Hacking The System: The Debate Over Athletes Getting PED Hall Passes
A series of hacks by the Fancy Bears team has raised questions about the legitimacy of therapeutic use exemptions in sport
A string of breaches into the World Anti-Doping Agency’s database by suspected Russian hackers hasn’t uncovered any performance-enhancing drug violations by the letter of the law, but the prevalence of therapeutic use exemptions is raising questions about the spirit of fair competition.
The Fancy Bears hackers, who claim to “stand for fair play and clean sport,” have posted the medical files of 127 athletes in six installments, touting these records as evidence of “doping athletes” even though no one has broken any rules. Each of the implicated Olympians had a TUE—that is, legal sanctioning to use otherwise banned substances for treatment—logged in WADA’s database. Tennis superstar Serena Williams was prescribed a series of anti-inflammatories, for instance, while gold-medal winning gymnastics sensation Simone Biles was shown to take Ritalin for her ADHD.
While U.S. Anti-Doping Agency CEO Travis Tygart told BBC Sport that Fancy Bears “are con artists” engaged in “a malicious and illegal invasion of athlete privacy followed by a baseless smear campaign,” other experts have taken a more measured view—and even the opposite stance.
“Hacking into WADAs database is an attempt to show that doping is sophisticated and can be done within the guidelines of the WADA code,” James Skinner, a sport management professor at London’s Loughborough University who has done research funded by WADA, wrote in an email. “It is therefore not considered to be doping although taking TUEs may be providing a competitive advantage. . . .
“Treatment should be to allow athletes to train and compete on a level playing field.”
While WADA defended TUEs as “a rigorous and necessary part of elite sport” and posted an explanatory document guiding readers through the process, some experts—and Russian president Vladimir Putin—have called either for a radical overhaul or the end of the system altogether.
“I think the whole concept should be ended and everybody should be allowed to use, at least for starters, any FDA-approved drug under medical supervision, and then we wouldn’t have to bother with these phony TUEs,” Dr. Norman Fost, Wisconsin professor emeritus and former bioethics program director, said. “We wouldn’t have to debate whether you really have the disease or whether you’re using it for treatment or enhancement. That whole dilemma, which is an unsolvable dilemma, would all go away.”
Among the documents disclosed by Fancy Bears were TUEs for British cyclist Bradley Wiggins to have three injections of triamcinolone, a corticosteroid that treats asthma and allergies but is also known to facilitate weight loss. One of the doses was apparently administered on June 26, 2012, which was four days before that summer’s Tour de France, which Wiggins won.
Ross Tucker, a South African professor and the proprietor of The Science of Sport, wrote on Twitter that “doping evolved to its current ‘frontier’—prescription meds, off-label use. Some people (the die hards) will say, ‘It’s all legal.’ But that’s just letting the ceiling become the floor. Erosion of ethics. It’s doping.”
“Well, it’s predictable that, wherever there’s room for interpretation or a loophole, humans will exploit it when the prize money is so enormous and the pressure to win is so great,” Julian Savulescu, an Oxford professor and director of the Institute for Science and Ethics, said. “It’s not surprising that people are using Therapeutic Use Exemptions ambiguously.”
The six-month, 162-game Major League Baseball grind long prompted a culture of amphetamines, locally called “greenies.” In the first year MLB began testing for them, back in 2006, 28 players received TUEs for ADHD in order to take Adderall or an equivalent; by 2013, that number had risen to 120. While 2-to-4 percent of American adults are typically diagnosed with ADHD, the share of MLB players with the condition rose from 3 percent to 14 percent as of three seasons ago, before slipping down to 111 in 2015.
“There is a need for greater transparency around TUE use to protect athletes with legitimate reasons for taking TUEs,” Skinner wrote, “however it needs to be balanced against the issue of the athlete’s right to privacy about their health.”
Such transparency could have another benefit: better research and supervision. Fost said there is a dearth of evidence linking steroids to their purported principle side effects of heart disease, cancer, and stroke. “It’s very hard to prove these things because it’s so hard to do research on these drugs because they’re all under ground and nobody who takes them is going to come forward,” Fost said.
