Introduction
There is an abundance of negative claims and evidence about the effects of AAS. These claims and evidence are much more visible and accessible than those about the beneficial effects of these substances. The consequence of this discrepancy is a state of misinformation.
I am not the first nor will be the last person to lament the results of dogmatic, moralistic, judgmental, emotional and profit-driven approaches to health practices. It is naïve, though, to insist that dogma, morals, interests (economic, religious, political) and “normative perspectives” (judging) don’t belong in science. We teach students according to the neutrality ethos but the truth is that interests have always been there. Why wouldn’t they stand out when research is about some hot topic? That’s when it gets out of hand and we end up with more harm than good. We end up with “bad drugs”, “bad foods”, “bad behaviors” when we don’t even completely understand their structure, their mechanisms of action and all the things that we should understand.
Methodologically sound research may result in recommendations such as “it’s not a good idea to consume thalidomide during pregnancy because it can have some seriously nasty effects on embryonic and fetal development” or “this weight management drug, DNP, is actually a poison: it uncouples oxidative phosphorylation in mitochondria and kills the vertebrate”.
Unfortunately, that is not true for several other drugs. The scientific community tried to prevent interests that could harm research neutrality: journals adopted guidelines concerning total disclosure of research funding, for example. It was not enough.
The example I will explore here is particularly harmful to the sports community: anabolic androgenic steroids. The media and the sanctioning bodies executives are quick to point their judgmental fingers to athletes who have “abused” steroids. That would be not so bad if the medical community was not frequently also judgmental, in some cases denying treatment to athletes who test positive for AAS. In line with them, families, schools and society at large also condemn users and abusers.
Most physicians are not researchers and, unfortunately, in the case of AAS, frequently react just like your average lay person: “these are bad drugs”. If questioned, most will list several side effects AAS don’t have, deaths caused by AAS, inexistent consensuses and ignore research on beneficial effects of this class of drugs. Researchers have provided a small body of literature concerning these “other” effects but not many will go into this rabbit hole. Researchers follow external agendas whether they want it or not. They need to persuade funding agencies, departments, they need to get hired and then tenured, and all this comes at a price.
Is it the physicians’ fault? Not really: it would take about 20 hours of reading primary sources every day for a physician to keep up with the literature in his field. They are fed information by “interested parties”.
Is it the researchers’ fault? Not really: one needs to pay the bills and keep a job. That frequently requires one to give up the pursuit of some questions.
Regardless of whose fault it is, the result is that society is over-exposed to the “demonizing” version of AAS effects. Laws were passed to make it illegal to even produce many of them in certain countries, to prescribe them except in rare clinical cases and to possess them. Rules (and laws) were passed to punish those who have AAS metabolites in their blood.
Users and potential users do what anyone does under a heavily moralistic crusade do: they hide. In hiding, they share misinformation, myths, and recipes. Frequently, recipes for disaster.
Forbidding and persecuting people because of “something” usually generates a large amount of misinformation about that something. Since sound decision-making is based on good quality and quantity of information, decisions about AAS use are often poor decisions.
Stories about how the dry laws fueled alcohol business and how forbidding young people to have sex resulted in unwanted pregnancies abound. It is often accepted that forbidding something usually results in misuse of that something or misacting that behavior. It is also often accepted that the more accessible information is provided, the less unwanted effects are observed.
In 2006, a strength coach (background in physical education, registered with the Federal Council of Physical Education) and a nutritionist (background in nutrition, registered with the Federal Council of Nutrition) from Brazil co-authored and published a book about AAS use. Their declared and genuine reason for doing that was that since kids were going to use the drugs anyway, they might as well teach them how to not get seriously harmed. The book contained taboo information such as what is stacking, what stacking makes sense and what doesn’t, effective doses, how to choose and how to inject. This approach is internationally known as “harm reduction” (see curated collection of sources below): we assume something potentially harmful is and will continue to be done. Instead of hunting down those who do it, we offer education, syringes and places they can crash while intoxicated, for example.
The book was published, both Federal Councils got the books confiscated and proceeded to disciplinary hearings with the objective of punishing the coach and the nutritionist. Lawyers reached out to reputable members of the coaching, sports nutritionist and sports medical communities for simple reference letters to support the “character” argument. Few supplied them. I wrote a four-page letter explaining health communication and harm reduction. The authors and I became best friends forever. They were both punished by their Councils. The books are shared to this day on pdf format in underground digital communities.
