Introduction
While the exact prevalence is unknown due to concern for underreporting and inconsistent definitions, sexual violence is estimated to affect up to 78% of athletes at all levels of sport and can have consequential long-term health effects.1–3 Sexual assault is one form of sexual violence that encompasses sexual contact without freely given consent. It includes a wide range of behaviours such as rape, sexual coercion and non-consensual sexual touching.4 Sexual assault has been a central concern in the sports medicine community over the past decade, and with prevalence estimates ranging from 0.5% to 12%, numerous guidelines, resources and toolkits have been developed to support survivors and empower physicians and organisations to respond appropriately.1 5–7 Despite this emphasis on prevention and response, there is substantial evidence that sexual violence continues to be under-reported by athletes. In a recent survey of over 1000 National Collegiate Athletic Association (NCAA) Division 1 athletes, only 9% filed a formal report despite three times that number experiencing some form of sexual violence while at college.8 This study also demonstrated athlete uncertainty and ambiguity in how to file a report, with 42% of athletes citing a lack of knowledge on where to report sexual violence.9 In the 2024 United States Centre for SafeSport Climate and Culture Survey, 89% of US athletes who experienced unwanted sexual behaviour during sports involvement did not submit a formal complaint or report.10 There is evidence that stigma and athletes’ perspectives around being believed and supported impact disclosure.11
Disclosure of sexual assault is often the first step for survivors to obtain physical and mental healthcare and legal assistance. The disclosure process and subsequent response can have a positive or negative effect on the survivor, impacting their recovery. 12 13 There is a long history of institutional failures, including those known in the sporting world, whereby institutions and the individuals connected with them have failed to adequately support survivors of sexual assault.13 14 One emerging concept to combat this institutional betrayal is the idea of ‘institutional courage’, which emphasises ‘accountability, transparency, actively seeking justice and making reparations where needed’.15 Response to sexual assault is complex and multi-faceted, often involving an interdisciplinary team and coordination across various groups.16 There is increasing literature advocating for the survivor to be centred in the response, and to include the voices of those with lived experience as well as a range of professionals who support them, in response development.17–19 Given the innateness of interdisciplinary care, care coordination and prioritisation of athlete health/safety in their role, team physicians are uniquely suited to lead prevention of and comprehensive response to sexual assault.14 However, recent literature suggests that the majority are not prepared to respond appropriately. In a 2024 international survey of sports medicine physicians, 25% of respondents reported being unsure of where to report, and 53% did not feel they had appropriate support to manage harassment or abuse concerns. The vast majority (84.6%) were interested in receiving more education on the topic.20 These findings highlight a disconnect between the calls to action for clinical competency in responding to sexual assault and the tools, education and culture supporting sports medicine physicians to feel confident doing so. One way to mitigate the uncertainty that both athletes and providers feel when approaching a sexual assault disclosure is to formalise components of the response via an emergency action plan (EAP). EAPs are written documents used to outline preparations and components of an emergency response to catastrophic events that can occur in sport.21 While traditionally EAPs have been applied to physical emergencies in sport such as sudden cardiac arrest, heat stroke and spinal cord injury, the National Athletic Trainers’ Association as well as the NCAA have published recommendations for the development of EAPs around mental health crises, including sexual assault, acknowledging the potential life-threatening nature of these crises.22 23
While sexual assault response requires a survivor-centred approach, necessitating degrees of individualisation, this modified Delphi study aimed to bring together professionals and athletes to identify consensus recommendations on core essential elements of an EAP for sports medicine personnel in the USA to support athletes who disclose an experience of sexual assault. We describe physical and mental health considerations, reporting requirements, legal considerations, and trauma-informed care support concepts, as well as best practices in developing and implementing a sexual assault EAP that can be adjusted and adopted by organisations at various levels of sport.
Methods
A four-step modified Delphi method was used to establish consensus on the essential elements of a sexual assault EAP (online supplemental figure 1).24 This study was approved as exempt by the University of Wisconsin-Madison’s Minimal Risk Institutional Review Board (Protocol #2024–1147) as it met the low-risk category of tests, surveys, interviews or observation (low risk).
