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Societal Alternatives to Anabolic Steroid Use

2000; Lippincott Williams & Wilkins; Volume: 10; Issue: 1 Linguagem: Inglês

10.1097/00042752-200001000-00001

1536-3724

Charles E. Yesalis, Michael S. Bahrke, James E. Wright,

Doping in Sports

In 1991, Robert Voy, MD, former Chief Medical Officer of the United States Olympic Committee, commented: If we will have reached a point of no return with this win at all costs attitude, the gold medals won't shine as brightly, the flags won't wave as boldly, the torch will flicker dimly, and we will have lost one of the greatest treasures ever known.1 It appears that Dr. Voy's predictions have already come to pass. In 1998 and 1999 alone, the public was bombarded with a constant stream of drug scandals that included, among others: • Chinese swimmers being ejected from the World Championships in Australia after having tested positive for banned substances; • former East German coaches and physicians tried and fined for their roles in the systematic doping of East German athletes over three decades; • a Canadian snowboarder, Ross Rebagliati, testing positive for marijuana after having won a gold medal at the Winter Olympics in Nagano, Japan; • Olympic gold medalist swimmer Michelle Smith deBruin being accused and found guilty of manipulating her urine sample in an out-of-competition drug test; • cyclists, coaches, physicians, and trainers participating in the Tour de France implicated in a widespread, systematic doping scheme; • Olympic champion shot putter Randy Barnes testing positive for androstenedione; • baseball home run king Mark McGwire admitting using androstenedione; • Olympic sprint champion Florence Griffith-Joyner dying at age 38, and rumors of prior performance-enhancing drug use that surrounded her victories at the Seoul Olympic Games being resurrected; • Uta Pippig, three-time winner of the Boston Marathon, testing positive for a high level of testosterone; and • Australian Open tennis champion Petr Korda testing positive for an anabolic steroid. When discussing the problem of performance-enhancing drug use, it is important to remember that sport is a microcosm of our society, and that the problems surrounding sport are by no means limited to drug use. During the 1980s, 57 of 106 universities in National Collegiate Athletic Association (NCAA) Division I-A were punished by the NCAA via sanctions, censure, or probation for rule violations. 2 These offenses did not involve illicit drug use by athletes, but rather unethical behavior of coaches, athletic administrators, staff, and faculty, the very men and women who should be setting the example for those athletes. More recently, United States collegiate athletes have been convicted of criminal offenses related to sports gambling. In addition, an NCAA survey of 2,000 Division I male football and basketball players found that 72% had gambled in some form and that 25% reported gambling on collegiate sports; 4% had even bet on games in which they played. 3 Among members of the International Olympic Committee (IOC), bribery, graft, and other corruption appear to be entrenched in the culture of the organization (Swift E, “Breaking point,”Sports Illustrated, February 1, 1999, pp. 34–35). 4 A common factor among all of these scandals is money. In the 1990s, there is no doubt that sport has become a multinational industry of huge proportions. The IOC, NCAA, National Football League (NFL), National Basketball Association (NBA), and Major League Baseball (MLB), among others, are all billion-dollar businesses (“A survey of sport: not just a game,”Economist, June 6, 1998, pp. 2–23; Hiestand M, “The B word—billion—no longer out of bounds,”USA Today, January 12, 1999, pp. 1A–2A). A free society often relies on the news media to inform the populace regarding the incidence and magnitude of problems, such as doping in sport. Even though the epidemic of drug use in sport has been common knowledge among insiders, the news media, especially in the United States, does not appear to have engaged in a widespread, concerted effort to chronicle this issue. Unfortunately, the media, particularly television news programs, are often influenced by conflicts of interest within their parent companies between those reporting the news and those responsible for the broadcast of major sporting events. Few would argue that an in-depth exposé of drug use, for example in the NFL or the Olympics, would enhance the marketing of these highly lucrative sporting events. Before any effort can be made to address the issue of doping in sport, it is critical that all of the stakeholders acknowledge that a problem exists. In this regard, we need to fully appreciate the high entertainment value placed on sport by society. Some go so far as to argue that sport is the “opiate of the masses,” a contention made by Karl Marx regarding religion. If sport has become the opiate of the masses, then we must be prepared for indifference on the part of the public regarding drug use in sport, at least at the elite level. Moreover, it could be argued that if substantial inroads are made regarding the epidemic of doping, fans may express anger rather than appreciation toward those fighting drug use. Many people view competitive sport as an escape from the problems of daily life, and do not wish to be confronted with the moral and ethical aspects of doping. Further, if antidoping efforts are successful, once bigger-than-life idols could begin to appear all too human in stature, and breaking of records at national, Olympic, and world levels could become so rare that the fervor of fans will wane and the sport business will suffer. In the United States, even high school sport appears to be expanding as a source of entertainment for adults, as shown by the increasing level of television coverage of high school football and basketball games. Consequently, it can be argued that the growth of the high school sport entertainment business is contributing to the increase in anabolic steroid use among adolescents that has been observed during the 1990s. Sport has also been used by governments as a tool to control the masses or as justification for their social, political, and economic systems. “Bread and circuses” (panem et circenses) were used in this fashion by the emperors of Rome. 5 Nazi Germany, the Soviet Union, East Germany, and Communist China all have used sport for political advantage. 