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We want healthy athletes and fair competition
  1. Yannis P Pitsiladis1,2,
  2. Fabio Pigozzi1,3,
  3. Michael Geistlinger1,4,
  4. José Kawazoe Lazzoli1,5,
  5. Maher Zahar1,6,
  6. Norbert Bachl1,7,
  7. Pedro Manonelles Marqueta1,8,
  8. William O Roberts1,9,
  9. Klaus-Michael Braumann1,10,
  10. Eduardo H De Rose1,
  11. Demitri Constantinou1,11,
  12. Anca Ionescu1,12,
  13. Christian Schneider1,13,
  14. Patrick Shu-Hang Yung1,14,
  15. Xavier Bigard1,15
  16. International Federation of Sports Medicine (FIMS)
  1. 1 International Federation of Sports Medicine, Lausanne, Switzerland
  2. 2 Department of Sport, Physical Education and Health, Hong Kong Baptist University, Kowloon, Hong Kong, Hong Kong SAR
  3. 3 Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
  4. 4 Department of International and European Law and Fundaments of Law, University of Salzburg, Salzburg, Austria
  5. 5 Biomedical Institute, Fluminense Federal University Medical School, Niterói, Brazil
  6. 6 Medical and Informatical Research and Education, Tunis, Tunisia
  7. 7 Institute of Sports Science, University of Vienna, Vienna, Austria
  8. 8 International Chair of Sports Medicine, Faculty of Medicine, Catholic University of Murcia, Campus de los Jeronimos, Murcia, Spain
  9. 9 Department of Family Medicine and Community Health, University of Minnesota, St Paul, Minnesota, USA
  10. 10 Department of Sports and Exercise Medicine, University of Hamburg, Hamburg, Germany
  11. 11 Centre for Exercise Science and Sports Medicine, University of Witwatersrand, Johannesburg, South Africa
  12. 12 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
  13. 13 Orthopädiezentrum Theresie, Munich, Germany
  14. 14 The Chinese University of Hong Kong Department of Orthopaedics and Traumatology, Hong Kong, Hong Kong
  15. 15 Union Cycliste Internationale, Aigle, Switzerland
  1. Correspondence to Professor Yannis P Pitsiladis, Department of Sport, Physical Education and Health, Hong Kong Baptist University, Kowloon, Hong Kong, Hong Kong SAR; ypitsiladis{at}

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The Enhanced Games

The Enhanced Games1 is a planned international multisport event masterminded by Aron D’Souza, Australian businessman, where athletes will not be subject to any form of testing by the World Anti-Doping Agency (WADA) for prohibited list of substances and methods. Initially planned to be held in Australia in 2024, after the Paris 2024 Olympics, the event is now destined to take place in 2025. Reactions from the sporting world have been extremely negative, highlighting the dangers of encouraging performance-enhancing drugs (box 1).

Box 1

Reactions from the sporting world highlighting the dangers of encouraging performance-enhancing drug

‘There’s only one message and that is if anybody is moronic enough to feel that they want to take part in that, and they are from the traditional, philosophical end of our sport, they'll get banned and they'll get banned for a long time.’12

‘Joining with WADA, other governments and the International Olympic Committee to express deep concerns over both the planned ‘Enhanced Games’ without antidoping requirements and the Russian organised ‘Friendship Games’ alternative to the Olympics’13

‘The idea of the Enhanced Games does not merit any comment. If you want to destroy any concept of fair play and fair competition in sport, this would be a good way to do it.’14

Members of the Executive Committee (ExCo) of the World Anti-Doping Agency (WADA) also affirmed their opposition to the so-called ‘Enhanced Games’, an event that would encourage the use of performance-enhancing drugs by athletes. The ExCo was united in condemning the ‘Enhanced Games’ as a dangerous and irresponsible concept. The health and well-being of athletes is WADA’s number-one priority. Clearly, this event would jeopardise both by promoting the use of potentially harmful substances and methods. As we have seen throughout history, performance-enhancing drugs have taken a terrible physical and mental toll on many athletes. Some have died. The ExCo stressed WADA’s position on this subject, warning athletes and support personnel, who wish to participate in clean sport, that if they were to take part, they would risk committing Anti-Doping Rule Violations under the Code. To be clear, WADA will encourage anti-doping organisations worldwide to test involved athletes before, during and after this event, in order to protect the integrity of legitimate sport.’15

Lord Coe, President of World Athletics12; Dr. Rahul Gupta, Director of the White House Office of National Drug Control Policy13; Statement from the International Olympic Committee (IOC)14; Statement from the WADA.15

