(Brainstorm)
AAS, scientific research and the effectiveness of forbidding and
punishing

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 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 does:
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
(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 cardio-vascular
disease, genetic determinants of cancer and, most of all, the lack
of undisputable 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
antypiretic 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.

<a
href="https://www.ncbi.nlm.nih.gov/sites/myncbi/1H_mfsx5KaD/collections/58752550/public/">View
my collection, "Anabolic androgenic steroids" from NCBI</a>

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.
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/496600

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.
https://www.thieme-connect.com/products/ejournals/html/10.1055/s-2007-965808

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. https://www.ncbi.nlm.nih.gov/pubmed/26074749

Introduction

What do athletes, users and potential users think about AAS

The state of the art: information about AAS and AAS use in the scientific literature

Extreme legal measures against AAS use

What are the legal alternatives?

Concluding remarks

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What do athletes, users and potential users think
about AAS

The state of the art: information about AAS and
AAS use in the scientific literature