Commentary: Steroid Madness- has the dark side of anabolic-androgenic steroids (AAS) been over-stated?

1. Introduction

Recently the journal Performance Enhancement & Health put out a call to produce a special issue on the dark side of human enhancement, including the use of legal and illegal substances, leading us to ponder whether the “dark side” of anabolic-androgenic steroids (from here on, “steroids”) has been overstated. In this commentary, we will briefly engage with this question by unpacking what we describe here as the “narrative of harm”, which tends to dominate discourses on steroid use in wider society. We then consider an alternative perspective on steroid use which focuses on the users’ experience and understanding, with particular attention to the role of pleasure. Finally, we conclude by exploring some of the negative policy consequences arising from the dominance of the “narrative of harm” and advance a regulatory approach grounded in rational and research informed discussions around both the pleasures and pains of steroid use. A more developed version of this argument can be found in the forthcoming collection Human Enhancement Drugs, published by Routledge in 2019 (Mulrooney, van de Ven, McVeigh, & Collins, 2019).

2. The narrative of harm

The most pervasive facet of the narrative of harm is that steroids pose serious health risks. Media and political discourses in particular tend to provide a sense that using these drugs is “akin to being a gun powder keg about to explode” (Soni & Nasrulla, 2018) or that users are on a “deadly crusade to get ripped” (Gorman, 2017). Yet, the reality is much more complex. For instance, the most commonly identified side effects are cosmetic in nature, such as oily skin (leading to acne) and fluid retention, which are generally reversible with cessation (Andrews, Magee, Combest, Allard, & Douglas, 2018; van Amsterdam, Opperhuizen, & Hartgens, 2010). However, it should be noted that much knowledge on the side effects of steroids comes from surveys based on self-report data and it is therefore not surprising that these studies predominantly report more aesthetic concerns. Several long-term health harms have also been reported such as increased blood pressure, suppression of gonadotropins, reduced insulin sensitivity (e.g. see Rasmussen et al., 2017, 2016), cardiovascular disease (Baggish et al., 2017) and cognitive deficiencies (Kaufman et al., 2015). Evidently, the potential for harm exists, however, such harms need to be contextualized. In a simple use vs. non-use dichotomy, of course people who use steroids are at greater risk of developing health harms related to their use than people who do not use. Indeed, the bottom line for current health policy is that non-medical steroid use is bad for your health.

Although it is often stated by health authorities and the media that steroids are harmful, data are lacking as to precisely how harmful they are. Most knowledge about the harmful effects of steroids is based on low level evidence, such as expert opinion, case reports or small observational studies, while clinical trials to study the efficacy and long-term effects of steroid use are absent (Smit & de Ronde, 2018). Yet, instead of acknowledging that we lack a comprehensive understanding of the health risks of steroid use, a “guilty until proven innocent” stance is often taken. Not only does this hamper our understanding of the health risks of these substances but also the advancement of medical research wanting to explore their therapeutic benefits. While the extent to which steroid use leads to critical health risks is unclear, there are other indicators we may draw on to gain a better understanding of the relative risks of these substances, for example, when comparing them to other illicit drugs. In a number of studies exploring relative drugs harms, steroids consistently appear low on the list for general harm as well as for physical, psychological and social harm to both users and society (e.g. Nutt, King, & Phillips, 2010; van Amsterdam, Nutt, Phillips, & van den Brink, 2015; van Amsterdam, Opperhuizen, Koeter, & van den Brink, 2010).

Furthermore, we must also be considerate to relative risks between users. Indeed, while there is evidence to suggest steroids do pose health risks, important contextual information is often left out such as, for example, the role of pre-existing health conditions, the use of unverified black-market products, the type of steroids used and/or the dosage and, in particular, the length of steroid using career. For instance, years of high dosages may impair testosterone function and some users may not themselves recover completely from anabolic steroid induced hypogonadism (ASIH) without the assistance of testosterone replacement therapy (TRT). Yet, perhaps one of the key aspects of blurring the line between the “pleasures and pains” of steroid use is the failure to reflect on use and misuse, though this is not foreign to discourses on drug use. Rather, it is the accumulation of factors, such as longer steroid cycles, increased dosages and poly-drug use, which increase the public health risk and, therefore, depending on their use patterns some users will run greater health risks than others. Taken together, discussions on steroid use must clearly distinguish between health harms that are likely to be centrally important to users in terms of both the probability of occurrence and potential severity, as well as the relativity of risk in terms of steroid use generally and between “typologies” of steroid users themselves (Christiansen, Vinther, & Liokaftos, 2017).

