Sports participation, performance and medical-psychiatric health and illness: Cultural and religious effects

We recently had a consultation with an athlete complaining of what she called “anxiety,” which developed after her family and religious leaders in her hometown, pressured her to not compete in a national sport competition for “religious reasons.” As this consult was unusual, it led to a search of the literature on the effect of religion and cultural influences on sports participation, performance and psychiatric-mental health and illness.

A Pubmed search and a review of a recent sports psychiatry textbook and of a journal issue focused on sports psychiatry over the past four decades found no relevant literature pertaining to this topic [1, 2]. As such, this paper focuses on the understanding, management and treatment issues in such cases for a sports physician. By way of example, we use historical material from Judaism and the religious teachings embedded in that culture – but we emphasize there are obvious strong parallels to other religions including Christian, Islamic, and Buddhist religions among many others. The point is that their practices can directly affect athletic performance and participation as well as what has been called “mental health.” Saying it another way, religious and cultural leaders have the authority to govern individual and family behaviors.

Religion and sports: Effects on participation, performance, and mental health

In this succinct historical review, we examine two facets of sports culture. We first focus on why the religion has produced such a negative response to Jews of all nations throughout the last two thousand years of history. We then shift to how the culture and religion has changed to more positively help athletes and finally give examples of both positive and negative influences as they manifest in individual, family, and cultural contexts.

This summary may seem to have too much detail, but it helps explain why the stresses on the athlete are so powerful, i.e. disruptive to sports function. That is, they are deeply ingrained in a culture from early childhood so they may affect an athlete as they grow and face decisions on sports participation.

The Old Testament depicts the Jewish nation as fierce and warlike throughout the first part of the Bible. Jews were aggressive, courageous warriors, and quite often mercenaries. The Jewish antagonism for sports, therefore, does not come directly from the Bible. It resulted in part from the actual historical effect of Alexander the Great conquering the known world, and more particularly that part of the Middle East populated by Jews. During the last part of the fourth century B.C. the Jewish world was dramatically influenced by Hellenic customs and traditions; one of the most problematic being athletics. When the Greeks made athletics a compulsory branch of their curriculum, many Jews were attracted to the Greek love of physical culture. The Jewish problem, however, literally arose in the locker room. Greek athletes embraced nudity, and nudity exposed Jews to ridicule of circumcision which led to attempts at disguise through crude attempts at surgery. Over time, the situation came to the attention of the rabbis who eventually provoked a crisis – as some Jews had built a gymnasium in Jerusalem in the heathen fashion. This specifically refers to the Greek habit of nude athletics, a practice which deeply violated the rabbi’s sense of modesty. In addition to the problem of circumcision ridicule, the Greeks treated the winners of their sporting events as Godlike, which also irritated the rabbis who felt that this was akin to the worship of “false Gods.”

From 167 to 160 B.C. the Maccabees revolted and ousted the Seleucid Greeks from the Jewish homeland. The Orthodox Hasmonean rabbinate was installed to lead the Jewish generations that followed, and Greek athletics were completely banned. The Greek obsession with sports was characterized as follows – Greek gyms were temples and the human body was worshiped not for housing the soul, but for its physical aesthetics. The Maccabee rabbis would have none of it and they banned sports with a vengeance that endured for the next 1800 years. Being the people of the book, the rabbis scoured the traditional writings and created a rabbinical body of literature that vastly overstated the argument. The argument, however, was so forceful, that it survived centuries of dissent, sadly reducing the Greek, and later Roman, concept of a sound mind and a sound body – to the Jewish view that if a Jew had a sound mind, God would take care of the rest. Today most psychiatrists would agree that a sound mind and sound body are interrelated.

Historically, when the rabbis decided to ban athletics, they had a wealth of rules to rely on. Judaism was not just a ceremonial religion; it had an oral tradition of rules that guided every aspect of human conduct. In the year 1000, Maimonides was said to have rationalized the oral law, making it into a more coherent body of law. Interestingly, Maimonides was a Spanish doctor, who did preach the value of exercise, but that part of his writings were, by and large, ignored by the conservative rabbinate. In 1864, Jewish rules of conduct were once again modernized into a comprehensive body of law called the Shulkan Aruch which is still in existence today and observed by Orthodox Jewry. Its first version was written in 1563. Up until the enormous immigration to the United States commencing in 1880, the bulk of world Jewry was Orthodox and so the Shulkun Aruch is instructive to tell us what the traditional Jewish approach to athletics was as late as 1900.

