Are steroids as bad as we think they are?
IT MAY NOT HAVE been the most substantive line in President Bush's State of the Union address last January, but it had to be the least controversial. "The use of performance-enhancing drugs like steroids in baseball, football, and other sports is dangerous," he intoned. "And it sends the wrong message -- that there are shortcuts to accomplishment, and that performance is more important than character."
This week it looked like Major League Baseball was finally falling into line. The immediate impetus, of course, was not a dusty presidential applause line but grand jury testimony by Barry Bonds, the game's biggest star, in which, as reported in The San Francisco Chronicle on Friday, Dec. 3, he admitted to taking anabolic steroids -- unwittingly, he insisted. While this came as a shock to no one who follows baseball, the resulting blast of outrage has put the baseball players' union, long opposed to meaningful drug testing, on the defensive. By last Sunday, Sen. John McCain was threatening to introduce legislation to toughen Major League drug testing if that's what it took. By Friday the president had reiterated his own demand. Throughout the week, the league and the players' union were at work on the outlines of a tougher testing regime.
But it's unclear just how wide the indignation spreads. Far from alienating fans, the steroid scandal unfolded during the course of a season of record baseball attendance. And a New York Times poll a year ago found that, among those under the age of 30, 41 percent didn't have the slightest problem with the use of performance-enhancing drugs by professional athletes.
Such nonchalance may be unsettling. Yet according to a few doctors and bioethicists, it's also rational. The concern over steroids -- and performance-enhancing drugs in general -- is misplaced, they argue. According to Adrian Dobs, an endocrinologist at the Johns Hopkins School of Medicine, for most steroid users the likelihood of "something terrible or catastrophic" happening is "probably pretty low." Moreover, argues Norman Fost, a pediatrician and head of the University of Wisconsin's bioethics program, "the claim that there's something immoral about using these drugs is based on very sloppy thinking or simple hypocrisy."
Needless to say, such arguments are met with everything from bemusement to exasperation by many doctors and policy makers. But thinkers like Fost (perhaps the most visible of the steroid skeptics) dismiss their critics as hysterics, pointing not only to the scant evidence of health risks, but the history of similarly controversial innovations in sport and the distorted way in which we tend to look at the risks athletes face. So are these drugs really so dangerous? And does using them really amount to cheating?
The first question, a medical one, would seem less open to dispute -- and up to a point, it's not. With anabolic steroids, for example, there's wide agreement that there are short-term hormonal effects like hair loss, acne, infertility, and, in women, male-pattern body hair and a lowered voice. But, as Fost points out, these are mostly cosmetic and, except for the voice changes, usually reversible.
The real horror stories involve cancer, strokes, and heart attacks. Lyle Alzado, the legendary NFL defensive lineman, died at 42 of brain cancer that he attributed to years of heavy steroid use. Jason Giambi, of the New York Yankees, developed a pituitary tumor this year that has been widely linked in the press to the steroids and human growth hormone (HGH) he has admitted to taking.
The biggest problem in assessing the danger of steroids, according to everyone involved in the debate, is the lack of data. In smaller doses, anabolic steroids have been used medically for 70 years, and the amounts some athletes take are in the range a doctor would prescribe for, say, a man who needed to replace testosterone lost due to testicular cancer. But for dosages above that -- and some body-builders have been known to take up to 100 times the "replacement dose" -- there's been almost no research, especially on long-term effects.
There is, for example, no established link between steroid use and either brain or pituitary tumors. Studies have shown a connection between orally ingested steroids and liver tumors, yet according to Harrison Pope, director of the biological psychiatry laboratory at Harvard Medical School's McLean Hospital and a longtime serious weightlifter, these are exceedingly rare. Furthermore, the vast majority of steroids today are taken topically or by injection, and are therefore not toxic to the liver in the same way. Researchers don't even list brain cancer among their concerns with steroid use.
