SafeSport – What Clinicians can do to Prevent Abuse and Harassment in Sport

Welcome to the Clinical Journal of Sport Medicine Podcast. [Music] Today's guest is Dr. Margot Montjoy. We're with us on the podcast to discuss harassment and abuse in sport and what we can all do about it. [Music] Margot Montjoy, MD-PhD, is an internationally esteemed sport medicine physician and associate clinical professor at McMaster University Hamilton, Ontario, Canada. She has worked in the area of identifying, treating and preventing, athletic, harassment and abuse for the International Olympic Committee, World Health Organization, Association for Summer Olympic International Federations, FINA and UNICEF. She's an active advocate of the prevention of harassment and abuse in sport through the Canadian Olympic Committee and the Canadian Academy of Sport and Exercise Medicine. Dr. Montjoy's as well, the lead author of three recent CGSM publications focusing on these important sport safety issues. And she's with us to talk today about her work and the International Safe Sport Initiative. Well, I want to welcome everyone to the first podcast of 2022 and it starts off with a bang. We have Margot Montjoy from McMaster University of Clinician Scientist at McMaster, whose purview extends around the globe. She does an amazing amount of work in international sports and we're going to talk about that today with a few papers she's just published in CGSM. Welcome to the podcast, Dr. Montjoy. Thank you very much. It's my pleasure to join you today. Well, we're really psyched to have you and you are prolific. We're going to talk about three papers today and this doesn't actually begin to sort of touch the tip of the iceberg, so to speak, with all of Dr. Montjoy's work. But we have an upcoming paper expected to publish in the March 2022 CGSM Safe Sport, perceptions of harassment and abuse from elite youth athletes at the Winter Youth Olympic Games in La Sant 2020. She's the lead author of that paper. We also have an accompanying editorial where she's the lead author. Nothing about us without us empowering the youth athlete voice and safe sport. And then already published in the November 2021 issue beneath the surface, mental health and harassment and abuse of athletes participating in the FINA Aquatics World Championships 2019. So as regular listeners of this podcast know, in the accompanying blog post, there'll be links to all the papers and I encourage you to do a deep dive into this. But I wanted to start by saying, I wanted to reach out to you actually after the November paper. And it reminded me of the great talk you gave at IOC Prevention in Monaco in 2017, where it really lit a fire under me about this problem, the scope of it, all the different dimensions of it. So I thought I'd ask you just for starters, I'm sure you work predated 2017. How did you get involved in this line of sports medicine research and advocacy and what may have prompted it? Thank you for your question. I suppose it probably started when I was a team dog in 1994 at the FINA World Championships. I was a fairly young new dog with the team at the time and it was my first time working with women's water polo. I was on the bench watching the game learning about the game at that point. And I saw the team captain, Miss Agold. And of course everyone was very upset. She came to the bench, she got out of the water, and the coach punched her in the face. And I was powerless to act. I did not know what to do. I didn't have the tools. And I didn't act. This was normalized behavior for that team. I was a little bit involved in the game. And I think that's probably what lit the fire in me that this was an acceptable behavior in sports. And I was powerless to do anything about it. And then you have to flash forward when I in 2000 I started working with the IOC. About 2006 the IOC medical commission meeting the president of ice hockey. I had some revelations of harassment abuse with the Sheldon Kennedy issue. And at that point the president of ice hockey federation said, "We as the IOC should do something." And I think Margot should lead it. So I then became the lead of the 2007 the meeting was 2006, but 2007 was the first IOC consensus on sexual harassment in sport. So for the ensuing 10 years between 2006 and 2016, I really had to work hard to encourage the IOC to act, to walk the walk, not just talk the talk. And finally in 2016 the IOC implemented their first games time framework for Olympic games. And that would lead nicely into the 2017 Monaco meeting, the IOC prevention conference that you heard me speak. And from here on in the IOC then has developed an IOC working group in her prevention of harassment abuse and games time frameworks for all of their events. So the rest is history so to speak. Yeah. Do you have an opinion on what may have been a turning point in at least awareness? I'm aware of like the work that you're doing. I'm aware of Brian Hanline and the NCAA and the work he's doing in mental health. Like I'm whatever I've been around sports mates long enough or a quote unquote old enough to have seen an evolution in awareness from like what you're describing. Like you know I'm on a bench and I've just taken care of a broken bone or something too. I also have an obligation to take care of someone's mind their spirit. Like how in fact a coach may be treating them. That's not separate from the whole patient. And it seems to me in my training that wasn't a part of it at all. And somewhere around like maybe the mid 2010s it became. Is it something maybe to do with the horrific stories like the Larry Nassau US gymnastics. It's so egregious and got so much press or do you you have a sense on what the sea change has been or do you think there's a sea change even baby in our