Biomedical Ethics Test

57Mountjoy M. Br J Sports Med January 2019 Vol 53 No 1

‘Only by speaking out can we create lasting change’: what can we learn from the Dr Larry Nassar tragedy? Margo Mountjoy1,2

As it turns out… Dr Nassar was not a doctor, he in fact is, was, and forever shall be, a child molester and a monster of a human being. End of story. He abused my trust, he abused my body and he left scars on my psyche that may never go away.

McKayla Maroney, Olympic Gold Medallist, London 2012.

Dr Larry Nassar was sentenced on 24 January 2018 to 40–125 years in prison in Eaton County and 40–175 years in Ingham County, Michigan, USA, for first-degree criminal sexual conduct in addition to 60 years in Federal court for child pornog- raphy. During the court proceedings, 156 women who call themselves the ‘army of survivors’, spoke about their abuse expe- riences in emotional and powerful victim impact statements. In the course of his professional career, Dr Nassar is alleged to have sexually abused approximately 256 female athletes from 1998 to 2015, often in front of parents. His victims were mainly gymnasts, some as young as 6 years of age. For some victims, the abuse occurred repetitively, up to 10 years in duration. Dr Nassar stated that his ‘medical treat- ments’ (which were invasive pelvic floor ‘therapy’ where he would digitally pene- trate girls’ vaginas and anuses) would cure physical injuries. He abused them in his clinic, his home, at training camps and at competition venues where he treated them alone in his hotel room, often after having sedated the athlete with sleeping pills. Dr Nassar referred to himself as the ‘body whisperer’.1

What is unique about this sexual abuse case is that Dr Nassar is an osteopathic sport medicine physician. One of our colleagues. One of our fraternity. Larry was the physician for the USA Gymnastics team and worked at four Olympic Games. He was a practising sport medicine physi- cian for a prestigious university in the

NCAA collegiate system in the USA, the team physician for a national sport feder- ation and a member of the US Olympic medical team; all coveted positions that connote success and accomplishment in our sport medicine culture. In these roles, the team physician is in a position of great privilege, responsibility and power.

What is sexuaL abuse iN spOrt? Sexual abuse in sport is defined by the IOC as ‘any conduct of a sexual nature, whether non-contact, contact or penetrative, where consent is coerced/manipulated or is not or cannot be given’.2 Consent for sexual activity does not apply to children given their inability to understand the concept.3 Sexual abuse has been categorised as a relational threat to child athletes. In the Nassar case, the abuse can also be classi- fied as an organisational threat with the added complexity that the abuse included medical mismanagement4 (see table 1). From the published science in this field, we know that sexual abuse occurs at all levels of sport and in all sports,5 6 and that elite athletes have a higher prevalence.6 7 Child athletes are also particularly vulnerable with a prevalence rate of sexual abuse reported between 2% and 22%.8 Child athletes are considered to be at higher risk due to relocation from home to distant training facilities as well as separation and isolation from family and school commu- nities caused by sport training demands.2 Finally, adolescent athletes are considered to be more vulnerable for sexual abuse due to the increased need for protection and supervision during this sensitive period of

physical, psychological and social growth and development.9

What are the impacts Of sexuaL abuse? The damage from the sexual abuse of Larry Nassar was apparent in the victim impact statements heard during his sentencing hearing. In her victim impact statement, Kyle Stephens stated:

Sexual abuse is so much more than a disturbing physical act. It changes the trajectory of a victim's life, and that is something that nobody has the right to do.10

Jamie Dantzscher (2000 Olympic bronze medallist) described her challenges with depression, anorexia and bulimia requiring hospitalisation for attempted suicide.11 Chelsey Markham committed suicide in 2009, which her mother directly related to her sexual abuse by Dr Nassar.12 The victims described the physical pain, shame and embarrassment as well as the loss of their childhood. Kaylee Lorinez stated that she lost trust in physicians and is unable to tolerate physical touch.13 Whitney Mergens’ statement identified her parents as victims also.14 Kyle Stephens attributes her father’s suicide to her abuse at the hands of Dr Nassar.10 Randall Margraves, a father of three victims, had to be restrained from attacking Nassar during the court proceedings.15