After the turn of the 20^th century and into the 21^st century, in both Israel and the United States, reform Judaism took a strong hold on religious practices, and today only about 13 percent of American Jewry actually practices Orthodox Judaism. A review of the Shulkhan Aruch tells a large part of the story about historic Jewish attitudes towards athletics. The rabbis stretched religious text to the point of irrationality. Every conceivable portion of the sacred law, the Torah, was invoked to ultimately prohibit athletics. For example, contact sports are out of the question because of the absolute prohibition against hurting oneself. Thus boxing, football and wrestling were completely forbidden. Additionally, the rules allowed exercise but were quite strict as to how one could limber up. One wonders how athletics could have been possible for Orthodox Jews if they followed the strict rules such as “it is prohibited to walk haughtily with stretched out neck, and nevertheless he should not bend his head too low” [3].

The end result of these rules would be that only a contortionist could participate in sports if he could manage not to walk in the custom of “the nations” (i.e. the gentile world) or the idol worshipers (probably also the gentile world). So the rabbis, having very precise legal minds made sports virtually impossible after the success of the Maccabee revolt and the institution of rabbinic law. Of course, it will be argued that there were interpretations of the interpretations that made sports acceptable, and that many rabbis in the years to come engaged in all sorts of physical activity such as juggling and dancing. But one of the clearest possible description of rabbinic attitude towards athletics has been aptly described as follows: “indulgence in athletics was viewed by the good guys in the story (of Hanukah) as tantamount to a denial of one’s Judaism. The fact that this episode has not been universally included in the teaching of the Hanukah story results in the historical irony that the name Macabee came to be applied today to (of all things) a Jewish athletic organization” [4]. Modern scholarship makes clear, therefore, that the Maccabee experience itself set the stage for the next two millennium of Jewish antagonism toward athletics.

During the Middle Ages the Jews were subjected to persecution in almost every country they lived in. With varying degrees of success, their fortunes varied from a modicum of calm, in the Ottoman Empire, to outright murder and expulsion in Spain and Russia. And throughout the Middle Ages, they generally lived in closed communities, in isolated Jewish quarters, and then eventually in the 16th century they were confined to tiny ghettos – making sports virtually impossible. Throughout this entire time, Jewish communities generally followed strict Rabbinic teachings with little exception or variation. If, as in the case of Spinoza in the 17th century, they strayed from religious orthodoxy, they were excommunicated, and ostracized from the community. As part of this orthodoxy, it was clear they were people of the book, and that the Greek style of athletics was strictly prohibited.

But interestingly, there were some exceptions in that athletics were not viewed as a monolithic category, and physical activity was allowed in certain circumstances. The critical factor was whether or not the activity was dangerous [5]. With a rule like this, it is easy to understand why Jewish children for at least 1500 hundred years, were severely discouraged from engaging in physical activity that could result in any injury.

But there was one major exception. Luckily for the Jews, the doctor, philosopher and Rabbi Maimonides was born in 1135 in Spain and became the first rabbi to rationalize Jewish law into a coherent code. But he was not just a rabbi; he was a trained 12^th century doctor, and actually understood the absolute necessity of physical activity as a prerequisite for good health. His writings which are the most authoritative commentary on the Torah ever written were quite explicit about the necessity of both a sound mind and a sound body, but he was very careful to stick to biblical text to bolster his arguments [6].

As it turns out, however, Maimonides focused on swimming as the ideal sport and specifically declared that swimming was required by Jewish law [7]. In one of his writings, he quoted Jewish law as follows, “With regard to his son a father is obligated to marry him off and teach him a craft. Some say he is also obligated to teach him swimming.” That meant certainly for Maimonides, that parents needed to be able to swim to save their children if they went too far into the water and started to drown. Thus, Maimonides took a very practical necessity for Jewish parents, and found language in the religious literature that commanded Jews to learn how to swim and teach their children to swim. He was not only a strict rabbi who laid down the law as it was actually written; he was also a very savvy doctor, and who did it hurt if he stretched his imagination to get kids swimming and then save them from drowning? One wonders if a thousand years later Mark Spitz, the most famous Jewish swimmer of all time knew and understood this very unusual debt that is owed to a very fine Jewish doctor.

The next introduction of sports into a small segment of the Jewish population has an interesting and almost accidental history. Up until the 18^th century, as we mentioned, the only sport actually encouraged was swimming which was seen as a necessary safety measure to guard children from drowning. This changed in the 18^th century not as a matter of intention, but as the result of a shift in Jewish demographics.

