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The Future of Steroids for Performance Enhancement in the U.S. Military

The Future of Steroids for Performance Enhancement in the U.S. Military Downloaded from https://academic.oup.com/milmed/article/183/7-8/151/4993704 by DeepDyve user on 20 July 2022 GUEST EDITORIAL AND PERSPECTIVES MILITARY MEDICINE, 183, 7/8:151, 2018 The Future of Steroids for Performance Enhancement in the U.S. Military LT Col Chad Peltier, MSC, USN; Kyle Pettijohn, PhD Soldiers, especially those in the Special Forces, rely on elite outlined five primary concerns that the military should pursue. levels of fitness to perform their jobs. Strength, endurance, These included encouraging further exploration of steroid use, and cognition, each of which contribute to greater fitness for understanding the true prevalence of steroids, understanding duty, may be improved through the use of performance the costs and benefits of steroids, connecting users to trusted enhancing drugs (PEDs), thus PEDs could increase the like- sources of information, and collaborating with other organiza- lihood of successfully completing a mission. Despite this tions to address these concerns. The motivation for these rec- potential improvement, PEDs are generally not legally avail- ommendations partially comes from an anonymous survey of able to Soldiers, which may be a missed opportunity. This is U.S. Army Rangers that revealed that ~1/4 used an illegal ste- not to argue that Soldiers should be given PEDs, but that we roid or other PED. This is a serious issue when considering should seek to more fully understand them and arrive at a the health of these Soldiers. Because of the illegality of ster- scientifically informed decision on whether to use PEDs in oids in the U.S. military, most users do not have professional specific circumstances. medical oversight. Further, 92% of users believe that medical PED is a general term that encapsulates any drug that a professionals lack knowledge about the science of steroid use user can take to improve performance by some measure, – and they are not wrong. The scientific literature regarding whether that is mental or physical. For instance, Modafinil is steroids use is severely lacking. Methodological limitations used for cognitive enhancement, capable of maintaining and legality issues limit the ability of researchers to thoroughly wakefulness and increasing performance in several cognitive investigate steroids. Here we will outline some of the existing tasks, while recombinant human erythropoietin can be used literature on steroid use, including potential positive and nega- for cardiovascular improvement and can increase a runner’s tive outcomes. We acknowledge that some conclusions are time to exhaustion by 54%. Though there are many poten- weakly supported, or only backed by survey data, but this tial PEDs that are worthy of further discussion, the primary only reinforces the overall conclusion: the existing literature focus here is steroids, with two studies specifically referencing on steroids is limited and additional research is necessary to the steroid testosterone. Because they increase muscle strength, establish their role in the future of the military. they can be useful to improve job performance for many in the Research into the costs and benefits of steroids is limited. military, including SEALs, Marines, Paratroopers, and Rangers. Both lab-based studies and surveys of real-world users have While the discussion is centered on steroids, many of the points distinct advantages and disadvantages. In lab-based studies, raised can be applied to other PEDs that are considered con- researchers have more control: males are given a measured trolled substances that have not been thoroughly investigated. dose of a single steroid over a specified time period, calorie Current and future use of steroids in the military is an issue intake is monitored, drug purity is known, and expectations that needs to be addressed. Researchers at a 2016 Consortium are often managed by placebo-controlled designs. The of Health and Military Performance (CHAMP) symposium advantage of lab-based studies is that they are able to answer specific questions accurately. One study was performed using active duty U.S. Soldiers who received weekly injec- Naval Medical Research Unit Dayton, 2624 Q Street, Area B, Wright- tions of either 100 (n = 8) or 300 (n = 7) mg of testoster- Patterson Air Force Base, Ohio 45433-7955 The views expressed in this article are those of the author and do not one. The 300 mg group increased average lean body mass necessarily reflect the official policy or position of the Department of the by 7.5 lbs, while there was no significant change for the Navy, Department of Defense, nor the U.S. Government 100 mg group. Physical performance changes were tracked doi: 10.1093/milmed/usy093 with isokinetic knee