profession. I do think there's a change in our profession. I think many of us more senior sport physicians were really trained in MSK type medicine with a sprinkle of asthma and a little touch of concussion. And that was about about what our real house was and of course field of play care that kind of thing. But really many of us are were family physicians before coming into sport medicine and family medicine. We are taught to look out for the entire individual and that their mental health and physical well being is a significant part of their satisfaction and joy in sport not to mention their health and well being. So I do think that a society has listened to not only physicians that are advocating beyond the joint care for individuals but also listening to athletes and listening to asking to say, Hey, I'm not OK. I need help and this is not working for me. I think the change shifted before the Larry Nasser issue Larry Nasser was fairly recent in the scope of things. It's pretty egregious, pretty horrific for health care professionals to have one of our own involved in such a horrific issue. But I think the I think the tide changed before turned before. Yeah, that's a good point. You touched on something I wasn't even thinking we're aware of that maybe to that idea of athletes themselves coming forward being more self aware and more willing to talk, you know, maybe it also has to do with platforms that they have access to that they didn't have access to in the early say 2000s, I mean, including things like Twitter or you know, Naomi Osaka, give telling her own story. Just a for instance about mental health. That's an interesting perspective I hadn't thought of. I think they've been empowered now. I think it's an empowered to have the voice, but also culture has changed so it's given them permission to speak Naomi Osaka Simone deals would not have speak to culture had not changed not to give them permission to speak. So I was actually delighted when Naomi Osaka and Simone bill spoke up because it meant that we've moved so far forward that they had permission to speak and they were actually honored for their bravery. And so that is a big move forward still disappointed that we didn't support enough that they had to be to the point where they spoke up. But nonetheless, step forward. Yeah, that's what that's what put. There's so much to talk about. I wanted to ask you. So basically now, maybe toggling back and forth between the the YAHG, Losan 2020 original research you published and then my mention of the FINA World Championships 2019 publication. If I said to you, can you tell us a little bit about some of the data that exists demonstrating the problems that exist in sport, you know, more or less what's the current scope of the problem. Let me teed up by saying when I was reading, I think it was the winter, youth Olympic games in your at least in one section probably your introduction you gave sort of a, you know, this is the scope of the problem. I mean, one thing that stood out is ranging from a Canadian study looking at reported sexual abuse in under 16 to 2% of athletes. 9% reported that and all the way to like an Australian study looking at reported sexual abuse in 18 or younger 9.7% approaching 10%. I mean, this is sexual abuse at I mean age under 18, you know, under obviously under age of consent like, oh my God, that's just one of the dimensions. But like that, those numbers stuck out to me. Like an Australia one study is like as many as one in 10. So what like there's so many dimensions you've talked about abuse, harassment, neglect, abuse, sexual abuse, I don't know where you'd want to separate, I said, what's the scope of the process? Well, and thanks, thanks for that question. It's really important, I think that the listeners to this podcast understand the breadth of what we're talking about. You're right, the Canadian study done quite a while ago, 1997 showed the about 2%, the Australian study which is 2012, showed sexual abuse about 10%. Now, there's a larger UK study of youth athletes that showed 3% sexual harm and about 24% physical harm. So this is a 2011 study and 75% emotional harm, so psychological distress. So that's pretty significant. There's some other studies done in Europe a little more recently through Belgium and through Netherlands that showed a 44% had experienced at least one form of harassment abuse while in sport and broken that down into about 10% physical, 33% psychological and about 15% sexual abuse before the age of 18. Now, this is a 2016 study. So these are about single countries pretty much and there's some single sport literature out there in world athletics. But the under 20 championships, 18% of males and 15% of females recorded sexual abuse and about 23% verbal abuse and 12% physical abuse. So these are large numbers. If you've got a team of 20 athletes, you may have a few that have had some significant problems. If you look at the winter yogge paper that was recently published in the CGSM, we asked the athletes when we explained what is harassment abuse in sport. Did they think it occurred in their sport? And 32% of our winter yogg athletes, so these are athletes from multi sports and from around the world. So a little different population than the other studies I've mentioned. 32% that harassed me, abuse either occurred or was very likely to have occurred in their sport. 