Research Electronic Data Capture (REDCap) was used to anonymously collect panellists’ demographic information and open-ended responses for Round 0.25 An online platform, Welphi (www.welphi.com), designed for easy facilitation of Delphi studies, was used to administer Delphi Rounds 1 through 3 (Welphi V.4.0). Each round was open for 2 weeks, with an additional week extended to those who did not complete the round by the closing date. Email reminders were sent 1 week after the round opened to those who had not yet completed the round. Up to two additional reminders were sent to panellists who had not completed the round after 2 weeks.
Formation of the Delphi panel
Members of the primary author group and study steering committee (a group of sports medicine physicians on the American Medical Society for Sport Medicine’s (AMSSM) Sexual Violence in Sport Subcommittee) determined the types of key groups to be included on the Delphi panel. Purposive sampling with suggestions from the steering committee was conducted for diverse representation in the following categories: (1) sports medicine physicians, (2) other sports medicine clinicians (ie, athletic trainers, physical therapists), (3) mental healthcare professionals, (4) athletics administrators, (5) researchers/policymakers/educators, (6) legal experts, (7) athletes and (8) child abuse paediatricians. Snowball sampling was used to increase athlete representation. Inclusion criteria consisted of: (1) experience/involvement in sports, (2) experience creating policy on sexual violence and/or (3) demonstrated clinical, research, advocacy or administrative experience specifically within the field of sexual violence. Steering committee members who met the inclusion criteria were invited to participate in the panel. Those who participated in the panel were not involved in the collection or analysis of results. All potential participants were recruited via email invitation overseen by the primary authors. Participants who were non-AMSSM members and completed all rounds were offered a US$100 honourarium.
Equity, diversity and inclusion statement
The study group aimed to recruit panellists with diverse professional backgrounds and lived experiences within sports, successfully including representation from a variety of levels of sport and various professional disciplines within sport and the field of sexual violence. Efforts were made to include representation of individuals from equity-deserving groups, especially those often underrepresented in sexual violence research (eg, individuals identifying as men and racial minorities), through concerted identification of potential participants with requisite experience by the steering committee.
All primary authors work as sports medicine physicians and/or researchers, and more women are represented. There is broad representation across levels of experience, including sports medicine trainees, junior faculty, mid-career and senior faculty in practice across the USA.
Patient and public involvement
To ensure the voices of those affected by the proposed sexual assault EAP were represented, athletes at various levels of sport were invited to participate on the Delphi panel and to be listed as group-authors for this manuscript. Athletes made up 21% of the Delphi panellists. This approach aimed to centre the athlete voice as essential to the knowledge and experience informing these consensus recommendations.
Delphi rounds
Round 0
Prior to initiating the Delphi study, an unstructured literature review was conducted to identify current guidelines on responding to sexual assault in the general population, sports EAP development and existing resources and recommendations related to sexual violence in sport.1 3–7 12 16 21 23 26–29 Resulting resources were used alongside recommendations from the steering committee to inform the development of the open-ended Round 0 questions in the following categories: (1) Physical Health Considerations, (2) Mental Health Considerations, (3) Trauma-Informed Care/Support, (4) Legal Considerations, (5) Institutional/Organisational Response, and (6) Implementation Recommendations.
Round 0 launched in September 2024 and panellists were provided with a reference sheet providing plain language definitions and descriptions of EAPs, sexual violence and sexual assault to improve consistency in understanding of the terminology referenced throughout the study. The research team used the results from the open-ended Round 0 to develop the closed-ended items for the remaining voting rounds (Rounds 1–3; November 2024 to January 2025). Initially, the research team intended to keep the scope of the EAP inclusive of all sexual violence, including both sexual assault and sexual harassment. However, after reviewing Round 0 comments, the scope of the EAP was narrowed to sexual assault due to concerns related to feasibility and implementation.
Voting rounds
During each voting round, panellists were asked to rate items on their importance and agreement using a 9-point Likert scale for non-ranking items and a 4- or 5-point numeric scale from least preferred (1) to most preferred (four or 5) for ranking items. Consensus cut-offs were determined a priori at 80% agreement for all non-ranking items (online supplemental table 1). For ranking items, consensus was determined a priori based on the SD of each response from least to most preferred (1–4 or 1–5). If all SD for a ranking item were <1, then consensus was reached. At the beginning of each round, panellists were encouraged to provide comments and review other panellists’ comments from prior rounds. Items that achieved consensus in each round were removed from consideration in future rounds. Items were not piloted prior to distribution.
