1. Baron DA, Martin DM, Abol Magd S. Doping in sports and its spread to at-risk populations: an international review. World Psychiatry. 2007;6:118–123.[PMC free article][PubMed]
2. Catlin DH, Murray TH. Performance-enhancing drugs, fair competition, and Olympic sport. JAMA. 1996;276:231–237.[PubMed]
3. Fernandez MM, Hosey RG. Performance-enhancing drugs snare nonathletes, too. J Fam Pract. 2009;58:16–23.[PubMed]
4. Metzl JD, Small E, Levine SR, Gershel JC. Creatine use among young athletes. Pediatrics. 2001;108:421–425.[PubMed]
5. Uvacsek M, Nepusz T, Naughton DP, Mazanov J, Ranky MZ, Petroczi A. Self-admitted behavior and perceived use of performance-enhancing vs psychoactive drugs among competitive athletes. Scand J Med Sci Sports. 2011;21:224–234.[PubMed]
6. National Institute on Drug Abuse, US Department of Health and Human Services Monitoring the future national survey on drug use, 1975–2003, volume II. College students and adults ages 19–25. [Accessed June 12, 2014]. Available from: http://www.monitoringthefuture.org/pubs/monographs/vol2_2003.pdf.
7. Green GA, Uryasz FD, Petr TA, et al. NCAA study of substance abuse habits of college student-athletes. Clin J Sports Med. 2001;11:51–56.[PubMed]
8. Kersey RD, Elliot DL, Goldberg L, et al. National Athletic Trainers’ Association position statement: anabolic-androgenic steroids. J Athl Train. 2012;47:567–588.[PMC free article][PubMed]
9. Cottler LB, Abdallah AB, Cummings SM, Barr J, Banks R, Forchheimer R. Injury, pain, and prescription opioid use among former National Football League (NFL) players. Drug Alcohol Depend. 2011;116:188–194.[PMC free article][PubMed]
10. McDuff DR, Baron D. Substance use in athletics: a sports psychiatry perspective. Clin Sports Med. 2005;24:885–897.[PubMed]
11. Wanjek B, Rosendahl J, Strauss B, Gabriel HH. Doping, drugs and drug abuse among adolescents in the State of Thuringia (Germany): prevalence, knowledge and attitudes. Int J Sports Med. 2007;28:346–353.[PubMed]
12. Botre F, Pavan A. Enhancement drugs and the athlete. Phys Med Rehabil Clin N Am. 2009;20:133–148.[PubMed]
13. Morse ED. Substance use in athletes. In: Baron DA, Reardon CL, Baron SH, editors. Clinical Sports Psychiatry: An International Perspective. Oxford, UK: Wiley; 2013.
14. Reardon CL, Factor RM. A systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40:961–980.[PubMed]
15. Riggs P, Levin F, Green AI, et al. Comorbid psychiatric and substance abuse disorders: recent treatment research. Subst Abuse. 2008;29:51–63.[PubMed]
16. Baron DA, Reardon CL, Baron SH. Doping in sport. In: Baron DA, Reardon CL, Baron SH, editors. Clinical Sports Psychiatry: An International Perspective. Oxford, UK: Wiley; 2013.
17. Yesalis CE. History of doping in sport. In: Bahrke MS, Yesalis CE, editors. Performance Enhancing Substances in Sport and Exercise. Champaign, IL, USA: Human Kinetics; 2002.
18. Landry GL, Kokotailo PK. Drug screening in athletic settings. Curr Problems Pediatr. 2004;24:344–359.[PubMed]
19. Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic. Clin Chem. 1997;43:1262–1279.[PubMed]
20. McGann B, McGann C. The Story of the Tour de France. Indianapolis, IN, USA: Dog Ear Publishing; 2006.
21. Teale P, Scarth J, Judson S. Impact of the emergence of designer drugs upon sports doping testing. Bioanalysis. 2012;4:71–88.[PubMed]
22. International Association of Athletics Federations IAAF commitment to healthy and drug free athletic. 2013. [Accessed August 29, 2013]. Available from: http://www.iaaf.org/about-iaaf/medical-anti-doping.
23. Federation Internationale de Football Association A brief history of doping. 2013. [Accessed August 29, 2013]. Available from: http://www.fifa.com/aboutfifa/footballdevelopment/medical/news/newsid=514062/index.html.
