Doping in sport

Goldman's dilemma

Goldman's dilemma, or the Goldman dilemma, is a question that was posed to elite athletes by physician, osteopath and publicist Bob Goldman, asking whether they would take a drug that would guarantee them success in sport, but cause them to die after five years. In his research, as in previous research by Mirkin, approximately half the athletes responded that they would take the drug,^[12] but modern research by James Connor and co-workers has yielded much lower numbers, with athletes having levels of acceptance of the dilemma that were similar to the general population of Australia.^[13][14]

Anabolic steroids

Anabolic-androgenic steroids (AAS) were first isolated, identified and synthesized in the 1930s, and are now used therapeutically in medicine to induce bone growth, stimulate appetite, induce male puberty, and treat chronic wasting conditions, such as cancer and AIDS. Anabolic steroids also increase muscle mass and physical strength, and are therefore used in sports and bodybuilding to enhance strength or physique. Known side effects include harmful changes in cholesterol levels (increased low-density lipoprotein and decreased high-density lipoprotein), acne, high blood pressure, and liver damage. Some of these effects can be mitigated by taking supplemental drugs.^[17]

AAS use in sports began in October 1954 when John Ziegler, a doctor who treated American athletes, went to Vienna with the American weightlifting team. There he met a Russian physician who, over "a few drinks", repeatedly asked "What are you giving your boys?" When Ziegler returned the question, the Russian said that his own athletes were being given testosterone. Returning to America, Ziegler tried low doses of testosterone on himself, on the American trainer Bob Hoffman and on two lifters, Jim Park and Yaz Kuzahara. All gained more weight and strength than any training programme would produce but there were side-effects.^[18] Ziegler sought a drug without after-effects and hit upon the anabolic steroid methandrostenolone, first made in the US in 1958 by Ciba and marketed as Dianabol (colloquially known as "d-bol").^[19][20]

The results were so impressive that lifters began taking more, and steroids spread to other sports. Paul Lowe, a former running back with the San Diego Chargers American football team, told a California legislative committee on drug abuse in 1970: "We had to take them [steroids] at lunchtime. He [an official] would put them on a little saucer and prescribed them for us to take them and if not he would suggest there might be a fine."

Olympic statistics show the weight of shot putters increased 14 percent between 1956 and 1972, whereas steeplechasers weight increased 7.6 per cent. The gold medalist pentathlete Mary Peters said: "A medical research team in the United States attempted to set up extensive research into the effects of steroids on weightlifters and throwers, only to discover that there were so few who weren't taking them that they couldn't establish any worthwhile comparisons."^[21] Brand name Dianabol is no longer produced but the drug methandrostenolone itself is still made in many countries and other, similar drugs are made elsewhere. The use of anabolic steroids is now banned by all major sporting bodies, including the ATP, WTA, ITF, International Olympic Committee, FIFA, UEFA, all major professional golf tours, the National Hockey League, Major League Baseball, the National Basketball Association, the European Athletic Association, WWE, the NFL, and the UCI. However, drug testing can be wildly inconsistent and, in some instances, has gone unenforced.

A number of studies measuring anabolic steroid use in high school athletes found that out of all 12th grade students, 6.6 percent of them had used anabolic steroids at some point in their high school careers or were approached and counseled to use them. Of those students who acknowledged doping with anabolic–androgenic steroids, well over half participated in school-sponsored athletics, including football, wrestling, track and field, and baseball. A second study showed 6.3 percent of high school student Football players admitted to current or former AAS use. At the collegiate level, surveys show that AAS use among athletes range from 5 percent to 20 percent and continues to rise. The study found that skin changes were an early marker of steroid use in young athletes, and underscored the important role that dermatologists could play in the early detection and intervention in these athletes.^[22]

Stimulants

Stimulants are drugs that usually act on the central nervous system to modulate mental function and behavior, increasing an individual's sense of excitement and decreasing the sensation of fatigue. In the World Anti-Doping Agency list of prohibited substances, stimulants are the second largest class after the anabolic steroids.^[15]

Benzedrine is a trade name for amphetamine. The Council of Europe says it first appeared in sport at the Berlin Olympics in 1936.^[33] It was produced in 1887 and the derivative, Benzedrine, was isolated in the U.S. in 1934 by Gordon Alles. Its perceived effects gave it the street name "speed". British troops used 72 million amphetamine tablets in the Second World War^[2] and the RAF got through so many that "Methedrine won the Battle of Britain" according to one report.^[34] The problem was that amphetamine leads to a lack of judgement and a willingness to take risks, which in sport could lead to better performances but in fighters and bombers led to more crash landings than the RAF could tolerate. The drug was withdrawn but large stocks remained on the black market. Amphetamine was also used legally as an aid to slimming and also as a thymoleptic before being phased out by the appearance of newer agents in the 1950s.

