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The popular image of the use of doping substances remains focused on sports people and on use in gyms. Increasingly, concern is being expressed that the use of doping substances may be gaining popularity in other settings. Some studies have suggested that homosexual men and young fashion-conscious individuals may be encouraged to use these substances for cosmetic purposes (Korkia and Stimson, 1993).

Commenting on the health risks associated with doping substances is problematic,  although I will attempt this in the next chapter. Very few good epidemiological data exist. The range of health effects associated with AS use range from cosmetic changes to more serious and potentially life-threatening conditions. There is therefore an urgent need to identify what is known about the risk of health consequences resulting from the use of
doping substances. Such information is of paramount importance in the design of educational material and for ensuring that interventions effectively target high-risk behaviours.

Considerable concern exists about the risks associated with the injection of AS and  associated drugs. The context in which injections occur is likely to influence both the risks associated with the behaviour and the public health interventions that are likely to be appropriate (Best and Midgely, 1999).

One of the main observations that can be made from a review of the literature (Haupt and Rovere, 1984; Brower et al., 1994; Yesalis and Cowart, 1998) on the use of AS is how  poorly understood are both the social implications and the epidemiology in comparison with other forms of drug consumption (Shapiro, 1992).

This is a concern because the prevalence of use of doping substances and involvement in illicit drug supply is found among certain groups such as night-club security staff and this may represent an opportunity for crossover between the growing illicit drugs market and the market for AS (Maycock, 1999). The patterns of use are often complex, involving multiple substances taken in sophisticated regimes. It is also important to realise that the use of these drugs does not necessarily carry with it the same negative connotations
and social stereotypes as the use of other illicit substances. It also remains unclear what will be the most effective strategies for reducing the use of these drugs or reducing the associated harms.

Anabolic steroid use can be viewed as a public policy issue. Public policy making is commonly depicted in terms of a natural logical sequence. From this perspective information about a troubling social issue is highlighted and then documented. It then becomes the role of public policy makers to assess the problem and its causes and to respond to the problem using policy tools such as initiating or adapting laws to deal with the issue. They would then continue to respond to the issue until it was alleviated. This is called the ‘rationality perspective’ and is the type of process that the public would expect to be in place to deal with social and health problems such as AS misuse (Rochfort and Cobb, 1994).

However, this somewhat simplistic approach does not appear to be mirrored in reality. Dery (1984) states that problems do not simply exist, they are not ‘objective entities in their own right’. Rational decision making rarely exists in reality. However, the model remains important as it allows researchers to identify barriers to rational decision making. It is often factors other than the objective conditions that are responsible for an issue’s place in the policy makers’ hierarchy. These factors will include the intensity of the issue,
advocacy and the relevance of competing issues. How does this apply to the issue of AS use?

Traditionally, the use of performance-enhancing drugs (PEDs) has been seen as an issue affecting sport alone. Its depiction in the media generally revolves around major sporting events such as the Olympic games or occasions when sportspeople have tested positive for a banned substance. These flurries of media coverage rarely address the social impact of AS use or the health risks to the wider population. The issue of PEDs, therefore, remains firmly focused within a sporting context in the public consciousness.

There are many perceptions of any particular problem and its place in the public consciousness (Peters and Marshall, 1993). It is only relatively recently that ‘problem definition’ has been studied as a means of trying to pull together all of the threads that have an impact on issue identification and policy formulation. Decision makers do not see problems in isolation but in a policy context. This involves a number of policies on related issues. The perceived problems may have generated a continually changing set of policies that have evolved over a period of time. In the case of AS and related substances, it is firmly placed in the context of existing drug policy. Therefore, any investigation into the position of AS in a policy context must also look at how it fits into present-day drug policy.