The personal costs of abuse to athletes can be extremely damaging, long lasting and persist well after the abuse has ended.16 Sexual abuse affects athlete psychological, social and physical health.17 We know from the non-sport population that childhood sexual abuse is a predictor of poor mental health, self-harm and suicide attempts.18 In the sport sector, other mental health sequelae of sexual abuse include substance abuse, eating disorders and psychosomatic illnesses19 as well as psychological distress in adulthood and a reduction in self-re- ported quality of life.20 The psychological

1Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada 2International Olympic Committee - Games Group, Lausanne, Switzerland

correspondence to Dr Margo Mountjoy, Department of Family Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; mmsportdoc@ mcmaster. ca

education reviews

table 1 Categorisation of the various forms of violence which threaten child athletes.4

threats to child athletes

individual relational Organisational

Injury Depression Self-harm Eating disorders Disordered eating

Sexual harassment Sexual abuse Physical abuse Forced physical exertion Emotional abuse Virtual maltreatment Neglect Bullying Doping

Abuse from spectators Discrimination Cultures which normalise abuse Unhealthy training programmes Hazing Medical mismanagement Systematic doping Age cheating

o n 1

5 Ja

n u

a ry 2

0 1 9 b

y g u e

st. P ro

te cte

d b

y co p

yrig h

t. h ttp

://b jsm

.b m

j.co m

/ B

r J S p

o rts M

e d

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

jsp o

rts-2 0

1 8

-0 9 9 4 0 3 o

n 2

3 Ju

n e 2

0 1 8 . D

o w

n lo

a d e d fro

m

58 Mountjoy M. Br J Sports Med January 2019 Vol 53 No 1

education reviews

impact is compounded for the victim by what is known as the ‘bystander effect’, as described by Larry Nassar’s ‘army of survi- vors’ when discussing the inaction of the various sport organisations who turned a blind eye to these athletes when they tried to report their abuse.21 Unwanted preg- nancy, sexual transmitted infections and urogenital/anogenital trauma are direct physical impacts of sexual abuse.2 Sexual abuse also has a negative effect on athlete performance, an increase risk of premature athlete dropout, doping and a willingness to cheat.22 Family members, teammates, friends and work colleagues can also be also negatively affected. For sport organ- isations, sexual abuse represents a signif- icant risk for loss of sponsorship, early athlete dropout, reputational damage and a loss of both fans and talent pool.2

What WeNt WrONg? How was Dr Nassar able to abuse for such a long time period? Why did no one stop him? How could the abuse reach such a magnitude of victims? These questions are poignant—for only by understanding how this tragedy occurred can we prevent a repetition of it in the future.

The recipe for Dr Nassar’s longstanding freedom to perpetrate can be explained as a melange of three key factors: (1) abuse of a power relationship, (2) a sport culture of secrecy and deference and (iii) failed sport leadership.

Sexual abuse occurs when there is an abuse of a power relationship.23 In this case, Dr Nassar was in a position of power over the athletes. His victims were vulnerable, young, injured female athletes. As part of his grooming process for the sexual abuse, he led the victims to believe that they were privileged to receive his care, and he lied to them that the sexual abuse was a form of legitimate medical treatment. He abused the trust that these athletes had in him as a physician.