Development of EAP templates
Using the statements that achieved consensus, the study team created two sample EAP templates—one for minor athletes without medical decision-making capacity and one for adults. Feedback on clarity of language and layout was obtained from members of the AMSSM sexual violence subcommittee and members of the Delphi panel. Both templates were edited by the study team using the feedback received. Importantly, no content-related changes were made to the EAP templates that would compromise the results of the Delphi study, ie, if an item did not achieve consensus but was recommended as an edit, the EAP template was not updated.
Results
32 individuals initially agreed to join the Delphi panel. Most panellists completed the demographic survey and responded to the open-ended round (n=26/32; 81%). 75% of panellists (n=24/32) completed Round 1. During the first round, one panellist recused themselves because they did not feel they had the appropriate expertise for the study. Panellists who did not complete Round 1 were not included in subsequent rounds. All remaining panellists completed Rounds 2 and 3 (n=24/24).
Among our Delphi panellists who completed all rounds, 19 (79%) self-identified as women and five (21%) as men (table 1). Most panellists identified as white (79%) and had achieved a graduate or professional degree (79%). The Delphi panel was made up of sports medicine physicians (38%), an athletic trainer (4%), a child abuse paediatrician (4%), mental health professionals (8%), athletics administrators (13%), legal experts (13%), researchers/policy makers/educators of sexual violence in sport (21%), athlete survivors of sexual violence (21%), and other (17%). The majority were affiliated with a college/university (54%) or a non-profit organisation (42%).
Table 1
Demographics and backgrounds of Delphi panellists
The first round consisted of 130 total items with 17 ranking items and 113 non-ranking items. 45/130 (35%) total items achieved consensus in the first round. A few revisions were made following the first round, and four ranking items were added prior to Round 2 (online supplemental table 2). The second round had 89 total items with 21 ranking items and 68 non-ranking items. In the second round, 25/89 (28%) items achieved consensus. No revisions were made following the second round. The third round had 63 total items with 17 ranking items and 46 non-ranking items. 20/63 (32%) remaining items achieved consensus (note: one item was inadvertently excluded from Round 2 to Round 3; see online supplemental table 4). Across all Delphi rounds, 90 statements achieved consensus (tables 2–5), ranging in scope from trauma-informed care considerations when handling a disclosure of sexual assault from an athlete survivor to EAP implementation recommendations for organisations. An overview of the consensus-based key elements of a sexual assault EAP is shown in figure 1, with specific elements further described below. Items that did not achieve consensus are reported in the supplementary materials (online supplemental tabels 3 and 4).
Table 2
General and mandatory reporting/confidentiality/consent items that achieved consensus
Table 3
Initial evaluation and follow-up plan items that achieved consensus
Table 4
All physical and mental health, athlete safety, and trauma-informed care items that achieved consensus
Table 5
All legal, established contacts/resources, and organisational/implementation items that achieved consensus
Figure 1
Key elements of a Delphi-informed sexual assault emergency action plan. SAFE, Sexual Assault Forensic Exam.
General guidance
In terms of general guidance, the Delphi panel strongly agreed/agreed that all sporting organisations should establish an EAP specific to sexual assault (96%) (table 2). Additionally, consensus was reached that branching logic for a sexual assault EAP should be based on whether the athlete has medical decision-making capacity (83%). All panellists agreed that an EAP for sexual assault should instruct the clinician to evaluate the immediate safety of the athlete (100%).
Mandatory reporting/confidentiality/consent
Consensus was reached that the EAP should include a requirement for the clinician to inform athletes what information they are required to report as a mandatory reporter (strongly agree/agree, 92%); details on who a mandatory reporter needs to report to, how to do so, and the timeframe (92%); and state and local laws and regulations regarding confidentiality and decision-making ability for minors related to their medical, sexual and mental health (92%) (table 2). In addition, consensus was reached that the EAP should contain information on how/when to contact the athlete’s parent/guardian if the athlete cannot consent based on state laws and regulations (84%).