It is difficult to place AS within the UK’s drug policy agenda. This is partly because in the early part of the 1990s drug policy was dominated by reducing or preventing the spread of viral infections, such as HIV, by intravenous drug injectors (Advisory Council on the Misuse of Drugs (ACMD), 1988, 1989, 1993). Anabolic steroids did not feature  prominently because little research had been done on the extent of AS use and the fact that AS is not injected intravenously. However, some commentators were able to foresee
problems related to the transmission of viral infections connected with AS use (Scott and Scott, 1989; Nemechek, 1991). In the latter part of the 1990s drug policy became driven by crime and criminality (Stimson, 2000). Although there has been an association made between AS use and violence (Choi et al., 1990; Schulte et al., 1993), no research has as yet identified an association with AS use and acquisitive crime. The use of AS has therefore
not appeared to rate a high position in the current drug policy agenda.

The only attempt by central government to address the issue of the use of AS and other performance-enhancing drugs was the change in the legal status in 1996. There are  concerns that the laws could have pushed AS use further underground. Since the  legislation was introduced there does not seem to be a slow down in the number of AS users in the UK; in fact the opposite seems to be true. There have been no attempts by the government to educate users or potential users of AS about the dangers inherent in their
use or even to provide health professionals with information or guidance not only about the legislation but also about the health issues and treatment of AS users. If this has been an attempt to legislate the issue away, it has obviously failed.

It may be that in future one of the factors influencing the provision of services will be the sheer number of users and the potential for the spread of infections such as HIV. As has been described previously, the number of AS users attending needle exchanges has grown steadily over the past decade. If this trend continues, and it shows no sign of slowing down, then it may be that it is more cost-effective to provide separate services for AS users than dilute and place a strain on the existing services designed for opiate users.

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Anabolex Dianabol Dbol D bol Methandrostenolone Steroid

The therapeutic use of AS has a number of aspects. They may be used with the main aim of changing the levels of hormones, or for the purposes of increasing protein synthesis (Wright, 1978). Since AS were first synthesized there have been developments in the understanding of these drugs. Research into the side-effects of these drugs has led to re-evaluation of their uses; for example, it is now unheard of to use this range of drugs in the treatment of psychological disorders (Taylor, 1991). It has been suggested that, although AS are associated with certain risks, selected patients may find these risks to
be acceptable; examples of possible cases include patients with advanced illness or muscle-wasting disease, or patients who have had no success with other treatments (Dobs, 1999).

The American Medical Association (AMA) claim that AS have limited medical uses in the following areas:

1. as treatment of persistent anaemia where red blood cells are unable to regenerate;
2. for control of metastatic breast cancer;
3. for hereditary angio-oedema;
4. to help to stimulate production of plasmin, which helps to break down the protein fibrin – build-up of which can cause thrombosis. These drugs have also been used in other vascular disorders such as Raynaud’s syndrome;
5. to assist protein build-up in those weakened after surgery or through long-term confinement;
6. to treat menopausal symptoms – in small doses and in conjunction with the female hormone oestrogen;
7. to replace testosterone in those men who have had the testes removed following surgery for testicular cancer. The prescribing of oral AS in these circumstances helps to maintain the patient’s secondary sexual characteristics;
8. to treat adolescent males with pituitary malfunction when they reach the appropriate age for puberty. Anabolics given for 4 to 6 months in the proper dosing schedule cause the growth spurt and development of secondary sexual characteristics.

The AMA admits to being more uncertain about some of these applications than others (such as adjunct therapy for conditions of protein deficiency), but acknowledges that steroids induce a sense of well-being in patients, stimulate the appetite and may be helpful for terminal patients.

The British National Formulary, produced jointly by the British Medical Association and the Royal Pharmaceutical Society, is far more cautious in its view of the medical value of AS. The only positive indication is for aplastic anaemia; the 2001 edition comments: ‘Their [AS] protein-building property led to the hope that they might be widely useful in medicine, but this hope has not been realised’. This means that prescribing levels for the drug are low in the UK.

