Performance-enhancing substances in young athletes — formative SAQs

SAQ 1 — The boy who gained nine kilograms (10 marks)

Stem: A fifteen-year-old boy presents with a sore shoulder. Alone in the consultation, he discloses that he has gained nine kilograms of lean mass over a term and has been injecting testosterone and an oral steroid bought online for four months. On examination he has severe cystic acne over his back and shoulders, gynaecomastia, and small testes for his pubertal stage. [6] [1]

a) Name the most likely class of substance and explain why the aromatisation of excess androgen is of specific concern in this adolescent. (2 marks) [4] [6]

b) List the physical stigmata that support the diagnosis and the baseline investigations you would arrange to quantify the harm. (3 marks) [6]

c) Explain why the cessation of androgens must be slow and supported, and what psychiatric risk an abrupt withdrawal carries. (3 marks) [4] [6]

d) Outline the five steps of the counselling pathway and the prevention evidence you would cite to the family. (2 marks) [5] [6]

SAQ 2 — The competitive runner and the contaminated supplement (10 marks)

Stem: A sixteen-year-old national-level runner asks whether she can keep taking her over-the-counter pre-workout supplement. She has an important championship approaching and has heard that another athlete in her squad tested positive for a stimulant traced to a supplement. [9] [1]

a) State the principle of strict liability and explain why the labelled supplement does not protect the athlete. (2 marks) [9]

b) Explain what is meant by inadvertent doping from supplement contamination and how common it is. (3 marks) [9]

c) Contrast the permitted ergogenic aids, such as creatine and caffeine, with the prohibited androgens in terms of evidence, harm, and doping-test risk. (3 marks) [1]

d) Give the specific supplement-counselling advice you would offer this competitive athlete before her championship. (2 marks) [9] [1]

Model answer — SAQ 1

a) The most likely class is the anabolic-androgenic steroids, taken at supraphysiological dose. A fraction of the excess androgen is aromatised to oestrogen, which in the still-growing adolescent accelerates the fusion of the epiphyseal growth plates and can reduce final adult height, an irreversible harm that is the specific paediatric cost of use. The same oestrogen excess produces the gynaecomastia. [4] [6]

b) The physical stigmata are the rapid lean-mass gain, the severe nodulocystic acne over the back and shoulders, the striae, the gynaecomastia, the testicular atrophy with small testes for the pubertal stage, and the accelerated male-pattern balding. The baseline investigations to quantify the harm are a full blood count, a lipid profile, a liver panel including transaminases, a renal panel and fasting glucose, a blood pressure, and an electrocardiogram, with a morning testosterone, luteinising hormone, and follicle-stimulating hormone to confirm the gonadal suppression and a bone age when premature fusion is suspected. A validated adolescent depression screen is mandatory. [6]

c) Cessation must be slow and supported because the excess androgen has suppressed the hypothalamic-pituitary-gonadal axis, and the endogenous testosterone is low. An abrupt withdrawal exposes the suppressed axis and produces a genuine hypogonadal withdrawal that can include depressive symptoms and suicidal ideation. The slow, supported taper, with explicit suicide-risk screening, a safety plan, and close follow-up, is the safeguard. [4] [6]

d) The five steps are to assess the substance, dose, route, duration, and harm and the goals the athlete is trying to reach; to educate honestly on the cardiovascular, growth, gonadal, hepatic, and psychiatric harms; to plan a slow, supported cessation with a mental-health safety net; to replace the use with a clean, evidence-based nutrition, training, and permitted-ergogenic plan; and to prevent relapse through structured prevention and engagement of the coach, the family, and the sporting environment. The prevention evidence to cite is the Goldberg ATLAS trial, which showed that a multidimensional, team-centred intervention reduced the intent to use and the actual use of anabolic steroids among adolescent athletes. [5] [6]

Model answer — SAQ 2

a) The principle of strict liability holds that the athlete is responsible for any prohibited substance found in their sample, regardless of how it got there or whether they intended to dope. The labelled supplement does not protect the athlete, because a substantial minority of over-the-counter products contain undeclared prohibited substances, and under strict liability the athlete bears the consequence of the positive test. [9]

b) Inadvertent doping from supplement contamination occurs when a product sold as a protein, pre-workout, or fat-burner contains an undeclared prohibited substance, often a stimulant, an androgen, or a metabolic modulator, that the athlete ingests unknowingly. The Kozhuharov review and related work document this as a real and recurrent source of unintentional doping, and it is the commonest cause of an inadvertent positive test in the competitive athlete who has not deliberately doped. [9]

c) The permitted ergogenic aids, creatine monohydrate for repeated high-intensity work and caffeine for endurance and focus, have moderate and consistent evidence for specific tasks and carry comparatively low harm when dosed sensibly and sourced cleanly, and they are not prohibited. The prohibited androgens deliver potent muscle and strength gains but only at illicit and high cost, with cardiovascular, hepatic, growth, and psychiatric harms and an established dependence risk, and they are prohibited at all times, so their use carries a doping sanction on top of the health risk. [1]

d) The competitive athlete is advised to use only third-party-tested supplements from reputable suppliers, to avoid proprietary blends and products making extreme performance or fat-loss claims, and to understand that the label is no guarantee of what the product contains. She should know that she alone is responsible for any substance found in her sample, and she should register any supplement with her anti-doping organisation's supplement-risk programme where one exists. [9] [1]