Statements related to confidentiality, including instructing clinicians to inform adult athletes (before a potential disclosure) that information disclosed will not be shared with individuals outside of those they agree to and those necessitated by mandatory reporting laws (88%) reached consensus. Additionally, reminding adult athletes that they have the right to decline further evaluation and reporting to law enforcement, as long as no mandatory reporting statutes conflict (92%), reached consensus.
Initial evaluation
The Delphi panel agreed that the EAP should provide clear guidance about what specific information should be obtained during the initial disclosure (96%), but that clinicians should defer asking specific details about the sexual assault to an individual experienced in interviewing sexual assault survivors (91%). Consensus on extremely/very important elements that the initial responding clinician should assess and document included the following: date and time the incident occurred (87%); general description of what happened based on athlete report (83%); survivor’s name and contact info (88%); description of initial assessment of physical symptoms/injuries (88%); description of initial assessment of psychological symptoms, including suicidal ideation (92%); and what the athlete reports they need (eg, additional mental health support) (83%). Additional items related to the initial evaluation that achieved consensus can be found in table 3.
Sexual assault occurred within days to weeks
A Sexual Assault Forensic Examination (SAFE), commonly conducted by a Sexual Assault Nurse Examiner (SANE), is a comprehensive evaluation which includes obtaining a medical forensic history, performing a thorough examination including sample collection for evidence, and coordinating the treatment of injuries, sexually transmitted infections (STIs), suicidal ideation, alcohol and substance use disorder, emergency contraception and other non-acute medical concerns.30 If an athlete discloses having experienced sexual assault days to weeks ago, many items related to seeking a SAFE exam achieved consensus as strongly agree/agree. These items included directing clinicians to offer the option of a SAFE exam for evidence collection (96%), contact information for an appropriate facility to obtain a SAFE exam (96%), advice on how to preserve evidence if an athlete chooses to obtain a SAFE exam (84%), and arranging for someone to accompany the athlete to the facility where the SAFE exam will be conducted (92%). See table 4 for additional items that achieved consensus, including items on steps to take if an athlete declines a SAFE exam.
Sexual assault occurred within months to years.
Some athletes may not reveal an experience of sexual assault until months to years after it occurred. Some states may have limitations on the timeframe in which evidence can be collected during a SAFE exam, though the exam can still provide necessary evaluation and treatment.30 If an athlete discloses having most recently experienced a sexual assault months to years ago, consensus was reached that the EAP should instruct clinicians to connect the athlete with a mental health professional experienced in providing care for survivors of sexual assault (strongly agree/agree, 88%). Items that did not achieve consensus are in online supplemental tables 3 and 4.
Follow-up plan
Consensus was reached that the EAP should include the requirement to create a follow-up plan with an athlete (strongly agree/agree, 87%, table 3). In terms of what follow-up plans the clinician should arrange, items that achieved consensus as extremely/very important were a follow-up with a medical professional (88%) and a follow-up with a mental health professional (87%). It was also encouraged to include a contact person in the EAP designated to initiate protocols to reduce the chance of further harm if the alleged perpetrator is involved in the athletic space. Delphi panellists agreed/strongly agreed that the EAP should include support resources for responding clinicians and other individuals involved in supporting an athlete survivor (91%).
Athlete safety and trauma-informed care
Items that achieved consensus on how to provide trauma-informed care included: types of body language the responding individual should use (strongly agree/agree, 88%); examples of verbal language the responding individual should use (92%); environmental considerations, such as steps to allow privacy and confidentiality (92%); arranging for someone to accompany an athlete if they choose to undergo a SAFE exam (92%); instructions to create a safety plan (87%) (table 4), and to clearly explain next steps after collaborating with the athlete to make an agreed-on plan together (87%) (table 3).
Legal
Two items related to legal considerations achieved consensus: (1) the EAP should instruct clinicians to inform athletes of their option of making a police report (strongly agree/agree, 96%), and (2) the EAP should have information on how to assist the athlete in making a police report (83%) (table 5).
