i3

SUPPLEMENT

FIFA’s approach to doping in football

J Dvorak, T Graf-Baumann, M D’Hooghe, D Kirkendall, H Taennler, M Saugy
...............................................................................................................................
Br J Sports Med 2006;40(Suppl I):i3–i12. doi: 10.1136/bjsm.2006.027383

Background and objectives: FIFA’s anti-doping strategy relies on education and prevention. A worldwide
network of physicians guarantees doping control procedures that are straightforward and leave no place
for cheating. FIFA actively acknowledges its responsibility to protect players from harm and ensure equal
chances for all competitors by stringent doping control regulations, data collection of positive samples,
support of research, and collaboration with other organisations. This article aims to outline FIFA’s
approach to doping in football.
Method: Description of FIFA’s doping control regulations and procedures, statistical analysis of FIFA
database on doping control, and comparison with data obtained by WADA accredited laboratories as for
2004.
Results: Data on positive doping samples per substance and confederation/nation documented at the
FIFA medical office from 1994 to 2005 are provided. According to the FIFA database, the incidence of
positive cases over the past 11 years was 0.12%, with about 0.42% in 2004 (based on the assumption of
See end of article for 20 750 samples per year) and 0.37% in 2005. Especially important in this regard is the extremely low
authors’ affiliations incidence of the true performance enhancing drugs such as anabolic steroids and stimulants. However,
....................... there is a need for more consistent data collection and cross checks among international anti-doping
Correspondence to: agencies as well as for further studies on specific substances, methods, and procedures. With regard to
Professor J Dvorak, general health impairments in players, FIFA suggests that principles of occupational medicine should be
Chairman, FIFA Medical considered and treatment with banned substances for purely medical reasons should be permitted to
Assessment and Research
Centre, Department of enable players to carry out their profession. At the same time, a firm stand has to be taken against
Neurology, Schulthess suppression of symptoms by medication with the aim of meeting the ever increasing demands on football
Clinic, Lengghalde 2, players.
8008 Zurich, Switzerland; Conclusion: Incidence of doping in football seems to be low, but much closer collaboration and further
jiri.dvorak@kws.ch
investigation is needed with regard to banned substances, detection methods, and data collection
....................... worldwide.

N
T
he ongoing debate and controversies concerning doping uphold and preserve the ethics of sport
(that is, the list of prohibited substances and procedures,
and sanctions used in amateur and professional sport)
N safeguard the physical health and mental integrity of the
players
has raised public awareness of a problem that has not been
fully appreciated during the rapid development of various
N ensure that all competitors have an equal chance.
sports disciplines. FIFA introduced doping controls in 1970 to ensure that the
It is only 38 years since drug testing was first introduced results of national and international matches were a fair
at the1968 Olympic Games in Mexico City following reflection of the ability of those taking part. The FIFA Sports
amfetamine and nicotinyl tartrate related deaths of a Medical Committee is responsible for implementing doping
number of cyclists at the 1960 Summer Olympic Games in controls at all FIFA competitions and also for coordinating with
Rome and the 1967 Tour de France. Regular doping confederations and member associations. The overall manage-
controls have been conducted since, but these controls ment of doping controls is conducted by the FIFA administra-
have failed to prevent sportsmen and sportswomen from tion (Medical Office and the FIFA Sports Medical Committee).
taking performance enhancing drugs both during and out Over the past 12 years, the FIFA Medical Assessment and
of competition. Regrettably, banned and harmful sub- Research Centre (F-MARC) has developed a worldwide
stances are openly available, even without prescription. network of specialists who are involved in the educational
Drugs such as nandrolone can be purchased over the process within the confederations and national associations
internet in unlimited quantities. In recent years, an as well as in practical performance of doping controls for
increasing number of positive samples and cases of so- national, international, and FIFA competitions. The medical
called recreational drugs, such as marijuana and cocaine, doctors/sports physicians, following their Hippocratic Oath as
have been observed and need to be addressed accordingly. well as their professional and ethical values, play key roles in
In addition, media reports may encourage those competing FIFA’s long term strategy in the fight against doping. Many
at lower levels of sport to experiment in the use of such of these doctors are also team physicians in their national
substances without considering the possible side effects associations.
and medical complications, let alone the legal consequences
of their actions. Abbreviations: DCO, doping control officer; EPO, erythropoietin; FIFA,
Sporting associations, including the Fédération Fédération Internationale de Football Association; F-MARC, FIFA
Medical Assessment and Research Centre; hGH, human growth
Internationale de Football Association (FIFA), have stated hormone; IOC, International Olympic Committee; TUE, therapeutic use
that the fundamental aims of doping controls and anti- exemption; UEFA, Union of European Football Associations; WADA,
doping policies are to: World Anti-Doping Agency

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i4 Dvorak, Graf-Baumann, D’Hooghe, et al