24. International Olympic Committee Factsheet: the fight against doping and promotion of athletes’ health. 2013. [Accessed August 29, 2013]. Available from: http://www.olympic.org/Documents/Reference_documents_Factsheets/Fight_against_doping.pdf.
25. World Anti-Doping Agency A brief history of anti-doping. 2010. [Accessed August 29, 2013]. Available from: http://www.wada-ama.org/en/about-wada/history/
26. Voet W. Breaking the Chain. London, UK: Random House; 1999.
27. Bhasin S, Storer TW, Berman N, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996;335:1–7.[PubMed]
28. Bhasin S, Woodhouse L, Casaburi R, et al. Testosterone dose-response relationships in healthy young men. Am J Physiol Endocrinol Metab. 2001;281:E1172–E1181.[PubMed]
29. Storer TW, Magliano L, Woodhouse L, et al. Testosterone dose-dependently increases maximal voluntary strength and leg power, but does not affect fatigability or specific tension. J Clin Endocrinol Metab. 2003;88:1478–1485.[PubMed]
30. Wallace MB, Lim J, Cutler A, Bucci L. Effects of dehydroepiandrosterone vs androstenedione supplementation in men. Med Sci Sports Exerc. 1999;31:1788–1792.[PubMed]
31. Morales AJ, Haubrich RH, Hwang JY, Asakura H, Yen SS. The effect of six months treatment with a 100 mg daily dose of dehydroepiandrosterone (DHEA) on circulating sex steroids, body composition and muscle strength in age-advanced men and women. Clin Endocrinol. 1998;49:421–432.[PubMed]
32. Kohler M, Thomas A, Geyer H, Petrou M, Schanzer W, Thevis M. Confiscated black market products and nutritional supplements with non-approved ingredients analyzed in the Cologne Doping Control Laboratory 2009. Drug Test Anal. 2010;2:533–537.[PubMed]
33. Handelsman DJ. Clinical review: the rationale for banning human chorionic gonadotropin and estrogen blockers in sport. J Clin Endocrinol Metab. 2006;91:1646–1653.[PubMed]
34. Handelsman DJ. Indirect androgen doping by oestrogen blockage in sports. Br J Pharmacol. 2008;154:598–605.[PMC free article][PubMed]
35. Basaria S. Androgen abuse in athletes: detection and consequences. J Clin Endocrinol Metab. 2010;95:1533–1543.[PubMed]
36. Meinhardt U, Nelson AE, Hansen JL, et al. The effects of growth hormone on body composition and physical performance in recreational athletes: a randomized trial. Ann Intern Med. 2010;152:568–577.[PubMed]
37. Holt RI, Sonksen PH. Growth hormone, IGF-I and insulin and their abuse in sport. Br J Pharmacol. 2008;154:542–556.[PMC free article][PubMed]
38. Eichner ER. Stimulants in sports. Curr Sports Med Rep. 2008;7:244–245.[PubMed]
39. Higgins P, Tuttle TD, Higgins CL. Energy beverages: content and safety. Mayo Clin Proc. 2010;85:1033–1041.[PMC free article][PubMed]
40. National College Athletic Association NCAA guidelines to document ADHD treatment with banned stimulant medications. Addendum to the Jan 2009 guideline. 2010. [Accessed June 12, 2014]. Available from: http://www.lagrange.edu/resources/pdf/athletics/athletictraining/FAQ.pdf.
41. Shaikin B. Los Angeles Times. Baseball’s 2008 drug test results released in report. Jan 10, 2009. [Accessed September 17, 2010]. Available from: http://articles.latimes.com/2009/jan/10/sports/sp-newswire10.