That experience taught me a few lessons: first, the Councils have anything in mind except the best interest of patients and citizens. Second, instead of closing ranks and demanding that the Councils (which we pay for and which we vote for) drop all charges against the authors of the “damned book”, most people preferred to sit and watch as the two were burned at the stake. Third, potential users and users were pushed back into the darkness of the dark corners of the internet to obtain information. We all know that there is no quality assessment for digital publication. Users were unassisted, unequipped to handle technical information and abandoned.
What do athletes, users and potential users think about AAS
Users have inaccurate knowledge about AAS clinical effects, side effects and long-term consequences of use. There is an abundance of misconceptions and AAS use is rarely prescribed by physicians.
In this state of affairs, we don’t have an accurate idea of how much and what type of information users have or need. There are a few survey studies (below) that suggest AAS users are predominantly non-athletes using the drugs for cosmetic reasons, in high doses and polypharmacy (a combination of several drugs), using hazardous injection techniques and with poor knowledge concerning side effects.
My own unsystematic observation up to now has provided a scary scenario. Here is where it comes from:
- Occasional visits to underground steroid forums (if done systematically, this is called “digital ethnography”)
- Questions asked to me
- Exchanges of information with other professionals
- Public manifestations from users and potential users
- Behaviors that I have personally observed
With the exception of a few individuals that participate in those forums and provide high-quality technical information in plain language, the majority of AAS users are highly misinformed. For clarity, I will add (F) for “false”, (I) for “inaccurate” and (C) for “correct”:
- Have an idea that AAS are usually “testosterone analogs” (C). Many, especially women, are quite confused on that matter and believe that some AAS are not related to testosterone (F) and are, therefore, “female-friendly” (F). This is particularly true for oxandrolone and stanozolol. I’ve heard that from women suffering from severe virilization side effects.
- Believe that AAS will give them an advantage (C) but they don’t know how. They just “know” that AAS will make them stronger, bigger or faster (I);
- Believe that some AAS are “really dangerous” while others are “light” (F). Again, that is particularly true for women with oxandrolone and stanozolol, both of which are 17-alkilated compounds that often result in liver toxicity. Trenbolone and anadrol, on the other hand, will kill you (F).
- Feel that someone is lying to them (C), but they don’t know exactly who.
- Follow the prescription provided by the forum (they usually elect one “knowledgeable” member), by the dealer or by a friend (sometimes the coach).
- Believe that any drug test can be beaten (F). I have collected a few recipes. One of them, provided to me as a “sure thing” was ingesting detergent or even the hotel soap a few hours before the drug test. The detergent would bind to the testosterone analog metabolites and end up in their bladder as this new compound, undetectable by the chromatograph (F).
Some users:
- Hold on to the belief that “the more, the better” (F). It is hard to discuss the concept of dose-response with them.
- Don’t take the risk of hypogonadism seriously. These are the ones at the highest risk. Also, they believe hypogonadism is necessarily a temporary condition (F) easily handled by and “off” season with a few cheap drugs such as mesterolone (proviron) (F).
- Are convinced that the heart attack or cancer that killed some people they knew were caused by AAS (I). Well-meaning approaches about metabolic syndrome, obesity, diabetes, the natural history of cardiovascular disease, genetic determinants of cancer and, most of all, the lack of indisputable evidence concerning a causal relation between AAS and said disorders is met with rejection. From then on, AAS become evil drugs.
Several non-users who know about the existence of AAS:
- Are convinced that most sports supplements have “hidden AAS” in them (F/I). They are unimpressed by economic arguments, such as that the “contaminated” creatine would be the cheapest source of AAS in the history of AAS.
- That “those powders” (protein powders) contain evil drugs and probably AAS (F).
- Are convinced that AAS users usually die of liver failure (I). I don’t remember how many times I heard this version of reality. I do remember that one of them was from a physician-researcher that I held in great respect, who came from a reputable school, who was the head of his department and had both a MD and a Ph.D.
This item could easily take eight thousand words or more. I’ve had friends instructing me to apply nandrolone to a muscle tear to speed up the healing; I’ve seen friends gulping down about 1g of anadrol (20 pills) because they “forgot to take it yesterday”; I’ve seen friends shooting testosterone suspension with a couple of anti-inflammatory and antipyretic pills right before a meet because it’s fast-acting but hurts like hell.