Sexual abuse is fostered in a sport culture which denies, ignores or accepts abuse as the norm; a sport culture where athletes have no power or voice and are commodified in a ‘win at all costs’ envi- ronment. Sexual abuse is facilitated by a sport culture of secrecy and deference.24 Dominique Moceneau, 1996 Olympic gold medalist, describes the culture of USA Gymnastics as one of ‘psychological abuse’,25 which underpins all other forms of abuse, including sexual abuse.4 Psycho- logical abuse often overlaps and co-ex- ists with sexual abuse6 20—in reality, it is hard to imagine that sexual abuse could exist without a psychological abusive

component. The culture of USA Gymnas- tics is described by Aly Raisman, six-time Olympic medalist, as one with a ‘winning is everything’ ethos: Their (USA gymnas- tics) biggest priority from the beginning and still today, is their reputation, the medals they win and the money they make off of us.’21

Sexual abuse in sport is considered to be the result of failed leadership. We know that sexual abuse occurs in a sport culture where there is high perpetrator motiva- tion, low athlete protection (safeguarding policies and procedures) and high athlete vulnerability.2 Perpetrators seek out oppor- tunities to abuse in environments where there is little supervision or oversight.26 Jordyn Wieber, an Olympic gold medal- list (2012) and patient of Dr Nassars’ for 10 years, highlights this concept of failed leadership in her victim statement:

Larry Nassar is accountable. USA Gymnastics is accountable. The US Olympic Committee is accountable. My teammates and friends have been through enough, and now it’s time for change. The current gymnasts should not have to live in anxiety and fear as I did.27

USA Gymnastics demonstrated failed leadership in its lack of supervision of the National Team Training Centre in Texas, known as the Karolyi Ranch, which athletes have described as an emotion- ally abusive environment. USA Gymnas- tics delayed reporting the suspicion of sexual abuse for 5 weeks in 2015 and allegedly threatened athletes with a fine of US$100 000 if they were to speak out against Nassar. The organisation lacked athlete-safeguarding policies and proce- dures to handle allegations of abuse and had no mechanism to publically report abuse cases, thus enabling perpetrators to move locations and commence abuse in another gymnastics club. Until recently, there was no coach certification or training of USA Gymnastics officials in athlete safe- guarding. Athletes were required by USA Gymnastics to see Dr Nassar for manda- tory assessments, even after reports of abuse had been made. The President and entire Board of Directors of USA Gymnas- tics have since resigned over criticism of the mismanagement of the sexual abuse scandal.28

Michigan State University (MSU) was also implicated as culpable by Jordyn Weiber. Dr Nassar taught and practised medicine as an academic at this institution since 1997. Amanda Thomashow, a cheer- leader at MSU, reported her abuse by Dr Nassar in 2014 and an ensuing inquiry cleared him of wrongdoing stating that

his ‘treatments’ were appropriate medical therapy.29 Clearly, all institutions involved are experiencing reputational damage, and action is required to regain public and athlete confidence and to help to mitigate future recurrences.

LessONs LearNt It is incumbent on all of us in sport medi- cine to examine the details of the Nassar case to learn how to improve our practices to protect the athletes in our care from sexual abuse in sport. This begins with the acknowledgement of the underlying principle outlined in the IOC Consensus statement:

Athletes of all ages have a right to engage in ‘safe sport’: an athletic environment that is respectful, equitable and free from all forms of non-accidental violence to athletes. Everyone involved in sport will benefit from a sporting environment that is free from fear or favour, and are just as entitled to express their human rights in the context of sport as they are in any other setting.2

safeguarding policies and procedures It is also important for sport medicine physicians to ensure that all sport organ- isations we work with have safeguarding policies and procedures. Policies and procedures serve the purpose of safe- guarding athletes, protecting the integ- rity of sport and sport organisations, protecting those working in sport and promoting the values of safe sport (see box 1). The IOC has created a toolkit to help sport organisations develop and implement athlete safeguarding policies and procedures.30

In the Nassar abuse case, the victims were mostly child athletes during the time of the abuse. The International Safe- guards for Children in Sport addresses the protection needs of children and acts as a resource to assist sport organisations in the development of child athlete-specific policies and procedures.31

box 1 components of safe sport programs2

► Clear policies on the rights of athletes to safe sport.

► Associated codes of practice. ► Systematic recruitment and background screening.