And then there's "roid rage," the uncontrollable bursts of anger that have been blamed for assaults and, in a few cases, murders. High levels of testosterone are linked to aggression (they're also linked to an increased sense of well-being, which is why it was used as an antidepressant until the mid-1980s). But Charles Yesalis, a steroids expert and epidemiologist at Penn State, remains slightly dubious of the causality. "You will occasionally see some increase in aggression," Yesalis says, but "it will probably be very mild. . .. You take a state college on any given weekend and you will see as many cases of alcohol-induced rage as you will see in a hundred years with anabolic steroids."
Still, the absence of evidence does not mean there are no risks. There are, in fact, some risks that no one denies. Steroid use drastically lowers HDL (so-called "good cholesterol") and raises LDL (or "bad cholesterol") increasing the risk of a heart attack or stroke. And even Fost is adamant that there be strict penalties for the sale of steroids to adolescents since the compounds can stunt their growth.
For his part, Pope cites a recent study that found an eight percent attempted-suicide rate among subjects who had recently gone off steroids. Yesalis agrees that the depression connection is worrisome. Yet he knows of at most 20 steroid-related suicides in recent years. "Every death is a tragedy," he says, "but given that there are over 1 million people using these drugs in the United States," 20 suicides are not statistically significant.
But even if the drugs aren't particularly dangerous to athletes, do they nonetheless discredit their achievements on the field? Are they, in other words, dangerous to sport itself?
Maxwell J. Mehlman, a law and bioethics professor at Case Western Reserve University, doesn't think so: "I see no difference between an achievement due to drugs and achievements due to changing equipment, like the fiberglass pole in pole vaulting or oversized tennis rackets." The difference, he argues, between gains due to a juiced baseball and juiced baseball players "ultimately boils down to a matter of taste, of aesthetics."
It's possible to extend Mehlman's argument back through a long history of now-accepted innovations once decried as counter to the spirit of sport: cleats, for example, or synthetic running tracks, or specially designed low-drag swimsuits. Or, if you go back to the 18th century, training itself -- a great affront to the gentlemanly amateurism that used to be seen as the highest ideal.
One of Fost's favorite examples of what he calls "the hypocrisy and the moral incoherence of the anti-drug hysteria movement" is that of erythropoietin, or EPO, which physiologically replicates the effects of training at altitude or sleeping in a low-oxygen tent. But the latter two are approved of, while EPO use is banned. Of course, as Fost admits, EPO injections are much more dangerous, and several heart attacks in elite cyclists have been circumstantially attributed to it. To many, this might seem a perfectly logical reason to draw the line.
In the end, though, questions of harm are also questions of risk. The long-term effects of large doses of hormones like EPO or HGH can take decades to emerge. For Gary Wadler, a professor of clinical medicine at the New York University School of Medicine, a member of the World Anti-Doping Agency, and a longtime opponent of Fost's, this means "we have to just be very respectful of those kinds of drugs."
As an example, Wadler points out the many years it took to discover the risk of cancer associated with estrogen replacement therapy. Yesalis, on the other hand, notes that despite those discoveries, many women nonetheless have gone back on estrogen, in part because the cancer risk "is not big enough when balanced against the unwanted symptoms of menopause. Everyone assesses risk differently."
It's hard to deny that the allure of a pro contract or an endorsement deal doesn't raise the stakes to where some athletes are willing to take enormous risks with their health. And if performance-enhancing drugs were to be legalized, it would become, in some sports, all but impossible to compete without them.
Fost concedes these points, at least partly, but he also responds that we're perfectly willing -- in fact, eager -- to watch athletes risk their lives by skiing at 80 miles per hour down an icy slope or jumping off a high dive or playing football. He cites a recent study finding that more than three years playing in the NFL insures a 90 percent chance of permanent disability.
"The major risk of disability from the lure of fame and fortune of sport is the sport itself," Fost says. "Steroids are just way, way low on the list in terms of the risk of getting hurt or dying."
Drake Bennett is the staff writer for Ideas.