Everton, one of the top clubs in the English football league, were champions of the 1962–63 season, and it was done, according to a national newspaper investigation, with the help of Benzedrine. Word spread after Everton's win that the drug had been involved. The newspaper investigated, cited where the reporter believed it had come from, and quoted the goalkeeper, Albert Dunlop, as saying:

I cannot remember how they first came to be offered to us. But they were distributed in the dressing rooms. We didn't have to take them but most of the players did. The tablets were mostly white but once or twice they were yellow. They were used through the 1961–62 season and the championship season which followed it. Drug-taking had previously been virtually unnamed in the club. But once it had started we could have as many tablets as we liked. On match days they were handed out to most players as a matter of course. Soon some of the players could not do without the drugs.^[35]

The club agreed that drugs had been used but that they "could not possibly have had any harmful effect." Dunlop, however, said he had become an addict.^[35]

In November 1942, the Italian cyclist Fausto Coppi took "seven packets of amphetamine" to beat the world hour record on the track.^[36] In 1960, the Danish rider Knud Enemark Jensen collapsed during the 100 km team time trial at the Olympic Games in Rome and died later in hospital. The autopsy showed he had taken amphetamine and another drug, Ronicol, which dilates the blood vessels. The chairman of the Dutch cycling federation, Piet van Dijk, said of Rome that "dope – whole cartloads – [were] used in such royal quantities."^[37]

The 1950s British cycling professional Jock Andrews would joke: "You need never go off-course chasing the peloton in a big race – just follow the trail of empty syringes and dope wrappers."^[38]

The Dutch cycling team manager Kees Pellenaars told of a rider in his care:

I took him along to a training camp in Spain. The boy changed then into a sort of lion. He raced around as though he was powered by rockets. I went to talk to him. He was really happy he was riding well and he told me to look out for him. I asked if he wasn't perhaps "using something" and he jumped straight up, climbed on a chair and from deep inside a cupboard he pulled out a plastic bag full of pills. I felt my heart skip a beat. I had never seen so many fireworks together. With a soigneur we counted the pills: there were 5,000 of them, excluding hormone preparations and sleeping pills. I took them away, to his own relief. I let him keep the hormones and the sleeping pills. Later he seemed to have taken too many at once and he slept for a couple of days on end. We couldn't wake him up. We took him to hospital and they pumped out his stomach. They tied him to his bed to prevent anything going wrong again. But one way or another he had some stimulant and fancied taking a walk. A nurse came across him in the corridor, walking along with the bed strapped to his back.^[39]

Currently modafinil is being used throughout the sporting world, with many high-profile cases attracting press coverage as prominent United States athletes have failed tests for this substance. Some athletes who were found to have used modafinil protested as the drug was not on the prohibited list at the time of their offence, however, the World Anti-Doping Agency (WADA) maintains it is a substance related to those already banned, so the decisions stand. Modafinil was added to the list of prohibited substances on 3 August 2004, ten days before the start of the 2004 Summer Olympics.

One approach of athletes to get around regulations on stimulants is to use new designer stimulants, which have not previously been officially prohibited, but have similar chemical structures or biological effects. Designer stimulants that attracted media attention in 2010 included mephedrone, ephedrone, and fluoroamphetamines, which have chemical structures and effects similar to ephedrine and amphetamine.

Strychnine

Hicks and supporters at the 1904 Summer Olympics

These "de facto experiments investigating the physiology of stress as well as the substances that might alleviate exhaustion" were not unknown outside cycling.

Thomas Hicks, an American born in England on 7 January 1875, won the Olympic marathon in 1904. He crossed the line behind a fellow American Fred Lorz, who had been transported for 11 miles of the course by his trainer, leading to his disqualification. However, Hicks's trainer Charles Lucas, pulled out a syringe and came to his aid as his runner began to struggle.

