When Mother Nature Does the Doping

By David Baron, MD, Past President of the Group for the Advancement of Psychiatry and member of the GAP Committee on Psychopharmacology

Doping, broadly defined as the use of a banned substance to gain an unfair competitive advantage in sports, has been a highly publicized and controversial topic for the past six decades. Yet, despite considerable effort by all stakeholders to level the playing field and create a fair—or at least fairer—competitive environment, the issues only seem to have become more challenging and complicated.

The World Anti-Doping Agency (WADA), the world’s premiere doping control agency, and the International Olympic Committee (IOC) have proclaimed that efforts to control doping have three primary goals: the health and safety of the athlete; fair competition; and maintaining the integrity of sports.

However, the case of the South African three-time world champion runner, Caster Semenya, highlights one of the most difficult challenges for the world of sport in trying to achieve these goals. To be clear, however, hers is not a doping case; she did not use testosterone supplementation to gain an unfair advantage, and potentially put her health at risk. In fact, Semenya was assigned female at birth and raised as a girl. However, she was born with a 46, XY DSD, known as a Disorder or Difference of Sexual Development (DSD), and historically referred to as an intersex condition. This results in a higher level of testosterone than is typical for “normal” women.

To address the issue of what constitutes normal and what should be considered doping, WADA adopted a program several years ago called the Biologic Passport. This establishes the baseline for each athlete and compares the level over time. Each athlete is their own control, and so a positive test is determined by the change from their original baseline, not the baseline measure itself.

Unfortunately for Semenya, because she naturally has higher-than-normal levels of testosterone, she has still been banned from competition¹ in certain track distances, although not all. And as far as I can tell, no one is accusing her of doping, or taking testosterone to improve performance. It is just that her baseline levels are above the arbitrary limit for a female to compete in certain distances. Some people think this is a fair decision. However, the key words here are “arbitrary limit.” I am not persuaded that athletes like Semenya should be singled out for a higher level of scrutiny of their natural abilities than others.

I am speaking from the perspective of a former athlete, a coach, a sports medicine physician, a sports psychiatrist, an Olympic Doping Control officer, a founder of the World Psychiatric Association Section on Exercise, Psychiatry and Sport, a board member of the International Society of Sports Psychiatrists, and an NIMH representative regarding federal Drug-free workplace legislation. I have witnessed firsthand many athletes who have won the genetic lottery and have a distinct competitive advantage as a result of fate—that is to say, because of their genes and not because of pharmacology. There are many examples of natural traits that are well beyond the “normal range," yet athletes who benefit from them are not banned from competition or forced to have corrective measures to level the playing field.

For example, is it normal for a woman to be over 6 feet 4 inches tall with a wingspan approaching seven feet? Is it normal for a swimmer to be born with nearly webbed feet that act as mother nature’s fins?

Or if they did not win the genetic lottery, some athletes can benefit from factors that are not related to their commitment, dedication, and desire to win. Is it fair that athletes from some rich countries get access to the best training, coaches, and equipment from a very early age? Is it an unfair advantage to be born in a country where one can have access to all the best sports science has to offer to improve performance?

In any of the above cases, it is clearly not fair. However, it is by no means cheating.

What to do? There are no easy answers. Although fair competition is fundamental to sport, it is not as black-and-white an issue as one might hope for. The issue of achieving fairness for all concerned will continue to be the most significant challenge moving forward.

As sports fans, we marvel at the incredible accomplishments of elite athletes, often forgetting the blood, sweat, and tears that go into achieving what we observe. Like WADA, we expect fair competition, to maintain the integrity of sport and the ultimate determination of the champion. Cheating is not tolerated, but what is “fair”? Hopefully, the answer to this very complex and complicated question will be driven by science and thoughtful ethical considerations.

As highlighted in the award-winning Ted Lasso series, for some athletes, sport (soccer) is life. That level of dedication demands that those who determine fairness in sport deliver a gold-medal performance themselves.