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Doping Prevalence in Competitive Sport: Evidence Synthesis with “Best Practice” Recommendations and Reporting Guidelines from the WADA Working Group on Doping Prevalence

• Systematic Review
• Published: 26 April 2021
• Volume 51 , pages 1909–1934, ( 2021 )

Cite this article

• John Gleaves   ORCID: orcid.org/0000-0002-2398-4685 1 ,
• Andrea Petróczi 2 ,
• Dirk Folkerts 2 , 3 ,
• Olivier de Hon 4 ,
• Emmanuel Macedo 5 ,
• Martial Saugy 6 &
• Maarten Cruyff 7  

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The prevalence of doping in competitive sport, and the methods for assessing prevalence, remain poorly understood. This reduces the ability of researchers, governments, and sporting organizations to determine the extent of doping behavior and the impacts of anti-doping strategies.

The primary aim of this subject-wide systematic review was to collate and synthesize evidence on doping prevalence from published scientific papers. Secondary aims involved reviewing the reporting accuracy and data quality as evidence for doping behavior to (1) develop quality and bias assessment criteria to facilitate future systematic reviews; and (2) establish recommendations for reporting future research on doping behavior in competitive sports to facilitate better meta-analyses of doping behavior.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify relevant studies. Articles were included if they contained information on doping prevalence of any kind in competitive sport, regardless of the methodology and without time limit. Through an iterative process, we simultaneously developed a set of assessment criteria; and used these to assess the studies for data quality on doping prevalence, potential bias and reporting.

One-hundred and five studies, published between 1975 and 2019,were included. Doping prevalence rates in competitive sport ranged from 0 to 73% for doping behavior with most falling under 5%. To determine prevalence, 89 studies used self-reported survey data (SRP) and 17 used sample analysis data (SAP) to produce evidence for doping prevalence (one study used both SRP and SAP). In total, studies reporting athletes totaled 102,515 participants, (72.8% men and 27.2% women). Studies surveyed athletes in 35 countries with 26 involving athletes in the United States, while 12 studies examined an international population. Studies also surveyed athletes from most international sport federations and major professional sports and examined international, national, and sub-elite level athletes, including youth, masters, amateur, club, and university level athletes. However, inconsistencies in data reporting prevented meta-analysis for sport, gender, region, or competition level. Qualitative syntheses were possible and provided for study type, gender, and geographical region. The quality assessment of prevalence evidence in the studies identified 20 as “High”, 60 as “Moderate”, and 25 as “Low.” Of the 89 studies using SRP, 17 rated as “High”, 52 rated as “Moderate”, and 20 rated as “Low.” Of the 17 studies using SAP, 3 rated as “High”, 9 rated as “Moderate”, and 5 rated as “Low.” Examining ratings by year suggests that both the quality and quantity of the evidence for doping prevalence in published studies are increasing.

Conclusions

Current knowledge about doping prevalence in competitive sport relies upon weak and disparate evidence. To address this, we offer a comprehensive set of assessment criteria for studies examining doping behavior data as evidence for doping prevalence. To facilitate future evidence syntheses and meta-analyses, we also put forward “best practice” recommendations and reporting guidelines that will improve evidence quality.

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There is not a universal definition of doping. However, this study builds upon [ 1 ] definition where doping “refers to the set of prohibited substances and/or methods as identified by the ruling body of the particular sport”, which, “means that the term ‘doping’ in […] does not reflect other doping violations mentioned in the World Anti-Doping Code, such as whereabouts failures or trafficking.” We have also differentiated between therapeutic and unintentional use of prohibited substances to more clearly describe the phenomenon.

The connection between controlled substances in sport (doping) and in general is a complicated one. First of all, not all substances prohibited in sport are controlled substances for the general population, and this varies from one country to another. One example for this is anabolic steroids (AS). AS are prohibited in sport both in- and out-of-competition for all athletes around the globe under WADA regulations. However, whilst using AS is also illegal in some countries (e.g., Australia, US, Norway, Saudi Arabia), in other countries (e.g., UK, Canada, South Africa, Turkey) personal use is not illegal but production and supply without license are, regardless of who uses it. In countries where doping is a criminal offence (e.g., Austria, Germany, France, Italy, Israel), AS use is only illegal and can carry a prison sentence for athletes if they are subject to doping control, but not for the general population. AS is not a controlled substance in some countries (e.g., Japan, Bulgaria, Russia, Mexico).

Gender is the term used in official documents and reporting throughout sport governing bodies such as the International Olympic Committee, the Court of Arbitration for Sport, and the World Anti-Doping Agency to classify competition categories for men and women. As this evidence synthesis only related to competitive sport, the manuscript reflects the categorizations used by the competitive sport governing bodies.

A multitude of indirect estimation models exists. In the applied literature, these are often referred to as ‘randomized response technique’, even though not all models rely on randomization. For simplicity and to avoid confusion, we accepted this terminology for the review while noting its inaccuracy.

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Acknowledgements

The work was conducted as part of the Working Group on Doping Prevalence of the World Anti-Doping Agency (WADA). The authors thank Tony Cunningham, Marcia MacDonald, and Olivier Rabin for their critical review and constructive comments on the manuscript; and Annie Bachman for her assistance in extracting and compiling data.

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Andrea Petróczi & Dirk Folkerts

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Olivier de Hon

Penn State University, State College, USA

Emmanuel Macedo

University of Lausanne, Lausanne, Switzerland

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This paper represents part of the work by the World Anti-Doping Agency Working Group on Doping Prevalence conducted between September 2017 and December 2019, but WADA had no control over the drafting or content of this manuscript. John Gleaves, Andrea Petróczi, Olivier De Hon, Martial Saugy and Maarten Cruyff served as members of the Working Group (2017–2019) and they prepared this paper in their capacity as Working Group members, in collaboration with DF and EM. The Working Group members receive no salary for their work but expenses related to the travel for work were covered. Andrea Petróczi received grant funding from WADA previously as part of the Social Science Research Program, served as a member of the first Working Group on Doping Prevalence (2011–2012); and is currently involved in providing analysis and evaluation support for WADA’s Outreach Program in an unpaid advisory role. Martial Saugy worked at the Swiss Laboratory for Doping analyses (LAD, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland) until 2016 and received funding from WADA Science Department prior to his involvement in this project. Olivier De Hon works for the National Anti-Doping Authority Netherlands. Dirk Folkerts and Emmanuel Macedo declare they have no conflicts of interest relevant to the content of this review.

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The definitions, questions, and rater criteria for the Quality Assessment of Doping evidence—Self-Reported Prevalence (QUAD-SRP) and the Quality Assessment of Doping evidence—Sample Analysis of Prevalence (QUAD-SAP) are available in Electronic Supplementary Material Appendix S1 and S2, respectively. All extracted data from the studies are available in Electronic Supplementary Material Appendix S3. The complete scoring for all studies is available in Electronic Supplementary Material Appendix S4. All other datasets generated during and/or analyzed during the current analysis are available from the corresponding author on reasonable request.

Authorship contributions

AP served as senior author on the project, conceptualized the study, led the development of quality assessment criteria, contributed to collating and synthesizing the independent quality assessments, contributed to the literature search, supervised DF and contributed to drafting the manuscript. JG drafted the manuscript, contributed to the development of quality assessment criteria, contributed to collating and synthesizing the independent quality assessments as well as the literature search and supervised EM. DF conducted the initial literature search, contributed to developing the quality assessment criteria and conducted independent quality assessment for all included studies under the supervision of AP. OH conducted independent quality assessment, contributed to developing the quality assessment criteria and literature search. EM conducted independent quality assessment under the supervision of JG. The best practice recommendations were formulated by AP, JG, OH, MS, and MC. All authors read and critically commented on the manuscript and approved the final version of the manuscript.

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Gleaves, J., Petróczi, A., Folkerts, D. et al. Doping Prevalence in Competitive Sport: Evidence Synthesis with “Best Practice” Recommendations and Reporting Guidelines from the WADA Working Group on Doping Prevalence. Sports Med 51 , 1909–1934 (2021). https://doi.org/10.1007/s40279-021-01477-y

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Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review

• Cornelia Blank   ORCID: orcid.org/0000-0002-5913-0251 1 ,
• Martin Kopp 2 ,
• Martin Niedermeier 2 ,
• Martin Schnitzer 2 &
• Wolfgang Schobersberger 1 , 3  

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Research in doping has focused on potential intervention strategies, increasingly targeting predicting factors. Yet, findings are inconsistent, mostly athlete-centred and explain only limited variances in behaviour. This critical review aims to (a) summarize studies that identified predictors of doping intentions, susceptibility, and behaviour in elite athletes and to (b) analyse in how far previous research included aspects beyond athlete-centred approaches, such as context and sporting culture. We reviewed 14 studies that focused on elite athletes. Situational temptation, attitudes, and subjective norms seem to be strong predicting variables of doping intentions ( r  ≥ 0.50), but intention was no predictor for behaviour. Attitudes were a significant predictor for both, doping susceptibility ( r  = 0.47) and behaviour ( r  = 0.30). Most of the predictors are athlete-centred and ignore macro-level factors that might help to explain how certain individual traits impact on the decision making process. The findings from this review call for a critical discussion of whether current doping-prevention research needs to take new directions. We propose future research to bridge findings of psychologists and sociologists, as it appears that doping behaviour cannot be explained by ignoring the one or the other. Impacts of sporting culture that have been identified in qualitative approaches need to be integrated in future quantitative approaches to test for its external validity. Inclusion of both, micro- and macro level factors may enable an integrative prevention program that creates a sporting culture without doping.

