“Well, I am certainly wiser than this man.  It is only too likely that neither of us has any knowledge to boast of; but he thinks that he knows something which he does not know, whereas I am quite conscious of my ignorance.  At any rate, it seems that I am wiser than he is to this small extent, that I do not think that I know what I do not know.”                                                                                  —Plato, Apology

Rest assured: recognizing the existence of uncertainty or confessing to lack knowledge on a given subject doesn’t make one’s position any weaker.  One could do worse, after all, than take the lead from Socrates, who posited that awareness of one’s ignorance is a step along the path of learning.

In that spirit, here’s some stuff I don’t know:
●    What actually happened that day: what the relevant parties said, thought, felt, or did (beyond what is represented in the IADT & CAS reports).
●    If Viktor Troicki has ever used PEDs or was doping in April 2013.  (Some will argue that this is the only thing that matters & since Troicki didn’t submit blood for testing that day, he himself forestalled further discussion of the case.  Obviously, I disagree with that position.)
●    Whether Troicki &/or the DCO deliberately misrepresented anything (to anyone) on the days in question or in their subsequent testimony.
●    Anything about the DCO involved other than what’s contained in (and can be deduced from) the two decisions.
●    What was in the written statements submitted on behalf of the parties or the oral testimony of witnesses at either hearing, unless it was quoted in the case summaries.
●    What I would have done in the position of any of those concerned.
●    Many, many other things—for instance, what’s in appendices two, three, five, or six of this rather lengthy TADP document.

However, since the end of last July, when Troicki’s suspension was first announced, I’ve filled in a few gaps in my knowledge.  At this point, I should probably note that while my blog’s name is a reference to Lucy van Pelt’s sideline offering psychiatric advice, I am neither a medical doctor nor a psychologist.  Luckily, one doesn’t have to be a board-certified MD or a licensed mental-health provider to enter the phrase “needle phobia” into an internet search engine.  Here’s what I learned in a matter of minutes, thanks to Google.

●    “Needle phobia” is the common name for a specific phobia of the “blood-injection-injury” type.  Specialists estimate that between 4-10% of the population suffer from it.
●    A specific phobia—called that because it is an “unwarranted fear of specific objects or situations”—is, in turn, a subset of the broader category anxiety disorder.  As probably goes without saying, both the specific blood-injection-injury phobia and anxiety disorders are medically-recognized conditions, the criteria for which are outlined in professional guides such as the Diagnostic and Statistical Manual of Mental Disorders.
●    Blood-injection-injury phobias (BIP) are marked by “a strong, persistent fear that is excessive or unreasonable,” and can be triggered by not only a present object (e.g., a needle) but also an expected procedure.  Whatever the specific stimulus, the response is anxiety, with physical discomfort and distress that can be severe—that is, a panic attack &/or loss of consciousness.  According to one clinician’s guide, “A person who must face one of these feared activities or objects will immediately begin to feel nervous or panicky, a condition known as anticipatory anxiety…. When it causes a patient to avoid feared situations, anticipatory anxiety can be a major inconvenience; it can even interfere with working” (259).  That the person may be aware his/her fear is “out of proportion to the actual danger or threat in the situation” doesn’t mean he/she has the power to control his/her response to it (6).
●    The condition—aspects of which can be genetically inherited, as well as learned—is a “neglected diagnosis,” in part because people who suffer from it “typically avoid medical care.”
●    Physiological symptoms associated with BIP include: sweat, muscle tension, trembling, heart palpitations, numbness, nausea, dizziness, lightheadedness, pallor, and difficulty breathing.  (While I consulted more authoritative sources than Wikipedia, much of the essential information is on that site.)
●    Significantly, BIP is also the only variety of specific phobia associated with vasovagal response, a type of neuro-cardiac episode involving decreased heart rate &/or blood pressure which can result in fainting.  Even if he/she doesn’t faint, a person suffering from a vasovagal episode “may experience an almost indescribable sensation of weakness or impending doom” (9).
●    As scientific studies have observed, BIPs “can be so severe that they interfere with receiving necessary medical care.”  Also, unlike patients with other kinds of phobia, those who suffer from BIP “are typically less responsive to relaxation techniques, which in fact may be counterproductive.”
●    Because BIP can cause fainting, falls, & associated trauma, it’s important that those drawing blood from a needle-phobic patient be aware of the condition and have ready assistance.

