Tuesday, 7 September 2021

Doping at the Tokyo Paralympic Games

As someone with a chronic, progressive disability, I have mixed views about the Paralympics. For me an inspirational story for someone with a disability is surviving another day in good cheer and not being too much of a burden on others. Interestingly as my disability has got worse my feelings about the Paralympics have, if anything, become more conflicted. I suspect what I am feeling is something akin to what I felt about elite sport when I was young. The realisation of a young boy that I was never good enough to play centre forward for the England football team has now been joined by an ageing man who has been reminded that another opportunity for sporting excellence has passed him by. Probably time to see my therapist again! 

Anyway, this is a roundabout way of saying that I watch the Paralympics solely as an example of elite sport and view it on those terms. Studies show that elite sport or even hosting the Olympic Games has no discernible benefit in improving the health of physical activity of the nation. I strongly suspect that the Paralympics likewise have minimal, if any, effect on the physical activity and/or rights of disabled people. But, actually why should we put this “burden of inspiration” on Paralympians. Let’s just treat them as elite athletes in their own right. No more, no less. Neither positive nor negative role models. Just ordinary people doing extraordinary deeds. The same as the Olympians. 


Viewed in that light, as I said about London 2012, we should expect the same issues to arise in Paralympic sport with regards to doping. And they do. In fact, Paralympians with spinal cord injuries even have their own unique way of cheating. “Boosting” by blocking a catheter, squeezing a scrotum or breaking a toe can increase performance by inducing a pain free rise in blood pressure. Even in more “normal” doping methods, Paralympians equal or outshine Olympians. We don’t have the Tokyo numbers yet, but in Rio 2016, roughly the same number of doping tests per competitor were carried out at the Olympics and the Paralympics. The Paralympians “won” by having 0.71% positive tests compared to the Olympians 0.59%. 


So let’s raise a “tainted” toast to Marcin Polak, the Polish visually impaired tandem cyclist. Polak ‘won’ a bronze medal on August 25, but then was informed two days later that he had tested positive for the blood booster EPO in an earlier out of competition test on August 2 and so had to cut short his Paralympic “journey” [1]. Polak reminds us that Paralympians are the same as Olympians in all ways, good bad and ugly. And that’s why – on reflection – I think I’ll carry on watching the Paralympics after all. Next stop Paris......


[1] For those wondering why Polack was allowed to compete on August 25,when his positive test sample was collected on August 2, this is a most likely due to the peculiarity of EPO testing. The interpretation of the test gel is somewhat subjective, so requires independent verification by a second anti-doping laboratory. So the Warsaw positive result had to be re-analysed, and confirmed  by the Tokyo lab, before the athlete would have been informed.  Hence the reason for the delay.  

Monday, 6 September 2021

Doping at the Tokyo Olympic Games

My first blog in almost two years. Perhaps because nothing much has changed in the period in the field or perhaps because I had other things to do in my life! Still, hopefully I can be a bit more fruitful in the future.

I covered my current views on the Olympics in a podcast I did for the Economist which is openly accessible by the link below. 





For the podcast, I was asked to comment on drugs like AICAR and other so-called “exercise mimetics”. I might follow up on this with a couple of future blogs. 


There was a nice graphic also from the Economist contrasting different countries doping in athletics 




I was also featured in an article in the Daily Telegraph newspaper (unfortunately behind a firewall).




If you don’t have time to follow these links, my take home messages about the Tokyo Olympics are:


·      It is unclear how much the pandemic has impacted on the effectiveness of out-of-competition anti-doping tests in the run up to the Olympics. Presumably it has been slightly easier to avoid being caught although it also might have been difficult to procure and effectively use doping methods.  

·      The IAAF’s Athlete Integrity Unit (AIU) are having an impact. I was surprised there was not more media outcry over the significant number of athletes not allowed to compete in the game because they were not tested enough, apparently through no fault of their own. I guess the list of athletes and the countries they represented did not appear high enough profile for the Western media I follow, although I suspect there was more outcry in the countries themselves, such as Nigeria. https://www.independent.co.uk/sport/olympics/olympics-tokyo-athletes-drug-testing-b1892437.html

·      We saw one highly significant event; the readmission of essentially the whole Russian team; this despite the Russian anti-doping agency still not being WADA compliant and no admission from Russia that there was any state involvement in cheating. This seems to have put this issue to bed, perhaps in a not altogether satisfactory manner. We await to see how IOC, WADA and CAS deal with the next state player that is involved in doping. It seems the precedent has been set for a mild rebuke for the county concerned. An individual who is selected by that country will still be able to compete with zero penalties unless doping evidence exists against that specific individual. Countries themselves will never suffer the ultimate sanction of their athletes not being allowed to compete in the Olympics. Time will tell if this works as any kind of deterrent. 

·      The issue of potentially non-performance enhancing drugs being on the banned list arose (at least in the US media) because of the positive test for cannabis of Sha'Carri Richardson in the US Olympic trials. This case just seems to show that even the high-profile athletes in a country with a well-funded and assertive anti-doping agency, still don’t seem to treat the WADA list with enough seriousness. Richardson should have known she would likely be drug tested if she finished in the top three at the US trials and  – so whatever her mental state at the time – her elite athlete warning bells should have sounded off that she was breaking a rule that would likely result in a ban. Given how well she ran at the trials, she was obviously superbly prepared in every other way to perform.