I therefore decided to inject him with a milligram of sulphate of strychnine and to make him drink a large glass brimming with brandy. He set off again as best he could [but] he needed another injection four miles from the end to give him a semblance of speed and to get him to the finish.^[40]

The use of strychnine, at the time, was thought necessary to survive demanding races, according to sports historians Alain Lunzenfichter^[41] and historian of sports doping, Dr Jean-Pierre de Mondenard, who said:

It has to be appreciated that at the time the menace of doping for the health of athletes or of the purity of competition had yet to enter the morals because, after this marathon, the official race report said: The marathon has shown from a medical point of view how drugs can be very useful to athletes in long-distance races.^[2]

Hicks was, in the phrase of the time, "between life and death" but recovered, collected his gold medal a few days later, and lived until 1952. Nonetheless, he never again took part in athletics.^[42]

East Germany (the GDR)

In 1977 one of East Germany's best sprinters, Renate Neufeld, fled to the West with the Bulgarian she later married. A year later she said that she had been told to take drugs supplied by coaches while training to represent East Germany at the 1980 Summer Olympics.

At 17, I joined the East Berlin Sports Institute. My speciality was the 80m hurdles. We swore that we would never speak to anyone about our training methods, including our parents. The training was very hard. We were all watched. We signed a register each time we left for dormitory and we had to say where we were going and what time we would return. One day, my trainer, Günter Clam, advised me to take pills to improve my performance: I was running 200m in 24 seconds. My trainer told me the pills were vitamins, but I soon had cramp in my legs, my voice became gruff and sometimes I couldn't talk any more. Then I started to grow a moustache and my periods stopped. I then refused to take these pills. One morning in October 1977, the secret police took me at 7am and questioned me about my refusal to take pills prescribed by the trainer. I then decided to flee, with my fiancé.^[43][44]

She brought with her to the West grey tablets and green powder she said had been given to her, to members of her club, and to other athletes. The West German doping analyst Manfred Donike reportedly identified them as anabolic steroids. She said she stayed quiet for a year for the sake of her family. But when her father then lost his job and her sister was expelled from her handball club, she decided to tell her story.^[43]

Ilona Slupianek in 1981.

East Germany closed itself to the sporting world in May 1965.^[2] In 1977 the shot-putter Ilona Slupianek, who weighed 93 kg, failed a test for anabolic steroids at the European Cup meeting in Helsinki and thereafter athletes were tested before they left the country. At the same time, the Kreischa testing laboratory near Dresden passed into government control; it reputedly made around 12,000 tests a year on East German athletes but without any being penalised.^[2]

The International Amateur Athletics Federation (IAAF) suspended Slupianek for 12 months, a penalty that ended two days before the European championships in Prague. In the reverse of what the IAAF hoped, sending her home to East Germany meant she was free to train unchecked with anabolic steroids, if she wanted to, and then compete for another gold medal, which she won.

After that, almost nothing emerged from the East German sports schools and laboratories. A rare exception was the visit by the sports-writer and former athlete, Doug Gilbert of the Edmonton Sun, who said:

Dr (Heinz) Wuschech knows more about anabolic steroids than any doctor I have ever met, and yet he cannot discuss them openly any more than Geoff Capes or Mac Wilkins can openly discuss them in the current climate of amateur sports regulation. What I did learn in East Germany was that they feel there is little danger from anabolica, as they call it, when the athletes are kept on strictly monitored programmes. Although the extremely dangerous side-effects are admitted, they are statistically no more likely to occur than side-effects from the birth control pill. If, that is, programmes are constantly medically monitored as to dosage.^[45]

Other reports came from the occasional athlete who fled to the West – 15 of them between 1976 and 1979. One, the ski-jumper Hans-Georg Aschenbach, said: "Long-distance skiers start having injections to their knees from the age 14 because of their intensive training."^[2] He said: "For every Olympic champion, there are at least 350 invalids. There are gymnasts among the girls who have to wear corsets from the age of 18 because their spine and their ligaments have become so worn... There are young people so worn out by the intensive training that they come out of it mentally blank [lessivés – washed out], which is even more painful than a deformed spine."^[46]