While acknowledging that some side effects are indeed real, most are minor, Fost argued, particularly when applied to an elite athlete population: acne, voice-deepening, male-pattern baldness, and infertility, which are all reversible when one stops doping. Furthermore, he said, the number of deaths as a result of football is “logarithmically higher” than the deaths attributed to steroid use in medical literature.
“The alleged harms are wildly overstated and, in many cases, are just simply made-up, just fabricated,” Fost said. “Some of the drugs are harmful, but almost never are they more harmful than the sport itself.”
Savulescu called for independent monitoring, which could help optimize dosage for both health and performance reasons. He wrote in a 2004 British Journal of Sports Medicine article that part of what makes sport so compelling is “the appreciation of an extraordinary performance” and that nature already determines potential more than nurture, writing that sport is already “the province of the genetic elite (or freak). . . . By allowing everyone to take performance enhancing drugs, we level the playing field. We remove the effects of genetic inequality. Far from being unfair, allowing performance enhancement promotes equality.”
He took pains to note the importance of athletes’ health, suggesting that health testing should replace drug testing to make sure no one exceeds unsafe ranges.
“My argument has always been that, if you’re taking a substance that’s reasonably safe, it’s better that it’s open, that it’s supervised, and that you’re staying within safe parameters,” Savulescu said.
One thing the experts did make clear is that more open availability of drugs should not extend to youth athletes. They are susceptible to another serious side effect—stunted growth—that does not apply to adults.
“These arguments are questionable on a number of levels, in particular the moral dilemma surrounding doping practice,” Skinner wrote. “Prevention is the best strategy for young people, we therefore need to know more about young people, how their attitudes develop and how their perceptions develop, this will allow us to restrict or reduce the use of drugs.”
Skinner conducted research for WADA in 2009 that explored youth attitudes toward PED use and found that the characteristics of youth users are those with high moral disengagement, a focus on winning competitions over mastering skills, and universal, tacit acceptance.
“Our findings suggest that young athletes who believe there is high drug use in sport believe they are more likely to use PEDs,” he wrote. “Our findings suggested these young athletes intend to use PEDs as they think everyone else is using—they see drugs everywhere—[and] believe it is common.”
Putin, who has denied Russian government involvement in the hacks, proposed making medical reports public a mandate for elite athletes and suggested making the competition and/or results of those using TUE drugs into a “special category.”
“We need to understand what to do about [TUEs], otherwise we could soon face all records and victories going only to people who are ill with, let’s say, chronic illnesses,” Putin said at a recent sports forum. WADA director general Olivier Niggli rejected the idea in an interview with the Associated Press, saying, “I think every human being has a right of being treated for medical conditions.”
Finding the right balance between treatment and enhancement can be a goalposts-moving endeavor. “It is not the intent of WADA to prevent athletes with medical conditions from participating, but it is its intent to prevent an athlete from using the medication in such a manner so as to gain an unfair athletic advantage,” Dr. Gary Wadler, who has served on multiple WADA committees, told the New York Times in 2008.
Calibrating policies to construct a proper boundary between what is and is not acceptable ought to rely more heavily on the voice of the athlete constituency, some say.
“If they’re the essential stakeholder, we should be listening to them,” Lisa Kihl, a Minnesota professor who has researched sport management ethics and policy, said. “Do they want drug-free? What does drug-free mean? What are the consequences if somebody doesn’t compete drug-free? They have to get on the same page.”
WADA’s criteria for its banned list is for a substance to meet two of these three criteria: enhancing performance, posing a health risk, or violating the “spirit of sport.” Even that can be a nebulous definition.
Savulescu, for one, thinks the use of many legal painkillers run contrary to the spirit by eliminating a natural check. That holds true not only for contact sports like hockey and American football, but also for any endurance sport in which strong medication becomes necessary.
“If you want to preserve the value of health, then you ought to not allow athletes to compete when their health is being compromised,” Savulescu said. “If you need steroids in cycling, then you ought to not be competing in that, period.
“. . . That’s a line that has to be drawn. My point has simply been, these people are enhancing their performance and they are damaging their health. That’s exactly what is not meant to be happening.”
A surprising number of cyclists have been diagnosed with asthma—there was a recent Cycling Tips article actually entitled, “Why do so many elite cyclists have asthma?”—in part because such high-performing athletes use a broader range of lung function than the average person, making them more prone to suffering flare-ups. One type of inhaler, salbutamol, is now available to all cyclists without a TUE because studies have shown (such as this one in the British Journal of Sports Medicine) that it treats acute asthma symptoms without enhancing performance.