Established contacts/resources
Several established contacts specific to minors and adults reached consensus as very/extremely important for inclusion in the EAP. These contacts included the following: mental health crisis counselling contacts, local emergency services, a certified facility for obtaining a SAFE exam, a medical professional in charge of follow-up and a mental health professional in charge of follow-up (see table 5 for percentage breakdown for minor and adult specific items). A few additional specific contacts achieved consensus for minors only, including law enforcement (88%), child protective services (92%), a paediatrician who specialises in child abuse (83%) and family support services (83%).
Implementation of EAP
Several items were developed to determine implementation strategies for an EAP for sexual assault. Consensus was achieved that all individuals interacting with athletes should receive training on using the EAP (strongly agree/agree, 96%). In addition, consensus was reached that organisations should have a system in place for debriefing after a disclosure occurs (96%) and organisations should track the usage of the EAP and its outcomes (87%) (table 5).
The ranked preferences for reviewing and rehearsing the EAP included that it should be reviewed and updated annually (most preferred) and rehearsed annually (most preferred) in small groups with a member from each type of role involved in response (most preferred) (table 5).
Discussion
Sexual assault can have an enormous effect on the survivor’s physical and mental health, as well as significant societal, cultural and organisational implications. While there has been increased recognition of the need for sexual assault prevention, especially within sporting culture, unfortunately, it still occurs.8 Prevalence ranges are vast, and sexual violence is frequently underreported due to systemic barriers and societal stigma, suggesting that any estimation of prevalence in the literature is an underestimation of the scope of this problem.1 8 9 31–33 As a result, sports medicine clinicians may not have extensive experience with an athlete disclosing sexual assault, and as previously reviewed, many physicians feel unsure of how to appropriately respond in this emergent situation.20 Various studies within and outside the sporting context highlight the need for increased education among those responding to sexual assault.20 26 34 35 Instituting an EAP is one approach for implementing an accessible, comprehensive resource on sexual assault response in a format familiar to sports medicine physicians. While not meant to automate response to an intensely personal experience, some degree of standardisation can improve competency in situations with a high level of complexity. Having a clinical standard has been identified as critical to increasing awareness and accessibility of survivor-centred sexual assault responses.35 Written and practised policies, including an EAP, may combat institutional/organisational challenges such as personnel turnover. It may also more clearly define the reporting process and protocolise the response, mitigating the uncertainty, cognitive biases and conflicts of interest that may drive underreporting.32 33
With an emphasis on clear, effective communication about response options, sports medicine clinicians using an EAP may be able to provide more certainty to athletes whose hesitation to disclose or engage in treatment may be related to concerns about a lack of transparency and unforeseen consequences.25–27 Through this modified Delphi study, we present recommendations for providing a referenceable and practical tool, an EAP, that fills the knowledge gap reported by sports medicine clinicians and provides direct steps to take when supporting and treating an athlete who has experienced sexual assault. These recommendations should be adapted to incorporate the needs of the specific athlete as well as specifics of local and organisational requirements and jurisdiction.