After the 1990 German reunification, on 26 August 1993 the records were opened and evidence found that the Stasi, the state secret police, supervised systematic doping of East German athletes from 1971 until reunification in 1990. Doping existed in other countries, says the expert Jean-Pierre de Mondenard, both communist and capitalist, but the difference with East Germany was that it was a state policy.^[47] The Sportvereinigung Dynamo (English:Dynamo Sports Club)^[48] was especially singled out as a center for doping in the former East Germany.^[49] Many former club officials and some athletes found themselves charged after the dissolution of the country. Victims of doping, trying to gain justice and compensation, set up a special page on the internet to list people involved in doping in the GDR.^[50]

State-endorsed doping began with the Cold War of 1947–1991, when every Eastern Bloc gold represented an ideological victory. From 1974, Manfred Ewald, the head of East Germany's sports federation, imposed blanket doping. At the 1968 Summer Olympics in Mexico City, the country of 17 million collected nine gold medals. Four years later the total was 20 and in 1976 it doubled again to 40.^[51] Ewald was quoted as having told coaches, "They're still so young and don't have to know everything." In July 2000 Ewald received a 22-month suspended sentence, to the outrage of his victims.^[52] Often, doping took place without the knowledge of the athletes, some of them as young as ten years of age. It is estimated that around 10,000 former athletes bear the physical and mental scars of years of drug abuse;^[53] one of them, Rica Reinisch, a triple Olympic champion and world record-setter at the 1980 Summer Olympics, has since suffered numerous miscarriages and recurring ovarian cysts.^[53]

Two former Dynamo Berlin club doctors, Dieter Binus, chief of the national women's team from 1976 to 1980, and Bernd Pansold, in charge of the sports medicine center in East Berlin, were committed for trial for allegedly supplying 19 teenagers with illegal substances.^[54] Binus was sentenced in August,^[55] Pansold in December 1998 – both were found guilty of administering hormones to underage female athletes from 1975 to 1984.^[56]

Virtually no East German athlete ever failed an official drugs test, though Stasi files show that many did produce failed tests at Kreischa, the Saxon laboratory (German:Zentrales Dopingkontroll-Labor des Sportmedizinischen Dienstes) that was at the time approved by the International Olympic Committee (IOC),^[57] now called the Institute of Doping Analysis and Sports Biochemistry (IDAS).^[58] In 2005, 15 years after the end of East Germany, the manufacturer of the drugs, Jenapharm, still found itself involved in numerous lawsuits from doping victims, being sued by almost 200 former athletes.^[59]

Former Sport Club Dynamo athletes who publicly admitted to doping, accusing their coaches:^[60]

• Daniela Hunger
• Andrea Pollack

Former Sport Club Dynamo athletes disqualified for doping:

• Ilona Slupianek^[61] (Ilona Slupianek failed a test along with three Finnish athletes at the 1977 European Cup, becoming the only East German athlete ever to be convicted of doping)

Based on the admission by Pollack, the United States Olympic Committee asked for the redistribution of gold medals won in the 1976 Summer Olympics.^[62] Despite court rulings in Germany that substantiate claims of systematic doping by some East German swimmers, the IOC executive board announced that it has no intention of revising the Olympic record books. In rejecting the American petition on behalf of its women's medley relay team in Montreal and a similar petition from the British Olympic Association on behalf of Sharron Davies, the IOC made it clear that it wanted to discourage any such appeals in the future.^[63]

Soviet Union

According to British journalist Andrew Jennings, a KGB colonel stated that the agency's officers had posed as anti-doping authorities from the IOC to undermine doping tests and that Soviet athletes were "rescued with [these] tremendous efforts".^[64] On the topic of the 1980 Summer Olympics, a 1989 Australian study said "There is hardly a medal winner at the Moscow Games, certainly not a gold medal winner, who is not on one sort of drug or another: usually several kinds. The Moscow Games might as well have been called the Chemists' Games."^[64]

A member of the IOC Medical Commission, Manfred Donike, privately ran additional tests with a new technique for identifying abnormal levels of testosterone by measuring its ratio to epitestosterone in urine. Twenty percent of the specimens he tested, including those from sixteen gold medalists, would have resulted in disciplinary proceedings had the tests been official. The results of Donike's unofficial tests later convinced the IOC to add his new technique to their testing protocols.^[65] The first documented case of "blood doping" occurred at the 1980 Summer Olympics as a runner was transfused with two pints of blood before winning medals in the 5000 m and 10,000 m.^[66]

