Ethical Considerations
Regarding Anabolic-Androgenic
Steroid Use
Emphasis
on the Exercise Professional
Gregory G. Frounfelter,
ATC, CSCS
Greg E. Bradley-Popovich,
MSEP, MS, CSCS
Doctor of Physical Therapy
Candidates
Department of Physical Therapy
Creighton University,
Omaha, NE
Abstract
The use of anabolic-androgenic
steroids (AAS) as a means to improve athletic performance is not a novel
idea in the realm of exercise physiology, strength and conditioning, or
sports medicine. The article briefly overviews the mechanisms and
reasons for the use of AAS in sport, but its main purpose is to explore
the moral arguments for and against the use of such ergogenic aids.
The role of the medical care provider is emphasized with respect to the
athlete’s decision whether or not to use AAS for sport performance enhancement.
Keywords: anabolic-androgenic
steroids, ergogenic aids, ethics, morals
Background
Anabolic-androgenic steroids
(AAS) are synthetic drugs that mimic the effects of the male hormone testosterone
(1). Although there are legitimate medical applications
for AAS, they are sometimes used by athletes as an ergogenic aid to improve
performance and/or physique (1). They are nearly
always used in conjunction with resistance training, and by athletes who
are involved in sports that emphasize power production. Alarmingly,
there have been increasing reports of AAS use by people who desire to use
the drugs’ muscle-building effects to enhance their physical appearance
(1-3, 5). It appears that these
drugs, whose use was limited to elite and professional athletes, are now
making their way into the training regimes of high school and college students
(1-2, 4). Also, AAS use is no
longer limited to a predominately male population, with females becoming
increasingly more involved in using AAS (5).
The exact physiological mechanism
of AAS is not well understood. It is thought that there are three
physiologic pathways for AAS to act. First, these drugs cause increased
protein synthesis in cells that are sensitive to AAS. Second, AAS
provide an anti-catabolic effect by decreasing the effects of catabolic
hormones released secondary to intense exercise. Finally, AAS are
thought to help increase nitrogen retention, an indicator of protein synthesis,
by shifting to a positive nitrogen balance, thus making better utilization
of ingested protein in the cellular environment (1).
Recent evidence suggests
that one myotrophic action of AAS in vivo is to increase the number of
myonuclei, which occurs in skeletal muscle fibers through the enlistment
of nearby satellite cells that are developmentally residual muscle precursors
(6). Previous research has shown regulatory effects
of anabolic steroids on satellite cells in in vitro (7).
Greater satellite cell activity leads to greater fusion of nuclei with
muscle cells, the end result of which being more nuclei to direct protein
synthesis and to maintain a more favorable nucleus-to-volume ratio (6).
Normally, muscle growth potential has a ceiling described as the nucleus-to-volume
ratio (aka DNA unit or nuclear domain), which recognizes that a nucleus
can reliably sustain a limited volume of cell (6).
Because myonuclei persist until near the point of cell death (8),
once incorporated, the additional nuclei may be a permanent cellular fixture
in healthy myocytes.
AAS have been shown in some
studies to have serious consequences associated with their use under certain
circumstances. Traditionally, general side effects of AAS for sports
enhancement have been thought to include:
-
Physiological dependence
-
Psychological changes
-
Blood lipid profile changes
-
Elevated blood pressure
-
Cardiac myopathy
-
Liver disease/cancer
-
Increased body hair
-
Increased libido
-
Increased acne (2,
5, 9).
Gynomastinoma, testicular
atrophy, and priapism may occur specifically in men (9).
Women may experience masculinization and clitoral enlargement secondary
to AAS use (2, 5). Pre-adolescents
may experience early musculoskeletal maturity, including premature closure
of the growth plates (2, 5, 10).
Some AAS-induced side effects may not be reversible, and many, such as
liver disease/cancer and cardiomyopathy, may develop later in life years
after the AAS use has ceased (5, 10).
Some of these effects are socially disabling while others are life threatening.
In either event, the side effects can be a high price to pay for the benefits
associated with AAS use. Although there is evidence to substantiate
the occurrence of certain alleged AAS side effects, some authors claim
that AAS side effects have traditionally been distorted and overstated
(11-12).
Perhaps surprisingly, the
refereed literature is historically unclear whether AAS actually enhance
athletic performance. Until recently, most impressions of improved
performance and appearance of AAS users were based primarily on anecdotal
evidence instead of controlled research (9). Authorities
now recognize that many early clinical studies of AAS were methodologically
flawed, and that subsequent well-controlled studies have demonstrated enhanced
body composition following AAS administration (i.e., increased lean body
mass and decreased fat mass) (12-14). Bhasin’s
landmark study in 1996 demonstrated increased lean body mass and strength
in individuals involved in both training and non-training conditions who
administered AAS (15). It is noteworthy that no
side effects were reported as a result of the 10-week intervention.
