Schmidt Ralph E.1,2,*, Schneeberger Andres R.2,3, Claussen Malte C.2,4
1 Department of Psychology, University of Geneva, Switzerland
2 Psychiatric University Hospital Zurich, Department of Psychiatry, Psychotherapy, and Psychosomatics, University of Zurich, Switzerland
3 Department of Psychiatry, University of California San Diego, USA
4 Clinic for Depression and Anxiety, Psychiatric Centre Muensingen, Muensingen, Switzerland
Abstract
The “Magglingen protocols” and other cases of abuse in sports have attracted public attention to the problem of interpersonal violence against athletes. This article summarizes the scientific literature on the prevalence of different forms of interpersonal violence in sports, on personal, organizational, and cultural risk factors for victimization, and on psychopathological consequences of athlete abuse. In conclusion, recommendations for trauma-informed interdisciplinary prevention and intervention programs are outlined.
Zusammenfassung
Die «Magglingen-Protokolle» und andere Fälle von Missbrauch im Sport haben die öffentliche Aufmerksamkeit auf das Problem der zwischenmenschlichen Gewalt gegen Sportler gelenkt. Dieser Artikel fasst die wissenschaftliche Literatur zur Prävalenz verschiedener Formen zwischenmenschlicher Gewalt im Sport, zu persönlichen, organisatorischen und kulturellen Risikofaktoren für Viktimisierung und zu den psychopathologischen Folgen von Missbrauch bei Sportlern zusammen. Abschliessend werden Empfehlungen für traumainformierte interdisziplinäre Präventions- und Interventionsprogramme skizziert.
Schlüsselwörter: Missbrauch, zwischenmenschliche Gewalt, posttraumatische Belastungsstörung, Sport, trauma-Informierte Pflege
Introduction
In 2020, the so-called “Magglingen protocols” – testimonials of eight female artistic and rhythmic gymnasts – attracted widespread attention to different forms of harassment and violence athletes are often faced with behind the shiny façades of elite sports [1]. Ever since, more instances of athlete abuse have been brought to public awareness in Switzerland, for example by 33 former students of the “Ballettschule Theater Basel” [2]. Despite such scandals that spurred public debate, current data suggest that interpersonal violence against athletes is far from declining: For instance, Swiss Sport Integrity received 264 hints at possible violations of ethical standards in 2022 and this number might rise to up to 400 in the present year [3].
In this article, we provide a summary of the scientific literature on three aspects of this topic:
a) the prevalence of different forms of interpersonal violence in sports;
b) personal, organizational and cultural risk factors for interpersonal violence in sports;
c) psychopathological and somatic consequences of interpersonal violence in sports.
In conclusion, recommendations for interdisciplinary prevention and intervention programs are provided.
Prevalence of Different Forms of Interpersonal Violence in Sports
In line with research into adverse childhood experiences, the following forms of interpersonal violence against athletes may be distinguished: sexual abuse, physical abuse, psychological abuse, and neglect [4]. Physical abuse supposes physical contact with an athlete in the context of sports and comprises behaviors such as shaking, pushing, punching, hitting, choking, strangling, burning, or stabbing [5]. Psychological abuse includes behaviors such as insulting, humiliating, ridiculing, rejecting, excluding, isolating, threatening to leave an athlete or threatening to hurt someone or something he/she likes, pressuring an athlete to train while injured, pressuring an athlete to engage in unhealthy eating behaviors to achieve an ideal weight, or pressuring an athlete to consume doping products [5]. Neglect may concern physical or psychological needs and is of particular importance for young athletes because coaches and other staff members often fulfill parental functions when taking care of them, especially during outdoor training or tournaments and competitions abroad [5,6]. Physical neglect refers to a failure to supervise an athlete leading to physical problems or injuries; medical neglect refers to a failure to provide an athlete with necessary medical care; emotional neglect refers to a failure to supervise an athlete, thereby increasing the risk of psychological, physical or sexual abuse, and includes abandonment of an athlete during a training or a trip; and educational neglect refers to a failure to adequately support the school or professional career of the athlete [5].