Closely connected to individual health harms, a frequently cited side effect of non-medical steroid use is aggression and violence. Indeed, since the mid-1980s, the notion that steroid use leads to aggressive or violent behaviour became widespread, giving rise to the term ‘roid rage’, used to denote steroid-related aggression (Dunn et al., 2014). Once again, this facet of the narrative of harm is amplified by the media and law enforcement discourses which often recount how steroids played a central role in particularly brutal acts of violence such as, the case of wrestling star Chris Benoit (Chappell, 2007) or, more recently, the London Bridge terrorist attack (BBC, 2018). Although the animal literature has found a direct, positive relationship between testosterone and increased aggressive behaviour (McGinnis, 2006; Melloni, Connor, Xuan Hang, Harrison, & Ferris, 1997), providing important insights into some of the behavioural consequences of steroid use, it does not and cannot capture all aspects of the human experience. Indeed, studies that have examined the relationship between aggressive behaviour and substance use by humans show a much more complex picture. While testosterone may facilitate both aggressive and rewarding behaviour in humans (Dreher et al., 2016), in general, the relationship between substance use (including steroids) and aggressive behaviour is likely accounted for by third variable factors, such as personality traits, neuropsychological risks, environmental influences, socio-economic status, poly-substance use and, with the exception of alcohol, is not causally related (Lundholm, Frisell, Lichtenstein, & Langstrom, 2015; Tomlinson, Brown, & Hoaken, 2016), highlighting the complexity of hormone/behaviour-relations.

Lastly, the caricature of non-medical steroid users as narcissistic, self-absorbed ‘gym bros’ suffering from body image issues provides an equally simplistic account of user motivations and ignores the spectrum of user typologies. In media articles, for example, steroid users are often portrayed as young adults or teenagers who are insecure about their body and are experiencing a “crisis of male ego” (Walsh, 2018) by seeking the “ripped Loved Island look” (Burrows, 2017). Yet, typically, a person’s first experience using steroids is reported to occur in their mid to late twenties (McVeigh & Begley, 2017), with many steroid users having an above average education and income, and not being involved in sports (Christiansen et al., 2017; Cohen, Collins, Darkes, & Gwartney, 2007). To this end, there is an increasing body of research which shows that there is substantial variability in steroid-using populations in terms of motivations for use, health risk potential and health seeking behaviours (Christiansen et al., 2017; van de Ven, Maher et al., 2018b; Zahnow et al., 2018). Indeed, while some use for cosmetic reasons (e.g., to increase muscle mass and strength) others will use these substances to improve sporting performance, for anti-ageing purposes, to increase energy levels and/or to recover more quickly from an injury (Begley et al., 2017).

A specific subtype of body image disorder linked to this group is muscle dysmorphia, often referred to as “bigorexia” in the media, which was first described in the early 90s (Pope Jr, Katz, & Hudson, 1993). The main feature of muscle dysmorphia is body dissatisfaction, in particular regarding one’s muscles, which may, for example, lead individuals to use steroids and other enhancement substances, engage in unhealthy eating practises, and engage in excessive physical exercise even when injured or experiencing pain (Olivardia, Pope, & Hudson, 2000). Yet, there is no solid evidence as to how many people who use steroids actually have or will develop a body image disorder, or what the association is between the two. While some studies point towards an association (e.g. Rohman, 2009), others do not find an association and, for example, show that the attachment style of a person is an important predictor for someone to develop muscle dysmorphia (e.g. Fabris, Longobardi, Prino, & Settanni, 2018). Perhaps most concerning, in a recent systematic review of the literature on muscle dysmorphia, Sandgren and Lavallee (2018) concluded that the “methodological quality of recent muscle dysmorphia research was considered low due to a lack of clinical samples, measurements not using validated cut-off scores, and the research designs”.