► Education and training. ► Complaint and support mechanisms. ► Monitoring and evaluation systems.

o n 1

5 Ja

n u

a ry 2

0 1 9 b

y g u e

st. P ro

te cte

d b

y co p

yrig h t.

h ttp

://b jsm

.b m

j.co m

/ B

r J S p

o rts M

e d

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

jsp o

rts-2 0

1 8

-0 9 9 4 0 3 o

n 2

3 Ju

n e 2

0 1 8 . D

o w

n lo

a d e d fro

m

59Mountjoy M. Br J Sports Med January 2019 Vol 53 No 1

education reviews

box 2 clinical approach to athlete disclosures of sexual abuse40

► Actively and empathetically listening to and psychologically supporting the patient/athlete.

► Acknowledge his/her courage in speaking about this abuse.

► Assure the athlete that this experience is not their fault.

► Simultaneously encourage disclosure and yet avoid leading questions.

► To facilitate this disclosure and to demonstrate trust in the athlete, the sport doctor should not denigrate the perpetrator.

► Keep accurate record completion. ► STOP the abuse: report the disclosure to the appropriate authorities, legal statues, sport organisation.

► Ensure athlete safety. ► With a multidisciplinary treatment team, investigate and manage any associated medical (physical or psychological) presentations.

► Support team mates, members of the entourage and family members.

Larry Nassar as an osteopathic sport medicine physician had additional codes of conduct that should have guided his behaviour. Related to the practice of medicine in general, there are regula- tions to protect the public from physi- cian abuse. The oldest resource is the Hippocratic Oath which is taken by most physicians on their graduation from medical school. The original transla- tion explicitly prohibits physicians from engaging in sexual conduct with patients: ‘Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons….’32 In most countries, physicians are bound by the legal codes of conduct mandated by local licensing bodies or Colleges of Physicians and Surgeons. In the USA, Dr Nassar was governed by the Code of Medical Ethics of the American Medical Association.33 Finally, sport medicine physicians are guided by the principles outlined in the Olympic Movement Medical Code.34 This document adapts the relevant human rights and ethical medical practices into the sport-specific context. Article 1.1.1 of the Olympic Movement Medical Code states that:

Athletes enjoy the same fundamental rights as all patients in their relationships with physicians and healthcare providers, in particular, respect for: a. their human dignity; b. their physical and psychological well-being; c. the protection of their health and safety; d. their self-determination; and e. their rights to privacy and confidentiality.34

The Olympic Movement Medical Code outlines the relationship boundaries between the sport medicine physician and athletes describing best practices with respect to health protection during training and competition, confidenti- ality, informed consent and privacy. The vulnerability of the growing child athlete to the physical, psychological and social health risks unique to the sport environ- ment is also explicitly highlighted.34

cultural change Safe sport can only occur if there is a change in the culture of sport to one where athletes are respected and empow- ered to speak and influence change.2 Sport medicine physicians can play an integral role in advocating for athlete rights and in promoting safe sport by raising aware- ness through educational interventions. The IOC has developed two resources available for this purpose: (1) a coach and

athlete interactive e-program on Sexual Harassment and Abuse in Sport35 and (2) an athlete e-course called ‘safeguarding athletes from harassment and abuse’ found in the IOC Athlete Learning Gateway portal.36

medical management of sexual abuse  When I learnt of the Larry Nassar case, I contacted a colleague who was a member of the US Olympic medical team. He asked the questions that many of us in sport medicine might have been thinking: What should I have noticed in the abused gymnasts? What should I do if an athlete discloses abuse? One important lesson learnt from Larry Nassar is that clinical competency in the ability to identify and manage sexual abuse should be included in sport medicine fellowship training programmes.37

‘Clinical competency in the ability to identify and manage sexual abuse should be included in sport medicine fellowship training programmes.’

