Abstract

With the conviction of a US gymnastics coach on criminal sexual conduct and other charges, our attention is inevitably drawn to the sporting world in India. The case points to the imperative need for regulations, mandates and ethical codes to protect athletes, especially elite performers under pressure to win. As is now evident, authoritarian structures that do not allow athletes a voice are perfect locations for abuse. An examination of the state of ethical codes and regulations in sports in India is long due. This short essay looks at the issues that must find space in public discussion and in the deliberations of sporting bodies, with a particular emphasis on the role of the medical profession in sports.

Keywords:sexual harassment, sports, ethics, gender, doping, youth, medical profession

Four years ago, the conviction of the former US gymnastics team doctor, Larry Nassar, on multiple charges of sexual abuse of gymnasts prompted heated public discussion and introspection leading to a general disquiet in the sporting arenas across the world. Between 1998 and 2015, Nassar sexually abused over 256 female athletes, with impunity. In January 2018, Nassar was sentenced to 40-175 years in Michigan for first-degree criminal sexual conduct, and another 60 years in federal prison for convictions on child pornography charges [1]. As the horror-sheet unfolded, the reputations of individuals and institutions that had together either abetted the perpetrators or failed to protect athletes, went into free fall.

The numerous outcomes have shaken the athletic world in the US and elsewhere. After this, there is no room for complacency on matters of athlete safety anywhere, and no sporting organisation in any country can say with conviction — “This could never happen here.” Significantly, a question asked repeatedly is how the abuse, over many years, and across institutions, could occur despite the network of regulations that exist in all sports institutions in the US. But it is equally noteworthy that the abuse would not have come to light or been addressed even after the persistence of Olympian gymnast Aly Raisman and others, had these regulations not existed. This is a point worth pondering and is the prompt for this essay, which is not a scholarly exposition but a compilation of facts from media sources, and aims to raise some uncomfortable questions on the safety and security of our athletes co-opted to the project of putting India on the podium. It may, perhaps, lead to a serious discussion not only on the power that coaches and sporting institutions wield over athletes, but on the codes of ethics in sports; the institutional regulations and mechanisms for protection and redress, and, especially, the critical role of the medical and related professions associated with sports.^a

It is instructive to briefly look at the numerous institutional failures, organisation-wise, in this case. In the US, there are multiple bodies that administer sports. Unlike many other Olympic countries, the US does not have a single “sports ministry” or a central government entity for regulation and coordination of amateur or Olympic sport. Sport is regulated differently at various levels, tailored to fit the needs of a particular sport and to different settings such as Olympic, state level or collegiate sports making for an overlapping and confusing sets of policies. The various professional sports are regulated by their respective leagues, all of which are private non-profit entities that are not under direct government purview. Olympic sports come under the purview of the United States Olympic & Paralympic Committee (USOPC) or other bodies such as USA Gymnastics, or USA Swimming — all private entities. Collegiate sports, a big entity in the US, is governed by the National Collegiate Athletic Association (NCAA).

The offender with the most liability in the Nassar case is perhaps, USA Gymnastics. Established in 1963, it was charged with ensuring “safe participation” within the sport of gymnastics and has a substantial code of ethics. It has been charged on numerous counts of failing to come to the rescue of gymnasts under its fold. It also refused to believe there was any wrongdoing on the part of Nassar. The other agency that failed to act is of course USOPC. Both employed Nassar as the team physician. He was, reportedly, constantly in touch with athletes and saw himself as a “horse whisperer” for gymnasts; thus, including his physical manipulations on athletes as a necessary part of his role which the young athletes did not understand. Even worse was the response of the Michigan State University (MSU) where Nassar was employed first as an intern, with the department of Osteopathic Medicine, “volunteering” as a physician to the gymnasts. Here, he was documented as having met aspiring young gymnasts, not necessarily all with Olympic potential. MSU was faulted for having failed to act on the many complaints of gymnasts who dared to allege abuse and harassment not only by the physician, but by the coach in charge who knew of Nassar’s actions.