Anabolic steroids have been used to treat individuals with subnormal levels of hormones (Wright, 1978; Taylor, 1991). This application of testosterone therapy has been used in the treatment of impotent males and to initiate the onset of puberty in developmentally delayed boys (Hoberman and Yesalis, 1995). Testosterone derivatives and AS have also been used for their androgenic effects in the treatment of female to male transsexuals
(Korkia et al., 1996; Westaby et al., 1977).

Current research is taking place regarding the use of androgen therapy for the treatment of aging in males (Hoberman and Yesalis, 1995). The testosterone-derived treatments are already being used in a London clinic to treat males going through a ‘mid-life crisis’. There is speculation that, just as the female menopause has been recognized as a treatable  medical complaint, it may be possible to restore the vigour of middle-aged men going through the andropause.

There are a diverse range of medical complaints in which it may be necessary, or  desirable, to induce an increase in lean body mass; examples may include people suffering from wasting disease, malnutrition, or other advanced serious illness (Wright, 1978).  Anabolic steroids and testosterone derivatives have proved to be effective in the  treatment of a number of these types of conditions (Dobs, 1999). Anabolic steroids have been used in cases of malnutrition, including in patients with general non-specific  malnutrition. Elderly patients suffering from insufficient dietary protein intake may be prescribed AS to restore their nitrogen balance, increase appetite and muscle mass, and so produce a weight gain (Wright, 1978). Conditions such as cirrhosis, anaemia and  pulmonary disease may also benefit from treatment with AS (Mendenhall et al., 1995;  Schols et al., 1995; Ferreira et al., 1998). The anabolic effects of AS have also proved to be effective in patients with severe burns (Demling, 1999; Dobs, 1999), and in surgical  situations to improve the patients’ pre- and postoperative condition (Wright, 1978).

Some of the most recent research into the therapeutic applications of testosterone  derivatives and AS has been related to their use in the treatment of patients with HIV.  Anabolic steroids have been shown to increase the lean mass and appetite of patients  suffering from the muscle-wasting effects of the progression of HIV infection and AIDS (Dobs, 1999; Strawford et al., 1999).

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Anabolex Dianabol Dbol D bol Methandrostenolone Steroid

Anabolic steroids are associated with a range of adverse side-effects. Some of the adverse symptoms linked with AS are classified as psychological, or psychiatric. From the  mid-1980s onwards the popular press has been reporting the incidence of rages induced by AS, termed ‘roid rages’ (Lubell, 1989). There has been a significant level of controversy regarding the influence that AS may have upon the judgement of the individual user. Anabolic steroids have been associated with a number of violent crimes (Lubell, 1989; Lenehan et al., 1996); however, there has been speculation regarding the amount of influence these drugs exerted upon the offender’s behaviour. It is interesting to note that
although AS are now associated with adverse psychological symptoms, they were used between the 1930s and the mid-1980s, with varying levels of success, in the treatment of psychological disorders, such as depression (Taylor, 1991).

Research into the psychological effects of illicit AS use is difficult because it is more or less impossible to replicate the conditions under which AS are used illicitly. However, Su et al. (1993) conducted research into the effects of high doses of AS. They found that men taking a high dose of AS were likely to experience effects that included increased irritability, increased violent tendencies, increased mood swings and an increase in anger. This study was controlled and double blind, the subjects were also screened for previous substance misuse and psychological problems before taking part in the study. Other studies have shown similar relationships between use of AS and changes in mood and behaviour (Pope and Katz, 1988; Kouri et al., 1995; Corrigan, 1996; Lenehan et al., 1996; Borowsky et al., 1997).