Three quantitative studies involving large samples have as yet provided data on the prevalence of psychological, physical and sexual violence against athletes committed by peer athletes, coaches or other staff members. In a study conducted in the UK, more than 6,000 young athletes were asked about their experiences in organized sports before the age of 16 [7]. 75% of the respondents reported incidents of emotional abuse, 24% physical abuse, 29% sexual harassment, and 3% sexual harm. In a study conducted in Belgium and the Netherlands, more than 4’000 adults were asked about their experiences in youth sports [8]. 44% of the respondents had experienced at least one form of abuse, with 38% reporting incidents of psychological violence, 11% physical violence, and 14% sexual violence. In a recent study conducted in the Netherlands, Belgium (Flanders), and Germany, 1’665 elite athletes were asked about their experiences in organized sports [9]. Their replies suggest a lifetime prevalence of 71.9% for psychological abuse, 24.8% for physical abuse, and 30.6% for sexual abuse. 13% of the respondents experienced all three types of interpersonal violence. Of note, these prevalence rates for athletes are higher than those found in representative population samples, especially the prevalence rate for psychological violence [9]. For instance, a recent survey in Germany yielded prevalence estimates of 20% for psychological abuse in childhood, 13% for physical abuse, and 14% for sexual abuse [10]. Taken together, these findings suggest that the context of competitive sports is particularly conducive to interpersonal violence.
Risk Factors for Interpersonal Violence in Sports
Regarding risk factors for athlete abuse, two complementary lines of research may be distinguished: One that aims to identify the factors that increase the risk of being exposed to interpersonal violence (victim-focused approach), and another one that aims to identify the factors that increase the risk of committing interpersonal violence against athletes (perpetrator-focused approach). Table 1 summarizes the risk factors of being exposed to interpersonal violence (victim-focused approach).
Within the victim-focused approach, research on personal risk factors indicates that gender plays a role: Male athletes run a higher risk of experiencing physical violence, whereas female athletes seem to be more at risk of experiencing sexual violence [8,9]. However, some authors pointed out that it might be taboo for male victims to disclose sexual violence in strongly gendered settings such as sports, which could result in underreporting of such incidents [11-14]. In support of this interpretation, a survey among 480 athletes who participated at the World Athletics under 20 World Championships found a higher prevalence of sexual abuse in men (12%) when compared to women (7%) [15].
Apart from gender, belonging to a minority group also represents a personal risk factor for being victimized in sports. For instance, a survey of 4,043 adults who had participated in organized sports before the age of 18 found significantly higher prevalence rates of physical and sexual violence among respondents who belonged to ethnic minorities or who were lesbian/gay/bisexual (LGB) [8]. In the same survey, comparably higher prevalence rates for physical, sexual and psychological violence were also found among respondents with physical or mental disabilities (“para athletes”) [16].
Another personal risk factor relates to the level of competition. For instance, one study found that respondents who had competed at an international level before the age of 18 reported a significantly higher prevalence of psychological, physical and sexual violence as compared with those who had engaged in sports as recreational activity [8]. This finding is in accord with previous studies on emotional and sexual abuse in sports [17-19]. Given that elite athletes spend more time with coaches and other staff members in training centers and at competitions far away from home, family and friends, it has been suggested these contextual factors increase the risk of being exposed to abusive behavior [20].
As to organizational-institutional risk factors, accumulating evidence suggests that several aspects of athletes’ environment can play a role: The spatial, organizational and communicative isolation of certain institutions (e.g., training centers) [12,20]; power imbalance, especially between coaches, other staff members and athletes [21,22]; the suspension of common social rules, often legitimized by the search for peak performance [23,24], and, in a similar vein, the normalization of abusive behavior [25,26]; and a widespread culture of silence [27]. Another important organizational-institutional factor that facilitates abuse is the lack of easily accessible reporting procedures and the lack of violence- and trauma-specific training of healthcare professionals that leads to overlooking and underreporting actual cases of abuse [27].