Another seriously culpable perpetrator of abuse was the Karolyi Ranch run by Bela and Martha Karolyi, which over 20 years became the highly favoured and elite training ground — “the gymnastic factory” — for Olympic gymnasts and coaches [2]. The Ranch in a remote area in Texas housed gymnasts and subjected them to harsh training and verbal and emotional abuse, ostensibly to make them tough enough to sustain the high level of stress and competition at the Olympic arena. The Ranch gained a mythical status among gymnasts in training as the place that fashioned Olympians. The housing and living conditions of the gymnasts at the Ranch were abysmal, and the physical and psychological abuse that the athletes received was unnecessarily harsh. Coaches who attended training programmes at the Ranch adopted the “Karolyi mentality” that spread nationally. Power and authority rested with the organisers, and no complaints were entertained. No regulatory body had any jurisdiction over the private Ranch that was affiliated to the USOPC specifically for Olympic training. In these circumstances, Nassar fashioned himself as a sort of “saviour” whose “medical” treatment of the worst injuries after the harsh training masked sexual abuse that young gymnasts could not complain about. It was all a case of “either take it and earn an Olympic medal or quit”. Gymnasts have alleged that here and elsewhere the harsh treatment dealt out by the coaches, paved the way for a charming medical practitioner like Nassar to offer “treatment” that the young girls accepted as part of the entire package of training. The coaches’ refusal to monitor Nassar’s actions, even after knowing about the sexually abusive nature of his treatments, is the worst of the offences. That coaches, who are primarily charged with not only training but taking care of young athletes, allowed this to happen, hits at the very ethos of the sport credo of winning against all odds [3].

The Indian scene

Sports in India is governed by two major bodies, the Ministry of Youth Affairs and Sports and the Indian Olympic Association (IOA) that is autonomous and has under it the state IOAs, and various sports federations as members. Non-Olympic sports like cricket have their own bodies and are directly affiliated to their parent international bodies.^b There is plenty of anecdotal evidence and reportage that the federations are run as fiefdoms where regulations make little difference (although there do not appear to be systematic case studies of academies). In sum, the sports world is governed by a set of empires, each with a feudal, hierarchical and patriarchal organisational structure. This also means overall regulations are hard to put in place, whether they affect the functioning of these bodies or impact the sport and its practitioners.

It is easy to believe that athletes are safe from sexual and other abuse in India. But that would be a delusion. A recent report in the Indian Express, based on information obtained through RTIs, shows that there have been 45 complaints to the Sports Authority of India from its 24 affiliated centres [4]. Of these, more than half have been against coaches and significantly, almost all have been dismissed with “punishments” such as a small cut in pay or a reprimand. The predatory coaches have continued to work in these institutions. In many cases, the athletes — many of whom come from poor economic backgrounds who see athletics as a means of employment and upward mobility — may have been “persuaded” to overlook the assault and harassment in the interest of their progress in sports. In most cases, coaches are given, what is termed “exemplary” punishment and/or transferred, and continue to oversee young girls. For instance, a complaint by two girls, at the Sports Authority of India (SAI) camp of Gandhinagar, alleged that the coach was seeking sexual favours and had blackmailed them with purported videos that he would release. SAI held an inquiry and decided to transfer the coach to another centre and moved the complaint to the newly set-up sexual harassment complaints cell, where it was queued. In another case, where the girls alleged that the coach was touching them inappropriately, asking them to undress on the pretext of taking weights and measurements, he was “punished” with early retirement from that centre. This was among the few cases where punishment was meted out, but no attempt was made to blacklist the coach who was free to work at other arenas [4]. In 2013, when a woman shooter complained of sexual harassment by male shooters in the team, the latter were suspended and the case referred to the Athletes’ Commission [5]. The Commission, an elected body under the Indian Olympic Committee that allows athletes to have a say in sports administration, has no particular statute or system for examining complaints of this nature.

The sports training arena, as Meena Gopal [6], a state athlete and sports sociologist, points out, ought to be a safe and nurturing environment that engenders trust. And yet, athlete−coach relations have been extremely paternalistic, with practices that are remnants of feudal times making for an environment that has bred predators. The situation, unless corrected, will only get worse in the emerging environment. Large numbers of youth are being drawn into the many new sports academies that offer specialised training and coaching, with the one goal of winning at all costs. Today, there are no overarching regulations governing such centres and no complaints redressal systems in place to ensure athletes’ safety. In these circumstances, the power driven, win-or-quit milieu that is emerging in sports will make it a fertile ground for the victimisation of athletes. In fact, a systematic global review of literature on abuse in sports shows that abuse is not only widespread in sports but is likely to be more frequent at higher levels of sports. Particularly at risk are those from minority groups and the socially, culturally and economically vulnerable [7].