42. Judkins C, Prock P. Supplements and inadvertent doping – how big is the risk to athletes. Med Sports Sci. 2012;59:143–152.[PubMed]
43. Kendall KL, Smith AE, Graef JL, et al. Effects of four weeks of high-intensity interval training and creatine supplementation on critical power and anaerobic working capacity in college-aged men. J Strength Cond Res. 2009;23:1663–1669.[PubMed]
44. Branch JD. Effect of creatine supplementation on body composition and performance: a meta-analysis. Int J Sport Nutr Exerc Metab. 2003;13:198–226.[PubMed]
45. Elliott S. Erythropoiesis-stimulating agents and other methods to enhance oxygen transport. Br J Pharmacol. 2008;154:529–541.[PMC free article][PubMed]
46. Bailey JA, Averbuch RN, Gold MS. Cosmetic psychiatry: from Viagra to MPH. Directions in Psychiatry. 2009;29:1–13.
47. Kindermann W. Do inhaled beta(2)-agonists have an ergogenic potential in non-asthmatic competitive athletes? Sports Med. 2007;37:95–102.[PubMed]
48. Davis E, Loiacono R, Summers RJ. The rush to adrenaline: drugs in sport acting on the beta-adrenergic system. Br J Pharmacol. 2008;154:584–597.[PMC free article][PubMed]
49. Bougault V, Boulet LP. Is there a potential link between indoor chlorinated pool environment and airway remodeling/inflammation in swimmers? Expert Rev Respir Med. 2012;6:469–471.[PubMed]
50. World Anti-Doping Agency The World Anti-Doping Code: The 2013 Prohibited List International Standard. 2013. [Accessed August 23, 2013]. Available from: http://www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-Prohibited-list/2013/WADA-Prohibited-List-2013-EN.pdf.
51. Petroczi A, Naughton DP. Potentially fatal new trend in performance enhancement: a cautionary note on nitrate. J Int Soc Sports Nutr. 2010;7:25.[PMC free article][PubMed]
52. Watson P, Hasegawa H, Roelands B, Piacentini MF, Looverie R, Meeusen R. Acute dopamine/noradrenaline reuptake inhibition enhances human exercise performance in warm, but not temperate conditions. J Physiol. 2005;565(Pt 3):873–883.[PMC free article][PubMed]
53. Schmitt L, Millet G, Robach P, et al. Influence of “living high-training low” on aerobic performance and economy of work in elite athletes. Eur J Appl Physiol. 2006;97:627–636.[PubMed]
54. Vardy J, Judge K. Can knowledge protect against acute mountain sickness? J Public Health. 2005;27:366–370.[PubMed]
55. Suedekum NA, Dieff R. Iron and the athlete. Curr Sports Med Rep. 2005;4:199–202.[PubMed]
56. Maughan RJ, Shirreffs SM. Nutrition for sports performance: issues and opportunities. Proc Nutr Soc. 2012;71:112–119.[PubMed]
57. Koshy KM, Griswold E, Schneeberger EE. Interstitial nephritis in a patient taking creatine. N Engl J Med. 1999;340:814–815.[PubMed]
58. Edmunds JW, Jayapalan S, DiMarco NM, Saboorian MH, Aukema HM. Creatine supplementation increases renal disease progression in Han:SPRD-cy rats. Am J Kidney Dis. 2001;37:73–78.[PubMed]
59. Saugy M, Avois L, Saudan C, et al. Cannabis and sport.
There has been a huge amount of academic, policy, and public debate over the years about doping in sport (i.e. the use of banned performance enhancing substances or drugs and other prohibited practices), and significant resources devoted to addressing it.
Doping is a complex issue – we are still striving to understand how and why it happens, and how to prevent it. But despite the attention doping in sport has received, there is still significant public disagreement about how best to respond to this problem.
Public discussions on doping usually break down - sometimes because of the way we argue about such issues, and often due to inconsistent reasoning. If you want evidence of this take a look at the online comments pages on sports doping articles, or start your own debate with friends and see how far it goes.
Greater clarity is needed on how people think and argue about doping in sport. In this piece I look at the common positions people take on doping, what these commit us to, and the consequences of mixed messages going unchallenged.
Why people dope
Assuming you care about doping in the first place (some people don’t), a key issue to clarify is your theory about why people dope. Your position here is important for discussing the doping issue because, whether you realise it or not, this informs your views on what should be done about it.
Some people believe the doping decision simply comes down to the individual’s desire to win or gain advantages of some type. To them, doping is mostly determined by individual psychological factors, and should therefore be addressed as an issue of personal responsibility and culpability.
