What Makes These Hormones
So Evil?
by John Williams
"Laws are like sausages. It's better not to see them being made."
Otto von Bismarck (1815-1898)
Introduction
In the United States, anabolic-androgenic steroids (AAS) have always
been considered drugs. Contrary to what today's young athletes may believe,
these substances were never stocked on the shelves of the corner grocery
store. However, only within the last decade have these drugs been classified
as "controlled substances," thereby placing them in the same general
category as more infamous drugs, including heroin, cocaine, LSD, and
methamphetamine. The purpose of this article is to examine some of the
social, medical and legal
forces which have driven these changes and which continue to influence
the use, abuse, and prohibition of anabolic-androgenic steroids.
What Led to the Classification of AAS as Controlled Substances?
Historically, AAS were classified as prescription drugs; they could
be dispensed only upon the order of a licensed medical practitioner,
who could then monitor their use and control individual dosages.1
Minors could not obtain prescriptions for AAS without the informed consent
of their parents or guardian. Since medical practitioners knew that
the administration of hormones could affect the body's natural development,
particularly in adolescents, they rarely prescribed AAS for minors,
except in cases of a genuine medical disorder. Thus, as we examine the
history of AAS and the progression toward their prohibition, we should
be mindful of the following:
- Anabolic-androgenic steroids were subject to government regulation
long before legislators decided to criminalize their use;
- Prior to the criminalization of AAS, proper dosages could be
prescribed and potential side effects could be monitored by trained
medical practitioners;
- Existing government regulation, a practitioner's medical judgment,
and the required consent of legal guardians have always stood as
natural barriers between adolescents and their use of AAS.
In June of 1889, Charles Édouard Brown-Séquard, a 72-year-old physiology
professor, announced at the Société de Biologie that he had injected
himself with extracts of dog and guinea pig testicles, resulting in
an increase in his physical strength and health; further research into
these purported effects led to the synthesis of
testosterone in
1935.2 During World War II, German scientists began to synthesize
other anabolic steroids, experimenting with human prisoners, as well
as with German troops, whose aggressive tendencies they hoped to increase.3
Adolph Hitler's personal physician reported that Hitler was given injections
of testosterone derivatives for various maladies.4 Ironically,
one of the initial therapeutic uses of AAS was treatment of chronic
wasting, such as was experienced by Nazi concentration camp prisoners.5
As early as the 1950s, bodybuilders and strength athletes began to
experiment with AAS. Soviet weightlifters demonstrated impressive strength
gains from the use of testosterone derivatives, and their secret was
passed on to the Americans at the 1954 World Championship.6
By the 1960s, the medical community was conducting controlled scientific
studies of the effects of AAS on strength and muscle mass.7
Early studies yielded promising results, but later research concluded
that no palpable strength or muscle gains resulted from the use of AAS;
recently, this trend has reversed, with scientists again finding that
AAS promotes strength and muscle gains.8 This discrepancy
in scientific findings leads one to wonder if some researchers intentionally
misrepresented scientific findings in order to discourage the use of
AAS for physical enhancement.
By the late 1960s, the use of AAS had become commonplace amongst
bodybuilders and strength athletes, a trend which was quite noticeable
in Olympic competition; the androgynous appearance of female athletes
from former Communist bloc nations was a regular source of bawdy humor.