26% weren't sure and the rest said no. So that is an interesting number. And if I did compare that in the papers of the 2018 summer yogge, we did the similar methodology in the summer athletes in Buenos Aires 2018. Similar numbers, 34% it was said that harassment abuse was likely or very likely to have occurred in their sport. So I think this is a wake up call for sport medicine. We got to be paying attention to this. I'm hearing numbers as big as one in three units. One of the things I want to ask you, and it's a little bit of a tangent on just the scope, but you touched on so many different sports and so many different organizations. You yourself are involved in several organizations. I think high level, even in influence decisions. It ranges from the IOC to your previous association with FINA. But can you enumerate all the different international organizations you're involved with, you're bringing attention to these problems to several stakeholders? Well, thanks. Yeah, I have my, I am quite busy. And my hands are full. So I'm on the IOC Medical Commission Games Group, which is an actual career thrill for me to be involved in that aspect. With the IOC, I also am a member of their expert working group on harassment and abuse and sport, as well as their working group on mental health. So that's really a very thrilling for me to be able to influence activity of the IOC for athletes and for coaches and for physicians. In addition, I work for the World Antidoping Association and A SWAT. I chair A SWAT. And that is the Association of Summer Olympic International Federation. So all the different Olympic sports have an international federation that runs them. And they have a medical committee, most of them. And I chair all of the medical committees together. I worked for 21 years as FINA, chair of their medical commission. And now I'm working with FIFA in their scientific advisory board. So that's football slash soccer. And I also work for World Rugby on their anti-doping advisory committee. And I am a member of the International Golf Federation as well. That's amazing. How do you do it? How do you do? It's a labor of love. And it's certainly an exciting thrill for me to be involved in these sports. And to be able to influence policy procedures, education, rural changes, and to be present at these events and watch these athletes perform. Well, one thing I wanted to ask you about is, you know, again, this notion of safe sport, this term that comes up in a couple of your papers. What is it specifically? And I don't know if we've talked about it yet, but where do the initiative originate? How is it currently structured or employed? Can you comment on safe sport? The safe sport, the term originated in the paper that I published in 2016 for the British Journal of Sport Medicine. And that's the IOC consensus statement on harassment abuse in sport or non-accidental violence, harassment abuse. And the safe sport is defined as being an athletic environment that is respectful, equitable, and free from all forms of harassment and abuse to athletes. So it's a fairly simple statement. Basically, we want an environment that we want in all of our aspects of life that's respectful, equitable, and free from harassment and abuse. It's currently realized through education of all stakeholders. It's meant to help encourage research. It's also meant to be positive. People want to have safe sport. It's a positive thing to attain as opposed to the term harassment abuse for some people is a dirty word. It's a negative thing. It has negative connotations. And it's hard for many people to speak up. So by calling it safe sport that we can empower people to achieve safe sport, I find it helps to empower action a lot more effectively than maybe the stick that can't stick. So the thing we can aspire to and to work towards that's positive. I like that. That makes sense to me. It's almost like you're defining this is the way it should be asking the athlete, do you feel you're there? And if they're like, no, I'm not, that may be, I don't know, easier, but a way it can be, one could become aware. I don't feel like I'm in that safe sport environment. As opposed to as you say, defining it by the basement, are you being harassed? Are you being abused? Those kind of things. People may say, no, I can't believe this has happened to me. No, I'm not. But you could go, this is what it's supposed to be. It's like, man, I'm not there. That's not happening. It's with me right now. You did a good, in the editorial, just for the listeners, and I encourage you again to go to the original papers themselves. But you quote an anonymous athlete in the Youth Olympic Games in 2020, which again just summarized what you're saying. Safe sport is creating an environmental aisle athletes to complete and train at their best without worrying about harassment and abuse. I mean, you can't get any sort of clearer than that. We should all be on board for that. Yeah, I was delighted when I saw that quote, because we asked athletes in that study, the Winter Yacht study, how would they define the term safe sport? Only 10% actually knew that safe sport was free from harassment and abuse. Now, I think that more know what it is, because when we asked other things, about 30% of the athletes were able to define harassment and abuse. But when we asked them to define safe sport, only 10% said free from harassment abuse. Much more spoke about freedom from injury, freedom from anti-doping issues. Safe environments in terms of heat or cold. But only 10% were able to define the term safe sport. That's a little bit the premise of my editorial, because if our athletes aren't understanding the terminology we're using, then we need to rethink the terminology we're using or how we come up with terminology. That's cool. Hey, so I have a couple more questions I want to get to and I want to be mindful of your time. I don't know if you have any space for something you want to make sure the listeners listen to or hear. But I want to ask really quickly, are there some specific athlete populations that are at higher risk for these issues, neglect, harassment and abuse than others? Definitely, the