The lack of adequate regulation and monitoring is even more evident in the area of performance enhancing drugs in sports, which impact not just national sports performance, but more importantly, the health and safety of athletes. India’s National Anti-Doping Agency (NADA) and its regimens have had limited success in controlling the use of performance-enhancing drugs (PEDs). The accreditation of the National Dope Testing Laboratory was suspended in 2019 and only restored in 2021 [8, 9]. Testing, inefficient as it is, has shown a sharp rise in the number of athletes testing positive over the years. The Anti-Doping Rule Violations (ADRV) Report by World Anti-Doping Agency (WADA) recorded India as the third highest ADRVs — 17% of all samples tested — among all athlete nations [10]. Between the 2021 Tokyo Olympics and the 2022 Birmingham Commonwealth Games, nine athletes have tested positive for sophisticated drugs [11].

While safeguards and systems are important, there is a larger issue here. As Pullela Gopichand, national badminton coach and Olympian, points out in a two part essay, it is this intense competition (gaining ground recently) to be the best at all costs, that leads to athletes losing their sense of self and boundaries, and to other aberrations [12, 13].

Do medical bodies have a role?

The Nassar horror alerts us to the issue of the role of medical bodies and the adherence to medical ethics by practitioners in sports. On the question of how legitimate were the “treatments” given by Nassar to the gymnasts mainly for pain relief, the American Osteopathic Association has said that these treatments were probably extensions of accepted and selectively used “osteopathic manipulative therapy” (including intravaginal manipulation) [14]. However, there are conditions to its use: the informed consent of the patient; the use of gloves and lubricants, presence of a third party and adequate safeguards to protect the patient from infection and mitigate pain. None of these conditions were met when Nassar “treated” his young patients. Only in 2017 did the Michigan Department of Licensing and Regulatory Affairs suspend his licence under the Public Health Code for reasons of “public health, safety and welfare” [15]. His licence was permanently withdrawn in 2019, only when ordered by the Attorney General [1]. The shocking failure of the medical licensing and regulatory bodies to recognise and put a stop to unethical practices by a physician, before the scandal blew up, has gone relatively unnoticed.

In India, all SAI institutions for instance, have associated medical facilities or at least the involvement of medical personnel, physiotherapists, psychologists and nutritionists who, one supposes, are in constant touch with athletes. It is also evident that an athlete injured or abused would approach the medical establishment. Commentators point out that the “sports medicine” doctor can play an important role in preventing abuse. A core clinical competency of the sports physician is this ability to spot the signs of sexual abuse and act. A competent and ethical sports medicine specialist can play a key role in preventing physical, psychological and sexual abuse of athletes [16].

The role of medical personnel has so far come into question in cases of doping. At the 2008 Commonwealth Youth Games, Pune, WADA launched the Play True programme that was aimed at encouraging athletes to reject doping and be a generation of “clean athletes”. And yet, in India itself the programme has received only lip service for several reasons, though no systematic review of practices is available. For one, the sportspersons who train at SAI centres are, as often as not, barely school educated, with little knowledge of English and hardly any access to information. As Mohan points out, in most cases of doping, the athletes plead guilty but point to the physician who prescribed them the “supplements or some medicine” that contained banned substances [17]. After all, as Prakash [18] points out, growing up as they do in an environment where the paediatric doctor or the primary care physician regularly prescribed supplements for “energy” or better performance, why should they suspect these supplements as being out of bounds now? It is widely acknowledged in casual conversation that the consumption of “pre-contest fixes” is evident even at district level school athletics meets. While the overall responsibility for the health and safety of athletes and for putting in place level playing fields all round lies with the sports authorities, it is evident that medical bodies and practitioners involved in sports have a critical and influential role to play here. Currently, with no specific codes of conduct for medical practice in sports, there is little that can be done to prevent unthinking and risky treatments and the abuse of athletes.

While allegations of sexual harassment and misconduct on the part of medical and related professions in the field of sports in India have been few, it would be foolish to believe that they do not exist. This silence is simply a reflection of the awe in which people hold doctors so that even outside sports, there are a few cases of sexual misconduct that get reported. With the increasing impetus to introduce sophisticated multi-pronged training programmes to achieve the highest levels of performance, harassment and/or the pressure on the athlete to submit to procedures and medications prescribed will likely rise. Who is to monitor all this?

Internationally, several medical associations have adopted codes of conduct in sports. Apart from the comprehensive code of the International Federation of Sports Medicine, the World Medical Association (WMA) adopted a revised and amended Declaration on Principles of Health Care in Sports Medicine in October 2021^c that specially focused on two elements: the use of supplements, anabolic steroids and the World Athletic Association’s decision on gender classification requiring the ingestion of drugs to reduce the levels of blood testosterone in order to pass their requirement for being classified “female”. The WMA strongly decried the use of supplements and opposed the decision on forcing female athletes to ingest exogenous androgens to “become female” [19]. In April 2019, the WMA in fact, urged physicians not to enforce the International Association of Athletics Federations rules on classifying women athletes.