Initial evaluation considerations
With sexual assault, both physical and mental trauma can occur, necessitating an approach to physical and mental well-being, as well as attention to the concepts of mandatory reporting and legal considerations. EAP items emphasised by the Delphi panel include the importance of wrap-around evaluation such as evaluating the immediate safety of the survivor, connecting the athlete with mental health resources specific to those who have experienced trauma, treating their physical and mental health conditions, offering the athlete the option of undergoing an examination with specially trained SAFE personnel for evaluation/management of physical/psychological injuries, prevention/treatment of STIs, pregnancy prevention/testing if applicable, evidence preservation, and providing options for reporting to law enforcement. These recommendations are consistent with the US leading healthcare organisation, legal and victim advocacy guidelines.4 16 36–38
Athlete safety and trauma-informed care
Our results also highlight the essential nature of incorporating trauma-informed care concepts to the care of sexual assault survivors, which is consistent with previously published guidelines for responding to sexual assault.16 Specifically, our Delphi panel highlighted the importance of body language, verbal language and environmental considerations, with suggestions to provide specific examples, in ensuring physical and psychological safety for athlete survivors and to decrease the risk of further trauma. They also encouraged empowering the athlete with choice and control, being transparent about mandatory reporting requirements prior to the athlete disclosure in order to enhance trust, and facilitating ongoing peer and professional support. Delphi panellists further emphasised athlete safety by including the importance of protocols if the alleged perpetrator is involved in the athletic space. This adheres to international standards for combating violence in sport, and it is crucial that organisations abide by a clear process for disciplinary action to reduce the chance of continued harm.39 40 These recommendations are consistent with the six key principles of trauma-informed care, (1) safety, (2) trustworthiness and transparency, (3) peer support, (4) collaboration and mutuality, (5) empowerment, voice and choice, and (6) awareness of cultural, historical and gender issues, as well as prior qualitative research regarding response to sexual assault disclosure.4 16 26 36–38
Established contacts/resources
Collaborative, multi-disciplinary response teams have been recommended as a way to improve response to sexual assault, including in the recent IOC consensus statement on interpersonal violence and safeguarding in sport.1 Forming Sexual Assault Response Teams (SARTs) is one proposed mechanism for increasing the use of community resources, minimising trauma, enabling access to comprehensive and immediate care and facilitating criminal investigation/prosecution to hold perpetrators accountable and prevent future sexual assaults.27 38 SARTs have been suggested to improve some legal outcomes and survivors’ experiences when seeking help and reduce secondary trauma.41 The multiple contacts/resources recommended by the Delphi panellists for inclusion in an EAP highlight the importance of applying this multi-disciplinary, collaborative response to the athletic milieu. This may help combat isolation between athletic organisations and broader community or institutional sexual violence resources, which traditionally has been seen as a challenge in sexual violence response within athletics.42 As depicted in the minor EAP example template, utilisation of local resources such as Child Advocacy Centres may help improve coordinated efforts. Partnership with local resources and organisations is crucial to effectively implementing a comprehensive sexual assault response. While no studies exist in the sports medicine context, a study of forensic nurse coordinator care in paediatric patients found that coordinated efforts to improve follow-up care resulted in a 40% increase in adherence to evidence-based clinical care post sexual assault disclosure.43
EAP implementation
Implementation of a sexual assault EAP is inherently complex and will necessarily differ based on individual circumstances and organisational structures. To ensure that the EAP operates as effectively as possible and as intended, our Delphi panellists agreed that a sexual assault EAP should be rehearsed annually in small groups and involve team members in various roles. The sexual assault EAP is meant to be a dynamic document, and annual review and update was emphasised, with organisations encouraged to have systems in place for meaningful engagement around training personnel, tracking usage and debriefing after usage. To the best of our knowledge, there are no studies available within the sports medicine context; a simulation education event involving fourth year medical students led to competence interviewing sexual assault survivors and improved confidence in their skills.44 Annual practice of sexual assault EAPs in small groups, as suggested by the Delphi panellists, may help improve sports medicine physician competency and self-efficacy when supporting an athlete after sexual assault. This is crucial as competency in employing best practices for medical and psychological treatment, as well as survivors’ positive perception of help-seeking interactions, has been suggested to decrease long-term effects, including post-traumatic stress.34
Beyond the individual competency built around the use of the sexual assault EAP, it is critical to consider the organisational structures in which they are implemented. Sport environments, which have historically been noted as spaces with power imbalances and their own set of rules outside of the typical societal moral accountability, necessitate building a culture of readiness to engage (eg, cultural awareness of potential events) and recognition of violations before reporting can take place.45 While beyond the scope of this study, to avoid purely symbolic rather than meaningful policy implementation, sports medicine physicians, as leaders of athletes’ healthcare teams, should reflect on the institutional dynamics within their specific organisation to address potential barriers. Organisational change models suggest considering resource availability, culture, leadership engagement, knowledge accessibility and prioritisation to ensure successful implementation.46
A related concept emerged in the Delphi results suggesting that athletes should have access to the sexual assault EAP and any related Standard Operating Procedures, encouraging transparency about the expected process after disclosure. This is of particular importance in cases of sexual assault given that the sporting world has long been plagued by inadequate responses, secrecy and cover-ups in previous instances of these allegations leading to the survivor experiencing additional trauma.35 The importance of transparency is salient in the context of institutional betrayal, as introduced earlier in this paper, whereby inadequate response can cause additional harm to sexual assault survivors.47 48 This should serve as impetus for institutions to build appropriate partnerships and resource allocation to ensure that the full EAP can be realised. Failure to provide institutional support for key elements of the EAP may result in institutional betrayal, whereas effectively supporting meaningful implementation may contribute to institutional courage and improved outcomes on an individual, organisational and societal level.15
EAP templates
To help guide clinical practice, we present examples of an EAP template using these consensus-based recommendations for adult (figure 2) and minor (figure 3) athletes. There are different needs when responding to sexual assault for minors given differences in mandatory reporting requirements and consenting ability. Resources and best practices for care also differ. The minor EAP also includes the recommendation to include contact information for Child Protective Services and a paediatrician or family medicine physician specialising in child abuse, whereas including contact information for Adult Protective Services did not reach consensus for the adult EAP. While beyond the scope of this study, there may be circumstances related to adult athletes without decision-making capacity where inclusion of contact information for Adult Protective Services may be applicable.