Regarding cultural risk factors, emerging evidence suggests that the larger cultural context in which sport-related structures and activities are embedded may play a role in facilitating interpersonal violence against athletes. For instance, one of the rare international studies on the prevalence of abuse in sports found that German athletes were more at risk of interpersonal violence than were their Dutch and Flemish counterparts, except for severe sexual violence [9]. However, these findings need to be interpreted with caution because methodological differences between the questionnaire studies (e.g., age of participants; timeframe of abuse) in the three mentioned cultural regions could at least partly account for the observed disparities in prevalence. Nevertheless, cultural differences in the prevalence of different forms of interpersonal violence may exist in the general population: For instance, surveys suggested higher levels of psychological, physical and sexual abuse in Germany when compared with the Netherlands [29,30]. Clearly, more comparative international research is warranted to gauge the impact of socio-economic, cultural, and religious factors. Comprehensive and detailed knowledge about these factors may inform the development of prevention and intervention programs that are tailored to regional habits and norms (e.g., educational practices in cultures with individualistic vs. collectivistic value orientation) [15].
Research within the perpetrator-focused approach seeks to determine who (e.g., coaches, teammates, staff members or other stakeholders) is most likely to behave in abusive ways against athletes and which factors increase the risk of such behavior. A pioneering study analyzed retrospective accounts of 1,785 adults in Belgium and the Netherlands on the experience of psychological, physical or sexual violence in sports before the age of 18 [31]. The main findings of this study were as follows: (i) The majority of respondents who had experienced psychological, physical or sexual violence reported more than one perpetrator (from 54% for physical violence to 70% for psychological violence); (ii) the majority of perpetrators were male (from 51% for psychological to 76% for sexual violence), with the exception of psychological violence directed against female athletes where the most common perpetrator profile was “several female athletes”; (iii) for all three types of interpersonal violence, the perpetrators were mainly peer athletes; (iv) for all types of interpersonal violence, the severity of the reported incidents was rated as higher when more than one perpetrator was involved; and (v) while sexual violence was most frequently committed by “known others” (excluding coaches and peer athletes) within the sports organization, it was more severe if a coach was mentioned as a perpetrator. Additional perpetrator-focused research is clearly needed, for example in-depth investigations into personality traits, offending strategies, and group dynamics [31].
In a systemic perspective that integrates personal, organizational-institutional, and cultural risk factors, particular attention should be given to conditions that create and maintain a culture of silence, which seems to be a central risk factor for sexual violence. There are several obstacles for disclosure of sexual violence, particularly for children, for example insecurity in the appraisal of what happened, feelings of guilt and shame, as well as fear of consequences for the sports career [20]. Systematic information of stakeholders (e.g., athletes, parents, coaching staff, board members) and creation of reporting and counselling opportunities in athletes’ environment are essential steps for “smashing the wall of silence” [5]. Outside of sports, a recent review of recipients of disclosure of childhood sexual abuse revealed that older children and adolescents preferentially turn to peers, keeping abuse largely hidden from adults [32]. If this finding also applies to child and adolescent athletes, prevention efforts should include those whom they trust the most.
Psychopathological Consequences
The consequences of interpersonal violence in the context of sports can be extremely devastating and comprise effects that vary widely in form, expression, and severity. Emotional, physical, and sexual abuse of athletes, especially in childhood or adolescence, is very likely to result in profound and long-lasting sequelae on both physical and mental health [33].
Numerous studies conducted in the general population have demonstrated that exposure to traumatic experiences markedly increases the risk for developing a variety of somatic illnesses, including diabetes, hypertension, cardiovascular disorders, chronic pain conditions, and autoimmune diseases. Regarding psychopathological consequences, single episodic traumatic events typically lead to acute stress disorders or post-traumatic stress disorders marked by symptoms of intrusion, avoidance, negative alterations in cognitions and mood, hyperarousal, and reactivity issues. In contrast, chronic, repetitive, and complex traumatic experiences, especially those originating in childhood, more frequently result in psychiatric outcomes such as complex post-traumatic stress disorder, dissociative disorders, somatoform disorders, eating disorders, substance use disorders, depression, self-harm, suicidal behaviors, personality disorders, psychotic disorders, and attachment disorders [34].