Documents obtained in 2016 revealed the Soviet Union's plans for a statewide doping system in track and field in preparation for the 1984 Summer Olympics in Los Angeles. Dated prior to the country's decision to boycott the Games, the document detailed the existing steroids operations of the program, along with suggestions for further enhancements. The communication, directed to the Soviet Union's head of track and field, was prepared by Dr. Sergey Portugalov of the Institute for Physical Culture. Portugalov was also one of the main figures involved in the implementation of the Russian doping program prior to the 2016 Summer Olympics.^[67]

West Germany

The 800-page "Doping in Germany from 1950 to today" study details how the West German government helped fund a wide-scale doping programme. West Germany encouraged and covered up a culture of doping across many sports for decades.^{[68][69][70][71][72][73]} Clemens Prokop, head of Germany's athletics federation, told Reuters Television in an interview, "It is a bit of a problem that there is a short version that has been published and that names have not been named."^[74]

Immediately after the 1954 FIFA World Cup Final, rumors emerged that the West German team had taken performance-enhancing substances. Several members of the team fell ill with jaundice, presumably from a contaminated needle. Members of the team later claimed they had been injected with glucose,^[75] and the team physician Franz Loogen said in 2004 that the players had only been given Vitamin C before the game.^[76] A Leipzig University study in 2010 posited that the West German players had been injected with the banned substance methamphetamine.^[77]

According to the German Olympic Sports Association (DOSB), doping was common in the West German athletes of the 1980s. West German heptathlete Birgit Dressel died at age 26 due to sudden multiple organ failure, triggered at least in part by long-term steroid abuse.^[78] In the newly emerging doping discussion in 2013 after submission of the final report of the anti-doping commission, the former German sprinter Manfred Ommer accused the Freiburg physician Armin Klümper: "Klümper was the largest doper on this planet."^[79]

China

China conducted a state-sanctioned doping programme on athletes in the 1980s and 1990s.^[80] The majority of revelations of Chinese doping have focused on swimmers^[81] and track and field athletes, such as Ma Junren's Ma Family Army (馬家軍).^[82]

More recently, three Chinese weightlifters were stripped of their gold Olympic medals for doping at the 2008 Summer Olympics.^[83]

In a July 2012 interview published by the Sydney Morning Herald newspaper, Chen Zhangho, the lead doctor for the Chinese Olympic team at the Los Angeles, Seoul and Barcelona Olympics told of how he had tested hormones, blood doping and steroids on about fifty elite athletes.^[84] Chen also accused the United States, the Soviet Union and France of using performance-enhancing drugs at the same time as China.^[84]

In 2012 and 2017 Xue Yinxian revealed systematic doping of Chinese athletes in Olympic Games (and in other international sport events). He has claimed that more than 10,000 athletes in China were doped in the systematic Chinese government doping program and that they received performance-enhancing drugs in the 1980s and 1990s. He stated that the entirety of international medals (both in the Olympics and other international competitions) won by Chinese athletes in the 1980s and 1990s must be taken back. This is contrary to previous statements by the Chinese government, which had denied involvement in systematic doping, claiming that athletes doped individually. The International Olympic Committee and the World Anti-Doping Agency have investigated these allegations.^{[85][86][87][88][89]}

Russia

Systematic doping in Russian sports has resulted in 47 Olympic and tens of world championships medals being stripped from Russian competitors—the most of any country, more than four times the number of the runner-up, and more than 30% of the global total. Russia also has the most competitors that have been caught doping at the Olympic Games, with more than 200.^[90]

Russian doping is distinct from doping in other countries because in Russia the state supplied steroids and other drugs to sportspeople.^[91] Due to widespread doping violations, including an attempt to sabotage ongoing investigations by the manipulation of computer data, on 9 December 2019 the World Anti-Doping Agency (WADA) banned Russia from all international sport for four years. As at the 2018 Winter Olympics, WADA will allow individual cleared Russian athletes to compete neutrally under a title to be determined (which may not include the name "Russia", unlike the use of "Olympic Athletes from Russia" in 2018).^[92]

Russia later filed an appeal to the Court of Arbitration for Sport (CAS) against the WADA decision.^[93] The Court of Arbitration for Sport, on review of Russia's appeal of its case from WADA, ruled on 17 December 2020 to reduce the penalty that WADA had imposed. Instead of banning Russia from sporting events, the ruling allowed Russia to participate at the Olympics and other international events, but for a period of two years the team cannot use the Russian name, flag, or anthem and must present themselves as "Neutral Athlete" or "Neutral Team". The ruling does allow for team uniforms to display "Russia" on the uniform as well as the use of the Russian flag's colors within the uniform's design, although the name should be up to equal predominance as the "Neutral Athlete/Team" designation.^[94] Russia can appeal the decision.^[95]