·      At the games themselves there were the usual spattering of positive tests. The cynical comment is that you only catch the “dopy” dopers at the Games themselves, as those in the know will be well aware of how long a drug lasts in their system and will arrive “clean”. It is true that sometimes a better detection method can catch dopers unawares. However, this happens rarely at the Games themselves, but instead when samples are retested over the next 10 years. Over 130 athletes were retrospectively stripped of their results from the Rio 2016 and London 2012 Games. Athletes who have doped at the 2021 Olympics can really only breathe a sigh of relief that they have got away with cheating when the samples they have given are destroyed in 2031.  

·      In light of the above it was unusual that a positive test for one of the more high-profile track and field athletes - Blessing Okagbare – was reported at the Games.  Okagbare tested positive for human growth hormone. However, although reported at the Games, the test was taken out-of-competition on 19 July. Despite already having received any performance benefit, she would probably have tested ‘clean’ when competing at the Games, again stressing the importance of out of competition testing (it should be noted that Okagbare  has so far not admitted to any offence) https://www.athleticsintegrity.org/downloads/pdfs/disciplinary-process/en/AIU-PRESS-RELEASE-BLESSING-OKAGBARE-OF-NIGERIA-PROVISIONALLY-SUSPENDED.pdf

·      Of course, for my own country the big issue was the sprinter CJ Ujah, who was one of the athletes in the 4 x 100m silver medal winning team. He tested positive for S23 and ostsarine – two Selective Androgen Receptor Modulators. These are on the banned list for two reasons. First they are aimed at improving muscle mass (like anabolic steroids) but without the adverse sex hormone side effects; and secondly they are both investigational drugs that are not approved for human use anywhere in the world. This doesn’t stop unscrupulous supplement companies adding them to their formulations. Of course, as they are not approved for human use, they won’t be listed on the label. It looks like this ‘mislabelling’ might be the defence CJ Ujah’s laywers will use. https://www.dailymail.co.uk/sport/olympics/article-9896225/CJ-Ujah-set-blame-labelling-error-positive-test-strip-GB-4x100m-relay-silver.html
If Ujah still has the bottle in question, can get it retested and show it contains S23 and ostarine, this might just reduce the length of his penalty. But, I predict that the silver medal will still be lost, as he won’t be able to prove that he did not get a performance benefit from the drug in his system.

·      I am continually surprised why elite athletes insist on using supplements that have minimal performance benefit (unless they contain anbabolic steroids or SARMS of course). Taking ANY supplement seems a very high risk:reward ratio. It suggests athletes  (or their coaches) have not carefully read or digested the comprehensive IAAF Consenus statement on nutrition. The only evidence-based supplements are caffeine, bicarbonate, beta-alanine, nitrate, and creatine (none of which are on the banned list) https://journals.humankinetics.com/view/journals/ijsnem/29/2/article-p73.xml.   
It follows that if an athlete sees performance benefits using any other supplement than these five, it is likely a placebo effect or due to a “contaminant” in the bottle.  A contaminant that could get you a ban. 
Caveat emptor. 

Monday, 7 October 2019

Nobel Prize for working out how EPO works!

It’s nice to blog about the science of EPO (erythropoietin) without immediately talking about doping for a change. Today three great scientists were awarded the Nobel Prize in Physiology or Medicine for working out how mammalian cells sense and adapt to oxygen availability. The science underpinning the award to William G. Kaelin Jr, Sir Peter J. Ratcliffe and Gregg L. Semenza is described here. 

Most sports scientists and athletes know that EPO is a protein that increases the number of red blood cells. Altitude training increase levels of EPO and hence increases the number of red blood cells, increasing the amount of oxygen in the blood and potentially increasing performance. The discoveries of Semenza, Ratcliffe and Kaelin revealed that a protein called HIF-1 alpha binds to DNA and increases the production of several proteins including EPO. EPO then binds to other proteins that increase the synthesis of red blood cells. However, in the presence of oxygen HIF-1 alpha is degraded inside the cell in a structure called the proteasome. Thus, when oxygen is abundant there is not enough HIF-1 alpha to bind to DNA, EPO levels fall to normal and red blood cell production decreases. 

Of course, directly injecting EPO or receiving a blood transfusion bypasses the clever biological pathways that safely regulate the number of red blood cells in the body that match oxygen supply and demand. Hence the reason for blood doping being banned in sport. In fact, if you look at current research following on from the work of Kaelin, Ratcliffe and Semenza, you can see other proteins that could be targeted to increase or decrease red blood cell production. This is relevant for developing new drugs to treat anaemia and cancer. Of course it could also be relevant to sports doping; the HIF-1 alpha/ EPO pathway is perhaps the most obvious “known unknown” when it comes to new drugs in sport. By this I mean, we know modifying this pathway could improve sports performance, but it is unknown if anyone is currently exploiting it. Or at least no one has been caught doing it, which amounts to the same thing. But it would not surprise me if people were trying.

In a personal level this is the second time my research career has intersected with research that led to a Nobel Prize. The other time was the role of the gas nitric oxide that controls blood flow in the body. It is one of the privileges of a scientific career to be close to seeing such clever people in action, even if that closeness sometimes just involves admiring their research at conferences and in publications. 

