Why it’s better we don’t discuss anti-doping. And yet, I’m doing it again.

Great piece by Eric Vandenabeele of Fitness.be on why the wording anti-doping and doping in relation to a fitness context is not appropriate. It is a health and not a cheating issue. Eric argues that we need to adopt performance and image enhancing drug (PIED) terminology and focus on health policy, not anti-doping policy.

Read the fill article here: Why it’s better we don’t discuss anti-doping. And yet, I’m doing it again.

Researching the Use of Unlicensed Weight Loss Drugs in Women: Breaking Assumptions

Measuring tape, pills and scales

By Jennifer Germain, Centre for Public Health, Liverpool John Moores University

Just over two years ago I began a PhD which aims to explore the use of unlicensed weight loss (UWL) drugs amongst females. Whilst I have always had a personal interest, and had researched areas around eating behaviour, body image and eating disorders, my background and knowledge of weight loss drugs and other drug use was at that point very limited. Perhaps in part due to this, I was not originally aware of the complicated and nuanced motivations for why people used UWL drugs. In hindsight, I realise that I started this research with quite a naïve and simplistic approach, which I feel had been shaped by my own experiences as a female living in an image conscious society. From a very young age, I have like most been inundated with images depicting ever-changing body trends and ideals; ranging from the voluptuous curves of Pamela Anderson, androgynous shape of Kate Moss to the current trends of the Kim Kardashian bum, thigh gap and abs crack. Being a public health researcher in the area of human enhancement of course does not make me impermeable to the feelings of inadequacy created in a society, which has such strong beauty and body ideals. However, where I needed to be wary was in the danger of allowing my own thoughts and feelings influence how and what I thought about those who are using UWL drugs. Now, further into the PhD process, although I’ll admit I am still relatively new to the world of drugs research, I have realised that the assumptions I held about those who are using weight loss drugs, many of which I didn’t even realise I had at the beginning of this process, are ultimately untrue.

Reflecting on my research process there were three assumptions that influenced my views on UWL drug use. First of all, my PhD focuses specifically on the use of UWL drugs in women as my initial assumption was that the vast majority of UWL drugs users would be female;

Of course women are the ones taking weight loss drugs, all women want to be thin.”

I also wanted to move this area of research away from focusing on male dominated bodybuilding communities and the use of fat burner drugs such as 2,4 dinitrophenol (DNP). In order to capture information relating to the use of UWL drugs in women I conducted an online forum analysis. The analysis was aimed at specifically identifying discussions relating to those drugs. In particular I was looking for threads and posts centred on the UWL drugs DNP, Sibutramine and Rimonabant. Searches were carried out on online search engines for the name of each drug plus the word forum and the top 30 websites from each search was accessed. In order to specifically identify female forum users, (1) I used online analytical tools to identify which forums had the highest proportion of female users, (2) looked for forums with specific sub-forums aimed at women, and (3) identified forums where it was possible to identify the gender of the forum posters. During this process it was apparent that a very large proportion of online discussions relating to UWL drugs came from men or at least took place on forums that were dominated by male users. In addition, I also carried out searches on video sharing websites such as YouTube, looking for females who were posting their experiences of using UWL drugs. What my searches here found that was whilst the larger share of advertisements promoting the purchasing of UWL drugs were aimed at women, the overwhelming majority of videos discussing the use of the drugs were made by men. Of course, there could be many different reasons for this, for example women may be more reluctant than men to share that they are using UWL drugs, but regardless of this, I realised that my assumption that women would be overwhelmingly more likely to use UWL drugs was incorrect.

bottle of diet pills with measuring tape

My second assumption was centred on the idea that women use extreme weight loss measures such as UWL drugs primarily due to social pressures;

The pressures women face to conform to an ideal body is the main reason why women use UWL drugs.”

The analysis I have carried out of online communities does provide some evidence of this nature with some women being deeply unhappy with their bodies, comparing themselves to others and being so desperate to lose weight that they are willing to try any means with UWL drugs usually the last resort. Quotes from the analysis such as “I feel like clawing my face off when I look at myself in mirror”, “I’ve just ordered more [weight loss pills] cos I’m that desperate” and “She looks awesome. Standing next to her sucks” illustrate this point. However, it was also apparent that there are many other reasons why women are using UWL drugs. For instance, women spoke of using these drugs whilst competing in fitness or bodybuilding competitions, “I am planning to do my first bodybuilding competition and I’m looking for some advice regarding supplements”, to increase energy, “I don’t credit them for burning fat but they do have a kick”, or because they had seen a plateau in their weight loss, “The only reason I am taking them is because I have reached a plateau in my weight loss and need a little bit of a boost”. Finally, many women spoke of using UWL drugs to maintain their weight and simply saw them as just another part of their overall weight loss strategy: “Diet pills should be regarded as supplements. You should still exercise and diet alongside them”. It became abundantly clear that the motivations and reasons for why women are using UWL drugs are far more complicated than simply because of the society we live in.

My final assumption focused on the idea that women taking UWL drugs are not aware of the harms and risks of doing so;

“The drugs are being taken out of desperation, women just haven’t considered how potentially dangerous they might be.”

Again, this is an extremely simplistic view, if we think of other risky behaviours that people engage in then we know that even when people are aware of the dangers of, e.g. smoking, consuming too much alcohol or eating excessive amounts of fatty food, this doesn’t necessarily mean that they stop those behaviours. Quite often, the effect, so how good you feel engaging in that behaviour or taking that drug, completely outweighs the side effect. This was particularly apparent in my research as the majority of women who were taking UWL drugs were not doing so without any consideration of the risks or side effects, but instead are informed users making informed choices. They have done their ‘research’ and they are seeking out information about these drugs such as examining the risks and the side effects: “Have you women ever tried DNP? If so how did it feel?”,What are the dangers associated with taking these pills?” or they have already sought out this information and are making an informed choice “I just read up on DNP…it does not sound pleasant says the angel on my left shoulder, but losing half a pound a day would be tempting says the devil on my right shoulder”.

Using online forum analysis to identify UWL discussion has enabled me to achieve an overall picture of the main attitudes, feelings and experiences related to UWL drug use. Reflexive practices of challenging my assumptions and considering the impact of my own experiences, perceptions and feelings has altered my research positionality, enabling me to have a much more complex and complete understanding of the motivations and reasoning behind UWL drug use, which I lacked at the beginning of the PhD process. Furthermore, this stage has informed the design of the subsequent stages of my PhD with my attitude shifting from a wholly preventative viewpoint of how can we stop UWL drug use to instead considering how we can learn from online communities in how best to promote and share information about safe UWL drug use. I have moved away from seeing UWL drug use as a completely negative behaviour carried out by desperate individuals to an appreciation of the many different groups and motivations for its use.

If you would like to read more about weight-loss drugs in general I recommend reading:

  1. McVeigh, J., Germain, J., & van Hout, M.C. (2016). 2,4-Dinitrophenol, the inferno drug: a netnographic study of user experiences in the quest for leanness. Journal of Substance Use.
  2. Petroczi, A., Vela Ocampo, J.A., Shah, I., Jenkinson, C., New, R., James, R.A., Taylor, G., & Naughton, D.P. (2015). Russian roulette with unlicensed fat-burner drug 2,4-dinitrophenol (DNP): evidence from a multidisciplinary study of the internet, bodybuilding supplements and DNP users. Substance Abuse Treatment, Prevention and Policy.
  3. Hoxha, B., & Petroczi, A. (2015). Playing with fire? Factors influencing risk willingness with the unlicensed fat burner drug 2,4-Dinitrophenol (DNP) in young adults. Public Health.
  4. Yen, M., & and Burns Ewald, M. (2012). Toxicity of weight loss. Journal of Medical Toxicology.

Review: ‘Sports Criminology: A Critical Criminology of Sports and Games’

By Katinka van de Ven and Kyle J.D. Mulrooney

We have recently been invited to review the book ‘Sports Criminology: A Critical Criminology of Sports and Games’ by Prof. Nic Groombridge. To our knowledge, this is the first book to explore the connections between sport and crime from a critical perspective. More importantly, by giving this venture a name and tracing some of its boundaries, this book invites those interested in a critical criminology of sports to unite under the banner of sports criminology. The book covers a broad range of topics, from sports scandals to the possibility of crime prevention through sport. In the book numerous examples are explored from a range of countries and from sports such as American football, boxing, soccer, skating and sumo wrestling. Nic has an international reputation for his writing in sport and criminology and also reflects on his work and own sport experience throughout the book where relevant. He also draws influence from the sociology of sports and sports law, but concludes that sports criminology can add something new from a critical perspective. His enthusiasm for the subject is evident in his popular blog http://www.sportscriminology.blogspot.co.uk/ and tweets @criminology4u.