6 Consequently, such governments arguably would be less than enthusiastic participants in the fight against doping, or for that matter, even publicly acknowledging the existence of widespread doping. On the contrary, there is a reasonable amount of evidence that the governments of the Soviet Union, East Germany, and Communist China all played significant roles in the systematic doping of their athletes. With many societal problems, identifying potential solutions is easy, but agreeing on a proper course of action and successfully completing it are difficult. The following are our alternative suggestions for dealing with the use of anabolic steroids and other performance-enhancing drugs: legalization, interdiction, education, and alteration of societal values and attitudes related to physical appearance and winning in sport. Legalization: An End to Hypocrisy? The legalization of illicit drugs has for some time been the subject of heated debate: comments range from “morally reprehensible” to “accepting reality.” Legalization would reduce the law enforcement costs associated with illicit anabolic steroid use and the substantial cost of drug testing. Even some opponents of legalization must concede that such an action would lessen the level of hypocrisy in sport. It can be argued that society and sport federations have turned a blind eye or have subtly encouraged drug use in sport as long as the athletes have not been caught or spoken publicly about their use of anabolic steroids. 1,7,8 In the United States, legalization of anabolic steroid use in sport would involve two levels of authority. At one level, federal and state laws related to the possession, distribution, and prescription of anabolic steroids would have to be changed. If in the future anabolic steroids become an accepted means of contraception or as treatment for “andropause,” it is difficult to understand how anabolic steroids could remain a Schedule III controlled substance in the United States. At the second level, bans on anabolic steroids now in place in virtually every sport would have to be rescinded. Legalization would bring cries that the traditional ideals of sport and competition were being further eroded. However, given the continued litany of drug and other sport scandals that have taken place in full public view, in this jaundiced age it is hard to imagine that many people believe the so-called traditional ideals even exist in elite sports. It has long been asserted that legalization of anabolic steroids would force athletes to further expose themselves to the potential for physical harm or to compete at a disadvantage. Some have even questioned the basic premise that banning drugs in sport benefits the health of athletes and have argued that “the ban has in fact increased health risks by denying users access to medical advice and caused users to turn to high-risk black market sources.” 9 Legalization would allow athletes to use pharmaceutical-grade steroids while being monitored by a physician. It can also be argued that the dangers of steroid use are not, in itself, a realistic deterrent, given the existing levels of use of tobacco, alcohol, and other illicit drugs that pose similar risks. In 1999, it seems that legalization of anabolic steroid use in sport is not acceptable. However, if the impotence of drug testing, which is now in full public view, persists for much longer, it is easy to imagine the IOC or other sport federations throwing up their hands in frustration and allowing the athlete with the best chemist to prevail. Interdiction: A Question of Cost-Effectiveness The United States federal government and all state governments currently have laws regarding distribution, possession, or prescription of anabolic steroids. 10 The Federal Food, Drug, and Cosmetic Act (FFDCA) was amended as part of the Anti-Drug Abuse Act of 1988, such that distribution of steroids or possession of steroids with intent to distribute without a valid prescription became a felony. This legislation not only increased the penalties for illicit distribution of steroids but also facilitated prosecution of these crimes under the FFDCA. In 1990, the Anabolic Steroids Control Act was signed into law by President Bush and added anabolic steroids to Schedule III of the Controlled Substances Act. This law institutes a regulatory and criminal enforcement system whereby the United States Drug Enforcement Administration (DEA) controls the manufacture, importation, exportation, distribution, and dispensing of anabolic steroids. However, the act did not provide extra resources to the DEA for shouldering the added responsibility. As the use of anabolic steroids is increasingly criminalized, drug use will likely be driven further underground, and the source of the drugs will increasingly be clandestine laboratories, the products of which are of questionable quality. It also appears that in some areas criminalization has already altered the distribution network for anabolic steroids; athletes used to sell to other athletes, but sellers of street drugs are now becoming a major source of anabolic steroids. 