Wednesday, 29 May 2019

Expert reaction to Court of Arbitration for Sport (CAS) ruling on Caster Semenya’s appeal of the IAAF hyperandrogenism regulations

I was on holiday during the CAS ruling on the appeal of the CAS hyperandrogenism regulations, so my comments are a bit late.  The comments of the other experts who contacted the Science Media Centre can be found at this link


My comments are reproduced below:

"In my personal opinion, the IAAF regulations have as good a scientific basis as they are going to get in the foreseeable future.  HOWEVER, this does not mean that they are ethically ‘right’.  That is a separate matter.  We should focus on the ethics of what we want to encourage as participation in female sport, and not get hung up on criticising the fine details of science that is never going to be as conclusive as we would like.

Although they have not released their detailed reasoning, the CAS decision to disallow the Caster Semenya and Athletics South Africa appeals is not surprising given their previous opinion in the case of Dutee Chand.  Chand appealed against the IAAF’s original hyperandrogenism regulationsIn the Chand case, CAS ruled that discrimination based on requiring a defined level of plasma testosterone was permitted if “on the balance of probabilities the Regulations are a proportionate means of achieving the legitimate objective of ensuring fairness in athletics competition.”  The Court did not have a fundamental issue with the discrimination itself.  It just had to be scientifically justified.  The IAAF were then given “the opportunity to provide the CAS with scientific evidence about the quantitative relationship between enhanced testosterone levels and improved athletic performance in hyperandrogenic athletes.”  The IAAF then brought forward new regulations based on scientific evidence claiming that there was a significant advantage in certain events, specifically 400m, 800m, 1500m and mile.  So the new case hinged not on whether discrimination is justified, but instead how large were the benefits of increased (natural) endogenous testosterone in female athletes.  This new IAAF data was based on comparing performance of elite athletes at these distances with their testosterone levels.  The published correlational data partially support this decision at 400m and 800m, but are less clear for the mile and 1500m (although scientifically it is hard to see why benefit at 800m would not partially transfer into a benefit at 1500m).  Hence the current CAS Panel suggestion that the IAAF “consider deferring the application of the DSD Regulations to these events until more evidence is available.”

By asking the IAAF to use science to determine quantitively the specific advantage raised testosterone levels bring in elite athletes, CAS are, in my opinion, asking science to do too much.  Proving evidence at the level of a specific event for individual athletes is only possible if you are allowed to drop or increase these levels in a controlled manner and measure the change in performance.  Some of this individual data may indeed be in the final CAS report (although likely in redacted form).  However, even then, individual hyperandrogenic DSD athletes will likely respond differently to changes in their testosterone levels.  So any percentage change in performance would not be readily transferable to other DSD athletes.  In effect the request for the IAAF to respond to the Chand ruling for more science was doomed to provide some light, but also more confusion.  It is likely that this is the reason for the verdict being majority, and not unanimous.
Testosterone increases during development are clearly the dominant, if not sole, reason why male athletes outperform female athletes.  The science is reasonably clear that DSD athletes with raised tesosterone levels will have some performance benefit even if their body only partly responds to those increased levels.  But other factors clearly contribute to performance.  In this context it is worth noting that Caster Semenya won the London 2012 800m when the original IAAF DSD regulations requiring lowered tesosterone were in force; the regulations were lifted for the Rio Olympics and she then won by greater margin.  Using the IAAF regulations to handicap athletes with DSDs will have an effect on performance, but will likely not prevent them competing at an elite level.  It seems to me predominantly an ethical, not scientific, question whether such discrimination is a “necessary, reasonable and proportionate means of achieving the IAAF’s aim of preserving the integrity of female athletics in the Restricted Events.”  Asking science to work at the level of granularity requested by CAS of the IAAF is part of the problem not the solution.  Instead athletes and the public need to decide if they are happy with the percentage of DSD athletes being significantly over-represented at the elite level, compared to their prevalence in the general population.  Adopting the IAAF regulations would decrease this over-representation, but likely not eliminate it entirely.  I think this is predominantly a societal question rather than a scientific one.

Is there a link to current regulations on transgender athletes and doping?
The IAAF testosterone regulations regarding DSD (differences in sexual development) need to be seen in the light of their (and the IOC’s) anti-doping and transgender regulations.  This is NOT to say that females with DSD or male to female transgender athletes are cheating of course.  But the science underpinning the possible performance benefits of their situation is related.  And in many cases – perhaps surprisingly – the doping data is easier to access.

On doping regulations: there is good evidence that increasing exogenous testosterone levels (or taking artificial anabolic steroids) enhances sport performance.  This effect is greater in females than males.  It is (partially) reversible if anabolic steroids stop being taken.  It is no surprise that anabolic steroids preferentially enhanced performance in female athletes in the former East Germany (where they were likely given to junior athletes).  Nor that the Russians state doping system had some of its greatest ‘successes’ when giving anabolic steroids to female middle distance runners.  Therefore doping is banned.

On transgender regulations: lowering plasma testosterone levels is the main goal of male to female transgender hormone therapy.  Transgender women, who are transitioning or have transitioned from male to female, are treated with hormones (by choice) to lower their plasma testosterone levels to similar levels as required by the IOC regulations.  This decreases their performance.  Therefore they are allowed to compete in a female category after hormone therapy to lower their testosterone.
Nothing about elite sports performance is ever going to be amenable to scientific conclusions ‘beyond reasonable doubt’.  This is because the fractional differences in competition at the highest level are so small and the population so difficult to study ethically and practically.  In my opinion the current evidence is as good as we are going to get to show that both endogenous (natural) and exogenous (doped) testosterone levels enhance female sports performance.  In the terms of the Court of Arbitration of Sport, I am personally “comfortably satisfied” that both exogenous and endogenous testosterone increases sports performance in elite female athletes.  Of course a lot of other factors, genetic and environmental, also affect sports performance, but that is a separate story."