In 1975, the Medical Commission of the International Olympic Committee
(IOC) added anabolic steroids to its list
of banned substances, and testing began at the 1976 Montreal Olympic
Games.9 The most notorious violation of the IOC's drug policy
came in 1988, when Olympic sprinter Ben Johnson was stripped of his
gold medal in the 100-meter after testing positive for the use of AAS;
another positive test in 1993 resulted in Johnson being subject to a
lifetime ban.10
Acting upon the lead of the IOC, the National Collegiate Athletic
Association (NCAA) followed suit. Although the NCAA had, in principle,
banned the use of AAS in the college sports in 1973, it was not until
1986 that it initiated an active testing program.11 Likewise,
the National Football League (NFL) began testing professional football
players for AAS use during training camps in 1986, and by 1990, the
NFL's testing program included random tests during the regular competitive
season.12
The medical community was not blind to the fact that AAS were regularly
distributed outside legal channels; in December of 1986, the American
Medical Association (AMA) published a report that endorsed the efforts
of law enforcement to curb illegal distribution of AAS and promoted
educational efforts to increase public understanding of the issues surrounding
the use of AAS.13 Nevertheless, the AMA opposed the criminalization
of AAS because government regulation of prescription drugs already existed,
and because AAS did not meet the traditional criteria for scheduling
drugs as controlled substances.14 Despite this opposition,
a few vocal practitioners published studies and lobbied strenuously
for AAS to be classified as illicit drugs.15 As a result,
the Anabolic Steroids Control
Act was passed into law by the federal legislature, and AAS were
classified as Schedule III controlled substances.16
Once AAS were classified as controlled substances under federal law,
mere possession could result in penalties of imprisonment of up to one
year for a first offense, with enhanced penalties for subsequent offenses.17
Manufacturing, distributing or dispensing AAS, or possessing AAS with
purpose to do the same, could result in imprisonment up to five years.18
However, the most onerous burden under the new classification may have
been the one placed on medical practitioners by the Code of Federal
Regulations: if a practitioner prescribes AAS for any purpose other
than a "legitimate medical purpose * * * in the usual course of his
professional practice," or for "authorized research," he or she may
be prosecuted as common drug dealer and subjected to the same penalties.19
Although the general public presumes that federal jurisdiction is
without limit, it is not. Federal authorities cannot possibly investigate
and prosecute all drug cases, nor do they have the universal jurisdiction
to do so. Approximately 92% of all drug trafficking convictions are
in state courts, as are nearly all convictions of simple drug possession.20
Therefore, nearly all states have adopted the federal classification
of anabolic steroids as controlled substances.21 Perhaps
more interesting are the specific limitations which some states have
placed on medical practitioners regarding prescriptions for AAS. Ohio
law specifically prohibits a licensed health professional from prescribing,
administering, or personally furnishing "a schedule III
anabolic steroid for the purpose of human
muscle building or enhancing human athletic performance."22
A Texas statute prohibits a medical practitioner from dispensing, prescribing,
delivering, or administering AAS for anything other than "a valid medical
purpose," further stating that "bodybuilding, muscle enhancement, or
increasing muscle bulk or strength through the use of an anabolic steroid
or human growth hormone listed in Schedule III by a person who is in
good health is not a valid medical purpose."23 Statutes such
as these are clearly intended to intimidate medical practitioners and
preclude any possibility that AAS will ever be legally prescribed for
physical enhancement.
The attack on AAS did not end with their legal prohibition. Passionate
statements before Congress continue to this day. On October 20, 1999,
in a statement before the Senate Committee on Commerce, Science and
Transportation, drug czar Barry McCaffrey asserted that "the international
sale of steroids is becoming increasingly sophisticated and entrenched
in criminal networks."24 Furthermore, McCaffrey has joined
in the active movement to ban prohormones, stating, "The DEA is engaged
in a scientific process to determine if Andro [androstenedione]
actually produces muscle growth -- and, in turn, whether it should be
classed as a steroid."25
As we stand at the turn of the millennium, AAS have been
banned in sports,
prohibited by law, and vilified before the general public. But what
is it that makes anabolic-androgenic steroids so evil?
Why Should AAS Be Illicit Drugs?
Anabolic-androgenic steroids are clearly the "bastard child" of controlled
substances. A review of federal and state drug schedules reveals that
nearly all controlled substances are listed in sub-classifications which
describe them in terms of their immediate psychoactive effects: stimulants,
depressants, hallucinogens, and narcotics or opiates.26 Since
AAS appear to have no immediate mood-altering effects, how did they
come to be classified amongst this collection of unlike drugs?
Numerous references have been made in popular literature to the "serious
side effects" of anabolic steroids. But what substantial side effects
are well established by scientific evidence?
We know that certain AAS, when taken in substantial amounts, are
toxic to the liver; however, this applies largely to 17-alpha-alkylated
steroids, such as methandrostenolone
(Dianabol) and oxymethelone
(Anadrol®-50).27 There appears to be no strong evidence
of such hepatotoxicity in orally-effective testosterone esters, such
as methenolone acetate
(Primobolan) and testosterone
undecanoate, nor in the many injectable testosterone esters, including
testosterone cypionate
(Depo-Testosterone) and
nandrolone decanoate
(Deca-Durabolin).28 It has also been suggested that hepatocellular
carcinoma (liver cancer) may result from the long-term use of 17-alpha-alkylated
AAS, although a regression of tumors has been noted when AAS use is
discontinued.29
Liver toxicity alone can hardly justify the classification of AAS
as controlled substances. Paracetamol, also known as acetaminophen (Tylenol®),
is touted as "the most trusted combination of strength and safety in
pain relief today,"30 yet liver damage, even fatal hepatic
necrosis, has been reported from repeated therapeutic usage of
this over-the-counter drug, particularly from therapeutic usage
amongst alcoholics.31 Nevertheless, even if the hepatotoxicity
of 17-alpha-alkylated AAS is a matter of great concern, the banning
of less toxic AAS contributes to the problem. A perfect example is
stanozolol (Winstrol),
a 17-alpha-alkylated steroid that is toxic to the liver in both its
oral and injectable form, but which continues to be readily available
on the U.S. black market because of its use as a veterinary drug (Winstrol®-V).32
One might logically speculate that the current use of more toxic AAS
is less a matter of choice than one of accessibility, where the availability
of safer choices has been limited by a legal prohibition that applies
to all AAS, regardless of their toxicity.