Notably, some countries, such as Austria, France and Italy, have criminalised the use of a World Anti-Doping Code (WADC) Prohibited Substance2 while many more countries have also enacted sports-specific legislation that criminalises other Anti-Doping Rule Violations beyond the use of a WADC Prohibited Substance including (1) the possession of WADC Prohibited Substances or Methods; (2) the supply or distribution of WADC Prohibited Substances or Methods (trafficking); (3) the administration or prescription of WADC Prohibited Substances or Methods to athletes and (4) failing to cooperate with antidoping investigations being conducted by an International or National Anti-Doping Organization or other public authority.2

The International Federation of Sports Medicine position

Despite much opposition, the Enhanced Games in some forms are likely to happen given the financial backing.3 The International Federation of Sports Medicine (FIMS), an international organisation comprising national sports medicine associations that span all five continents, with an executive committee that includes representative members from IOC, WADA, Association of Summer Olympic International Federations and Association of International Olympic Winter Sports Federations, and whose mission is to assist athletes in achieving optimal performance by high-quality medical care and training,4 is adamantly opposed to the Enhanced Games.

The President of the Enhanced Games holds the opinion that ‘Drug testing is about fairness, not safety.’ He states as follows: ‘At the Olympics, athletes are drug tested after each competition. Clearly, the goal of the Olympics’ drug testing regime is to ensure fairness through the threat of punishment for those who use enhancements. There is little concern for safety, as the Olympics have no mandated health-testing programme. Olympians, 44% of whom have used enhancements in the past year, are able to compete regardless of any undiscovered health risks. This is why athletes competing in the Enhanced Games will receive free medical screening prior to competition, which will ensure that they are healthy and able to compete. The screening will involve an echocardiogram, blood tests and genomic sequencing, in order to build up a full picture of the athlete’s health, and allow athletes to make an informed decision about whether they are safe to compete. The Enhanced Games aim to be the safest sporting event in the world. At the Enhanced Games, we prioritise athlete safety. In partnership with top scientists and clinicians, we are developing a full-system medical precompetition screening protocol—to protect athletes competing in the Enhanced Games.’ 5

FIMS strongly distances itself from this kind of interpretation of competitive sport. In citing the difference between fairness and safety, the president of the Enhanced Games seems to move the discussion onto a philosophical level. The priority of FIMS must be to safeguard the three cardinal principles that form the basis of medical care of athletes without exception: scientific analysis, study of the physical condition of the individual and protection of health.6 The claim that antidoping tests do not protect the safety of elite athletes has no scientific basis and therefore, this claim can vehemently be dismissed. Notably, for a substance or method to be added to the WADA Prohibited List, it must meet at least two of three criteria of Article 4.3 for Including Substances and Methods on the Prohibited List,7 that includes an actual or potential health risk to athletes (in addition to having the potential to enhance or enhances sport performance and violates the spirit of sport). Even if there is a reduced health concern to elite athletes participating in the Enhanced Games due to the declared medical controls-although this remains to be determined. Our concern as FIMS also focuses on the health hazards of drug use in young aspiring athletes, especially those who will never make it into the Enhanced Games. The grave concern of FIMS is that young individuals will be exploited in the quest for fame and fortune and the allure of the Enhanced Games.

Medical screening insufficient to guarantee the safety of ‘enhanced’ athletes

The procedures and protocols under development by the proponents of the Enhanced Games are reported to safeguard athlete health while upholding the principle of personal choice in the use of enhancements (personal communication with the President of the Enhanced Games). It is their intention to conduct numerous evaluations of athletes participating in the Enhanced Games to inform a multitiered, risk-based approach to informed consent, athlete’s eligibility to compete and health insurer coverage. In scenarios where athletes do not meet the specified health criteria for participation, athletes (it would appear), will have the option to appeal the decision or seek continued involvement. This process under development is expected to involve an established system of external arbitration allowing an impartial third party to review the case and consider any appeals or arguments put forth by the athlete regarding their health status and eligibility. The Enhanced Games also intend to apply a similar system of external arbitration to athletes wishing to contest any sporting and/or financial sanctions that may be imposed in the event of alleged use of prohibited enhancements—what enhancements will be permitted and prohibited remain to be declared. The Enhanced Games policy under development will consider all relevant factors in determining whether an athlete can be held responsible and what penalties should be imposed. Considerations will include the athlete’s intent, fault, negligence or knowledge of use, as well as a realistic assessment of sporting advantage gained.

