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Cherry-Picking and Lemon-Dropping Lessons from Anti-Doping to Boost Abuse Prevention in Sport

Cherry-Picking and Lemon-Dropping Lessons from Anti-Doping to Boost Abuse Prevention in Sport

Unethisches Verhalten im Sport: Was lehrt uns der Kampf gegen Doping zur Stärkung der Missbrauchsprävention?


Unethical behaviors in sport are a matter of global concern. The current surge in reports on abuse of athletes across sports and all over the world is reminiscent of the doping scandals in the 1980s and 1990s that made many believe that doping was endemic in Sport.

This realization eventually led to a concerted effort of sport stakeholders and the founding of the World Anti-Doping Agency, which has since established itself as the world’s governing body in anti-doping with substantial influence and power.

Framing the history and trajectory of anti-doping as a precedent of what has worked and what has not in righting sports’ wrongs, this review asks: what can the two-decades-long anti-doping ‘fight’ teach us about protecting athletes from abuse? Exploring various aspects from the effectiveness of external regulation and the challenges of a centralized legalistic approach to athlete health protection and accountability, several lessons that have implications for safeguarding athletes can be identified. Behavior change is a long and demanding process for individuals and organizations.

Centering athletes’ voices and lived experiences in practical research approaches while integrating multi-sector stakeholders can help ensure that methods and findings are fit-for-purpose and inform effective, sustainable athlete-safeguarding practices, programs, and policies.

Key Words: Dangerous Behavior, Doping in Sports, Interpersonal Relations, Physical Abuse, Sexual Abuse, Psychological Abuse


Unethisches Verhalten im Sport ist eine globale Herausforderung. Die derzeitige Flut von Berichten über den weltweiten Missbrauch von Athleten in den verschiedensten Sportarten erinnert stark an die Dopingskandale der 80er und 90er Jahre, die es allen Beteiligten zunehmend klarmachten, dass Doping im organisierten Sport endemisch war.

Diese Einsicht führte letztendlich zum Zusammenschluss ganz verschiedener Interessensgruppen und zur Gründung der Welt Anti-Doping Agentur, die sich inzwischen als der weltweite Dachverband aller Anti-Doping Organisationen mit erheblichem Einfluss und Macht etabliert hat.

Dieses Review unterzieht die Geschichte des Kampfes gegen Doping und die derzeitigen Ergebnisse einer eingehenden Untersuchung im Hinblick darauf, was sich als unwirksam und was sich als wirksam erwiesen hat, und was die Bekämpfung von Athletenmissbrauch aus diesen Erfahrungen lernen kann. Verschiedene Aspekte von der Effizienz eines weltweit gültigen und sportartenübergreifenden Anti-Doping-Regelwerkes und den Herausforderungen eines zentralen, legalistischen Ansatzes zum Primat des Gesundheitsschutzes und der Frage des persönlichen Verschuldens werden angesprochen. Eine angestrebte Verhaltensänderung von Organisationen und Personen ist ein langwieriger und schwieriger Prozess.

 Ein praxisorientierter Forschungsansatz, der auf der Sichtweise und den Erfahrungen von Athleten beruht und Experten aus ganz verschiedenen Fachgebieten einbezieht, verspricht die beste Aussicht auf effektive und tragbare Regelwerke und Standards zum Schutz von Athleten vor Missbrauch und Belästigung.

Schlüsselwörter: Gefährliches Verhalten, Doping im Sport, Zwischenmenschliche Beziehungen, Körperlicher Missbrauch, Sexueller Missbrauch, Psychischer Missbrauch

Leveraging an Old ‘Fight’ to Safeguard a New Generation of Athletes

Recently, a powerful scourge has (re-)surfaced in sport: systemic athlete abuse, including various manifestations of psychological, physical, sexual, and neglect-related harm, against diverse athlete cohorts in various global settings (3, 9, 14, 217). As sport is a microcosm of society, it has its own deep-rooted culture of norms and self-regulation that provide fertile ground for illicit behaviors and practices which rest on entrenched power imbalances (25). Acknowledging this painful truth is the first step towards a remedy. The second and more practical step is identifying solution-focused approaches focused on mechanisms and root-cause analyses. Examining the history of another unacceptable practice in sport, such as doping, may be a good place to start. Like abuse, doping is an unethical behavior long observed in sport – but there is a difference (Figure 1). Unlike abuse, doping has captured the sporting world’s time, attention, and resources for decades (19). Globally, anti-doping efforts significantly outpace safeguarding initiatives. Framing the history and trajectory of anti-doping as a precedent of what has worked and what has not in righting sport’s wrongs, this editorial asks: what can the anti-doping ‘fight’ teach us about protecting athletes from abuse? The intent is to explore how the belief that doping in sport is wrong became common, uniting governments and sports organizations worldwide, and to consider which elements of this decades-long effort can inform effective safeguarding strategies (Figure 1).