The state of the art: information about AAS and AAS use in the scientific literature
There are evidence-based publications concerning AAS harmful side effects but there is also a small body of published evidence concerning their beneficial effect. Considering their quality and content, much more research is needed to reach any consensus. Here are some of the findings.
A Pubmed search with the search terms “anabolic androgenic” in the title/abstract resulted in 1654 entries. Of the first 40 articles, only four were not about AAS harmful effects or even about “AAS abuse disorder”. It doesn’t get any more balanced as we proceed.
View my collection, “Anabolic androgenic steroids” from NCBI
Effects and side effects in this collection include: psychopathology, cardiac stress, sudden cardiac death, liver cancer, pancreatic hyperplasia, hypogonadism, neurotoxicity, gynecomastia, dementia, kidney disorder, unsafe sexual behavior, violence and much more.
The problem with this body of published work is its lack of epidemiological relevance. Most catastrophic effects were individual cases reported as case studies. Since it is unethical to conduct pharmacological experiments expecting harmful effects in humans, the only experimental studies were conducted in animal models which may or may not be applicable to humans. The few studies that actually investigated “clandestine users” surprisingly found none of the horrible effects from the article titles. In a study that followed 20 AAS users (bodybuilders) for two years (Benetti et al 2008), all that was detected were asymptomatic atherogenic modifications in the lipid profile, lower sperm count and slightly higher liver function indicators. A study about AAS related deaths (Frati et al 2015) that examined the medical literature reporting them found 19 cases between 1990 and 2012. Nineteen cases in 22 years: there is no way to make a case for a public health emergency with this. Psychiatric studies show a higher incidence of “major mood disorders” among AAS users (Pope & Katz 1994): 25% of users displayed at least one episode during the study compared to 18% of non-users. Wait: 25% versus 18%? The study is well-written, the research was clearly well-funded and there is data about psychiatric illness symptoms dose-response to AAS use. However, one can’t help but take the conclusions with a grain of salt.
There is a small body of research about beneficial effects of AAS reported in humans and some potential beneficial effects from animal models. They include increased bone density, muscle hypertrophy, faster bone healing, increased satellite cell production, prevention and reversion of sarcopenia (and osteopenia), improved mood, improved cognitive function, improvement of sexual desire and function, beneficial changes in body composition, systemic lypolisis, overload hypertrophy (lasting effect after single exposure to AAS) and reversion of hypogonadism. Most of these studies were conducted in aging men and women or in patients with specific disorders (hypogonadism, sarcopenia, HIV, sexual dysfunction). There are few studies on healthy adults. The obvious conclusion is that much more research is needed to reach any consensus.
Extreme legal measures against AAS use
AAS possession, without a prescription, is illegal in many countries. Some countries are abusing the law. Why?
The history of the legal war on steroids has been covered by different authors. Drug control is obviously more recent than drugs, which have been around for a couple of thousand years. Each country has their own drug regulations and they are enforced as any law.
Like many controlled drugs, AAS are used without prescription and users try as best as they can to not get arrested and charged.
Since the early 2000s, a few European countries, ironically known for their respect for human rights (Belgium, Sweden, Denmark and Norway), started to implement a radical form of AAS use law enforcement that came to be known as “muscle profiling”: muscular individuals can be forced to submit to a drug test and face prosecution. Several bodybuilders have been arrested on this basis and foreign bodybuilders are warned that they are “not welcome”.
In Denmark, for example, any person that becomes a member of any gym signs an agreement to comply with the national anti-doping agency (created to monitor elite sports). Similar initiatives are underway in Sweden and Norway.
Drug testing is not cheap. Why are these countries willing to pay such a high price to hunt down AAS users? What damage are AAS doing to their societies?
An excerpt from an article you can find in the collection below is particularly significant:
Performance and image enhancing drug (PIED) is deemed as morally reprehensible by the general population, and therefore a practice that should be banned and criminalized (…). However, there seems to be a tendency amongst policy makers to frame steroid or PIED use outside of elite sport as an issue within sport, and to call for the same types of policies that are being used in anti-doping (Mulrooney & van den Ven 2015).
As much as I dug into legal documents and police accounts of the arrests resulting from muscle profiling, I couldn’t find the answer to the basic question: what is the social damage being deterred by this policy? Apparently, none. As the article excerpt above words out, AAS use is “deemed as morally reprehensible by the general population”. If there is no social damage (people causing car accidents for driving intoxicated, committing gun-related crimes or sex offenses), not even alleged, not to mention proved to be caused by AAS, then we must assume there are undeclared or irrational motives.
