What the Athletic Trainer Should Know About Sexual Abuse/Assault Signs, Symptoms, and the Duty to Report
The National Athletic Trainers’ Association (NATA) Code of Ethics consists of principles, which guide our members’ conduct on issues such as equitable treatment, regulatory compliance, positive representation of the athletic training profession, ethical conduct including appropriate relationships, and patient safety and advocacy.1 The athletic trainer’s primary responsibility is to the patient.
If at any time an athletic trainer (AT) suspects that an inappropriate behavior such as sexual abuse is occurring to a patient, it is the duty of the AT to report the perceived actions to the proper authorities. Failure to report any suspicion of sexual abuse to the proper authorities generally will be considered to be a NATA Code of Ethics violation and may also constitute a violation of state and/or federal laws, both of which have serious implications on one’s athletic training certification and regulatory status.
Like all health care professionals, ATs enter into a social contract with the public to assure them that they will provide trustworthy patient-centered care. The AT upholds the social contract by adhering to the standards of professional practice, including the NATA Code of Ethics, and engaging in evidence-based practice and continuous education. As such, the highest priority is the patient and quality care, which includes the recognition of the signs and symptoms of sexual abuse and awareness of our legal obligations.
Awareness of Sexual Abuse of Children and Youths
Federal and state laws on child maltreatment establish acts or behaviors that define child abuse. The Federal Child Abuse Prevention and Treatment Act (CAPTA) has defined sexual abuse as, “the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.”2
Sexual abuse of a child includes activities such as fondling a child’s genitals, penetration, incest, rape, sodomy, indecent exposure, and exploitation through prostitution or the production of pornographic materials.2 While this definition is reported in child sexual abuse, the parameters also may apply to any adult sexual assault victim. Included in this description would be any patients that athletic trainers provide care or another person with whom they interact. A key element of sexual abuse or assault is that it involves any sexual act performed by one person on another without consent, but also may result from the use of unwanted sexual touching by the threat of force, coercion, or the inability of the victim to give consent, such as a minor child or an adult incapable of granting consent.
Protecting Young Victims from Sexual Abuse and Safe Sport Authorization Act of 20173 is a federal law that was passed in January of 2018 to protect young athletes from sexual abuse. This Act extends the duty to report suspected child abuse to certain adults who are authorized to interact with minor or amateur athletes at a facility under the jurisdiction of a national governing body. A national governing body is an amateur sports organization that is recognized by the International Olympic Committee. Furthermore, it states that an individual who is required to report, but fails to do so, is subject to criminal penalties. Without question, the duty to report under this regulation extends to athletic trainers.
Mandatory Reporting of Domestic Violence to Law Enforcement by Health Care Providers Reporting Abuse of Adults
Most U.S. states have enacted mandatory reporting laws, which require the reporting of specific injuries and wounds, and suspected abuse or domestic violence for individuals treated by a health care professional. This pertains to all individuals to whom health care professionals provide treatment or medical care, or those who come before the health care facility.4 Since state laws vary from state to state, the AT is strongly advised to check his or her state’s mandatory reporting laws for specifics and clarification.
Signs and Symptoms of Sexual Abuse anD Assault
The AT must be aware of his or her mandated duty to report sexual abuse, regardless of the patient’s age. Therefore, an important first step in fulfilling a mandatory reporting obligation is ability to recognize associated signs and symptoms. These signs and symptoms can be: 1) witnessed in person, 2) having a patient or another person with whom you interact with reporting the signs and symptoms, or 3) clear statements that one has felt sexually abused by another person.
The first step in helping patients or others who have been sexually abused, be it minor children or adults, is learning to recognize the signs and symptoms of abuse. The list below, though not fully inclusive, provide examples of signs and symptoms of a victim who has experienced sexual abuse or assault. The important point is to be aware of any changes in behavior that may be suggestive of sexual abuse or assault.