History of Anti-Doping

Doping dates back to ancient times but became increasingly more sophisticated after the second World War when nationalism and professionalization began to shape high-performance sport (5, 10). Ethical objections were initially slow to emerge but were ultimately triggered by revelations of systematic doping in East German athletes in the 1960s; exposure and cover-ups amongst global track and field idols in the 1980s; a flood of positive tests in dominant Chinese swimmers in the early 1990s; and the Festina scandal during the 1998 Tour de France (12).

By the 1990s, many believed doping was endemic in sport. Sports organizations’ anti-doping policies were fragmented at best and varied widely, as did attitudes and beliefs about doping. Action was taken when more and more highly publicized cases of doping in revered high-profile athletes began to damage the image of elite sport and the Olympic spirit (4).

Adoption of External Regulation

Growing global concerns culminated in the 1999 World Conference on Doping (37) convened by the International Olympic Committee and the establishment of an independent external regulatory body – the World Anti-Doping Agency (WADA) in the same year.

The almost universal acceptance of WADA and its rules by national, regional, and international sports organizations deeply rooted in self-regulation and non-interference by governments and external parties, might come as a surprise (11). However, both participation in and bidding for hosting the Olympic Games are linked to Code compliance, equipping the agency with extraordinary power (35).

Two decades and several versions of the World Anti-Doping Code (the Code) (36) and International Standards and Guidelines later, WADA has firmly established itself as anti-doping’s governing body, overseeing compliance with a universal Code that directs policies, rules, and regulations worldwide (29).

Limitations of the Code

The Code and its underpinning documents have been continuously amended and refined. Revisions were aimed to improve clarity, increase fairness toward athletes, and prevent athletes’ lawyers from finding loopholes that enable their clients to escape sanctions. However, the price to pay for watertight Articles, is that they have become largely incomprehensible for pedestrian stakeholders without judicial backgrounds – including athletes.

This widening gap between athletes and the very regulations and policies meant to protect clean athletes sparks criticism by an increasingly vocal athlete movement. Furthermore, the complex technical language and legal intricacies used in the Code introduce inequality between athletes who can afford legal advice and representation and those who cannot (28).

Anti-Doping and Athlete Health Protection

Finch and colleagues recently asserted that one high-priority area for research and innovation in international sports science is longitudinally studying athletes’ health, including patterns of illness, unintentional injury, and intentional injury (i.e., abuse) (8). Similarly, health is one of the values underlying the fundamental rationale for the Code. Protecting athletes’ health, seen by some as patronizing, remains the central aim and commitment of many healthcare providers and others in sport (10, 26). Within the doping context, it can be a helpful framework to guide decision-making.

The criteria for placing a substance on the prohibited list are 1. the potential to enhance performance; 2. whether it represents a potential or actual health risk; or 3. whether it violates the spirit of sport (4). The health risk to athletes can be assessed based on the evidence in the current medical and pharmacological literature, guidelines, and practice.

Accountability Rests on Athletes’ Shoulders

Athlete support personnel may instigate, be complicit in, actively enable, and cover up doping – the same can be said for abuse. This was considered in the 2015 version of the Code. Despite this, the principle of strict liability enshrined in the Code continues to place the major burden on athletes. It is also primarily their personal freedom and privacy that is heavily limited by rules requiring them to provide personal information, report their whereabouts, and be available for doping tests around the Clock.

To be effective, sanctions meant to deter athletes from doping must present greater disadvantages than the perceived advantages from doping in the short- and long-term. Consequently, current sanctions are substantial and may result in an athlete missing their once-in-a-lifetime chance to participate in the Paralympic or Olympic Games. Frequently, sanctions are career-ending, not only because of the extent of the ban but also the public shame, team exclusion, and sponsorship loss.

Shifting from Legalistic to Social Science Approaches

A large and diverse group of experts constitute WADA’s leadership. The same can be said of the national anti-doping associations’ decision-making panels. Lawyers and scientists play fairly central roles within these circles, and legalistic approaches to anti-doping historically relied heavily and almost exclusively on detection, reporting, and punishment paradigms where doping behavior was deterred through negative consequences. Importantly, a few years ago WADA intentionally began incorporating social science research as well as evidence-based practice, policies, and procedures informed by social science into its work, reflecting a growing realization that dismantling unethical behaviors in sport requires more than punishment-focused thinking. A whole-person, bio-psychosocial approach is needed to fully understand and undo bad behaviors, realizing the importance of concurrent bottom-up approaches (15, 18).

Here’s why: long before an athlete dopes (intentionally or unintentionally) – and similarly, long before a sport actor is abused or abuses – there is a continuum of unethical behaviors that ensue (24). While there may ultimately be a culmination in sanctionable acts, the narrow set of unequivocally reportable behaviors represents only the tip of an iceberg, the majority of which lies far beneath the threshold for formal reporting and sanctioning (Figure 2). Hence an over-reliance on legal frameworks misses important elements of the Story.

Unlike legalistic approaches, ecosystem or bio-psychosocial approaches to behavior change posits that systems, inherently inter-disciplinary, need to change – not just people – and that positive motivators (i.e., rewards) also have a role to play in fortifying behavioral accountability (16).