and elbow extension/flexion and Published by Oxford University Press on behalf of Association of showed significant increases in strength for the 300 mg Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. group. While this study demonstrates that a higher dose of MILITARY MEDICINE, Vol. 183, July/August 2018 151 Downloaded from https://academic.oup.com/milmed/article/183/7-8/151/4993704 by DeepDyve user on 20 July 2022 testosterone results in increased lean body mass and strength, high incidence of side effects in steroid users could be due to the strength tests used are out of the norm for most athletes. using multiple drugs, the interaction between drugs, high doses, Bhasin et al used more conventional measures of strength impurity, duration of use, or pre-existing health issues. The last in a well-designed, placebo-controlled study that crossed tes- point is especially important for behavioral consequences of ste- tosterone injections (placebo, testosterone) and exercise (no roid use. While it appears that steroid use can increase aggres- exercise, exercise three times a week) in 43 men divided into sion, it would fit with current knowledge about illegal drug use four groups of subjects over ten weeks. The results showed that those who are aggressive are more likely to seek out that, among those who exercised, the testosterone group drugs, thus confounding any survey research suggesting ster- increased their one rep max squat 37% compared to 19% in oids are the direct cause for increased aggression. the placebo group, a significant difference. Among those Another indirect evaluation of the effects of steroids on who did not exercise, the testosterone group increased their strength can be conducted by comparing the amount of weight one rep max squat by 13%, while the placebo group only lifted in an untested lifting competition versus a drug-tested saw an increase of 3%. Though this difference was not sig- lifting competition. An untested division (Raw Unity) lifted nificant, the testosterone group significantly increased their 17% more weight than the tested division (United States of squat, even in the absence of exercise. This study demon- America Powerlifting), suggesting that among elite athletes, strates testosterone can be used to improve performance steroids may result in a large advantage. While it is possible when combined with an effective training method and main- that a steroid user could have cheated tests in the tested divi- tain, or even improve strength, while on a mission where sion, or a non-steroid user could have entered the untested strength training is not possible. division, these deviations would only serve to minimize the While the studies described above advanced our knowl- differences between the two groups, thus underestimating the edge regarding the potential benefits of testosterone, they effects of steroids. Further, this 17% benefit that is likely attrib- also demonstrated the disadvantages of lab-based studies in utable to PED use aligns with the 5–20% increase in strength that it failed to represent real-world conditions. The dose of reported in the literature. testosterone used by Bhasin et al (600 mg) was less than that Steroid use has both costs and benefits, but studies show- injected by more than 60% of real-world users, a single drug ing these effects are often correlational and unclear. Even was administered, despite 95% of users using multiple drugs, current studies cannot address the potential costs and bene- and the duration of the study was only 10 wk, while 96% of fits of steroids. For example, one ongoing study is examin- users use steroids for more than a year. These unrealistic ing whether testosterone can reduce the negative effects of conditions can lead to underestimates of both the benefits caloric restriction on physical and mental performance. This and costs of steroid use. For instance, there was not a single is a well-designed study that will address an important ques- reported side effect in these studies, but a survey of real- tion, but it does not answer whether steroids can be used to world users revealed 496 out of 500 respondents experienced maximize performance in Soldiers, nor does it tell us how a at least one side effect. While isolating the effects of a single Solider would react in a non-calorie-restricted environment. steroid over a short period of time is important to advance our Among the questions future research needs to address are knowledge of steroids, it is also important to understand usage what is the optimal dose, how long can one sustain use patterns and effects in real-world conditions. before health consequences outweigh physical advantages, Surveys are one way to research steroid use in the real what can medical supervision do to mitigate side effects, world. The advantages and disadvantages of survey research what effects are unique to each sex, and