Sunday, 24 March 2019

Expert reaction to editorial about testosterone, women athletes, and rules in elite sport

Referring to my last blog the Science Medic Centre has now posted all three of its expert opinions. So you can read them for yourself and see how three experts can come to somewhat different opinions about the same paper. Actually two of them pretty much agreed and one didn't, but now you can read for yourself and make up your own mind.


Meanwhile  the Court of Arbitration for Sport has received new material from both sides of the argument.


The decision is now delayed from his coming Tuesday (March 26) until the end of April

Thursday, 21 March 2019

Caster Semenya, IAAF, testosterone levels and editorial in British Medical Journal

I was asked by the Science Media Centre to provide an expert reaction to an editorial about testosterone, women athletes, and rules in elite sport, as published in the British Medical Journal. The article can be found at this link. 

As well as my “biochemical” comment, the Science Media Centre received two other expert comments from endocrinologists. Interestingly, whilst one endocrinologist wrote a very short note supportive of the article, the other was highly critical and wrote a lengthy piece outlining the editorial’s scientific shortcomings. I’ll see if I have permission to post that article later on this blog as it is really interesting and chimes with what I think. 

Interestingly my opinion was quoted very differently (but still correctly) by both the BBC and the Daily Mail

As I say at the end of my piece, there are some good reasons to drop the IAAF regulations on differences in sexual development (DSD). But I don’t think bad supporting science is one of them. In the words of TS Eliot from the play Murder in the Cathedral:

 “The last temptation is the greatest treason: To do the right deed for the wrong reason”. 

My full expert opinion on the BMJ editorial follows below:

First the closer overlap between male and female plasma testosterone levels in elite sport noted in this paper is perhaps not surprising for a number of reasons:

(a) Increases in plasma testosterone in female athletes (in part due to differences in sexual development, DSD) are likely to improve performance more than similar increases in men.  Therefore women with higher testosterone levels will probably be overrepresented in elite athletes.  It is well known that the proportion of conditions leading to high testosterone levels is higher in elite female athletes compared to the male population.  For example at the Atlanta 1996 Olympics several female athletes tested positive for the SRY gene on a Y chromosome.  SRY induces testosterone production during puberty so this likely led to increased levels of plasma testosterone.  This testosterone was considered not to be having an effect on their body (androgen insensitivity syndrome, AIS).  So an XY apparently “male” genotype led to a female phenotype.  The prevalence of AIS in the non elite athlete population is much lower than the 7 in 3387 found in this sample of Olympians.  This suggests that increased testosterone levels either do still slightly increase performance in some AIS females OR make them more likely to choose to become athletes.  Either way, this is ONE example of why testosterone levels in female elite athletes may have a closer overlap with male elite athletes than in the population at large.

(b) Taking artificial anabolic steroids will likely lower the levels of the natural anabolic steroid (testosterone) in athletes.  These effects can potentially be quite long term.  Without knowing the number of athletes previously steroid doping in any sample this is difficult to correct for.  I suspect because of the greater adverse side effects in female athletes rather than males, males take higher steroid doses than females.  This would result in anabolic steroid use lowering the natural male testosterone levels more than the female levels, again closing the gap and increasing the overlap.

(c) The major physiological effects of plasma testosterone levels occur during puberty.  However, it is not possible to test at puberty in future elite athletes.  By its very nature any later testing is of somewhat secondary value.  So an elite male athlete might have low testosterone now, but at the crucial time in their development it was significantly different from the future elite female athlete.  It is hard to see how any data can be collected in this area.  So the IAAF make do with what they can actually measure.

Second, gathering hormone data in elite sport is difficult.  It is even harder (and potentially unethical) to gather performance data under conditions where these hormone levels are made to drop or rise due to external factors. Therefore by its very nature correlation data of the type described in this article will become important.  But it is individual data that really matters, and this is even harder to get access to for the obvious grounds of medical confidentiality.  As the authors mention Caster Semenya, it is perhaps instructive to look at her 800m times* at global championships when the IAAF testosterone levels were in place or not.  This is worth mentioning as you can be sure the same discussion has been had amongst other female elite athletes (and also athletics fans).  In periods when the testosterone regulations were not in place Semenya won all the global championships she competed in.  When they were in place she ran slower and was second to cross the line at global championships.  The winner those times (Mariya Savinova) was banned for doping (possibly by taking substances including anabolic steroids) and thus possibly giving her the same advantage by cheating that Semenya (who was not cheating) had been denied by the IAAF regulations.

Third, the IAAF testosterone regulations regarding DSD (differences in sexual development) – although not mentioned explicitly – need to be seen in the light of their (and the IOCs) anti doping and transgender regulations.  This is not mentioned by the authors of this article, but seems relevant.  This is NOT to say that females with DSD or male to female transgender athletes are cheating of course.  But the science underpinning the possible performance benefits of their situation is related.  And in many cases – perhaps surprisingly – the doping data is easier to access.