The book looks at sport and crime from two perspectives: (1) how criminology might add to sports studies beyond sociology and law, and (2) how the study of sport might add to criminology more generally. It argues for the need of a sports criminology and sets out some of its potential connections and contributions. The first chapter highlights the possibilities of sports criminology and also looks at areas involving sport and crime that might be regarded as less central to sports criminology such as crowd violence or crimes by or against sports stars. This chapter specifically details what might fall under the umbrella of sports criminology. Chapter two looks at a variety of sports and how issues of crime, social control and criminal justice affect them. Nic not only discusses the more obvious issues such as football violence or the use of performance and image enhancing drugs in athletics but also engages with the crime and corruption found in sports such as sumo wrestling and cricket. In chapter three Nic examines crimes and victimizations in relation to sports stars. For example, the ‘skating scandal’ in which Tonya Harding, together with her husband, arranged an off-rink assault on her ice skating rival Nancy Kerrigan. In chapter four and five a variety of criminological theories are introduced that either directly or indirectly have relevance to sport and vice versa. Chapter four covers the more mainstream criminology theories, such as classism and positivism, while chapter five assesses the contributions critical criminological theories, such as masculinity studies and cultural criminology. Chapter six looks at issues of sport and criminal justice covering topics such as crime control, politics, socially constructed realities, corruption and performance enhancing drugs. In chapter seven aspects of crime prevention and desistance are explored. For example, the use of organized football in prisons or the use of boxing as part of rehabilitation programs. In the final concluding chapter Nic reflects on the nature and extent of sports criminology and what a critical criminology of sport has to offer.

In our latest commentary Kyle and I note that ‘sport is in crisis’: from the involvement of organized crime, illegal betting and corrupt judges, to the socio-economic impact of the Olympics on host cities and the use of performance and image enhancing drugs by professional athletes. We need to confront these issues head on and it is clear that sports criminology has the ability to breathe new life into these debates and aid in the development of realistic ways to confront these issues. This is therefore a much needed book. However, after reading this book we were left with some questions. So, we approached the author for a ‘Q and A’ and he was more than willing to oblige.

Thank you Nic for doing this ‘Q and A’. We are just curious what inspired you to write this book?

“N: As the preface notes, I’ve always been a keen participant in and spectator of a wide variety of sports. I’ve always used sporting metaphors in my teaching to illustrate criminological issues but was always aware that sport can be very excluding, particularly around gender and sexuality. Moreover as a criminologist I tend to see crime and deviance in everything even the mundane and close to hand, even in the personal. Looking back over some of my work from nearly 20 years ago I see I was hinting at this work.

In the book you describe the kinds of sports issues would fall in the category ‘sports criminology’, and discuss the relations between sport, law and criminology, but do not provide a clear definition. How would you define ‘sports criminology’?

“N: I like to think I’ve had a hand in the genesis of both green and queer criminology and in surveillance studies. As I came late to academic life after 20 years in the Home office and have worked almost entirely at a teaching-centred University my research has been sporadic, self-directed, multi-disciplinary, even ill-disciplined. My experience has been that these sub-criminologies have gone off in directions that I could foresee but were more narrow and partisan than I hoped. I expect the same of sports criminology.

I try to define what it is and what it isn’t with this in mind but a) I’m reluctant to be pinned to the mat and b) am politically disinclined to attempt to direct or to gain followers. I do worry that it will just become rebadged football hooliganism studies or just concentrate on drugs in sport. Worse still would be to incorporate these into a correctionalist or administrative criminology.

Also my intention for green, queer and now sports criminology is not to create sub-fields but to enrich the wider subject.

Best-Boxing-Gloves1[1]

You note in the book that it has been more about boxing than intended. Although you do use quite a few boxing examples, we actually were impressed with the wide range of topics you cover in this book. However, the focus seems to be on crimes committed by or to the athletes including, but not limited to, the use of doping, cheating within games, corruption and the use of (legitimate) violence. While you address some wider sport-related criminological issues, such as illegal betting, this seems to receive little attention in your book. For example, state-sponsored doping programs (e.g., East-Germany and Russia) and the negative impacts of hosting mega sports events such as the Olympics (e.g., people forced out of their houses and economic loss) are only mentioned in passing. Is this something you consider an essential part of sports criminology and will you expand on this in any future editions?

You are right I see the emphasis on crime/deviance/harm within sport not so much crime by sports people though there may be links or overlaps. I only had limited space and felt that reference to the work of others might assist. So on doping I mention Paoli and Donati’s book (2014) ‘The Sports Doping Market: Understanding Supply and Demand, and the Challenges of their Control’ and Haberfeld and Sheehan’s book (eds.) ‘Match-Fixing in International Sports: Existing Processes, Law Enforcement, and Prevention Strategies on match fixing’, along with Brooks, Graham, Aleem, Azeem and Button, Mark’s work (2013) ‘Fraud, Corruption and Sport’ as sports criminology. However, I note these need a more critical edge.

I am aware too that I’ve missed much and hope that both what I say and fail to say will prompt further contributions before a second edition or collection.

I mention many sports and theories and examples over historic time. Also at the same time as I was writing even more about doping/corruption and the nexus of them came out. I had to leave those for tweeted commentary.

In chapter seven you discuss the use of sport to prevent crime, as an aid to rehabilitation or encourage desistance. While crime prevention is not the primary objective of sport and physical activity, it may have a positive influence in steering (young) people away from trouble. For example, in Project Oracle, a study on sport and youth violence in London, it is noted that sport can act as a distraction from violent and criminal activities and also as a way to bring young people into contact with opportunities for achieving wider goals such as furthering their education or finding work. On the other hand, sports-based intervention can also have a negative impact on youth violence. For instance, Project Oracle also found “that the programme had the unintended consequence of possible violence during practice sessions and matches. It was thought that opposing gangs would clash during the activity, illustrating how the presence of a specific social group (gangs) could alter intervention dynamics” (McMahon & Belur, 2013: 11). This is just one example of sport-based interventions and in your book you, for example, you also mention boxing interventions for offenders. In your experience, do you think that sport can play an important role in preventing crime and/or rehabilitating offenders? Are there any drawbacks?

As is clear I like sport. I also like art and culture. All should be available to all. When sport or art is expected to do more than be its own justification – i.e. to cure crime, health or save the economy or national mood – then problems can occur. I particularly know from my time in the Home Office that good projects frequently had to recast themselves to obtain grants. Project oracle exists to properly assess such claims as are made. But we all know and the Kids Company case shows that charisma and good anecdote can trump the evidence base. I try to be fair in that chapter but am largely agnostic. Indeed, I think that if motor projects or boxing ‘work’ it is not necessarily the car and driving or fighting but perhaps addressing issues of masculinity (often heterosexual but homosocial).

As is clear I’m squeamish about boxing but believe that if it is legal then it should be available in prison.

In addition, in the book you cover many different criminological topics related to sports. You mention that particular topics are quite extensively studied. Football hooliganism being one of them and as you note in your book people often even assume that when you mention sports criminology you mean the study of football hooligans (or the involvement of sports starts in crime). Outside of these more ‘obvious’ topics, what do you think is currently an emerging issue that has not received the attention it deserves? What topic would you like to see explored further?

Think I’ve covered much of that but clearly fallout from FIFA and Olympic revelations still ongoing should be followed up by those who see themselves as Corporate or State Crime oriented. Further just to note the sporting in crime and to tackle tricky issues like the conflicts and contradictions raised by claims by some that hunting animals for sport might help young men turn away from crime.

The act of hunting can shift, channel and redirect an integral need in all of us. We are wild to the core, and this wildness – disciplined, focused and integrated – can be a force for transformation and healing for us all.’ Caspar Walsh The Guardian 15 November 2015

Finally, we of course are wondering, what’s next? What are your plans for getting sports criminology on the map?

Obviously trying to sell the book but not necessarily the concept. I want to speak to non-sports people and to criminology more widely. As you note it is broad and shallow. Whilst I don’t want followers I would like some people with deeper knowledge to fill in the gaps.

I think I should mention that in addition to trying to cover every sport and every criminological theory including my own takes on queer, green and even gothic criminology I conclude with a provocation

In earlier chapters I’m sceptical of the sport-cures-crime claims I’m also sceptical of the sport-causes-crime claims too. In the conclusion however, I do suggest that consent is a crucial element in sport which is deeply underplayed but that work on it might help sports men think through some of the on and off field activities.

Thank you Nic for your time and for answering our questions.

