How should officials decide when cutting-edge medical interventions for athletes cross the line?

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Victoria Jackson is a sports historian and lecturer of history in the School of Historical, Philosophical, and Religious Studies at Arizona State University. She responds to Maureen McHugh’s short story “The Starfish Girl.”  This column originally appeared in Slate and is used with permission.

Are elite athletes who undergo cutting-edge medical interventions after injuries benefiting from performance enhancement, and doing so to the degree that they should be barred from competition? What if the athlete suffered from an injury so traumatic that it made the medical intervention necessary? And anyway, if we expect these world-class athletes to strive to be the best—you know, whatever it takes—why should the organizations that govern competition have the power to force athletes out of certain treatments they deem to be on the bad side of “clean sports”?

Guest columnist Victoria Jackson

As a former professional track and field athlete who’s intimately felt that fervid drive to keep competing, it’s obvious that spectators often take these questions for granted.

I watched peers go through surgeries to have detached hamstrings reconnected. I witnessed not one, but two friends break their femurs (the biggest bone in a human body) midrace. And I wanted to line up at the Olympics trials so badly that I trained through many stress fractures—so many that I’ve lost track. I could have worked the system, but I turned down offers to see questionable doctors who diagnosis “conditions” and write therapeutic use exemptions to clear athletes to use medicines and “vitamins” normally on the dirty side of the World Anti-Doping Agency’s clean-sport line.

Still, I went through my fair share of state-of-the-art treatments: bone stimulators, injections, sound-wave therapies, shock-wave therapies, electronic-stimulation therapies, laser therapies, and countless others, their names forgotten. To be the best in the world, you have to take risks, training on that red line at 99.9 percent capacity. If you cross it, you break. But if you manage to ride the line, you open up to the possibility of maximizing your full potential, and, in my opinion, reaching transcendence: the point of pure beauty and performance ecstasy. To think this doesn’t require much scientific intervention along the way is naïve and very wrong.

To actually make the tricky judgments as to what counts as cutting-edge and what gets flagged as cheating in the therapeutic treatment of athletes’ bodies, however, we athletes have ceded incredible power to national and international sports officials. Rules and rulings from the World Anti-Doping Agency, the International Olympic Committee, FIFA, the International Association of Athletics Federations, and others not only order the make or break decisions of whether and how we are allowed to compete, but also carry a cultural power that leeches out into the rest of society.

Yet sports officials often demonstrate little awareness of the moral authority that comes with the power to determine what does and does not provide an “unfair competitive advantage.” Their decisions about medical intervention and performance enhancement—rulings, they claim, that serve the cause of “clean sport”—affect broader ideas of who is good and who is evil. Think of 2003 Lance Armstrong, on No. 5 of seven back-to-back Tour de France titles. He shined as one of the most beloved celebrity athletes for his inspirational story as a cancer survivor, and the work of his charitable foundation. At the time, we knew that Lance Armstrong took certain kinds of therapeutic drugs known to be performance enhancers during his cancer treatment—and we didn’t consider that to be a form of cheating. (And doing so would be kind of messed up—he did have cancer, after all!) But about a decade later, when investigations turned up evidence that he had also been “blood doping,” injecting EPO (a hormone that promotes red-blood-cell production), and using human growth hormone throughout much of his career—and concealing it—the public, and the U.S. Anti-Doping Agency, drew the line.

Now, at a time when various types of genetic engineering and other biotechnologies seem poised to change the future of our bodies, we know that sports officials will soon be making incredibly consequential decisions about whether or when these kinds of interventions will be allowed for elite athletes. But I’m not convinced that their rulings will always keep the science—and what’s fair for all competitors—in mind.

Maureen McHugh’s “The Starfish Girl” captures how these decisions made from afar (in the case of the International Olympic Committee, a sleek, glassy architectural wonder on the banks of Lake Geneva will soon replace an 18th-century Swiss castle as its headquarters) play out in very real, life-changing ways for the athletes.