On doping regulations: there is good evidence that increasing exogenous testosterone levels (or taking artificial anabolic steroids) enhances sport performance.  This effect is greater in females than males.  It is (partially) reversible if anabolic steroids stop being taken.  It is no surprise that anabolic steroids preferentially enhanced performance in female athletes in the former East Germany (where they were likely given to junior athletes).  Nor that the Russians state doping system had some of its greatest ‘successes’ when giving anabolic steroids to female middle distance runners. Therefore doping is banned.

On transgender regulations: lowering plasma tesosterone levels is the main goal of male to female transgender hormone therapy.  Transgender women, who are transitioning or have transitioned from male to female, are treated with hormones (by choice) to lower their plasma testosterone levels to similar levels as required by the IOC regulations.  This decreases their performance. Therefore they are allowed to compete in a female category after hormone therapy to lower their testosterone.

Nothing about elite sports performance is ever going to be amenable to scientific conclusions “beyond reasonable doubt”.  This is because the fractional differences in competition at the highest level are so small and the population so difficult to study ethically and practically.  In my opinion the current evidence is as good as we are going to get to show that both endogenous (natural) and exogenous (doped) testosterone levels enhance female sports performance.  In the terms of the Court of Arbitration of Sport, I am personally “comfortably satisfied” that both exogenous and endogenous testosterone increases sports performance in elite female athletes.  Of course a lot of other factors, genetic and environmental, also affect sports performance, but that is a separate story.

Summing up, in my personal opinion, the IAAF regulations have as good a scientific basis that they are going to get in the foreseeable future.  HOWEVER, this does not mean that they are ethically “right”.  That is a separate matter.  I write as someone who personally cheered Caster Semenya on to victory in the 800m in the 2017 World Athletic Championships in London (when the DSD regulations were not in force).  However, we should focus on the ethics of what we want to encourage as participation in female sport, and not get hung up on criticising the fine details of science that is never going to be as conclusive as we would like.

Finally, I caution against the authors making too much of the effects sport has on the real world.  They say “History compels us to ensure that decisions about genetic superiority are supported by objective, rigorous, and reproducible data” and “These issues highlight the fact that although sports policies exist to serve the organisations that develop them, the effect of these policies on individuals, societies, and even medical science has far reaching implications.”  Sport – and especially elite sport – as we know it is a social construct created by (largely) males at the end of the 19th Century.  We have chosen in society to place a huge value on it and honour its participants with wealth and fame.  But it is inherently sexist.  Biological females have no chance of competing on an equal footing with males – in terms of physical sports performance they demonstrably can’t compete.  Equality of opportunity in sport does NOT equal equality of outcome.  In fact it does not come close.  In nearly all adult sports there would be NO female winners if we did not have a separate female category.  This is unlike any other activity we value in our society. Therefore elite sport has created a special protected space for females (female sport).  Inevitably this creates tension at the interface as noted in this article.  But it is important that writers – such as the authors – do not try and put sport on a pedestal.  Decisions, such as those of the IAAF, relate to the rather special social construction of the sporting world.  We should note give them added importance by trying to translate them into more important parts of life and society.  The Olympic Charter claims that the practice of sport is a human right.  Well this may be the case, but in my opinion it is low on the list of ones that we should use as an example of how to construct how we run our society.”

* Caster Semenya times:
Pre regulation requiring testosterone levels to be dropped (2009 World Championship Berlin): Winner, 1:55.45
Post Regulation (2011 World Championships Daegu): Second*, 1:56.35
Post Regulation (2012 Olympics London): Second*, 1:57.23
Regulations dropped (2016 Olympics Rio): Winner, 1:55.28
Regulations dropped (2017 World Championships London): Winner, 1:55.16.
* upgraded to Winner after Mariya Savinova disqualified for doping offences (likely including anabolic steroids).

Friday, 14 December 2018

An overview of the last five years of drugs in sport and doping science

Run, Swim, Throw, Cheat has just been published in a Japanese edition. I am very pleased that there is still interest in a book published in 2012. When introducing this edition, I felt it was worth writing an extended update of the doping science scene during the last six years - or at least the five years since I write a new introduction for the 2013 paperback edition of the book. I thought it also might make an interesting – if somewhat lengthy – blog entry for readers of this blog who can’t read Japanese. So here is the English version of the introduction. 

Introduction to Japanese edition of Run, Swim, Throw, Cheat 

Run, Swim, Throw, Cheat was published just in time for the London 2012 Olympics; this was not a coincidence of course!  However, most of its subject matter does not date rapidly and everything you will read in this Japanese translation is as sound scientifically as it was when written. Minor updates on new drugs and testing methods were included in the blog I write (and occasionally update) at www.runswimthrowcheat.com.

What does change is the stories that illustrate the science. Most notably the Lance Armstrong Tour de France scandal came to light the year following that in which the book was published. There is not even a hint of his wrongdoing in the original printing of the book. This was remedied in the 2013 paperback version and much of the introduction I wrote for that edition is given over to discussing the Armstrong saga. 

The London 2012 Olympics itself had few doping scandals during the event itself, although I did manage to witness the one medal that was overturned. The culprit was the Byelorussian shot putter, Nazdeya Ostapchuk (when you read this book you will realise that it is not surprising that shot putters, especially female ones, are particularly able to benefit from doping). At the time I was sat in the Olympic stadium next to a New Zealand journalist who was cheering for Valerie Adams to retain her gold medal. She did just that, but only received it much later when Ostapchuk was disqualified by the International Olympic Committee (IOC) for doping.