Until Bhasin’s study, it was thought that there must be four concurrent
conditions present for AAS to improve athletic performance (16):
-
AAS must be administered to
previously trained athletes during training (16).
-
The AAS administration must
be concurrent with a high protein/calorie diet (16).
-
Sensitive techniques for measuring
strength must be utilized (16).
-
The AAS must be administered
for prolonged periods of time (4.5 months) in order to measure significant
training effects (9, 16).
Although it appears that
the number of AAS users is decreasing according to some sources, it is
important to realize that AAS are still being used (17).
Secondary to the persistent use of AAS, it is imperative that healthcare
practitioners and exercise professionals be prepared to recognize and address
treating a patient for a condition while he/she may be concurrently using
AAS. This is especially true if the patient is involved in a sport
where strength, power, and size are beneficial for performance, such as
the field events in track and field or American football.
Ethical Management of
the Athlete
One could take the stance
that AAS use should be banned outside of treatment for medical conditions
because of possible side effects associated with their use. However,
this is a very parentalistic, or paternalistic, view, and it may not hold
true for adults or professional athletes who view AAS and their consequences
as a fair trade-off for success in sport (18).
This perspective of a balanced exchange may be especially accurate for
athletes who train for years to advance through the levels of elite sport
only to find that many of their competitors are using AAS . These
athletes are then forced to decide to use AAS, compete at a perceived disadvantage,
or abandon competition in general (19).
In sport, participants usually
attempt to gain an advantage over opponents and win the contest through
that advantage. This may be done in the context of fair play, gamesmanship,
professional foul, or doping with substances such as AAS (18).
If all athletes competing within a given sport or contest decided to use
AAS, does that produce an unfair competitive environment? The situation
probably would remain unfair unless all athletes had access to the same
types and quality of drugs (19). Some argue that sport
is constituted as free interplay between the participants (19).
If this is so, and the participants openly and freely choose whether or
not to use AAS despite knowing the potential side effects, then this action
is an expression of the athletes' autonomy (18-20).
An argument could be made
against AAS use because they may give the athlete the chance to perform
outside the natural limitation of man. However, this argument is
inherently weak because one could say the use of coaches, vitamins, or
weight training potentially allows one to perform at a level outside one’s
natural limitations, and these strategies are readily accepted practices
in sport (18). It is the scientific application
of training principles that allow an athlete to hone his or her skills
in sport. One really needs to decide if sport is a test of character
and excellence within the human condition. If this is the case, then
the use of AAS might be thought to limit the development of character,
and it is inherent that drug use is wrong because it removes participants
from the human condition and into a pharmacologically-induced state (18).
While the unfair competitive
advantage of acute AAS use by athletes has been debated for decades, a
more recent concern is the possibility that AAS may confer long-term benefits
in athletes with a history of AAS intervention. Given that AAS increase
myonuclear number (6-7) and that myonuclei are resistant
to degradation even in necrosing myocytes (8), we propose
that an advantage may be conferred months or even years beyond cessation
of exogenous AAS supplementation. As long as the additional myonuclei
are present, an enhanced ability to synthesize muscle protein will likely
remain. Some evidence supports this speculation, showing that although
half of the AAS-induced increases in lean body mass and muscle mass are
lost at approximately 2 months post-intervention in non-athletic males,
lean body mass remained significantly elevated at 5-6 months post-intervention
(21). Remarkably, these increases in lean body
mass occurred without a resistance exercise intervention. Therefore,
it is plausible that in athletes who regularly strength train, an enhanced
ability to adapt to training stimuli remains for an extended, perhaps infinite,
period beyond AAS use. If this is accurate, then this raises the
additional ethical dilemma of whether or not if athletes who have ever
used AAS should be allowed to compete with lifetime drug-free athletes.
The Role of the Health
Professional
The topic of testosterone
and its synthetic equivalents certainly remains a contemporary issue, having
recently been featured as the cover story of Time magazine (22).
Because the subject of anabolic steroids is high profile, healthcare professionals
may, by default, be scrutinized for their opinions on the matter as well
as any association with athletes who use AAS. Coincidentally,
the very same month when the Time article appeared, a controversial opinion
on the topic of AAS use by athletes was published in ESPN Magazine (23).
This alternative perspective was provided by Jose Antonio, PhD, FACSM,
CSCS.
In the ESPN article, Dr.
Antonio, a member of the American Society of Exercise Physiologists (24),
stated in essence that an athlete could safely use anabolic steroids, gain
significant amounts of muscle mass and strength, with little to no side
effects, particularly when carried out under the supervision of a medical
professional. In the same article, Gary Wadler, MD, responded, “Saying
there’s a safe way to use steroids is an absolutely irresponsible statement.”
