Jul 2014

Physicians and the Sports Doping Epidemic

John Hoberman, PhD
Virtual Mentor. 2014;16(7):570-574. doi: 10.1001/virtualmentor.2014.16.7.oped1-1407.

 

After 25 years of nonstop doping scandals involving elite athletes such as cyclists and sprinters, the major role physicians have played in these doping cultures has received much less attention than it deserves, and especially in medical circles. Physician involvement in these illicit, and often medically dangerous, practices will seem counterintuitive to those who associate physicians with the task of healing and the injunction to do no harm. The reality, however, is that many doctors have been providing athletes with doping drugs and expertise throughout the modern doping epidemic that dates from the 1960s [1-5]. It was during that decade that anabolic steroids became common in Olympic sports such as weightlifting and track and field. Over the past half-century, the global demand for androgenic doping drugs has grown to serve multiple niche markets that include the elite athlete population along with much greater numbers of police officers, firefighters, military personnel, bodybuilders, and members of other “action-oriented” male subcultures [6, 7].

Doping in Sport

Physicians dope athletes for a variety of reasons that can range from unethical service to the state to the gratifying of their own immature emotional needs. The East German doctors who participated in the doping of thousands of young athletes, including the administration of anabolic steroids to pubescent girls, functioned within a state-sponsored apparatus whose political mission of sportive nationalism trumped medical ethics [8]. State-sponsored doping in West Germany expressed similar nationalist ambitions that could not be fully realized in a democratic society [9]. The gold medals won by East German athletes at the 1976 Montreal Olympic Games persuaded many West German sports physicians that it was time to adopt the use of androgenic drugs as a matter of national policy [2, 10]. At the Congress of German Sports Physicians held in Freiburg in October 1976, the most prominent West German sports physicians minimized the medical dangers of anabolic steroids and recommended that they be administered to athletes under medical supervision [2, 10]. Far from being a German specialty, however, this pro-steroid mindset can be found among sports doctors around the world. The repeated doping scandals involving the Tour de France, to take one example, have clearly demonstrated that there is an international medical doping culture that could properly be called Dopers Without Borders. Some physicians have issued therapeutic use exemption (TUE) certificates to athletes that are unwarranted but allow their use of drugs that are believed to boost athletic performance [11, 12].

One rationalization for physician-managed doping is the “lesser harm” argument [13]: since athletes do not possess the self-discipline or knowledge to limit their intake of doping drugs, it is the physician’s responsibility to exert some control and thereby limit medical harm. What such physicians do not understand is that at least some of these athletes will top off their medically sanctioned doses with drugs they obtain on the black market.

The proponents of legalizing “medically supervised” doping imagine that such arrangements between doctors and athletes are comparable to proper clinical relationships between doctors and patients [13]. In fact, these are doctor-client relationships that can subordinate medical judgment and the client’s health to the demands of performance. This mismatch is exacerbated when doctors become infatuated by the celebrity of their “patients.” Some doctors identify so strongly with athletes’ goals or derive so much satisfaction from the athlete’s celebrity status that they willingly abandon medical norms in favor of the ambitions of athlete-clients who are now in charge of their medical “treatment.” In the world of Mixed Martial Arts (MMA), these practitioners are known as “mark doctors”—“fan boy doctors who are willing to write up prescriptions for drugs to fighters in exchange for a celebrity rub” [14].

This type of emotional dependence works in both directions. Just as doctors can succumb to the charismatic appeal of athletes, athletes can revere doctors as if they were infallible gurus. In his memoir The Secret Race, the doped former professional cyclist Tyler Hamilton writes that the notorious Italian doping doctor Michele Ferrari “was our trainer, our doctor, our god” [15].

Finally, the doping doctor can engage in the pharmacological manipulation of athletes because he yearns to participate in a transcendent performance [16-19]. Lothar Heinrich, a German sports physician who doped professional cyclists at a sports-medical clinic in Freiburg, stated in 2007: “When you watch sports you are always hoping for a miracle…. You hope to participate in something of historic significance” [16]. In most cases, however, I see the profit motive as far more influential than any interest in producing record performances.