To summarize, this book is a good start for those seeking to get familiar with the crime and deviance that may occur in sports and how the field of criminology can aid in explaining these phenomena. It does well in offering insights into a wide range of issues including but not limited to; surveillance, drug use, policing, social control, race, gender and sexuality within sport – which is of interest to many criminologists. However, it is here where sports criminology’s limitations are revealed. As the book tries to cover so many different aspects of and possible areas of exploration under the banner of sports criminology, it lacks a deeper and in-depth knowledge and understanding of the criminological issues related to sports. Nevertheless, as we have highlighted above, this is the first book of its kind and therefore such a broad scope is necessary when sketching the contours of the rapidly emerging sub-field that is sports criminology. The book does a fantastic job of introducing readers to sports criminology and offers a starting point for those interested in a critical criminology of sport.

On a more personal note, we thoroughly enjoyed reading this book. The writing style is very approachable and the content is engaging throughout. We would particularly recommend this book to anyone who wants to get familiar with sports criminology: not only criminologists and other academics interested in sports but also to individuals who want a new perspective on deviance, crime and social harm and its relation to sport.

9781447323150-188062-800x600

 

Blog 4: The Gateway Hypothesis of IPED Use: Current Knowledge and Future Research

 

By Ian Boardley

Introduction

The gateway hypothesis was originally developed in the context of recreation drugs, suggesting that use of softer drugs such as marijuana could act as a “gateway” to eventual use of harder drugs such as heroine. Subsequently, the gateway hypothesis has been applied in sport and exercise, suggesting that use of permitted forms of performance enhancement (e.g., nutritional supplements, some medicines, performance enhancing technologies) may facilitate athletes’ progression towards image and performance enhancing drugs (IPED) use. However, research testing this hypothesis is limited to cross-sectional research that has only tested the relationships between these different forms of enhancement at a single point in time. As such, the effects of permitted performance enhancement techniques on IPED use over time are yet to be tested. A more robust test of the gateway hypothesis would be to investigate whether use of permitted forms of performance enhancement are predictive of changes in known determinants of IPED use over time. Three likely indicators of IPED use are explicit attitudes towards IPED use (i.e., athletes’ positive evaluations of IPED use), automatic IPED preferences (i.e., a collection of self-relevant thoughts regarding IPED use instinctively retrieved from memory) and doping moral disengagement (six psychosocial mechanisms used to justify and rationalize IPED use). Importantly, mid-to-late adolescence is thought to represent a key transitional life stage during which athletes may be particularly susceptible to gateway influences on IPED use, as attitudes towards IPED use are likely to be still forming during this stage. Thus, given their life-stage university-student-athletes may be particularly susceptible to gateway influences on IPED use. As such, research testing the gateway hypothesis in university-student-athletes may be particularly informative. The aim of the current article is to provide a more detailed background to the gateway hypothesis, and also many of the conceptual arguments that underpin its main tenets. Once this is done, I will then describe a line of research that will commence this autumn designed to empirically test a number of these conceptual arguments.

Background Literature

The most widely used permitted form of performance enhancement is nutritional supplement use. Many athletes are known to use nutritional products such as protein supplements, caffeine and creatine monohydrate to supplement their diet in an attempt to facilitate the training effect. Importantly, researchers have demonstrated a positive link between nutritional supplementation and IPED use, therefore providing some support for the gateway hypothesis. For instance, qualitative work has shown IPED users believe once the performance benefits of nutritional supplementation plateau, athletes often look to IPEDs to facilitate further performance improvements (Boardley & Grix, 2014; Boardley et al., 2014, 2015). Similarly, quantitative research has demonstrated prevalence of IPED use is more than three times higher in athletes using nutritional supplements than it is in to athletes who do not, and that nutritional supplementation is a strong predictor of IPED use (Backhouse et al., 2013; Hildebrandt et al., 2012; Ntoumanis et al., 2014). As such, research evidence to date supports the possibility that nutritional supplementation could facilitate progression towards IPED use.

Another potential gateway to IPED use are off-label or over-the-counter medicines. Medicines are drugs or other preparations designed to prevent or treat illness or injury (e.g., painkillers, diuretics, decongestants; Mottram & Chester, 2015) that can be used to support athletic training and performance (Boardley et al., in press). Whilst some athletes take medicines to help cope with pre-existing conditions (e.g., asthma) or injury, there is strong evidence of inappropriate and excessive use of medicines in sport (e.g., Lazic et al., 2011; Tscholl et al., 2008a, 2008b). Although some medicines used by athletes may be permitted, the increased use of such substances may lead to a reliance on pharmaceuticals that could eventually lead to athletes experimenting with IPEDs (Donovan, 2009; Petróczi, 2013).

It has also been suggested that the use of performance enhancing technologies may also lead to IPED use. Performance enhancing technologies include equipment, clothing and oxygenation methods designed to facilitate performance and/or the training effect (Donovan, 2009), and the Incremental Model of Doping Behaviour (IMDB) suggests routine application of permitted practices such as these could lead to IPED use (Petróczi, 2013). Whilst not contravening the rules of sport, the ethics of applying such technologies has been questioned by some, especially when they enhance performance with no additional effort (Donovan, 2009; Miah, 2005). Thus, performance enhancing technology use may be another gateway influence of IPED use.

The IMDB also suggests mid-to-late adolescence may be of particular interest for researchers investigating the gateway hypothesis (Petróczi, 2013). More specifically, increased autonomy from parents and influence from peers mean this may be a period during which athletes are likely to further form and strengthen their attitudes towards IPEDs. One particular population that experiences a sudden increase in autonomy from parents and influence from peers during mid-to-late adolescence are university students. As such, university-student athletes may be a particularly interesting population to study in research investigating the gateway hypothesis.

Researchers often investigate key determinants of IPED use in lieu of reported use of IPEDs due to the difficulties involved in obtaining accurate data on IPED use (Morente-Sánchez & Zabala, 2013; Ntoumanis et al., 2014). One potential determinant of IPED use are explicit attitudes towards IPEDs, which represent positive evaluations of engagement in IPED use (Ntoumanis et al., 2014) and have been shown to be indicative of IPED use in athletes (Morente-Sánchez & Zabala, 2013). Further, a recent meta-analysis found positive attitudes towards IPEDs to be one of the strongest correlates of IPED use (Ntoumanis et al., 2014). Importantly, the IMDB suggests the doping mindset consists of both functional (i.e., whether IPED use is viewed as effective in enhancing performance) and moral (i.e., whether IPED use is viewed as morally right or wrong) attitudes, with IPED use being facilitated by increases in functional attitudes towards IPEDs.

The IMDB suggests to obtain a more complete picture of the mental processes governing IPED use, automatic doping preferences (i.e., assembled evaluations of self-relevant thoughts regarding IPEDs contextually retrieved from mental representations) should be investigated alongside explicit attitudes (Petróczi, 2013). Quite recently, researchers have started to investigate automatic doping preferences, and variants of the Implicit Attitude Test (IAT) have proved to be a promising approach to assessment (Brand, Heck, & Ziegler, 2014; Petróczi et al., 2010). Work using such approaches has found automatic doping preferences to be more positive in athletes who use IPEDs compared to non-users (Brand, Wolff, & Thieme, 2014; Petróczi et al., 2010). Importantly, it is generally assumed that IAT-based measures are less susceptible to socially desirable responses than explicit attitude measures. Thus, automatic doping preferences may constitute another useful indicator of IPED use for researchers looking to test the gateway hypothesis.

Moral Disengagement (MD) represents another key correlate of IPED use (Ntoumanis et al., 2014). MD is a collective term for a series of six psychosocial mechanisms that allow athletes to justify and rationalize IPED use (Bandura, 1991; Boardley & Grix, 2014). Importantly, quantitative (e.g., Hodge et al., 2013; Zelli et al., 2010) and qualitative (Boardley & Grix, 2014; Boardley et al., 2014, 2015) research has supported a positive link between MD and IPED use. With respect to the IMDB, tension between functional and moral attitudes to IPED use (i.e., IPED use is functional but against my moral beliefs) can lead to cognitive dissonance (i.e., uncomfortable feelings resulting from conflicting attitudes, beliefs or behaviours that motivate alteration in attitudes, beliefs or behaviours to reduce discomfort; Festinger, 1962). Thus, the incongruent functional and moral attitudes associated with the doping mindset may result in increased MD, as MD allows people to violate their moral standards without experiencing negative emotions (Bandura, 1991).