literature does show us there are more vulnerable groups of athletes, which have higher reported levels of abuse in sport. And one is the youth or child athlete and they have lower their power within sport system is less because of their age. Also elite athletes are at higher risk of harassment. abuse and I think that's because there's more at stake and they're more entrenched within that culture. Also the paraathlete, the disabled athlete, is at higher risk because of the need for more physical contact perhaps but also because of discriminations outside of sport against disabled athletes. And finally the LGBTQ, there's a nice study by Denison Cook that shows quite clearly that any athlete that identifies as LGBTQ is at greater vulnerability for harassment and abuse in sport. And this is disturbing because we know the impact that happened to athletes as a result of harassment abuse. In some cases can be quite devastating and long-lasting. And Adults studied that have had a history as a child of harassment abuse report a lower quality of life. So we really need to be cognizant of all athletes that have been victims of harassment abuse or survivors, however you want to term it. But in particularly these more vulnerable populations. Well put, my last question for you is we have a lot of listeners to this podcast. They're not all specifically sports medicine clinicians but you are, I am, by the way, I'm also family medicine trained originally. I hear what you're saying all the way here. But if I asked what specifically is the role that we can play moving forward in prevention of harassment and abuse in athletes. I mean we submitted even going back what would the 2022 Dr. Mountjoy do in that setting when the person is punched in the face in 1994? I would have been very different. I would have been very vocal for sure. So there's many things that the sport medicine clinician could be that the physician, physiotherapist, teen nutritionist, dietitian can do. And I think I like to break it down into primary prevention and secondary prevention. And with primary prevention we know we have a role in primary prevention to protect athlete health through education, educating athletes and coaches and sport leaders. Advocacy work, making sure that our sport organization that we're involved with has policies and procedures for safeguarding and reporting mechanisms. And sure that I have as a clinician working with athletes, all of the team have trauma informed skills to know how to recognize trauma in individuals. And I don't mean physical trauma. I mean mental trauma, harassment and abuse to be able to manage the cases when an athlete identifies the things that are in trouble because they're not going to book an appointment for you on Tuesday at two o'clock to say I want to report her as an abuse. That doesn't go into happen because of the stigma and society. So how do you recognize it? How do you give them permission to disclose how do you manage a disclosure? And then how do you support an athlete? What's your clinical approach to this? So there is literature on this. It's published that I've published in this area and we have a role and it should be embedded in all training of fellows in sport medicine and in all health professions that work with athletes. This should be one of their skills. We know how to check the ACL. We know how to check the shoulder for laxity. We should know how to recognize an athlete who's being abused. We know how to handle a disclosure and how to support them, their teammates and their family who are all affected by this. So that's the secondary prevention point. That's the early detection. That's the early intervention. That's being able to manage a disclosure and support and treat that athlete appropriately, mentally and physically and their teammates. So we have a big role to play. In addition to sport leaders and sport legal individuals, but as clinicians it is a health issue. This issue has impact on athletes' health, physical health and mental health. We have literature to show that athletes who have been harassed and abused have higher rates of injury. Athletes that have been harassed and abused have higher rates of mental health problems. That's in the phenopaper that I've published in November that has correlates of athletes with reported harassment abuse, had higher injury rates and also had higher mental health problems with depression and eating disorders. So that is our responsibility as team physicians and health professionals that we look after prevention injuries by actually making sure that there's no history of harassment abuse. And if we see an athlete with mental health problems, asking them if they've had a history of harassment abuse and giving them permission, that if they ever have such problems that they can come and talk to me on a safe person. So I hope I've encouraged everyone listening today that work with athletes, that if they don't have these skills to please get them and that they have a role, very important role to play in this aspect of their athletes' health and well-being. You definitely have inspired me, that's for sure. Well thank you, as ever, for all the work you do, not just the primary research and the teaching, but your advocacy and activism at the highest levels. I think your influence is tremendous and I really appreciate your time joining us on the podcast today, Dr. Muncher. My pleasure, thank you for the invitation and thank you to all your listeners who hopefully will go out and out after listening today. The links to the papers we discussed will be in the blog postliner notes for the podcast. Go to cjsnblog.com for the blog and cjsportmed.com for the papers themselves. Any way you engage with us on cjsportmed, we hope you join us again real soon. you