Doping is generally considered to be unsportsmanlike and believed to create unfair advantages while destroying the values of sport. In view of the importance to protect the athletes’ health and integrity, results of a previous survey indicated that preventing doping in elite sport is considered as the highest priority from 35 international sporting federations (Mountjoy and Junge 2013 ). Nevertheless, Wagner and Pedersen ( 2014 ) have previously reported that the general population does not trust the doping management of international sporting federations due to ongoing doping scandals despite the implementation of the World Anti-Doping Agency (WADA) in 1999. Significant amounts of money have been spent on (a) identifying new policies and measures to prevent doping and (b) implementing these measures. However, if the general population perceives this money to be spent on inefficient prevention strategies, then their trust may decrease even further. Therefore, the identification of processes that lead to doping behaviour should be of interest to both science researchers and sport governing bodies entrusted with doping prevention. Prevention strategies that are grounded on transparently accumulated scientific evidence might help to reduce the above mentioned lack of trust not only of the general population but also of the athletes themselves (Overbye 2016 ).

Deterrence and education

Increasing doping controls as part of a deterrence approach represents one possibility to prevent doping. Nevertheless, results from current research offer a number of explanations as to why this approach does not seem to be successful on its own. For example, as already mentioned above, there is a lack of trust among athletes in effective doping controls (Overbye 2016 ). Trust of the athletes is crucial for bans to work as a deterrent, as it is not the act of doping but the discovery of doping that is punished (Petróczi and Haugen 2012 ). Highlighting the negative health effects of doping has also been unsuccessful (Engelberg et al. 2015 ; Huybers and Mazanov 2012 ; Probert and Leberman 2009 ; Schnell et al. 2014 ). The only deterrents that appear to be partially effective are social sanctions and humiliation (Huybers and Mazanov 2012 ; Overbye et al. 2014 ), which were both included in the Australian Anti-Doping Agency’s prevention program called “You can never win your reputation back” (Huybers and Mazanov 2012 ). Based on this evidence, current doping prevention measures focus on more than mere deterrence strategies. Additional education-based prevention approaches (i.e., Goldberg’s ATLAS program) (Goldberg et al. 2000 ) have been increasingly applied to prevent negative behaviour before it occurs, especially with respect to athletes’ health, integrity, and fairness, as well as values in sports. Nonetheless, education in the sense of transferring information does not appear to be successful either. Previous studies have identified only weak, if any, association between knowledge about doping and its side effects, and doping intentions and/or behaviour (Blank et al. 2014 ; Ntoumanis et al. 2014 ). It appears that the effectiveness of the health message in trying to prevent doping is questionable (Engelberg et al. 2015 ). As a result of the acknowledged complexity of the doping phenomenon scientists suggest that only a firm understanding of factors involved in doping as well as their relationships will potentially result valid pro-social interventions for doping (Johnson 2012 ). Therefore, subsequent research that has focused on identifying reasons for doping behaviour, has been inspired mainly, but not exclusively, by research in the field of health- and social psychology (Lazuras et al. 2015 ) and focusing on the individual athlete.

Psychological factors

Doping is considered to be a complex behaviour. A recent meta-analysis by Ntoumanis et al. ( 2014 ) summarized and compared literally all known psychological predictors of doping behaviour in all physical settings and at all performance levels. Findings included variables from the theory of planned behaviour (TPB) (Ajzen and Madden 1986 ), additional attitude-behaviour relations (Bentler and Speckart 1979 ), deterrence (Paternoster 1987 ) and self-determination theory (Ryan and Deci 2000 ), as well as combinations of these variables (Donovan et al. 2002 ; Strelan and Boeckmann 2003 ). In addition, implicit measures were also included (Brand et al. 2014 ; Petroczi et al. 2008 ). Even though this meta-analysis provides extensive information for the scientific and practical community, including all competition levels might dampen the significance of the result for the elite athletes. A number of studies included within this meta-analysis involve recreational athletes who are not part of sporting organizations that signed the WADA anti-doping code and are therefore not directly confronted with the offense of doping (Arandjelovic 2015 ). Additionally, motivations for doping in these sports may be different from motivations of elite athletes who are training to compete in major sporting events, such as the Olympic Games or World Championships (Bilard et al. 2011 ; Elliot and Goldberg 1996 ; Wiefferink et al. 2008 ). The Olympic Games are considered to be the most important event in an athlete’s life, and winning a medal at the Olympics is the highest goal to which an athlete can strive. Chester and Wojek ( 2015 ) have recently criticized existing research in recreational athletes as not necessarily being representative for elite athletes. It is expected that elite athletes face different situational pressures within their daily training routine, and a previous study has shown that situational factors mediate several predictors of doping behaviour (Barkoukis et al. 2013 ). In line, only a few of the findings from Ntoumanis et al. ( 2014 ) were observed in a recent qualitative study by Engelberg et al. ( 2015 ), who analysed interviews with doped athletes. Some correlations observed in the meta-analysis of Ntoumanis et al. ( 2014 ) were in the opposite direction of correlations observed in Engelberg et al. ( 2015 ). Explanations for these diverse findings might be (a) the different target populations, (b) difficulties of evaluating doping behaviour (i.e. in most research athletes are asked to self-report about their doping behaviour) and (c) different methodological approaches that are hardly comparable.

Sociological approaches

Given the constant number of positive doping samples, one could either speculate that despite the growing body of research that helps understanding the underlying psychological processes of doping behaviour, the preventive strategies seem to lack success or that the analytical detection methods have improved. Considering the first hypothesis, many researchers opened the debate to shift from an athlete-centred approach to a much wider approach. Especially in sociology this debate already has an extensive history. Stewart and Smith ( 2008 ) have proposed a macro model that also includes sporting context and—culture. They further acknowledged that an athlete’s decision to dope might not always be rational and be influenced by a range of impacts. Therefore, even though beneficial, socio-psychological theories to explain doping behaviour might not always fit as they are mostly based on rational and intentional decision making. It has to be acknowledged that athletes are embedded in community cultures and practices (Wagner 2010 ). Copeland and Potwarka ( 2016 ) claimed that doping can be understood on a cognitive level of the individual, but furthermore that the contextual-organizational level must not be ignored. Parts of this contextual-organizational level are for example impacts of commercialization and globalization as well as sporting culture and the perception of its own identity (Stewart and Smith 2008 ).

Summarizing, there already exists a rapidly growing body of research aimed at explaining doping behaviour. Nevertheless, findings are very heterogeneous and appear to have a mainly athlete-centred focus which might be due to several reasons outlined above. This heterogeneous landscape of research findings renders the formulation of clear prevention strategy difficult and there is the need to summarize these findings to possibly identify generalizable common predictors.

Aims and objectives

Building on the comprehensive work of Ntoumanis et al. ( 2014 ), this meta-analytic review has two major objectives. First, this review aggregates and interprets research efforts towards the identification of predictors of (a) doping behaviour, (b) intentions that are most proximal to doping behaviour (Armitage and Conner 2001 ; Bilic 2005 ; Elliot et al. 2003 ; Godin and Kok 1996 ), and (c) susceptibility to doping behaviour, which is commonly used as a substitute for doping behaviour itself. Given the expected differences between amateur and elite athletes that have been outlined above, only studies that included applied multivariate analyses of elite athletes competing at the national level or higher are included in this review. Findings based on different empirical models are reviewed and compared as appropriate. With this approach, we aim to determine whether it is possible to identify common predictors of doping intentions, susceptibility, and behaviour of elite athletes. More importantly, we aim to critically discuss whether it is reasonable to quantify overall effect sizes of these predictors due to different operationalization methods of equal psychological constructs.

The second major aim is to analyse whether or not previous research, that allows meta-analytic calculations, included aspects beyond the athlete-centred approach. Findings and possible non-findings will be critically discussed to provide both, a scientific data compilation that might allow for the definition of preventive strategies as well as starting points for future research to close a potential gap between micro- and macro level oriented research approaches.

Search methods for identification of articles

A systematic literature research was performed to document the findings of previous studies with respect to predicting factors on doping, intentions, susceptibility, and behaviour. Our search included original studies published in scientific peer-reviewed journals between 1999 (the founding year of WADA) and January 2016 and indexed in the MEDLINE and/or EBSCO (including SocIndex, Academic search elite, Business source premier, Cinahl, Pre-Cinahl, Hospitality and Tourism index, Inspec, PsychArticles, PsychInfo, SportsDiscus, Lista) databases using the search terms “doping”, “performance enhancing drugs”, “drugs AND sport” as well as by combining each of these terms with “determinants”, “correlates”, “risk factors”, “precipitating factors”, and “model”. This search term strategy was previously used by Backhouse et al. ( 2007 ) for a final report to the WADA. Additionally, we manually searched the reference lists of every primary study for additional publications.

Assessed outcomes

The main outcomes of interest were predicting factors for doping susceptibility and doping behaviour; however, as intentions have been said to be an important proximal factor to behaviour (Armitage and Conner 2001 ; Bilic 2005 ; Elliot et al. 2003 ; Godin and Kok 1996 ), we included predicting factors for intentions as the third outcome of interest. Outcomes were exclusively recorded by self-reporting questionnaires and were displayed in prevalence percentages and/or computed scores as the results of regression analyses and/or structural equation modelling.

Data extraction

Two researchers (CB, WS) independently performed the literature research, quality assessment, and data extraction. Any disagreements about inclusion of trials were resolved by discussion with the three remaining researchers (MK, MN, MS). According to a standardized form, the investigators extracted data that was methodologically and scientifically sound and collected the following variables: author and year of publication, journal title, characteristics of the target population of the study (including sample size and age), the dependent variable(s) of the study (intentions, susceptibility, behaviour), the included psychological concepts, and the outcome of the study (tested model and/or individual predicting factors).