On 19 February 2021, it was announced that Russia would compete under the acronym "ROC", after the name of the Russian Olympic Committee. On aftermatch, the IOC announced that the Russian national flag would be substituted by the flag of the Russian Olympic Committee. It would also be allowed to use team uniforms bearing the words "Russian Olympic Committee", or the acronym "ROC" would be added.^[96]

On 15 April 2021, the uniforms for the Russian Olympic Committee athletes were unveiled, featuring the colours of the Russian flag.^[97][98] On 22 April 2021, the replacement for Russia's anthem was approved by the IOC, after an earlier choice of the patriotic Russian war song "Katyusha" was rejected. A fragment of Pyotr Tchaikovsky's Piano Concerto No. 1 is used.^[99][100]

United States

In 2003, Wade Exum, the United States Olympic Committee's director of drug-control administration from 1991 to 2000, gave copies of documents to Sports Illustrated that revealed that some 100 American athletes failed drug tests from 1988 to 2000, arguing that they should have been prevented from competing in the Olympics but were nevertheless cleared to compete; those athletes included Carl Lewis, Joe DeLoach and Floyd Heard.^{[101][102][103][104]} Before showing the documents to Sports Illustrated, Exum tried to use them in a lawsuit against USOC, accusing the organization of racial discrimination and wrongful termination against him and cover-up over the failed tests. the Denver federal Court summarily dismissed his case for lack of evidence. The USOC labelled his case "baseless" as he himself was the one in charge of screening the anti-doping test program of the organization and clarifying that the athletes were cleared according to the rules.^[105][106]

Carl Lewis broke his silence on allegations that he was the beneficiary of a drugs cover-up, admitting he had failed tests for banned substances, but claiming he was just one of "hundreds" of American athletes who were allowed to escape bans, concealed by the USOC. Lewis has acknowledged that he failed three tests during the 1988 US Olympic trials, which under international rules at the time should have prevented him from competing in the 1988 Summer Olympics.^[107] Former athletes and officials came out against the USOC cover-up. "For so many years I lived it. I knew this was going on, but there's absolutely nothing you can do as an athlete. You have to believe governing bodies are doing what they are supposed to do. And it is obvious they did not," said former American sprinter and 1984 Olympic champion, Evelyn Ashford.^[108]

Exum's documents revealed that Carl Lewis had tested positive three times at the 1988 Olympics trials for minimum amounts of pseudoephedrine, ephedrine, and phenylpropanolamine, which were banned stimulants. Bronchodilators are also found in cold medication. Due to the rules, his case could have led to disqualification from the Seoul Olympics and suspension from competition for six months. The levels of the combined stimulants registered in the separate tests were 2 ppm, 4 ppm and 6 ppm.^[105] Lewis defended himself, claiming that he had accidentally consumed the banned substances. After the supplements that he had taken were analyzed to prove his claims, the USOC accepted his claim of inadvertent use, since a dietary supplement he ingested was found to contain "Ma huang", the Chinese name for Ephedra (ephedrine is known to help weight-loss).^[105] Fellow Santa Monica Track Club teammates Joe DeLoach and Floyd Heard were also found to have the same banned stimulants in their systems, and were cleared to compete for the same reason.^[109][110] The highest level of the stimulants Lewis recorded was 6 ppm, which was regarded as a positive test in 1988 but is now regarded as negative test. The acceptable level has been raised to ten parts per million for ephedrine and twenty-five parts per million for other substances.^[105][111] According to the IOC rules at the time, positive tests with levels lower than 10 ppm were cause of further investigation but not immediate ban. Neal Benowitz, a professor of medicine at UC San Francisco who is an expert on ephedrine and other stimulants, agreed that "These [levels] are what you'd see from someone taking cold or allergy medicines and are unlikely to have any effect on performance."^[105] Following Exum's revelations the IAAF acknowledged that at the 1988 Olympic Trials the USOC indeed followed the correct procedures in dealing with eight positive findings for ephedrine and ephedrine-related compounds in low concentration. The federation also reviewed in 1988 the relevant documents with the athletes' names undisclosed and stated that "the medical committee felt satisfied, however, on the basis of the information received that the cases had been properly concluded by the USOC as 'negative cases' in accordance with the rules and regulations in place at the time and no further action was taken".^[112][113]

Cycling

Floyd Landis

Controversial athlete Floyd Landis, shown here at the 2006 Tour of California, triggered a public scandal when caught doping to help his cycling.