Despite permitted forms of performance enhancement being potential gateways to IPED use, the availability of performance enhancement alternatives is a situational factor that could also weaken positive attitudes towards IPEDs (Petróczi, 2013). Concordantly, effective anti-doping education programmes have been found to include presentation of alternatives to IPEDs (Backhouse et al., 2007). Further, exposure to information on functional foods as alternatives to IPEDs can have a desirable effect on beliefs regarding performance enhancement (James et al., 2010). Interestingly, if presented correctly, permitted forms of performance enhancement could act as a protective factor against – rather than a facilitator of – IPED use.

Upcoming Research

According to World Anti-Doping Agency (WADA) (2015), IPED use in sport is problematic because it (a) provides an unfair advantage over competitors, (b) potentially results in negative health consequences, and (c) contravenes the spirit of sport. The IMDB (Petróczi, 2013) and the gateway hypothesis of doping in sport (Backhouse et al., 2013) suggest IPED use evolves as part of routine application of permitted performance enhancement practices. However, researchers have not investigated the effects of nutritional supplementation and use of medicines and performance enhancing technologies on determinants of IPED use over time. As such, research is needed that tracks the influence of potential gateways to IPED use on key determinants of IPED use longitudinally. Also, research is needed to determine the effect of conflicting functional and moral attitudes on doping MD. Further, although permitted forms of performance enhancement have the potential to act as protective factors against IPED use, athletes often view them as precursors to it (Boardley & Grix, 2014; Boardley et al., 2014, 2015). Thus, there is a need for research that aids our understanding of how licit forms of performance enhancement can most effectively be presented as alternatives to – rather than precursors of – IPED use.

To investigate these issues, we have recently obtained funding from the WADA to fund a three-year research project with university-student-athletes that will utilise both qualitative and quantitative methodologies to further our understanding of the issues raised in this article. Further information on this project – including how people can potentially get involved – will be made available through the Human Enhancement Drug Network (HEDN) once the project commences in September 2016.

Further Reading

Boardley, I. D., & Grix, J. (2014). Doping in Bodybuilders: A Qualitative Investigation of Facilitative Psychosocial Processes. Qualitative Research in Sport, Exercise, & Health, 6, 422–439.

Boardley, I.D., Allen, N., Simmons, A., & Laws, H. (in press). Nutritional, Medicinal and Performance Enhancing Supplementation in Dance. Performance Enhancement & Health.

Boardley, I. D., Grix, J., & Dewar, A. (2014). Moral disengagement and associated processes in performance enhancing drug use: A national qualitative investigation. Journal of Sport Sciences, 32, 836–844.

Boardley, I. D., Grix, J., & Harkin, J. (2015). Doping in Team and Individual Sports: A Qualitative Investigation of Moral Disengagement and Associated Processes. Qualitative Research in Sport, Exercise, & Health, 7, 698–717.

Backhouse, S. H., Whitaker, L., & Petróczi, A. (2013). Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms. Scandinavian Journal of Medicine and Science in Sports, 23, 244–252.

Hildebrandt, T., Harty, S., & Langenbucher, J. W. (2012). Fitness Supplements as a gateway substance for anabolic androgenic steroid use. Psychology of Additive Behaviors, 26, 955–962.

Ntoumanis, N., Ng, J. Y. Y., Barkoukis, V., & Backhouse, S. (2014). Personal and situational predictors of doping use in physical activity settings: A meta-analysis. Sports Medicine, 44, 1603-1624.

Petróczi, A. (2013). The doping mindset—Part I: Implications of the Functional Use Theory on mental representations of doping. Performance Enhancement & Health, 2(4), 153-163.

Blog 3: Nutritional Supplements and Doping in Sports – A Controversial Issue

By Dr. Elena Atienza Macias

In the field of doping suppression, there is a tenuous division between nutritional supplements and drugs. In this regard, it is especially alarming that supplements may contain substances that are potentially dangerous to the health of the athletes, and contain components that are prohibited under anti-doping regulations either by themselves, as prohormones or as metabolic products. In fact, a large percentage of positive results in doping controls* are due to the presence in, or contamination of supplements with substances listed in the well-known “Prohibited Substances and Methods List“.

On the other hand, I should point out that it is not only high-level athletes who use this type of substance to compete more effectively: their use is widespread in all levels of society, such as bodybuilders who use protein supplements to increase muscle growth or women who take fat-burners to lose weight. In these cases, we often find people who do not practice a sport purely for “leisure” but rather, to achieve certain ideals of beauty through the design of their body shapes, practices specifically aimed at the cultivation of the body, in gyms, fitness rooms and the like. Not only are supplements being used more widely, they are highly available, and several studies have revealed that there is a lack of security and quality control.

In this blog post, I intend to set forth, briefly but rigorously, the mix of legal issues around the extended use of (incorrectly) so-called “food supplements”, trying to express in full the complex inventory of problems arising from the ad hoc regulation in the field of doping in sport. I will do this by specifically looking at the Spanish situation.

Nutritional supplements as doping substances?

Stating the problem

Nutritional supplements (also known as “dietary supplements” or “food supplements”) are defined legally in Spain — by the Royal Decree 1487/2009, of 26 September, on food supplements — as food products consisting of concentrated sources of nutrients and presented with the aim of complementing the intake of such nutrients in the normal diet. In light of this Royal Decree, there is a wide range of nutrients and other elements that may be present in food supplements including, among others, vitamins, minerals, amino acids, essential fatty acids, fibre, various plants and herbal extracts.

There is no doubt that an athlete must take special caution when consuming supplements, as they could contain substances that are banned in professional sport. It is, therefore, recommended that athletes evaluate the need for their consumption with the help of dietician or nutrition professional. If they are deemed necessary, athletes should avoid buying products labelled in foreign languages, purchased through third parties or over the Internet without knowing their origin and level of confidence, as this could increase chances of buying ‘contaminated’ supplements.

col_ukad_supplements_case4

Source: UK Anti-Doping (UKAD)

An issue which relates to this is that the vast majority of substances banned in sport are found in drugs coming to the athlete from clandestine markets. The “Council of Europe Convention on the counterfeiting of medical products and similar crimes involving threats to public health” (MEDICRIME Convention) applies. In this regard, the Council of Europe created the so-called MEDICRIME Convention in December 2010, which constitutes, for the first time, an international treaty in the field of criminal law on counterfeiting of medical products that pose a threat to public health. Spain is the second country that has ratified the Convention. MEDICRIME gives States a powerful tool to combat this issue: the introduction of common minimum standards on criminal law and litigation among all subscribers of the Treaty countries. It also provides contact points in national health systems, reference laboratories, the police and the Customs authorities to ensure the exchange of information and cross-border cooperation. So the ratification of this Convention and its entry into force is an important step in the pursuit of the illegal trafficking of medical products from the international point of view, including the substances and methods prohibited in sport.

Following this line, recently the Director of the mentioned “Spanish Agency for Health Protection in Sport” (popularly known in Spain as AEPSAD) —Enrique Gómez Bastida—, and the Director of the “Spanish Agency for Medicines and Health Products” (also known as AEMPS) —Belen Crespo Sanchez-Eznarriaga—, have signed a framework collaboration agreement—the Collaboration Agreement between the AEPSAD and the Spanish Agency for Medicines and Health Products, Madrid, Spain, May 26, 2015 —whose objective is to articulate lines of cooperation, collaboration, coordination and communication between the two agencies in the protection of athletes’ health through the prevention of and fight against doping in sport. In this sense the AEPSAD had detected that some violations of the anti-doping regulations were derived from, among others things, the proliferation of illegal drugs that contain substances whose consumption can pose a risk to the health of athletes, including substances banned in sport or the acquisition of drugs outside the channels legally established for their custody, preservation and dispensation.

Now, at this point I wonder whether nutritional supplements have the same control as drugs. The answer, as we might have expected, is no; if nutritional supplements were regulated as drugs they would not be in the legal limbo which they are in, and it would be irrelevant to talk about problems of control and regulation. In fact, food supplements do not count as medication and are not subject to the specific controls on the pharmaceutical industry; so they may be contamination with undeclared substances which are prohibited in sport. And in practice it turns out that a large percentage of positive results in doping controls** are due to the presence or contamination of food supplements with substances included in the list of substances and methods prohibited in sport.

The problem is accentuated because an athlete can be sanctioned because of a positive control due to a prohibited substance in a supplement. Thus, in connection with the sanctions regime and the fight against doping, the AEPSAD warns that the detection of the presence of a prohibited substance or its metabolites or markers in an athlete’s bodily specimen is classified as a very serious violation, punishable by a two-year suspension in accordance with article 22.1 of the Law 3/2013. In these cases, to claim lack of knowledge of their presence due to ignorance or a faulty label, is not a valid justification.