With this information at hand, let’s return to Pete Bodo’s assessment: “Personally, I have some trouble buying the idea that a strapping, 6’3” professional athlete in the full bloom of health is so squeamish that he can’t give blood.”  In concluding his post, Bodo observes, “The reality is that not you, not I, not even the great former No. 1 and six-time Grand Slam champion Novak Djokovic, really knows the truth about how and why Troicki decided to skip that blood test.”  He’s not entirely wrong, is he?  We don’t know the whole truth: after all, none of us were in the room or, more importantly, in Troicki’s body that day.  But here are a few things someone even minimally curious about blood-injection-injury phobia does know: that it’s not about being “squeamish” (consider both the imprecision and connotation of that word choice, if you will); that one of the three basic criteria of the condition is avoiding needle procedures altogether or, when unavoidable, enduring them with considerable distress; and that, yes, a professional athlete—whether “strapping” or not—can suffer from it.  That’s the thing about such medical disorders, which (in Troicki’s and some 75% of needle-phobes’ cases) have both inherited physiological and learned psychological components: they don’t discriminate.  And they don’t cease to exist or cause real difficulty in people’s personal and professional lives because some unaffected others are resistant to “buying the idea.”

While Bodo is certainly not the only tennis expert to establish himself as something less than that when it comes to needle phobia, his invocation of Troicki’s size, strength, and line of work in expressing his skepticism does considerably more harm than others’ inaccuracy or silence on the subject.  For starters, Bodo is among the most accomplished and respected of anglophone tennis writers; so, his word carries more weight than it might if he had a lesser reputation or smaller platform.  Next, he perpetuates ignorance and incuriosity about a mental-health condition by displaying his own—if not proudly, then certainly without hint of self-consciousness.  Further, he reinforces the stigma associated with the condition by implying it’s a kind of weakness.  (Although Bodo didn’t go the extra step of telling the Serb to “toughen up,” plenty of others suggested precisely this as a solution; one example is in the first reader question to which Tignor responds here.)  Not merely privately doubting but publicly questioning if Troicki—neither a tennis aesthete nor one of the WTA’s “tear-stained drama queens” but, let’s face it, a manly man—really suffers from an occasionally debilitating anxiety disorder speaks volumes about Bodo’s assumptions about physical ability, gender, mental health, and the relationship between them.  More than that, it speaks to the freedom people feel to judge and dismiss things they don’t understand.

This sort of attitude wouldn’t be so troubling if it weren’t so common.  That it is, unfortunately, so can be seen in many pop-cultural spheres, though sports appears to be lagging behind other parts of the entertainment industry when it comes to mental-health awareness.  Not incidentally, one of the best pieces of sports writing I read last year is “Man Up,” an essay Brian Phillips wrote on masculinity and mental health in response to a bullying scandal in the National Football League.  Tennis is not the NFL, and the mere fact that the former is an international, individual sport in which women and men compete alongside one another—on the same courts and, often, for equal prize money—means that there is more awareness of and sensitivity to difference than there might otherwise be.  But, as I’ll discuss in the next lesson, tennis is hardly ahead of the athletic pack when it comes to tackling mental-health issues among its ranks.

That Viktor Troicki suffers from a needle phobia—as opposed to being a person who simply “doesn’t like giving blood” or “didn’t want to provide a sample that day for his own personal reasons,” per Richard Ings’ characterizations—is abundantly clear from the IADT summary.  And if one doesn’t want to take Troicki’s word for it that “the giving of blood is something that he faces with trepidation and that induces feelings of panic,” that he has fainted during the procedure in the past, and “that he feels unwell for the rest of the day after” the process, there’s the testimony of Professor Slobodanka Djukić.  A specialist in microbiology and immunology who has treated Troicki in Belgrade, Professor Djukić confirmed that he “reported dizziness with vertigo, nausea and chest pain following the taking of blood samples” (B9I).  We might know even more about his condition had the IADT or CAS quoted from the statement the FFT’s Dr. Bernard Montalvan submitted on Troicki’s behalf.

Since neither the original decision nor the appeal went into much detail about how Troicki has responded to previous needle procedures as an ITF athlete undergoing required anti-doping tests or a human being seeking routine medical care, I decided to look into it myself.  Taking a bit more time than in my initial Google search, I gathered the following information about the condition.

