Image copyright Reuters Image caption The paedophile tried to claim his accusers "fabricated" allegations for money and fame
Ex-US Olympic gymnastics team doctor Larry Nassar has been sentenced to 40 to 175 years after testimony from nearly 160 of his victims.
The judge dismissed Nassar's attempted apology as insincere, saying he would "be in darkness the rest of his life".
Nassar pleaded guilty to 10 counts of sexual assault against girls and young women, including Olympians.
The 54-year-old had already been sentenced to 60 years for possession of child pornography.
Media playback is unsupported on your device Media caption Larry Nassar speaks as judge says 'I've signed your death warrant'
Judge Rosemarie Aquilina told Nassar during the sentencing: "As much as it was my honour and privilege to hear the sister survivors, it was my honour and privilege to sentence you.
"Because, sir, you do not deserve to walk outside of a prison ever again."
She told the paedophile: "You have not owned yet what you did. I wouldn't send my dogs to you, sir.
"I've just signed your death warrant".
Media playback is unsupported on your device Media caption What it was like to testify against Larry Nassar
Following seven days of emotional testimony from Nassar's victims, he was given an opportunity to address the court.
"What I am feeling pales in comparison to the pain, trauma, and emotional destruction that all of you are feeling," he told the packed courtroom.
"There are no words to describe the depth and breadth of how sorry I am for what has occurred," he added.
A story of survival
Rajini Vaidyanathan, BBC News, Lansing, Michigan
Throughout the seven-day hearing, the stories have been strikingly similar - the former USA Gymnastics team doctor would call the women in for treatment, but instead of taking away their pain, he stole their innocence. Some were so young they didn't realise until years later that they had been sexually abused.
As Larry Nassar sat in his prison overalls, just metres away from them, survivor after survivor looked him in the eye and reminded him of what he'd done to them. And that's been the most extraordinary thing about this hearing.
While the content of their testimony has been harrowing, it's also been inspiring. For survivors of sexual abuse it's hard to relive the experience, let alone do so in front of your attacker.
Follow @BBCRajiniV
But Judge Aquilina revealed he had written a letter to her after his guilty plea claiming his accusers had "fabricated" allegations to gain money and fame.
Court spectators gasped as the judge read a passage in which Nassar said he had been "manipulated" into admitting his guilt.
"I was a good doctor because my treatments worked, and those patients that are now speaking out are the same ones that praised and came back over and over," Nassar wrote.
He added in the letter: "Hell hath no fury like a woman scorned."
As the judge finished her sentence, witnesses in the packed courtroom stood and applauded her verdict.
His sentencing follows a week of harrowing testimony from scores of women, including Olympic gold medal gymnasts Aly Raisman and Jordyn Weiber.
Media playback is unsupported on your device Media caption Racheal Denhollander speaks at Larry Nassar trial
Their teammates, McKayla Maroney, Gabby Douglas and Simone Biles, also revealed they had been abused by Nassar.
In 2015, USA Gymnastics - the sport's top governing body - quietly cut ties with Nassar over allegations about his professional care.
An investigation in 2014 resulted in a three-month suspension from Michigan State University (MSU), where he coached.
But he continued to see patients until he was publicly accused of abuse in a 2016 report by the Indianapolis Star newspaper.
Later that year, he was arrested and charged by Michigan officials with sexual contact with a child.
A year later, he was sentenced for child abuse images found on his computer.
Media playback is unsupported on your device Media caption Sister survivors condemn master manipulator
Rachael Denhollander, who was one of the first women to publicly accuse Nassar, pointed the finger at MSU in court on Wednesday.
"How much is a little girl worth? How much is a young woman worth?" Ms Denhollander, now a lawyer, asked as she described the abuse that occurred when she was 15 years old.
"No one believed because they did not listen," she said, recounting the several times victims told MSU of their allegations.
"Victims were silenced, intimidated, told they were receiving medical treatment, and at times sent back to be further abused.
"This is what it looks like when institutions create a culture when a predator can behave unabated."
Skip Twitter post by @Simone_Biles To Judge Aquilina : THANK YOU, YOU ARE MY HERO
Shout out to all of the survivors for being so brave & speaking like the queens that you are while looking at that monster. He will no longer have the power to steal our happiness or joy. I stand with every one of you 💛 pic.twitter.com/b5SMmjZgeW — Simone Biles (@Simone_Biles) January 24, 2018 Report
Ms Denhollander said trauma at the abuse she suffered had "cast a horrific shadow" over her medical care when she gave birth to three children, including two daughters.