Despite a vast body of evidence indicating that the mental health consequences of interpersonal violence in sports can be extremely severe, there remains a surprising lack of empirical studies focused on elucidating trauma-related psychiatric morbidity specifically in athlete populations [35]. Many athletes first experience significant psychological trauma during childhood, adolescence, or early adulthood, which entails substantially elevated risks for chronic mental health issues across the lifespan [36]. Trauma frequently leads to a disruption of impulse control and emotion regulation capacities, which can in turn lead to increases in risky, self-destructive behaviors, and further trauma exposure through activities like substance abuse, interpersonal violence, and risky sports practices. Furthermore, trauma augments risks for sustaining physical injuries like concussions or orthopedic injuries through impacts on motor coordination, spatial awareness, reaction times, and cognitive processing [37]. Athletes who have experienced repetitive psychological traumatization over their athletic careers typically demonstrate patterns of performance decline, burnout, involuntary early retirement from sports, and long-standing struggles with the previously mentioned psychopathological conditions and somatic complaints [38].
Of note, traumatized athletes frequently exhibit “masked” presentations of psychiatric distress characterized by prominent symptoms of somatization, avoidance, and dissociation. Physical injuries that appear puzzlingly treatment-resistant and are often attributed to the overtraining syndrome may in fact reflect somatic manifestations and biomarkers of underlying psychological trauma [39]. The phenomenon of dissociation as a psychological defense mechanism is particularly prevalent among traumatized athletes given its potential adaptive value for improving performance under conditions of extreme stress [40]. However, dissociation may also reach pathological levels and likely contributes to substance abuse and doping.
Conclusion
In sum, the current scientific literature suggests that the different forms of interpersonal violence are more frequent among elite athletes than in the general population. Psychological maltreatment represents the most prevalent form of abuse, followed by physical maltreatment and sexual abuse. A complex constellation of risk factors at the personal, organizational, and cultural levels conspire to produce the high rates of interpersonal violence observed in sports settings. At the personal level, minority status based on ethnicity, sexual orientation, or disability appears to increase risk, as does participation at elite competitive levels. Organizational dynamics such as isolation, imbalanced power structures, tacit normalization of abusive behaviors, a culture of silence, and a lack of effective reporting channels enable abuse patterns to develop and persist. Though more research is needed, cultural influences related to societal norms and attitudes also likely contribute risk in some contexts.
The psychological toll inflicted by emotional, physical, and sexual abuse can be extremely severe for athlete victims. Myriad psychiatric outcomes have been linked to trauma exposure in sports, including somatic disorders, (complex) post-traumatic stress, depression, anxiety, eating disorders, self-harm behaviors, and substance abuse. Abuse frequently impairs athletic performance, motivates early retirement, diminishes self-esteem, and triggers dissociative tendencies. Traumatized athletes often cope through avoidance and somatization, masking underlying distress. By disrupting impulse control and heightening risky behaviors, athletic trauma also increases susceptibility to further injuries and re-victimization.
The initially mentioned ”Magglingen protocols” [1], subsequent media coverage of other cases of interpersonal violence in sports, and data published by the Ethics Office of Swiss Sports Integrity highlight the prevalence of athlete abuse in Switzerland and the need for the development of research, prevention and intervention programs. The multilinguistic structure of Switzerland calls for a culture-sensitive approach including all regions of the country, thereby potentially providing new insights into the role of cultural contexts in the occurrence of interpersonal violence. Of particular interest would be longitudinal studies that allow to monitor the prevalence of interpersonal violence, associated risk and resilience factors, as well as psychopathological consequences of victimization beyond the end of sports careers.