Beyond Sport

The involvement of physicians in the doping of athletes must be understood in the larger context of the promotion of hormonal enhancements for entire populations of prospective “patients.” In an era when testosterone-replacement drugs are being mass-marketed as an elixir of youth—a marketing ploy the editor of JAMA was protesting as far back as 1939 [20]—distinguishing between traditional therapy and enhancement procedures is becoming increasingly difficult. Warnings against indiscriminate testosterone supplementation from The Endocrine Society and other medical authorities cannot compete in the media marketplace with drug company television advertising [21]. Doping doctors, who have been operating along this frontier since the 1960s, can be seen as the vanguard of an army of medical practitioners who have left the traditional practice of medicine for the cash-only business of male hormone replacement therapy. The American Academy of Anti-Aging Medicine (A4M), founded in 1992 by two Belize-educated osteopaths, has been the principal promoter of this trend [22, 23]. Consequently, the pro-steroid lobby of the sports world is now dwarfed by the enormous lobbying operation being waged by “anti-aging” doctors, their (often unregulated) clinics, and the pharmaceutical industry that supplies them with testosterone products [24].

Conclusion

The connection between doping athletes, their physicians, and the expanding world of “anti-aging” medicine is exemplified by the recent controversy involving the professional baseball star Alex Rodriguez and the unregulated clinic in Coral Gables, Florida, that is accused of supplying him with androgenic doping drugs. The 549 anti-aging clinics currently operating in the state of Florida are unregulated to the point that some of them are owned by felons [25]. The athletes they supply constitute a miniscule fraction of their male clientele, many of whom are receiving interventions to produce conspicuous musculature, sexual rejuvenation, or both [24]. This medical commerce is presided over by a dysfunctional state Department of Health that does not effectively regulate a type of medical practice that is carried on in a legal gray zone and in violation of best practices [24]. The entire operation depends on physicians’ offering “hormone consultations” that produce diagnoses of “deficient” testosterone levels (“low T”) that are “restored” by prescription drugs [25].

In summary, the physician-assisted doping of athletes has had two major effects on the modern world. First, it has transformed high-performance sport into a chronically overmedicated subculture the pharmacological practices of which violate the ethical norms of sport. Second, the doping doctors of the sports world have pioneered “entrepreneurial” medical practices that are now available to enormous numbers of people in search of hormonal rejuvenation. The unwillingness of the doping doctors to accept the notion of natural limits to athletic performance is being imitated on a much larger scale by a doctor-enabled hormone enhancement industry that has thus far encountered no significant obstacles to growth.

References

  1. See, for example, Dubin CL, ed. Commission of Inquiry into the Use of Drugs and Banned Practices Intended to Increase Athletic Performance. Ottawa: Canadian Government Publishing Centre; 1990: 385-393. http://epe.lac-bac.gc.ca/100/200/301/pco-bcp/commissions-ef/dubin1990-eng/dubin1990-eng.htm. Accessed May 16, 2014.
  2. Hoberman J. Mortal Engines: The Science of Performance and the Dehumanization of Sport. New York: The Free Press, 1992:252-265.

  3. Waddington I. Sport, Health and Drugs: a Critical Sociological Perspective. New York and London: E & F Spon/Taylor and Francis; 2000:127-134, 135-153, 156, 158-159.

  4. Hoberman J. Sports physicians and the doping crisis in elite sport. Clin J Sport Med. 2002;12(4):203-208.
  5. Hoberman J. Sports physicians and doping: medical ethics and elite performance. In: The Social Organization of Sports Medicine: Critical Socio-Cultural Perspectives. Malcolm D, Safai P, eds. New York: Routledge; 2012:247-264.

  6. Sweitzer PJ. Drug law enforcement in crisis: cops on steroids. De Paul J Sports Law Contemp Probs. 2004;193(2):195, 198.