As the court adjourned on Wednesday, the US Olympic Committee (USOC) announced it would hold an independent investigation into the sex abuse scandal.
"The USOC has decided to launch an investigation by an independent third party to examine how an abuse of this proportion could have gone undetected for so long," USOC chief executive Scott Blackmun wrote in an open letter.
On Tuesday, the National Collegiate Athletic Association (NCAA) said it would investigate MSU's original handling of the gymnasts' abuse claims.
Hours after Nassar's sentence was read, lawmakers in the Michigan House of Representatives overwhelmingly approved a resolution calling on the head of MSU to resign.
"We have lost confidence in the ability of President Lou Anna K Simon to lead a transparent investigation, to implement changes that will ensure it never happens again, to protect students, and to lead Michigan State University forward," the resolution said.
Media playback is unsupported on your device Media caption What it was like to testify against Larry Nassar
Former Olympic doctor Larry Nassar has been handed a jail sentence of 175 years in Michigan for abusing female athletes he was supposed to be treating.
Here, the BBC's Rajini Vaidyanathan, who was in court, and Roland Hughes detail the extraordinary testimony given in court by the survivors of his abuse.
This article contains graphic details of sexual abuse
One hundred and fifty-six young women - mothers, sisters, daughters, Olympians.
All say they were abused by the same man: former Team USA gymnastics doctor Larry Nassar.
Over seven days, they took to the stand one by one to do what few survivors of sexual abuse ever get the chance to do - directly confront their attacker.
Nassar had already pleaded guilty to 10 counts of sexual assault for abusing young girls under the guise of medical treatment.
Women who filed criminal complaints against Nassar spoke out at his sentencing hearing in Lansing. But they were followed by close to 150 others, many of whom chose to do so without the anonymity to which they were entitled.
Kyle Stephens was the first to tell her story.
For years she was known only as Victim ZA, but last Tuesday morning, she stood before Judge Rosemarie Aquilina and calmly shared her name.
In doing so, she waived her anonymity in public just as she was about to testify to the damage her abuser had done.
"I was ready to speak," Kyle said in an interview with the BBC after her testimony. "I think it was really empowering to get up there and give my story from start to finish."
For decades, Larry Nassar abused young women. It was Kyle's call to police that led to him finally being arrested.
Unlike many of the other women who shared their stories in this case, Kyle wasn't a gymnast and a patient of Nassar's. Her parents were friends with his family.
As she stood in the small courtroom, photos of her as a smiling child were projected on to a screen. Nassar first abused her when she was six, "when I still had not lost all my baby teeth".
Image copyright Kyle Stephens Image caption Images of Kyle Stephens as a child were projected on to a screen in court
It began with him exposing himself. Later, he would masturbate before her. Then, he physically abused her - all while both their families were in the same house.
When Kyle, aged 12, told her parents that Nassar would rub his erect penis on her bare feet, he denied it. Back then, her parents did not believe her, and urged her to apologise to him.
"He forced me to grow up really fast," Kyle told the BBC after the hearing. "It was such a benign action until you grow up and realise it was a vile thing."
Image copyright AFP/Getty Images Image caption Kyle Stephens addressed Nassar (foreground) in court
Seven minutes into her testimony last Tuesday, delivered alongside her mother, Kyle looked up at Judge Rosemarie Aquilina and politely asked if she could address Nassar directly.
She reminded him of how her parents invited him round to their home after she had accused him. Sitting in her living room, he had denied abusing her and had said that if she was ever really abused, she should remember to report it.
"Well Larry, I'm here," she told him in court. "Not to tell someone, but to tell everyone.
"Perhaps you have figured it out by now, but little girls don't stay little forever. They grow into strong women who return to destroy your world."
In her teens, Kyle was asked to babysit Nassar's two daughters. Doing so helped her protect them, she told the court, and allowed her to save enough money to pay for counselling.
Having reached a point where she had started to question whether the abuse had indeed occurred, she tried again to explain to her parents what had happened.
This time, they believed her.