Only comprehensive and detailed scientific knowledge will us allow to develop effective prevention and intervention programs that target risk and resilience factors, screen for psychopathological consequences, and provide competent and adapted care. Important steps have recently been taken in this direction in Switzerland, including the creation of a reporting centre under the umbrella of Swiss Sports Integrity, the initiative Health4Sport [41] of the specialist societies for sports medicine, sports psychology, physiotherapy, and sports nutrition in Switzerland, or the program on Safeguarding and Sport presented at this year’s Sport & Exercise Medicine Switzerland (SEMS) Congress. Further efforts and initiatives that build on and expand these recent positive developments are clearly needed.
In view of the serious medical and psychopathological consequences of interpersonal violence, especially if it occurs in the sensitive developmental stages of childhood and adolescence, early detection and diagnosis are of paramount importance and concrete proposals for corresponding screening procedures have recently been made [42]. Competent detection, diagnosis, and treatment of violence-related psychopathology require clinical expertise beyond standard training in psychiatry or psychotherapy that must include training in psychotraumatology.
Trauma-specific expertise should be evidence-based and trauma-specific interventions should be guideline-compliant. Trauma-informed prevention and intervention programs are best provided within an interdisciplinary network including psychiatrists, psychologists, physicians, physiotherapists, coaches, and other staff members. To smash the previously mentioned wall of silence that typically surrounds athlete abuse, the prevention and intervention network should ideally also include athletes’ confidants: peers, parents, other family members or friends.
Practice points
- • Interpersonal violence is more prevalent in competitive sports than in the general population
- Risk factors include female gender, sexual orientation, minority status, institutionalized culture of silence, and lack of reporting procedures
- Violence-related consequences include (complex) post-traumatic stress disorder, dissociation, depression, anxiety disorders, eating disorders, substance abuse, and somatic disorders
- Early screening and intervention within an interdisciplinary network of trauma-informed care is of paramount importance to safeguard athletes’ health
Correspondence
Ralph E. Schmidt, PhD
Adjunct Professor
Psychiatric University Hospital Zurich
Lenggstrasse 31
CH-8032 Zurich
Switzerland
ralph.schmidt@pukzh.ch
References
1. Gertsch C, Krogerus M. Die Magglingen-Protokolle. Im Kunstturnen und in der rhythmischen Gymnastik gehören Einschüchterungen, Erniedrigungen und Misshandlungen zum Alltag. Acht Frauen erzählen. Das Magazin. 2020;44:8-43.
2. Gregoris N, Batthyany S., Kardos A. Und alle schauen weg. Schülerinnen der Ballettschule Theater Basel berichten von jahrelangem Missbrauch. Die Behörden unternahmen wenig. Wie kann das sein? NZZ am Sonntag. 2022;43:75-7.
3. Bräuer S. Magglingen: Debakel ohne Ende. NZZ am Sonntag. 2023;41:38-9.
4. Schmidt RE, Schneeberger AR, Claussen MC. Interpersonal violence against athletes: What we know, what we need to know, and what we should do. Sports Psychiatry. 2022;1:78-84. doi: 10.1024/2674-0052/a000014
5. Fortier K, Parent S, Lessard G. Child maltreatment in sport: Smashing the wall of silence: A narrative review of physical, sexual, psychological abuses and neglect. Br J Sports Med. 2020;54: 4–7. doi: 10.1136/bjsports-2018-100224
6. Stirling AE. Definition and constituents of maltreatment in sport: Establishing a conceptual framework for research practitioners. Br J Sports Med. 2009;43:1091–99. doi: 10.1136/bjsm.2008.051433
7. Alexander K, Stafford A, Lewis R. The experiences of children participating in organised sport in the UK. London: NSPCC;2011.