The fight against doping in football focuses on education tests after each match. Between 1994 and 2005, 3327 doping
and prevention with regular in-competition and out-of- controls (men and women) were performed during three
competition controls. In past years, approximately 15 000 consecutive FIFA world cups (USA, France, Korea/Japan),
doping controls were performed annually on footballers, with two consecutive Olympic games (Sydney, Athens) as well as
over 20 000 performed in both 2004 and 2005. FIFA the last Women’s World Cup (USA, 2003), the FIFA U-19 in
articulated its unyielding position in the fight against doping Thailand, the FIFA U-17 World Cup in Peru, the FIFA
prior to the world cup competition in both 1998 and 2002 Confederations Cup in Germany, the FIFA Club World Cup in
(FIFA Magazine May 2002)1 and reinforced its strategy in the Japan, the FIFA Beach Soccer World Cup in Brazil, the FIFA
FIFA Magazine in March 2004.2 U-20 World Cup in the Netherlands, and FIFA World
Physicians demonstrated their strong support of the FIFA Championship in Futsal, Chinese Taipei, as well as during
long term strategy in its fight against doping before the 2002 the World Cup 2006 preliminaries. Only four samples tested
FIFA World Cup Japan/Korea. The team physicians of all 32 positive during this period: one for ephedrine and pseudoe-
finalists signed a joint declaration in the fight against doping, phedrine in 1994 one for cannabis and one for nandrolone
supporting FIFA’s decision to introduce routine blood during the FIFA World Youth Championship 2003 held in the
sampling to analyse for blood doping and erythropoietin United Arab Emirates, and one for ephedrine in Angola. This
(EPO). This was a firm message to the football community reflects an overall incidence of 0.12% positive cases over the
and demonstrated the excellent collaboration and coopera- past 11 years. The extremely low incidence of positive cases
tion between the FIFA Sports Medical Committee and the during FIFA competitions indirectly confirms the FIFA long
team physicians taking care of the players before and during term strategy in the fight against doping: that education and
the competition. The team physicians of all the finalists of the prevention play a key role in keeping high profile competi-
2006 FIFA World Cup Germany again reinforced the fight tions free of doping.
against doping with a joint declaration signed on 5 March It can only be assumed that team sports such as football
2006 to keep this unique event free of doping. are not as prone to misuse of performance enhancing
substances as are individual sports. During the 2004
DEFINITION Olympic Games in Athens, there were 27 positive cases—all
Doping is defined as any attempt by a player, either in individual athletes and none in any team sport partici-
themselves or at the instigation of another person such as pants. It might be hypothesised that the close collaboration of
manager, coach, trainer, doctor, physiotherapist, or masseur, the team sport medical committees since the 2000 Olympic
to enhance mental and physical performance non-physiolo- Games in Sydney, positively influenced the attitude of
gically or to treat ailments or injury—when this is medically fairplay among team sports during the Olympic Games in
unjustified—for the sole purpose of taking part in a Athens.
competition. This includes using (taking or injecting), Close collaboration between accredited laboratories, the
administering, or prescribing prohibited substances before reporting system, and the central control system is an
or during a competition. These stipulations also apply to out- important tool for statistical recording of the extent of
of-competition testing for anabolic steroids and peptide doping in football in the future. Although several prominent
hormones, and to substances producing similar effects. Any footballers have tested positive for drugs in recent decades,
other prohibited method (for example, blood doping) or the true extent of the problem is unknown. Even if we
manipulation of collected samples is likewise classified as assume that doping is still not a major issue in team sports
doping. such as football, any estimation of the problem can be
The detailed definition as related to the anti-doping rule considered as merely an unscientific hypothesis or specula-
violations is presented in the current FIFA doping control tion. To meet the challenges brought about by this situation,
regulations (January 2006).3 Doping contravenes the ethics of FIFA has taken action to develop closer collaboration
sport, constitutes an acute or chronic health hazard for between the medical committees of the various confedera-
players, and may have fatal consequences. tions. In October 1999, the FIFA Sports Medical Committee
and the Union of European Football Associations (UEFA)
THE EXTENT AND SCOPE OF DOPING IN FOOTBALL Medical Committee met to discuss the latest sports medicine
FIFA is a global organisation that unites over 250 million issues with the aim of not only combating doping but also
footballers in 207 countries. Around 40 million of these developing educational programmes designed to meet the
players are female. Currently, confederations, national fundamental objectives outlined above.
associations, or both that fall under FIFA’s management, Similar meetings have been conducted between the
carry out their own doping controls at the competitions they representatives of the FIFA Sports Medical Committee and
stage. However, the urine or blood samples, or both must be the medical committees of the Confederation of North,
analysed at laboratories accredited by FIFA/World Anti- Central American and Caribbean Association Football
Doping Agency (WADA). These laboratories send reports on (CONCACAF) (North and Central America, 2000, 2001),
any ‘‘chemically positive’’ A samples to the member associa- Asian Football Confederation (AFC) (Asia, 2001, 2002, 2005),
tions, and FIFA headquarters for management and WADA and Confederation Africaine de Football (CAF) (Africa, 2003,
for information. Once the FIFA medical office receives a 2004). During 2005, meetings were conducted with the newly
positive A sample report, it requires follow up information established Oceania Football Confederation (OFC) Sports
from the national association/confederation in question, or Medical Committee and Confederación sudamericana de
both—that is, the results of the possible B sample decision Fútbol (CONMEBOL) with the aim of harmonising doping
made by the particular disciplinary committee. If the control procedures, improving the understanding of the
information is not provided, the FIFA disciplinary committee scientific background of doping, and enhancing the FIFA
takes appropriate action. Since the 1994 FIFA World Cup in network of doping control officers (DCOs) who fulfil
the USA, the FIFA Medical Office has undertaken stringent educational duties as a part of their responsibilities.
registration of analysed samples. According to the statistics of the International Olympic
A new doping control policy for FIFA competitions was Committee (IOC) (until 2003) and WADA accredited
introduced at the FIFA U-17 World Championship in New laboratories (as of 2004), approximately 20 750 doping
Zealand in 1999. Since then, during tournaments, two players controls are performed annually on football players. The
from each team are randomly selected to undergo doping majority of the controls are done in Europe and North and

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Doping in football i5

50 47 70
64
45 2004 2004 58
60
2005 2005
40 38
50
35
30 40
30
30
25
20 17
20 11
16
15 13 10 7
4 2
0 2 0 1 0
10 9 0
6 AFC CAF CONCACAF CONMEBOL OFC UEFA
5 3 4
0 Figure 2 Positive doping samples by confederation (excluding
0
Cannabis Cocaine Anabolic Stimulants Miscellaneous testosterone/epitestosterone (T/E)): FIFA 2004 and 2005. See text for
steroids abbreviations.

