Name, Image, and Likeness and the Health of the Young Athlete: A Call to Action for Sports Medicine Providers and the Athletic Healthcare Network

Abstract

Context:

In June 2021, the National Collegiate Athletic Association (NCAA) adopted a new policy allowing NCAA athletes the opportunity to benefit and profit from their name, image, and likeness (NIL). Several state high-school associations have established policies to guide their members and students through the new era of NIL. While the potential benefits cannot be ignored, NIL presents novel responsibilities and stressors to athletes. This paper will review the paucity of literature on the effect of NIL on youth athletes and bring attention to mental health, well-being, or academic performance impacted by NIL.

Evidence Acquisition:

Articles were identified through Google and PubMed search starting from NIL policy approval (June 30, 2021). Search terms included “name, image and likeness” and “NIL.”

Study Design:

Clinical commentary.

Level of Evidence:

Level 5.

Results:

Although 1 article was identified through PubMed search and numerous articles were identified through Google search, no articles directly evaluated the effects of NIL on the mental health, well-being, or academic performance of youth athletes.

Conclusion:

It is critical for sports medicine providers and other members of the athletic healthcare network to familiarize themselves with these emerging topics to best serve their patients and communities. The athletic healthcare network must be prepared to address possible NIL-related health ramifications for our patients and their families and help them navigate a confusing and predatory landscape. We must provide resources to youth athletes to minimize the risks associated with NIL involvement and related activities, and to ensure that athletes with NIL contracts are able to balance their academic and athletic responsibilities. Fostering strong relationships between stakeholders and sports medicine staff is paramount to creating an environment that permits honest discussions about NIL and the health of athletes from youth to adulthood.

Strength-of-Recommendation Taxonomy:

N/A.

In June 2021, the National Collegiate Athletic Association (NCAA) adopted a new policy allowing NCAA athletes the opportunity to benefit and profit from their name, image, and likeness (NIL). NIL policy is governed by individual state legislature and, moreover, the ability of high school athletes to receive NIL deals is regulated by individual state high school athletic associations. As of June 2023, 30 state high school associations permitted high school athletes to monetize through NIL while maintaining high school eligibility. ¹⁵ Several state high school associations have established policies to guide their members and students through the new era of NIL. Although varying state to state, most NIL contracts allow for the promotion of the student athlete’s own identity via a brand or business. However, payment for performance-related activities is prohibited if they imply endorsement or sponsorship of clothing or gear depicting the name/logo of the school or reference to state association accolades or championships.^1,2 Despite allowing athlete compensation, legal and legislative clarity as well as a national permanent singular solution remains lacking not only for institutions but for the student-athletes and their families. Our position is not to debate the merits of NIL as it pertains to amateurism, entrepreneurship, or an athlete’s ability to earn money. Instead, as NIL opportunities move to younger age groups, and with so many basic questions left unanswered, this article will bring attention to how NIL may affect the mental health, well-being, or academic performance of youth athletes. It is critical for sports medicine providers and members of the athletic healthcare network to familiarize with these emerging topics to best serve their patients and communities.

Literature Review

A PubMed search was performed on April 1, 2023, using search terms “name, image and likeness” and “NIL” starting from NIL policy approval (June 30, 2021). One article included NIL when evaluating supplement use in NCAA athletes. ⁸ A Google search with our search terms was also completed on April 1, 2023. While there are numerous nonpeer-reviewed articles discussing NIL and its consequences, we did not identify any articles that directly evaluated the effects of NIL on mental health, well-being, or academic performance of the youth athlete.

NIL Effect on Athlete Mental Health/Well-being

As the world of NIL in college and high school sport is new, there is a paucity of data relating to the impact of these changes on athlete mental health. Athletes struggle with mental health issues, often at different rates and in different ways than the general population. ¹⁷ Youth and high school athletes endorsed higher levels of depression, anxiety, dejection, anger, and decreased quality of life and sleep when compared with pre-COVID-19 pandemic levels.^4,11-14,16 Critically, this timeframe also encompasses the implementation of NIL. Moreover, Table 1 lists potential negative interactions and consequences of NIL in which sports medicine providers should be aware.