Despite the fact that most sport medi- cine fellowship programmes do not train competencies in this field, it behoves all of us in the field to have a clinical approach for the identification and management of sexual abuse. To being with, we should be able to recognise the signs and symptoms of abuse in sport. As athletes are often silenced by their abuse, they are reluctant and frightened to disclose. As a result, as a team doctor, we should be vigilant to recognise the physical, psychological, behavioural and sport performance indi- cators of sexual abuse as described in the ‘impacts’ section above. Having a high index of suspicion and verifying athlete safety if concerned is recommended. Should an athlete disclose abuse to you, box 2 outlines a ‘best practice’ clinical approach to follow.

cONcLusiON As outlined in the BMJ Opinion blog of 29 March9, 2018, ‘The Larry Nassar tragedy—never again’,38 we as sport medicine physicians must act to ensure that our athletes feel safe and respected and that we can be trusted to act in the best interest of their physical and psychological health. May Dr Nassar be a wakeup call to our profession to ensure that we are not found guilty of the famous anonymous quote, ‘History repeats itself because no one was

listening the first time’. By speaking up and being an integral part of change, we as sport medicine physicians should strive to create a safe sport environment for our athletes. While it is difficult to hear the impact statements of the victims of Larry Nassar, we must learn from them, and as a legacy to their suffering, we cannot allow another similar tragedy to occur.

That you still think that somehow you are right that you are a doctor and you are entitled and you don't have to listen and that you did treatment. I would not send my dogs to you, sir. There is no treatment here.39 Judge Rosemarie Aquilina

***For more information on sexual abuse in sport, please listen to the BJSM podcast: http:// ow. ly/ sxaT30kuWZQ.

acknowledgements This editorial is dedicated to the numerous victims abused by Dr Larry Nassar; the brave young women who found the courage to speak up to ensure that generations of athletes to follow will be better protected as young women in elite sport. May their actions serve to facilitate their own healing and as a wake-up call for sport organisations and sport medicine communities to ensure safe sport for all. Finally, I would like to acknowledge the pioneering work in this field of Professor Celia Brackenridge, who laboured and lobbied tirelessly throughout her career to protect athletes from harassment and abuse in sport.

contributors MM contributed to the conception and design, drafting and revising the manuscript.

competing interests None declared.

o n 1

5 Ja

n u

a ry 2

0 1 9 b

y g u e

st. P ro

te cte

d b

y co p

yrig h t.

h ttp

://b jsm

.b m

j.co m

/ B

r J S p

o rts M

e d

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

jsp o

rts-2 0

1 8

-0 9 9 4 0 3 o

n 2

3 Ju

n e 2

0 1 8 . D

o w

n lo

a d e d fro

m

60 Mountjoy M. Br J Sports Med January 2019 Vol 53 No 1

education reviews

patient consent Not required.

provenance and peer review Not commissioned; externally peer reviewed.

author note ’Only by speaking out can we create lasting change’. Stokes D. http://www. dashannestokes. com/ quotes. html (accessed 18 Feb 2018).

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

to cite Mountjoy M. Br J Sports Med 2019;53:57–60.

Accepted 22 May 2018 Published Online First 23 June 2018

Br J Sports Med 2019;53:57–60. doi:10.1136/bjsports-2018-099403

RefeRences 1 Chavez C. 144 Women and girls to make victim impact

statements at Larry Nassar’s Sentencing. https://www. si. com/ olympics/ 2018/ 01/ 22/ larry- nassar- sentencing- victims- abuse- stories (accessed 18 Feb 2018).

2 Mountjoy M, Brackenridge C, Arrington M, et al. The IOC consensus statement: harassment and abuse in sport. Br J Sports Med 2016:1019–29.

3 Archard D. Sexual consent. Boulder, CO, USA: Westview Press, 1998.

4 Mountjoy M, Rhind DJ, Tiivas A, et al. Safeguarding the child athlete in sport: a review, a framework and recommendations for the IOC youth athlete development model. Br J Sports Med 2015;49:883–6.

5 Fasting K, Brackenridge C, Sundgot-Borgen J. Prevalence of sexual harassment among norwegian female elite athletes inrelation to sport type. Int Rev Sociol Sport 2004;39:373–86.

6 Vertommen T, Schipper-van Veldhoven N, Wouters K, et al. Interpersonal violence against children in sport in the Netherlands and Belgium. Child Abuse Negl 2016;51:223–36.