Figure 1 Doping statistics per substance (excluding testosterone/ following up cases, particularly the less experienced FIFA
epitestosterone (T/E)): FIFA 2004 and 2005. member associations. As of January 2006, this database
allows tracking each positive sample with the aim of having
South America. The numbers of doping controls continue to the final decision of the member association’s disciplinary
increase in the other confederations. In this respect, FIFA committee no later than 90 days after the analysis of the B
developed its own database to keep records on the substances sample.
being reported as positive to allow online control of The FIFA database will allow a continuous cross-check
management of these samples within the different confed- with the WADA database (ADAMS, Anti-Doping And
erations and member associations. During 2004 and 2005, 88 Management System), once that is operational, not only to
(0.42% based on the assumption of 20 750 samples per year) control the reporting system of the WADA accredited
and 78 (0.37%) positive samples, respectively, were registered laboratories, but also to allow prospective studies on
at FIFA (fig 1). The increase is probably because of improved sanctions related to the different substances, the severity of
reporting systems used by the laboratories as a result of the the violation, or both.
implementation of WADA (March 2004). The majority of the
positive cases were detected or reported by the European LIST OF PROHIBITED SUBSTANCES
laboratories which receive most of their samples from the Like most major governing bodies of sports and the IOC, FIFA
European national associations (figs 2 and 3). has drawn up lists of both prohibited doping substances and
Following FIFA’s 2003 meeting in Zurich with medical methods. The categories of prohibited substances and
representatives of the Olympic Team Sports Federations and methods are approved by the FIFA Sports Medical
representatives from WADA accredited laboratories, it was Committee and follow the Prohibited List and International
possible to obtain reliable data on analyses of doping samples Standards published by the WADA. The most recent FIFA
performed by the WADA accredited laboratories (fig 4). There doping control regulations and list of banned substances
was quite a discrepancy in the numbers of samples analysed (January 2006) are divided into three main sections contain-
in the laboratories for football (FIFA) ranging from 42 ing different categories of prohibited drugs and methods (box
analyses in Seoul to 4159 in Rome. Analysis of these data 1). Additional methods and substances such as stimulants,
might influence the future strategy of the distribution of the narcotics, cannabinoids, and glucocorticosteroids are
samples to the laboratories. Knowledge of the total number included for in-competition testing. The 2006 list includes
of football samples analysed during the year 2004 allows specified substances that are examined for monitoring
calculation of the incidence of positive samples in total purposes and are particularly susceptible to unintentional
(0.42%), and the distribution and calculation of incidence in anti-doping violations because of their general availability in
the different confederations of FIFA (table 1), and the most medical products or because they are less likely to be
commonly found prohibited substances (table 2). The
analyses presented do not include the applications for
therapeutic use exemption (TUE) or the pending T/E 2004
(testosterone/epitestosterone) ratio cases. These cases are 18 17 2005
extremely difficult to manage and have motivated F-MARC 16
to undertake a new research study in collaboration with the
14 13 13 12
WADA accredited laboratory in Lausanne for direct proof of
testosterone in urine. This study is currently underway. 12
10 10
The relatively low incidence of positive doping samples, 10 8 9
especially for the true performance enhancing drugs such as 8
8

anabolic steroids and stimulants, support the assumption

that there is no evidence of systematic doping. Other 6 5

important support for the assumption for no evidence of 4 3 3

2 2 2 2
systematic doping has been provided by UEFA (2005/2006 2 1 1 1
Champions League competition). All 32 participating teams 0 0 0 0 0
0
have undergone unannounced doping controls in their
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medical doctors. All 320 samples were declared negative.

et
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The newly developed FIFA database for management of all

samples collected worldwide allows tracking the records of Figure 3 Positive doping samples for Europe by country (excluding
DCOs and has proved to be an extremely useful tool for testosterone/epitestosterone (T/E)): FIFA 2004 and 2005.

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i6 Dvorak, Graf-Baumann, D’Hooghe, et al

4500 Figure 4 Numbers of samples

4159 analysed in 2004 at WADA accredited
4000 laboratories for doping.

3500
3112

3000
2548
2500

2000
1536
1500
1165
994
1000 881

565 572
470 473 515 528
500 402 405 421 421
226 257
152 199
42 45 45 84 86 96 107 108 134
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successfully misused as doping agents. A doping violation high level of agreement as far as the lists of banned
involving such substances may result in a reduced sanction substances and methods were concerned. This was because
provided that the (FIFA Doping Control Regulations p. 33): the confederations simply decided to adopt the current FIFA
doping control regulations. A detailed survey of the doping
control regulations issued by national football associations in
athlete can establish that the use of such specified
1999, however, revealed some differences in the procedures
substances was not intended to enhance sports perfor- and inclusion of certain substances in the categories of
mance prohibited substances.
Following this comparative study, the FIFA Sports Medical
An extensive list for each category of prohibited substances is Committee and F-MARC issued a proposal to the executive
provided by FIFA in the annual doping control regulations. committee to harmonise the doping control regulations of all
These lists are always followed by the words ‘‘and related national associations and to adopt the list of prohibited
substances’’ to include all substances that have a similar substances and methods. Following FIFA’s executive com-
chemical structure and/or pharmacological effect. mittee decision, the FIFA congress ratified the decision at its
Even though the majority of the drugs described are Ordinary Congress in Seoul (May 2002), which paved the
banned in football, some categories are more capable of way for the decision of the FIFA Extraordinary Congress in
enhancing a player’s performance than others and, as such, Doha/Qatar (December 2003). This follows the method of
may well be used in our sport. Two categories not commonly individual case management and will extend expulsion
used by players are narcotic analgesics and diuretics. The sanctions by the disciplinary committees of national associa-
narcotic analgesics used are mainly from the opioid family— tions for all international matches, and vice versa.
for example, morphine. Diuretics are used as masking agents
in certain sports. Both of these categories are contraindicated Stringent rules of procedure
for the types of exercise that footballers have to perform on Although the in-competition Doping Control Regulations
the field over 90 minutes. Three categories that could involve outline a clear procedure, the out-of-competition controls
footballers are stimulants, anabolic agents, and peptide have not been performed routinely in football mainly because
hormones. the professional football player is ‘‘in competition’’ almost
the entire year except during brief seasonal breaks (two to
four weeks) or if in rehabilitation after severe injury.
CURRENT DOPING CONTROL REGULATIONS
FIFA and UEFA jointly produced a set of regulations for
Cooperation between the confederations and national
out-of-competition doping controls for the first time before
associations
EURO 2000. About one month before the tournament, all the
A comparative study of the existing doping control regula-
competing countries were informed that unannounced
tions issued by the FIFA confederations in 1999 showed a
doping controls might be carried out at training camps and
the procedure to be followed. After lots had been drawn to
Table 1 2004 doping statistics (per confederation) from
WADA accredited laboratories (excluding T/E)
Table 2 Substance per positive sample from
Football WADA accredited laboratories (2004)
confederation Samples Positive Incidence (%)
Substance Sample Incidence (%)
AFC 1 058 4 0.38
CAF 715 2 0.28 Cannabis 37 0.18
CONCACAF 275 0 0.00 Cocaine 30 0.14
CONMEBOL 3 993 17 0.42 Anabolic steroids 14 0.07
OFC 226 1 0.44 Stimulants 3 0.01
UEFA 14 483 64 0.44 Miscellaneous 4 0.02
Total 20 750 88 0.42 Total 88 0.42