Inclusion and exclusion criteria

Due to the meta-analytic approach, the review was limited to studies that evaluated predicting factors with respect to doping intentions, susceptibility, and/or behaviour of elite athletes competing on national level and above. We excluded manuscripts in which the sample was described with words such as “non-competitive”, “amateur” and/or “competing at club level”. Studies with focus on no matter which age groups, type of sports, and country were included. Studies that were not aimed at evaluating predictors with respect to intentions, susceptibility, and/or behaviour but rather included findings of this kind as ancillary results were excluded. Studies that focused on body building, gym-users and high-school/college sports were excluded, especially given the evidence of different reasoning (i.e., body image) for taking prohibited substances within these sports (Laure et al. 2004 ; Leifman et al. 2011 ). Studies that focused on adolescents participating in amateur level (i.e. high-school sport) were excluded. Publications that reported results from a mix of elite and non-elite athletes as per definition of the authors were excluded if such results were undistinguishable. Studies not reporting Pearson’s correlation, odds ratio or the mean standardized difference were not included in the meta-analytical statistics but included in the study. Finally, reports that described solely theoretically developed models without empirical testing were excluded. Figure  1 summarizes the study search and inclusion process.

Flow chart of search strategy

Excluded articles

The study search yielded a total of 1107 results, and 793 of these studies were rejected based on the title. A total of 324 abstracts were screened, and the full text of 71 of these studies including the bibliography was analysed. In sum, 57 articles were rejected due to the target group (31), no doping relation (7), no predictors (6), qualitative research (3), no report on Pearson’s correlation, odds ratio or the mean standardized difference (4), or description of theoretical models (6).

Included articles

In total, 14 studies were included in the analyses. Four studies focused on doping intentions (Barkoukis et al. 2013 , 2015 ; Lazuras et al. 2010 , 2015 ), four studies focused on doping susceptibility (Barkoukis et al. 2014 ; Gucciardi et al. 2011 ; Hodge et al. 2013 ; Whitaker et al. 2014 ), six studies focused on doping behaviour (Donahue et al. 2006 ; Dunn and Thomas 2012 ; Jalleh et al. 2014 ; Mazanov et al. 2008 ; Petroczi 2007 ; Uvacsek et al. 2011 ).

Quality analyses

Based on the nature of research in doping prevention, most studies are either quantitative self-reporting or qualitative interviews. Until now, barely any randomized controlled trials and/or experiments have been performed to evaluate predictors of doping attitudes, intentions, susceptibility, and/or behaviour. Therefore, applying methods such as the scale developed by Jadad et al. ( 1996 ) for data quality analysis was not feasible; however, we evaluated data in terms of their quality based on sample size, response rate, reliability (Cronbach’s alpha), and comparability of questionnaires.

Data synthesis

To structure the outcomes with respect to different psychological concepts, we aligned the organization to psychological constructs from the literature. Therefore, attitudes, subjective norms, perceived behavioural control (PBC), and intentions were subsumed under the concept of TPB (Ajzen 1991 ). (Non-) user favourability and (non-) user similarity were subsumed under the construct of prototype modelling used by Whitaker et al. ( 2014 ), and additionally, we added descriptive norms to this construct (operationalized in all of the included studies as the estimated prevalence of doping in others) (Barkoukis et al. 2013 , 2014 , 2015 ; Lazuras et al. 2010 , 2015 ; Uvacsek et al. 2011 ; Whitaker et al. 2014 ). As suggested by the theoretical drugs in sports deterrence model (DSDM) (Strelan and Boeckmann 2003 ), which is based on the deterrence theory, we subsumed situational temptation (as mostly pressure from the outside), personal morality, affordability, availability, legitimacy, threat, and benefit appraisal under the construct of deterrence theory (DT). Variables describing autonomous/intrinsic, controlled/extrinsic, and amotivation as well as coach-controlled, controlling teammate, autonomy-supportive coach, and teammate climate were combined under the concept of self-determination theory (SDT) (Ryan and Deci 2000 ). Variables of sport motivation (win orientation, competitiveness, goal orientation, mastery avoidance/effort, performance avoidance/ability, and performance approach/external reasons) were aggregated under the construct of achievement goal orientation/sport orientation (AGO) (Gill and Deeter 1988 ). Sportspersonship was the term used for the sportspersonship orientation scale, which was developed by Vallerand et al. ( 1997 ) and includes items such as respect for rules, opponents, and officials. Any kind of moral operationalization was also subsumed under sportspersonship. Experience was the term used for the combination of knowledge, past and current behaviour.

As effect sizes, Pearson’s correlation coefficients were given for the examination of the relation of two continuous variables and odds ratios (OR) for the examination of the relation of two dichotomous variables, respectively. Whenever different operationalization methods were applied for the same concept in different studies, i.e. both, dichotomous and continuous variables were used for the same construct in different studies, the OR or the mean standardized difference was converted to Pearson’s correlation to allow comparison of the studies. This procedure was previously proposed by Borenstein et al. ( 2011 ). According to Schmidt and Hunter ( 2015 ), random-effect models in meta-analysis of correlations are superior to fixed-effect models in terms of the accuracy of the confidence intervals. Therefore, meta-analytic methods were applied according to the random-effect method of Hedges and Olkin ( 1985 ), described in detail by Field ( 2005 ).

The mean effect size for every predictor was calculated using weighted Fisher’s r-to-Z and Z-to-r transformation for Pearson’s correlations (Fisher 1921 ). Due to the small number of included studies, this method is less biased than other methods (e.g. Hunter & Schmidt method) (Field 2005 ). Additionally, 95 % confidence intervals were calculated for the mean effect sizes, when possible. Pearson’s correlations between 0 and 0.1 were considered as small, 0.1 and 0.3 as medium and 0.3 and 0.5 as large (Cohen 2013 ). The classification of OR was defined as small (1.68–3.47), medium (3.47–6.71) and large (>6.71) (Chen et al. 2010 ).

Methodological quality of included studies

Available Cronbach’s alpha ranged between 0.51 and 0.98. After discussion among the authors, no study was excluded due to quality issues, even though Cronbachs-α was not indicated for all studies. Different operationalization methods of the included constructs are outlined in Table  1 .

Study participants

Basic characteristics of the included studies are displayed in Table  2 . Three studies focused on adolescent athletes (Barkoukis et al. 2014 ; Donahue et al. 2006 ; Lazuras et al. 2015 ). Sample sizes ranged from 60 (Barkoukis et al. 2015 ) to 1684 (Dunn and Thomas 2012 ). Performance enhancing substance use prevalence in the included studies ranged from 4 % (Mazanov et al. 2008 ) to 14.6 % (Uvacsek et al. 2011 ).

Outcome measures

All studies included only one outcome variable of interest: (a) intentions (Barkoukis et al. 2013 , 2015 ; Lazuras et al. 2010 , 2015 ), (b) susceptibility (Barkoukis et al. 2014 ; Gucciardi et al. 2011 ; Hodge et al. 2013 ; Whitaker et al. 2014 ) and (c) behaviour (Donahue et al. 2006 ; Dunn and Thomas 2012 ; Jalleh et al. 2014 ; Mazanov et al. 2008 ; Petroczi 2007 ; Uvacsek et al. 2011 ). Total variances explained are displayed in Table  2 . Four studies did not indicate explained variance values (Donahue et al. 2006 ; Mazanov et al. 2008 ; Petroczi 2007 ; Uvacsek et al. 2011 ). Social desirable behaviour was controlled for in five studies (Barkoukis et al. 2014 ; Lazuras et al. 2010 , 2015 ; Petroczi 2007 ; Whitaker et al. 2014 ). Significant predictors for doping intentions, susceptibility, and behaviour including the respective effect sizes are displayed in Table  3 . None of the studies directly addressed contextual or sporting culture-related predictors. Yet, based on the operationalization (refer to Table  1 ) predictors subsumed under situational temptation, motivational climate, subjective norms, and the self-determination theory might represent facets of sporting culture (Stewart and Smith 2008 ).

The major aims of this study were first to critically review published findings regarding predictors of doping intentions, susceptibility, and behaviour and second to analyse and discuss to what extent these results also include factors from beyond the athlete-centred, psychological perspective. Findings outlined that barely any quantitative research included variables beyond an athlete-centred focus and most of the included studies stem from socio-psychological approaches. In regard to the investigated variables, situational temptation and attitudes were the strongest positive predictors for doping intentions, whereas current behaviour and subjective norms were the strongest predictors for doping susceptibility. Furthermore, doping behaviour was best predicted by situational temptation followed by attitudes and doping beliefs.

For all three outcome variables, our study confirms most of the results found by Ntoumanis et al. ( 2014 ). However, in contrast to the Ntoumanis et al. ( 2014 ) study, we found that in elite athletes competing in national international competitions and adherent to the WADA code, attitudes, but not intentions, were a predictive factor for doping behaviour. In the literature, attitudes were the most proximal antecedent to doping behaviour among studies that excluded intentions (Jalleh et al. 2014 ). In line, our meta-analysis also outlined a positive predictive value of attitudes on behaviour. Summarizing the results from previous anti-doping research, it appears that in the framework of doping, attitudes do have a positive predicting value even though this association is controversially discussed in literature. Ajzen and Fishbein ( 1977 ), the founder of the theory of planned behaviour concluded that the attitude-behaviour relationship may be weak and inconsistent. Also in the doping prevention literature findings of the individual studies are inconsistent, which might be explained by methodological heterogeneity in the operationalization of attitudes.

In contrast to the study of Ntoumanis et al. ( 2014 ) and to previous research from the theory of planned behaviour (Armitage and Conner 2001 ; Bilic 2005 ; Elliot et al. 2003 ; Godin and Kok 1996 ), intentions were no predictor for doping behaviour. An explanation might be found in the ongoing discussion about whether doping behaviour is considered to be rational and volitional decision making. For example, Petroczi and Aidman ( 2008 ) highlighted the fact that doping occurs in a life-cycle model in which individual differences, as well as systemic factors (e.g., motivational climate), play vital roles in self-belief formation (i.e., attitudes and intentions) and interact with situational and environmental factors (e.g., experience, perceived behavioural control, availability) to influence doping behaviour. Consistently with this hypothesis, the sporting culture, which is said to shape attitudes, beliefs and intentions (Smith et al. 2010 ), is considered to be another important factor in the decision to dope (Copeland and Potwarka 2016 ; Engelberg et al. 2015 ).