International and European Legislation

In the context of a zero-tolerance approach to doping, there was a major step forward on October 19, 2005, during the 33rd General Conference of UNESCO held in Paris, when the International Convention against Doping in Sport was approved. Once ratified by signatory countries, this permitted regulatory harmonization and the effective enforcement of the World Anti-Doping Code in the territory of the signatories. This Convention already highlighted this problem and although it pointed out that the Governments enjoy a certain degree of flexibility in terms of how they put the Convention into effect, whether by legislation, regulation, administrative policies or practices. However, the signatory States, including Spain which ratified the Convention on October 25, 2006, are required to adopt specific measures to:

“Encourage producers and distributors of nutritional supplements to set “best practice” in the labelling, marketing and distribution of products that might contain prohibited substances”.

In the European regulatory landscape, I could highlight the Regulation (EU) No. 1169 / 2011 of the European Parliament and the Council on food information to the consumer. Known as “Regulation IAC”, it entered into force December 12, 2011, being applicable from December 13, 2014, with the exception of the provisions relating to nutritional information, which shall apply from 13 December 2016. The regulation requires labelling of food supplements “in a clear and comprehensible manner” to help consumers who want to make their decisions about food and diet with greater knowledge of the facts. In addition, they “must indicate the country of origin or place of provenance of a food, given that the absence of such an indication may lead to misleading consumers as to the true country or place of origin of that product”.

Within the anti-doping agency of the United States (known as USADA), a law of great significance in this field was passed: the Designer Anabolic Steroid Control Act of December 2014, which is intended to prevent steroids being marketed as food supplements or distributed under a false labelling. The adoption of this law has been a crucial key in the protection of athletes at all levels and consumers from companies that sell designer steroids masquerading as supplements. As part of the USADA Mission for ‘clean’ (of doping) athletes, the Agency works to help athletes understand the risks associated with the use of food supplements.

The position of the Spanish Agency for Health Protection in Sport

The AEPSAD alerts athletes of the possible consequences, both for their health and in terms of possible sporting sanctions, of a lack of vigilance in the purchase and consumption of food supplements. Athletes must remain active in anti-doping in sport and should ensure that no prohibited substance enters their body, being held responsible when their presence is detected.

Among the mechanisms which they have devised, and are backed by the AEPSAD, the “absence of banned substances certification program” called Informed Sport is emphasized. The international scientific group LGC (which leads the program) has been working with the Agency in order to increase awareness of the risks associated with unintentional doping which can be derived from products contaminated with substances prohibited by WADA.

Informed_sport_logo_1

Source: Informed Sport

The AEPSAD proactively advises Spanish athletes and sports organizations on the problem of unintentional doping and refers to Informed Sport as the most effective and widely recognized way to minimize the risk. In addition to AEPSAD educational material in Spanish aimed at its stakeholders, LGC has presented its program to the leaders of the Spanish sports supplement industry, offering its advice in the area of quality assurance. As I mentioned before, this is a program of testing and certification of food supplements created by the British company LGC, endorsed and developed in conjunction with national anti-doping organizations (such as UKAD in the UK or NADA in Germany), which gives athletes access to safe purchasing of supplements.

The problem of contamination with nutritional supplements: the controversial Contador case

A high-profile case within this problematic is that of the famous Spanish cyclist Alberto Contador. This athlete was sanctioned with a two-year suspension, including the loss of the 2010 Tour de France—in which he tested positive for Clenbuterol—and all other victories achieved until January 25, 2011,the dies a quo established for that period, considering that the positive test of the athlete for Clenbuterol was more likely to have been caused by the ingestion of a contaminated (nutritional) supplement than by a blood transfusion or by ingestion of contaminated meat (the argument was put forward by the rider). The hypothesis of contaminated food supplements was considered by Court of Arbitration for Sport as the most likely cause, although I cannot ignore the fact that the court expressly admitted that it could not be certain that this was the case. From this point of view, the Contador case is considered as archetypal as regards the rule of objective responsibility in questions of sporting disciplinary action.

On February 6, 2012 the Court of Arbitration for Sport (CAS), headquartered in Lausanne, ruled on the case of doping that surrounded the Spanish cyclist Alberto Contador. He was sentenced to pay a fine of 2.485.000 Euros to the International Cycling Union (UCI), and to be banned for two years. The cyclist tested positive in both samples A and B in a doping test carried out in September 2010, during the Tour de France. Specifically, 50 pictograms of a substance banned by both the World Anti-Doping Agency (WADA) and the UCI, called Clenbuterol, were found in his body. This substance is a drug that is known to improve athletic performance. While initially, the Competition Committee acquitted the cyclist on the grounds of lack of fault or negligence—being unable to declare him liable for violation of an anti-doping standard, under Article 296 of the anti-doping rules of the UCI, which requires voluntary ingestion of prohibited substances—the CAS, however, resolved the case using the so-called “nutritional supplement theory”.

With this theory, the CAS is saying that, although it has not determined how the banned substance entered the athlete’s body, the most likely means was via a nutritional supplement, in such a way that if the athlete fails to demonstrate that they have been completely diligent, it is enough to condemn them under a rigorous application of the principle of objective responsibility. This case is paradigmatic in that the principle in dubio pro reo, characteristic of every branch of law, falls in favour of the principle of objective responsibility, reversing the burden of proof

Opposite the case of the cyclist Contador, we could highlight that of Australian Michael Rogers. Unlike the Spaniard, Rogers did successfully use the argument about ingestion of contaminated meat to be absolved of his positive test for Clenbuterol, according to a statement from the UCI. The Australian had tested positive in the laboratory in Tokyo in a control carried out on October 20, 2013. He won the Cup of Japan and was provisionally suspended by the UCI. However, the world time trial champion claimed as the cause, the eating of contaminated meat in China during his participation in the Tour of Beijing. The UCI, after consultation with the WADA, concurred with the alleged cause and acquitted him.

In any case, I cannot talk, in purity, of a true objective responsibility, but rather of a quasi-objective responsibility, because this does not automatically impose responsibility according to the mere result, but admits the possibility of reducing or even eliminating sanctions if the accused athlete manages to prove that there has been no fault or negligence on their part, or at least that there has not been significant blame, to which end they have to demonstrate how the prohibited substance has entered their body.

Conclusions and suggestions for further research

Following on from my Ph.D. thesis main conclusions, the following statements can be drawn: the introduction of a system based on the principle of strict liability becomes one of the most legally controversial aspects, if we consider the general system of Spanish Administrative Law, which has as its starting point the principle of guilt. This principle would be totally distorted and invalidated if the strict liability is accepted: indeed, the mere occurrence of the event (i.e. the existence of a prohibited substance in the athletes` body) is sufficient to trigger the presence of an offence. The author’s intentionality and will are totally neglected. As a consequence, —and taking into account that the strict liability is not completely excluded in our legal system— the reasons for accepting a doping system governed by the strict liability should be solid, in the light of the disadvantages and negative effects that the aforementioned principle can, in our judgment, determine.

The raison d’être of this kind of liability, supported by the majority of scholars’ positions, remains in the preventive nature that permeates the sport world: it has the aim to achieve “normalcy” in the development of sport competitions, and to obtain the least possible violation.

On the contrary, our position is strongly opposing this approach, and in the course of this study it has been proved through several arguments: a) our thesis argues that the fight against doping does not justify, in any case, the violation of rights and fundamental legal principles, as in this case the presumption of innocence, which is related here to the principle of culpability. In fact, the athlete` fault is presumed, and the burden of proof of his/her innocence is left upon him/her (probatio diabolica). Some classical criteria are completely neglected, such as the invincible error of prohibition that occurs in this case when the athlete, knowing that the action of doping is illegal, considers that his/her conduct does not infringe the law because of an error that he/she cannot avoid to commit, despite his/her diligence (e.g., the case of a mislabelling of a prohibited substance); b) we also state that the strict liability in this context must be excluded —and we advocate for the revision of this principle— as it can lead to truly unfair and disproportionate situations (e.g., the punishment of innocent athletes) and to cases in which there is no legal protection in the hands of the authority that is judging the athlete, and thus ultimately decides at its own discretion.

More information on Elena’s research and other work in this area can be found here:

Atienza Macías, E., «2015 WADA code comes into effect: significant changes in the Spanish legal arena», The International Sports Law Journal (ISLJ), Vol. 15, No.1, Asser Press — Springer, Berlin-Heidelberg, Germany, 2015, pp. 49-54.

Atienza Macías, E., «Doping and health protection: a review of the current situation in the Spanish legislation», The International Sports Law Journal (ISLJ), Vol. 14, Numbers 1-2, Asser Press — Springer, Berlin-Heidelberg, Germany, June 2014, pp. 138-142.