3. The user’s voice and the pleasures of steroid use

Research in the field of alcohol and psychoactive drugs has highlighted the importance of acknowledging the benefits and pleasurable effects of substance use and the use of substances by healthy individuals (e.g. d’Angelo, Savulich, & Sahakian, 2017; Hamilton & Aldridge, 2019; Holt & Treloar, 2008; O’Malley & Valverde, 2004; Power, 2018; Ritter, 2014; Winstock & Nutt, 2013). Following this line, an implication of the narrative of harm is that it tends to overlook and ignore the role of pleasure in the consumption of steroids. Even where this may be acknowledged, paternalism and morality tend to take precedence over individual choice. However, this position is at odds with a number of riskier socially accepted and legalized pursuits such as the consumption of tobacco and alcohol, and, more recently, surgical and non-surgical cosmetic enhancement.

Indeed, with respect to these pursuits, Western liberal democracies generally concede that consenting adults have the right to choose pleasure at the risk of pain (or even injury or death) and we accept this in many facets of life more broadly (e.g. sport) so long as individual freedoms do not impinge on the “common good”. Yet, there is a stark contrast between the way society treats cosmetic steroid use as compared to non-surgical cosmetic enhancement such as the use of Botox and dermal filler or surgical enhancement such as breast augmentation or blepharoplasty (eyelid surgery), despite the relative risks involved (Balk, Earley, Avendano, & Raman, 2016; Brennan, Wells, & Van Hout, 2018). Indeed, while both surgical and non-surgical procedures have become increasingly normalized and arguably celebrated (e.g., Vogue) as a personal prerogative of self-improvement (Featherstone, 2010), steroid use remains largely pathologized despite questions being raised about the relative harm of these substances. This may be, in part, because of the legal/regulatory context in which these respective practices occur, but that is only because policy makers have chosen to deal with this particular form of enhancement through repression.

We often overlook the fact that there will be many users who will use these substances for their immediate gratification (e.g., feelings of strength) or delayed gratification from ‘higher’ objectives (e.g., constructive efforts/functional enhancement). Indeed, there is a plethora of self-reported data from qualitative studies with regard to the role of “pleasures” in the consumption of steroids (e.g. Kimergård, 2015; Monaghan, 2001, 2002; Underwood, 2017). For instance, while Monaghan (2002) notes that bodybuilders tend to sharply contrast themselves with ‘other’ drug takers, often based on their pursuit of a “higher objective than pleasure” in contrast to, for example, the pleasure of getting high. He also points out that “bodybuilders derive aesthetic pleasure from their own and other members’ body modification practices”, linked to both feelings and constructive efforts. In other words, while “the ‘highs’ associated with chemical bodybuilding are achieved rather than pharmacological”, they are nonetheless pleasure inducing and part of the appeal of drug taking in this context. In addition to the delayed gratification which comes from body/performance modification, it is not unusual for users to report pleasurable feelings such as increased libido, greater confidence and increased wellbeing and strength (Begley et al., 2017; Underwood, 2017).

Given the centrality of pleasure for many users in the consumption of these substances, pleasure is an essential part of a coherent and reasoned response to steroid consumption. The current “pathology paradigm” (Mugford, 1988; cited in Moore, 2008) engrained in the narrative of harm is dominated almost exclusively by individual and social risks with little to no acknowledgment of pleasure as a benefit in its own right. This is particularly relevant considering the questions raised above with respect to absolute and relative risk, the notion of individual choice and a risk/benefit analysis. Perhaps most worrisome, failing to acknowledge the role of pleasure and other benefits in the consumption of these drugs may hinder our ability to address the phenomenon and ultimately curbs advances in regulatory frameworks. It is to this we now turn.