7 Fasting K, Brackenridge C, Knorre N. Performance level and sexual harassment prevalence among female athletes in the Czech Republic. Women in Sport and Physical Activity Journal 2010;19:26–32.

8 Brackenridge CH, Bishopp D, Moussalli S, et al. The characteristics of sexual abuse in sport: A multidimensional scaling analysis of events described in media reports. International Journal of Sport and Exercise Psychology 2008;6:385–406.

9 David P. Human rights in youth sport: a critical review of children’s rights in competitive sport. London, UK: Routledge, 2005.

10 Stephens K. Larry Nassar’s abuse victims, in their own words. https://www. cnn. com/ 2018/ 01/ 16/ us/ nassar- victim- impact- statements/ index. html (accessed 20 Dec 2018).

11 Dantzscher J. Victim impact statements against Larry Nassar: ’I thought I was going to die’. https://www.

theguardian. com/ sport/ 2018/ jan/ 24/ victim- impact- statements- against- larry- nassar- i- thought- i- was- going- to- die (accessed 20 Feb 2018).

12 Markham C. Victim of ex-USA gymnastics doctor says abuse led to dad’s suicide. https://www. reuters. com/ article/ us- gymnastics- usa- nassar/ victim- of- ex- usa- gymnastics- doctor- says- abuse- led- to- dads- suicide- idUSKBN1F52MS (accessed 20 Feb 2018).

13 Lorinez K. Gymnast Kaylee Lorincz gives her victim impact statement. http://www. abc. net. au/ news/ 2018- 01- 25/ gymnast- kaylee- lorincz- gives- her- victim- impact- statement/ 9360410 (accessed 20 Feb 2018).

14 Mergens W. 144 Women and girls to make victim impact statements at Larry Nassar’s Sentencing. https://www. si. com/ olympics/ 2018/ 01/ 22/ larry- nassar- sentencing- victims- abuse- stories (accessed 20 Feb 2018).

15 Margraves R. Dad who lunged at Larry Nassar to donate funds to groups that help sexual assault survivors. https://www. cnn. com/ 2018/ 02/ 08/ us/ msu- father- donates- fundraiser- money/ index. html (accessed 20 Feb 2018).

16 Fasting K, Brackenridge C, Walseth K. Consequences of sexual harassment in sport for female athletes. Journal of Sexual Aggression 2002;8:37–48.

17 Burke M. Sexual harassment in sport: impact, issues and challenges. J Philos Sport 2003;30:97–100.

18 Chaplo SD, Kerig PK, Bennett DC, et al. The roles of emotion dysregulation and dissociation in the association between sexual abuse and self-injury among juvenile justice-involved youth. J Trauma Dissociation 2015;16:272–85.

19 Sundgot-Borgen J, Fasting K, Brackenridge C, et al. Sexual harassment and eating disorders in female elite athletes - a controlled study. Scand J Med Sci Sports 2003;13:330–5.

20 Vertommen T, Kampen J, Schipper-van Veldhoven N, et al. Severe interpersonal violence against children in sport: Associated mental health problems and quality of life in adulthood. Child Abuse Negl 2018;76:459–68.

21 Raisman A. Full text of aly raisman victim impact statement. http://www. dailymail. co. uk/ news/ fb- 5290123/ FULL- TEXT- ALY- RAISMAN- VICTIM- IMPACT- STATEMENT. html

22 Yukhymenko–Lescroart MA, Brown ME, Paskus TS. The relationship between ethical and abusive coaching behaviors and student-athlete well- being. Sport, Exercise, and Performance Psychology 2015;4:36–49.

23 Tomlinson A, Yorganci I. Male coach/female athlete relations: gender and power relations in competitive sport. Journal of Sport and Social Issues 1997;21:134–55.

