WMA Declaration on Principles of Health Care in Sports Medicine

Adopted by the 34^th World Medical Association General Assembly, Lisbon, Portugal, September/October 1981,
revised by the 39^th World Medical Association General Assembly, Madrid, Spain, October 1987,
by the 45^th World Medical Association General Assembly, Budapest, Hungary, October 1993,
by the 51^st World Medical Association General Assembly, Tel Aviv, Israel, October 1999,
reaffirmed by the 185^th WMA Council Session, Evian-les-Bains, France, May 2010,
and revised by the 72^nd WMA General Assembly (online), London, United Kingdom, October 2021

PREAMBLE

Sports medicine physicians are physicians concerned with the prevention and treatment of injuries and disorders that are related to participation in sports. In some countries, sports medicine physicians are recognized as medical specialists. They are trained to address issues associated with nutrition, sports psychology and substance misuse, and may also counsel athletes on injury prevention.

Considering the involvement of physicians in sports medicine, the World Medical Association (WMA) recommends ethical guidelines for sports medicine physicians, recognizing the special circumstances in which their medical care and health guidance is given.

Anabolic Agents and Performance Enhancing Drugs and Methods

The use of anabolic agents, performance enhancing drugs, pain killers and performance enhancing methods by athletes is contrary to the rules and ethical principles of athletic competition as set forth by most sports governing bodies. Performance enhancing drugs and methods have been associated with adverse health effects.

The sports medicine physician should be aware that methods, drugs or interventions which artificially modify blood constituents, biochemistry, genome sequence, gene expression or hormone levels and do not benefit patients, violate the basic principles of the WMA’s Declaration of Geneva, which states: “the health and wellbeing of my patient will be my first consideration.”

The WMA believes that the use of anabolic agents and performance enhancing drugs and methods is a threat to the health of athletes and is in conflict with the principles of medical ethics. The physician must oppose and refuse to administer or condone any means or method which is not in accordance with medical ethics, or which might be harmful to the athlete using it. The physician must also inform athletes of potential health risks.

Examples of these drugs and methods include, but are not limited to:

• The use of drugs or other substances whatever their nature and route of administration, including central-nervous-system stimulants or depressants and procedures which artificially modify reflexes, alter a sense of well-being and/or general mental outlook.
• Procedures or therapeutics to mask pain or other protective symptoms if used to enable the athlete to take part in events or training activities when clinical signs make his or her participation inadvisable. This includes allowing participation in athletic activity when doing so would be dangerous to the athlete.
• Procedures or therapeutics used to mask the presence of other performance enhancing drugs or to induce rapid water or weight loss.
• Measures aimed at an unnatural improvement in or maintenance of endurance or oxygen carrying capacity during competition. This includes the manipulation of blood and/or blood components defined as the administration or reintroduction of blood or red blood cell products of any origin into the circulatory system, artificially enhancing the uptake, transport, or delivery of oxygen using chemicals such as erythropoietin, or other forms of intravascular manipulation to artificially increase red blood cell mass, unless medically indicated for the treatment of a documented disease or medical condition. Blood doping also exposes the athlete to unwarranted and potentially serious health risks.
• Use of anabolic agents including “designer steroids”, which are substances that are undetectable through the use of standard testing methods.
• Use of anabolic steroid precursors, including dietary supplements, that claim to provide “safe” steroid equivalents, but that metabolize in the body into anabolic steroids.
• Use of non-approved substances which have no current approval by any governmental regulatory health authority for human therapeutic use, for example, drugs under pre-clinical or clinical development, discontinued drugs, designer drugs or substances approved only for veterinary use.
• Use of peptide hormones, growth factors and related substances to increase red blood cell count, blood oxygenation or oxygen-carrying capacity.
• Use of hormone and metabolic modulators, which are substances to modify hormone activity by blocking the action or increasing the activity of a hormone.

Of special concern is the use of anabolic agents and steroid precursors in adolescents. Young users are considered particularly susceptible to potentially serious health problems during this physically and emotionally vulnerable period when their own hormonal cycles are changing. In females, anabolic agents have been associated with a number of adverse effects, some of which appear to be permanent even when drug use is stopped. Physicians should strongly discourage using these products.

World Athletics Gender Rules for Classifying Female Athletes

World Athletics 2018 Eligibility Regulations for Female Classification^[1] imposes an upper hormonal limit for athletes wishing to compete in the female category in certain disciplines of international athletics competitions.

The WMA opposes World Athletics’ rules^[2] requiring female athletes with differences in sex development to take drugs to reduce and maintain their natural level of blood testosterone in order to compete. The mere existence of a condition caused by a difference in sex development, in a person who has not expressed a desire to change that condition, does not constitute a medical indication for treatment. Medical treatment solely to alter athletic performance is unethical.

RECOMMENDATIONS

1. Sports medicine physicians have an obligation and duty to respect and comply with the ethical standards of the medical profession.
2. The sports medicine physician who cares for athletes has an ethical responsibility to recognize the special physical and mental demands placed upon athletes by their participation in athletic activities. The physician’s duty is to preserve the athlete’s mental and physical health and not solely to increase athletic performance.
3. When the sports participant is a professional athlete and derives livelihood from that activity, the physician should understand the occupational health aspects involved.
4. The sports physician should give his or her objective opinion about the athlete’s state of fitness clearly and precisely, leaving no doubt as to his or her conclusions.
5. In all sporting events, it is the physician’s duty to decide whether the athlete is medically fit to compete in an event. This decision cannot be delegated to other non-physician professionals.
6. In order to carry out his or her ethical obligations, the sports medicine physician’s authority must be fully recognized and upheld, particularly when it concerns the health and safety of the athlete. Concern for the athlete’s health and safety must override the interests of any third party.
7. The sports medicine physician is obligated to uphold the ethical principles of the medical profession. This includes the right to privacy and respect for the confidential nature of the patient-physician relationship. These principles and obligations should be supported by an agreement between the sports medicine physician and the athletic organization involved.
8. The sports medicine physician must oppose and refuse to administer any substance or condone any means or treatment method which is not in accordance with medical ethics and/or which might be harmful to the athlete using it. The physician must also inform athletes of potential health risks.
9. The sports medicine physician should be invited to participate in the design and modification of a sport’s rules and regulations in order to protect the health and safety of athletes.
10. The sports medicine physician, with patient consent, should work cooperatively with the patient’s personal physician, and keep him or her fully informed of the patient’s current condition.
11. All physicians should recognize that the desire to enhance performance, appearance, and/or well-being is not limited to elite athletes. Amateur and recreational athletes, as well as adolescents, are also at risk of and subject to sociocultural pressures to misuse anabolic agents and performance enhancing drugs and methods. A harm-reduction approach with discussions focused on risks, harm minimization, prevention strategies, and health promotion is recommended.

[1] Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”

[2] Specifically, Rule 2.3 of Competition Rule 3.6, “Eligibility Regulations for the Female Classification.”