Call to action for safeguarding in anti-doping

Introduction

In June 2011, the first author published the summary report of a research program conducted with the World Anti-Doping Agency (WADA) [1]. The research aimed to understand the “psycho-social determinants of [athletes’] doping behaviors” and “athletes[’] experience[s] during the sanction period, in order to construct a multi-disciplinary intervention program that promotes [athletes’] clean and safe comeback in the sports world and their social-professional integration…to enrich anti-doping prevention campaigns.” ([1], p. 6) The report detailed the findings from qualitative interviews with 11 athletes who were, at the time, under sanction for an anti-doping rule violation (ADRV). The athletes experienced a range of consequences following their sanctions (e.g., social, emotional, financial, physical), all of which contributed to mental health troubles. All the athletes positively responded to the proposal of mental health support services for sanctioned athletes, and the majority were supportive of ideas of additional support for physical training, career development, participation in prevention campaigns, and a support person with similar lived experience to provide guidance during the sanction period. The report concluded with a recommendation for an anti-doping prevention program, WINDOP, that would incorporate these support systems as a part of a three-level process of early education, mental health monitoring, and rehabilitation [1].

In the 11 years since the report’s publication, little has changed. WADA has not yet implemented such a system, though a large investment was made in the anti-doping education and learning (ADeL) platform available online [2]. The monitoring process of anti-doping screenings still does not take into consideration athletes’ psycho-social states, and a 2020 review of 22 Olympic committees found no offering of comprehensive rehabilitation support available to athletes after an ADRV [3]. While only a few national Olympic committees (NOCs) offer resources of any kind, a similar number emphasized that they intentionally and immediately sever all support to an athlete after an ADRV [3]. Continued research about forced retirement from sport has had a primary focus on causes like injury or deselection (for examples, see [4, 5, 6, 7, 8]). A 2014 study replicated the research published in the 2011 WADA report, and found highly similar qualitative results about sanctioned athletes’ experiences [9].

Restating the problem

Research published since the 2011 report has only served to reinforce the issues highlighted therein. The first author, as a private clinician, has continued working non-systematically with a small number of athletes, after they independently found his information and contacted him privately following an anti-doping notification or sanction. To our knowledge, WADA has no policy of referring sanctioned athletes to such services, and has no rehabilitation program in development, although the IOC has acknowledged the issue and refers athletes to their Athlete365 platform [3]. The health risks to sanctioned athletes are clear, and have been for over a decade, and yet almost nothing has been done to address them. We identify two primary causes of this inaction.

First, the general approach to anti-doping regulations considers doping behaviors to be a moral failure [10]. In this way, athletes are “policed” and punished as criminals [11]. This perspective tends to reinforce a treatment of “offenders” void of empathy, leading those responsible for athletes to knowingly forgo their duty of care [3].

Second, practically speaking, the size of the population of sanctioned athletes is negligible. In 2019, 278,047 samples were collected by worldwide anti-doping organizations (ADOs), which resulted in 1,537 ADRVs, 0.55% of all samples [12]. This is a fairly consistent figure as, from 2013 to 2019, the range of annual ARDVs was between 1,326 and 1,687 [12]. Consider that Russia, even after massive teamwide sanctions, had more athletes compete at the 2016 Rio Olympic Games (over 270) than they had ADRVs in 2019 (167, the highest of any country that year) [12, 13]. Financially and operationally, it does not make sound business sense to invest ADOs’ limited resources into such a small population when they could serve a much larger portion of the community.

In order to see any action on programs for protecting the well-being of sanctioned athletes, these realities must be addressed. The myth of doping as a moral failure has been refuted by illustrating how important social influences are in athletes’ decision-making [14]. Separately, an estimated 40% of athletes with an ADRV genuinely did not intend to consume a banned substance [15], and a significant portion of sanctioned athletes are cited for recreational, rather than performance enhancing, drugs [1]. Conceivably, these athletes may not be of the same moral deficiency traditionally assumed of a “doping cheater.”

