Performance-enhancing substances in young athletes — branching viva

Candidate brief

You are the adolescent-medicine registrar in the clinic. You have eight minutes to answer the examiner's questions on the young athlete below. The viva branches through the diagnostic framework, the pathophysiology and the harm, the management, and then to a second scenario on inadvertent doping. Be prepared to justify each answer with the underlying mechanism and the relevant evidence. [1] [6]

Opening scenario

A fifteen-year-old boy presents with a sore shoulder. Seen alone and asked directly, 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 the last four months. He has severe cystic acne over his back and shoulders, gynaecomastia, and small testes for his pubertal stage. [6] [1]

Branch 1 — Framework and diagnosis. What framework governs performance-enhancing substance use in the young athlete, and what is the principle of strict liability? How do you make this diagnosis, and why is the confidential history the diagnostic test? [6]

Branch 2 — Pathophysiology and harm. Describe the mechanism of the anabolic-androgenic steroids and the harm they do to the still-growing adolescent. Why is the aromatisation to oestrogen of specific concern, and what cardiovascular, gonadal, hepatic, and psychiatric harms must you name? [4] [6]

Branch 3 — Management. Outline the counselling-first management. Why must the cessation be slow and supported, and why must the response never be punitive? What is the safe replacement you offer, and what does the ATLAS evidence show? [5] [6]

Pivot scenario — The contaminated supplement

The examiner now introduces a sixteen-year-old competitive runner who takes an over-the-counter pre-workout supplement and who has heard of a squad-mate who tested positive for a stimulant traced to a supplement. [9]

Branch 4 — Strict liability and inadvertent doping. What is inadvertent doping from supplement contamination, and how common is it? Why does the labelled supplement not protect the athlete under strict liability? [9]

Branch 5 — Permitted ergogenic aids and counselling. How do the permitted ergogenic aids, creatine and caffeine, differ from the prohibited androgens in evidence and harm? What specific supplement-counselling advice do you give the competitive athlete? [1] [9]

Examiner's marking key

Strong answers will:

• State the WADA prohibited list and the principle of strict liability, and name the confidential non-judgemental history as the diagnostic test [6]
• Explain the androgen-receptor mechanism, the gonadal-axis suppression, and the aromatisation that fuses growth plates early [4]
• Name the cardiovascular, hepatic, growth, gonadal, and psychiatric harms, including the dependence and the suicidal withdrawal [4] [6]
• Outline the counselling-first management with a slow supported cessation and cite the ATLAS prevention evidence [5]
• Explain inadvertent doping from supplement contamination and counsel third-party-tested supplements [9]

Weak answers will:

• Reach for blood tests before the confidential history, or respond punitively and breach the alliance [6]
• Miss the irreversible paediatric harm of premature growth-plate fusion [4]
• Recommend abrupt cessation without the mental-health safety net [4]
• Treat supplements as inherently safe and omit the strict-liability and contamination counselling [9]