The first question I asked a couple of law scholars with experience in international comparative analysis is how these arbitrary acts can happen with no legal backlash? Don’t they hurt these countries’ constitutions? I have no answer.
The second question is unanswerable: in a multi-cultural society, who is the authority to determine if something is “morally reprehensible” to the point of creating a set of legal instruments to punish violators?
Once upon a time having sex with someone of the same sex was “deemed morally reprehensible” and therefore was “banned and criminalized”. With the progress of secularization in democratic societies, anachronic anti-gay laws disappeared.
The use of drugs or engaging in behaviors considered “dangerous” is a serious political, cultural and legal can of worms. Why should anyone be forbidden to engage in dangerous behaviors if there is no societal damage? And if there is a reason, who decides that? We haven’t established that AAS are dangerous in principle, though. There is some level of agreement that they may be, depending on dose and frequency, as dangerous as thousands of other commercialized drugs and substances that are not subject to such harsh persecutory measures.
What are the legal alternatives?
Drug legalization, the war on drugs and harm reduction: how do AAS fit in?
Three things can be done concerning AAS use at the social level: keep it criminalized, hunting down and punishing users and dealers; adopt harm reduction strategies; legalize (or decriminalize) them. An educational component could be added to any of the three approaches but they are qualitatively different.
Harm reduction is defined as the strategy or set of strategies whose primary goal is the reduction of the harm caused by a risky behavior rather than the reduction of the behavior itself. It is based on evidence that such strategies result in a stronger decrease in harm induced by the risky behavior than those whose goal is to deter or prohibit the behavior itself. Harm reduction is impossible unless some level of decriminalization is adopted by the country. The collection below contains one article by McVeigh and collaborators (2016: Harm reduction interventions should encompass people who inject image and performance-enhancing drugs) that argues for harm reduction for AAS use.
Decriminalization and legalization is a whole new can of worms that we’ll leave for another occasion (or never). For those interested, I have added a curated collection (below) with documents related to legalization and decriminalization initiatives and the harmful effects of the war on drugs.
Concluding remarks
My preliminary conclusions about AAS use, misuse and abuse point to a more social-cultural than a true public-health problem. I believe there is scientific evidence for the development and persistence of AAS abuse soon after this class of drugs was available. I don’t see evidence that AAS abuse is any more damaging than other substance abuse behaviors. Actually, I can’t find evidence for social damage similar to what has been suggested (and supported by correlation, even if not causation) for alcohol, cocaine, crack or opioid abuse. I can’t find evidence of extreme danger such as can be found for other commonly abused drugs such as insulin, diuretics or thermogenic substances.
I can circumscribe a distinct body of evidence about the existence of AAS harmful health effects. If they are the side effects or the target effect is a matter of how observation is framed. Molecules don’t come with instruction manuals. Society (since long before the existence of institutionalized medicine) decides there is something to be cured or a desired condition to be achieved and then identifies something that has biological action in the human body related to that. Usually it has many other effects. In the case of AAS, there are several harmful effects. There are several beneficial effects, also well substantiated by research.
I can also see the blank space that is usually filled with “more research is needed on this subject” instead of a law prohibiting a behavior.
There is no possible scientific evidence to support a “morally reprehensible behavior”. Morals don’t belong in science and should not inform scientific agendas. Ethics are a different matter (as in not performing harmful human experimentation).
Since I am not a law scholar I defer to others’ expertise on the matter. Apparently, AAS regulatory apparatus is not very convincing.
Unfortunately, we are left with no answers to the important questions and with a huge group of people potentially vulnerable to the harmful effects of this chapter of the war on drugs. The victims, as always, are the users.
References
Pope, Harrison G., and David L. Katz. “Psychiatric and medical effects of anabolic-androgenic steroid use: a controlled study of 160 athletes.” Archives of general psychiatry 51, no. 5 (1994): 375-382.
Bonetti, Antonio, F. Tirelli, A. Catapano, D. Dazzi, A. Dei Cas, F. Solito, G. Ceda et al. “Side effects of anabolic androgenic steroids abuse.” International journal of sports medicine 29, no. 08 (2008): 679-687.
Frati, Paola, Francesco P Busardo, Luigi Cipolloni, Enrico De Dominicis, and Vittorio Fineschi. “Anabolic androgenic steroid (AAS) related deaths: autoptic, histopathological and toxicological findings.” Current neuropharmacology 13, no. 1 (2015): 146-159.