The drug Ostapchuk had in her system was the anabolic steroid, metenolone. Athletes seem to favour this steroid as it is claimed to have fewer androgenic (i.e. sexual) side effects. I was surprised that Ostapchuk was caught at the games. I stress in this book that careful planners will stop taking a drug long enough before a prestigious event so it is out of their system when they compete. Although Ostapchuk has never admitted her doping, I thought at the time that she – or her team – must have made a miscalculation. Indeed at her disciplinary hearing she was given a shortened one-year ban, as it was claimed her coach, Alexander Yefimov, had drugged her food. In the words of the head of the Belarusian anti-doping agency, Alexander Vanhadlo, "Yefimov confessed that he added the banned drug metenolone into Ostapchuk's food because he was worried by her unimpressive results ahead of the Olympics”. Yefimov was then banned for four years by the Belarus' national anti-doping agency.

However, subsequent events show it was not an isolated incident. Recent re-tests of old urine samples using more modern and sophisticated techniques mean that eight athletes, including Ostapchuk, have since been found guilty of doping at the 2005 World Championships in Helsinki by the International Association of Athletics Federations (IAAF) and at the 2008 Olympic games in Beijing by the IOC. The emerging story is that Ostapchuk (or her team) were using drugs that at the time they thought could not be detected. It now looks like improvements in analytical techniques mean they got their timings wrong for when she should come off the drug. Strike one up for the anti-dopers!

There is a depressing note associated with this story. Immediately after the shot put final, the UK discus thrower, Brett Morse, tweeted from the Olympic village that Ostapchuk must be doping; his evidence was primarily that she looked like a man. Readers of my blog will know how much I disagree with unsubstantiated accusations about named athletes. This just tars everyone, even clean athletes, with the doper’s label. Quite rightly Morse was criticized at the time and the offending tweet removed. The fact that Ostapchuk was stripped of her medal was, of course, not surprisingly subsequently seen by Morse as a vindication of his tweet. Since writing this book, I have met many clean athletes unfairly accused of doping – especially on the internet. Morse’s tweet, especially as its substance did proved correct, might have the undesirable effect of leading to more of these unfair accusations.  Indeed during London 2012, the biggest “doping” scandal was centred on the Chinese swimmer Ye Shiwen who has never tested positive for doping before or since these games. The suspicion was merely based on her breaking the world record. In the current suspicious times, it pays to not win your event by too large a margin….  

Yet, the real scandal of the 2012 Olympics was only revealed five years later, when the full extent of Russia’s state doping system was revealed by a combination of the whistle blowers Grigory Rodchenkov and Yuliya Stepanova, the German reporter Hajo Seppelt and the Independent Commission reports of the World Anti Doping Agency (WADA) chaired by Dick Pound and Richard McLaren. Exactly how many Russian were doping in London 2012 (and of course later in the 2014 Winter Olympics in Sochi) will never be known, but as a consequence of retesting, 29 London medals had been returned for doping offences, 13 of which were from the Russian team. As a personal experience visiting the London games in my home city were an amazing uplifting experience, with some of the happiest crowds I had ever seen in the city. How they would have felt if they had known at the time that this level of cheating was occurring is not difficult to imagine. I should mention at this point that Russia still denies it was involved in a “state sponsored” doping regime. This denial is why - as of 2018 – the country is still banned from the Paralympics by the International Paralympic Committee (IPC), although the International Olympic Committee (IOC) has seen fit to reinstate them into the Olympic community. 

What is clear from London 2012 and Sochi 2014, is that, however clever the drug testing, it is irrelevant if the testers themselves are corrupt; and the state have a unique ability to cover up this kind of cheating. Clever science will always be trumped by clever politics. What is perhaps more interesting from a scientific point of view is that the kind of doping Russian athletes were involved in was not too different from what was found to be effective over 40 years earlier by the East German state sponsored system. Whilst there were some newer drugs of potential - if not scientifically verified - performance benefit such as meldonium, the core of the program was anabolic steroids to increase strength and power in, especially, female athletes. In fact the main difference was possibly the use of lower doses so that the female athletes were less obviously over muscled, decreasing suspicion that they were doping. Where there was a difference is that the effectiveness of blood doping (EPO, blood transfusions) had been discovered since the East German program; this benefitted both male and female athletes. It is one of the conclusions of my book that the real “game-changing” benefits of doping come from anabolic steroid use by female athletes in “power” events and blood doping by male and female athletes in “endurance” events. This conclusion, has if anything, been confirmed by what the Russian whistle-blowers and WADA reports revealed of the Russian program. 

There was a backlash against WADA, IOC and IPC led by the Russian government and various hacker groups such as Fancy Bears.  The Russians complained that they had been unfairly singled out as there was widespread doping elsewhere. This could perhaps be called the “Lance Armstrong” defence. Armstrong claims he should keep his seven Tour de France titles as his rivals were cheating at the same time. Although, in my opinion their abuses were generally more flagrant then their rivals, the Russians and Armstrong were correct that cheating is widespread in sport. Two other Tour de France winners lost their titles due to a doping offence and - if 13 out of 29 London 2012 medal cheats were Russians - 16 out of 29 were obviously not. In May 2016, at the same time as Russia was being investigated, the Anti-Doping Agency of Kenya was declared non compliant by WADA due to concerns about the implementation of its anti doping programs; Kenya only regained its compliance a day before the start of the 2016 Rio Olympics.  In August 2013, Renee Anne Shirley, the former executive director of Jamaica’s Anti-Doping Commission (JADCO), revealed her concerns about a lack of adequate out-of-competition drug testing prior to the London 2012 Olympics. This led to an official audit of JADCO by WADA in November 2013, the resignation of the entire JADCO board, and subsequent improvements to the Jamaican anti doping program, following a new partnership with the Canadian Centre for Ethics in Sport.  Although the situations described do not mean that individual athletes in these countries are guilty of doping, the lack of effective anti doping regimes in some countries will always make it harder to be confident that a sport is clean. 