Testing for fairness and health

FIMS welcomes medical screening capable of discovering possible health risks for competitors. Indeed, antidoping is not just to guarantee fairness. The fundamental rationale of the WADC is that ‘antidoping programmes seek to protect the health of Athletes and to provide the opportunity for athletes to pursue human excellence without the Use of Prohibited Substances and Prohibited Methods.’ 3 Furthermore, the statement above by the President of the Enhanced Games5 disregards the current distribution of competencies in Olympic sports. The medical screening of athletes to ensure that they are healthy and fit to compete is organised by the Olympic International Federations and not by the IOC itself. Each federation administers their own sport and is responsible for the health of their athletes when competing internationally, including at the Olympic Games. This typically entails them overseeing, or obliging, their members to be responsible for the medical screening of athletes to minimise the risk to their health. As a major tenet of antidoping is the health of athletes, antidoping is an essential part of the all-encompassing medical care for healthy athletes. An athlete, who participates in doping, above all else endangers their own health. FIMS, therefore, holds that medical screening as such is not sufficient to guarantee the safety of athletes. For example, many of the side effects of banned substances will only be observed after several years of use and will not be detected by a single blood test. There are also many examples where screening is ineffective in detecting the long-term side effects of banned substances, such as psychiatric disorders induced by anabolic-androgenic steroids,8 the effects of growth hormone on reproductive function, the acceptable level of left ventricular hypertrophy or the risk of hepatocellular carcinoma. (eg,9). Clearly, the type of medical assessment suggested in the context of Enhanced Games will not be sufficient to detect the side effects of many banned substances.

Access to resources

Another consideration relates to access to financial and medical resources. Of concern to FIMS is how aspiring athletes, attracted to the offerings of the Enhanced Games but without significant financial resources, and athletes from developing countries, will access such specialist medical care and ‘protect’ their health. It is well publicised that enhancements are being prescribed under medical supervision to interested celebrities, influencers and the very rich in exclusive clinics, where a single 1-hour consultation can cost a few thousand dollars. A further unfortunate effect of the Enhanced Games is a likely further widening of the gap between developing and wealthier countries in sporting performance.

Anti-doping must evolve

Despite what one may think about the Enhanced Games, its inevitability could ironically help detect those who dope by better understanding the methods used to dope. Currently, due to the secrecy of the drug culture in sport, nobody knows what the dopers are up to until it is too late. As a result, preventative measures are not as effective as they could be and the exact adverse health implications for athletes are yet to be determined. There is also the reputational damage to sport to consider. Sports fans do not know what events are clean, how much doping is going on or how efficient International Federations, the IOC, WADA and other antidoping organisations are at detecting those who dope. And, of course, any detection and punishment is often after the fact.10 Clean athletes are cheated out of a place on the podium and fans are left in the dark—wondering, cynical or just losing interest. It remains to be determined if the Enhanced Games can bring doping into a light where it can be properly studied. This may involve an uncomfortable evolution of antidoping science so ethical research could be conducted during doping to allow us to understand the life cycle of different substances and/or methods and their effects on elite performance, the body and health. FIMS and antidoping organisations armed with this information could then come up with smarter more directed ways to detect drug use in sport and better inform athletes regarding potential adverse health effects of drug use. With this rigorously researched and peer-reviewed knowledge, antidoping organisations could shorten the periodisation window thus making masking of drug use more difficult and determine the best combination of detection processes to use to make testing more effective.

It would appear that athletes participating in the Enhanced Games must participate in longitudinal studies in order to compete for the riches being offered, then FIMS and antidoping organisations could gather precise data for the first time from a large cohort of athletes who have admitted to doping to determine the long-term effects of various types of drug use. This information could be used to demonstrate the true health consequences of drug use or to dispel myths and inform decisions about the prohibited list. Ironically, the inevitable negative health impact of performance-enhancing drugs could act to discourage athletes from participating in the Enhanced Games and the increased knowledge on doping practices and the development of new antidoping tests could also strengthen the trust of athletes in drug free Olympic sport. However, all these possibilities and options cannot overrule the commitment of all sports and medical people involved to comply with the WADA. FIMS must insist that the Enhanced Games respect the ethical principles of sport medicine. Like never before in the history of modern day sport, there is an urgent need to protect the ideals of the Olympics and Olympism. FIMS remains thoroughly dedicated to the Olympic values and committed to the Olympic Movement Medical Code.11

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  • Collaborators International Federation of Sports Medicine (FIMS): The International Federation of Sports Medicine (Fédération Internationale de Médecine du Sport or FIMS) is an international organisation comprising national sports medicine associations that span all five continents, with an Executive that includes representative members from IOC, WADA, Association of Summer Olympic International Federations (ASOIF) and Association of International Olympic Winter Sports Federations (AIOWF), and fundamental purpose to assist athletes in achieving optimal performance by high-quality medical care and training (

  • Contributors YPP wrote the first draft of the manuscript, and all authors critically revised subsequent versions until all authors could approve the final manuscript. YPP is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests YPP, FP and MZ are members of the IOC Medical and Scientific Commission. All authors are members of the Executive Committee of the International Federation of Sports Medicine (FIMS)

  • Provenance and peer review Not commissioned; externally peer reviewed.