Gleaves, J. / Christiansen, A.V., «The Curious Cases of Clenbuterol», International Network of Humanistic Doping Research Newsletter, Editorial, June 2014, INHDR, Aarhus University — Department of Public Health, Aarhus, Denmark, 2014.

Schönfelder, M., «Nutritional Supplements – Creatine», Biomedical Side Effects of Doping, Sarikaya, H. / Peters, C. / Schulz, T. / Schönfelder, M. / Michna, H. (Eds.), Institute of Public Health Research, Technische Universität München, Munich, Germany, 2007, pp. 154-170.

WADA, Athletes must show caution due to contaminated meat, November 23, 2011.

* This information is based on facts and figures taken from the “Spanish Agency for Health Protection in Sport” (Agencia Española de Protección de la Salud en el Deporte or AEPSAD), available at: http://www.mecd.gob.es/aepsad/informed-sport.html. The Agency´s data extracted from “Informed-Sport”, which is a quality assurance program for sports nutrition products, suppliers to the sports nutrition industry, and supplement manufacturing facilities. The program certifies that all nutritional supplements and/or ingredients that bear the Informed-Sport logo have been tested for banned substances by the world class sports anti-doping laboratory, LGC. Athletes choosing to use supplements can use the search function above to find products that have been through this rigorous certification process. Information available at:  www.Informed-Sport.com.

 ** I would like to refer to the facts and figures taken from the presentation made by the Director of the Spanish Agency for Health Protection in Sport on the occasion of the course concerning new WADA Code, held in Santander at the Menéndez Pelayo International University. The Director of the Agency  assured that approximately 85% of all positive for doping in sport, given in Spain, are “accidental doping”; that is to say, athletes without intent to consume any medication for doping. See the data fields extracted from the presentation of AEPSAD Director, available at: http://www.uimp.es/gabinete-de-comunicacion/actualidad-uimp/andreas-krieger-el-dopaje-nos-muestra-la-cara-desconocida-del-deporte-de-elite.html.

Blog 2: A Typology of Human Enhancement Drugs (HEDs): The Case of Sexual Enhancers

By Rosa Koenraadt

Whether it’s a herb, powder, pill or cream, there is no shortage of advertisements promising quick and easy weight loss or muscle growth without diet or exercise. According to many of these ads you can lose 25 pounds in two weeks simply by taking slimming pills, or develop a six-pack by taking the right dietary supplements. And this is only the start; there are vitamins, minerals and herbs that are said to prevent you from getting the flu, hair growth drugs that supposedly restore your voluminous hair, and drugs that give you an amazing tan without having to rely on the sun. Whether much of this is true remains doubtful, but the fact is that human enhancement drugs (HEDs) are all around us. A wide selection of products to look young, to become slim or to feel fit are legally available in local pharmacies, drugstores and/or supermarkets. However, HEDs are not only available through the traditional supply chain but a wide assortment of lifestyle drugs and products are illegally offered as well via under-the-counter in shops, through online marketplaces and pharmacies, or from your local dealer on the street.

HEDs are defined as products being taken for reasons to improve the quality of life and/or to enhance human attributes or abilities. However, what kind of products, consumers and markets can we specifically identify? It is clear that human enhancement drugs are in high demand. Reasons why pills, products and creams are consumed on such a wide scale are diverse. Students who buy cognitive enhancers (e.g., Ritalin) online to improve study results belong to a different category of consumers than men who purchase sexual enhancers (e.g., Viagra) in the pharmacy with a doctor’s prescription. In order to gain a better understanding of the reasons they are consumed, to identify stages between healthy and problematic consumption, and to analyze the different legal, illegal and semi-legal HED markets, it is important to disentangle the variety of HEDs that are currently widely available. It is therefore valuable to adopt a typology of different types of legal, illegal and semi-legal HEDs, to understand the differences between markets, motives, quality, side effects and consumers.

As described in the previous HED blog there are six general types of HEDs: (1) muscle drugs (e.g., steroids); (2) weight-loss drugs (e.g., ephedrine); (3) image enhancers (e.g., skin-lightening products); (4) sexual enhancers (e.g., Viagra); (5) cognitive enhancers (e.g. Adderall); and (6) mood and social behavior enhancers (e.g., Diazepam). Here, I will explore sexual enhancers with particular attention to the variety of products available and the most avid consumers of these products. What follows is based in part on my current research on the trade in illicit lifestyle medicines in the Netherlands. For my research project I have conducted interviews with suppliers, traders and consumers of illicit medicines in the Netherlands and China, analyzed websites and court cases of suppliers and traders, and conducted a survey among 592 users that bought medicines online.

Medical and recreational consumers

Sexual enhancers (SEs) are drugs that are being taken in order to stimulate the erectile function and/or have the purpose as an aphrodisiac to improve arousal and sexual behavior. Some of the SEs, such as Viagra and Cialis, are used as a medical treatment for men with erectile dysfunction. In March 1998, the American Food and Drugs Administration first approved Viagra as a new medicine for the treatment of erectile dysfunction. Within one year of release the drug was available in 77 countries worldwide and one and a half years later, the medicine was being prescribed to 15.6 million men in the U.S. alone. In 2003, Cialis was approved and in 2007 Levitra followed with the active ingredients Tadalafil and Vardenafil respectively.

Although the initial purpose of these products was as a medicine for the prescribed treatment for erectile dysfunction, these substances became popular to a much wider audience. Therefore, with regards to consumption a distinction can be drawn between medical/clinical consumers on the one hand, and recreational consumers on the other. Medical consumers of SEs are diagnosed with an erectile dysfunction and have a medical/clinical reason for using SEs. Medical consumers are able to buy SEs in the pharmacy with a doctor’s prescription.

Recreational users however, do not have a clinical diagnosis for using SEs, but are taking the SEs for lifestyle purposes. For instance, recreational consumers may use SEs to prolong sex, to be able to perform sexually after a night out of drinking, out of sheer curiosity or for extra confidence while engaging in sexual activity. As one male respondent (53) claimed: “I use [SEs] for almost ten years already. Usually when I visit these [fetish] parties. When you are taking drugs like XTC, you can try to have sex but it will not work. A friend of mine gave me a Kamagra pill to try. Sometimes the combination feels heavy, but it is important not to take too much at the same time.” Another user stated (28): “I had a date with someone I met on a holiday. We met in a nice hotel and I thought well, let’s take some of this to enjoy the night even more.”

The boundaries between recreational and medical consumers may become blurred, as both medical and recreational consumers may use SEs for lifestyle purposes to some extent. However, we can draw a distinction between patients who – for whatever reason – could potentially purchase SEs with a doctor’s prescription and the recreational consumers who take the SEs for extra fun, curiosity or extra confidence on a first date, without the possibility to obtain the medication through the official pharmacy.

Licit and illicit SEs

The distinction between medical and recreational consumers is an important step that brings another division in the market. We have the regulated market where SEs are manufactured, distributed and sold through the regulated supply chain. This may include the natural food supplements in the supermarket or the medicines available through the (online) pharmacy. Alternatively, we can distinguish the illicit market where unregulated or unlicensed supplements and medicines are being sold. This may include the sale of counterfeit medicines or unlicensed generics. In between the two – and illustrative for HEDs – we can also identify a semi-legal market, or a market at the boundary between legality and illegality. This includes mainly adulterated food supplements with experimental chemical substances, for example herbs that claim to be fully natural but contain the active substance Sildenafil.

Generally speaking, recreational consumers are able to legally purchase products that do not require a doctor’s prescription such as licit natural food supplements and over-the-counter (OTC) SEs. As these products do not always have the desired effect, recreational users may move to purchase actual medicines in the illicit market. Medical consumers are able to purchase licit SEs both in the supermarket, drugstore and medicines with a doctor’s prescription. But this group of consumers may often for financial reasons, convenience or shame to visit a doctor, purchase SEs in the illicit market as well (see figure 1).

Nieuwe figuur Rosa.jpg

Figure 1: typology of licit and illicit consumption of sexual enhancers

Similar to the blurring boundaries between consumers, the differences between legal and illegal SEs is not always clear. However, it is important to acknowledge the overall distinction between products sold in the regulated supply chain, often through pharmacies, some online pharmacies, drugstores, or supermarkets and those products sold on unregulated or illicit markets, such as fake online pharmacies or vending sites, street dealers or under the counter in shops.

The balance between the licit and illicit market is difficult to estimate, as the scale of an illicit markets is inherently difficult to measure. Naturally, in illicit markets traders, vendors and users are trying to hide from enforcement agencies. While surveys and interviews may provide estimates as a first measure, they are often unreliable. For example, for the respondents it is often difficult to determine whether the product is legal or not. In 2014, an interesting study was conducted in an attempt to estimate the scale of the market through the use of sewage. As the SE Viagra contains the effective ingredient Sildenafil, the National Institute for Public Health and the Environment (RIVM) in the Netherlands compared the amount of Sildenafil in the sewage in four different cities in the Netherlands with the official sales of Viagra through pharmacies. In turns out that at least 60% of the measured Sildenafil in sewage cannot be traced back to the sale through official pharmacies.