Others believe doping choices are driven by a mix of psychological, social, cultural, and systemic factors, rather than individual traits alone. In this view, doping occurs due to the interaction of individual factors (e.g. the desire for winning, improvement, pain management, recovery, career longevity, economic gains, and belonging), and wider socio-cultural and systemic factors (e.g. social background and experiences, team/club/sport culture, sport governance systems, perceived efficacy of anti-doping system, and so on).
Against doping in sport
The question of whether you are for or against doping in sport is also clearly important. If you are against doping in sport, as most people are, there are a number of arguments you might run here.
For example, you may think doping is wrong because:
- It is against the defined rules and laws governing sport.
- It is unfair and goes against the level playing field ideal.
- It represents a health risk and is harmful to the individual.
- It harms the athletes who choose not to dope (e.g. they exit sport early, or their career is impacted from being cheated out of results and earnings).
- It contravenes other values defined as the ‘spirit of sport’ (e.g. fair play and honesty; health; character and education; fun and joy; teamwork; respect for self and others; courage; community and solidarity).
- It sends an unacceptable message about the place and impact of sport in society.
The important thing to note here is that anti-doping advocates vary in their relative emphasis on the above arguments. For some, it is all about the rules of sport, and related ethics and integrity requirements. While for others, the health risk and harm issue is paramount.
For doping in sport
Some people in academic circles argue that doping should be permitted in sport – either in an open free for all as it used to be, under medical supervision, or under the framework of regulated decriminalisation.
The proponents of these more liberal positions on doping commonly argue the following:
- The level playing field ideal is a myth - there are numerous legal performance enhancing strategies that are unequally available across sports and countries (e.g. expensive training facilities and programs, technologically superior equipment, nutritional, medicinal and other aids etc).
- Current banned drugs and substances are not inherently harmful, nor the biggest sources of risk and harm when you consider injury rates and long-term physical outcomes in some sport.
- The true spirit of elite sporting competition is closer to the Athenian ideal of superhuman effort at any cost (including risks and injuries), and doping is consistent with that.
- Supervised regulated use of performance enhancing drugs and substances, and other banned practices (e.g. blood transfusions) would reduce health risks and harms.
- Prohibition policies and punitive measures create hidden, uninformed, and riskier doping which exacerbates health and other harms.
Again, people who argue for doping in sport may place different weight on some of the above arguments over others. Further, belief in one or other of these arguments doesn’t commit you to all of them.
Doping prevention approaches
If you are opposed to doping, you should also have a position on how to prevent or reduce it – your discussions on the topic won’t get far if you’re against doping but have nothing to say on what to do about it.
On doping prevention you could take a zero tolerance stance, where you favour restrictive surveillance and testing protocols, and punitive responses for even minor doping transgressions. Implicit in this stance is the belief that because the individual chooses to break known rules by doping, they should take responsibility and be punished accordingly if caught or if they confess, or make later admissions.
Zero tolerance advocates might also believe that doping in sport can ultimately be eradicated. But this is not a necessary belief for this position - for example zero tolerance proponents might simply favour the strong public message in sports doping policy that includes punitive responses.
Alternatively, you could adopt a prevention stance based on harm minimisation principles. Implicit in this position is the belief that doping will always exist in sport, and so the pragmatic aim of prevention is to reduce doping harm (to dopers, other athletes, spectators, sport generally), rather than total eradication of the behaviour.
Harm reduction proponents emphasise an athlete health and welfare focus over harsh punitive measures (i.e. criminalisation specifically). People here are less concerned with upholding individual responsibility as far as punishment goes. They believe doping prevention is better achieved through a focus on broader social, cultural, and systemic factors (e.g. team/club/sport culture, sport governance systems, ethics and integrity culture and systems, etc) rather than individual factors alone.
Punishing dopers doesn’t work
People who argue for harm minimisation approaches believe punitive measures alone will be ineffective in reducing or preventing doping in sport. As above, one reason for this is they believe doping behaviour is driven by a range of factors, and so doping prevention too must take a broad focus (beyond individual behaviour and psychology) to achieve widespread and lasting change.
Another claim made here is that penalties for doping such as fines, suspensions, and even lifetime bans are unlikely to deter doping, and will not eradicate it. The analogy often cited here this is the case of death penalties for murder not halting murder rates, or harsh criminal penalties for illicit drug possession, supply and use failing to reduce or eliminate those proscribed behaviours.