The negative psychological and behavioral effects of AAS, commonly
known as "'roid rage," seem to be accepted as a proven fact in popular,
nonscientific literature;33 however, there is little conclusive
proof that supports this presumption. Once again, such effects appear
to occur in cases involving 17-alpha-alkylated steroids, but not in
cases involving 17-beta-estrified steroids.34 Furthermore,
the existing studies cannot account for the pre-steroid tendencies of
individual users with respect to violence and aggression, nor can they
account for the psychological "placebo effect" that may occur from an
AAS user's expectations of heightened aggression. A detailed critique
of those studies, and flaws in their methodology, can be found in a
recent Meso-Rx
article by Jack Darkes, an expert in the psychology of drug use.35
At best, we can conclude that "'roid rage," to the extent that it exists,
may be limited to specific varieties of AAS, and that such hyper-aggressive
states may well be the result of preexisting tendencies or predetermined
expectations of the user.
There has been much criticism of AAS for their effect on a user's
cardiovascular health; however, this research is also highly speculative.
One study involving bodybuilders who self-administered AAS found that
AAS users had a ratio of "bad" low-density lipoprotein cholesterol (LDLC)
to "good" high-density lipoprotein cholesterol (HDLC) that was four
times that of non-users;36 however, other studies have indicated
that this effect is, once again, limited to 17-alpha-alkylated steroids.37
Later studies have indicated that AAS users retained substantial increases
in lean body mass and muscle size three months after withdrawal, but
with lipoprotein levels which were no different than those of non-users.38
Furthermore, a study involving controlled dosages of a 17-beta-estrified
steroid showed that a 22-27% decrease in HDLC was almost completely
reversed six weeks after discontinuation.39 It should also
be noted that diet is also a substantial factor in the analyses of lipoprotein
levels and ratios; decreases in the intake of saturated fats and dietary
cholesterol can reduce LDLC levels by more than 33%.40 Simply
put, there seems to be no concrete evidence that the use of AAS leads
to permanent cardiovascular health risks.
The greatest disgrace amongst the anti-AAS medical community may
be its "code of silence" as to the major health benefits of AAS
use. Though rarely mentioned by the medical practitioners, scientific
studies have concluded that "anabolic-androgenic steroid use as practiced
by contemporary athletes is a potent modulator of immune responsiveness."41
This benefit to the human immune response is by no means inconsequential,
particularly to those with whose immune systems have been damaged by
disease or congenital defects. The use of AAS is becoming an important
element in the treatment
of AIDS patients, not only to prevent AIDS-related "wasting," but
also to boost a severely depressed immune response. Further information
on the use of AAS in AIDS treatment may be found at the
Medibolics™
web site.42
Without question, AAS produce several minor side effects which are
not life-threatening. But are these minor problems sufficient to warrant
the classification of AAS as illicit drugs? Are many of these side effects
nothing more than minor annoyances which many people endure as a result
of their own hormonal balances?
Acne has long been associated with elevated levels of
free testosterone, particularly amongst young women.43
Since AAS are potent providers of free testosterone, they are also recognized
as a cause of acne.44 But isn't acne, to varying degrees,
an inevitable consequence of adolescence? Doesn't every teenager learn
to contend with the "zits" brought on by the raging hormonal imbalances
of puberty?
It is also well established that AAS use can lead to gynecomastia,
an abnormal expansion of the mammary glands in human males.45
Although this condition is generally undesirable amongst men, it is
far from life-threatening, and it appears to be treatable by the use
of antiestrogenic compounds such as
tamoxifen (Nolvadex®)46,
or by simple cosmetic surgical procedures which have been practiced
for approximately 500 years.47 In any event, it is apparent
that the negative effects of gynecomastia are largely aesthetic and
not a justification for criminalization of AAS.