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Doping in football i7

Clinical studies show that until recently most of the doping

Box 1 FIFA doping control regulations: substances encountered have been, as a general rule, drugs
categories of banned substances and methods developed for therapeutic purposes and are primarily used for
medical therapy. Today, however, an increasing number of
Prohibited substances substances are being developed for the sole purpose of
doping, and no studies have been conducted into their
N Anabolic agents clinical effectiveness. This is an important reason why
N Hormones and related substances specially trained physicians, working in close cooperation
N b2 agonists with laboratory specialists, should serve as doping control
N Agents with antiestrogenic activity coordinators. The doctor not only has to carry out the control
procedure, but also has an educational function before,
N Diuretics and other masking agents
during, and after the doping control.
Prohibited methods
PROHIBITED SUBSTANCES PRESCRIBED FOR
N Enhancement of oxygen transfer MEDICAL REASONS (TUE)
N Chemical and physical manipulation If there is any doubt regarding the appropriate therapeutic
N Gene doping treatment of a player who has a medically confirmed
pathological condition, drugs containing prohibited or
Substances and methods prohibited in competition partially prohibited substances could be permitted in excep-
tional cases if:
N Stimulants
N Narcotics N the player’s health would be impaired if the prohibited
N Cannabinoids drug were withheld
N Glucocorticosteroids N no performance enhancement could result from the
prohibited substance being administered as medically
prescribed
select four national teams, two DCOs (one from UEFA and N no permitted or practical alternative drug is available in
place of the prohibited substance.
one from FIFA) visited the training camps in question at
around 11 am and immediately reported to the national In such a situation, a player or his or her doctor must request
team’s head of delegation. The head of delegation was for a TUE by submitting a formal application to the FIFA
requested to find a suitable location for collecting the Doping Control Sub-Committee. Strict confidentiality is
required samples. The players to be tested—four per team— necessary and guaranteed.
were then drawn by lots and the doping control procedure FIFA has become part of an international network in this
was carried out by the UEFA and FIFA doctors immediately field, initiated by the Australian Sports Drug Medical
afterwards. The experience of these out-of-competition tests Advisory Committee (ASDMAG), and will be able to draw
showed the need for a much greater level of cooperation on the accumulated body of knowledge from other team
between national associations, confederations, and FIFA to sports, WADA, and individual cases. The TUE applications are
ensure that procedures for standard doping controls and managed by the FIFA Doping Control Sub-Committee. A
unannounced out-of-competition controls were brought copy of approval or rejection is automatically sent to WADA
more closely into line. for information and possible appeal.
A similar procedure for out-of-competition controls was
performed in training camps before the FIFA World Cup 2002
LABORATORY ANALYSIS OF SAMPLES
(Korea/Japan) and Euro 2004 (Portugal). The procedure
Chain of custody
proved to be feasible and the compliance of involved teams
The laboratories that are in charge of doping analysis
and individual players was 100%. Out-of-competition, unan-
throughout the world are all specialised and well equipped
nounced controls are planned prior to the FIFA World Cup
institutions, empowered by their national sporting autho-
Germany 2006.
rities to analyse the urine samples received from sporting
authorities. WADA has established an accreditation system
The need to use a medical doctor as a DCO for such laboratories. A total of 33 laboratories were fully
Although some sporting organisations and anti-doping accredited in 2005 (box 2). This accreditation is based on
agencies continue to employ coordinators who are not quality control checks performed annually on each labora-
medical doctors, FIFA and its member confederations insist tory. The main objective of accreditation is to guarantee
on physicians for doping controls. This requirement requires uniform quality of analysis at laboratories all over the world.
closer analysis. International federations, including FIFA, use these official
Players from teams selected to undergo a doping test are laboratories for their major events and competitions. The
required to provide details of any treatment with medicines laboratory is requested by the governing body concerned to
from 7 weeks to 72 hours before the test or the competition analyse samples and is obliged to comply strictly with the
in question. All medicines that a player has received must be rules laid down in their medical codes. The laboratories treat
listed together with details of the method of administration, all samples anonymously with each sample being labelled
dosage, and medical indications. The information declared on with a code number known only to the player and the
the forms used for this purpose is covered by patient committee in charge of the controls. This is essential to assure
confidentiality and may not be communicated to non- the player that the analysis is completely objective and to
medical personnel (for example, the general secretary of the avoid any undue pressure on the laboratory which analyses
football association concerned, the player’s coach or the the samples.
club’s general manager) unless the A sample tests positive. The results (negative or positive) are communicated to the
For confidentiality reasons alone, it is essential that the DCO committee in charge of the controls. If the A sample is
is a physician with appropriate qualifications for this positive, the test is performed a second time before the result
position. is sent to the relevant committee. A copy from the report of