This argument leads to the second major aim of this meta-analytic review to analyse aspects beyond the athlete-centred approaches. None of the reviewed studies neither explicitly included macro-level factors such as sporting culture and context nor have any of them based their rationale on sociological theories. This finding is interesting as qualitative research suggests the usefulness of macro-level factors in explaining doping behaviour. Some facets of the included variables are part of this macro level and might help to understand why athletes dope and other do not, even though they might display similar personality traits and characteristics. In detail, we found self-determination theory, descriptive norms, moral and situational temptation to be significant predictors for doping behavior and controlled coach climate and subjective norms were predictors for doping susceptibility.

Given the findings from qualitative approaches, especially the sporting culture seems to be a very powerful link in the process of the decision to dope (Copeland and Potwarka 2016 ; Engelberg et al. 2015 ; Smith et al. 2010 ). This is explained based on the social ecological theory that considers attitudes and behaviours to be not only driven by personal intrinsic factors but also by environmental influences. These also include the proximal athletes’ network and the significant role of coaches, team-mates and also peers that has been previously reported elsewhere (Madigan et al. 2016 ; Martin et al. 2014 ; Ommundsen et al. 2006 ). Being part of a certain sporting culture might also mean adopting certain norms and beliefs the individual might not have had prior to entering this specific culture. Especially in cycling, the majority reports a culture that represents a “normalization of doping” (Pappa and Kennedy 2012 ). Not living up to these standards might threaten the social identity of the athletes, which is why these athletes might decide to dope. Apparently, it is not enough to understand that norms impact on doping behaviour but it is important to also understand how these norms are constructed (Ohl et al. 2015 ). Sporting culture does not only shape norms but also moral understanding on what is right or wrong. The sporting culture of elite sport also defines a certain competitive nature that is posed on the athletes (Stewart and Smith 2008 ). Stewart and Smith ( 2008 ) argue further that such a sporting culture might result in violating aspects of autonomy and self-determination, factors that we could also identify to be associated with doping behaviour.

Given the apparently great influence coaches seem to be able to execute on athletes (Huybers and Mazanov 2012 ) in combination with the predictive value of coach climate on doping susceptibility, we also support the call for broader value-based education that includes athletes’ support personnel (Momaya et al. 2015 ). However, coaches do not consider doping prevention as their task (Engelberg and Moston 2016 ). As indicated by Copeland and Potwarka ( 2016 ), these preventive approaches should ensure the improvement of ethical team culture by including leadership elements and informing athletes about the actual prevalence of doping, which should prevent a “normalization-of-doping” culture as proposed by Woolf et al. ( 2014 ).

Major concerns remain about the methodological approaches used in socio-psychological research studies on doping behaviour that have emerged over the past decade. Future studies should focus on using reliable and comparable instruments for data aggregation as suggested by Backhouse et al. ( 2007 ). Future research might also want to use instruments that are designed to enable the production of information on causality, such as experimental or longitudinal studies with at least two time points. Before investing financial resources in prevention measures, we should try to identify intervention points that have proven to be causal for doping behaviour throughout various studies, and also develop and evaluate new intervention measures. Last but not least, missing links between intentions and behaviour might be explained with (a) the difficulty to reliably assess doping behaviour using questionnaires and (b) because perspectives beyond the athlete-centred psychological one should be integrated. Other approaches, as for example shown in the (sports) economics literature based on the game theory (Buechel et al. 2014 ; Haugen 2004 ) analyse the doping phenomenon in sports from a socio-economic perspective. The integration of these economic theories, such as Nash equilibrium, Pareto efficiency and the prisoner’s dilemma would be also interesting for this study. Nevertheless, including this perspective would be beyond the scope of this meta-analysis, but should be included inpotential further research.

Some limitations of the present review need to be addressed as well. Socially desirable behaviour was controlled in only five studies (Barkoukis et al. 2014 ; Lazuras et al. 2010 , 2015 ; Petroczi 2007 ; Whitaker et al. 2014 ), and the overall impact of socially desirable behaviour was small. Nevertheless, we cannot exclude potential biased results in studies that (a) did not control for socially desirable behaviour and (b) due to the fact that its effect on model level might be more significant (Petroczi and Nepusz 2011 ). All included studies that reported on doping behaviour measured behaviour via self-report rather than objective measures (e.g., hair analyses, etc.). Therefore, the potential for inaccurate self-reports may lead to biased results. A possible solution to this problem is offered by using either experimental designs or randomized response techniques as used in previous research (de Hon et al. 2015 ; Pitsch and Emrich 2011 ). Future research should assess predictors of doping behaviour by assessing the dependent variable using such techniques. Another limitation might be the diverse definitions of “performance enhancing substances (PES)”. Not all of the included studies presented a PES definition to their respondents. This might have led to under- and overestimation of the figures in the original studies, as not all respondents might be correctly informed about whether or not substances they consume are PES as defined by the WADC. Finally, ecological validity may be an additional limitation of the present review. Included studies were restricted to a narrow target population of elite athletes, and further research is needed to validate these results in additional target samples. Furthermore, it would be interesting to compare results between different definitions of “elite” as proposed by Swann et al. ( 2015 ).

In summary, aggregating previous research resulted in some generalizable predictors of doping intention, susceptibility and behaviour emerged from this review. However, most of these predictors are athlete-centred and ignore macro-level factors that might help to explain how certain individual traits are developed and why some theoretical models from health-psychology do not seem to be easily transferred to doping behaviour. This finding is astonishing, as results from qualitative approaches suggest the usefulness of macro-level factors in explaining doping behaviour. These findings must be acknowledged as a lot of the qualitative approaches included and questioned athletes who have committed to doping and therewith overcome the biggest limitation of the quantitative studies, namely reliably assessing doping behaviour. An additional striking factor is the limited data availability from only six Western countries. Given this limitation, no conclusion can be drawn about potential cultural factors that impact on the decision to dope.

The findings from this review call for a critical discussion of whether current doping-prevention research needs to take new directions. These strategies are often aimed at changing attitudes and intentions because health-related behavioural theories suggest its effectiveness. However, findings of the current study indicate an unclear picture about the predicting value of intentions on doping behaviour. This might be due to methodological issues or the fact that doping behaviour is too complex and macro level factors must not be ignored. Obviously, psychologists and sociologists both do a very important job in explaining doping behaviour. Yet their findings need to be integrated, as it appears that doping behaviour cannot be explained by ignoring the one or the other. Literature that directly addresses the macro level is mainly narrative and based on qualitative research, which is a useful tool to receive in depth-information on an unknown field but possibly not suitable to draw general conclusions that are sound enough to base prevention strategies on. Thus, it allows generating hypotheses about why athletes dope that need to be integrated in future quantitative approaches to test for its external validity. Finally, there is the urgent need for sound and qualitatively high studies about the mechanisms behind the decision to dope also from Eastern countries to assess possible specific cultural characteristics.

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Authors’ contributions

CB, WS, and MK planned the study. CB performed the systematic literature search. CB, WS, MK and MS separately reviewed and evaluated the search hits and decided on the in- or exclusion. MN performed the statistical- and meta-analysis. All authors engaged in writing the discussion and conclusion. All authors read and approved the final manuscript.

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Blank, C., Kopp, M., Niedermeier, M. et al. Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review. SpringerPlus 5 , 1333 (2016). https://doi.org/10.1186/s40064-016-3000-0

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• Doping prevention
• Micro-level
• Macro-level
• Sporting culture

Doping in Sport and Fitness: Volume 16

Table of contents, introduction: unbinding doping contexts.

This chapter introduces the main aims and ambition with the anthology, which is to bring together research from diverse perspectives on doping and Image and Performance Enhancing Drug (IPED) use. The chapter highlights existing but often backgrounded links between sport and fitness doping research and present a re-reading of the cultural history of doping through which simplistic divisions, such as that between sport and fitness, are deconstructed. Further, by unbinding the hegemonic divide between sports doping and fitness doping, new insights (and themes) concerning anti-doping, health and risk, new emerging doping spaces and the gendering of this field of research are brought to the fore. These themes are then used as point of departure when introducing the different chapters and scholars that contribute to the volume at hand.

Part 1 Anti-Doping Policy

Athletes, law and the world anti-doping code: a perspective.

This chapter explores the relationship between athletes and sports law within the anti-doping narrative. The World Anti-Doping Code is the most important reference to understand this relationship. Athletes are constantly pressured to meet standards beyond reasonable expectations. This chapter explores the anti-doping narrative from the athletes' perspective, mapping out the inherent legal hurdles impeding delivery of equitable outcomes for the athletes. Such hurdles are the result of lack of bargaining power by the athletes. This chapter critically evaluates the existing literature on the anti-doping narrative and identifies the gaps in the structures affecting the athletes, Sports Governing Bodies and the World Anti-Doping Agency (WADA). This chapter then focuses on the usurpation of athlete's rights through the instrumentality of the WADA Code that appears to predominantly promote and protect the interests of the governing class against those it governs. It is one of the first to analyze the existing anti-doping narrative and its impact on athlete's right within the 2021 WADA Code, which has not introduced any fundamental changes to the existing anti-doping narrative. The chapter argues for a more equitable treatment of the athletes while enforcing the 2021 Code, and for revising the existing anti-doping measures vis-à-vis athletes and opens possible areas of future research.

Rights, Responsibilities and Power in Sport Anti-Doping: The Court of Arbitration for Sport

The chapter presents a critical analysis of the functions of the Court of Arbitration for Sport (CAS), identifying how athletes who appeal to CAS for resolution of doping disputes face the problems of ‘stacked decks’ and ‘repeat parties’. A detailed critique of CAS's claim that it supports athletes' human rights, in the document titled ‘Sport and Human Rights: Overview from a CAS Perspective’, reveals the shaky ground on which the CAS authors based their argument. Detailed analyses of several recent doping cases reveal chronic problems of inconsistent and subjective awards, and, in the case of Chinese swimmer Sun Yang, issues of racist discrimination.