The science of safeguarding in sport can learn from the social science shift in anti-doping. While there is no formal central body or agency in safeguarding that is equivalent to WADA, it is encouraging to see that decision-makers in athlete safeguarding often talk across diverse disciplines: human rights, public health, medicine, social work, psychology, law, and ethics, among others (17). This suggests a leaning towards a systems approach. Of note, there is no definitive evidence to suggest that a single, centralized, global body is needed. It is similarly unclear that this would be the preferred approach, especially considering that human relationships – complex and heavily influenced by context – are at the heart of abuse.

Centering Athletes’ Voices in Anti-Doping

For some in the anti-doping fight, 1989 was an important year (21). As the Berlin Wall fell, athletes around the world began to realize that border crossing would begin to increase in international sport – constituting a threat to those who wanted sport to be clean and free of doping. Athletes spearheaded the move to include not only in-competition testing but also out-of-competition testing to attack what some felt would be a globalization of doping philosophies and behaviors (4). The concept of border-crossing is a threat in safeguarding as well, as sport actors who have abused athletes may simply change federations, sports, or countries to evade repercussions and continue abusing. That athletes’ voices, concerns, priorities, and perspectives furthered this development in the anti-doping fight is instructive.

How Successful Is the Global Anti-Doping Movement in Curbing Doping?

The short answer is: ‘we do not know.’ It remains illusionary to determine the true prevalence of doping in sport, which presents an obstacle for both scientists and policymakers in assessing the success of anti-doping measures. The same can be said of abuse prevalence (32).

The global prevalence of doping in sport based on positive tests has remained at <1 – 2% for years now (34). The global prevalence of doping in various sport settings based on sports science literature ranges from 14% to 39% (or from 1% to 70% in questionnaire studies). Heterogeneous research methods and study populations explain this variation (7).

A critical aspect of successful deterrence is the capacity of current technologies to accurately detect doping. Studies have shown that many athletes do not perceive current testing programs as a continuous threat deterring those determined to cheat from doing so (23). This is partly because testing technology seems to remain a step behind the active development of new doping substances. As a result, education has emerged as a promising prevention strategy (34).

History Is the Best Teacher, but It May Have the Worst Students

All forms of abuse, including psychological, physical, and sexual harassment and/or abuse, neglect, hazing, and bullying, are violations of athletes’ basic human rights (6, 22). As such, anti-doping and athlete safeguarding are both exercises in health and human rights protection (31).

Today, abuse in sport is probably is where doping was at the end of the 1990s. However, there is a remarkable difference: the momentum created by athletes and athlete organizations who have spoken out against abuse over the last few years is unprecedented and shows no signs of abating (20). This creates a unique chance to right this wrong by placing athletes’ voices front and center and to listen to those immediately impacted.

Considering lessons from anti-doping, only an athlete-centered, systems-based approach carried by a multidisciplinary coalition of scientists and sport stakeholders has any prospect of ‘success.’ Neither doping nor abuse can be solved within the framework of one discipline (1, 14). We need multi-sector and truly globally balanced collaboration that integrates the complex multi-layered system of Sport.

Current abuse detection systems often place the onus on athletes to report harmful incidents (27, 33). This process can cause athletes even more harm and trauma (30) and may thus deter athletes who have experienced or witnessed abuse. The accountability for effective protection has to be shared, placed on more robust shoulders than those of athletes alone, and go beyond improved reporting Systems.

Charting a Path Forward Using Experiential Wisdom and Translational Research

From what we know today, an over-reliance on deterrence and punishment paradigms in anti-doping does not necessarily work. Prevention through education may be helping the ‘fight’, and positive reinforcement of good behavior in rewards-based systems has been shown to help other fields outside sport achieve positive culture change (15, 38). Positive psychological approaches to harm prevention shift the focus from risk factors to protective factors. Further, in hyper-competitive environments where ‘carrots’ (i.e., rewards, positive consequences) may mean more to sports persons than ‘sticks’ (i.e., punishments, negative consequences), reinforcement approaches may compel the lasting behavior change sport so desperately needs if the scourge of abuse is to be routed (16).


From the foregoing, five challenges and responses in the ‘fight’ against doping that have implications for athlete safeguarding stand out (see Table 1).

Behavior change is a long and demanding process for individuals and organizations (2). Centering athletes’ voices and lived experiences in practical research approaches while integrating multi-sector stakeholders can help ensure that methods and findings are fit-for-purpose and inform effective, sustainable athlete safeguarding practices, programs, and policies. If sport is to maintain its power to positively transform individual lives and serve humanity (13), updated approaches to global athlete safeguarding are needed, those that, among other things, are bolstered by the wisdom of history.

Conflict of Interest

The authors have no conflicts of interest.


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Yetsa A. Tuakli-Wosornu, M.D., M.P.H.
Assistant Clinical Professor,
Department of Chronic Disease Epidemiology
Yale School of Public Health
60 College Street,
New Haven, CT, 0651