Nassar, 54, graduated from the University of Michigan in 1985 and joined the medical staff of the US national gymnastics team based in Indianapolis a year later.
In 1997, alongside his work with the national gym team, he began working as a team physician at Michigan State University (MSU). He began abusing Kyle Stephens a year later.
He worked for the US gymnastics team in four Olympic Games, regularly rushing to the help of gymnasts who might have fallen awkwardly.
Image copyright IOP/AFP/Getty Images Image caption Many of Nassar's victims cited the moment he helped injured gymnast Kerri Strug at the 1996 Olympics, a moment that boosted his reputation as a caring, well-respected doctor
Carrie Hogan, a former softball player at MSU, told the court it was seen as a "privilege" to be treated by Nassar. Successful treatment could make a difference to the university's stars on the brink of a sports career.
"I was very aware of the signed photographs of the Olympic gymnasts he had treated," she said. "He was the best of the best." Others said he was seen as a "god" in the gymnastics world.
In an episode of a gymnastics podcast broadcast in December 2013, Nassar spoke about how important it was to look after young athletes.
"Not just physically but mentally, you have to protect your athletes," he told GymCastic, speaking uncharacteristically slowly. "You have to let them know they will be cared [for]."
He also warned of the danger of mental injury to athletes, saying "the physical injuries almost always they can recover from. The mental injury leaves the scars that keep coming back and haunt them later."
Many of the women who spoke in court said that after he abused them, they were intimidated by his powerful status.
Reporting the offence - if they understood that they had been subject to an offence at all - felt almost impossible.
Nassar had a strikingly similar pattern of how he abused young women, the vast majority of whom were gymnasts.
They came to him often in pain, looking for help.
At their most vulnerable moment, he tried to convince them what he was doing was normal - even talking about everyday life and joking as he touched them.
Media playback is unsupported on your device Media caption Former gymnast Jeanette Antolin: 'You made me believe you were my friend'
By projecting a sense of normality from his position of authority, Nassar made his victims feel they were wrong to believe this was abuse, and that they would be in the wrong if they complained.
"I remember having the option of keeping my spandex on, which I was very grateful for and chose," said Jennifer Rood Bedford, a volleyball player at MSU between 2000 and 2003.
"He had me lay down face down on the medical table. When he started treatment, I remember him saying his treatment relied upon applying pressure to areas around the pelvis and that this was normal.
"So when he went down there, I just told myself it was normal, that he knows what he's doing and don't be a baby.
"I remember laying there and thinking 'Is this OK? This doesn't seem right'."
Rachael Denhollander, a former gymnast from Michigan, was the first victim to speak up publicly in 2016.
She told the BBC that Nassar abused her during every visit she made to his clinic over a year after she turned 15.
Nassar would position Rachael's mother at the head of the table so she was not able to see what he was doing.
With one hand, he would carry out sports massage. With the other, covered by a towel, he would insert his fingers into Rachael's vagina or anus. In one of their last sessions, he unhooked her bra and fondled her breast - the only time Rachael said she knew she was definitely being assaulted and not treated.
Media playback is unsupported on your device Media caption Nassar reacts as former gymnast Gwen Anderson testifies
Many of the women said their trust in male relatives, partners, doctors, strangers, friends and teachers was destroyed as a result of Nassar's actions.
"My first reaction was to question myself, to blame myself," said Jennifer Rood Bedford.
"I wanted to believe the best in people, but no matter how much I rationalised - he's a doctor, he's treating you, he didn't mean for that to happen - I couldn't shake the voice in my head that something wasn't right."
If you have been affected by child sexual abuse, sexual abuse or violence, help and support is available.
If you are in the UK, you can find links here: BBC Action Line
If you are in the US, you can contact Rainn, the national sexual abuse hotline, here, or by calling 800.656.HOPE
For Gwen Anderson, a former gymnast who competed for her state of Michigan, the abuse began when she was just 12.
Now, as a teacher to girls of the same age, she says she sees Nassar's actions in an even starker light.
"I teach 12, 13, 14-year-olds every day," she told the court. "And every single day, when I look at them, I am faced with the reality of how young and defenceless we were when you molested us.
"I look at them every single day and I think to myself 'I am their safe place. I am their protector. I am their encouragement. I am their motivator. I am their rock'."
