For years, USA Gymnastics felt it aggressively safeguarded hundreds of thousands of athletes from sexual abuse. Yet the protocols designed to show gymnasts, coaches, staff and parents how to report abuse were muddled, confusing and not well enforced.
The fallout, according to a former federal prosecutor hired to independently review the organization's handling of abuse cases, was "inadvertent suppression" and a culture that emphasized performance about protection.
A culture in desperate need of change.
"There needs to be a clear articulation that the culture is athlete safety first, not just success on the field," Deborah Daniels said Tuesday after releasing her lengthy report. "It needs to start with the board (of directors) and needs to permeate through the entire organization."
Daniels laid out 70 recommendations - all unanimously adopted by the board Monday night - aimed at giving USA Gymnastics more power to monitor the safety of 200,000-plus athletes affiliated with member gyms.
"We want to prevent abuse," Daniels said. "We know there will still be abuse occurring, (but we) want to make sure reporting and handling of report is done as well as possible."
USA Gymnastics ordered the review last fall following a series of civil lawsuits filed against the organization and a former team doctor by a pair of gymnasts who claim the physician sexually abused them during their time on the U.S. national team. USA Gymnastics has denied wrongdoing. The organization stated it went to authorities quickly in the summer of 2015 after hearing claims of abuse against Dr. Larry Nassar but later amended the timeline following a Wall Street Journal report, saying it conducted a five-week internal review before going to the FBI.
"A delay is impermissible," Daniels said.
A Michigan judge on Friday separately ordered Nassar to stand trial on charges of sexually assaulting six young gymnasts who said he molested them while they sought treatment for injuries. It is one of four criminal cases against Nassar in the state. The longtime Michigan State University doctor is a defendant or co-defendant in numerous civil suits.
John Manly, a California-based attorney whose firm is representing more than 100 alleged victims of abuse by Nassar, called the report "a public relations facade."
"The report calls for a change in culture but those who created the toxic culture remain in charge of the organization," Manly said in a statement. "The lack of any real investigation, facts or accountability for those who failed thousands of boys and girls victimized by Nassar and others in the report is disturbing."
Nassar's downfall began just weeks after the U.S. women's Olympic gymnastics team dominated the podium in Rio de Janeiro, taking home fistfuls of medals, including a second straight team gold and four total golds for all-around champion Simone Biles.
Instead of a victory lap, the organization has spent much of the last 10 months doing some soul-searching.
"We thought we were doing a lot," Chief Operating Officer Ron Galimore said. "We need to do better."
Enter Daniels, who interviewed more than 160 people affiliated with USA Gymnastics, visited 25 member clubs and attended a handful of competitions after being commissioned in November. She called for a "complete cultural change."
Getting there won't be easy. Even as the board endorsed Daniels' recommendations, it declined to set a timetable for full implementation, though board Chairman Paul Parilla stressed USA Gymnastics is "committed to strengthening our policy."
Daniels' recommendations include requiring all USA Gymnastics members to immediately report suspected sexual misconduct to legal authorities and the U.S. Center for SafeSport. Daniels also suggested USA Gymnastics prohibit adults from being alone with minor gymnasts "at all times" and bar unrelated adults from sharing or being alone in a sleeping room with gymnasts. She also recommended preventing adult members from having "out of program" contact with gymnasts through email, text or social media.
Daniels said athletes are taught to follow instructions and obey coaches and trainers, one of several factors discouraging reports of abuse.
"Athletes sometimes aren't aware of where the boundaries are, so they're not trained in that regard," Daniels said. "Parents aren't real sure (either)."
Daniels also suggested stripping membership from clubs that fail to report claims of child abuse, plus periodic random audits to see if updated policies are being obeyed. There are also plans to create a database that would allow member clubs to track coaches who switch clubs.
"USA Gymnastics has never felt it had the ability to exert influence over the club," Daniels said. "You can use membership to enforce the policies."
Daniels said the process USA Gymnastics had for investigating claims was "cumbersome" and "somewhat mysterious."
"There needs to be a very clear protocol for how these reviews are conducted, there needs to be a clear timeline," she said. "Frankly they need to be kept in a database."
While also taking the role of the USA Gymnastics president out of the equation. Former president Steve Penny resigned in March under pressure for the way the organization handled charges of sexual abuse. Daniels wants USA Gymnastics to remove the president from determining the disposition of allegations, having the board oversee the process instead. USA Gymnastics is in the process of finding Penny's replacement.
Many of the recommendations fall in line with policies put forward by the U.S. Center for Safesport. The organization operates independently from the U.S. Olympic Committee and organizations governing Olympic sports. The USOC and the 47 national governing bodies (including USA Gymnastics) help fund the center - about $13.3 million through five years - but don't have any say about how it operates or the cases it investigates.
Daniels believes the number of gymnasts abused nationwide through the years is "far higher" than what has been reported based on her experience as a federal prosecutor but stressed "my recommendations are forward looking and not in relation to anything that may have happened in the past."
She also believes third parties should be allowed to report suspected abuse.
"Young athletes (in their teens or younger) and their parents are highly unlikely to report ongoing abuse to the authority that has so much power over the athlete's success in the sport," Daniels wrote.
A notion Daniels hopes the recommendations in her report helps dispel.
"What we've recommended can't happen overnight, it will take thoughtful and strategic planning to implement," she said. "If USA Gymnastics adopts recommendations and implements them, it is poised to be in the forefront."