The newly formed Indian Society of Sports and Exercise Medicine (ISSEM)’s objects do not list ethical conduct in sports medicine, nor has it attempted to evolve a code of conduct. Its primary objective appears to be to promote sports and the sports movement and “provide medical and scientific guidance to make the country excel in sports” [20]. No other body in India appears to have seen the need for a code of ethics for doctors in sports medicine.

Interestingly, the Medical Council of India (MCI) (now, National Medical Commission) has reportedly recognised the US Doctor of Osteopathic Medicine degree recently and has allowed these degree holders to practise in India, after several petitions from such degree holders over the years [21]. Other than these, there are 35 MDs and 120 diplomas in sports medicine, as listed on the ISSEM website [22]. With the rapid expansion of sports institutions, the specialties of sports medicine and related areas will very likely grow. There is then, a growing need to pay attention to the ethical conduct of medical and associated practitioners and develop comprehensive codes.

There is no denying the fact that the medical practitioner is the first point of contact in cases of sexual abuse and assault in sports. The profession is also closely linked to the use and abuse of performance-enhancing drugs. Further, the doctor and allied professionals are the ones, on the field and off, who diagnose all health conditions in general including injuries, prescribe treatments and withdraw such treatments, when unnecessary. It is these professionals who at the ground level “regulate” the use of a variety of drugs. Does this situation not call for a more specific code of medical ethics in sports? This would be a starting point for a number of others that would ensure the safety and health of sportspersons.

In conclusion

The Nassar disaster has thrown light on the fact that the feudal, hierarchical and patriarchal organisational structures in sports are the ideal environment for perpetrating abuse. It is in these fiefdoms that regulations, even if in place, crumble.

This culture of empire, of fiefdoms in sports in India needs to be broken by making the administration of sports more democratic. With India poised to expand grassroot sports via the school system, athlete-focused regulations, mandates, codes of behaviour and a structure of sports ethics is urgently needed. In their absence, we have no way of protecting children picked out of their familiar environment and thrust into unfriendly and unfamiliar “training” regimes towards achieving Olympic glory for the nation.

Ensuring that athletes have a voice in the administration of sport and representation in the highest bodies may be one useful reform. Feminist writings on competitive sport are a useful springboard for wider discussion on democratising sports [23] and for exploring alternatives to the competitive regimen in sports ^d [24].

The US Center for Safe Sport (SafeSport) that has jurisdiction over all allegations of abuse in the US Olympic movement is a step in the right direction [25]. SafeSport, a non-profit set up in 2017, is also charged with developing policies and has adopted a SafeSport Code. In Canada, there are proposals to set up a national independent body to ensure protection of children from abuse in sports, challenging the current environment of control, the exercise of power and authority that combine to perpetrate abuse [26]. Should India not be considering a comprehensive, multi-disciplinary assessment of how to prevent abuse in sports and develop a grounded code of ethics that would find purchase across disciplines and institutions? Can sports medicine disciplines and associations perhaps take a lead in this movement towards a healthier and safer sports environment?

There is a groundswell of activity internationally to develop regulatory structures to protect gender rights and human rights within sports. India needs to take a hard look at its current codes and regulations, bridge gaps and establish compliance frameworks, where athletes can protest wrongdoing and hope to be heard.^e Isn’t it time we put the athlete at the centre of the national Olympic dream? And as Gopichand asks, should we not abandon the “Do or Die” credo for a more humane one, “Play and Live”?

^a Aware as I am of the unfolding literature on the subject, this is not a scholarly exposition, but more an assemblage of information to raise some issues.

^b There are also any number of semi-legal entities in sports that may or may not be affiliated to any state or national bodies.

^c The WMA Declaration on Principles of Health care in medicine was first adopted by the 34th World Medical Association General Assembly (WMA-GA), Lisbon, Portugal, September/October 1981. It was later amended by subsequent WMA-GAs in October 1987, October 1993, and in October 1999. It was reaffirmed by the 185th WMA Council Session, Evian-les-Bains, France, May 2010, and amended by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021.

^d The challenge to this top-down approach may well come from grass root bottoms up sports mobilisation such as the initiative Sabah Khan [24] (2021) describes or the Hockey Village India in Rajasthan (closed since 2018)]

^e See Patel [27](2021) for an illuminating discussion on gender and human rights regulations in sports.