A further distinction

The licit market for SEs may be divided among prescription drugs, over-the-counter products and herbal food supplements. For example, in the Netherlands SEs containing Sildenafil can only be purchased with a doctor’s prescription. However, ‘natural’ SEs may be purchased in the drugstore or pharmacy and do not require a doctor’s prescription. Importantly, regulations on which medicines need to be bought with a prescription differ from country to country and often change over-time.

Finally, an analysis conducted by the Dutch RIVM on seized SEs offers further distinction within the illicit market. Specifically, the RIVM identified four different groups.

  1. A first class consists of counterfeit medicines, such as the fake Viagra, Cialis or Levitra pills. Brand names are used, however the drugs are not originating from the claimed company or are mislabeled at a later stage. In the report of the RIVM these counterfeit SE’s accounted for 17% of the analyzed products.
  2. The largest proportion of illicit SE is illicit generics. These are pharmaceuticals legally produced in one country but not accepted in another. The best known example is Kamagra, originating in India. Based on the analyses from 2012, 69% of all analyzed SEs belonged to that group.
  3. The third group is the illicit food supplements, which are very much related to novel psychoactive substances (NPSs). The food supplements contain analogues (or: ‘designer drugs’), which are substances with the same pharmacological effect as the original substance (such as Sildenafil) but they may differ in side effects and potency. Often the full effects are even unknown. Besides, the packages usually claim a ‘natural food supplement’ on the label but in reality they contain active substances. One problem with this is that consumers may assume to take supplements while in fact they are using a pharmaceutical.
  4. A fourth group has been labeled illicit other. This group consists of SEs containing other chemical substances (such as illicit drugs or other medicines) or SEs in other forms. For example, instant coffee powder for men containing Sildenafil.

Another category that might be added to this typology is the unlicensed drugs which are the SEs that are manufactured outside the legitimate supply chain, without the use of an existing brand name.

Two examples of category (1) counterfeit SEs, and (4) ‘illicit other’ containing Sildenafil:

Afbeelding 1Afbeeldong 2

Photos taken by the author at Dutch customs, Amsterdam 2012

Conclusion

It is clear that, as with many human enhancement drugs, within the domain of SEs there is a great deal of overlap between the types of consumers, types of products and markets. For all the HEDs applies that there may be a distinction between recreational and medicinal consumers, or products containing legal or illegal substances, yet there are various grey zones with semi-legal substances or reasons for consumption that lie at the boundary of a medical and lifestyle need. Motives for consumption, popularity of products and the health risks may vary over time and culture as well. Nevertheless, in order to unravel the complexities of the HED markets, a good place to start is to discuss and elaborate on the different types of users, to distinguish between various reasons for HED consumption, and to identify different types of legal, semi-legal and illegal human enhancement drugs.

For any suggestions, comments and/or questions, please contact Rosa Koenraadt through email, Twitter or through the HED team.

More information on this topic can be found here:

  • Koenraadt, R.M. & de Haan, M. (forthcoming). De aankoop van geneesmiddelen via internet. Een onderzoek naar het koopgedrag, de motieven, risicoperceptie en informatiebehoefte van online kopers van geneesmiddelen. Utrecht: Willem Pompe Instituut voor Strafrechtswetenschappen.
  • Koenraadt, R.M. (2015). Cultural criminology and the Internet: Challenges for online criminological research. In: De Jong, F. (ed.), Overarching views of Crime and Deviancy; Rethinking the Legacy of the Utrecht School. The Hague: Eleven International Publishers, p. 547-564.
  • Koenraadt, R.M. (2014). Blauwe handel. Een criminologisch kwalitatief onderzoek naar illegale erectiemiddelen in Nederland. Tijdschrift voor Seksuologie, 39, 8-14.
  • Koenraadt, R.M. (2012). Blue pills on the black market. CIROC Newsletter, 10, 4-5.

The author would like to thank Katinka van de Ven and Kyle Mulrooney for their time and valuable comments.

Blog 1: HEDs, PIEDs and NPSs

Understanding the similarities and differences between human enhancement drugs (HEDs), performance and image enhancing drugs (PIEDs) and novel psychoactive substances (NPSs).

By Katinka van de Ven

Over the past several years, different types of drugs have entered the global drug scene. Where before traditional drugs such as cannabis and cocaine were the main go to for recreational drug users, there is now an emergence of ‘new’ drugs that have similar effects, called ‘novel psychoactive substances‘ (NPSs) or ‘legal highs’. NPSs are drugs which are designed to be similar chemically and/or pharmacologically to known controlled drugs (e.g., cocaine), are substances related to medicine, and are often sold (online) as ‘safer’ and ‘legal’ alternatives to traditional drugs. The growing demand for NPS and its rapid diffusion in countries around the world, is currently one of the main challenges needing to be addressed by drug policies. However, while countries across the globe are responding to this emerging NPS issue and are introducing laws to control this unregulated market, another rapidly rising illicit drug market has remained relatively ignored: the market for human enhancement drugs (HEDs). The only exception being in the context of sports doping, where drugs such as steroids, have been recognized as a threat to the health of athletes and the morality of sport for some time now.

Indeed, the emerging threat to public health posed by the use of HEDs has been largely ignored (e.g., cardiovascular disease, dependence, mood syndromes, skin infections), and little research and, therefore, a lack of knowledge, exists surrounding the prevalence of HED use, its effects and health harms, and its supply. Nevertheless, academics, practitioners, the news media and others have begun to pay attention to the sale and consumption of HEDs. However, the ways in which these sources conceptualize and operationalize HEDs differ widely: some consider HEDs as a part of NPSs, while others define them as ‘lifestyle drugs’ or performance and image enhancing drugs (PIEDs). In addition, it is not always clear to what type of substance are specifically being referred to when talking about HEDs (e.g., steroids, weight-loss drugs). Yet, in order to draw comparisons and to measure research variables it is essential to be clear about what we mean by HEDs and what types of HEDs we are talking about. The intention of this blog is to define HEDs and its subcategories, and to invite readers to add to this definition, or any of the drug profiles described on the HED website for that matter. This blog is a ‘living document’, meaning that it hopes to evolve and change over time as we work towards a greater understanding of HEDs.

HEDs are often used in an attempt to become faster, stronger and smarter, to look thinner, to increase happiness, to ‘reverse’ ageing, and various other reasons related to improving the quality of life and to enhance human attributes or abilities. Specifically, HEDs can be divided into six categories: (a) muscle drugs (MDs) (e.g., steroids), (b) weight-loss drugs (WDs) (e.g., ephedrine), (c) image enhancers (IE) (e.g., skin-lightening products), (d) sexual enhancers (SEs) (e.g., Viagra), (e) cognitive enhancers (CEs) (e.g. Adderall), and (f) mood and social behaviour enhancers (MBEs) (e.g., Diazepam). (a) Muscle drugs are used to enhance the structure and function of skeletal muscle. These substances are consumed for cosmetic reasons (e.g., increase muscle definition), medical reasons (e.g., to increase weight in AIDS patients), and to enhance physical performance (e.g., increase strength). Examples of muscle drugs are anabolic androgenic steroids (AAS), human growth hormone (HGH) and Erythropoietin (EPO). It should also be noted that some of these drugs do not necessarily (directly) ‘enhance muscle’. For example, EPO is used to stimulate the number of red bloods cells, which then leads to an increase in the oxygen carrying capacity of the blood and ultimately delivers more oxygen to the muscles. The extra oxygen significantly increases the muscles’ energy production and can therefore help to improve an individual’s performance output ability: meaning higher intensity for a longer duration. So, while EPO does not lead to a ‘growth in muscles’, it does have the potential to increase someone’s ‘muscle energy’, and for this reason is added to the ‘muscle drug’ category. Therefore, ‘muscle’ does not only refer to someone’s increase in muscle mass, but also in the ability to enhance speed, energy levels, strength, and/or other muscle-related qualities.