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i8 Dvorak, Graf-Baumann, D’Hooghe, et al

Unfortunately, not all banned substances used in sport can

Box 2 FIFA/WADA accredited laboratories in 2005 be detected using this technology (a false negative). In
addition, some of them have exactly the same structure as
Ankara (Turkey) their natural endogenous forms and are quite difficult to tell
Athens (Greece) apart.
Bangkok (Thailand)
Barcelona (Spain) The T/E ratio
Beijing (China) Widespread use of anabolic steroids in doping began in the
Bloemfontein (South Africa) 1980s and testosterone was one of the preferred androgenic-
Bogota (Colombia) anabolic agents. Until recently, it was difficult to differentiate
Cambridge (England) between synthetic and natural testosterone in the body. The
Cologne (Germany) only method available was a quantitative one involving the
Gent (Belgium) establishment of a ratio with another steroid called epites-
Havana (Cuba) tosterone, which is similar to testosterone and is very stable
Helsinki (Finland) in its concentration. The normal Caucasian and African
Kreischa (Germany) populations have a mean ratio (testosterone to epitestoster-
Lausanne (Switzerland) one, T/E) of 1.5:1 (for males) with some variability, rising to
Lisbon (Portugal) 4:1 in rare cases. The mean ratio for Asian people is generally
London (England) lower than 1:1. A player with excessive levels of testosterone
Los Angeles (USA) will have a much higher ratio, resulting from an increase in
Madrid (Spain) testosterone concentration. It was later decided that the
Montreal (Canada) maximum permissible T/E ratio would be 6:1, and that any
Moscow (Russia) ratio over this limit would be declared positive. Currently, the
Oslo (Norway) limit for an adverse finding is fixed at 4:1.
Paris (France) In addition to the T/E ratio, monitoring of the complete
Penang (Malaysia) steroid profile of the player over time can also demonstrate
Prague (Czech Republic) manipulation. This can be due to the consumption of other
Rio de Janeiro (Brazil) steroids such as testosterone precursors which can be easily
Rome (Italy) purchased over the internet. Moreover, new laboratory
Seibersdorf (Austria) instrumentation, the isotope ratio mass spectrometer
Seoul (Korea) (IRMS), allows differentiating between steroids of endogen-
Stockholm (Sweden) ous and exogenous origin in urine. This tool, together with
Sydney (Australia) retrospective data on the player, if they exist, and in some
Tokyo (Japan) cases, additional endocrinological investigations, will provide
Tunis (Tunisia) the disciplinary commissions with the opportunity to make
Warsaw (Poland) the most accurate decision in a timely manner.
A validation study initiated in 2004 by FIFA jointly with
Swiss Anti-Doping Laboratory (LAD, the WADA accredited
any positive case is simultaneously sent to the international laboratory in Lausanne) is in progress.
federation (if the committee in charge is not in charge of the
controls) and to FIFA and WADA. The committee in charge The case of nandrolone
then informs the player who then has a limited time to Just before the FIFA World Cup in France in 1998, a number
request analysis of the B sample. of well known players tested positive for small amounts of
nandrolone metabolites in their urine. Nandrolone (chemical
The sample analysis name nortestosterone) is an anabolic steroid often encoun-
Samples are analysed with the aim of identifying all tered in bodybuilding doping cases. In general, this com-
detectable banned substances. The equipment used is state pound is taken in high doses and its degradation products
of the art technology designed to generate a ‘‘molecular (metabolites) remain detectable in urine for up to several
fingerprint’’. The technique of choice is gas (or liquid) months. Before the 1998 World Cup, FIFA commissioned an
chromatography controlled with detectors based on mass independent anti-doping laboratory (LAD) to carry out a
spectrometry. Chromatography is the first step in the analysis, collaborative study to obtain a true picture of the situation in
consisting of a preliminary separation in the mixture of football. With the agreement of national and international
several natural or non-natural substances contained in each bodies, every player from every team in the top national
urine extract. After the substances have been sorted, a mass leagues in Switzerland (A and B leagues) was tested after a
spectrometer provides a picture of the molecular structure game (356 players in total over two weekends) in collabora-
that can be compared with others stored in the chemical tion with the Swiss anti-doping committee. The results
databases of the computer that controls the entire system. were compared with those obtained by testing amateur
The aim of these analyses is to prove that no banned footballers and students. Without revealing anything about
substances are present in the urine samples provided by the origin of these products, the study showed some
‘‘clean’’ players (the vast majority: a true negative), so that a players had nandrolone metabolites in their urine after the
player can then be declared negative. In positive cases, the game. The traces of metabolites in the urine of those players
same technology must also deliver absolute chemical proof were very small, and all were below the limits of a positive
that a banned substance or its degradation products (called reading.
metabolites) are present in the urine (a true positive). Every On the basis of this study, FIFA was able to organise the
possible step is taken to prevent samples from erroneously anti-doping programme for the 1998 World Cup with a
being declared positive (a false positive); in general, the degree of assurance to provide reliable information to the
purpose of B sample analysis is to provide confirmation of the competing teams to rule out any occurrence of false positive
result obtained during the first test in the presence of the tests. With FIFA’s support, this study into nandrolone and its
player or one the player’s representatives. derivate substances continued. Extraordinary variability in

