In this analysis, we used the number of athletes in each event as the denominator. To assess if being granted a TUE affects the chance of winning medals, the probability of winning a medal with a TUE versus that of winning a medal without a TUE was calculated for each event. The categorisation was based on exercise physiology and information provided by experts in sport organisations. We also subcategorised some sports into endurance (aerobic capacity primary factor for success) and non-endurance with the intent to see if there was an association with B2A TUEs. We recorded the number of ACs with TUEs by sport (with specific disciplines for some sports) across all Games. We stratified by gender for each Games, each substance class and each resource category (as defined earlier). An AC was defined as one athlete competing in one event. We provided a descriptive analysis that includes the number and percentage of athlete competitions (ACs) with TUEs. 19 The cut-offs were a priori: US$400 billion. Second, the countries were grouped according to their annual gross domestic product (GDP) in 2017 as a proxy for wealth, using data available from the United Nations. The cut-off for each category was decided a priori as 250 athletes, representing the sum of all athletes sent to the five Games. 18 Countries sending larger teams generally invest more resources in sport. First, they were grouped based on the number of athletes sent to the Games, because the Olympic team size has been shown to be the best single predictor of Olympic medals. To account for this potential confounding, the countries that athletes competed for (Sport Nationality in the IOC data) were classified into one of three categories based on country resources. 17 18 Since they are also more likely to have easier access to quality medical care than those from less resourced countries, they are more likely to be diagnosed with a valid medical condition and granted a TUE. Therefore, our objectives were to describe the prevalence of TUEs at the five Games between 20 and to assess if athletes who had been granted a TUE were more or less likely to win a medal compared with athletes without a TUE.Ĭountries differentiated according to resourcesĪthletes from countries with more resources are generally expected to produce better performance due to higher quality and more effective training, coaches, facilities and so on. 14 Although the number of athletes with TUEs was low, theoretically it was possible that every athlete with a TUE could have won a medal. 13 WADA previously reported that during the 2016 Summer and 2018 Winter Olympic Games (Games), with 11 3 competing athletes, respectively,~1.2% had valid TUEs in each Games. 10–12 In a survey of Danish athletes in 2013, there was a perception that those with TUEs had an unfair advantage. There have been occasional comments in the media that elite sport was rife with athletes with TUEs, and suspicion of cheating was cast on these athletes. 9 All TUE applications are evaluated by a panel of independent physicians, known as a TUE Committee. 7 The process is regulated and well-defined in the World Anti-Doping Code 8 and the International Standard for Therapeutic Use Exemptions (ISTUE) a TUE may be granted only if all the critical ISTUE criteria are met. 6 The concept of allowing athletes with legitimate medical conditions to compete, now known as Therapeutic Use Exemptions (TUEs), remains widely accepted by athletes and sports authorities. 1 4Īs the List grew and included common therapeutic agents, for example, glucocorticoids and insulin, it became clear to sport federations, the IOC and physicians that there was a need for medical exemptions to ensure that athletes with medical conditions would not be unfairly excluded. 4 5 The World Anti-Doping Agency (WADA) inherited the responsibility of publishing the List in 2004. 3 4 In 1967, the International Olympic Committee (IOC) created a ‘Prohibited List’ that consisted of stimulants and narcotics. 1 2 In 1928, the International Amateur Athletics Federation became the first federation to prohibit specific substances (stimulants). The desire for fair and clean competition, without the use of performance-enhancing substances, has been an integral element of sports.
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