(b) Weight-loss drugs are substances used to enhance weight-loss. Most of these drugs work by reducing appetite and/or stimulating metabolism, leading to a reduction in body fat and overall body weight. Examples of weight-loss drugs are Clenbuterol, Ephedrine and 2,4-Dinitrophenol (DNP). (c) Image enhancers are used to enhance the appearance of the skin and hair. There are various products in this category but in principle it may be divided into three types: (1) drugs to tan or lighten the skin, (2) products to stimulate hair growth or prevent hair loss, and (3) drugs to prevent wrinkles or smoothen the skin. Examples of image enhancers include Finasteride (hair growth product), Melanotan I and II (skin darkening drugs), and Botulinum toxin products (skin enhancing product). (d) Sexual enhancers are drugs that enhance (normal/abnormal) erectile function and aphrodisiacs, which increase sexual arousal and desire. Examples of sexual enhancers are Sildenafil, Tadalafil and Yohimbe. (e) Cognitive enhancers, also known as ‘smart drugs’ or ‘brain doping’, are used to enhance cognitive functions including short-term memory, concentration, comprehension and alertness. Examples of cognitive enhancers are Methylphenidate, Modafinil and Piracetam. Finally, (f) mood and social behaviour enhancers are taken for the purpose of altering and/or improving one’s state of mind or feelings. There are different types of mood and social behaviour enhancers but in general they may be divided into three categories. First, drugs to suppress the effects of adrenaline and to calm the nerves. For example, consider an individual taking beta-blockers before his or her presentation to quell the physical sensation brought upon their ‘nervousness’. Second, drugs to suppress pain such as the use of painkillers (e.g., Oxycodone), for instance, by professional athletes so they can keep playing despite injuries. Finally, drugs to alter an individual’s mood, for example, someone using selective serotonin re-uptake inhibitors (SSRI) (anti-depressant) to increase energy levels and to improve positive feelings of well-being. However, the latter seems to be used more often for therapeutic reasons rather than for ‘enhancement’ (e.g., the use of SSRIs when someone is clinically depressed). Therefore, it may be questioned if this is a true form of enhancing (normal) abilities, or rather involves the use of drugs to return to a ‘healthy’ or ‘normal’ mental health.

In addition to their categorical differences, the HEDs listed above may be used for various enhancement purposes and are not necessarily used for one type of enhancement. Indeed, what makes these drugs so complex is that HEDs may be used by (1) different people and for different purposes, (2) the same people, at different times, for different purposes, and (3) the same people, at the same time, for multiple purposes. For instance, Melanotan II is used for its tanning effects but is sometimes also used for its sexual properties. Similarly, HGH is used for both its muscle enhancing effects as its weight-loss properties.

That said, one specific area of interest within the spectrum of HEDs are drugs that are more frequently associated with professional, amateur and recreational sport: the muscle enhancers, weight-loss drugs and image enhancing drugs. These three categories are commonly referred to as performance and image enhancing drugs (PIEDs). The use of the term PIEDs has evolved over the last couple of decades. Originally, the term ‘performance enhancing drugs’ (PEDs) was used to describe a wide variety of substances used by athletes in an effort to enhance their performance. The term ‘PEDs’ is still widely adopted and tends to refer to an elite sport context but has also been applied when there is no direct link to competitive sports. Yet, in general the word PEDs falls more in line with ‘doping’; a term that is specifically reserved for (elite) sport. In recent years, however, it has become clear that other groups, aside from athletes, are increasingly using these types of substances (muscle enhancers, weight-loss drugs and image enhancing drugs). The main goal of these ‘non-athlete’ using groups is aesthetic modification (e.g., lose weight, increase muscle mass) and to a lesser extent, athletic enhancement. As such, the term ‘performance and image enhancing drugs (PIEDs)’, and in some cases ‘image and performance enhancing drugs (IPEDs) or ‘appearance and performance enhancing drugs’ (APEDs), is considered more suitable when describing these substances.

While PIEDs may be associated with various types of users, in general they are largely associated with recreational trainers/athletes (e.g., recreational weight-trainers, power-lifters or bodybuilders). Notably, many consider the term ‘PIEDs’ as just another word for HEDs. However, as PIEDs are strongly associated with recreational, amateur and/or professional sport and tend to include substances that improve sporting performance (e.g., EPO) and/or physical appearance (e.g., steroids), it is, in our view, preferential to consider them simply as a subset of HEDs. Considering the way ‘performance’ is used here, referring to ‘athletic performance’ and not to other types of performance (e.g., enhancing sexual or cognitive performance), and that ‘image’ refers to bodily modification, we suggest the term PIED, IPEDs or APEDs be adopted when referring to a sport-specific context, whether this be recreational (e.g., fitness trainers), amateur (e.g., local soccer) or professional (e.g., Olympic track and field athletes), and to apply the term HEDs when referring to the general HED-using population (e.g., students who use Adderall, men who use testosterone to boost testosterone production).

Moreover, one could argue that cognitive enhancers should be included in the category PIEDs, as drugs such as Methylphenidate and Modafinil are on WADA’s Prohibited List and could potentially increase sport performance. However, the fact that a substance is on WADA’s Prohibited List says very little, as, for example, recreational drugs such as marijuana and cannabis are also on the list, yet these substances do not offer performance enhancing capabilities to athletes. Therefore, as I also argue in this blog, PIEDs are substances that more generally are used within a sport-specific context (recreational, amateur and/or processional). Although cognitive enhancers may be used in sport populations for ‘athletic-performance-enhancing reasons’ in general these substances are not taken for this reason and are predominantly used to enhance other functions in daily life (e.g., the use of Modafinil by pilots to boost alertness and manage fatigue), and, therefore, are not included in the overall PIED category.

We also need to consider: what separates HEDs from NPSs and traditional drugs? HEDs are used for different reasons (e.g., to enhance sport performance) than other illicit drugs and NPSs (e.g., to get ‘high’), and users of HEDs often do not necessarily perceive themselves as ‘drug users’. Specifically, HEDs are often used to enhance or to increase the value or perception of human attributes or abilities (e.g., muscle growth, skin darkening), and are not used to provide gratification or pleasure as a result of their ‘psychoactive properties’. Nonetheless, some overlap may be found between the three different drug markets. First of all, let’s look at the difference between NPSs and HEDs. Key features of NPSs are that they are: (1) not approved for human consumption and have unpredictable side-effects, (2) are often sold as something else such as plant chemicals and bath salts, (3) are relatively unknown to health care providers and other professionals, (4) are usually not mentioned in the scientific literature, (5) are easily available (in particular online), and (6) when they are a medical product, these substances are often not used according to medical guidelines (e.g., prescribed dosage). Therefore, NPSs and HEDs share many features such as the perceived ‘legal status’, their (online) availability, being promoted and sold online as legal alternatives, and in that there are certain HEDs created to ‘mimic’ the effects of traditional HEDs. For example, ‘designers steroids’ are created to mimic the effects of existing steroids and are made to evade detection (e.g., doping controls) and legal prohibition. Nonetheless, NPSs and HEDs are heterogeneous in terms of their chemical group, desired effects, type of users, consumption patterns, medical risks and psychopathological disturbances. Indeed, in general HEDs are not ‘new’, in many instances they have been approved for human consumption, are not usually used for their psychoactive effects, and in most countries are controlled for by drug, medicine or other laws.

Second, certain HEDs overlap with the traditional drug market in the sense that similar drugs are used, albeit for different reasons. For example, marijuana is used as a HED for its weight-losing properties (although there is no strong evidence to support this), while this substance likewise may be used as a traditional drug for relaxation purposes. Another example is cocaine, although predominately used as a recreational drug (e.g., produces feeling of euphoria and wellbeing), it is also sometimes used for its performance enhancement effects (e.g., increases alertness with low doses) or weight-loss purposes (e.g., appetite suppressant). Finally, an overlap may even be found between illicit drugs, NPSs and even HEDs. For example, nalbuphine (Nubain) and Gamma Hydroxybutyrate (GHB) cross all three groups. Taking a closer look at GHB: this ‘club drug’ is used as a recreational drug for its intoxicating, euphoria, and sedative effects, while at the same time it is used by bodybuilders and other weight-trainers for its anabolic effects due to protein synthesis. However, there is no strong scientific evidence to support that GHB works for these enhancement purposes. In addition, although GHB has been used as a recreational drug since the 1990s, this substances and its analogues gamma-butyrolactone (GBL) been classified in the literature as a NPS.

Figure 1 provides an overview of our discussion; the different types of HEDs, what are considered PIEDs, and how this connects to the traditional drug market and the illicit market of NPSs. Please feel free to leave remarks and provide feedback in order to optimize the definition of HEDs and the description of the six drug profiles.

HED model

Figure 1. An overview of the different types of HEDs, what PIEDs are, and how HEDs connects to the traditional drug market and the illicit market of NPSs.

I would like to thank Kyle J.D. Mulrooney, M.A., and Prof. Jim McVeigh for their time and for sharing their thoughts on the topic of HEDs.