Evidence-Based Anti-Doping Education: Fact or Fiction?

There are two key approaches in doping prevention research: (1) to investigate why athletes dope (i.e. risk factors) and (2) to investigate why athletes do not dope (i.e. protective factors). Both approaches aim to reduce the occurrence of doping. Even though there is a lot of evidence showing which factors protect athletes from doping, there is still the problem of putting research into practice. Currently, evidence-based prevention is lacking. In this chapter, we propose a roadmap of possible solutions in three areas: improving the translation of research findings into practice, increasing financial resources and training of human resources, and acknowledging the recipients' voice.

Part 2 Health and Risks

The use of anabolic androgenic steroids as a public health issue.

In recent years there have been increasing calls for the use of anabolic androgenic steroids (AAS) and associated drugs to be recognized as a public health issue. In the domain of the competitive athlete and professional bodybuilder, recent decades have seen the diffusion of AAS from the hardcore gyms of the 1980s and 1990s to the mainstream exercise and fitness environments of the twenty-first century. Alongside the apparent increases in the use of these drugs, there is a growing evidence base in relation to harms – physical, psychological and (to some extent) social. But is this form of drug use a public health issue? What criteria should we use to make this judgement? What is the available evidence and has our understanding of the issue improved? By drawing on the authors' research in the United Kingdom and the wider international literature this chapter will explore these issues and attempt to answer the fundamental question – is the use of anabolic steroids a public health issue?

The Experiences of Healthcare Professionals With PIED Consumers and the Experiences of PIED Consumers With Healthcare Professionals: A Systematic Literature Review

The aim of this review was to amalgamate the extant literature that has investigated the experiences of healthcare professionals with PIED consumers and the experiences of PIED consumers with healthcare professionals, with a specific focus on medical practitioners. A systematic search was undertaken to identify studies that explored the experiences and perspectives of healthcare providers working with clients who use PIEDs, as well as to identify studies that explored the experiences and perspectives of PIED consumers with healthcare providers. Ten studies were included, of which four explored the experiences of healthcare providers with PIED consumers, and six explored the experiences of PIED consumers with healthcare providers. A sizeable proportion of healthcare providers come into contact with PIED consumers, with these interactions mostly related to consumers asking for information, though a small but significant proportion indicate they have been asked to prescribe doping agents. Of the six studies which focused on the consumer experience, five focused on PIED consumers; these studies found that while large proportions reporting accessing a medical practitioner, larger proportions did not, with the doctor's lack of knowledge cited as one reason. More research is needed to investigate how they come into contact with this group of consumers, their level of knowledge and any training that they may need. Given the harms associated with PIED use, and the lack of disclosure of use to healthcare providers, more research is needed to understand the barriers and facilitators for consumers to accessing health care.

Taking ‘the God of all Steroids’ and ‘Making a Pact With the Devil’: Online Bodybuilding Communities and the Negotiation of Trenbolone Risk

Previous research has found that people who use anabolic androgenic steroids (hereafter ‘steroids’) typically describe these drugs as safe. However, research exploring the inside perspective on steroid risk has focussed on steroids in general, and failed to examine how particular steroids are viewed and experienced. During my online ethnographic research in bodybuilding communities, I found discussion of one particular steroid said to cause significant physical, psychological, social and sexual harm: trenbolone. Trenbolone is a veterinary drug used to increase muscle in beef cattle that has been found to have neurodegenerative and genotoxic effects on animals. It has been used by bodybuilders since the 1980s, and recent research has found it to be one of the most popular steroids used by bodybuilders. If trenbolone is described by bodybuilders as causing significant harm, why do so many bodybuilders use it? This chapter attempts to answer this question through a description of bodybuilder folk models of trenbolone risk. Using a social life of drugs approach it describes: (1) the effects of trenbolone; (2) how these effects are given meaning as either harms or benefits, and then weighed against each other; (3) how the risks of trenbolone are reduced through harm reduction strategies and (4) the role of online communities in negotiations of trenbolone risk. Trenbolone was found to occupy a mythical status in bodybuilding communities, in part because of the conflicted relationship bodybuilders have with the drug. This conflicted relationship illustrates the inherent ambivalence of drugs, which are always both remedy and poison.

Part 3 Doping Arenas and Communities

Steroid use among inmates in belgian prisons.

While steroid use in the sports context has already been extensively studied by academic researchers, its patterns and implications in the prison context have received scant attention. Why do inmates use androgenic–anabolic steroids (AAS)? How does this use relate to sports activities, in particular fitness training, and what does it mean vis-à-vis the body image that is promoted in this environment? Does it even relate to fitness or sport? How do prison authorities regulate or prevent prisoners' AAS use? This empirical study is based on 28 interviews with 19 inmates and nine staff members (guards, managers) of four Belgian prisons. We showed that steroid use is largely connected with fitness activities and that it has an instrumental, goal-oriented dimension. AAS are used for athletic/performance purposes, e.g. increasing muscular strength. They also help gain or maintain a satisfactory body (self-)image, which has implications on the own identity, prestige and power relations within the prison community. In jail, the body is a major type of symbolic capital that is intended to reinforce status and cope with the difficulties and actual conditions of incarceration. We also observed differences in the perceived legitimacy of the various drugs that are used in prison. While guards are more tolerant towards AAS than other drugs, prisoners are less prone to openly confess to using AAS. Admitting to using AAS would damage the inmate's reputation, the legitimacy of his muscled body, and the subsequent goals of individual power and prestige.

How Digital Fitness Forums Shape IPED Access, Use, and Community Harm Reduction Behaviours

With digital spaces an increasing feature of our everyday lives, and the internet now a primary means of sourcing IPEDs and information regarding their use, this chapter seeks to understand how digital fitness forum communities shape the dissemination of culturally embedded harm reduction advice. Findings are drawn from two netnographic studies of fitness forums, which identify several key areas in which community norms and structures served to inform harm reduction behaviours. This included embedded forum reputation systems and the ways in which these shaped IPED access, including through elevating ‘expert’ users and encouraging informed discussion regarding product quality, to the emergence of steroid testing services from forums as a community harm reduction tool. Second, forums were observed to often encourage users to conduct research and inform themselves regarding safe use, though limitations to this norm were also documented in relation to poor-quality medical advice, highlighting the issues with IPED users' reliance on anecdotal advice in the contexts of prohibition. Finally, the role of digital fitness forums as ‘digital backstage’ is considered, examining both how this can be harmful to IPED users from excluded or ‘otherised’ groups, but simultaneously offers cultural participants the opportunity for airing vulnerabilities in a space where their masculine identity is not threatened in doing so, thus facilitating harm reduction among cultural ‘insiders’.

The 2021 WADA Code, Recreational Athletes and Ethical Concerns

In response to widespread concerns about health and fairness within elite sport, the World Anti-Doping Agency (WADA) was established as an organization to tackle the use of performance enhancing drugs in sport. Whilst significant efforts have been made to regulate performance enhancement in the context of elite sport, the use of prohibited substances continues to persist. Doping rules are now potentially applicable across sporting levels, not just within elite sport. The WADA has further formalized its jurisdiction in recreational sport by defining the term ‘recreational athlete’ for the purposes of their regulation within and by the 2021 WADA Code. The extension of Anti-Doping Policy into recreational sport broadens the scope of anti-doping's regulatory framework but is consistent in its health protection rationale, and its attempt to preserve sporting integrity. There are, however, a number of ethical concerns associated with the application of Anti-Doping Policy within recreational sport. Anti-doping policy was originally designed exclusively for elite athletes and although amendments have been made within the revised 2021 World Anti-Doping Code, it is unclear whether this extension is justifiable or operationalizable on a global scale. This chapter pays particular attention to the 2021 WADA Code revisions and draws attention to the role of anti-doping policy within recreational sport. Here we raise some ethical concerns associated with the 2021 WADA Code and critically examine the implications for recreational athletes.

Part 4 Gendering Doping

Cultural manspreading in doping environments: theorizing the gendering of doping spaces, sexualities, and the social.

This chapter introduces the sociologically informed concept of cultural manspreading , which is used to critically examine how gender and power operate in relation to doping and image and performance enhancing drug (IPED) use. Though not exclusively, the chapter centres on the online doping context and how men and women in different forums navigate their doping lifestyles and identities. By focusing on the online doping context, the chapter brackets not only the focus on sport and fitness that has dominated much research, but also the physical dimension that have been at the heart of manspreading in public discourse. Thereby the concept is theorized for wider interpretations, including analysis of men dominating spatial, social and sexual aspects/domains of doping subcultures to the detriment of women or subordinate men. Though doping subcultures are steeped in a masculinity that prioritizes muscular masculinities and construct men as experts and sources of knowledge about doping, the chapter also illustrates how both men and women sometimes play into and challenge such patterns and gender dynamics. Indeed, at times, women's presence in different doping spaces can be a challenge to the default male position. Further, by introducing women-only doping forums the chapter argues that women can begin to debate and share their experiences uninterrupted, developing their own store of knowledge, and setting the female body and experience as default. This supports the idea of a gradual formation of a sis-science doping culture.

Bodybuilding, Gender and Drugs

This chapter presents an auto-ethnographic journey into the world of women's bodybuilding and the role performance-enhancing drugs play in the pursuit of muscularity in this growing, but hard-to-reach, subculture. The research addresses a paucity in the literature and paves the way for further research to inform public health initiatives for this population. Synthesizing journal entries, field observations and informal conversations recorded over the course of 18 months, this chapter provides insight into the rituals and practices present in bodybuilding culture. This embodied narrative explores the decision-making process surrounding anabolic androgenic steroid use in the context of competitive endeavour, including the impact that cultural norms, peer influence and personal narrative have on their uptake. It also sheds light on the experiences of being a woman in a man's world and the additional stigma women face when attempting to increase their muscularity. It also highlights the personal and professional challenges involved in auto-ethnographic endeavour.