Continued use of AAS can lead to atrophy of the testicles; this is
due to the endocrine feedback loop, whereby a male's body reacts to
the introduction of additional testosterone by reducing its own natural
production of both testosterone and sperm.48 However, this
effect appears to be
reversible upon the cessation of AAS use, and medical researchers
have found it to be therapeutically useful for birth control.49
A report of the World Health Organization is particularly interesting
in this respect: after global trials of AAS as a male contraceptive,
they found only minimal short-term physical side effects from doses
exceeding those which caused Ben Johnson's Olympic disqualification!50
The minor side effects of AAS are naturally more pronounced when
they are used by women. Negative side effects can include enlargement
of the clitoris, hirsutism (masculine hair growth), and deepening of
the voice, while the positive side effects may include muscle growth
and reduction of body fat.51 Although most women would wish
to avoid the negative aspects of AAS use, it appears that none of the
foregoing side effects are life-threatening, and if
AAS use by women is strictly
limited in time and dosage, the positive effects of muscle growth and
fat reduction might prove to be an acceptable trade-off.
- Comparison to Other Medical Procedures
While the serious side effects of AAS use appear to be mostly speculative,
and the minor side effects are largely limited and reversible, critics
of AAS use will often justify the
criminalization
of these drugs by pointing to the fact that their use is predominantly
for cosmetic purposes and to enhance athletic performance, not for treatment
of legitimate medical disorders. Therefore, it seems fair that these
criticisms be evaluated by comparing AAS use to legal medical
procedures which are used solely for cosmetic and physical enhancement.
Cosmetic surgery has become commonplace within our society. For actors
and models, whose physical appearance is an essential element of their
work, it is often accepted as an absolute necessity. Yet cosmetic surgery
is far from risk-free. Serious complications and at least one death
have been reported as a result of local infection from purely cosmetic
rhinoplasty ("nose jobs").52 Infection has been reported
in as much as 7% of all cases of augmentation mammoplasty (breast enhancement
surgery),53 and various other complications have been observed
after cosmetic breast surgery, including Mondor's disease (hardening
and blockage of veins underlying the breasts),54 fibromyalgia
(aching pain in muscles and connective tissues) and chronic fatigue
syndrome,55 and the frequent hardening, leakage, or collapse
of implants.56 Suction-assisted lipectomy or "liposuction"
(the surgical removal of body fat by suction) is now the most common
cosmetic surgical procedure in North America, despite the fact that
it has resulted in significant incidences of blood vessel blockage and
death.57 Nevertheless, all of these purely cosmetic surgical
procedures remain legal in the United States. Can it be said that these
invasive surgical procedures are somehow safer than the controlled administration
of AAS by a qualified practitioner for the purpose of muscle and strength
enhancement?
Purely cosmetic pharmaceutical treatments are also quite popular
in the United States. America's obsession with hair has led many men
to develop a severe phobia of male pattern baldness, and the pharmaceutical
companies have gleefully exploited that fear.
Finasteride (Propecia®)
is an oral prescription drug originally designed to treat benign prostate
hyperplasia, but which is now used to combat common male pattern baldness
by reducing the conversion of testosterone into dihydrotestosterone
(DHT), a primary cause of common baldness.58 Since finasteride
operates by the manipulation of male hormones, as do anabolic-androgenic
steroids, its side effects tend to be similar or converse to those of
AAS. Reported side effects include impotence, allergic reactions, loss
of sexual desire, and gynecomastia, and pregnant women are warned not
to even touch broken tablets because of possible deformities to the
sexual organs of a male fetus.59 Tretinoin (Retin-A® or Renova®),
is a topical prescription drug used to treat acne, but its use has been
expanded to the removal of wrinkles and striae (stretch marks) on skin;60
its possible side effects include skin rashes and peeling and severe
swelling and burning sensations.61 Despite the substantial
side effects of these prescription drugs, they remain legal for use
in purely cosmetic therapy.
Those most extreme medical procedure for modification of physical
appearance is considered by many to be an abomination: gender reassignment
surgery, i.e., "sex change operations." Despite the horror that
many people experience when confronted with this subject, gender reassignment
"is now an established and accepted practice in many parts of the world."62
Gender reassignment involves extensive surgical alteration of the genitals,63
as well as hormonal therapy, which in female-to-male transsexuals involves
the administration of anabolic-androgenic steroids.64
It is interesting to note that in one study, the administration of these
androgens to female-to-male transsexuals resulted in no serious morbidity
(disease) in nearly 300 cases of long-term use,65 while in
another study, the mortality and morbidity of male-to-female transsexuals
treated with female hormones was far beyond that of female-to-male transsexuals
treated with androgens.66 While the ethics of gender reassignment
are debatable on a case-by-case basis, it is worthy of comment that
in one study involving 20 patients seeking gender reassignment, more
than half were found to exhibit psychotic trends.67 Nevertheless,
gender reassignment is legal in the United States, and it continues
to be a legally legitimate purpose for prescribing AAS!