●    Blood-injection-injury phobia—in part because it was only added to the DSM in 1994 and in part because people wrongly assume it’s “a simple issue”—is poorly understood and often dismissed, even by health-care professionals.  Still, as this clinical psychologist notes, “Good management of needle phobia can literally save lives.”
●    One of the challenges of researching BIP is that “the physical body is studied ‘in pieces’ in a number of different disciplines…. This is very apparent when reviewing the quantitative literature in and around needle phobia.  Classification as a specific phobia places needle phobia within the realm of psychology and psychiatry… and yet this is a fear that is accompanied by wide ranging physiological responses” (21).  In other words, while BIP isn’t “all in your head,” it is often regarded as the exclusive concern of proverbial “head-shrinkers.”  Several of the pieces I read indicated that needle-phobes are actually (even if not consciously) afraid of vasovagal syncope, not needles or blood—that is, of their body’s response, not the procedure in question.
●    Though many who suffer from BIP simply try to avoid triggering stimuli (e.g., by staying away from doctor’s offices), the condition can also be managed through alternative injection methods; with medication, from topical anesthetics & anti-anxiety drugs to sedation; and in therapy, particularly of the cognitive-behavioral variety.  Matthews notes that stories about treatment suggest “therapy, at best, needs to be highly individualized and is both very time consuming, expensive, and has variable success” (13).
●    Specific tips for managing phobias can be found here.  It bears repeating that trying to get someone who is needle-phobic to relax may well be the wrong thing to do, as it can actually increase the possibility of fainting.
●    A cognitive-behavioral psychologist I consulted recommended this title from the self-help aisle (and I can attest it makes perfectly decent airplane reading): Overcoming Medical Phobias: How to Conquer Fear of Blood, Needles, Doctors, and Dentists.
●    Unfortunately, “doctors, nurses, and other people tasked with administering vaccinations and drawing blood are not typically properly educated about needle phobia.  They’re accustomed to patients who dislike needles and may reassure them with promises that the puncture won’t hurt or will only take a minute.  But with a true needle phobic, these reassurances don’t work.”
●    As I wish went without saying, “the behaviour, skill and care afforded by health practitioners makes a significant difference in both preventing the development of needle phobia in children… and in lessening the phobic response and reported fear of adults” (13).  Chapter six of Matthews’ study offers recommendations for clinical practice, “in terms of [both] caring for patients with needle phobia and supporting and assisting nurses to provide expert technical and pathic care” (96).  Perhaps someone who works for the ITF &/or IDTM should read it.
●    Some evidence to support the claim that everything’s on YouTube: video tips for medical professionals who deal with patients’ fear of needles during the phlebotomy process.  Of course, not all such fears meet the diagnostic criteria for BIP.
●    Last, but not least, more needle-free procedures may soon be in our future.

What I take away from all of this is that there was nothing in the least unusual about Troicki’s seeking to avoid a needle procedure on that April day—or, for that matter, on any other.  Ings is no doubt correct when he observes, “seeking a pass that day was not necessary.”  At the same time, a statement like this fails to take the nature of the phobia into account.  Although it may not have been medically necessary “to skip it this time,” it clearly felt necessary to Troicki; in his words, he was “not able” to give blood (3.15C).  People with untreated BIP never want to give blood; they’d always prefer to bypass needle procedures—such is the condition.  In a case like this, where occasional blood testing is one of his professional obligations, Troicki has to cope with his condition better than he did that day.  This might be easier for him to do if he sought treatment (for all I know, he has done so over the past year).  In all likelihood, his condition would also be easier to manage if Viktor felt confident that the BCOs with whom he interacts on the job had been trained to deal with the challenges to the routine process someone like him poses.

There are so many “what if…?” questions we could ask about how the circumstances and outcome of that encounter might have been different.  What if Troicki had only been selected to give a urine sample that day?  What if he weren’t already feeling physically ill?  What if he’d encountered a DCO less inclined to be sympathetic and accommodating (this is not my view but, rather, how both Troicki and the CAS interpreted her behavior; see 9.12-14 and 9.28C) and more inclined to speak in authoritative, unequivocal terms about the seriousness of the situation?  I’m sure anyone reading this can think of other such questions.  The hypothetical question I think is most important (because it has implications far greater than Troicki’s one-year suspension) is this: what if the ITF recognized that needle phobia is a psychological disability that needs to be accommodated—for example, by modifying sample-collection procedures, as the International Standard for Testing, adopted by WADA signatories, allows for other forms of disability (see Appendix Four, section 5.4 and Annex B)?  I’ll return to the issue of disability in sports in lesson 4.

As I said at the outset, I don’t blame the DCO for not having been better prepared to handle the predicament last April.  It’s not her fault that “this was the first time [in 15 years of anti-doping work] that [she] found herself in the precise situation which she faced with Mr Troicki” (29aI).  (For that matter, we don’t even know if “the precise situation” refers to dealing with a player who’s requesting to get out of or delay giving a sample, dealing with a needle-phobic player, or both.)  Going forward, however, I will blame the ITF if they do little to learn from what transpired that day.  That writers weighing in on the subject, or other players and fans opining on it, could also stand to learn a bit more is fairly obvious from responses to Troicki’s case.  But the stakes of their not knowing relevant things—and, in many cases, seeming not to be aware they don’t know—are much lower.  Regardless, all those responding, whether formally or informally, would benefit from practicing empathy, the focus of lesson 3.  (Return to the discussion overview here.)