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Doping in football i9

excretion was shown, making the relation between dosage, (Penang, January 2001), UEFA (Zurich, January 2001),
time delay, and urine concentration critical. Involvement of a CONCACAF (Miami, February 2001), and OFC (Auckland,
world governing body in such a research programme is New Zealand, March 2001), and also in Tunis in January
essential if any worthwhile progress is to be made in this 2004, Marrakesh in November 2004, Buenos Aires in
area. The players can also be given the assurance that, March 2005, Oman in May 2005, Port of Spain in
scientifically and ethically, they start a match on an equal December 2005, Auckland in February 2006, and Buenos
‘‘playing field’’ with their opponents as far as doping is Aires in April 2006.
concerned. The DCOs, as members of the FIFA network, are currently
spread around the world. To make doping control cost
THE PEPTIDE HORMONES effective, the FIFA Congress followed the recommendation of
There are several peptide hormones in the list of prohibited the Sports Medical Committee that DCOs are, by profession,
substances, of which the two most important are EPO and physicians who follow the Hippocratic Oath and their
the human growth hormone (hGH). professional laws. DCOs perform doping controls on their
national team in their country when playing against a team
EPO from another country. The FIFA doping control procedure is
The use of EPO in sport can be established by analysing urine straightforward and transparent, leaving no room for
by a novel method based on the biochemical properties of cheating or wrongdoing when all steps are performed in
EPO. EPO and its analogues are too large to be filtered by the the presence of representatives from both teams. This makes
kidney and are easily eliminated in urine. As their concen- the logistics easier and significantly reduces the costs
trations in urine are so low there was a need for improvement involved, particularly for qualifying matches for major
in biochemical technology to allow the detection of this competitions.
product in urine. Thus, in 2000, the WADA accredited
laboratory in Paris implemented a method based on a small
RESEARCH
structural difference between recombinant and natural EPO
The current list of banned substances contains a number of
to determine whether doping had taken place. This method is
drugs for which there is no conclusive scientific evidence to
now applied in several accredited laboratories in the world.
justify inclusion on the list. Research on selected substances
has highlighted some performance enhancing effect whereas
hGH
other references are doubtful. In view of the potentially
The chemical structure of bioengineered hGH is almost
enormous repercussions (as demonstrated at the Sydney
identical to the natural hormone produced by the body.
Olympic Games) there are several ways of improving the
Consequently, it is particularly difficult to differentiate
current situation.
between the injected and the natural hormone. Recently
developed methods use blood as a biological sample for the
determination of a specific ratio diagnostic for the use of
N A database containing all currently listed substances
should be set up. This should give details on the
recombinant hGH. This new approach clearly demonstrates pharmacological background, research findings, and clin-
the necessity to implement blood sampling for anti-doping ical papers documenting the effects of the particular
purposes. substance.
Blood sampling N Borderline substances should be reconsidered on the basis
of research studies providing scientific analysis of their
Recently, blood has been introduced as an alternative
effect on physical and psychological performance as well
biological matrix to urine for anti-doping sampling purposes.
as effect on the metabolism.
Since 2004, blood has been recognised as absolutely
necessary for reliable results for some forbidden substances N A standard study design (double blind, randomised trials)
should be set up for substances under scrutiny, proved in
and methods. The list of these substances and methods is not
definitive, but currently, hGH, synthetic haemoglobins, and pilot projects and implemented multicentrically. The
homologous blood transfusions can be reliably detected with results of such studies should form the basis for future
several blood matrices. inclusion on the list of prohibited substances.
Some other blood tests are also carried out in certain
sports, not for the purpose of determining the presence of
N Tracing and identification of masking agents.

doping, but rather as general health checks conducted in the Such initial research work might help to reduce the list of
context of medical screening of the competitors. This has banned substances so that the focus can be on the major
potential for the future and could easily be introduced by problem areas such as anabolic steroids, and peptide
some national or international federations depending on hormones and related substances, such as human chorionic
their structural organisation. However, this concept is more gonadotrophin, hGH, and EPO. Research into nandrolone
difficult to implement in larger federations which have metabolism in footballers, conducted with FIFA’s support,
players on every continent. eloquently documents the complexity of the problem. The
study showed that current laboratory methods cannot
FIFA NETWORK OF DCO S distinguish between endogenous metabolism and exogenous
In cooperation with the football confederations and national intake of nandrolone. Although the cut-off level of 2 ng/ml
associations, FIFA has established a worldwide network of would appear rational, it is not scientifically proved, leaving
more than 250 specially trained physicians who act as FIFA’s the door wide open for discussion. Further double blind
DCOs. With regard to medical confidentiality and the studies are in progress in an attempt to obtain the scientific
necessity for specific knowledge in the field, FIFA only evidence needed to end the ongoing speculation. Until then,
accepts physicians as DCOs. this cut-off level is valid and will remain in effect.
To ensure ‘‘unity of doctrine’’ all DCOs attend instructional FIFA has realised and documented its responsibility by
seminars conducted by F-MARC (Professor Jiri Dvorak, supporting research studies that promise to enhance current
Chairman) and FIFA Doping Control Subcommittee medical knowledge. A combined effort with other interna-
(Professor Toni Graf-Baumann, Chairman). Such seminars tional sports federations, the IOC, and anti-doping agencies
have been held for CAF (Tunis, November 2000), AFC might, however, accelerate the process.