Intersections of Gender, Doping and Sport: The Shared Implications of Anti-Doping and Sex Testing

This chapter focuses on what we know about the intersections of gender, doping and sport and addresses the history, complexities and nuances of how gender impacts perceptions of and research on doping in sport. After establishing briefly what the physiology, psychology, media studies and sociology literature demonstrates with respect to the intersection of doping and gender, this chapter addresses how and why gender was neglected in the creation of anti-doping policies. The lack of thought toward gender in the creation of the current anti-doping system, combined with the conflation of drug testing and sex testing issues by the International Olympic Committee's medical commission in the 1960s, has led to persistent gender stereotypes associated with anti-doping rule violations. As a result, unintended overlap between sex testing and drug testing continues, with implications for the eligibility of intersex and transgender athletes.

Conclusion: Doping: Unbound

This chapter concludes the volume. This is done in two capacities. First, the contributing chapters within in each theme are brought together through a reflexive discussion on current debates on anti-doping approaches, health and risk, doping arenas and communities, and the gendering of doping. Second, the interrelationships between the themes are discussed, pointing to new research directions.

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• Jesper Andreasson

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Reporting doping in sport: national level athletes' perceptions of their role in doping prevention

Affiliation.

• 1 Institute for Sport, Physical Activity and Leisure, Leeds Metropolitan University, Leeds, UK.
• PMID: 24673128
• DOI: 10.1111/sms.12222

This paper qualitatively explores national level athletes' willingness to report doping in sport. Following ethical approval, semi-structured interviews were conducted with nine national level athletes from rugby league (n = 5) and track and field athletics (n = 4). Thematic analysis established the main themes within the data. Contextual differences existed around the role that athletes perceived they would play if they became aware of doping. Specifically, track and field athletes would adopt the role of a whistle-blower and report individuals who were doping in their sport. In comparison, the rugby league players highlighted a moral dilemma. Despite disagreeing with their teammates' actions, the players would adhere to a code of silence and refrain from reporting doping. Taking these findings into account, prevention programs might focus on changing broader group and community norms around doping. In doing so, community members' receptivity to prevention messages may increase. Moreover, developing skills to intervene (e.g., speaking out against social norms that support doping behavior) or increasing awareness of reporting lines could enhance community responsibility for doping prevention. In sum, the findings highlight the need to consider the context of sport and emphasize that a one-size-fits-all approach to anti-doping is problematic.

Keywords: Anti-doping education; bystander responsibility; performance-enhancing substances; qualitative.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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Drug abuse in athletes

Claudia l reardon.

Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

Shane Creado

Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the history of doping in athletes, the effects of different classes of substances used for doping, side effects of doping, the role of anti-doping organizations, and treatment of affected athletes. Doping goes back to ancient times, prior to the development of organized sports. Performance-enhancing drugs have continued to evolve, with “advances” in doping strategies driven by improved drug testing detection methods and advances in scientific research that can lead to the discovery and use of substances that may later be banned. Many sports organizations have come to ban the use of performance-enhancing drugs and have very strict consequences for people caught using them. There is variable evidence for the performance-enhancing effects and side effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

Introduction

Doping, defined as use of drugs or other substances for performance enhancement, has become an important topic in virtually every sport 1 and has been discovered in athletes of all ages and at every level of competition. 2 – 4 See Table 1 for rates of use of a variety of substances, whether doping agents or recreational substances, among different populations of athletes as reported in various recent research studies. 5 – 10 Of note, self-reports are generally felt likely to yield under-reported figures. 5 Importantly, performance-enhancing drugs (PEDs) are not restricted to illegal drugs or prescription medications, such as anabolic steroids. 11 They include dietary supplements and a variety of compounds that are available at grocery and health food stores and online. 12

Substance use rates among different populations of athletes as reported in various recent research studies

Abbreviation: WADA, World Anti-Doping Agency.

Drug abuse in the athlete population may involve doping in an effort to gain a competitive advantage. Alternatively, it may involve use of substances such as alcohol or marijuana without the intent of performance enhancement, since athletes may develop substance use disorders just as any nonathlete may.

Athletes may turn to substances to cope with numerous stressors, including pressure to perform, injuries, physical pain, and retirement from a life of sport (which happens much earlier than retirement from most other careers). 13 Additionally, athletes may be significantly less likely to receive treatment for underlying mental illnesses such as depression. 14 Athletes receive comprehensive treatment and rehabilitation for physical injuries, but this may be less often the case for mental illness, because of their sometimes viewing mental illness as a sign of weakness. 14 Untreated mental illness is often associated with substance use, perhaps in an effort to self-treat. Alternatively, substances of abuse may cause mental illness. 15

We will especially focus on doping in this review, which specifically aims to serve as a single paper that provides a broad overview of the history of doping in athletes, the effects of different classes of drugs used for doping, side effects of doping, the role of anti-doping organizations, and the treatment of affected athletes.

Materials and methods

For this review, we identified studies through a MEDLINE search. Search terms included the following, individually and in combination: “doping”, “athletes”, “steroids”, “drug abuse”, “mental illness”, “drug testing”, “anti-doping”, “psychiatry”, “sports”, “depression”, “substance abuse”, “substance dependence”, “addiction”, “history”, “side effects”, “drug testing”, “treatment”, “androgens”, “testosterone”, “growth hormone”, “growth factors”, “stimulants”, “supplements”, “erythropoietin”, “alcohol”, “marijuana”, “narcotics”, “nicotine”, “Beta agonists”, “Beta blockers”, “diuretics”, “masking agents”, “gene doping”, “National Collegiate Athletic Association”, and “World Anti-Doping Agency”. We restricted results to the English language and used no date restrictions. We retrieved all papers discussing drug abuse in athletes. We reviewed the findings of each article, and reviewed the references of each paper for additional papers that had been missed in the initial search and that might include findings relevant to the scope of our review. Ultimately, 67 manuscripts or chapters were felt relevant and representative for inclusion among those referenced in this paper.

History of doping in athletes

The belief that doping is only a recent phenomenon that has arisen solely from increasing financial rewards offered to modern day elite athletes is incorrect. 16 In fact, doping is older than organized sports. Ancient Greek Olympic athletes dating back to the third century BC used various brandy and wine concoctions and ate hallucinogenic mushrooms and sesame seeds to enhance performance. Various plants were used to improve speed and endurance, while others were taken to mask pain, allowing injured athletes to continue competing. 17 – 19 Yet, even in ancient times, doping was considered unethical. In ancient Greece, for example, identified cheaters were sold into slavery. 1

The modern era of doping dates to the early 1900s, with the illegal drugging of racehorses. Its use in the Olympics was first reported in 1904. Up until the 1920s, mixtures of strychnine, heroin, cocaine, and caffeine were not uncommonly used by higher level athletes. 16

By 1930, use of PEDs in the Tour de France was an accepted practice, and when the race changed to national teams that were to be paid by the organizers, the rule book distributed to riders by the organizer reminded them that drugs were not among items with which they would be provided. 20

In the 1950s, the Soviet Olympic team began experimenting with testosterone supplementation to increase strength and power. 16 This was part of a government-sponsored program of performance enhancement by national team trainers and sports medicine doctors without knowledge of the short-term or long-term negative consequences. Additionally, when the Berlin Wall fell, the East German government’s program of giving PEDs to young elite athletes was made public. 1 Many in the sporting world had long questioned the remarkable success of the East German athletes, particularly the females, and their rapid rise to dominance in the Olympics. Young female athletes experienced more performance enhancement than did male athletes. Unfortunately, they also suffered significant and delayed side effects, including reports of early death in three athletes. 19

The specific substances used to illegally enhance performance have continued to evolve. 21 The “advances” in doping strategies have been driven, in part, by improved drug testing detection methods. 21 To avoid detection, various parties have developed ever more complicated doping techniques. 21 Further, new doping strategies may result from advances in scientific research that can lead to the discovery and use of substances that may later be banned. Over the past 150 years, no sport has had more high-profile doping allegations than cycling. 16 However, few sports have been without athletes found to be doping.

Many sports organizations have come to ban the use of PEDs and have very strict rules and consequences for people who are caught using them. The International Association of Athletics Federations was the first international governing body of sport to take the situation seriously. 22 In 1928, they banned participants from doping, 22 but with little in the way of testing available, they had to rely on the word of athletes that they were not doping. It was not until 1966 that the Federation Internationale de Football Association and Union Cycliste Internationale joined the International Association of Athletics Federations in the fight against drugs, closely followed by the International Olympic Committee (IOC) the following year. 23

The first actual drug testing of athletes occurred at the 1966 European Championships, and 2 years later the IOC implemented their first drug tests at both the Summer and Winter Olympics. 24 Anabolic steroids became even more prevalent during the 1970s, and after a method of detection was found, they were added to the IOC’s prohibited substances list in 1976. This resulted in a marked increase in the number of doping-related disqualifications in the late 1970s, 24 notably in strength-related sports, such as throwing events and weightlifting.

