competition amongst these athletes for attention and a lot of jealousy and that can be bred to create higher performance, higher levels of performance or fight for a position on the team. And then we're quiet about it. I've never heard anyone talk about this before. So we need to start talking about this and we need to say it's OK to talk about this. Also there are other risks that are more closely related to the specific sport. Again, I talked about the hierarchy. There are performance-based rewards. For those of you who were here a couple of years ago in Boston when Madison Kosian talked about this and about getting rewarded with food because they were withholding food from her and so she went to someone that she thought would help her and give her food, imagine that as being the way that you find comfort and then this person takes advantage. Linking rewards to compliance with this system. There are rules and procedures which we do this. If you're a team physician, it's not necessarily common nor do we even tell athletes they have an opportunity to go see someone else if they want to. No, this is your team doctor. This is your athletic trainer. This is who you need to see. There's not a formal process and I'd say for most of us who volunteer, there's not really a formal process for who is working with the team, who's being hired. Is there any screening of this? Oftentimes we don't have training in it. I know I didn't. Most of us don't. We'll get to that. But training in these things. There are in medicine obviously many, many times when we legitimately need to be touching our patients and so we need to recognize that that can be done in appropriate ways and in inappropriate ways and sometimes our patients don't know the difference. So discuss that. And then the subsummation of individuality within these competitive structures. What this means is that we are creating teams. Oftentimes an individual who has an individual concern is not encouraged to say so because it disrupts the team. Location is a risk factor when we travel with teams, especially nationally, internationally. We don't necessarily have the situations or the environments that we're used to, nor do they. Things like massages that are given by coaches or an athletic trainer, et cetera, and supervisory figures may or may not be inappropriate. I think they can be. Being alone with a coach or a staff member in a car, giving them a ride home, things like that. These are all places where we need to be aware of what's going on or could go on. I'm kind of going to skip through this slide because I think it's a little bit, it applies to a lot of things in how we reduce errors. It applies to a lot of things that we do in medicine. I think we can apply this in general to anything. This isn't just specific to this. What we need to do is we need to recognize more specifically in this situation how we can advocate and how do we recognize what's going on. There's a high association with certain things, such as eating disorders. There is over 45% association with some type of eating disorder and sexual abuse on both sides. You could say this about people who have eating disorders are more likely to be abused or people who have been abused are more likely to have eating disorders. That data is fairly linear back and forth. Sometimes you'll see they're having difficulty in, say, a college or high school athlete where they're not performing as well academically or in their sport. They maybe don't sleep as well. Those are things that can be clues, but I don't know all the clues. We need to figure out how to educate ourselves. One of the things we've been working on with AOSSM, I've been representing the team physician athlete advocacy on this and working with the AMSSM, the NATA, and others with the U.S. Center for Safe Sport on creating a module for us to take to educate ourselves. It's going to be free. It actually is being released right now. Yesterday, the first version was released. It'll be accessible on Monday. We'll send out a link through AOSSM, so if you want to sign up for this, you can take it. It was funded by the Department of Justice. We're very proud that we were able to do that because that allowed us to give it to everyone for free. There are other resources, such as consensus statements. Many members of the forum got together and wrote a consensus statement that the academy published a couple of years ago. There are courses out there, and we learned a little bit about the mental health courses yesterday. I think it was yesterday when we had that session. How do we intervene? This is very difficult. I don't think we're quite there yet, but if you learn the signs and symptoms and you educate yourself, you can go to Safe Sport. If this is an Olympic, Paralympic sport, if this is a developmental academy, if this is an NGB-sanctioned event, the Title IX offices in most colleges and universities will have resources for you. If you're fortunate enough to have sports psychologists at your disposal, please use them. If they're minors, it is mandatory that you report this to the FBI. In the high school situation, and if you even suspect it's mandatory that you report this, there are actually criminal punishments for not reporting this, so we need to be aware of that, especially if someone says that maybe you did know and ignored it. So what we really need to do is work toward preventing it, and how do we do that? We need to create safe environments for all of our athletes. That may mean having chaperones. That may mean having traveling training rooms instead of using a hotel room. It may be standardizing our practice and what's expected so that our athletes know, I'm not supposed to be in your hotel room getting my knee examined, even though everything is above board. I would probably be in a better, more medical-oriented place to do that, but what we really need is we need to earn their trust. That's not going to be easy. We've lost a lot of it as a group, none of us, hopefully, in particular, and it's going to take a long time. So what are we doing right now? As I said, using some of the safe sport training, which will be coming out here shortly. The IOC and the NCAA do have toolkits for this. We need to validate the athletes' stories and perspectives and make sure they know we hear them. I think there's probably some room for recognizing this in areas such as athlete physicals, if they have things, a history of self-harm, maybe scars that could indicate cutting, maybe eating disorders, et cetera, that we probably need to have some questionnaires and some standardization to ask those questions. But our goal is to increase the reporting of incidents, not decrease it. We know it's happening. We just want to make sure people are telling us about it so that we can do something about it. We need to change the culture. We need to put the medical team on the athlete's side. We know that's where we are. They need to know that's where we are. And we need to create an environment where abuse is not easily hidden. So future actions, big, giant, blank slide. I am open to any and all ideas about this. But it needs to encompass the following. Athletes deserve an expectation of safe sports and safe health from all of us. Sports medicine physicians, we are in a position to advocate for them, for their safety, to care for them, and to monitor our own peers if need be. And we need to be committed to long-term solutions, including education and working with our multidisciplinary teams to continue to raise our voices. These are my references, some of which are our consensus statement. I do want to thank a few people. Ned, who I see in the back of the room, thank you. Advocacy and mentorship and sponsorship. I got this idea. I brought it to Ned, and he said, I know where to take this. And so elevating and helping us get there, thank you so much. Karen Sutton, who's no longer – she had to leave earlier today, but she was my partner in crime in this entire thing from the very beginning. Julie Campbell, who's in this picture, she's an athletic trainer. I've worked for the University of Denver for the past 18 years, and these are my gymnasts. And I can tell you, we wouldn't have gotten there without Julie, without this team. They've inspired me. I hope they inspire you.

advocating for athletes

protecting athletes from sexual abuse

preventing sexual abuse in sports

addressing power imbalances in sports

creating safe environments for athletes