Figure 2
Emergency action plan template for adult athletes. SAFE, Sexual Assault Forensic Exam; STI, sexually transmitted infection.
Figure 3
Emergency action plan template for minor athletes. SAFE, Sexual Assault Forensic Exam; STI, sexually transmitted infection.
A well-written EAP can minimise ambiguity, decrease the threshold required for action and simplify the process for easier use, potentially increasing reporting and effective impact.33 It may also address challenges around awareness of resources and policies due to the complexity of existing policies, practices and resources. Having consistent access to standardised and transparent resources on reporting and support systems has been suggested as a means to help improve these challenges.32
These EAPs represent a necessary starting point in the identification and development of resources to support comprehensive, trauma-informed care of athletes who experience sexual assault; however, future research should assess the ability to appropriately implement the EAP based on the level of sport and feasibility of adoption within the sports medicine community. This study is a first step in the identification and development of resources. Future work will include content and face validity exercises to ensure relevance, representativeness and comprehensiveness of the EAP template. We will also engage with athletes, researchers, policymakers and clinicians, including deliberate inclusion of those who hold marginalised identities and are part of under-resourced contexts, to qualitatively assess the barriers and facilitators to implementing the EAPs with different populations and in varying contexts. There is a pressing need for more research to evaluate additional requirements for supporting athlete survivors of sexual violence, as well as using implementation science to evaluate the effectiveness of any adopted interventions.
Limitations
While attempts were made to recruit a diverse, representative panel, our Delphi panel primarily consisted of women, those residing in suburban settings and those who identified as white and non-Hispanic. This potentially excludes valuable experiences and opinions from those in equity-deserving communities, which is particularly relevant given that individuals from under-represented groups experience disproportionate levels of sexual violence. Additionally, we used snowball sampling to increase athlete participation, which may have resulted in potential biases toward like-minded responses from these athletes. All our panellists resided within North America, which may limit generalisation of results to other parts of the world. While we used purposive sampling to identify those with requisite lived and practical experience, there was no standardised definition of ‘expertise’ among our panellists, which led to inclusion of individuals with varying levels of expertise in the field. We included a range of key groups in our panel, though after some attrition, the largest proportion were sports medicine physicians, which introduces the risk that the experience and perspectives of this group were overrepresented in the results. The recommendations contained here should be taken in light of these contextual factors. Via our modified Delphi approach, we conducted asynchronous, electronic surveys. Panellists were able to write anonymous comments to provide background on their selections, though it is likely that this format (as opposed to in-person discussion) limited in-depth exploration of this complex topic.
Based on panellist feedback during the open-ended round, the study team opted to improve internal validity by narrowing the scope to address only sexual assault, though this limits generalisability to other forms of sexual violence which are equally as important, necessitate competency in response and may also carry legal obligations. Future research should explore recommendations related to other forms of sexual violence. While the EAP developed in the current study is comprehensive, its implementation may be limited based on the setting. For example, NCAA Division I universities and elite sporting organisations will have greater access to resources, but implementing all elements of the EAP in the community setting may be less feasible. We encourage organisations to consider community partnerships which may help address these barriers.