4. Implications of the narrative of harm

Our central point of contention with the narrative of harm, is the way in which the dominance of the discourses that comprise it have come to occupy discussions around steroids to the exclusion of others. The key problem being that, without nuance, the public and policy-makers are presented with a distorted reality from which to respond to steroid use. Indeed, there are a number of serious implications driven by this narrative and the pre-cautionary principle it tends to emphasize. Chiefly, a narrative centred on public health harms, the potential for violent behaviour and psychological disturbance naturally prioritizes repressive means to combat the issue. Add to this the incompatibility of harm reduction with two other dominant narratives that tend to dominate discussion on steroids, that of doping in sport and the use of steroids by youth, and it is not surprising that punitive mechanisms lead the charge in what has been called the “war on doping”.

Extreme examples include Denmark and Belgium where every-day gym users are subject to drug testing regimes with punitive implications (Christiansen, 2011; van de Ven & Mulrooney, 2014, 2017; van de Ven, 2016). Furthermore, a number of countries (e.g. Australia, Sweden, and the US) have rescheduled steroids so that their production, sale and even consumption come with increasingly harsh penalties (van de Ven & Mulrooney, 2014). For example, increased attention on violence in Sydney’s (Australia) night time economy formed part of the arguments which led to a raft of legislative changes including rescheduling steroids as a schedule I drug. This means steroids are now classed alongside heroin, cocaine and ice in the highest category of dangerous illicit drugs (van de Ven, Dunn, & Mulrooney, 2018a). As evidenced in other drug markets (e.g. Caulkins & Reuter, 2006; Lenton & Heale, 2000; Volkow, Poznyak, Saxena, Gerra, & Network, 2017), this repressive approach of criminalizing use has resulted in its own set of harms such as subjecting users to prison or felony convictions, as happens in some jurisdictions, which can destroy a person’s employment and educational opportunities, adversely impacting their own lives and the lives of their families.

Furthermore, even where harm reduction initiatives are advanced, the narrative of harm surrounding steroids leads to the natural conclusion that these drugs need to be controlled if not by the threat of punishment than at least by making them more difficult to access. The issue with this, as much research has shown (e.g. Caulkins & Reuter, 2006), is that where there is demand there is supply and so users continue to consume, however, their sources and consumption practices are clandestine instead of medically regulated (Fincoeur, van de Ven, & Mulrooney, 2015). Indeed, many of the health harms so central to the narrative of harm could be more easily discovered by adopting a public health-oriented model of addressing the issue of steroid consumption. For instance, by not accepting the pleasurable effects or low risks of using certain pharmaceuticals, healthcare providers may be dissuaded from providing medical services to people who choose to continue their drug use for non-medical reasons. Importantly, many users know harm is only part of the story and so the primary definers of “the steroid problem” may lose credibility. Thus, it is perhaps not surprising that steroid users tend to report rather negative experiences in their interactions with medical professionals (Dunn, Henshaw, & McKay, 2016; Hope et al., 2013; Zahnow, McVeigh, Ferris, & Winstock, 2017). This is particularly relevant when it comes to attempting to engage users in harm reduction practices.

5. Conclusion

This commentary should not be read as an attempt to deny any harmful properties nor to promote the use of these substances. Rather, our intention is to question and critique the dominance of the narrative of harm, in light of a more nuanced appraisal of the evidence, and, most importantly, to highlight that in over-stating the dark side of steroids a skewed narrative has emerged which has the potential to increase harms in the name of public protection. The failure of the media, politicians and some academics to report this more complex and nuanced picture, focusing instead on isolated case reports of harms and tragedies, misinforms the public and policy-makers. This understandably directs the dialogue and policy into punitive territory and sows’ mistrust in those with otherwise benevolent intentions. Alternatively, we argue, that a more realistically balanced approach to these drugs, absent from morality and sensationalism, considerate of the users’ perspective and backed by scientific research, increases the capacity to reduce evidenced harms. Indeed, while there is evidence to suggest steroids are harmful, the dominant narrative of harm often fails to consider questions around the relative nature of harms and to weigh such risks against the pleasures derived from use. As such, it will help us to inject pleasure into the discourses on steroid use and its regulation, to have rational and critical debates on achieving pleasure while minimizing established associated risks, something that is particularly important in a world that appears increasingly willing and indeed eager to explore the opportunities for human enhancement.