It has also been suggested that some users of AS have a predisposition towards personality disorders. Cooper et al. (1996) conducted a study that showed that one in three of the AS-using individuals in their research satisfied the diagnostic criteria for at least one of the personality disorders before they started to use AS. These included  paranoid, schizotypal, antisocial, borderline, histrionic, narcissistic, and passive–aggressive personality trait disorders. Their results also suggested that significant  disturbances in personality profile are associated with, and possibly a direct result of, AS use. A study by Porcerelli and Sandler (1995) outlined a positive relationship between narcissistic personality traits and use of AS. Their study compared two groups made up of weightlifters and body-builders, one group consisting of AS users, the other of non-AS  users. The AS-using group had significantly lower levels of empathy but significantly  higher levels of narcissism than the non-AS-using group. The only difficulty involved in the interpretation of these results stems from the fact that personality traits prior to onset of AS use were not recorded, therefore it is impossible to conclude whether a predisposition to such traits is related to the initiation of AS use.

It is interesting that in a study of general practitioners from the Liverpool, Birmingham and Berkshire areas of the UK, the largest number of adverse effects observed by the doctors were psychological/psychiatric in nature. This result was common to all three areas surveyed (Lenehan et al., unpublished).

The potential societal implications of these adverse psychological effects have been  documented in a number of reports. Murder (Dalby, 1992; Corrigan, 1996), armed  robbery (Dalby, 1992), domestic violence (Schulte et al., 1993; Choi and Pope, 1994; Stanley and Ward, 1994) and child abuse (Schulte et al., 1993) are examples of crimes that have been associated with abuse of AS. The effects of AS and testosterone derivatives  upon road aggression are also subject to research. Ellingrod et al. (1997) conducted a  study using the Iowa driving simulator to discover the effects of physiologic and supraphysiologic doses of testosterone cypionate. They used weekly doses of 100 mg, 250 mg and 500 mg, and then tested the driving behaviour of the subjects. The study did not provide conclusive evidence of a relationship between AS and aggressive driving  behaviour, but it was suggested that greater doses of testosterone cypionate, i.e. over 500 mg per week, may be responsible for alterations in driving behaviour. Further research is required to determine the prevalence of AS-related incidents of driving aggression.

A report by Lubell (1989) documented two murder cases that were associated with AS use, namely the trials of Horace Williams and Glenn Wollstrum. In both cases the men that committed the murders were stated to have been psychologically normal before they  started to use AS. At each of the trials the defendants pleaded not guilty because AS use had caused insanity; however, these pleas were rejected by the respective juries and a guilty verdict was passed on both occasions. Although it has been established that use of AS may render certain individuals more prone to aggressive behaviour (Su et al., 1993), there is no conclusive evidence to support the theory that AS can be the direct cause of violence (Lubell, 1989; Pope and Katz, 1990; Kouri et al., 1995).

Research by Choi and Pope (1994) has suggested there is a link between male aggression towards women and AS use. Their study involved AS-using and non-AS-using athletes. The results showed that, while using AS, the user group reported significantly greater levels of aggression towards their female partners. The levels of aggression of the control group of non- AS-using athletes and the AS-using group during their off-drug cycle were not significantly different.

Other research has been carried out to discover the relationship between AS use and  sexual aggression. Yates et al. (1999) performed a study of the psychosexual effects of testosterone cycling in men. The doses used in this study were 100 mg, 250 mg and 500 mg of testosterone cypionate administered in weekly intramuscular injections. Their work showed that doses of testosterone up to five times the physiologic replacement dose do not present a significant risk of adverse psychosexual effects in most normal men. The  study also revealed that at doses starting from 500 mg of testosterone cypionate per week, a small proportion of men are more likely to experience adverse psychosexual effects. This result is particularly interesting because AS users frequently use doses of AS that are significantly greater than the recommended therapeutic dose (Duchaine, 1989; Hart, 1993; Lenehan et al., 1996). A study of sexual aggression in adolescents (Borowsky et al., 1997) has also shown a relationship between use of AS and sexual aggression.

Another particularly important issue is that there may be other drugs used in conjunction with AS; for example, the use of stimulants such as cocaine or amphetamines has been shown to be highly correlated with self reported aggressive behaviour (The Brown  University Digest of Addiction Theory and Application, 1994; Yesalis et al., 1993a). This pattern of drug use is not an uncommon practice in the AS-using community (DuRant et al., 1993; Lenehan et al., 1996; Lukas, 1996).