People who are unconvinced about the effect of punitive measures might also point out that even the severest doping penalties are unlikely to work in most cases, because under the current system athletes would challenge such penalties legally to uphold their right to compete, or preserve their rights for future earnings.
Finally, many people against punitive responses to sports doping also place a high value on forgiveness and redemption – a chance to start again with a clean slate. What often comes with this position is the view that the punishment and public humiliations suffered by some dopers (and their families) can be wrongly disproportionate to their original doping offence.
Punitive measures have a place
Supporters of punitive measures do not accept the analogy made between doping and criminal behaviour. They would argue the social, cultural and individual factors (including psychological determinants) of doping in sport are very different to those for murder and illicit drug use. As such, they also claim the thinking behind doping prevention approaches, including the expected impact of severe sanctions (not necessarily criminal), should be different too.
Zero tolerance advocates believe that, if applied appropriately, punitive measures can achieve desired sports doping prevention outcomes (i.e. reduced doping behaviour, reduced harm, or complete eradication). The view here is if doping policy is to include punitive measures (as per the current anti-doping framework), then these should be implemented competently and consistently in accordance with the defined policy aims and processes; and with clear and consistent public messages from sports governing bodies giving unambiguous support.
Supporters of punitive measures might also argue that it is not the current anti-doping policy framework that has failed, but rather the inadequate implementation of this framework by sports governing bodies and systems weakened by inconsistent practices, ineffective leadership, and ambiguous public messages about high profile doping cases.
Middle ground or mixed messages?
Doping in sport debates are often framed around the two ‘sides’ of harm minimisation and zero tolerance. At first glance, such positions appear distinct. In reality, people commonly shift between positions or argue a mix of both.
For example, you might believe that doping requires social determinants focused education and prevention programs (including capacity building in ethics and integrity, athlete culture and health and welfare and so on), AND progressively severe punitive measures in certain circumstances (e.g. for repeat doping offences, systematic team-based doping, related fraud and criminal activity).
A significant challenge for the doping in sport debate is predicting how people will think about and respond to doping cases. Ideally, careful reasoning based on the types of beliefs and positions summarised in this article would lead us to consistent responses, but that is not what often happens.
We see this with the sport of cycling - for example, compare most people’s strident opinions and responses about the Lance Armstrong case, to the relatively muted reactions about other cyclists who have doped (e.g. David Millar, Jan Ullrich, Erik Zabel, George Hincapie, Tyler Hamilton, Stuart O'Grady, Matt White, Neil Stephens, Alberto Contador, Alejandro Valverde, Danilo Di Luca etc).
We also see this in the responses from governments, sports governing bodies, and the sport itself. Again, the official reactions to the above cases in cycling have been markedly different - take a moment to reflect on where each of these riders are currently.
Most sports governing bodies and officials would claim they occupy a middle position between ‘crime and punishment’ and ‘education and prevention’ thinking and approaches. At face value, this seems like a sensible space for doping policy - the best of both worlds. However, this middle space can also be a fertile ground for mixed public messages and inconsistencies on doping that can undermine prevention efforts - as I have argued before in this Column (here and here).
By trying to occupy the middle ground on doping between zero tolerance and harm minimisation - trying to have it both ways - sports governing bodies run the risk of subsequently failing to implement either aspect of their doping prevention policies competently and consistently. Again, take a look at the recent criticisms made about the International Cycling Union.
Doping prevention efforts in all sports are undermined when mixed messages emerge from inconsistent thinking and action around doping policy - and especially when they continue unchallenged in public discussion and debates (e.g. ‘say no to doping’ but ‘say yes to ex-dopers in coaching positions’; ‘our sport is anti-doping’ but ‘ex-dopers manage our pro teams’; ‘strong doping prevention messages are needed’ but ‘ex-dopers are sponsoring elite teams, sports blogs, and working in sports media’).
What does your position on doping in sport commit you to? What should be done to prevent doping? What should we say about the mixed messages that exist about doping in sport?
Further reading: There is of a large academic literature, and a growing research evidence base, underpinning many of the points made in this article. If you are interested in further reading, a reasonable coverage of the issues can be seen at the Wikipedia doping in sport site, and Routledge have published a number of excellent academic books on this topic by some of the leading thinkers in this area.