8. Vertommen T, Schipper-van Veldhoven N, Wouters K, Kampen JK, Brackenridge CH, Rhind DJ, et al. Interpersonal violence against children in sport in the Netherlands and Belgium. Child Abuse Negl. 2016;51:223–36. doi: 10.1016/j.chiabu.2015.10.00
9. Ohlert J, Vertommen T, Rulofs B, Rau T, Allroggen. Elite athletes’ experiences of interpersonal violence in organized sport in Germany, the Netherlands, and Belgium. Eur J Sport Sci. 2021;21(4):604-13. doi: 10.1080/17461391.2020.1781266
10. Witt A, Rassenhofer M, Allroggen M, Brähler E, Plener PL, Fegert JM. (2018). The prevalence of sexual abuse in institutions: Results from a representative population-based sample in Germany. Sex Abuse. 2018;31;643-61. doi: 10.1177/107906321875932
11. Hartill M. Sport and the sexually abused male child. Sport Educ Soc. 2005;10:287-304. doi: 10.1080/13573320500254869
12. Hartill M. The sexual abuse of boys in organized male sports. Men Masc. 2009;12:225-49. doi: 10.1177/1097184X07313361
13. Parent S, Bannon J. Sexual abuse in sport: What about boys? Child Youth Serv Rev. 2012;34(2):354–359. doi: 10.1016/j.childyouth. 2011.11.004
14. Vertommen T, Schipper-van Veldhoven NH, Hartill MJ, Van Den Eede F. Sexual harassment and abuse in sport: The NOC*NSF helpline. Int Rev Sociol Sport. 2015;50:822-39. doi: 10.1177/1012690213498079
15. Bermon S, Adami PE, Dahlström Ö, Fagher K, Hautala J, Ek A, Anderson C, et al. Lifetime prevalence of verbal, physical, and sexual abuses in young elite athletics athletes. Front Sports Act Living. 2021;3:657-624. doi: 10.3389/fspor.2021.657624
16. Tuakli-Wosornu YA, Sun Q, Gentry M, Ona Ayala KE, Doolan FC, Ottesen TD, et al. Non-accidental harms (‘abuse’) in athletes with impairment (‘para athletes’): A state-of-the-art review. Br J Sports Med. 2020;54:129–38. doi: 10.1136/bjsports-2018-099854
17. Gervis M, Dunn N. The emotional abuse of elite child athletes by their coaches. Child Abuse Rev. 2004;13:215-23. doi: 10.1002/car.843
18. Leahy T, Pretty G, Tenenbaum G. (2002). Prevalence of sexual abuse in organized competitive sport in Australia. J Sex Aggress. 2002;8:16-36. doi: 10.1080/13552600208413337
19. Stirling AE, Kerr GA. Elite female swimmers’ experience of emotional abuse across time. J Emot Abuse. 2007;7:89-113. doi:10.1300/J135v7n04_0589
20. Bjørnseth I, Szabo A. Sexual violence against children in sports and exercise: A systematic literature review. J Child Sex Abus. 2018;27(4):365–385. doi:10.1080/10538712.2018.1477222
21. Mountjoy M, Brackenridge C, Arrington M, Blauwet C, Carska-Sheppard A, Fasting, K, et al. International Olympic Committee consensus statement: Harassment and abuse (non-accidental violence) in sport. Br J Sports Med. 2016;50:1019–29. doi: 10.1136/bjsports-2016-096121
22. Tuakli-Wosornu YA. Infographic: A guide to understanding athlete abuse. Br J Sports Med. 2021;55:1439–40. doi: 10.1136/bjsports-2021- 104194
23. East J. The causes of violence in sport: Who is to blame? In: Brackenridge C, Kay T, Rhind D, editors. Sport, children’s rights and violence prevention: A sourcebook on global issues and local programs. London: Brunel University Press; 2012. p. 18-24.
24. Tschan W. Professional sexual misconduct in institutions: Causes and consequences, prevention and intervention. Boston, MA: Hogrefe Publishing; 2013.
