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CONTROVERSIES STEROIDS IN SPORT RISKS TO HEALTH
The use of steroids for performance and image-enhancing reasons has been associated temporally with a diverse number of adverse effects on physical and psychological health, including fatal events (25). These are drawn primarily from self-reported effects, case reports and cross-sectional studies. Commonly cited effects include cosmetic effects (eg. acne, androgenic alopecia, gynaecomastia), reproductive dysfunction, liver dysfunction/disease (predominately seen with 17a-alkylated oral compounds), cardiovascular dysfunction/disease, anxiety, aggression, depression and dependence (Table 2). However, this area remains under- researched, and the conclusions that can be drawn, especially in relation to the more serious effects, are limited by methodological issues – perhaps most notably the failure to recognise the following: n Compound-specific effects of steroids n Heterogeneous nature and practices of this group, especially in relation to polydrug regimes (drugs used, dose taken, duration of use) n Lack of prospective studies within this population. The first two of these points are a major determinant of the unique pharmacological milieu experienced by users and, in turn, a critical component in our understanding of the pathogenesis of steroid-related health effects that may develop over time. Furthermore, variables such as sex, age, lifestyle and genetic factors are also likely to play a significant role in this process. Ultimately, these limitations in the evidence base have restricted the ability to quantify risks from a clinical perspective and, therefore, provide unambiguous information on risks to users. Compounding the risks to health from the
pharmacological effects of these drugs, steroid users also face multiple risks posed by injecting, as more than 70% of users in the UK inject these drugs (and many of the related drugs) (13–15). These risks include damage to the injection site and surrounding structures, abscesses and, in those who share injecting equipment (or reuse injecting equipment and, subsequently, share multi-dose vials with others), blood-borne viruses such as human immunodeficiency virus (HIV), hepatitis B and hepatitis C (26). Furthermore, as the majority of users have access only to drugs of a dubious origin (of which a large proportion are counterfeit) there are significant health implications in relation to the adulteration of these preparations, including doses being significantly higher than that stated on the label; the substitution of one type of steroid for another (eg. a cheaper, highly androgenic steroid is substituted for a more expensive, low androgenic steroid); contamination with other drugs; and, non-sterile preparations (26–28).
THE LEGAL STATUS OF ANABOLIC STEROIDS In the UK, steroids (along with the related drugs clenbuterol, growth hormone and chorionic gonadotrophin) are controlled as class C drugs under Schedule 4, Part II of the Misuse of Drugs Act 1971. Possession for personal use is legal if in the form of a medicinal product (including import and export). However, supply (including giving or sharing), intent to supply and production are illegal and punishable with up to 14 years’ imprisonment and/or an unlimited fine.
EVERYBODY Paul de Kruif, The male hormone, 1945
IT WITHIN THE REACH OF
THE GROWING DEMAND FOR TESTOSTERONE WILL SOON BRING
PREVENTING ANABOLIC STEROID USE There has been limited research on preventing and reducing existing steroid use within the general population (29). Work from the US has shown that in high-school students, knowledge-only programmes, despite increasing knowledge of steroids, at best do not alter intention to use or actual use; at worst, the use of scare tactics resulted in a trend towards a more positive attitude towards use. The Athletes Training and Learning to Avoid Steroids (ATLAS) programme was a multi-dimensional health promotion programme aimed at adolescent American football players. Partly peer-led and based on social learning theory, the programme provided education on steroid use and training in exercise, nutrition and communication skills. Although this programme did have a significant effect on some self-reported health behaviours, most notably reducing illicit drug use and improving nutrition at 1-year follow-up, it failed to demonstrate a significant difference in the number of individuals taking up steroid use compared with the control group. Ultimately, the challenge to develop successful interventions that are context-sensitive, and that are acceptable to and meet the needs of specific groups, will depend on advancing our understanding of both the structural and personal factors that serve to drive steroid use, how these may interact, and how they may be amenable to change. These areas of research are still in their infancy.
REDUCING THE HARM ASSOCIATED WITH ANABOLIC STEROID USE Finally, it is important to recognise that some individuals still choose to use these drugs despite our best intentions. From a public health and professional practitioner perspective, the health of the individual must have primacy (while taking due cognisance to ethical and legal obligations). To this end, these individuals should be provided with harm-reduction advice in a non-judgemental way. Key points for practitioners and some basic harm-reduction advice are provided in Box 1.
SUMMARY n Alongside the classic anabolic (muscle-building) and androgenic effects, testosterone acts on virtually every tissue in the body, thus exerting a diverse number of physiological actions, including effects on behaviour and the cardiovascular system n Steroids mimic to varying degrees the actions of testosterone. They carry modifications that enhance bioavailability and/or modify pharmacological effects. Common modifications are those that increase the ratio of anabolic to androgenic activity n The self-directed use of steroids to enhance performance and image has become widespread in the general population. In the UK where they are used in high-dose polydrug regimes n There is a complex interaction of structural and personal factors, such as the media, peer influence, occupation and body image dissatisfaction, which drive the use of steroids
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