24 Hartill M. Concealment of child sexual abuse in sports. Quest 2013;65:241–54.

25 Moceanu D. Olympic gold medalist dominique moceanu describes ’Culture of Abuse’ at USA gymnastics. http:// insider. foxnews. com/ 2018/ 01/ 26/ dominique- moceanu- larry- nassar- usa- gymnastics- abuse- scandal- martha- bela- karolyi (accessed 20 Feb 2018).

26 Brackenridge CH, Kirby S. Playing safe: assessing the risk of sexual abuse to elite child athletes. Int Rev Sociol Sport 1997;32:407–18.

27 Wieber J. Jordyn Wieber at sentencing: ’Nobody was protecting us’ from Larry Nassar. https://www. lansingstatejournal. com/ story/ news/ local/ 2018/ 01/ 19/ jordyn- wieber- aly- raisman- court- make- nassar- statements/ 1047184001/ (accessed 20 Feb 2018).

28 Kirby J. The sex abuse scandal surrounding USA Gymnastics team doctor Larry Nassar, explained. https://www. vox. com/ identities/ 2018/ 1/ 19/ 16897722/ sexual- abuse- usa- gymnastics- larry- nassar- explained (accessed 20 Feb 2018).

29 Thomashow A. She filed a complaint against Larry Nassar in 2014. Nothing happened. https://www. cnn. com/ 2018/ 02/ 01/ us/ msu- amanda- thomashow- complaint- larry- nassar/ index. html (accessed 20 Feb 2018).

30 International Olympic Committee. IOC Toolkit for IFS and NOCS. 2018. Retrieved from Safeguarding athletes from harassment and abuse in sport. https:// hub. olympic. org/ athlete365/ safeguarding/ (accessed 20 Feb 2018).

31 CPSU. International safeguards for children in sport: NSPCC, 2014.

32 Edelstein L. From the hippocratic oath: text, translation, and interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943. (accessed 18 Feb 2018).

33 American Medical Association. The Code of Medical Ethics of the American Medical Association. https:// www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC3399321/ (accessed 24 Feb 2018).

34 International Olympic Commmittee. Olympic movement medical code. 2016. https:// stillmed. olympic. org/ media/ Document% 20Library/ OlympicOrg/ IOC/ Who- We- Are/ Commissions/ Medical- and- Scientific- Commission/ Olympic- Movement- Medical- Code- 31- 03- 2016. pdf (accessed 24 Feb 2018).

35 International Olympic Committee. Sexual harassment and abuse in sport. www. olympic. org: http:// sha. olympic. org/#_ ga= 2. 222852958. 433268301. 1519365376- 1750641476. 1504994135 (accessed 20 Feb 2018).

36 International Olympic Committee. Athlete learning gateway: safeguarding athletes from harassment + abuse. www. olympic. org: http:// onlinecourse. olympic. org/ course/ baseview. php? id= 39 (accessed 20 Feb 2018).

37 Humphries D, Jaques R, Dijkstra HP, et al. A Delphi developed syllabus for the medical specialty of sport and exercise medicine. Br J Sports Med 2018;52.

38 Mountjoy M. The Larry Nassar tragedy- never again. blogs. bmj. com/ bmj/ 2018/ 03/ 29/ margo- mountjoy- on- the- larry- nassar- tragedy- never- again/ (accessed 1 Apr 2018).

39 Aquilina R. Read Judge Rosemarie Aquilina’s powerful statement to Larry Nassar. https://www. cnn. com/ 2018/ 01/ 24/ us/ judge- rosemarie- aquilina- full- statement/ index. html (accessed 18 Feb 2018).

40 Marks S, Mountjoy M, Marcus M. Sexual harassment and abuse in sport: the team physician’s role in prevention. Br J Sports Med 2012;46:905–8.

o n 1

5 Ja

n u

a ry 2

0 1 9 b

y g u e

st. P ro

te cte

d b

y co p

yrig h t.

h ttp

://b jsm

.b m

j.co m

/ B

r J S p

o rts M

e d

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

jsp o

rts-2 0

1 8

-0 9 9 4 0 3 o

n 2

3 Ju

n e 2

0 1 8 . D

o w

n lo

a d e d fro

m