25. Hlavka HR. Normalizing sexual violence: Young women account for harassment and abuse. Gend Soc. 2014;28:337-58. doi: 10.1177/ 0891243214526468
26. Parent S, Fortier K. Comprehensive overview of the problem of violence against athletes in sport. J Sport Soc Issues. 2018;42:227–46. doi: 10.177/0193723518759448
27. Jeckell AS, Copenhaver EA, Diamond AB. The spectrum of hazing and peer sexual abuse in sports: A current perspective. Sports Health. 2018;10:558-64. doi: 10.1177/1941738118797322
28. Gubbels J, Assink M, Prinzie P, van der Put CE. Why healthcare and education professionals underreport suspicions of child abuse: A qualitative study. Soc Sci. 2021;10(98):1-21. doi: 10.3390/socsci10030098
29. Witt A, Rassenhofer M, Allroggen M, Brähler E, Plener PL, Fegert JM. (2018). The prevalence of sexual abuse in institutions: Results from a representative population-based sample in Germany. Sex Abuse. 2018;31;643-61. doi: 10.1177/107906321875932
30. Schellingerhout R, Ramakers C. Scholierenonderzoek Kindermishandeling 2016 [School study Child Maltreatment 2016]. Nijmegen: Radboud Universiteit; 2017. Available from: https://www.wodc.nl/binaries/2668B_Volledige_Tekst_tcm28-257873.pdf
31. Vertommen T, Schipper-van Veldhoven N, Wouters K, Kampen JK, Brackenridge CH, Rhind DJ, et al. Interpersonal violence against children in sport in the Netherlands and Belgium. Child Abuse Negl. 2016;51:223–36. doi: 10.1016/j.chiabu.2015.10.00
32. Manay N, Collin-Vézina D. Recipients of children’s and adolescents’ disclosure of childhood sexual abuse: A systematic review. Child Abuse Negl. 2021;116(1):104192, 1-20. doi: 10.1016/j.chiabu.2019. 104192
33. Santiago PN, Ursano RJ, Gray CL, Pynoos RS, Spiegel D, Lewis-Fernandez R, et al. A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: Intentional and non-intentional traumatic events. PloS One. 2013;8(4):e59236. doi: 10.1371/journal.pone.0059236
34. Petruccelli K, Davis J, Berman T. Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis. Child Abuse Negl. 2019;97:104127. doi: 10.1016/j.chiabu.2019.104127
35. Rice SM, Purcell R, De Silva S, Mawren D, McGorry PD, Parker AG. The mental health of elite athletes: A narrative systematic review. Sports Med. 2016;46(9):1333-53. doi: 10.1007/s40279-016-0492-2
36. Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, et al. Mental health in elite athletes: International Olympic Committee consensus statement. Br J Sports Med. 2019;53(11):667-99. doi: 10.1136/bjsports-2019-100715
37. Aron CM, Harvey S, Hainline B, Hitchcock ME, Reardon CL. Post-traumatic stress disorder (PTSD) and other trauma-related mental disorders in elite athletes: A narrative review. Br J Sports Med. 2019;53(12):779-84. Doi : 10.1136/bjsports-2019-100695
38. Wilinsky CL, McCabe A. (2021). A review of emotional and sexual abuse of elite child athletes by their coaches. Sports Coach Rev. 2021;10:84-109. doi: 10.1080/21640629.2020.1775378
39. Jackson DB, Posick C, Vaughn MG, Testa A. Adverse childhood experiences and traumatic brain injury among adolescents: findings from the 2016–2018 National Survey of Children’s Health. Eur Child Adolesc Psy. 2021;31:289-97. doi: 10.1007/s00787-020-01687-1
40. Schmidt RE, Schneeberger AR, Claussen MC. Four reasons why we should screen for dissociation in competitive sports. Sports Psychiatry. 2023;2:37-41. doi : 10.1024/2674-0052/a000040
41. Gojanovic B, Albertin K, Bizzini M, Clenin G, Flück JL, Mathieu N, et al. Health4Sport – 13 safeguarding principles so that young athletes can thrive in multidisciplinary sporting environments. Br J Sports Med;2021;55:952-53. doi: 10.1136/bjsports-2021-104699
42. Gonzalez Hofmann C, Wyssen A, Schorb A, Allroggen M, Dallmann P, Schmidt RE. Sports psychiatric examination in competitive sports. Ger J Sport Med. 2021;72:307-15. doi: 10.5960/dzsm.2021.502
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