Wadler continued, “And it’s nothing new. Years and years ago there
were people saying it, fringe people. But no member of the medical
community with any knowledge or integrity would ever say something like
that. First and foremost, it’s a violation of federal law.
Steroids can be used only for legitimate medical treatment within the context
of a doctor/patient relationship” (23). In spite
of Dr. Wadler’s assertion, Dr. Antonio recently co-authored a review paper
published in the Canadian Journal of Applied Physiology which states verbatim
that “based on the available evidence, we would posit that the administration
of moderate doses (200-300 mg/wk for 6-12 weeks once per year) of an injectable
androgen, such as testosterone enanthate or nandrolone decanoate, in healthy
adult males could induce positive changes in body composition and athletic
performance with little or no side effects” (11).
The unethicality of AAS use
by athletes is obvious because AAS may offer an unfair competitive advantage.
What is less clear is the role of the professional in the counseling of
athletes who use or desire to use AAS. Many persons undoubtedly agree
that the role of the professional is to educate the athlete as to the unwanted
side effects of AAS to dissuade their use. However, if an athlete
is steadfast in his/her decision to utilize such drugs, should the role
of the professional with a background in pharmacotherapeutics then become
to offer guidance in the use of AAS to minimize the medical sequelae?
The above scenario in which
the professional stands to protect and benefit the athlete through guidance
in the administration of an illicit substance presents an ethical dilemma.
We are certainly not the first authors to elaborate on this dilemma, because
it has been addressed several times throughout the years, particularly
in popular bodybuilding publications. Nonetheless, we are unaware
of any authors who have published these thoughts in a peer-reviewed forum.
Although several self-trained
gurus have stepped up to the challenge of providing information about AAS
to athletes, this is markedly different from the role of the professional
in such matters. While self-educated authors and trainers are bound
by laws, regarding practicing medicine without a license, they are not
bound by a professional code of ethics. This is an essential distinction
between professionals and nonprofessionals, because membership in a professional
organization, such as the American Society of Exercise Physiologists, adds
another tier of accountability.
The importance of an understanding
of ethics by exercise professionals has been previously impressed and the
fundamental terminology defined (26). Ethics provides
a systematic examination of moral conflict. In the instance of a
health-care professional (e.g., exercise physiologist) who is aware of
an athlete’s intentions to use anabolic steroids, there are several possible
paths of action.
First, the professional may
elect to take a hands-off approach while an athlete haphazardly self-administers
anabolic agents. The justification could be the professional’s adherence
to his/her respective code of ethics, which may contain a stipulation regarding
the improper administration of medications. A second discouraging
influence may be federal law that restricts the use of AAS. Another
possible reason for abstaining from assisting the athlete is that the professional
may perceive any education regarding the drugs as a means of facilitating
a potentially deleterious behavior. Thus, providing the knowledge
to utilize potentially harmful substances may be considered an act of maleficence,
which is the act of “doing harm” to a patient. This is a violation
of the ethical principle of nonmaleficence, which is the cornerstone of
virtually all codes of ethics for healthcare professionals.
A second, albeit controversial,
avenue for the professional to follow is to assist the athlete in illegal
pharmacological intervention. The rationale for choosing to help
the athlete may be that the professional is demonstrating the ethical principle
of beneficence (i.e., doing good) by providing skilled services to decrease
the chances of sequelae. In other words, assistance from someone
proficient in exercise endocrinology or pharmacology is beneficent because
it is in the athlete’s best interest to have a knowledgeable individual
design such a program. This perspective is in agreement with the
comments of Antonio (23).
Some may contend that Antonio’s
comments violate tenets 4 and 6 of the ASEP Code which state, respectively:
“Exercise physiologists are expected to conduct health and fitness, preventive,
rehabilitative, educational, research, and other scholarly activities in
accordance with recognized legal, scientific, ethical, and professional
standards” and, “Exercise physiologists are expected to call attention
to unprofessional health and fitness, preventive, rehabilitative, educational,
and /or research services that result from incompetent, unethical, or illegal
professional behavior” (25).
However, his comments may
be construed as being supportive of tenets 9 and 10, which read, respectively:
“Exercise physiologists should participate in and encourage critical discourse
to reflect the collective knowledge and practice within the exercise physiology
profession to protect the public from misinformation, incompetence, and
unethical acts” and “Exercise physiologists should provide health and fitness,
preventive, rehabilitative, and/or educational interventions grounded in
a theoretical framework supported by research that enables a healthy lifestyle
through choice."(25) If, as Dr. Antonio suggests,
a healthcare professional protected a person from his/her own incompetence
by designing an evidence-based pharmacotherapeutic AAS regimen to minimize
negative health consequences, then these tenets are upheld. Of course
there is also some inherent violation of these tenets due to legal and
other ethical issues embedded in the tenets.
