This post was written by Tavin Fonseka (see LinkedIn page) with supervision by Dr. Chih Wei Teng.
Women’s 1500m heats London, 2012. CC: Flickr by Tom Page
Imagine a world where injuries that once ended careers became nothing more than mere setbacks. Athletes will heal faster, stronger, and with a greater resiliency previously thought impossible.
Cell and gene therapies (CGTs)—once reserved for critical medical cases—are now transforming elite sports, enabling athletes to repair and regenerate muscles, tendons and cartilage at levels superior to traditional treatments. However, these cutting-edge therapies do not only apply to just recovery; they can unlock a new horizon of human potential.
This results in a complex debate on what is fair and ethical in sports. Is this a new form of doping? Some treatments, particularly those involving growth factors or gene modifications, walk a fine line with their potential to enhance strength or endurance. While these therapies are seen to be rehabilitative, the question remains: Are these treatments pushing the boundaries of what is possible, or a gateway to the unnatural demise of fair competition?
Fair competition
The concept of “fair competition” in competitive sports athletics is increasingly complex, particularly as advancements in nutrition and technology challenge traditional notions of what constitutes a level playing field. Fair competition ideally ensures that all athletes have equal opportunities, but the current competitive climate demonstrates that this ideal is far from reality.
Consider mechanical doping, where athletes use technological enhancements, such as motors embedded in bicycles or innovative prosthetics. Another notable case is the use of highly engineered running shoes that athletes like Eliud Kipchoge wore during his historic sub-two-hour marathon, further blurring the lines of fair competition. These shoes utilized innovative materials and designs that can dramatically enhance performance, leading to debates about whether these shoes should be allowed in competition.
Alongside mechanical innovations, nutritional advancements are critical in how athletes prepare and perform. Tailored diets and cutting-edge supplements can optimize performance and recovery, offering advantages that were unavailable to past generations of athletes. For example, recovery drinks rich in electrolytes and proteins have become standard, enabling athletes to train harder and recover faster, thus raising the bar for what was previously considered “normal” performance.
Sports nutritionists now employ precise macronutrient timing strategies, allowing athletes to maximize their energy stores and minimize fatigue during competition. This accessibility to sophisticated nutritional strategies can create disparities between athletes who have access to expert advice and resources, and those who don’t.
While these advancements can lead to extraordinary athletic achievements, they complicate the concept of fair competition by creating uneven playing fields based on access. The essence of fair competition lies in balancing the celebration of human potential with the need for equity, ensuring that while athletes reach new heights, the competition remains just and equitable for all.
Gene doping in athletics
Gene doping is attractive to some athletes because it is difficult to detect. Since the recognition of gene doping for performance enhancement, the anti-doping community and scientists from different disciplines have focused their efforts on developing robust methods for gene doping detection.
With the evolving nature of gene therapies over the last decade, it has been increasingly difficult to detect the overexpression of key genes that lead to enhancement over recovery or capture the limited window of opportunity where the misuse of gene therapy can be accurately detected.
Figure 1 highlights some of the key genes that are likely candidates for genetic doping, where more comprehensive PCR and gene expression testing are required. Furthermore, blood or urine samples are insufficient in some cases, and more invasive tests, such as muscle biopsies, are needed. All these variables make it very difficult to detect and enforce gene doping regulations in sports.
Figure 1: Potential gene doping candidate genes associated with sports performance. (Source: Gene Doping in Sport – Perspectives and Risks)
WADA and stem cells
Established in 1999, the World Anti-Doping Agency (WADA) is the international body responsible for monitoring and regulating doping in elite sports. WADA regulates the use of cell therapies in sports under the principle of prohibiting methods or substances that enhance performance artificially or pose a risk to athlete health.
As stem cell therapy treatments are increasingly explored for their potential to repair injuries and enhance recovery, WADA is cautious about their application due to concerns over performance enhancements.
The agency classifies stem cell therapies under its Prohibited List if they involve substances or techniques that artificially enhance athletic performance. Stem cells derived from the athlete’s own body, used to treat injuries, are generally allowed if they don’t involve prohibited substances or methods, such as growth factors or genetic manipulation. However, treatments that lead to increased oxygen delivery, muscle growth, or other enhancements may result in sanctions. WADA’s position underscores its commitment to distinguishing between legitimate medical interventions and therapies that result in an unfair competitive advantage while promoting athlete health and safety within a regulated framework.
The line between doping and medical enhancement is often drawn based on the intent, method and outcome of the intervention. Medical treatments are permitted when their primary purpose is to restore health or treat legitimate medical conditions without giving athletes an unfair advantage.
Doping, on the other hand, involves the use of substances or methods that artificially enhance performance beyond natural limits, undermining fair competition. WADA draws this line by focusing on three key criteria: whether the intervention enhances performance unnaturally, poses health risks to the athlete, or violates the spirit of sport.
Looking at WADA’s current protocol for regulating cell therapies, one apparent problem is that most of the time only blood and urine samples are taken. As discussed earlier, muscle biopsies are required for gene doping aimed at enhancing muscle performance. Gene editing or insertion, specifically in muscle tissue, would be most evident here.
Research has shown that generic blood tests aren’t enough, and PCR and localized gene expression tests are required. However, the current protocol established by WADA doesn’t enforce these kinds of tests, which leaves an incentive for athletes to use cell therapies as a form of doping mimicked as “rehabilitation.”
A recommendation for WADA would be to conduct these tests along with routine blood/urine tests on a six-month basis. If done less frequently, the chance of detecting specific candidate genes decreases (see Figure 1 above). Tests would also have to be done on a sport-by-sport basis and, ideally, a registry of gene levels across all athletes would be collected to establish natural levels of gene expression and elevated levels. In the sport of cycling, without a less invasive approach, athletes could have biopsies taken from their calf and quadriceps. Over time, a registry of gene expression data can be established, which would then form a baseline of natural levels of gene expression. The rationale is that if an athlete reports back with higher levels of IGF-1, for example, it could be an indicator of genetic doping. Thus, a further investigation can be done.
Ultimately, while most athletes use cell therapies as a means of recovery, they can have long-term enhancing effects. The balance lies in preserving the integrity of sport while allowing athletes access to medical care and ensuring fair and natural competition. However, with advancements made to equipment and nutrition, could elite athletic performances even be considered natural?
Another consideration that needs to be addressed by WADA and other sporting bodies is how we punish athletes who do intentionally dope. In the case of illegal supplements like steroids, the effects would wear out after a couple of months. However, gene and cell therapies have a more prolonged, if not permanent, enhancement on one’s body. Would they need to be banned permanently? Or would athletes need to undergo treatment that would “reverse” these effects? As it is still an emerging technology, it is hard to say. However, it is clear that WADA’s approach to cell therapies and gene doping needs to be reconsidered.
This blog was produced by the CCRM Australia Clarity Unit, a multi-disciplinary think tank with a market research and reporting mission to accumulate thought leadership and analysis to facilitate the commercialization and diffusion of regenerative medicine into the health care sector. For more information or to learn how CCRM Australia Clarity can benefit your organization, please visit the website.
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