While the fight against stimulants and steroids was producing results, 24 the main front in the anti-doping war was rapidly shifting to blood doping. 25 This removal and subsequent reinfusion of an athlete’s blood in order to increase the level of oxygen-carrying hemoglobin has been practiced since the 1970s. 25 The IOC banned blood doping in 1986. 25 Other ways of increasing the level of hemoglobin were being tried, however. One of these was erythropoietin. 25 Erythropoietin was included in the IOC’s list of prohibited substances in 1990, but the fight against erythropoietin was long hampered by the lack of a reliable testing method. An erythropoietin detection test was first implemented at the 2000 Olympic Games. 25

In the 1970s and 1980s, there were suspicions of state-sponsored doping practices in some countries. The former German Democratic Republic substantiated these suspicions. 25 The most prominent doping case of the 1980s concerned Ben Johnson, the 100 meter dash champion who tested positive for the anabolic steroid stanozolol at the 1988 Olympic Games in Seoul. 25 In the 1990s, there was a noticeable correlation between more effective test methods and a drop in top results in some sports. 25

In 1998, police found a large number of prohibited substances, including ampoules of erythropoietin, in a raid during the Tour de France. 25 , 26 The scandal led to a major reappraisal of the role of public authorities in anti-doping affairs. As early as 1963, France had been the first country to enact anti-doping legislation. Other countries followed suit, but international cooperation in anti-doping affairs was long restricted to the Council of Europe. In the 1980s, there was a marked increase in cooperation between international sports authorities and various governmental agencies. Before 1998, debate was still taking place in several discrete forums (IOC, sports federations, individual governments), resulting in differing definitions, policies, and sanctions. Athletes who had received doping sanctions were sometimes taking these sanctions, with their lawyers, to civil courts and sometimes were successful in having the sanctions overturned. The Tour de France scandal highlighted the need for an independent, nonjudicial international agency that would set unified standards for anti-doping work and coordinate the efforts of sports organizations and public authorities. The IOC took the initiative and convened the First World Conference on Doping in Sport in Lausanne in February 1999. Following the proposal of the Conference, the World Anti-Doping Agency (WADA) was established later in 1999.

Performance-enhancing effects of substances used by athletes

There is a research base demonstrating that many doping agents are in fact performance-enhancing. However, some substances (eg, selective androgen receptor modulators, antiestrogens, and aromatase inhibitors), used in an effort to enhance performance, have little data to back up their effectiveness for such a purpose. Note that the studies cited in this paper are chosen as being historically important or representative of the bulk of the research on the topic, and the broad overview provided in this paper does not aim to cite all evidence on the effects of these substances. Additionally, research on this topic is limited by the difficulty in performing ethical studies due to the high doses of doping agents used, potential side effects, and lack of information on actual practice.

Androgens include exogenous testosterone, synthetic androgens (eg, danazol, nandrolone, stanozolol), androgen precursors (eg, androstenedione, dehydroepiandrosterone), selective androgen receptor modulators, and other forms of androgen stimulation. The latter categories of substances have been used by athletes in an attempt to increase endogenous testosterone in a way that may circumvent the ban enforced on natural or synthetic androgens by WADA.

Amounts of testosterone above those normally found in the human body have been shown to increase muscle strength and mass. For example, a representative randomized, double-blind study involved 43 men being randomized to four different groups: testosterone enanthate 600 mg once per week with strength training exercise; placebo with strength training exercise; testosterone enanthate 600 mg once per week with no exercise; and placebo with no exercise. This was a critical study in demonstrating that administration of testosterone increased muscle strength and fat-free mass in all recipients, and even moreso in those who exercised. 27 A second study from the same investigators 5 years later further demonstrated a dose–response relationship between testosterone and strength. 28 Another double-blind trial of exogenous testosterone involved 61 males randomized to five different doses of testosterone enanthate, ranging from 25 mg to 600 mg, along with treatment with a gonadotropin-releasing hormone agonist to suppress endogenous testosterone secretion. That study demonstrated findings similar to the previous one, in showing a dose-dependent increase in leg power and leg press strength, which correlated with serum total testosterone concentrations. 29

Androgen precursors include androstenedione and dehydroepiandrosterone (DHEA). We found no evidence that androstenedione increases muscle strength. 30 DHEA is available as a nutritional supplement that is widely advertised in body building magazines as a substance that will improve strength. However, results from placebo-controlled studies of DHEA in males have been mixed. 30 , 31 One study involved 40 trained males being given DHEA 100 mg per day, androstenedione, or placebo, with no resulting differences in muscle mass or fat-free mass between groups. 30 A second study involved nine males and ten females randomized to receive DHEA 100 mg daily or placebo for 6 months, who were then crossed over to the other group for a further 6 months. The males but not females showed increased knee and lumbar back strength during DHEA treatment. 31

Selective androgen receptor modulators are not approved for use in humans in any country, but athletes are able to obtain these substances on the Internet. 32 No studies were found looking at the effects of selective androgen receptor modulators on muscle strength or mass in humans.

Other forms of androgen stimulation include exogenous human chorionic gonadotropin, antiestrogens such as tamoxifen, clomiphene, and raloxifene, and aromatase inhibitors such as testolactone, letrozole, and anastrozole. These substances may result in increased serum testosterone. 33 However, we found minimal research demonstrating an effect on muscle strength. 34 While androgens of different forms have been shown to improve muscle strength and mass, they have not been shown to improve whole body endurance per se. 35

Growth hormone and growth factors

Growth hormone and growth factors are also banned by WADA. Research shows recombinant human growth hormone to increase muscle mass and decrease adipose tissue. One representative study randomized male recreational athletes to growth hormone 2 mg/day subcutaneously, testosterone 250 mg weekly intramuscularly, a combination of the two treatments, or placebo. 36 Female recreational athletes were randomized to growth hormone 2 mg daily or placebo. In both males and females, growth hormone was associated with significantly decreased fat mass, increased lean body mass, and improved sprint capacity (although with no change in strength, power, or endurance). Sprint capacity improvement was even greater when growth hormone and testosterone were coadministered to males.

Growth factors include insulin-like growth factor and insulin. They are presumed to have similar effects to growth hormone, but have not been studied in athletes. 37 Athletes use these substances because of their apparent anabolic effect on muscle. 37

Stimulants include amphetamine, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, dimethylamylamine, cocaine, fenfluramine, pemoline, selegiline, sibutramine, strychnine, and modafinil. Research has shown stimulants to improve endurance, increase anaerobic performance, decrease feelings of fatigue, improve reaction time, increase alertness, and cause weight loss. 38 Of note, while WADA bans stimulants as a class, it does allow use of caffeine. Energy beverages now often include a variety of stimulants and other additives including not only caffeine, but also the amino acids taurine and L-carnitine, glucuronolactone, ginkgo biloba, ginseng, and others. 39 Caffeine content can be up to 500 mg per can or bottle. The potential performance benefits of the other ingredients in energy beverages are unclear. For example, taurine may improve exercise capacity by attenuating exercise-induced DNA damage, but the amounts found in popular beverages are probably far below the amounts needed to be of performance-enhancing benefit. 39

Of note, the number of athletes, especially at top levels of competition, reported to be using stimulant medications has markedly increased in recent years. In the USA, the National Collegiate Athletic Association acknowledged that the number of student athletes testing positive for stimulant medications has increased three-fold in recent years. 40 There has also been concern about inappropriate use of stimulants in major league baseball in the USA. According to a report released in January 2009, 106 players representing 8% of major league baseline players obtained therapeutic use exemptions for stimulants in 2008, which was a large increase from 28 players in 2006. 41 Therapeutic use exemptions allow athletes to take otherwise banned and performance-enhancing substances if their physician attests that they should for medical reasons.

Nutritional supplements

Nutritional supplements include vitamins, minerals, herbs, extracts, and metabolites. 39 Importantly, the purity of these substances cannot be guaranteed, such that they may contain banned substances without the athlete or manufacturer being aware. Studies have shown that many nutritional supplements purchased online and in retail stores are contaminated with banned steroids and stimulants. 42 Thus, athletes could end up failing doping tests without intentionally having ingested banned substances. 42 Creatine is not currently on the WADA banned list and is the most popular nutritional supplement for performance enhancement. 3 Studies demonstrate increased maximum power output and lean body mass from creatine. 43 , 44 As such, some allowable nutritional supplements may have ergogenic effects, but may have insufficient evidence supporting their ergogenic properties to rise to the level of being banned.

Methods to increase oxygen transport

Substances athletes use to increase oxygen transport include blood transfusions, erythropoiesis-stimulating agents such as recombinant human erythropoietin and darbepoetin alfa, hypoxia mimetics that stimulate endogenous erythropoietin production such as desferrioxamine and cobalt, and artificial oxygen carriers. Transfusions and erythropoiesis-stimulating agents have been shown to increase aerobic power and physical exercise tolerance. 45 However, the ergogenic effects of the other agents are debatable. 45

Other recreational drugs

Other recreational drugs that may be used in an attempt to enhance performance include alcohol, cannabinoids, narcotics, and nicotine. 13 WADA does not currently ban nicotine but bans cannabinoids and narcotics. Alcohol is banned in six sports during competition only. All of these substances may be used by athletes to reduce anxiety, which may be a form of performance enhancement, but we found little research looking at actual performance enhancement from these agents. Narcotics are used to decrease pain while practicing or playing. Nicotine may enhance weight loss and improve attention. 46

Beta agonists

There is debate as to whether beta-2 adrenergic agonists, for example, albuterol, formoterol, and salmeterol, are ergogenic. 47 There is anecdotal evidence of improvements in swimmers who use these substances prior to racing. 48 Additionally, oral beta agonists may increase skeletal muscle, inhibit breakdown of protein, and decrease body fat. 48 However, there is some evidence suggesting that swimmers may have a relatively high prevalence of airway hyperresponsiveness due to hours spent breathing byproducts of chlorine, such that beta agonists may be needed to restore normal, not enhanced, lung function. 49

Beta blockers

Beta blockers such as propranolol result in a decreased heart rate, reduction in hand tremor, and anxiolysis. These effects may be performance-enhancing in sports in which it is beneficial to have increased steadiness, such as archery, shooting, and billiards. 48

Other prescription drugs

Diuretics and other masking agents may be used as doping agents. 12 Diuretics can result in rapid weight loss such that they may be used for a performance advantage in sports with weight classes, such as wrestling and boxing. 12 Diuretics may also be used to hasten urinary excretion of other PEDs, thereby decreasing the chances that athletes will test positive for other banned substances that they may be using. 12 Masking agents in general conceal prohibited substances in urine or other body samples, and include diuretics, epitestosterone (to normalize urine testosterone to epitestosterone ratios), probenecid, 5-alpha reductase inhibitors, and plasma expanders (eg, glycerol, intravenous administration of albumin, dextra, and mannitol). 50

Glucocorticoids are sometimes used by athletes in an attempt to enhance performance because of their anti-inflammatory and analgesic properties. 12 However, there is minimal research to show any performance benefits of this class of drugs.