Thus far, we have introduced
one scenario with two avenues resulting in an ethical dilemma. A
multitude of other scenarios exists. For example, what if a collegiate
athlete using AAS asked a health professional to help the athlete circumvent
a positive drug test by teaching the athlete strategies to beat the testing
system in order to avoid losing an athletic scholarship? Or, what
if an athlete wanted you to procure sterile, genuine AAS for their use
as opposed to the dangerous, black-market variety the athlete may alternatively
receive? Perhaps an athlete may ask you to use your expertise to
give the athlete an injection because the athlete is fearful of piercing
an artery or a nerve. Healthcare professionals who may be intimately
involved with athletes are well served to mentally rehearse these and other
scenarios in the event one should ever be faced with such challenging situations.
As healthcare and exercise
experts, we are responsible to serve our patients’ best interests and cause
no harm (20). We have moral obligations that center
on trust, loyalty, and confidentiality. We believe that if a patient
is autonomous then it is ultimately his/her decision whether or not he/she
uses AAS, thus demonstrating the ethical principle of autonomy. However,
it is up to us to provide the best possible information to that patient
so he or she may make a truly informed decision (4).
There are many dubious sources of information regarding AAS for patients
to consult; healthcare practitioners who work with potential AAS users
need to be these sources of truth.
Likewise, we must be prepared
to assist AAS users who may range a great deal in age (2,
27).
For the adult population, educational interventions would best be conducted
in a one-on-one situation. If minors are suspected of AAS use, education
needs to be directed toward the patient and parents. However, patient
education may be insufficient for the patient who uses AAS, because these
drugs may be physically and psychologically addicting (20,
28-29). AAS users who try to discontinue the drug
use often go through withdrawal symptoms akin to those associated with
alcohol, cocaine, or opiate withdrawal (30). The
most prevalent symptoms of AAS withdrawal are depression, fatigue, decreased
libido, insomnia, anorexia, dissatisfied body image, and increased desire
to continue to take AAS (28). With these
possible side effects in mind, it may be necessary to refer the patient
to a counseling program that specializes in drug rehabilitation (29,
31-33).
It would also be appropriate for a patient discontinuing AAS use to seek
counseling for the depression (29-30) and altered body
image (16) that are often associated with AAS withdrawal.
In the United States, AAS
are controlled substances and are illegal to possess without a prescription
(29). Therefore, a patient using AAS for non-medical
conditions is breaking the law and could be reported to the law enforcement
authorities. However, the practitioner probably will not know the
exact manner in which the patient has acquired these drugs. In any
event, due to the psychological changes these drugs may induce, the healthcare
professional has a moral and legal duty to report any patients if they
become a danger to themselves or others. In this way, society can
be protected and patients’ best interests can be served (20).
Summary
Although AAS use is not
common among all athletes, it does appear that AAS use may occur from high
school age through adulthood (2, 4,
32).
Therefore, healthcare practitioners must be able to educate athletes and
their families, and refer them to the proper healthcare professionals for
the athlete’s healthcare needs (20,
30-31).
The use of AAS can affect many spheres of a patient’s life. It stands
to reason that because of its multifactorial cause and broad implications,
treatment for AAS use and addiction will require the expertise of many
healthcare professionals. The eventual decision to use AAS, after
weighing the risks versus the benefits, is ultimately up to the patient.
As healthcare providers and consultants, it is up to us to provide an enlightened
path for our patients and to assist our patients as it serves their best
interests.
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About
the Authors
Greg
Frounfelter is a Certified Athletic Trainer and Certified Strength and
Conditioning Specialist. He is currently a Doctor of Physical Therapy
(DPT) candidate at Creighton University in Omaha, Nebraska. He is
a former USA Powerlifting National Deadlift Champion and Nebraska State
Powelifting Champion. He currently serves as the Nebraska Chairman
for the National Strength and Conditioning Association and is actively
involved in the sport of rugby.
Greg
Bradley-Popovich holds master's degrees from West Virginia University in
Exercise Physiology and Human Nutrition, and he is a Certified Strength
and Conditioning Specialist. He is currently a Doctor of Physical
Therapy (DPT) candidate at Creighton University in Omaha, Nebraska where
he is researching the use of ergogenic aids in the treatment of medical
conditions.
Corresponding
author: Greg Frounfelter, 2502 Franklin Street, Bellevue, NE 68005
402-292-3787,
gfrounfe@creighton.edu
Copyright
©1997-2001 American Society of Exercise Physiologists. All Rights
Reserved.
ASEP
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