11 Even though the legal apparatus to control steroid trafficking exists, enforcement agents already are struggling to handle the problems of importation, distribution, sales, and use of other illicit drugs such as cocaine and heroin. 11 Based on what we know about the physical, psychological, and social effects of steroids, it is neither realistic nor prudent that enforcement efforts for steroids should take precedent over those for more harmful drugs. This line of reasoning should not be used as a rationale for a lack of effective action against steroids; nevertheless, the outlook that limited resources can be stretched to cover yet another class of drugs is not optimistic, 11 especially given recent increases in recreational drug use among adolescents. 12 The availability of anabolic steroids in this country suggests that there is reason to believe that the United States simply may not have the law enforcement manpower to deal with apprehending and punishing sellers of anabolic steroids and other performance-enhancing drugs. Nonetheless, between February 1991 and February 1995, 355 anabolic steroid investigations were initiated by the United States DEA. 13 There have been more than 400 arrests, and more than 200 defendants have been convicted. However, because of the way criminal penalties were developed for steroid infractions, an individual brought to court on charges of distribution or selling must be a national-level dealer to receive more than a “slap on the wrist” and/or a short visit to a “country club” prison. For this reason, United States law enforcement agents often do not bother pursuing small cases because the costs of prosecution vastly outweigh any penalties that will be assessed. Drug testing by sport federations is yet another form of interdiction. Such testing has been partially successful when directed at performance-enhancing drugs that, to be effective, must be in the body at the time of competition, such as stimulants and narcotics. Drug testing has been even less effective against anabolic steroids, which are used during training or used to enhance an athlete's capacity to train. Testing can be circumvented by the steroid user in several ways. Generally, to avoid a positive test result, athletes can determine when to discontinue use before a scheduled test or, in the case of an unannounced test, titrate their dose using transdermal patches or skin creams containing testosterone so as to remain below the maximum allowable level. Further confounding the issue are other drugs used by athletes, such as human growth hormone and erythropoietin, for which no effective tests currently exist. Moreover, testing for anabolic steroids is expensive (∼$120.00/test), and although organizations like the IOC, NFL, or NCAA may be able to institute such procedures, the cost is prohibitive for the vast majority of secondary schools. Consequently, only a handful of secondary school systems in the United States test for anabolic steroid use. Although interdiction through law enforcement and drug testing has intuitive appeal, its impact on the nonmedical use of anabolic steroids and other performance-enhancing drugs is open to debate. Since the flurry of legislative activity at the state and national levels regarding control of the manufacture, distribution, prescription, and possession of steroids in the late 1980s and the early 1990s, use among adolescents in the United States has increased significantly. As to the future of testing, it is difficult to be optimistic: over the past 30 years, drug users have consistently outplayed the drug testers. In addition, one can only speculate as to the future challenges posed by impending advances in genetic engineering. Will we be able to genetically enhance muscle mass, aerobic capacity, vision, and neurologic response? 14 Education: Is Anybody Listening? Since the 1980s, the United States Public Health Service, the United States Department of Education, and many state education departments, state and local medical societies, private foundations, and sports federations have been involved in prevention efforts related to steroid abuse. For the most part, these have centered on development and distribution of educational materials and programs such as posters, videos, pamphlets, and workshops. For example, the Iowa High School Athletic Association has developed an educational booklet that provides information on the effects of steroid use but also includes strength-enhancing alternatives to steroids and prevention ideas. 15 The United States Department of Education and other sources have developed a variety of informational posters targeted at high school students to provide facts about steroids, their adverse effects, alternatives to their use, and their illegal status. 16,17 Video distributors now have a wide range of videotape programs available on steroid use prevention and body building techniques. 18 Educational consulting firms provide antisteroid training, program, and curriculum development to junior and senior high schools across the United States. 