Child or teenager:
- Has difficulty walking or sitting
- Suddenly refuses to change for gym or to participate in physical activities
- Experiences a sudden change in appetite
- Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior
- Becomes pregnant or contracts a venereal disease, particularly if under age 14
- Reports sexual abuse by a parent or another adult caregiver
- Behaves secretive or isolated
- Exhibits trouble in school with grades or behavioral issues
- Talks of death or suicide
- Shows little attachment to parent, guardian or other significant adult in their life
- Avoids being around or making eye contact with certain individuals
- Post-Traumatic Stress Disorder (PTSD) symptoms such as loss of appetite, trouble sleeping, hypervigilance, easily agitated over minor issues
- Declining grades or withdrawal from school
- Substance or alcohol abuse
- Risk taking behavior
- Loss of interest in activities that they used to enjoy, including sports participation
- Self-harm such as cutting or burning oneself
- Talk of death or suicide ideation
Duty to Report and Avenues for Reporting of Sexual Abuse or Assault
The next step is to take action on the knowledge or suspicion of sexual abuse or assault. Mandatory reporting of child sexual abuse is a legal and ethical responsibility of all athletic trainers.5, 1
All states, the District of Columbia, American Samoa, the Northern Marianas, Guam, Puerto Rico and the U.S. Virgin Islands have statues that identify persons who are required to report any suspected child maltreatment to an appropriate agency, such as child protective services or law enforcement, or toll-free reporting hotline.6 A good resource on mandatory reporting of child sexual abuse is Child Welfare Information Gateway, Mandatory Reporters of Child Abuse and Neglect.6 In this report, mandated reporters per state and American territories are defined. Clearly, athletic trainers fit into the health care provider categories listed in the report.
In the event that an adult patient or an adult with whom the AT comes in contact is known to be, or suspected to be, a victim of sexual abuse or assault, the AT should report this to the proper authorities per state and federal law such as law enforcement or a toll-free hotline.
A mandatory report must be made when an AT suspects, or has reason to believe, that a child or adult has been sexually abused. The AT must immediately notify the Department of Children’s Services or a law enforcement agency of the suspected abuse. What is NOT required in these laws is for the reporting chain to go through the ATs supervisor or administration. The place of employment, per employment guidelines, can also be notified, but there is no legal mandate to report to the employer. Notification to the proper legal authorities must come first if an employment guideline mandates reporting any sexual abuse to employment administration.
In the event that an athletic trainer is the one suspected of committing sexual abuse or assault, in addition to reporting to the authorities identified previously, the individual also has a duty to report to the NATA and Board of Certification.
The ATs primary responsibility is to the patient, and this responsibility goes beyond providing quality health care; patient safety and advocacy are paramount. The athletic trainer must remain vigilant in recognizing and reporting possible sexual abuse or assault. It is important to remember that duty to report is based on the suspicion of abuse; evidence is not required. We recommend that ATs take a proactive approach in working with employers and school systems in establishing a protocol for employees to report suspected or known sexual abuse or assault of their patient, child or adult affiliated with the organization.
This paper does not provide legal advice; athletic trainers and other affected individuals should consult appropriate counsel to clarify their obligations in situations discussed herein.
References and Resources
- National Athletic Trainers’ Association. www.nata.org/codeofethics. Accessed February 12, 2018.
- Child Welfare Information Gateway. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms. Children’s Bureau. www.childwelfare.gov/pubs/factsheets/whatiscan.cfm. Accessed February 12, 2018.
- S.534-Protecting Young Victims from Sexual Abuse and Safe Sport Authorization Act of 2017. 115th United States Congress.
www.congress.gov/bill/115-congress/senate -bill/534/text?format=txt. Accessed February 12, 2018.
- Compendium of State Statutes and Policies on Domestic Violence and Health Care; Produced by Family Violence Prevention Fund. 2010.
- Colston M.A., Neal TL. (2016). Mandatory reporting and cyber-safety issues (part 1). NATA News. April 2016;28(4):38-39.
- Child Welfare Information Gateway. MandatoryReporters of Child Abuse and Neglect. Children’s Bureau. www.childwelfare.gov/systemwide/laws_policies/statutes/manda.cfm. Accessed February 12, 2018.