Athletes may also use phosphodiesterase-5 inhibitors in an attempt to attain increased oxygenation and exercise capacity, since they have vasodilatory effects. 51 However, again, little research exists to support a performance benefit from these substances.

Psychiatric medications, including antidepressants, anxiolytics, antipsychotics, and anticonvulsants, are generally not on the WADA banned list. 14 Bupropion is an antidepressant that is on the WADA 2014 monitoring list, meaning WADA is monitoring for any concerning trends of inappropriate use. One small study of nine males suggested that bupropion, when used acutely in warm environments, may allow athletes to push themselves to higher body temperature and heart rates without perceiving greater effort. 52 Otherwise, there is very minimal evidence that any of these classes of psychiatric medications enhance performance. 14

Nondrug performance-enhancing measures

Gene doping is a concerning potential method of nondrug performance enhancement and is banned by WADA. The potential to directly affect strength and endurance through gene manipulation has been demonstrated in laboratory mice, but no human athletes thus far have been found to be using this method. 16

Additionally, athletes may legally attempt to improve physical performance in a number of nondrug ways. 53 These have varying degrees of research into their effectiveness and safety, and include hypoxia induction techniques. 53 For example, athletes may train at high altitudes, which can result in erythrocytosis. Some studies suggest that a high–low method of sleeping at high altitude followed by training at low altitude is a better training strategy than training or sleeping at either high or low altitudes alone. 54 Some athletes have tried sleeping at simulated high altitude by using low oxygen tents. Athletes may also make dietary changes to try to increase hemoglobin levels. 55 , 56

Side effects of substances used by athletes

It is presumed that most if not all doping agents have potential short-term and/or long-term side effects. Unfortunately, given the high doses of these agents used by athletes, it is difficult to confirm such effects. It would be unethical to give dosages as high as those used by athletes for performance enhancement effects to participants in research studies. 16 Knowledge about side effects may be gleaned from empirical observation, reports of admitted users, and effects in patients prescribed such agents for medical conditions. Table 2 lists the potential side effects of various forms of doping. 57 – 59

Potential side effects of different substances and methods of doping

Note: Copyright © 2013. John Wiley & Sons. Adapted with permission from 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. 16

Anti-doping organizations, drug testing in athletes, and rules

Drug testing typically occurs only in organized, competitive sports. At the college level, organizations such as the National Collegiate Athletic Association 60 and individual member institutions conduct standard drug testing programs and enforce penalties for positive tests.

Elite athletes competing at international and national levels are subject to standardized anti-doping guidelines under the auspices of WADA and related national organizations. WADA is the international independent agency that publishes the World Anti-Doping Code, which is the document harmonizing anti-doping policies in all sports and all countries. 61 The Code was first adopted in 2003 and became effective in 2004. The Code sets forth specific anti-doping rules and principles that are to be followed by the anti-doping organizations responsible for adopting, implementing, or enforcing anti-doping rules within their authority, including the IOC, International Paralympic Committee, international sport federations (for example, the International Cycling Union), major event organizations, and national anti-doping organizations (for example, the US Anti-Doping Agency).

WADA revises and publishes its list of banned substances approximately annually. It specifies those banned substances and methods that are prohibited at all times (both in-competition and out-of-competition) because of their potential to enhance performance in future competitions or their masking potential, and those substances and methods that are prohibited in-competition only. The list may be expanded by WADA for a particular sport.

WADA has also taken the lead in the development of the athlete biological passport concept. 61 WADA’s athlete biological passport operating guidelines took effect in 2009. The fundamental principle of the athlete biological passport is based on the monitoring of selected parameters over time that indirectly reveal the effect of doping, as opposed to the traditional direct detection of doping by analytical means. This concept gained momentum as a result of questions raised during the 2006 Olympic Winter Games surrounding suspensions of athletes by their federations following health checks that reported high hemoglobin levels. An athlete’s passport purports to establish individual baseline hormone/blood levels, which are monitored over time for significant changes. A positive test result would consist of too dramatic a change from the established individual baseline. This approach is intended to protect athletes from false-positive tests resulting from naturally occurring high levels of endogenous substances, while catching those attempting to cheat by using naturally occurring substances.

In the event that an athlete and his or her medical providers feel it necessary, for documented medical reasons, that he or she continue to take a banned substance, WADA may consider granting a therapeutic use exemption, a concept mentioned earlier. A therapeutic use exemption must be on file before an athlete tests positive for the substance allowed by that therapeutic use exemption.

Treatment of affected athletes, including counseling and psychiatric support

The first level of addressing the problem of drug abuse by athletes is prevention. 13 Drug screening is used in higher-level athletics both to deter athletes from using drugs and to punish and offer opportunities for rehabilitation to those who are found to have done so. Didactic education is another method aimed at prevention. 62 On the one hand, some authors and clinicians feel that among the most effective preventive strategies for drug abuse in sports is frequent, accurate, very closely observed, truly random urine drug testing. 13 , 63 However, some view drug testing as ineffective at preventing use of PEDs. 64 The argument for the latter is that these interventions target doping behavior rather than athlete attitudes. Athletes ultimately focus on their performance, and thus may view doping as rational behavior. 63 Moreover, knowledge of the potentially dangerous consequences from doping imparted via didactic education does not necessarily dissuade athletes. For example, in 1997, Bamberger and Yaeger surveyed 198 Olympic athletes. When asked if they would use PEDs under the hypothetical conditions of knowing they would not be caught and knowing their use would result in victory, 195 of 198 responded “yes”. Moreover, if the caveat was added that they would die within 5 years, 61% of the athletes still said they would use them. 65

There is little research available to guide counseling and psychiatric approaches to treatment of athletes who abuse drugs. 64 However, motivational interviewing approaches have been suggested for athletes with drug abuse or doping problems, since athletes may often present in the precontemplation stage of change. 13 , 64 Important elements of motivational interviewing include: 64

• Clinician empathy
• Developing discrepancies between where the athlete wants to go in life after sport and the impact that continued use of the substance might have on those goals. During this process, the provider helps athletes to clarify conflict among their values, motives, interest, and behaviors.
• Rolling with resistance. When resistance inevitably occurs, providers should avoid arguing with athletes, as that can exacerbate resistance to change. The provider may “agree to disagree” on certain points with some athletes. Providers may propose or “wonder about” certain alternative viewpoints or actions, but they do not impose or insist upon them.
• Encouragement of self-efficacy. Athletes may need to shift their viewpoint from one of being willing to do whatever it takes to win, to acknowledging that they would use PEDs only if ultimately incapable of succeeding without them (with the hope that athletes will never get to that point). If an athlete is physically dependent on a drug, then additional strategies may be needed. These may include pharmacologic interventions such as naltrexone, acamprosate, or disulfiram for alcohol dependence, or buprenorphine for opiate dependence. 13 Additionally, providers should assess for comorbid mental illness, since co-occurrence of physical dependence and mental illness is commonplace. 13 Any underlying mental illness should be treated. 13 A recent review paper on the epidemiology of mental illness in athletes noted that some mental illnesses such as depression are probably as common in athletes as nonathletes. 14 Twelve-step facilitation, cognitive behavioral therapy, and network therapy are also approaches that may be helpful for athletes who are abusing drugs, although studies are preliminary. 10 , 13 , 66

Conclusion and suggestions

Drug abuse in athletes is a significant problem that has many potential underlying causes. The drive to be the best in sport dates to ancient times, as does the use of performance-enhancing substances. With the ever-mounting pressures faced by athletes, it is not surprising that drug abuse by athletes exists across essentially all sports and age groups.

Suggestions for those undertaking research and clinical work with athletes include:

• If providers become aware of an athlete using PEDs, they should educate the athlete about the potential risks of continued use, regardless of any evidence that suggests this may not be influential for all athletes. Providers should encourage discontinuation of the abused substance(s).
• There is great variance in drug testing programs in different sports and at different levels of competition. 13 More high-quality, prospective, randomized trials should be undertaken to determine the deterrent efficacy of various types of PED screening programs, and changes should be made to those types of screening programs found to be ineffective. 8

Common signs and symptoms of substances relatively commonly used by athletes

Note: Copyright © 2013. John Wiley & Sons. Adapted with permission from Morse ED. Substance use in athletes. In: Baron DA, Reardon CL, Baron SH, editors. Clinical Sports Psychiatry: An International Perspective . Oxford, UK: Wiley; 2013. 8 , 13

• The efficacy of education about PED use as a preventative measure needs further study. Early integration of well designed prevention curricula into sports programs may be beneficial. 8 However, as alluded to earlier, at least one preliminary study suggests that educational programs that solely emphasize the negative effects of PEDs may be ineffective for young athletes. 67
• Mental health professionals should be included in the network of team doctors and other health care providers readily available to athletes. Psychiatrists are often helpful in developing strong drug prevention policies that emphasize education and treatment and not just sanctions. 13 Mental health care professionals should have a year-round presence with the athletes and teams with whom they are working so as to build trust. 13
• Screening for and treatment of underlying mental illnesses such as depression that may contribute to self-treatment with drugs by athletes should be increased. The effectiveness of this screening should be studied.
• Athletes who are using drugs are often skeptical of the medical field. This may be partly with good reason, as many health care professionals are unfamiliar with the mentality of athletes or common drug abuse patterns in this population. Accordingly, referral networks or team assistance programs consisting of health care professionals familiar with these issues should be established for athletes and teams. 62 The effectiveness of these models should be studied.
• Research should examine differences in treatment approaches that may be needed for athletes who have been using drugs for a shorter versus longer period of time.

Trainers, coaches, and health care providers should provide evidence-based, safe alternatives to PED use, including optimal nutrition, weight-training strategies, and psychological approaches to improving performance, all of which may help with athletes’ confidence in their natural abilities.

The authors report no conflicts of interest in this work.