It is unclear when and how Nassar's abuse of his patients started, though the first allegations date to 1994.
In August 2016, the Indianapolis Star published a story detailing allegations of sexual abuse committed by coaches working for USA Gymnastics. It claimed that the sporting body did not report allegations of abuse to relevant authorities.
The initial article did not name Nassar. But after it was published, Rachael Denhollander realised this was her chance to speak up.
The newspaper published allegations against him from two named former gymnasts, including Rachael, a month later.
"I knew this was how it was going to have to be done," she told the BBC outside court. "When you have a predator who is surrounded by two very powerful institutions, one anonymous voice is never going to be enough.
"When you have a predator who is manipulative, gregarious and as engaging as Larry is, you have to be willing to meet him where he is the most comfortable - on very public ground. And never flinch."
Media playback is unsupported on your device Media caption Gold medallists Raisman and Wieber face their abuser
Rachael's bravery helped encourage other women to come forward. In the corridors outside the sentencing hearing, countless women cited Rachael's actions as inspiration for their own decision to speak up.
As a result, instead of 90 survivors sharing their stories of abuse over four days - as had been expected at the start of the hearing - 156 women and girls ended up doing so over seven days.
The feeling in the courtroom throughout was one of collective empowerment and solidarity built through a shared experience of horror.
Last week, four-time Rio Olympic champion Simone Biles issued a statement to say she too had been abused by Nassar. On Friday, Olympic gold medallists Aly Raisman and Jordyn Wieber came to court to detail what he did to them during the 2012 Games in London.
Nassar was eventually arrested on 21 November, 2016.
He was sentenced to 60 years in jail a year later for three counts relating to child sex abuse images on his computer.
He then pleaded guilty to molesting females at his home, at a gymnastics club and in his MSU office, a plea that led to the 156 pre-sentence testimonies.
"I realise what I am feeling pales in comparison to the pain, trauma and emotional disturbance that I have wreaked," Nassar told the survivors as the hearings drew to a close.
"There are no words that can describe the depth and breadth of how sorry I am for what has occurred.
"I will carry your words with me for the rest of my days."
At the start of the hearings, Nassar had stared blankly down at his hands, avoiding eye contact with all those who came forward to speak.
But on Wednesday, his former colleague, gym coach Tom Brennan, stood alongside Gwen Anderson while she was testifying. "Look at her," he yelled at the man he called his former mentor, ordering him to pay attention to the women as they testified.
After that, Nassar appeared to look up and listen to the survivors with greater frequency.
The question of how repentant he was remained unanswered at the end of the hearings, however: Judge Aquilina read excerpts of a letter he sent her, saying he was a good doctor, and that the media had convinced the young women to believe he had acted wrongly.
Media playback is unsupported on your device Media caption Judge Aquilina: 'I have just signed your death warrant'
Judge Aquilina's role in this case was crucial. Almost every testimony began with survivors thanking her for her support and encouragement.
Given that Nassar had admitted his guilt months before, Judge Aquilina had no obligation to be impartial. As she took on the role of therapist, advocate and friend to the women who stood before her, she condemned his actions.
"The monster who took advantage of you is going to wither, much like the scene in the 'Wizard of Oz' where the water gets poured on the witch and the witch withers away," she told one woman after her testimony.
She also encouraged a number of the abuse survivors not to kill themselves when they said they had considered suicide - taking their own lives would hand Nassar victory, she said.
"I know you're a little nervous, pretend you're talking to me and your mum," she told one another woman as she prepared to deliver her testimony.
A crime writer in her spare time, Judge Aquilina's words were a powerful force throughout the hearing. She described the women as "sister survivors" and "warriors" who had demonstrated "superwoman steel."
"I didn't want even one victim to lose their voice," she told the court, as she explained why she was prepared to let the hearing go on for as long as it took to hear all of the survivors who wanted to speak.
The survivors, in turn, responded. One after the other waived their anonymity and came to realise this was a chance to take charge of their own story.
Media playback is unsupported on your device Media caption Tiffany Thomas Lopez: "You created an army when you violated us"
Not all the women knew each other, but many acknowledged the invisible bond between them, and the strength they had gained from the others who had spoken in court.
One former MSU softball player, Tiffany Thomas Lopez, told Nassar she was part of "the army you created when you violated us", going on to say: "Your actions have had me by the throat for years. I'm ready to be released from your clench."