The more interesting backlash, at least scientifically, came from the Fancy Bearshackers. They exposed the use of the Therapeutic Use Exemption (TUE) in athletes, claiming these were a form of “legalised” doping. None of the athletes concerned had committed any doping offence. Indeed, in many of the cases revealed by the cyber hackers, it is hard to see how the drugs taken could be beneficial to performance. But there is still an interesting discussion to be had around the science. TUEs are given for drugs designed to treat an athlete’s medical condition without enhancing performance; being performance “enabling” the intent is that they allow an athlete with a pre-existing medical condition to compete on a level playing field with their healthy peers. A concern is that athletes, their coaches and/or doctors, might “game” the system to their benefit. This was an accusation levelled at the British Olympic and Tour de France Champion cyclist, Sir Bradley Wiggins, over the unusual medication used to treat his severe seasonal hay fever, triamcinolone. Although not a first line medical treatment, as a powerful long lasting anti-inflammatory corticosteroid, triamcinolone is used by some doctors for treating hay fever and rhinitis. The critics’ claim is that a side effect of triamcinolone is weight loss, enabling a rider to lose weight but not power, a potential advantage for a cyclist in a climb. Although this is an interesting idea, the scientific evidence supporting this is weak and Wiggins and his then employers, Team Sky, strenuously denied any performance benefit for what was, it should be remembered, a WADA approved  therapeutic use exemption.

Another area that is causing current concern in Britain is the inhaled bronchodilator salbutamol, required for many athletes with asthma to breathe freely.  A TUE is only required for salbutamol if you need to take an excess in a short period (essentially this equates to eight “puffs” in a eight hour period). It is not clear that exceeding this level is performance enhancing; there is little if any performance effect in short term studies, although WADA claim that over time at high dose it might increase muscle mass. However, once a limit is set, it must be policed. The British multi Tour de France winner, Chris Froome was recently investigated due to the high level of salbutamol recorded in his urine sample during his La Vuelta victory in 2017. The WADA doping threshold in a urine sample (1,000ng/ml) was set to be impossible to reach unless an athlete inhales more than the eight puff limit. However, this has been disputed by some recent scientific research, which shows that the rate of salbutamol transfer from drug inhalation to appearance in the urine is highly variable and it is indeed possible to exceed the limit when an individual is not exceeding the permitted inhalations.

Froome and Team Sky disputed that he took too high a dose. The resultant case was all about the science. Could Froome convince the authorities that there is a plausible explanation for the anomalous urine reading? Is it possible given the conditions at the time for Froome to have exceeded the urine threshold whilst only taking the approved levels of the drug? Froome was under the doping limit throughout the rest of the Vuelta and indeed the whole season despite multiple testing in competition, so it seems highly unlikely that he was attempting the kind of long-term use that WADA claim can be performance enhancing.   It is notable that few people reporting this case – even the Froome critics – claimed that he would have received a short-term performance benefit for any one off salbutamol abuse. The discussion focused on the science of the test and whether a rule was broken. A week before the start of the 2018 Tour de France, the cycling authorities (UCI) ruled that they were satisfied that Froome did not commit any offence, and WADA decided not to appeal the UCI’s decision. The UCI’s decision was based on experts’ interpretation of data provided by Team Sky and WADA including information about the specific circumstances of Froome’s metabolism of the drug. Sometimes it feels that following elite cycling is as much about the underpinning science as the action itself. It is perhaps no surprise that when I have given presentations about my book, the cycling fans are the most knowledgeable in the audience! 

Another area of sports science that has become a current hot topic since I wrote this book is the hyperandrogenism and transgender athletes in female sport. Hyperandrogenism is defined as a female with higher than average levels of the sex hormone tesosterone (i.e. in the male range), provided it has also been shown this hormone is able to be exert its physiological effect. 

This is not a doping issue; no one is claiming the athletes are cheating. However, some of the science is related. Most sports have separate male and female categories. Given the cynical view that some athletes will cheat if they feel they can get away with it, there has been concern as to whether males can get an advantage by masquerading as females. As I discuss in the book, the history of how to “police” this gender boundary has historically been fraught with difficulties and prejudice. In most sports the issue has been quietly forgotten about. However, changes in society have made this veil of ignorance harder to maintain. There is an increasing acceptance of transgender and intersex people as individuals that should not suffer prejudice for who they are. There is also an increasing number of countries where gender can legally be self-determined. These facts have brought sex and gender politics back to the forefront of the sporting regulators. 

