“We just can’t fix a problem we don’t understand, and we can’t understand the problem unless and until we have all the facts. If we don’t do all we can to get these facts the problems we are here to address will persist and we are deluding ourselves if we think other children will be spared the institutionalized tolerance and normalization of abuse that I, and so many, had to endure.”1  On September 15, 2021, these words echoed across the United States Senate chamber as Aly Raisman and three other decorated gymnasts, Simone Biles, McKayla Maroney, and Maggie Nichols, provided poignant testimony before the Judiciary Committee Hearing that highlighted the enormous failures of multiple organizations, including the Federal Bureau of Investigation (FBI), in responding to and investigating allegations of sexual abuse within USA Gymnastics. As revealed in the Inspector General’s report and emphasized in Maroney’s testimony, the FBI “sat idly by as dozens of girls and women continued to be molested by Larry Nassar.”1  Of Nassar’s more than 330 victims, at least 70 young athletes were abused after the Indianapolis FBI became aware of allegations made against Nassar.1  After the Senate Judiciary Committee Hearing, USA Gymnastics and the United States Olympic & Paralympic Committee reached a $380 million settlement with 500 female athletes who had been abused by Nassar or others within the sport.2  Through their testimony, Raisman, Biles, Maroney, and Nichols crystallized the need for urgent action across disciplines to safeguard young athletes from abuse, be it physical, sexual, or psychological, as well as bullying and harassment by peers.

Although high-profile cases of abuse, such as the Nassar case, are reprehensible, the benefits of sports participation in childhood should not be overshadowed, because they are expansive and extend beyond physical and mental health to social skills, as well as to academic and career performance.3  Through athletics, children are taught valuable lessons in time management, deferred gratification, work ethic, fair play, conflict resolution, and leadership, among other competencies.3  Additionally, physically active children are more likely to become physically active adults, leading to sustained benefits across their lifetimes.3 

Despite these benefits, burnout and overuse injury are becoming increasingly recognized. There has been a substantial decline in sports participation among children in the United States over the past decade. Between 2008 and 2018, the percentage of children aged 6 to 12 years who regularly participated in organized team sport decreased from 45% to 38%.4  Campaigns like “Don’t Retire, Kid,” which aired on ESPN, have drawn attention to the stark reality that most children quit playing sports by adolescence.4,5  Additionally, one-half of pediatric sports injuries are due to overuse, which may be related to shifts from multisport play to earlier sports specialization.5  Recently, a few athletes, including Simone Biles, have spoken candidly about the extreme pressures of competing at the elite level to the detriment of their mental health.1  Although adversity is important in the development of a young athlete, there is a point where performance suffers, particularly in the absence of supportive coaching.

Sport, unlike other sectors of society, often operates under its own code of ethics rooted in a “win at all costs” mentality that normalizes abusive coaching practices under the guise of competition.6,7  This includes coaching behaviors such as yelling at, intimating, or humiliating players with the purpose of toughening them and motivating them toward success.6  Additionally, there are unique features of the sporting environment that leave young athletes particularly vulnerable to abuse, including media attention, inherent trust placed in coaches and athletic staff, recruitment practices, time spent away from caregivers, and distant competition and training camps.8 

Using data collected through the National Surveys of Children’s Exposure to Violence, researchers examined the responses of 13 072 youth 0 to 17 years of age to their Juvenile Victimization Questionnaire and concluded that abuse in youth-serving organizations, which includes sports, was a relatively rare form of abuse (0.8%).9  However, our ability to ascertain the true prevalence of abuse in youth sport has been challenged by variable definitions of maltreatment, barriers to athlete disclosure resulting in underreporting, and a disproportionate focus among researchers on sexual abuse over physical abuse, psychological abuse, and neglect.7,8  In a recent review that included a discussion of prevalence studies conducted outside the United States, psychological abuse was described as a predominant form of abuse among athletes.7  This was demonstrated in a study of 1001 current and former Canadian national team athletes in which nearly 25% of retired athletes reported having experienced repeated psychological maltreatment, whereas 7% and 5% reported experiencing sexual harm and physical abuse, respectively.7  Yet, despite the increased attention on sexual abuse, several misperceptions remain. As an example, sexual abuse of athletes, as publicized by the popular media, typically involves abuse perpetrated by adults on young females, whereas victimization of male athletes and abuse of athletes by their peers remains underrecognized and underreported. This was highlighted in the 2016 International Olympic Committee consensus statement on harassment and abuse in sport, which revealed that peer athletes, rather than coaches, are the most likely perpetrators of sexual harassment.10 

Despite the inherent risks to children in youth-serving organizations, such as sports, where there are large aggregates of children and an “authority gradient,” only recently has there been a shift from disorganized outrage in response to reports of abuse to coordinated and multiagency prevention through the development of independent organizations including the US Center for SafeSport. Through independent investigation, concealing abuse allegations and conflicts of interest in handling abuse internally can be mitigated.

Thus far, there has been little discourse among medical professionals within the United States about recognizing and responding to abuse, harassment, and bullying in youth sports. As pediatricians, we are uniquely positioned to advocate for safe sport during our encounters with patients and their families. At an individual level, we have an opportunity to provide anticipatory guidance to caregivers regarding sports participation and safe sport practices during well-child examinations. Specifically, we should be counseling caregivers to inquire about how coaches and volunteers are screened, whether there is formal abuse-prevention training within their child’s sports organization and to educate themselves on the program’s code of conduct and policies pertaining to travel, approved communication between coaches and athletes, and maintaining a safe locker room, among others.3,11,12  Parents should be encouraged to observe practice. If a coach or team uses closed practice policies, then parents should ask about alternatives to allow for a designated person, such as a single parent, to monitor practices as well as coach and athlete behaviors. Caregivers should also be informed of mechanisms for reporting abuse concerns if they suspect abuse or their child discloses maltreatment. The United States Center for Safe Sport has developed a parent toolkit that provides concrete recommendations, which have been summarized and modified in Tables 1 and 2.12 

Screening for maltreatment should also be incorporated into the preparticipation sports physical. Patients should be asked about abuse by coaching staff, bullying; hazing, and harassment by their peers; pressures to perform when injured; burnout; and familiarity with processes of disclosing abuse and maltreatment.

As a larger medical community, we must work with our colleagues within and outside of medicine to identify knowledge gaps and create formalized partnerships. As Aly Raisman astutely highlighted, “we just can’t fix a problem we don’t understand.”1  Thus, there is a need for additional research into the epidemiology of maltreatment in youth sports within the United States to develop targeted and evidence-based prevention initiatives. At the forefront, we must make external barriers for perpetration very high.

Now that there is congressional attention, let us unite in our desires to promote physical activity while ensuring that our young athletes are protected from exploitation and abuse.

Dr Canty drafted the initial manuscript and performed revisions, Dr Giardino conceptualized the paper and critically reviewed and revised the manuscript, and both authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: Dr Giardino was a founding member of the board of trustees of the United States Center for SafeSport in March 2017.

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