As the hearings went on past the four days that were initially scheduled, anger gradually built towards the institutions where Nassar worked.
Aly Raisman, part of the gold medal-winning gymnastics team in the 2012 Olympics, demanded an independent investigation into how Nassar was allowed to continue abusing girls even after complaints were made.
She attacked both USA Gymnastics - an organisation she said was "rotting from the inside" - and the US Olympic Committee for their lack of support. Three senior USA Gymnastics board members subsequently quit.
The focus has now shifted on to who knew what, and when.
Image copyright Reuters Image caption Rachael Denhollander, "the five-star general in the army of survivors"
The Lansing State Journal newspaper reports that seven women or girls made complaints about Nassar to coaches, trainers, police or university officials between 1997 and 2015.
In 2014, an investigation by MSU even cleared Nassar of wrongdoing after a recent graduate accused him of molesting her. Two years later, he was under arrest.
The university has put aside $10m (£7.2m) to reimburse former students for counselling, but is being sued by about 140 women.
On Friday, MSU's board of trustees asked the Michigan attorney general's office to conduct an outside review into how it handled the allegations. There is also growing pressure on MSU President Lou Anna Simon.
As Nassar starts his jail sentence - brought about by a team of female investigators, prosecutors and judges - the battle to seek answers from the authorities is only just starting. Why did they not listen to survivors' stories sooner?
Rachael Denhollander, now a mother of three and a lawyer, was the last to give her testimony on Wednesday. Judge Aquilina called her "the five-star general in the army of survivors".
For Rachael, the sentence has been a vindication of her decision to speak out publicly 16 months ago.
"I'm so deeply grateful for where we are," she told the BBC. "But it's absolutely heartbreaking to me.
"To know that the vast majority of those little girls could have been saved from what they went through is devastating."
If you have been affected by child sexual abuse, sexual abuse or violence, help and support is available.
If you are in the UK, you can find links here: BBC Action Line
If you are in the US, you can contact Rainn, the national sexual abuse hotline, here, or by calling 800.656.HOPE
The two-time Olympic gymnast Aly Raisman confronted the former USA gymnastics doctor Larry Nassar in court during his sentencing hearing. More than 100 girls and women – including Raisman and her fellow Olympic champions Simone Biles, Gabby Douglas and McKayla Maroney – came forward to describe the impact of his abuse. 'Abusers, your time is up,' said Raisman.
Gymnastics Larry Nassar's 'death warrant': sexual abuser jailed for up to 175 years Nassar given between 40 and 175 years in prison in abuse trial
A total of 156 survivors gave victim impact statements in court
Disgraced physician was already facing 60 years in separate case Play Video 1:42 'Little girls don't stay little forever': abuse victims confront Larry Nassar – video
The former USA Gymnastics team doctor Larry Nassar has been sentenced to between 40 and 175 years in prison for abusing athletes in his care. Judge Rosemarie Aquilina reached her decision after a sentence hearing that heard from dozens of women and girls, including Olympic champions Aly Raisman and McKayla Maroney.
Victim impact statements against Larry Nassar: 'I thought I was going to die' Read more
Nassar, who also treated athletes at Michigan State University, had already admitted in November to molesting seven girls in his care under the guise of treatment. But a total of 156 girls and women came forward to speak at the seven-day sentencing hearing, saying they had also suffered abuse at his hands, with two dozen more submitting private letters to the court. The sheer volume of survivors who wanted to tell their story meant that the hearing, which was initially expected to last four days, stretched into a second week.
“It is my honor to sentence you because, sir, you do not deserve to walk outside of a prison ever again,” the judge said. “Anywhere you walk, destruction would occur to those most vulnerable.”
She added: “I just signed your death warrant.”
Play Video 2:41 'Larry Nassar, I hate you': abuse victims in their own words – video
Aquilina said the sentence reflected not only the seven counts to which Nassar pleaded guilty, but also the survivors who came forward during the sentencing hearing “because the depth of all of your crimes have cut into the core of this community”.
“The breadth and ripple of this defendant’s abuse and destruction is infinite,” prosecuting attorney Angela Povilaitis said in her closing remarks. “Nassar used his prestige to gain [his victims’] trust and to exploit them, leaving many of them emotionally shattered by a man they not only trusted but loved. In competitive gymnastics, he found the perfect place for his master manipulation.”
