title: Between medical treatment and performance enhancement: an investigation of how elite athletes experience Therapeutic Use Exemptions.
abstract: BACKGROUND
  Athletes can be allowed to use substances from the prohibited list (the doping list) if they have a medical condition. If so, a Therapeutic Use Exemption (TUE) is required. The boundaries between the use of pharmacological substances due to a medical need and doping are sometimes blurred. Although manipulating the system of TUE granting potentially represents an entry stage for doping, few studies examine how athletes perceive TUE management and relate this to current anti-doping policy.
  
  
  METHODS
  645 Danish elite athletes (mean age 22.12, SD=5.82) representing 40 sports completed a web-based questionnaire about their experience and perception of TUE (response rate: 43%).
  
  
  RESULTS
  19% of the respondents had been granted a TUE. 85% of athletes granted a TUE regarded their use of the TUE system as necessary to compete on equal terms with other athletes. Administrative hurdles for TUE prevented 7% of athletes from applying. 53% of the athletes considered that being "allowed" to dope by means of a TUE was of importance for their (hypothetical) wish to try out doping. 51% believed that athletes in their sport received TUEs without a medical need. Athletes granted TUEs had more than twice as high odds to distrust the efficacy of the system than athletes never granted a TUE. The belief that TUEs were misused was especially common among endurance athletes, regardless of them having experience with TUEs or not. 4% believed it would be okay to receive a TUE without a medical need.
  
  
  CONCLUSIONS
  The results confirm that TUE is a problem in anti-doping policy. The fact that distrust in TUE administration increases once an athlete has experience of TUEs represents a challenge for anti-doping policy. We suggest more critical research on TUEs be carried out in order to improve harmonization and increase transparency in the regulations.
authors.affiliation: Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark. Electronic address: moverbye@ifi.ku.dk.
authors.forename: Marie
authors.initials: M
authors.lastname: Overbye
authors.affiliation: Department of Leadership & Corporate Strategy, University of Southern Denmark, Denmark.
authors.forename: Ulrik
authors.initials: U
authors.lastname: Wagner
mesh_terms: D000293:Adolescent; D000328:Adult; D056352:Athletes / Q000331:legislation & jurisprudence / Q000523:psychology*; D054874:Athletic Performance / Q000331:legislation & jurisprudence / Q000523:psychology*; D003718:Denmark; D004300:Doping in Sports / Q000331:legislation & jurisprudence / Q000523:psychology*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D020407:Internet; D008297:Male; D010465:Perception; D058573:Performance-Enhancing Substances / Q000627:therapeutic use*; D011795:Surveys and Questionnaires; D035502:Trust; D055815:Young Adult
chemical_list: D058573:Performance-Enhancing Substances
keywords: Athletes’ attitudes; Doping; Sports medicine; Survey; WADA; World Anti-Doping Code