There was a growing Jewish community in England by the middle of the 17^th century. When Sephardic Jews were allowed by Cromwell to come to England, shortly thereafter, a boxing craze sprung up in England, and Sephardic Jews, just like every other Englishman, became enamored with the sport. It was thus an historical coincidence that shortly after Portuguese Jews came to England, the sport of boxing started to become a prominent English pastime. Going back into history it is interesting to note that while boxing has been a very popular sport amongst the Greeks and Romans, it had virtually become unknown during the Middle Ages only to resurface in England around the turn of the 18^th century. Around 1700, shortly after the arrival of the Portuguese Jews, boxing matches started to spring up all over England. In 1764, Daniel Mendoza, the son of Spanish and Portuguese Jews, was born soon to go on to change the face of Jewish athletics for the rest of the modern era. Although unknown to present day Jews, Mendoza was the first Jewish athlete to gain widespread fame in the modern era. Mendoza went on to become an English superstar with an unparalleled boxing record from 1780 until 1790. In a 10 year period, he revolutionized English boxing, turning it from a staid boring sport of two men standing their ground and punching each other into a scientific match of brawn and brains in which each boxer danced and dodged and tested the other with numerous tactics that have become the standard fare of boxing. In 1790, Mendoza claimed the championship of all English boxing. In 1792 he retired.

Fast forward to the 20^th century – we find Easter European Jews coming to the United States in the millions. And as these Jews were assimilated into the American system of athletics, it should come as no surprise that almost immediately Jews started to excel in American boxing. The biblical prohibition of engaging in dangerous activities still resulted in a narrow selection of sports, but when Jewish teenagers did accept sports with a lower risk of harm, their progress was rapid and notable.

Treatment implications for the sports physician

Given the above, the questions for the sports psychiatrists and mental health therapists are – first why is the above important and secondly, how to integrate the positive influences emanating from a religion or culture when working with a league, team or individuals and work through the negative [1, 2]. We briefly describe what sports participation can do for neurodevelopment and mental health (broadly defined).

The first task is to get athletes back into the game. Among other reasons, sports provide pleasure and satisfaction in the broadest sense of the term both mentally and physically, but also fulfills psychological needs as in “being accepted as a member of the group” – emanating from the drive to maintain psychological and physiological homeostasis in the brain and body [11]. A sport involves not only intrapsychic but also interpersonal skills in understanding the “psyches or mindsets,” i.e., the strengths and weaknesses, of one’s own teammates, as well as the players on the other team and their strategies and match-ups [11]. The core interpersonal dynamics are “sharing,” i.e., teamwork rather than “solo drive fulfillment.” The idea is that each of the players will mesh and work together to achieve their goal of team chemistry (vide infra). It’s a little like a string quartet or an orchestra working together to make beautiful music – but here, it can be scoring or defending and communicating with teammates. It involves rapid decision making (intermixed with pauses as in baseball or football – just like life outside of sports). And these decisions go more smoothly if the players, regardless of race or color, accept each other

Once back playing/participating, the next issue is dealing with the religious-cultural issues, i.e. improving performance, improving brain health and decreasing psychiatric symptoms and illness. We briefly discuss the rationale for this from three points of view – first, sports and the interaction with the individual athlete’s mind and brain; second, sports and the interaction of individual and the team; and third, sports and the interaction in the athlete’s culture and community [11].

Summary and conclusion

Helping athletes – men and women, amateur and professional – and their teams to participate, compete and to do their best is the essential role for the sports physician. There are numerous brain-mind problems and illnesses we face. As it turns out, negative attitudes, pressures, and long-standing biases and injunctions emanating from culture and religion can affect both participation and performance. Additionally, creating a safe environment where athletes are not discriminated against, feeling comfortable discussing vulnerabilities, as well as creating a safe training environment are crucial. Common presenting symptoms such as “anxiety and/or depression” may develop in the athlete as they deal with these issues – and actually development of a psychiatric illness can be (in part) a result of not playing. We argue that sports treatment including medication and psychotherapeutic interventions like individual therapy, or family therapy or group therapy, depending on the problem need to be delivered based on a broad differential psychobiological diagnosis and different indications for treatment.

In the case example we discussed in the beginning of this paper, a combination of psychotherapy with the athlete, a family meeting with her family, and a course of antidepressant medication to treat her lowered mood and anhedonia was necessary to get her back into competition and most importantly, treat her mood disorder which had developed.

We may be of different religions, cultures, genders or race – but we sports physicians, share the aim of our patients to help them, regardless of our differences.