The disgraced physician gave a brief statement before Aquilina handed down the sentence, acknowledging the “pain, trauma and emotional destruction” experienced by his victims.
“Your words these past several days have had a significant emotional effect on myself and have shaken me to my core,” he said. “I will carry your words with me for the rest of my days.”
“Sir, I hope that’s true,” the judge said after Nassar concluded.
Aquilina read portions of the six-page, single-spaced letter Nassar wrote to the judge last week in which he said it was too difficult for him to listen to the victim impact statements, citing it as proof that “you have still not owned what you did”.
“Would you like to withdraw your plea?” the judge asked.
“No, your honor,” he said.
“Because you’re guilty, aren’t you, sir?”
“I accept my plea.”
Rachael Denhollander, one of three survivors to speak on Wednesday, was “absolutely” satisfied with the sentence on a day she wasn’t sure would ever come when she became the first of Nassar’s victims to come forward publicly in September 2016.
“The number of sexual assault victims Larry had was plain to me,” she said. “Whether or not anyone would feel safe to come forward, that was the wild card.”
After Aquilina delivered the sentence, the US Olympic Committee called on the directors of USA Gymnastics to resign. “The purpose of this message is to tell all of Nassar’s victims and survivors, directly, how incredibly sorry we are,” the USOC chief executive, Scott Blackmun, wrote in an open letter. “We have said it in other contexts, but we have not been direct enough with you ... The Olympic family is among those that have failed you.”
Those who confronted Nassar in the Michigan courtroom included household names such as Raisman and Maroney but most of those he abused never reached the elite level. The first witness in court when the hearing started last week was Kyle Stephens, who told the court she was abused by Nassar, a family friend, between the ages of six and 12. “Perhaps you have figured it out by now, but little girls don’t stay little for ever,” Stephens said. “They grow into strong women that destroy your world.”
Simone Biles, one of the stars of the Rio Olympics, said she had also been abused by the 54-year-old although she chose not to appear in court. “Most of you know me as a happy, giggly, and energetic girl,” the four-times Olympic gold medalist wrote on Twitter last week. “But lately I’ve felt a bit broken and the more I try to shut off the voice in my head the louder it screams. I am not afraid to tell my story anymore.”
Michigan State University, USA Gymnastics and the USOC have all been named as co-defendants in civil suits that appear headed to trial, with allegations that officials knew about Nassar’s abuse. One of the most vocal critics of the organisations that allegedly enabled Nassar has been Raisman.
Play Video 1:58 'I'm a survivor': US Olympian confronts abuser Larry Nassar in court – video
“Adult after adult protected you,” Raisman, who won gold medals at the 2012 and 2016 Olympics, said when she appeared in court last week. “How do you sleep at night? You are the person they had ‘take the lead on athlete care’. I cringe to think your influence remains in the policies they [USA Gymnastics] claim will make athletes safe.
“I will not rest until every last trace of the influence you had on this sport has been destroyed like the cancer it is.”
Raisman also told ESPN that USA Gymnastics “told [her] to be quiet” when she first told the organisation she had been abused by Nassar.
On Monday, three USA Gymnastics board members resigned over the scandal. Raisman took the USOC to task for taking credit for the resignations. “The Indy Star broke on August 4, 2016 after survivors courageously came forward sharing stories of sexual abuse and alleging organizational mishandling,” Raisman wrote on Twitter. “The next day, the USOC said they wouldn’t investigate (and even praised USAG’s work in the area of sexual abuse).
“For the past week, survivors came forward to courageously face a perpetrator of evil and to share their painful stories. Many of them, myself included, claim the USOC is also at fault. Was the USOC there to ‘focus on supporting the brave survivors’? No. Did they issue any statement then? Crickets …”
There have also been calls for the resignation of Michigan State’s president, Lou Anna Simon – including a scathing front-page editorial by the independent student newspaper that cast “Simon, her appointees and cheerleaders” as “enablers”. Simon has so far declined to stand down. Nassar was employed as a sports physician at the Lansing school from 1997 to 2016.
Nassar had already been sentenced to 60 years in prison in a separate case, regarding child abuse images.