Table 1.

Potential negative interactions and consequences of NIL participation

Extrinsic	Intrinsic	Extrinsic/Intrinsic
Coercion to participate for benefit of others	Contracts that pressure receiving care outside of medical home (eg, outside of school medical staff)	Loss of eligibility/scholarships for students who unknowingly violate NIL rules or who engage in unauthorized endorsements
Increased risk for abuse (eg, financial, psychological, physical, sexual, verbal, identity)	Pressure to engage in excessive and detrimental self-promotion and brand management	Shift in priority away from team success to individual success (eg, leading to distraction and source of conflict among teammates)
Child and adolescent exploitation by parents, agents or endorsers who will benefit from their participation	Contracts promoting products conflicting with the physical or mental health and safety of the athlete or the public (eg, alcohol, nicotine products, supplements with prohibited substances, exercise equipment/programs, medical procedures) or unknowing use of products containing prohibited substances
Increased influence of external stakeholders (eg, boosters, sponsors)
Recruiting power dynamics strengthening high-profile schools and weakening low-profile schools

NIL, name, image, and likeness.

Pressure From Compensation

Athletes who receive financial scholarship assistance may experience added stress related to financial compensation. NIL participation may increase and/or lead to pressure like the extra stress of athletes who receive academic financial scholarships. Student-athletes already experience tremendous pressure to perform athletically. This can also be compounded by academic responsibilities and personal and social obligations. Scholarship athletes may feel an intense pressure to play and perform, even beyond what they may feel their mind and body are capable. Injured athletes or those who experience mental health struggles may be influenced to persevere beyond their limit due to fear of losing their scholarship. Moreover, fear of reinjury can impact recovery and return to play. Once NIL contracts are established, athletes undertake the added burden of sustaining their performance for the entities to which they have licensed their name, image and/or likeness. This may be additive to stressors already experienced if the athlete is also receiving an academic scholarship. In addition, the pressure to also retain an NIL contract may further tip the scale of athletic enjoyment towards stress to perform, potentially uncovering or exacerbating underlying mental health conditions.

Pressure From Media

This current generation of athletes face a new frontier of public scrutiny through NIL. Whereas athletes were previously marketed via print, radio, and TV, current athletes must also contend with social media, which grants the public access to information about an athlete on a 24/7 basis and presents the opportunity for reciprocal communication through comments and sharing. High-profile athletes may even be assigned a social media manager to enhance their social media engagement. A total of 83% of fans interact with some kind of social media platform while watching an event on television. ¹⁰ Athletes with an NIL contract may be exposed to excessive or problematic social media use. There is a complex interplay between the use of social media and mental well-being, with problematic or excessive use of social media linked to worse mental health outcomes, something that was also exacerbated by the COVID-19 pandemic. ⁷

Impact on Team Dynamics

The social comparison theory posits that a person gauges their self-worth based on their own performance in various markers relative to their peers. ⁵ NIL brings an entirely new set of data with which an athlete may now evaluate themselves (ie, sponsorship, revenue, social media presence, etc). This can shift an athlete’s motivation to participate in sports away from intrinsic factors (eg, love of the game, personal goals, career/education ambition) to extrinsic factors (eg, financial gain, family/peer expectation, goals of sponsors, number of likes). This may cause a detrimental shift in priorities from an athletic goal or personal self-worth to whether their sponsorship is as lucrative as a teammate’s or how their social media presence compares with that of their peers.

NIL Effect on Academics in Youth Athletes

Potential Positive Effects

Because athletes must meet academic standards to maintain their athletic eligibility, athletes with NIL contracts may be more motivated to succeed academically to maintain their athletic eligibility. ⁹ As a result, NIL may increase commitment to their global success, including academics and athletics. Also, the financial equity offered by NIL may reduce financial educational burdens thereby increasing well-being and academic performance. For example, financial compensation obtained through NIL contracts may be particularly valuable to disadvantaged populations. In addition, the ubiquity of social media can help underrepresented athletes and sports gain extra recognition.

