I appreciate the opportunity to speak with you today on what is definitely a challenging topic. I don't have any disclosures. I'm going to start by providing some key resources and references, which is switching it up a bit. I'll define sexual violence, share some rather egregious cases, we'll review some sexual violence data, talk about the role of healthcare in both preventing sexual violence in sport, as well as caring for athletes who experience sexual violence, and we'll finish up with some legal obligations. There is the Rogues Gallery to the right. As I mentioned, I'm going to start with a few papers, which is kind of flipping it because normally references are at the end, but if you're working with athletes, I think these are some key references and some key resources for you, and you should be reading these, the first being the IOC Consensus Statement on assessment around harassment and abuse in sport. The second one is the position stand from the American Medical Society for Sports Medicine, which I had an opportunity to participate in. The third is a paper that I led with a group, a very large group from a variety of professional organizations on sexual violence in sport, expanding awareness and knowledge for sports medicine providers. So this is really kind of a how-to paper, you know, in terms of what we know to date. And two more, one would be, you know, if you're working with college athletes, you definitely ought to be familiar with the NATA policy against sexual violence on college campuses. And then last but not least, if you haven't read this book by John Kracauer, Missoula, I'd encourage you to do so. You know, you see the subtitle was Rape and Justice System in a College Town, and it is disturbing to say the least, but also incredibly eye-opening. And I will add that it was a little hard to read that book before I sent my daughter off to college. Let's start with some key definitions. So sexual violence includes acts that are not codified in law as criminal, but are nonetheless harmful and traumatic. It can include comments, threats, objectifying women, and non-consensual sharing of explicit photos, unwanted touching, hugging, or kissing, often referred to as sexual harassment, touching a victim in a sexual manner, sexual assault, and rape, defined as sexual penetration of any kind. I think it's really important that people are aware of this broad definition of sexual violence. And it is often preceded by grooming behaviors. These are manipulative behaviors that the abuser uses to gain access to a potential victim, to coerce them to agree to the abuse, and to reduce the likelihood of them being caught. It's usually employed by a family member or somebody else who is in the victim's circle of trust, such as a coach, teacher, could be a youth group leader, or others who naturally have some interaction with the victim. All right, I'm going to share a story. This is a real report, and it's in the literature, so I'm not identifying somebody. But this is not an atypical story, and one that sadly I've seen in my practice on more than one occasion. Sports was a haven for Brenda Tracy during her middle and high school years with volleyball and basketball, pulling the long-limbed adolescent out of her house and head. Tracy, now 46, grew up in an alcoholic home. She said she was sexually abused by her relative as a toddler and raped at nine by her high school babysitter's boyfriend. She said sports saved her. For a child who has been abused and hurt, sports was my sanctuary. But in 1998, Tracy, then 24, accused four Oregon State students, including two football players, of gang rape. All four men were arrested, but prosecutors told Tracy that her case would likely result in four acquittals, and she dropped the charges. And this is an all-too-familiar scenario. So here are some rather dire facts about sexual violence. Nearly one in five women have experienced completed or attempted rape during their lifetime. One in three female rape victims experienced it for the first time between the ages of 11 and 17. Eighty-two percent of juvenile victims are female. Ninety percent of adult rape victims are female. Girls ages 16 to 19 are four times more likely than the general population to be victims of rape, attempted rape, or sexual assault. Women ages 18 to 24 who are college students are three times more likely than women in general to experience sexual violence. Yet two-thirds of sexual assaults are not reported to the police. And two-thirds of individuals who are sexually victimized will be re-victimized. So it turns out that childhood sexual abuse is the greatest predictor of sexual re-victimization. How about in sports? Perpetrators are most likely to be male, and they may include, you know, peers, coaches, trainers, or other healthcare professionals. The incident increases with sport level. The risk is higher for athletes with disabilities and athletes who identify as lesbian, gay, bisexual, transgender, or queer. Athletes, again, often engage in the grooming behaviors that I previously described to build trust and use situations with less supervision as opportunities for their abuse. This is a pretty familiar story, I think, to all of us. And the resulting emotional distress further increases an athlete's vulnerability to future sexual violence. And of note, the type of sport, the amount of clothing worn, or the amount of touching required for sport has not been shown to increase the risk of sexual abuse. There are a number of risk factors that may increase the likelihood of somebody experiencing sexual abuse in sport, and they can be defined in three unique categories. One being athlete variables, the other coach variables, and the third being sport variables. So for athletes, you know, I highlighted some of those. You know, not only does a higher level of sport participation increase the likelihood, but younger athletes may be more vulnerable. Those who have a more distant relationship with their parents have low self-esteem and are highly dedicated to their coach. Some of the coaching variables, a male coach who is older and has a good reputation in sport and is therefore garnered universal trust by parents. And then the sport variables, and I think this one is really important. When there are many opportunities for trips away from home and limited opportunities for reporting sexual harassment and abuse, it is more likely to occur in that environment. So again, the Rogues Gallery, and I think that, you know, we're all familiar with Dr. Larry Nassar, who served as the chief medical officer for USA Gymnastics. He participated in and perpetrated sexual assault on athletes for over 20 years, yet he was regarded as the top gymnastics team physician in the world and an expert in pelvic floor dysfunction. But there have been 250 cases that have come forward of sexual assault on women gymnasts, and of course he has been charged and convicted for close to 200 years in federal prison. So he will never see the light of day. You may be less familiar with the physician on the right. That's Dr. Richard Strauss, and he was most notable to me as the really founding editor of Physician and Sports Medicine, but he was charged with sexual assault on 177 male student athletes when he was at Ohio State. He is a founder of AMSSM, you know, kind of the sibling organization to AOSSM. He committed suicide