19,20 Major television networks have presented special programming targeted at adolescent audiences to relay the possible consequences of steroid use (“Testing Dirty,” American Broadcasting Company Afterschool Special; “The Fourth Man,” Columbia Broadcasting System Schoolbreak Special; “Benny and the Roids,” Walt Disney Educational Productions). United States health educators have made some inroads in changing several high-risk behaviors, such as high-fat diets, sedentary lifestyles, and smoking. However, educators are well armed with vast quantities of scientific data regarding the deleterious nature of these activities. Further, these are behaviors on which society has increasingly frowned. In sports, however, athletes who use anabolic steroids have enjoyed significant improvements in physical performance and appearance, and society is much less likely to shun these behaviors. Adulation of fans, the media, and peers is a strong secondary reinforcement, as are financial, material, and sexual rewards. Another fly in the education ointment is the possibility that anabolic steroids taken intermittently in low to moderate doses may have only a negligible impact on health, at least in the short term. In 1989, several experts at the National Steroid Consensus Meeting concluded that according to the existing evidence, these drugs represent more of an ethical dilemma than a public health problem. 21 Although there is still little available evidence regarding the long-term health effects of anabolic steroids, many current or potential anabolic steroid users unfortunately mistake absence of evidence for evidence of absence. Even more frustrating is the fact that in two national studies, a large percent of the anabolic steroid users surveyed expressed no intention to stop using anabolic steroids if deleterious health effects were unequivocally established. 22,23 Clearly, the paucity of scientific information has impeded the formulation of effective health education strategies. Far more than that, the unsubstantiated claims of dire health effects made by some in sports medicine and sensationalized by the news media have further eroded communication between athletes and doctors. However, even if long-term deleterious effects were well documented for use of anabolic steroids, experience with teenagers and smoking suggests that substantial abuse would probably persist. 24,25 All of these problems and limitations in developing and disseminating effective prevention and intervention strategies could in great part explain the significant increase in anabolic steroid use among adolescents since 1990. Changing a behavior that has resulted in major benefits to the user, such as improved appearance and athletic performance, presents a monumental challenge. Traditional cognitive and affective education approaches to tobacco, alcohol, and drug abuse prevention have not been effective. 26 In fact, there is evidence that providing a prevention program that uses scare tactics to dissuade adolescents from becoming involved with anabolic steroids may actually lead to increased usage, possibly because additional information stimulated their curiosity. 27 This observation helped lead to a prevention program (Adolescents Training and Learning to Avoid Steroids [ATLAS]) focused in part on positive educational initiatives related to nutrition and strength training. The program also focused on increasing adolescents' awareness of the types of social pressures they are likely to encounter to use anabolic steroids and attempts to inoculate them against these pressures. Adolescents are taught specific skills for effectively resisting both peer and media pressures to use anabolic steroids. Periodic monitoring and reporting of actual anabolic steroid use among adolescents was conducted in an effort to dispel misinformation concerning the widespread use of anabolic steroids among peers. Using peers as program leaders is an additional component. This program has been successful in significantly affecting attitudes and behaviors related to steroid use and remained effective over several years. 28 Unfortunately, the generalizability of the ATLAS program is open to question. The program focused on male high school football players and was not designed specifically to address anabolic steroid use among teenage girls, among whom rates of steroid use have doubled since 1990. In addition, the long-term effectiveness of this school-based program is still unknown and the program has yet to be replicated in other states. Moreover, there are two important and as yet unanswered questions regarding the ATLAS program. First, are school boards, in an age of constrained resources, willing to commit time and money to this relatively demanding program? Efficacy aside, it would be far easier and cheaper to continue to only give “lip service” to this problem and restrict efforts to an occasional talk by the coach and the use of readily available educational videos and posters. The second question is even more threatening to school officials. In an era when some believe that the “win at all costs” philosophy is gaining the upper hand, will some schools hesitate to unilaterally “disarm?” That is, will some schools hesitate to institute a program that could significantly reduce steroid use at the cost of conferring an advantage to an opponent who chooses to maintain a “see no evil” stance on the use of performance-enhancing drugs? This question is given some legitimacy by pervasive anecdotal accounts of high school coaches encouraging the use of, and in some instances selling, so-called supplements such as creatine, DHEA (dehydroepiandrosterone), and androstenedione to their athletes. Although educating athletes about the health risks and ethical issues associated with anabolic steroid use continues to hold some promise, this strategy certainly cannot be viewed as a panacea. Our Values Must Change Compared with