Potential Negative Effects

The emerging financial and social benefits of NIL may lead athletes to prioritize athletic endeavors over academic pursuits. Moreover, NIL creates multifactorial pressures (ie, brand management, social media presence, legal engagements, contractual obligations) that could lead to academic burnout. These new demands are also time consuming and may further distract athletes from their academic responsibilities. Overall, it will be important to offer resources and support to help athletes with NIL contracts successfully manage the balance between their academic and athletic responsibilities.

NIL Effect on Further Professionalization of Youth Sports

Youth athletes may be influenced by the potential to participate in sport at the college and/or elite level. NIL policies offer new pressures to succeed athletically to attain social and financial benefits. Such additive pressures may encourage intensive training, single-sport specialization, and sport professionalization at the youth and high school level. Because excessive focus on early intensive training and single-sport specialization in youth athletes is associated with increased risk of overuse injury and burnout, it will be important to provide resources to help promote overall athlete well-being, balance the demands of NIL participation on sports specialization, and provide education about the risks of excessive sport participation. ⁶

NIL Effect on Diversity, Equity, and Inclusion in Youth Sports

Numerous social determinants of health among youth and high school athletes also contribute to inequities in access and resources for sports participation. NIL policies may further broaden these inequities. Athletes may be influenced to enroll in programs with higher profiles and budgets to greater influence their own earning potential regardless of academic, social, or athletic fit. Also, an athletes’ socioeconomic status may impact their access to social media and brand management opportunities. These factors could directly translate to reduced NIL opportunities, further exacerbating inequitable access for specific groups of youth athletes.

Although athletes from disadvantaged backgrounds may have less access to NIL opportunities, the financial compensation and brand awareness through NIL may enable athletes from disadvantaged backgrounds to afford additional athletic endeavors. This could also open opportunities for them to engage in areas that were previously blocked to them.

Additional Considerations for the Sports Medicine Provider

As trusted providers, we must be equipped to help our youth athletes and their families navigate a potentially problematic and predacious environment. Although recent NIL rulings state that athletes can generate revenue, they are still constrained by complex and constantly evolving regulations. Navigating NIL relationships, pursuing sponsorship, and developing a model for self-promotion can be extremely complicated, especially when added to the mix of personal, academic, and athletic obligations. Athletes may need lawyers, agents, accountants, and financial advisers who can help them in this process; 40% of NCAA athletes have expressed a desire for more resources navigating NIL. ³ The fact that such a high number of college athletes feel that they are lacking in terms of this resource indicates a potential source of stress, as well as an opportunity to provide additional support to the youth athlete population.

Youth athletes may not have the ability to deal aptly with the financial gains achieved through NIL endorsements. An adult or fiduciary can help manage these new resources. However, these relationships can also be a source of contention and stress when the athlete’s well-being is not at the forefront. High-profile athletes, even if not necessarily the most talented, will benefit from NIL endorsements to a greater extent than their peers. An athlete struggling with these issues may benefit from collaboration with a sports psychologist with experience helping athletes navigate transitions between different levels of play.

Conclusion

NIL has arrived and is here to stay; its risks and benefits should not be ignored. We hope that this article raises awareness in the sports medicine community, prompting athletic healthcare professionals to seize the opportunity to educate themselves and their athletes on NIL-related issues. Health and safety protections, especially for younger and more vulnerable populations, need to be developed and implemented as NIL creates both opportunities and risks. We need to be prepared to address the possible health ramifications for our patients and their families as well as provide help to navigate a more confusing and predatory landscape. Fostering strong relationships between stakeholders and the sports medicine staff is paramount to creating an environment that allows for honest discussions about NIL and the health of athletes from youth to young adulthood. Future studies are necessary to investigate the potential effects of NIL on mental health, well-being, or academic performance of youth athletes.