(PDF) Steroid Madness- Has the dark side of anabolic-androgenic steroids (AAS) been over-stated?

Please

cite

this

article

in

press

as:

Mulrooney,

K.

J.

D,

et

al.

Commentary:

Steroid

Madness-

has

the

dark

side

of

anabolic-androgenic

steroids

(AAS)

been

over-stated?

Performance

Enhancement

&

Health

(2019),

https://doi.org/10.1016/j.peh.2019.03.001

ARTICLE IN PRESS

G Model

PEH-141;

No.

of

Pages

5

Performance

Enhancement

&

Health

xxx

(2019)

xxx–xxx

Contents

lists

available

at

ScienceDirect

Performance

Enhancement

&

Health

journa

l

h

om

epage:

www.elsevier.com/locate/peh

Commentary:

Steroid

Madness-

has

the

dark

side

of

anabolic-androgenic

steroids

(AAS)

been

over-stated?

Kyle

J.D

Mulrooneya,∗,

Katinka

van

de

Venb,

Jim

McVeighc,

Rick

Collinsd

aSchool

of

Humanities,

Arts,

Social

Sciences

and

Education,

UNE,

Armidale,

NSW,

Australia

bDrug

Policy

Modelling

Program,

Social

Policy

Research

Centre,

UNSW,

Sydney,

NSW,

Australia

cPublic

Health

Institute,

Liverpool

John

Moores

University,

Liverpool,

UK

dCollins

Gann

McCloskey

&

Barry

PLLC,

Mineola,

New

York,

United

States

a

r

t

i

c

l

e

i

n

f

o

Article

history:

Received

17

December

2018

Received

in

revised

form

6

March

2019

Accepted

26

March

2019

Available

online

xxx

Keywords:

Anabolic-androgenic

steroids

(AAS)

Performance

and

image

enhancing

drugs

(PIEDs)

Fitness

Bodybuilding

Public

health

Body

image

Consumer

participation

1.

Introduction

Recently

the

journal

Performance

Enhancement

&

Health

put

out

a

call

to

produce

a

special

issue

on

the

dark

side

of

human

enhance-

ment,

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

commen-

tary,

we

will

brieﬂy

engage

with

this

question

by

unpacking

what

we

describe

here

as

the

“narrative

of

harm”,

which

tends

to

domi-

nate

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

∗Corresponding

author

at:

School

of

Humanities,

Arts,

Social

Sciences

and

Edu-

cation,

UNE,

University

of

New

England,

Armidale,

NSW,

Australia.

E-mail

address:

kmulroon@une.edu.au

(K.J.D

Mulrooney).

URLs:

@CriminologyGuy

(K.J.D

Mulrooney),

@KatinkavandeVen

(K.

van

de

Ven),

@EnhancementDrug

(K.

van

de

Ven),

@mcveigh

jim

(J.

McVeigh),

@RickCollinsEsq

(R.

Collins).

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

partic-

ular

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

(lead-

ing

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

sur-

prising

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,

https://doi.org/10.1016/j.peh.2019.03.001

2211-2669/©

2019

Published

by

Elsevier

Ltd.

Please

cite

this

article

in

press

as:

Mulrooney,

K.

J.

D,

et

al.

Commentary:

Steroid

Madness-

has

the

dark

side

of

anabolic-androgenic

steroids

(AAS)

been

over-stated?

Performance

Enhancement

&

Health

(2019),

https://doi.org/10.1016/j.peh.2019.03.001

ARTICLE IN PRESS

G Model

PEH-141;

No.

of

Pages

5

2

K.J.D

Mulrooney

et

al.

/

Performance

Enhancement

&

Health

xxx

(2019)

xxx–xxx

reduced

insulin

sensitivity

(e.g.

see

Rasmussen

et

al.,

2017,

2016),

cardiovascular

disease

(Baggish

et

al.,

2017)

and

cognitive

deﬁcien-

cies

(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

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

harm-

ful

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

efﬁ-

cacy

and

long-term

effects

of

steroid

use

are

absent

(Smit

&

de

Ronde,

2018).

Yet,

instead

of

acknowledging

that

we

lack

a

compre-

hensive

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

soci-

ety

(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

proba-

bility

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

vio-

lence.

Indeed,

since

the

mid-1980s,

the

notion

that

steroid

use

leads

to

aggressive

or

violent

behaviour

became

widespread,

giv-

ing

rise

to

the

term

‘roid

rage’,

used

to

denote

steroid-related

aggression

(Dunn

et

al.,

2014).

Once

again,

this

facet

of

the

nar-

rative

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

ani-

mal

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

facili-

tate

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,

neuropsy-

chological

risks,

environmental

inﬂuences,

socio-economic

status,

poly-substance

use

and,

with

the

exception

of

alcohol,

is

not

causally

Frisell,

Lichtenstein,

&

Langstrom,

2015;

Tomlinson,

Brown,

&

Hoaken,

2016),

highlighting

the

com-

plexity

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

inse-

cure

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

educa-

tion

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

dissatisfac-

tion,

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

phys-

ical

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

sys-

tematic

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

Please

cite

this

article

in

press

as:

Mulrooney,

K.

J.

D,

et

al.

Commentary:

Steroid

Madness-

has

the

dark

side

of

anabolic-androgenic

steroids

(AAS)

been

over-stated?

Performance

Enhancement

&

Health

(2019),

https://doi.org/10.1016/j.peh.2019.03.001

ARTICLE IN PRESS

G Model

PEH-141;

No.

of

Pages

5

K.J.D

Mulrooney

et

al.

/

Performance

Enhancement

&

Health

xxx

(2019)

xxx–xxx

3

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

democ-

racies

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

increas-

ingly

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’

objec-

tives

(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

pharmaco-

logical”,

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

con-

sumption

of

these

substances,

pleasure

is

an

essential

part

of

a

coherent

and

reasoned

response

to

steroid

consumption.

The

cur-

rent

“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

prin-

ciple

it

tends

to

emphasize.

Chieﬂy,

a

narrative

centred

on

public

health

harms,

the

potential

for

violent

behaviour

and

psycholog-

ical

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

increas-

ingly

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

leg-

islative

changes

including

rescheduling

steroids

as

a

schedule

I

drug.

This

means

steroids

are

now

classed

alongside

heroin,

cocaine

and

ice

in

the

highest