The IAAF and – more recently – the IOC have attempted to scientifically categorise their female separate sports categories. Approved by the IAAF in 2011, the “Regulations Governing Eligibility of Females With Hyperandrogenism to Compete in Women's Competition” state that any female athlete with a level of testosterone above a stated value (i.e. in the “male range”) will not be allowed to compete until they had taken measures to reduce this value. Usually this would require some form of hormone or drug treatment. The IAAF argument was that the difference in sporting performance between elite men and women is predominantly due to higher levels of testosterone in men. This is why women tend to get excess benefits by doping with anabolic steroids (such as testosterone) when compared to men. Therefore it is “unfair” for someone with a natural high level of testosterone to compete as it gives them benefits akin to doping. Note that at no point did the IAAF blame a “hyperandrogenic” athlete nor argue that they were not a woman - just that they should not be allowed to compete in elite women’s sport without corrective treatment.

An Indian sprinter – Dutee Chand – refused to lower her testosterone level and challenged the legality of the regulations at the Court of Arbitration for Sport (CAS). On 24 July 2015 CAS issued an Interim Award in the arbitration procedure. They suspended the regulations for two years to give the IAAF the opportunity to provide scientific evidence about the quantitative relationship between enhanced testosterone levels and improved athletic performance in hyperandrogenic athletes. To summarise a long case, essentially the IAAF had argued that natural (endogenous) testosterone gave a female athlete the equivalent benefit that dopers achieved using unnatural added (exogenous) testosterone. CAS did not dispute this idea in principle, but wanted to see proof. In the meantime, from 2015 onwards, female athletes were once again allowed to compete with no checks on their high testosterone levels. 

The CAS ruling led to a IAAF and WADA funded study that looked at over two thousand observations from elite athletes competing at the 2011 and 2013 IAAF World Athletics Championships. Measurements were made of blood levels of testosterone and comparisons made to performance. The key finding is that after dividing the athletes into thirds – high, medium and low testosterone – women in the highest testosterone category performed significantly better in 400m, 400m hurdles, 800m, hammer throw, and pole vault. In the 400m, 400m hurdles and 800m there was also a correlation between the higher testosterone levels and the amount of the blood oxygen carrying protein, haemoglobin. This pattern was not seen in any male events.  In a separate study, female athletes with serum testosterone concentrations in the normal male range performed on average 5.7% better when their serum testosterone levels were unrestricted, compared to when their serum testosterone levels were suppressed. 

This new science led to the new IAAF eligibility rules for athletes with differences of sex development(DSD), requiring any female athlete with DSD to maintain her blood testosterone level below five (5) nmol/L to compete internationally in the 400m, 400m hurdles, 800m and 1500m. This means that athletes such as Castor Semenya will need to have drug therapy to reduce their tesosterone levels, if they still want to compete in their preferred events. The IOC looks set to incorporate these same levels into their new guidelines for transgender athletes. In the latter case the justification, at least in part, is that current best medical practice is to target these lower levels as part of the transition from male to female for transgender individuals. 

How does this relate to the doping issues I discuss in this book? London 2012 was the first Olympic games when hyperandrogenic athletes, including world champions such as Castor Semenya competed under regulations restricting their tesosterone levels. Their running times did increase, though Semenya still won the 800m title. However, in the actual race she came second. First past the line was the Russian athlete, Mariya Savinova.However, in 2014 Savinova was caught in undercover video footage appearing to admit to injecting testosterone and taking the banned steroid oxandrolone. This led to a WADA re-investigation of her blood samples, which found that she had used blood doping between 2010 and 2013.  She was subsequently banned by the IAAF for four years, a decision upheld by the Court of Arbitration for Sport (CAS) in February 2017. Savinova is currently appealing this decision, but as it stands, her London result has been forfeited and Semenya awarded the gold medal. So Savinova beat Semenya, but apparently (appeal pending) only by resorting to cheating, taking steroids to increase her muscle mass and blood doping to increase her haemoglobin levels. The 800 m is an event that requires both power (muscle mass) and endurance  (oxygen delivery). Tesosterone gives males from birth increases in both muscle mass and blood haemoglobin. Doping or hyperandrogenism mimic these male advantages. 

If I was writing the prologue to my book again, I would focus not on Ben Johnson’s 100m Olympic win in Seoul nor even the five runners who passed the line one after the other in the 1500m final in Helsinki and who each at some point in their careers was found guilty of doping. Instead I would showcase the London 2012 Olympic games 800m race. Yes, there is complexity in the science of doping and, hopefully, my book will help you understand this and entertain you at the same time. But the key message is simple. What really works – and what is game changing – is the use of anabolic steroids to increase muscle mass (especially in female athletes) and the use of blood doping to increase haemoglobin content in all athletes. Everything else is just noise. 

It is not clear whether these new IAAF DSD regulations will stand the test of time or whether they will face a new legal challenge. Is it ethical to focus on just one genetic difference that enhances performance? Testosterone is the key sex defining hormone, but it is not the only performance defining molecule in females or males, many of which will be similarly genetically determined. Ultimately the answer will not be down to the science, but to what society will accept. I was fortunate enough to be back in the London Olympic stadium in 2017 for the World Athletics Championships. This event took place during the period when the IAAF hyperandrogenism regulations were suspended. I, along with 60,000 other sports fans, cheered Castor Semenya home to the 800m victory she was denied in London 2012. The same crowd that had roundly booed ex-doper Justin Gatlin’s victory in the 100m race, rose to their feet to support Semenya. The lack of any hyperandrogenism regulations did not seem to be stifling their cheers. It certainly did not feel like an unfair victory to those in the stadium.