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i10 Dvorak, Graf-Baumann, D’Hooghe, et al

EDUCATING THE FOOTBALL COMMUNITY ABOUT aspects of the team sports federations based upon 184
DOPING AND PERFORMANCE positive samples between 1998 and 2003 in different sports.
Two issues of importance with regard to education of the After intensive discussions with Mr Pound, the manage-
football community are: ment of WADA, and a historic speech delivered by Mr Pound
(54th Ordinary FIFA Congress in Paris on 19 May 2004), an
N Collaborating with team doctors informal agreement on collaboration between FIFA and
N Supplements and special nutrition WADA was signed by the respective presidents and con-
firmed by the IOC President, Dr Jacques Rooge. Based upon
Continuous and close contact with team doctors is this agreement and adaptation of the FIFA Doping Control
necessary in countries where sports medicine is still devel- Regulations, changes have been incorporated in the FIFA
oping and where the team doctors may not have special Disciplinary Code.
training on doping issues. In view of the rapid changes in
doping with regard to both substances and methods of LEGAL BACKGROUND
administration, a constant exchange of information with all In this regard, the legal background will be briefly described.
team doctors is essential. Besides the fact of the problem, FIFA is a private association in accordance with Article 60 ff.
effective procedures against doping cannot be put into Swiss Civil Code with headquarters in Zurich, Switzerland.
practice unless a close, trusting relationship has been Consequently, FIFA is a legal person in accordance with
established between the team doctors and the DCOs. Swiss private law and has to comply with it when setting up
With regard to above, particular attention must be paid to its statutes and regulations.
food supplements and special diets that might be prescribed The principles of fault and individual case management are
for an player. Supplements or diets may contain banned essentials of Swiss sanction law and therefore have to be
substances, which means that the player may be taking considered when imposing private sanctions. Every sanction
substances (or using food supplements) without realising contains a distinctive individual component, because every
that it may contain a banned substance. If the player tests sentence has to take into account the fault of the delinquent.
positive, it is difficult to prove that the substance(s) in FIFA has been following these principles in its Doping
question originated in the player’s food or food supplements. Control Regulations from the beginning.
From the legal point of view, players testing positive in such To base its decisions on expertise, FIFA itself sought a legal
situations must bear the responsibility themselves. Here, too, opinion from the Court of Arbitration for Sport (CAS) about
a constant flow of information between DCOs and team the extent to which WADA’s code complied with Swiss law in
doctors helps everyone keep abreast of developments in the September 2005.
‘‘market’’ and prevent problems arising for players. In its legal opinion published in April 2006, CAS explicitly
The recently published summary of the ‘‘Nutrition for confirmed FIFA’s practice of individual case management
Football: the FIFA/F-MARC Consensus Conference’’4 clearly when sanctioning doping offences. In addition, CAS noted
states that there is no evidence to support the current that FIFA’s principle of individual case management com-
widespread use of dietary supplements in football. plies with the World Anti-Doping Code. At the same time, the
Supplements should be used only on the advice of qualified independent sports arbitration body, with headquarters in
sports nutrition professionals. Football players can stay Lausanne (Switzerland), has also ruled that FIFA’s provi-
healthy, avoid injury, and achieve their performance goals sions with regard to the fight against doping and the
with good dietary habits. Players should choose foods that sanctioning of doping offences are, to the greatest possible
support and optimise both training and match performance. extent, in line with the World Anti-Doping Code, and that
What a player eats and drinks in the days and hours before a they are also fully in line with Swiss law. CAS also compared
game, as well as during the game, can influence the result by FIFA’s provisions with those of the World Anti-Doping Code
reducing the effects of fatigue and optimising performance. in 22 main areas. In 16 points, including the definition of
Food and fluid ingested soon after a game and training can doping, the strict liability principle, the list of prohibited
accelerate recovery. All players should have a nutrition plan substances, therapeutic use exemptions, testing and analysis,
that takes individual needs into account. hearings, commencement of the ineligibility period, and
disqualification provisions regarding teams, CAS stated that
there were no material differences between the two sets of
FIFA’S COOPERATION WITH WADA
regulations.
On 4 February 1999, a Lausanne declaration on doping in Furthermore, CAS confirmed FIFA’s attitude by stating
sport was presented to the IOC and international sport that neither the IOC nor WADA has the right to dictate to
federations that an independent international anti-doping FIFA as regards the latter’s disciplinary regulations for the
agency should be established and fully operational by the fight against doping and the sanctioning of doping offences.
2000 Olympic Games in Sydney to coordinate the various According to CAS, international sports federations are free to
programmes necessary to realise the objectives. FIFA’s establish such provisions as they deem appropriate, especially
medical and legal representatives have developed a close as CAS also noted that the World Anti-Doping Code is not
collaboration since 1999 based on numerous meetings with legally binding per se. CAS reported differences in six areas
the representatives of the WADA, particularly following the between FIFA’s provisions and the World Anti-Doping Code,
meeting of FIFA President Mr Joseph Blatter and the although it only highlighted significant deviations in three of
Chairman of WADA, Mr Richard Pound, in Montreal in these points. CAS came to the general conclusion that with
December 2001. regard to the approach used to determine the level of
FIFA’s medical and legal experts contributed significantly punishment to be imposed, there are no considerable
to the improvement of the World Anti-Doping Code differences between the two sets of regulations. FIFA, as
particularly in versions 1 and 2. They insisted on having well as WADA, are in the process of finding a consensus to
independent expert opinion by prominent European judges maximum and minimum of sanctions.
and lawyers, including the International Sports Lawyers With regard to possibly eliminating a sanction in cases in
Association, on individual case management regarding which athletes prove that they did not act with fault or
positive cases. This individual case management has been negligence, CAS recommended that FIFA incorporate an
confirmed as a strategy by internal studies of the medicolegal appropriate provision in its regulations and not impose