Floyd Landis was the initial winner of the 2006 Tour de France. But a urine sample taken from Landis immediately after his Stage 17 win has twice tested positive for banned synthetic testosterone as well as a ratio of testosterone to epitestosterone nearly three times the limit allowed by World Anti-Doping Agency rules.^[127] The International Cycling Union stripped him of his 2006 Tour de France title. Second place finisher Óscar Pereiro was officially declared the winner.^[128]

Other endurance sports

In triathlon, 2004 Hawaii Ironman winner Nina Kraft, was disqualified for a positive test to EPO. She remains the only Hawaii Ironman winner to be disqualified for doping offences. Sports lawyer Michelle Gallen has said that the pursuit of doping athletes has turned into a modern-day witch-hunt.^[132]

Side effects in men

• Acne
• Impaired liver function
• Impotency
• Breast formation (Gynecomastia)
• Increase in oestrogen
• Suppression of spermatogenesis: As endogenous testosterone is the major regulator of the HPG axis, the exogenous testosterone and androgen anabolic steroids exert a suppressive effect of LH and FSH, leading to a decrease in intratesticular and secreted testosterone, decrease in spermatogenesis and sperm production.^[134]
• Lack of libido and erectile dysfunction: especially occurs in those men abusing aromatisable androgen anabolic steroids, resulting in high oestrogen levels. Although physiological levels of oestrogens are necessary for normal sexual function, the high doses and the imbalance between testosterone and estradiol appear to be the cause of sexual dysfunction.^[134]
• Increased sex drive
• Male pattern baldness
• Risk of heart failure

Side effects in women

• Hair loss
• Male pattern baldness
• Hypertrophy of the clitoris
• Increased sex drive
• Irregularities of the menstrual cycle
• Development of masculine facial traits
• Increased coarseness of the skin
• Premature closure of the epiphysis
• Deepening of the voice

In countries where the use of these drugs is controlled, there is often a black market trade of smuggled or counterfeit drugs. The quality of these drugs may be poor and can cause health risks. In countries where anabolic steroids are strictly regulated, some have called for regulatory relief. Anabolic steroids are available over-the-counter in some countries such as Thailand and Mexico.

Sports that are members of the IOC also enforce drug regulations; for example bridge.^[135]

Social pressures

Social pressure is one of the factors that leads to doping in sport.^[141] The media and society work together to construct a view of what masculinity and femininity should look like. Adolescent athletes are constantly influenced by what they see on the media, and some go to extreme measures to achieve the ideal image since society channels Judith Butler's definition of gender as a performative act.^[25] Examples of social pressures were given in a study done on an online bodybuilding community where bodybuilders doped because they felt like it was a rite of passage to be accepted into the community, and to feel validated.^[141] Both men and women are being materialized in the context of doping in sport; in an interview involving 140 men, it was concluded that "bodily practices are essential for masculine identity," and it was determined that the media highly publicizes female athletes who were strong, and thin.^[25] This leads to the issue of the consumption of performance enhancement drugs to achieve muscular or thin figures, and the assumption that the opponents are also taking performance-enhancing drugs, deeming it as an acceptable behavior to conform to.^{[142][143][144]} In addition, society's embracement of the "winning is everything" spirit leads many athletes to participate in doping, hoping that they will not be caught.^[145]

Physical pressures

Elite athletes have financial competitive motivations that cause them to dope and these motivations differ from that of recreational athletes.^[141] The common theme among these motivations is the pressure to physically perform. In a study of 101 individuals, 86% responded that their use of performance enhancement drugs were influenced by the potential athletic success, 74% by the economic aspect, and 30% by self-confidence and social recognition related reasons.^[146] In another study of 40 people, it was concluded that athletes used performance enhancement drugs for healing purposes so that they were an able competitor for the economic rewards involved with elite sports.^[147] Physical pressures often overlap with social pressures to have a certain body build. This is the case with muscle dysmorphia, where an athlete wants a more muscular physique for functionality and self- image purposes.^[25] The most popular motive for athletes to take supplements is to prevent any nutrient deficiencies and to strengthen the immune system.^[143] These factors all focus on improving the body for performance.