Research abounds on the mental health consequences convicted individuals face in, and after release from, prison (for examples, see [16, 17, 18, 19]). We see similar consequences in those who retire from sport, even if retirement was neither forced, nor due to an ADRV [6]. These effects on an individual’s identity loss are only exacerbated when abruptly forced [20], and when coupled with the social stigma of an ADRV, leaving their previous identity stripped of its value due to the “doped” label.

Moreover, there is an urgent need to resign the “moral” approach to anti-doping for a “health-based” approach to uphold a comprehensive safeguarding practice. Doping can be a form of physical abuse (whether self-inflicted or otherwise), or of self-harm induced by emotional or physical abuse from institutions or coaches [21]. The abrupt termination of support following a sanction ignores these possibilities and the behavior’s root causes. This kind of limited approach, as stated, intensifies the threats to athletes’ well-being, arguably rendering the approach itself a form of abuse.

Practically, administrative and governing bodies cannot be expected, in the short term, to implement flawless systematic protections of athletes’ well-being. However, these organizations must acknowledge that sanctioned athletes, despite their small numbers, are particularly vulnerable. Recognizing the threat they pose to athlete health, these organizations must be legally obliged to provide support for athletes potentially harmed by their policies. Considering the compounding factors that threaten individual health, and the irresponsibility ignoring this population any longer would constitute, we must relinquish the notion of moral righteousness and the excuse of frugality in order to ensure a safe reaction to a positive doping test.

Renewed call to action

As was done at the 2017 Macolin Anti-Doping Summit in Switzerland, we call for renewed, comprehensive approach to athlete safeguarding in anti-doping [22]. Some recent proposals for overhauling the anti-doping landscape have either narrowly focused on semantics [10], or grandiosely proposed the end of the multi-billion-dollar industry of professional sports, or universal 24-hour athlete surveillance [23]. While space does not permit to address all of Dimeo and Møller’s [23] suggestions, it is important to recognize how they are colored by Western, Global North assumptions about the resources available to athletes around the world.

We believe that the WINDOP program presented in 2011 still holds practical answers to produce global, systematic change while enhancing athlete protection. A brief restatement of the program follows:

1. (1)
   WINDOP Junior: Youth athlete prevention program using much of existing ADeL curriculum. Incorporate active participation from sanctioned athletes as part of reinsertion into sports world while increasing the emotional impact of the campaign on youth athletes.
2. (2)
   WINDOP Watch: Enhanced athlete screening that does not rely strictly on physical samples but also monitors psycho-social states for evaluating high-risk athletes, with resources like the IOC’s Sport Mental Health Assessment Tool [24].
3. (3)
   WINDOP Classic: Athlete rehabilitation support such as mental health services, professional skills development, physical training opportunities outside restrictions, legal advice in appeal process, guidance from formerly sanctioned athletes, serving in WINDOP Junior, and mentoring future sanctioned athletes.

We call on individual practitioners to be more aware of and proactively engage with their local population of sanctioned athletes [3]. Concurrently, WADA and ADOs must recognize their shortcomings in supporting these athletes, and work directly with practitioners to fill the gaps. It should not strain these organizations’ existing resources to simply connect athletes to outside help.

Conclusion

Any such program will require a certain investment in order to operate and will be restricted geographically where access to trained clinicians is uncommon. Although internet access is also limited globally, it is growing, and much of what WINDOP proposes can be conducted virtually. Online interventions have been shown to have positive effects on athletes [25], and much of the curriculum already exists online through ADeL and Athlete365.

While arguably the most complex element of the program, WINDOP Watch has industry-changing potential. Along with WINDOP Junior, this program addresses a broader population than the limited current target of anti-doping policies and literature, Olympic athletes. WADA illustrated that non-Olympic sports have ADRV rates roughly 3–4 times higher than Olympic sports [26], and athletes generally are more vulnerable in moments of career transitions, which occur multiple times before they ever reach the elite level [27]. Additionally, recent research illustrated the negative effects athletes experienced from simply being associated with a sanctioned athlete, even after retirement [28]. Thus, a program like WINDOP has the potential to affect multiple populations heretofore ignored in the pursuit of clean sport. By educating young athletes, monitoring athletes’ psycho-social pressures, and providing a safe path of rehabilitation, we can implement a health-based approach to safeguarding athlete physical and mental welfare through more responsible and effective global doping control.