Jinky Mendoza, the American gymnast and Olympic hopeful training for the Paris 2024 Games whom McHugh describes in compelling detail, shows the commitment demanded of elite athletes in the 21st century. When overrotating during a vault routine in practice causes a debilitating spine fracture that leaves her paralyzed from the neck down, she makes the difficult decision to undergo a “radical new medical procedure” that may offer the only hope of regaining any mobility: allowing doctors to insert starfish DNA into her cells. The invertebrate’s genes “turn on” her body’s dormant ability to repair its own limbs—and thus allow Mendoza to begin an excruciating path to healing and recovery. But does the aid of the starfish DNA somehow make her not “human” enough to fairly compete?

To add a layer of complexity to this question, McHugh introduces another athlete whose cutting-edge recovery method also puts her eligibility in question in the eyes of the all-powerful IOC. But with Mendoza’s competitor, Svetlana Moracheva, we get a slightly different question. Moracheva benefits from stem cell therapy that expedites the healing process of multiple torn ligaments in her knee. However, the cells used in her procedure were human—indeed, her very own.

With sports, however—as with the rest of the world—the decisions the governing organization will make won’t be based entirely on an objective, physiological understanding of the issues.

Mendoza and Moracheva become unlikely allies, and the friendship goes deeper than their shared vulnerability at the hands of the IOC. Despite their youth, they are veterans of international sport, and have internalized its politics of performance. They’re also masters of women’s gymnastics, a competition all about bodies on display. Sports like gymnastics and ice skating enthrall audiences by putting conflicting ideas about the bodies of female athletes on display: They require strength, power, and muscle, and yet demand a show of traditional feminine beauty, grace, and aesthetic appeal. While Serena Williams and others remind us strength and power are beautiful, the traditional male gaze continues to infect the sports industry and its fans, and female athletes often internalize and contribute to the thinking that feminine beauty and sporting power are somehow dichotomous. Sports marketers have capitalized on the appeal of this “contradiction” for decades. It’s part of what made the Nancy Kerrigan–Tonya Harding saga so juicy—and also ripe for socio-economic class analysis.

Moracheva is the Kerrigan; Mendoza, the Harding. Moracheva is praised for her beauty, specifically, her long, lean body type that makes commentators liken her to a Russian ballerina. Mendoza is the short, muscle-bound, springlike pocket rocket, and she cringes when Moracheva praises her power. Both women command an awareness of how much the politics of appearance will play into their fates. They both (if reluctantly) use social media, and both step up their game with media interviews in hopes of winning over the public, and, perhaps, the IOC too. Yet for all their savvy, McHugh reminds us of their youth in the text messages they write to each other. These elite athletes are girls, barely young adults. And their sporting fates—the amassing of all the time, the pain, the sacrifices they’ve made—rests not with them, but with the old, mostly white men in Lausanne, Switzerland.

The politics of appearance that will color those officials’ decisions don’t just come down to their gender either. For, in what is perhaps the most interesting layer of McHugh’s story, these women are different in an additional aspect. We learn Mendoza is Filipina American. As a woman of color, she can’t tap into the privilege that comes with white American identity, one that often plays in the favor of athletes who come before the historically Western European– and European American–dominated IOC. Nor can Moracheva, for that matter. Though she may have advantages as a “snow queen”–like, blue-eyed blonde, she comes from the “East,” and therefore carries with her Cold War associations of doping—cheating to achieve sporting glory. If recent actions by elite international-sports governing bodies show us anything, it’s that their decisions of what constitutes “unfair competitive advantages” have less to do with a careful consideration of the science and more to do with pedigree.

Take, for example, the recent persecution of female athletes with high testosterone—all of whom, by no coincidence, are women of color from the “global south”—by the International Association of Athletics Federations, the group that governs elite track and field competitions worldwide and is among the most powerful bodies within IOC hierarchy. Earlier this year, the IAAF instituted a new policy that rendered women with high testosterone ineligible to compete in middle-distance events against women. The decision came after years of fighting in the Court of Arbitration for Sport (also headquartered in Lausanne), which noted, as the New York Times summarized, that “science has not conclusively shown that elevated testosterone provides women with more of a significant competitive edge than factors like nutrition, access to coaching and training facilities, and other genetic and biological variations.” It also came alongside the vehement objection of advocates like medical anthropologist and bioethicist Katrina Karkazis, who have long worked to demonstrate that the IAAF’s stance on testosterone tells us more about efforts to keep South African 800-meter–runner Caster Semenya and athletes like her (all of the women questioned for high testosterone levels, so far at least, have been from the global south) out of sport.

