The sports landscape in 2026 is characterized by a tension that affects athletes, doctors, and society alike. On one side are major events such as the Olympic Winter Games in Cortina, where discipline, fairness, and a willingness to perform are still considered central values. On the other side, the so-called Enhanced Games are pushing into the public eye, a format that deliberately challenges these values and blurs the lines between sport, medicine, and pharmacological performance enhancement.
The Enhanced Games, planned as a multi-sport event in Las Vegas, explicitly allow participating athletes to use performance-enhancing substances. The organizers argue with the principle of bodily autonomy. However, from a medical and sports ethics perspective, this argument is oversimplified and potentially dangerous. Not without reason, the WADA (World Anti-Doping Agency) has condemned the format as "dangerous and irresponsible," and the IOC also warned that such a concept would destroy any foundation of fair play in sport.
Therapy or Enhancement? A Distinction with Far-Reaching Implications
The central problem lies in blurring a medically and ethically fundamental distinction: the difference between therapy and enhancement. In medical ethics, therapy refers to restoring a healthy normal state, while enhancement refers to deliberately increasing abilities beyond their natural level (Juengst et al., 2018). This distinction is not an abstract construct but has immediate clinical relevance.
Testosterone therapy is a good example: In men with hypogonadism, meaning laboratory-confirmed testosterone deficiency with clinical symptoms, hormone replacement is a guideline-compliant medical measure. The Endocrine Society explicitly recommends in its guidelines that the diagnosis should only be made with consistently low serum testosterone levels and corresponding symptoms (Bhasin et al., 2018). The goal is clearly defined: restoration of a physiological hormone range and improvement of quality of life.
The TRAVERSE study, one of the largest randomized studies on the cardiovascular safety of testosterone replacement therapy, showed that guideline-compliant replacement in men with hypogonadism is not associated with an increased risk of major cardiovascular events (Lincoff et al., 2023). These results underscore that if testosterone therapy is indicated and medically supervised, it is a safe and evidence-based treatment.
Something fundamentally different is the supraphysiological administration of testosterone or other anabolic steroids to healthy athletes for performance enhancement. Already the groundbreaking study by Bhasin et al. (1996) in the New England Journal of Medicine showed that supraphysiological doses of testosterone in healthy men lead to dose-dependent increases in muscle mass and strength. But these effects do not come without a price.
Health Risks: What Research Shows
The scientific evidence on the health risks of anabolic steroid abuse is clear. Chronic supraphysiological exposure to anabolic-androgenic steroids (AAS) is associated with severe cardiovascular complications, including ventricular hypertrophy, myocardial fibrosis, atherosclerosis, and sudden cardiac death (Torrisi et al., 2024). Forensic studies regularly show pathological findings in AAS-associated deaths, such as left ventricular hypertrophy, coronary thrombosis, and dilated cardiomyopathy (Ferrara et al., 2025).
A comprehensive analysis in the journal Circulation confirms that anabolic steroid abuse is associated with increased mortality, with cardiovascular diseases accounting for a significant proportion of deaths (Horton et al., 2024). These findings do not only concern elite athletes. The global lifetime prevalence of AAS use in men is about 6.4%, and among recreational athletes, it is even 18.4% (Sagoe et al., 2014). The vast majority of users are not competitive athletes but young to middle-aged men who primarily use these substances for aesthetic reasons.
Societal Signal: Far Beyond Elite Sports
The impact of a format like the Enhanced Games extends far beyond professional sports. It sends messages to fitness enthusiasts, young men on social media, people insecure about body image, aging, and masculinity. The danger lies in medical science no longer being understood as a tool for treating illness, but as a tool for the systematic optimization of the healthy.
This concern is empirically founded. Pope et al. (2019) describe in the Journal of Clinical Endocrinology & Metabolism a "hidden epidemic" of AAS abuse among young men, closely linked to body image disorders. Muscle dysmorphia, a subtype of body dysmorphic disorder according to DSM-5, affects approximately one in four male adolescents and young adults to a clinically relevant extent according to current studies (Murray et al., 2025). Affected individuals using steroids show more pronounced body image disorders, more extreme training and diet practices, and overall more psychopathological abnormalities (Pope et al., 2019).
When a high-profile sports event not only tolerates but actively promotes the use of performance-enhancing substances, it reinforces precisely those societal dynamics that already endanger vulnerable groups. Medicine loses its primary focus on patient well-being in public perception and becomes part of a market for self-optimization and competitive advantages.
Autonomy and Dependence: An Ethical Conflict
Proponents of the Enhanced Games often argue for the right to bodily autonomy. This argument deserves serious consideration but falls short when viewed in isolation. Autonomous decisions require that they be informed, reflective, and as free as possible from social or psychological pressure. In the context of anabolic substances, this is often precisely not the case.
From a medical perspective, autonomy must always be considered in conjunction with the principles of beneficence, non-maleficence, and informed consent, as outlined in the principles of medical ethics by Beauchamp and Childress. A liberal approach to performance-enhancing substances is ethically difficult to justify when there are significant risks of dependence, misperception, and long-term health consequences. The bioethics debate on enhancement, as conducted by Savulescu and Kahane, for example, provides intellectually stimulating arguments for liberalization but often neglects the empirical reality of vulnerable populations (Juengst et al., 2018).