legalization, interdiction, and education, our social environment appears to receive far less attention. Yet in many ways, the social environment exerts a more fundamental influence on drug use in sport than do the more superficial strategies described earlier. A number of performance-enhancing drugs, including anabolic steroids, are not euphorigenic or mood altering immediately after administration. Instead, the appetite for these drugs was created predominantly by our societal fixation on winning and physical appearance. An infant does not innately believe that a muscular physique is desirable; our society teaches this. Likewise, children play games for fun, but society preaches the importance of winning, seemingly at younger and younger ages. Ours is a culture that thrives on competition, both in business and in sport. However, we long ago realized that competition of all types must exist within some boundaries. A primary goal of competition is to win or be the very best in any endeavor. Philosophically, many in our society appear to have taken a “bottom-line” attitude, and consider winning to be the only truly worthwhile goal of competition. If we accept this philosophy, then it becomes easy to justify or be led to the belief that one should win at any cost. At that point, doping becomes a very rational behavior, with the end (winning) justifying the means (use of anabolic steroids and other drugs). This “win at any cost/winner take all” philosophy is not new. The winners in the ancient Greek Olympics were handsomely rewarded, and episodes of athletes cheating to obtain these financial rewards are well documented. 29–31 Smith 32 argued persuasively that the level of cheating in college athletics at the turn of the century exceeded what we see today. Even the legendary American football player Knute Rockne was quoted as saying “show me a good and gracious loser and I'll show you a failure.” American football coach Vince Lombardi went a step further with his philosophy that “winning isn't everything—it's the only thing.” Indeed, episodes of cheating, including drug use, have been commonplace at the collegiate, professional, and Olympic levels during the last four decades. 1,7,32–36 Moreover, because of reports in the news media and written and verbal testimonials by athletes, adolescents are aware of the part that anabolic steroids and other performance-enhancing drugs play in the success of many so-called role-model athletes. Our fixation on appearance, especially the muscularity of men, is also long lived. An entire generation of young men aspired to the physique of Charles Atlas, followed by yet another generation who marveled at the muscles of Mr. Universe, Steve Reeves, who played Hercules in several movies in the 1950s. Today's children look with envy at the physiques of Sylvester Stallone, Jean Claude Van Damme, Wesley Snipes, Linda Hamilton, and other actors and actresses whose movie roles call for a muscular athletic build. In addition, a number of professional wrestlers, such as Hulk Hogan and “Stone Cold” Steve Austin, and some elite athletes, such as professional baseball player Mark McGwire, are admired in part for their bigger-than-life muscularity. Anabolic steroid use among professional wrestlers, including Hulk Hogan, was given national attention during a steroid trafficking trial in 1991. The appointment by President Bush of Arnold Schwarzenegger, an individual who attained his prominence as a bodybuilder and movie star at least in part as a result of steroid use, as chair of the President's Council on Physical Fitness and Sports was yet another inappropriate message we sent our children. Such messages of material reward and fame as a result of drug-assisted muscularity and winning grossly overshadow efforts of posters on gym walls and videos that implore students to “just say no to steroids.” Some might argue that our attitudes and values related to sports and appearance are too deeply entrenched to change. That may be so, particularly when it comes to elite levels of sport; there is simply too much money involved. However, if we cannot control our competitive and narcissistic natures, we then must resign ourselves to anabolic steroid use, even among our children. Society's current strategy for dealing with the use of anabolic steroids in sport is multifaceted and primarily involves interdiction and education. However, 10 years after our society was made aware that our children were using steroids, our efforts to deal with this problem have not been very successful. Since 1989 a number of national conferences on anabolic steroid use have been held, sponsored either by the United States federal government or by sports and educational organizations. The purpose of these meetings was to gather and/or disseminate information or to achieve a consensus for action. At this point, all of these activities appear to have been a sincere effort to deal with the problem, but this strategy of attacking the symptoms while ignoring the social influence of drug use in sport obviously has been ineffective. If we maintain our current course in the face of increased high levels of anabolic steroid use (or use of other performance-enhancing drugs), then we as sports medicine professionals, parents, teachers, and coaches are guilty of duplicity—acting for the sake of acting. We plan and attend workshops, distribute educational materials, lobby for the passage of laws, and seek the assistance of law enforcement. All of these activities merely soothe our consciences in the face of our inability—or unwillingness—to deal with our addiction to sport and our fixations on winning and appearance.