“The first thing that struck me [about the hacks] was that nothing struck me,” former Australian Anti‑Doping Agency president Richard Ings told the Guardian. “Serena, for instance, had exactly the sort of medication—often for very short periods—you would expect for soft tissue injuries and was granted approval.”
Fost, who has degrees from Princeton, Yale, and Harvard, called meldonium’s recent inclusion on the banned-substance list “an example of just how ill-informed and irrational these rule-makers are in deciding what gets on the list and what isn’t.” He said he researched the drug and “can’t find a single article that shows it has any performance-enhancing qualities in otherwise healthy and particularly elite athletes”—its mechanism of treatment may alleviate the symptoms of patients with end-stage heart conditions but there’s no evidence of an athletic benefit.
“The most irrational part about it is, even if it did work, even if it had some performance-enhancing effect, the way it allegedly does that is by improving oxygen delivery to tissues,” Fost said. “Well, turn on your TV set on Sunday and [at] every NFL game you’ll see, when the players come off the field, they go and put a mask—the ones that have exerted themselves—to take, what? Oxygen. High concentrations of oxygen. Why? To improve oxygen delivery to their tissue, to help them get back to baseline faster. It’s legal, it’s ethical, it’s highly effective. Why is it that it’s perfectly OK to deliver oxygen to your tissues in a highly effective way, but it’s illegal and immoral to do it in a way that’s ineffective? The whole meldonium thing is incoherent from the start.”
Technological advantages are not restricted in the same way. Sure, moto-boosting—literally sticking a motor into your bicycle—is prohibited as an egregious advantage, but marginal improvements are permitted, such as aerodynamic uniforms, customized equipment fitting through 3-D scanning technology, and sophisticated data-driven training tools.
Fost’s go-to example to illustrate the murky nature of enhancements—one he has discussed in the American Medial Association’s Journal of Ethics, on ABC News, and in the New York Times—took place at the 1988 Olympics. There, Canadian sprinter Ben Johnson was stripped of his gold medal for steroid use while American swimmer Janet Evans was lauded for her three gold medals despite, Fost said, bragging that her advanced, greasy swimsuit shaved time off her races. Skinner, on the other hand, cautioned against a doping-to-technology comparison because they are separate issues.
Johnson later explained that the training required to run a sub-10-second 100-meter would almost inevitably breed injuries, telling the Daily Mail, “No athlete can survive that without using something.” Steroids, the sprinter said, were a necessary regenerative tool.
“I’d like to see us using our science and technology in an ethical way,” Savulescu said. “That involves using substances that enhance performance or enhance recovery from injury.”
Another prevailing counter-argument to permitting drug usage is that wealthy countries with greater sporting resources will have an exaggerated advantage, and creating equal access is logistically impossible.
The idea of limited-duration TUEs can also be fraught. Stuart Phillips, a kinesiology professor at Canada’s McMaster University, is among those who have called for lifetime bans to anyone found to be taking anabolic steroids because their effects on the body can linger for the rest of an athlete’s competitive years—while those drugs aren’t typically TUE fodder, one wonders if other substances could be found to last longer than anticipated. That speaks to the broader point about TUE dosage and whether the amount of the drug won’t exceed a playing field-leveling boost.
Michele Verroken, the former longtime head of UK Sport’s anti-doping group, told CNN that “we are in danger of medicalizing sport performance to get those marginal gains and that’s a really sad fact.” To curb potential abuse and protect medically defensible TUEs, she has urged, in a Telegraph editorial, to simplify the banned-substance list, end preventive use, hold prescribing physicians accountable, and changing attitudes to avoid normalization of use.
“The public are being led down a road that TUEs are now being associated with being a cheat, or dirty,” British field hockey player Samantha Quek, whose records were released by the hackers, told the BBC. “. . . TUEs aren’t about cheating. They are essential, sometimes even life-saving medical practices and should be viewed as such.”
There are plenty of athletes, Kihl said, who “work within a notion of integrity.” Those pushing the limits, however, are muddling the system for everyone.