Psychological motivations

Psychology is another factor to take into consideration in doping in sport. It becomes a behavioral issue when the athlete acknowledges the health risks associated with doping, yet participates in it anyway.^[148] This has to do with the psychological thinking that the drug will make one feel invincible.^[145] The individuals are very egotistic in their way of thinking and their motivation is dependent on the performance enhancement drug since they believe that it delivers the results.^[142] On a study on health psychology, Quirk points out three different psychological aspects that lead one to dope: social cognition, stress and strain, and addiction.^[148] The social and physical pressures can alter an athlete's way of thinking, leading them to believe that they must take performance enhancement drugs since everyone else is doing it, known as “the doping dilemma.”^[145]

Urine test

Under established doping control protocols, the athlete will be asked to provide a urine sample, which will be divided into two, each portion to be preserved within sealed containers bearing the same unique identifying number and designation respectively as A- and B-samples.^[153] An athlete whose A-sample has tested positive for a prohibited substance is requested an analysis of his or her B-sample after a confirmation test on sample A that delivered the same results. If the B-sample test results match the A-sample results, then the athlete is considered to have a positive test, otherwise, the test results are negative.^[154] This confirmation process ensures the safety of the individual.^[155]

Blood test

see also: blood doping

The blood test detects illegal performance enhancement drugs through the measurement of indicators that change with the use of recombinant human erythropoietin:^[154]

1. Hematocrit
2. Reticulocytes
3. Level of Iron

Gas chromatography-combustion-IRMS

The gas chromatography-combustion-IRMS is a way to detect any variations in the isotopic composition of an organic compound from the standard. This test is used to detect whether or not synthetic testosterone was consumed, leading to an increased abnormal testosterone/epitestosterone (T/E) level.^[154]

Assumptions:^[154]

• 98.9% of the carbon atoms in nature are ¹²C
• the remaining 1.1% are ¹³C

The lower the ¹³C  to ¹²C  ratio, the more likely that synthetic testosterone was used.^[156]

Athlete biological passport

The athlete biological passport is a program that tracks the location of an athlete to combat doping in sports.^[157] This means that the athlete can be monitored and drug tested wherever they are and this data can be compared to the history of their doping test results.^[158] There is an ongoing discussion about how this measure can be seen as a violation of an individual's privacy.^[158]

Re-testing of samples

According to Article 6.5 in the World Anti-Doping Code samples may be re-tested later. Samples from high-profile events, such as the Olympic Games, are now re-tested up to eight years later to take advantage of new techniques for detecting banned substances.^[159][160]

Cheating the tests

Athletes seeking to avoid testing positive use various methods. The most common methods include:

• Urine replacement, which involves replacing dirty urine with clean urine from someone who is not taking banned substances. Urine replacement can be done by catheterization or with a prosthetic penis such as The Original Whizzinator.
• Diuretics, used to cleanse the system before having to provide a sample (which have also been placed in lists of banned substances themselves to circumvent this practice).
• Blood transfusions, which increase the blood's oxygen carrying capacity, in turn increasing endurance without the presence of drugs that could trigger a positive test result.
• To avoid being tested during training periods, athletes can make themselves unavailable. To mitigate this, athletes have to report their location at any time. If intended doping tests could not be done because the athlete could not be found, three times during a year, it's considered a doping violation, same as refusing a test.^[161] There is a web site and a phone app, called ADAMS, in which athletes are expected to report their location.^[162][163]

Validity

Donald Berry, writing in the journal Nature, has called attention to potential problems with the validity of ways in which many of the standardised tests are performed;^{[164][subscription required]} in his article, as described in an accompanying editorial, Berry

argues that anti-doping authorities have not adequately defined and publicized how they arrived at the criteria used to determine whether or not a test result is positive [which are] ...calibrated in part by testing a small number of volunteers taking the substance in question. [Berry argues] ...that individual labs need to verify these detection limits in larger groups that include known dopers and non-dopers under blinded conditions that mimic what happens during competition.^[165]

The editorial closes, saying "Nature believes that accepting 'legal limits' of specific metabolites without such rigorous verification goes against the foundational standards of modern science, and results in an arbitrary test for which the rate of false positives and false negatives can never be known."^[165]