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Doping in football i11

sanctions on athletes who prove that a prohibited substance employee—for example, prescription medicines to protect the
entered their body through no fault or negligence of their employee from the effects of workday stress, such as b
own. FIFA, however, already follows such a practice by blockers.
applying the principle of guilt when sanctioning doping If we now consider a sport such as football, a number of
offences. In addition, FIFA was advised by CAS to adapt its examples can be identified. The proportion of players who
regulations to clarify WADA’s right of appeal against have allergies is similar to that in the general population, and
procedures followed in final-instance decisions. Conversely, the treatment will be the same—that is, appropriate therapy
it was noted that with its provision regarding the statute of often involving the taking of medicines, especially during
limitations, the World Anti-Doping Agency’s code is not in those times of the year when the allergen count is high. But
line with Swiss law. when we are dealing with open air sports, the treatment
This legal opinion from CAS has laid the foundations for prescribed could lead to problems since many of the drugs
FIFA to make the necessary adjustments to the relevant usually prescribed are on the list of banned substances (such
provisions independently. FIFA, together with WADA, under as corticosteroids) even though their prescription is medically
the moderation of the Sports Minister of England, Mr R justified.
Caborn, have discussed the points of differences in a An example of an American professional international
constructive way to reach a FIFA’s complete compliance woman player makes the situation clear. She has a relatively
with WADA code. Beyond that, after being operational for rare disease that makes her blood pressure and fluid balance
two years, it seems reasonable to reflect on the feasibility and subject to extreme variations; this in turn makes it impossible
applicability of the World Anti-Doping Code based upon the for her, without medical help, to pursue her profession at the
analysis of positive doping cases as related to the incidence and required level. She needs ongoing treatment with a miner-
management among the different member associations. Such alocorticoid (fludrocortisone). However, in contrast with
analysis is foreseen within the revision of the World Anti- those mentioned above, this medicine has neither an
Doping Code, which was initiated by WADA in April 2006. anabolic nor an anti-phlogistic effect and is thus not
technically a doping substance in the true sense of the term.
This raises the question whether it really constitutes doping if
OCCUPATIONAL MEDICINE IN FOOTBALL: A
a player can perform at the expected level only after taking
VISION such a medicine. We suggest that this is a problem that falls
Occupational medicine deals with all work related aspects of within the scope of occupational medicine. If such treatment
health that affect the employee’s ability to function effec- is prescribed for genuine medical reasons and involves taking
tively: the workplace itself, the type of work, the state of a drug that in itself has no doping effect, then we cannot be
health of the employee. In addition to purely physical aspects, talking about a case of doping, rather merely of enabling a
social and psychological influences must also be considered. professional player to exercise his or her normal profession.
It is easy to see that construction workers who are paid Occasional treatment with banned substances for ‘‘bona
according to how much work they complete will be subject to fide’’ medical reasons should be permitted if the facts of the
greater stress than, say, a gardener or office worker employed case are presented openly to the doctors in charge of the
on standard terms. Moreover, within any occupation there doping control.
are those—often a considerable percentage—who will reg- A quite different question is whether the ever increasing
ularly need medicines to function properly—for example, demands faced by professional footballers, in terms of the
those with diabetes, high blood pressure, allergies, rheumatic number of matches and tournaments in which they are
disorders. In such cases, any extra stress in the work expected to play, can be compensated for by taking medicines
environment can easily lead to a situation where the ability so that the required level of performance can be achieved over
of the person to function is close to the borderline of what and over again. Playing so frequently, in football as in other
can be physically expected. These people can often become sports, under circumstances necessitating more or less con-
incapable of continuing in the job or of only doing so under tinual treatment with painkillers and anti-inflammatory agents,
medical supervision and with the prescription of suitable can have serious long-term consequences that really cannot be
medicines. justified on the basis of occupational medicine or medical ethics.
There are definite limits to the level of stress under which In this case, the limits of doping are recognisable.
such people can function and it is the concern of occupational Admittedly there is no doping in the first two examples in
medicine to recognise and deal with these limits. terms of performance enhancing drugs being taken.
Occupational medicine aims to point out to both employer However, in the sense of medical treatment being used to
and employee that only under certain specified conditions suppress the symptoms of injuries and overexertion, clearly
will optimum performance be possible. The conditions that there is an aspect of doping involved. The workplace
could be recommended in such cases might include changes pressures on players in the short term lead to long term
in the workplace, in working hours, in the pressures of the effects being ignored. As long as the players in question and
job, or might specify regular medical treatment for the their associations all have the same approach, only a firm
stand by sports and occupational medicine will have the
effect of providing the players with at least partial protection
What is already known about this topic

Doping control in sports was introduced in 1968, with the What this article adds
aim of upholding and preserving the ethics of sport,
safeguarding the physical and mental integrity of players, According to the data presented, the incidence of doping in
and ensuring equal chances for all competitors. Different football seems to be quite low (0.4%). The vast majority of
approaches have been used in the fight against doping. positive samples are due to recreational drugs. These
These approaches should ideally be based on valid data of findings support FIFA’s strategy of education and prevention.
the true extent of doping and sound scientific knowledge of On the basis of principles of occupational medicine treatment
substances, their pharmacokinetics, pharmacodynamics, and banned substances for medical reasons should be allowed to
effects, and the detection methods. enable players to carry out their professional obligations.

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i12 Dvorak, Graf-Baumann, D’Hooghe, et al

from such long term damage. This is further reason why the M Saugy, Swiss Laboratory for Doping Analyses, Institute of Legal
campaign against real doping must be actively pursued. Medicine, Lausanne, Switzerland
Competing interests: None declared
.....................
Authors’ affiliations
J Dvorak, FIFA Chief Medical Officer, FIFA Medical Assessment and
Research Centre, FIFA chief Medical Officer and Department of REFERENCES
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T Graf-Baumann, FIFA Doping Control Sub-Committee, Teningen, FIFA Magazine 2002;May:23–5.
2 Dvorak J. There is nothing to gain from using drugs. FIFA Magazine
Germany
2004;March:16–19.
M D’Hooghe, FIFA Sports Medical Committee, Bruges, Belguim 3 FIFA doping control regulations (January 2006). Available at: www.fifa.com/
D Kirkendall, FIFA Medical Research and Assessment Centre, and documents/fifa/regulations/dopingreglement_06_e.pdf (accessed 3 May
Department of Orthopaedics, University of North Carolina, Chapel Hill, 2006).
NC, USA 4 Nutrition for Football: the FIFA/F-MARC Consensus Conference, September
H Taennler, FIFA Legal Divison, Zurich, Switzerland 2005 (www.FIFA.com).

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