  7. Police taking steroids to counter thugs. Sunday Times (London). December 6, 1998.

  8. See, for example, Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic government. Clin Chem. 1997;43(7):1262-1279.

  9. Ungerleider S. Faust’s Gold: Inside the East German Doping Machine. New York: St. Martin’s Press; 2001.

  10. Reinold M. Doping in Deutschland von 1950 bis heute aus historisch-soziologischer Sicht im Kontext ethischer Legitimation. Humboldt-Universität zu Berlin/Westfälische Wilhelms-Universität Münster; 17 April 2013. http://www.bisp.de/SharedDocs/Downloads/Aktuelles/Stellungnahme_BISp_DiD_2013_27_08.pdf?__blob=publicationFile. Accessed May 30, 2014.

  11. See, for example, Forshur T. Tennis makes you sick: therapeutic use exemptions (TUEs) revisited. Tennis Has a Steroid Problem. August 27, 2012. http://tennishasasteroidproblem.blogspot.com/2012/08/tennis-makes-you-sick-therapeutic-use.html. Accessed May 16, 2014.

  12. Zeman A. Testosterone replacement therapy banned by Nevada Athletic Commission, decision supported by Ultimate Fighting Championship. Girard Gibbs, LLP. http://www.girardgibbs.com/blog/testosterone-replacement-therapy-banned-by-nevada-athletic-commission-decision-supported-by-ultimate-fighting-championship/. Accessed May 16, 2014.

  13. Hoberman J. Testosterone Dreams: Rejuvenation, Aphrodisia, Doping. Berkeley: University of California Press; 2005: 170-178.

  14. Arnold Z. A crash course on testosterone, hypogonadism, and doping. Boxing Insider. May 10, 2012. https://www.boxinginsider.com/columns/a-crash-course-on-testosterone-hypgonadism-and-doping/. Accessed May 28, 2014.

  15. Hamilton T, Coyle D. The Secret Race: Inside the Hidden World of the Tour de France: Doping, Cover-ups, and Winning at All Costs. New York: Bantam Books, 2012:102.

  16. Kistner T, Burkert A. Meine arbeit ist teamarzt, nicht Dopingkommissar. Süddeutsche Zeitung. May 17, 2010. http://www.sueddeutsche.de/sport/dopingskandal-meine-arbeit-ist-teamarzt-nicht-dopingkommissar-1.735923. Accessed May 16, 2014.

  17. Hood A. The Sunday interview: T-Mobile’s Dr. Lothar Heinrich. Velo News. http://velonews.competitor.com/2007/02/road/the-sunday-interview-t-mobiles-dr-lothar-heinrich_11681. Accessed February 6, 2011.

  18. Pope HG Jr, Wood RI, Rogol A, Nyberg F, Bowers L, Bhasin S. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341-375.
  19. Layton JB, Li D, Meier CR, et al. Testosterone lab testing and initiation in the United Kingdom and the United States, 2000-2011. J Clin Endocr Metab. 2014;99(3):1-7.
  20. Sex hormones hold the stage. JAMA. 1939;112(19):1970.

  21. Schwartz LM, Woloshin S. “Low T” as in “template”: how to sell disease. JAMA Intern Med. 2013;173(15):1460-1462.
  22. Hoberman J, Testosterone Dreams, 14, 171, 291n.

  23. Who are the anti-aging specialists? Harvard Women’s Health Watch.Dec 2001:4.

  24. Hoberman J, Testosterone Dreams, 15-16, 145-147.

  25. Elfrink T. Biogenesis just hints at anti-aging catastrophe. Miami New Times. December 19, 2013. http://www.miaminewtimes.com/2013-12-19/news/biogenesis-mlb-scandal-tony-bosch/. Accessed May 28, 2014.

Citation

Virtual Mentor. 2014;16(7):570-574.

DOI

10.1001/virtualmentor.2014.16.7.oped1-1407.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.