back in the 90s, and Ohio State has paid about $41 million in restitution to his victims. And both these physicians did something that we refer to as breaking that medical social contract. You know, it's this concept of exchange of skills and expertise in medicine for respect and remuneration in society. They used their position of credibility as a team physician to sexually abuse the athletes who had entrusted their care to them. It's the worst kind of exchange, taking trust and turning it into personal gratification. So what are some next steps in addressing and preventing sexual violence in sport? Well, you know, I think that there are at least, you know, three key areas. One is, you know, developing and implementing policy, providing education, and making changes in the environment. And you know, we're starting to see policies come out from the IOC, U.S. Olympic and Paralympic Committee. Of course, we have the U.S. Center for Safe Sport, the NCAA, NATA, and of course, institutional policies that are there to protect athletes and physicians and other members of the athlete care team, you know, so that we are not put in any kind of a situation that may be perceived as compromising. There needs to be broader education, you know, to our athletes, to parents, coaches, both our sport coaches as well as our strength coaches, definitely to physicians. So I, again, appreciate the opportunity to speak to all of you today as well as to other, again, members of the athlete care team. And we need to make changes in the environment. You know, let's talk about the clinical environment. You know, I'm going to make an assumption that nobody in this room has ever done a pelvic exam in the training room, nor should you. You know, and I am a female physician who's, you know, worked with, you know, collegiate athletes for decades. And you know, that was definitely a line that I never, ever crossed, you know. So we need to make sure we're creating clinical environments, that we're inviting people into the exam room with us. And again, it's never felt that we're putting the athlete in a compromised situation. And we need to have identified multidisciplinary team members who, if somebody is actually experiencing sexual violence, that we can very quickly connect them to the resources they need. You know, whether that be the rape recovery center, whether that be a student counseling center on a college campus, you know, or other mental health professionals that may be involved in athlete care. And remember that, you know, none of us are trained to actually do a, you know, a rape exam. And we should be, if somebody does show up in your office or in your training room, you know, and they say they have acutely experienced sexual violence, we need to make sure that we're sending them to the proper professionals. We all have legal obligations, and certainly sexual violence against a minor must be reported. And so all health care providers are considered mandated reporters. And we need to understand our state laws in regard to reporting laws and recognize that it is our duty to report to legal authorities, even if we observe signs or symptoms of sexual violence in children. The law does not require the child to come before a mandated reporter. All that is required is that a specific disclosure is made, and failing to report child abuse can result in clinical or, excuse me, criminal or civil liability. Sexual abuse should be reported immediately and directly to local child protection services, and at least in the elite sport and collegiate sport level to the U.S. Center for Safe Sport. So these are some signs and symptoms that might prompt you to actually screen someone for sexual violence, and they, again, fall in multiple categories. You know, on the physical health side, it could include GI symptoms, urinary symptoms, headaches, fatigue, painful periods, pelvic pain, STIs, unwanted pregnancy. There are definitely sport-related signs and symptoms that, again, should arouse suspicion. So somebody with impaired sport performance or a non-healing injury dropping out of sport. And then, of course, I think most prominent are some of the mental health consequences that people experience as a result of sexual violence. So depression and anxiety, sleep disturbance, PTSD, eating disorders, self-harm behaviors, suicidality, and substance abuse. So you know, the litany of consequences when somebody experiences sexual violence is long and long-lasting. So I wanted to, you know, give you a, again, a not atypical scenario. Let's say you have a 20-year-old female soccer player, and she comes in to see you. She's complaining of chest tightness, racing heart. She's not sleeping well. She has nausea, no appetite, fatigue. The trainer tells you she's late to practice and irritable. How do you kind of broach that subject of possible sexual violence with this patient? And you know, this is one of the models that I think is easy to remember, and I think orthopedic surgeons love acronyms. I'm just teasing. I've just seen a lot of them. So we could use the SAVE model, which is, you know, screen, ask, validate, and evaluate. You know, and I think that, you know, there are a number of questions. These actually come from the American College of Obstetricians and Gynecologists, who are really kind of leading the way in some of the work around intimate partner violence. But think of the SAVE model. Screen patients for sexual violence, ask direct questions in a nonjudgmental way, validate what the patient has experienced and is feeling, and then evaluate, educate, and refer as necessary. So I want to take just a moment and talk about eating disorders. It's a big part of my practice. It's about 80% of the patients I see in my practice have eating disorders of the female athlete triad. And there are days when I look at my schedule, and 80% of the patients have experienced sexual violence. In fact, a history of rape increases the odds ratio for a lifetime incidence of eating disorder by a factor of 21. And amongst women with an eating disorder, the percentage who will experience intimate partner violence is also incredibly high. And many of these eating disorders that are listed here, you know, also lead to the female athlete triad, you know, which can have devastating consequences for the athlete and their participation in sport. So I think the takeaway here is screen women with a history of sexual assault for eating disorders, and screen women with eating disorders for a history of sexual assault. And it's certainly a big part of my practice. So in summary, sexual violence is common, it's often underreported, has lifelong consequences for those who experience it. Among athletes, perpetrators are predominantly male and include family members, peers, coaches, trainers, and other health care providers. And sexual violence is not only rape. It includes abusive comments, threats, objectifying women, nonconsensual sharing of explicit photos, unwanted touching, hugging or kissing, and touching the victim in a sexual manner. In sports medicine, we have an obligation to enact policies and provide education and training to ensure the development and delivery of clinical best practices in the prevention of sexual violence and in the care of athletes who have experienced it. Thank you very much. Thank you.

sexual violence

sports

healthcare

prevention

athletes