The True Evil Revealed
If the comparative dangers of AAS use for physical enhancement do
not warrant their criminalization, then what characteristic of these
substances justifies their classification as a controlled substance?
Perhaps a review of the legal definition would be instructive.
In addition to naming specific substances, federal law provides an
inclusive, general definition of "anabolic steroids"; identical or near-identical
definitions have been adopted by many states.68 The first
portion of this definition refers directly to the chemical nature of
the substance:
"[A]ny drug or hormonal substance, chemically and pharmacologically
related to testosterone (other than estrogens, progestins, and corticosteroids)
..."69
The most interesting aspects of this portion of the definition are
the exclusions. Nearly all steroid compounds are "chemically and pharmacologically
related to testosterone," but certain steroid hormones were not deemed
appropriate for criminalization. Estrogens and progestins, female hormones
commonly used in contraceptives, were specifically exempted from status
as illicit drugs, as were the predominantly catabolic corticosteroids,
which are commonly used to treat inflammation. Thus, the chemical portion
of the general definition is of little help in determining the reason
for criminalization.
The true basis for banning AAS is revealed in the latter portion
of the general definition:
"... that promotes muscle growth, and includes * * * any
salt, ester, or isomer of a drug substance described or listed in
this paragraph, if that salt, ester, or isomer promotes muscle
growth."70
By definition, the single characteristic of AAS that makes them subject
to classification as controlled substances is the fact that they
promote muscle growth. The statutory definition does not refer to
dangerous side effects or potential for abuse, only the promotion of
muscle growth. This factor is no mystery to those who support the criminalization
of these substances. In October 1999, drug czar Barry McCaffrey clearly
expressed his desire to ban androstenedione by stating:
"The DEA is engaged in a scientific process to determine if Andro
[androstenedione] actually produces muscle growth -- and,
in turn, whether it should be classed as a steroid."71
What conclusions can be drawn from this single, defining characteristic
of AAS? We are not faced with a definition which would ban all
steroids, since many steroid drugs are exempted from that definition.
Nor are we faced with with a definition that refers to specific dangers.
Rather, we are faced with a definition that seeming leads to only one
conclusion: muscle growth must be a bad thing!
Part II: The
Demonization of Anabolic Steroids: Modern Society's Love-Hate Relationship
with Strength and Muscle
Footnotes
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2Hoberman JM; Yesalis CE. The history of synthetic testosterone.
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3Taylor WN, Macho Medicine, supra at 8.
4Id. at 8-9.
5Hoberman JM, et al., Synthetic testosterone,
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6Id. at 77.
7eg., Fowler WM Jr; Gardner GW; Egstrom GH. Effect
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9Yesalis C. Incidence of anabolic steroid use: a discussion
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12 Ferstle J. Evolution and politics of drug testing.
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13Taylor WN, Macho Medicine, supra at 37.
14 Id. at 58.
15 Taylor WN. Synthetic anabolic-androgenic steroids:
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16 Anabolic Steroids Control Act of 1990, Pub. L. 101-647,
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17 21 U.S.C. 844.
18 21 U.S.C. 841(b)(1)(D).
19 21 C.F.R. 1306.04(a).
20 Brown JM; Langan PA. Felony Sentences in the United
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21 e.g., Ohio Revised Code 3719.41; Florida Statutes
893.03; Texas Health & Safety Code 481.104; and New York State Consolidated
Laws: Public Health 3306.
22 Ohio Revised Code 3719.06(B).
23 Texas Health & Safety Code 481.071(b),(c).
24 McCaffrey, Barry R. "Before the Senate Committee on
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25 Id.; see also, Collins R; Williams JM. Banning
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2621 U.S.C. 812; 21 C.F.R. 1308.01-1308.15; R.C. 3719.41
(Ohio).
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28Id.; Kuipers H; Wijnen JA; Hartgens F; Willems
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34 Bahrke MS, Yesalis CE and Wright JE. Psychological
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37 Kopera H. Side effects of anabolic steroids and contraindications,
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38 Hartgens F, et al. (1996) Body composition,
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39 Kuipers H, et al. (1991) Influence of anabolic
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40 Lewis B. Diet and exercise as regulators of lipid risk
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49 Schurmeyer T; Knuth UA; Belkien L; Nieschlag E. Reversible
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71 McCaffrey, Barry R. Before the Senate Committee,
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