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Anabolex Dianabol Dbol D bol Methandrostenolone Steroid

At present, accurate statistics for prevalence of AS use in the UK are not available. As mentioned earlier, there are many variables that may render small- or large-scale prevalence studies inaccurate. Previous British studies, such as those by Lenehan et al. (1996) of AS use in the north-west of England and the Williamson (1993) study of drug use at a technical college in Stirling, provide only localized information. It is perhaps easier, and possibly more practical, for us to consider the trends and patterns of AS use rather than simply the number involved in this type of behaviour. In this way we may be better equipped to understand and alleviate any of the problems stemming from this type of substance use. The importance of factors such as availability of fake or counterfeit steroids, use of clean injecting equipment and regular medical checks for users should also be considered.

Korkia and Stimson (1993) attempted to explore the extent and uses of AS in the UK from a public health perspective. Twenty-one gymnasia in England, Scotland and Wales were surveyed by questionnaire yielding a response rate of 59% (1667 respondents). They found that 9.1% of men and 2.3% of women had taken AS at some time, and 6% of men and 1.4% of women were current users. Considerable variation was found in the prevalence of use, ranging from no reports (in three gyms) to 46%. Patterns of use and perceived side-effects were investigated with a group of 110 AS users recruited through social networks.

In-depth interviews with the users revealed that 97 men and 13 women had been using AS regularly for 2.05 and 1.9 years, respectively. Seventytwo of those interviewed injected AS. Up to 16 different drugs were taken by interviewees during the present or last cycle. Most (77%) interviewees reported experiencing two or more side-effects. Of the 97 men interviewed, 56% reported testicular atrophy, 52% gynaecomastia, 36% elevated blood pressure, 56% fluid retention, 25% injuries to tendons, 22% nosebleeds and 16% frequent colds. Six men reported problems with kidney function and five with liver function. Of the 13 women interviewed, eight reported menstrual irregularities, eight fluid retention, four clitoral enlargement, three decreased breast size, and two elevated blood pressure. Forty-eight per cent were concerned about the long-term side-effects of AS use, and 44% indicated that they would discontinue taking AS if it were proven that they could cause serious side-effects, such as cancer. Twenty-two per cent indicated that they would not stop using AS and 33% were unsure. Fifteen per cent reported having permanent side-effects. Eighty-seven per cent said that they would continue using AS even if their possession became illegal. Over a third (35%) said that they received regular medical checks for AS use. Although the data from this study do not attempt to estimate the number of AS users in the UK, it does suggest that AS use is relatively common among regular gym attenders in British towns. The results suggest that AS use has diffused in many parts of Britain, with ‘pockets’ of very high-user groups. The authors state that it is impossible to estimate the prevalence for Britain as there are no reliable data regarding the number of gyms in the UK.

Lenehan et al. (1996) used a similar method to Korkia and Stimson, except that they included more types of gymnasia (n = 43), and used trusted outreach workers to administer the survey; this might explain the higher level of AS use reported. Of 58% responding, 50% of hardcore (respondents mostly using freestanding weights) users, 31% of mixed (more strength than cardiovascular equipment) users and 13% of fitness (more cardiovascular than strength  equipment) users reported that they had taken AS.

Perry et al. (1992) conducted a prevalence study of AS use among people using gymnasia on a regular basis (i.e. three or more times a week) in West Glamorgan. The rate of use was 38.8% out of 160 individuals. Over 58% of AS users admitted injecting more than 30 times, and 57% of injectors admitted to injecting in the year prior to interview. Fifty per cent had taken oral AS in the previous year and 56.4% had taken tablets on 30 or more occasions. The potential for HIV transmission via needle sharing was a particular concern in this study. Eight people had been involved in some
form of needle-sharing activity.

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