The Vonn Comparison: Injury Risk is Not the Same as Enhancement
A frequently raised argument is: If Lindsey Vonn is allowed to compete in an Olympic downhill race with a freshly torn cruciate ligament, there are hardly any arguments left against low-dose testosterone administration under medical supervision. This comparison seems plausible at first glance but falls short upon closer examination.
There is a significant difference between an athlete participating despite an injury, accepting an individual risk, and the targeted medicinal modification of performance as part of a competition model. In the first case, it's about sport despite health limitations, a personal risk decision. In the second case, it's about a systemic change in the logic of competition, which creates pressure to conform, promotes medical competition, and, in the long run, establishes the expectation that pharmacological optimization is the norm.
Furthermore, the term "low-dose" is misleading in this context. Even a low-dose exogenous testosterone administration in a eugonadal athlete represents a performance-relevant intervention. WADA grants Therapeutic Use Exemptions (TUEs) for testosterone only in narrowly defined exceptional cases with confirmed hypogonadism, and even then, strict conditions apply. The fact that another athlete competes at high risk of injury does not justify normalizing pharmacological enhancement in sport.
What We Hope For in the Debate
The discussion surrounding the Enhanced Games is not just a sports policy question but touches upon the fundamental understanding of medicine, health, and medical responsibility. Three aspects are particularly relevant:
First: Conceptual clarity. The debate can help to distinguish more cleanly between medical therapy, prevention, regeneration, and enhancement. This differentiation is often blurred in public discussion but is central to medical practice and patient decision-making.
Second: Awareness of vulnerable groups. It is foreseeable that young men, fitness enthusiasts, and people with performance or body image pressure will be particularly receptive to the narratives of such a format. The prevalence of muscle dysmorphia and AAS abuse in precisely these populations underscores the urgency of preventive measures (Pope et al., 2019; Sagoe et al., 2014).
Third: Protection of medical integrity. Especially in the area of testosterone, it is crucial not to let therapy be drawn into the wake of performance fantasies, lifestyle promises, or commercial oversimplification. Medically indicated testosterone therapy for confirmed deficiency must remain clearly separated from any form of enhancement, to protect those patients who need legitimate treatment.
Conclusion
The Enhanced Games may spark a critical debate about modern competitive sports. However, to conclude from the existence of abuses in the anti-doping system that pharmacological performance enhancement should be normalized is not a solution but a shift in norms with potentially far-reaching health and social consequences. As doctors, athletes, and society, we have a responsibility to clearly and consistently defend the line between medical therapy and performance enhancement.
Our Recommendations for You
If you want to delve deeper into these topics, you will find helpful practical perspectives in two episodes of our "Men's Health" podcast.
Dr. Golo Röhrken, physician and sports scientist with his own experience in triathlon and Ironman, talks in episode 97 about what really influences athletic performance, beyond substances and quick promises: Podcast #97: How to really optimize your performance
The question of where exactly the line between medically indicated therapy and doping lies is illuminated from a medical perspective by Dr. Eva Bunthoff (Board of NADA) and Jutta Müller-Reul in episode 76, one of the most well-founded classifications on this topic that we know: Podcast #76: Testosterone in competition: What is allowed?
Sources
- Bhasin, S., Storer, T. W., Berman, N., et al. (1996). The Effects of Supraphysiologic Doses of Testosterone on Muscle Size and Strength in Normal Men. New England Journal of Medicine, 335(1), 1–7.
- Bhasin, S., Brito, J. P., Cunningham, G. R., et al. (2018). Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, 103(5), 1715–1744.
- Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics (8th ed.). Oxford University Press.
- Ferrara, M., et al. (2025). Forensic approach in cases of anabolic-androgenic steroid abuse and cardiovascular mortality. Frontiers in Cardiovascular Medicine, 12, 1585205.
- Horton, D., et al. (2024). Cardiovascular Disease in Anabolic Androgenic Steroid Users. Circulation.
- Juengst, E. T., Moseley, D., & Greenberg, E. M. (2018). Limits to human enhancement: nature, disease, therapy or betterment? BMC Medical Ethics, 19, 4.
- Lincoff, A. M., Bhasin, S., Flevaris, P., et al. (2023). Cardiovascular Safety of Testosterone-Replacement Therapy. New England Journal of Medicine, 389(2), 107–117.
- Murray, S. B., et al. (2025). Muscle dysmorphia in adolescents and young adults. The Lancet Child & Adolescent Health.
- Pope, H. G., Kanayama, G., Athey, A., et al. (2019). The Health Threat Posed by the Hidden Epidemic of Anabolic Steroid Use and Body Image Disorders Among Young Men. Journal of Clinical Endocrinology & Metabolism, 104(4), 1069–1074.
- Sagoe, D., Molde, H., Andreassen, C. S., et al. (2014). The global epidemiology of anabolic-androgenic steroid use: A meta-analysis and meta-regression analysis. Annals of Epidemiology, 24(5), 383–398.
- Torrisi, M., et al. (2024). Impact of Anabolic–Androgenic Steroid Abuse on the Cardiovascular System: Molecular Mechanisms and Clinical Implications. International Journal of Molecular Sciences, 26(22), 11037.