There’s another twist too. The IAAF ruled that these women who produce naturally high levels of testosterone are barred from competing as women—unless they modify their bodies with drugs or surgery to inhibit testosterone production. If they elect to stay in their natural bodies, the IAAF says, they can only be eligible to compete against men. In other words, counter to standard anti-doping and other anti-unnatural performance-enhancement positions, these women must manipulate their bodies with chemical or medical intervention in order to be cleared to compete. It implies it’s Semenya’s body that’s unnatural, that it’s not female.

All the attention that the IAAF has paid Caster Semenya since earning gold in the 800-meter race at the 2009 World Championships in Athletics (truly, this has been an obsession of the federation’s) stands in contrast with the treatment of athletes like American distance-running star Galen Rupp.

Rupp’s training group, the Nike Oregon Project, has been playing with the “gray area“ of performance enhancement for years under the direction of coach and running legend Alberto Salazar. Though Rupp is now twice an Olympic medalist and 32 years old, he’s been a sort of science experiment since Salazar invited him to join the group in high school, at which point Rupp began receiving technological and medical interventions to improve his performance. This has included the less controversial high-priced bells and whistles that come with training at Nike World Headquarters, like cryogenic therapyanti-gravity and underwater treadmills, and even an altitude house. (Some elite athletes sleep and train in altitude tents to simulate living at higher altitudes, since this causes the body to adapt to the lower oxygen levels by producing more red blood cells and hemoglobin.)

But it has also included more contentious interventions, including allegedly using testosterone creamasthma and thyroid drugs, and infusions of the amino acid L-Carnitine despite lacking—or, with some, having questionably diagnosed—medical conditions that would necessitate such treatments. Though these have provoked media attention and a U.S. Anti-Doping Agency investigation of Rupp and some of his fellow Nike Oregon Project teammates, the investigation remains in limbo—seemingly in perpetuity. It’s unclear exactly why the case hasn’t moved forward. But many suspect that Nike’s power within national and international sports, especially within track and field, likely has some influence. For now, Rupp races unimpeded. Meanwhile, Semenya has to weaken her body if she wants to compete.

Gray areas will always exist when it comes to drawing the line between clean and dirty in sports. But one can’t help but think that more diversity in the powerful institutions that govern fair play might get those lines drawn in fairer ways.

Sport, like the world in which it exists, is made up of hierarchies, systems of power that privilege some at the expense of others. Ideas about race, gender, socio-economic class, nationality, and ability (and, in “Starfish Girl,” even species) play out on—and inside—the bodies of athletes more explicitly than other bodies because they are performing bodies, bodies trained for display. At the same time, sports-governing bodies have evolved to a lesser degree than many other international institutions. While we may think of sport as an escape from reality and think that IOC officials and their policies don’t really matter, the decisions made about who gets to compete and how carry much cultural power.

We consume hundreds of subtle and not-so-subtle messages when we watch sports on screens. These performances inherently provide drama; stories ripe for interpretation. The commentators’ narrations matter (see: “Russell Westbrook is out of his cotton-picking mind”), the camera operators’ shot selections matter (see: crying beautiful women at the 2018 World Cup), and the bodies in competition matter. Jinky Mendoza pulling off a flawlessly executed vault and Caster Semenya winning a race and flexing her muscles signal to viewers—girls and boys, all around the world—that so-called women like them have the freedom to compete, excel, and relish the victory. They own their bodies, their power; they feel the beauty of perfect performance. We should feel privileged when they share it with us.

McHugh leaves us with the athletes answering the question—after their painful recoveries, and after, in the case of Mendoza, the IOC struck down her lifelong dream to compete in the Olympics—“Would I have my body changed to be an elite gymnast?”

Although I retired from competitive elite track and field, I still run every day. I have to run every day. I often ask myself what I would do if I lost the ability to run. I don’t like to think about the answer. Mendoza and Moracheva almost lost their ability to be gymnasts, to be who they are. Science gave them back their sport, their identities. Would they still be Jinky and Svetlana if they were no longer gymnasts?

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