what physical bene- are the opposite of the lab-based research described above. fits can be expected. These questions are only the first set of Surveys can reveal the long-term consequences of steroids, hurdles that need to be addressed before accepting steroid real patterns of steroid use, and gather data from more users use outside of the lab. If the research indicates that the bene- than can be included in a lab-based study. Whereas the pre- fits outweigh the costs, then moral and ethical questions viously mentioned studies found no side effects of steroid need to be addressed. use, surveys show there are many side effects ranging from The potential use of steroids raises several ethical con- acne to liver tumors. Some side effects are sex dependent: cerns. Perhaps the most prevalent is whether use would be males may experience testicular atrophy, decreased sperm mandatory. This is a complex issue; research will almost cer- production, or gynecomastia (breast development), while tainly show negative health consequences of steroid use in women may experience clitoral hypertrophy, breast atrophy, some individuals. Should military commands require or a deeper voice. These effects may not reverse even with Soldiers to use a potentially harmful drug? Military com- the cessation of steroid use. Steroids may also induce behav- mands already put Soldiers in dangerous situations where ioral changes. For instance, 90% of users reported increased consequences, life or death, are much more immediate con- aggression, or “roid rage.” Steroids may also result in general cerns than the potential side effects of steroids. Commanders irritability, mood swings, psychosis, and depression. make these decisions after assessing the costs and benefits. The primary disadvantage of survey research is the inability Our position is that the decision to use or not use steroids is isolate a single cause of the positive or negative effects. The similar. It may be that steroid use would have such an 152 MILITARY MEDICINE, Vol. 183, July/August 2018 Downloaded from https://academic.oup.com/milmed/article/183/7-8/151/4993704 by DeepDyve user on 20 July 2022 impact on mission success that forgoing them would jeopar- inherently incomplete. The research currently being con- dize the safety of military personnel. Conversely, there is a ducted on the effects of steroid use in a caloric-deficient pop- question as to whether steroid use can truly be optional. ulation is a well-designed study which could serve as a Even if there is no explicit order to use steroids, and use is model for future research into the efficacy of steroid use in a technically optional, environmental factors, such as peer population focused on training or performance enhancement. pressure or competitiveness, may coerce the individual who Additional research is needed to refine the problems of side might not otherwise use them. effects associated with use of a controlled, measured dose and An additional concern is how steroid use would differen- may bring additional ethical concerns to light. Steroids repre- tially affect women. While there is little to no lab-based sent a potentially useful tool to increase the performance of research on the effects of steroid use in women, there is military personnel, but the current state of knowledge makes survey-based and anecdotal evidence that testosterone-based the value of this tool, and its associated cost-benefit trade-offs, PEDs will have more adverse effects in women than men. unknown. Further research is required before any definitive One survey-based study revealed that while women taking conclusions can be reached. steroids increased lean body mass, increased strength, and decreased fat mass, they also experienced a deepened voice, REFERENCES increased facial hair, increased aggressiveness, clitoral 1. Minzenberg MJ, Carter CS: Modafinil: a review of neurochemical enlargement, menstrual irregularities, and breast atrophy. actions and effects on cognition. Neuropsychopharmacology 2008; Some of these changes are irreversible, though it is once 33(7): 1477. again impossible to isolate the effects of one drug as most of 2. Thomsen JJ, Rentsch RL, Robach P, et al: Prolonged administration of the interviewed women were taking multiple steroids. Is it recombinant human erythropoietin increases submaximal performance more than maximal aerobic capacity. Eur J Appl Physiol 2007; 101(4): ethical to put women at greater risk if the availability of ster- 481–6. oids creates an atmosphere in which their use is necessary 3. Givens ML, Deuster PA, Kupchak BR: CHAMP symposium on andro- for career advancement? In 2013, a 3-yr phase-in began to gens, anabolic steroids, and related substances: what we know and what open all combat roles to women. If the use of steroids we need to know. Mil Med 2016; 181(7): 680–6. becomes a de-facto necessity to serve in certain roles, women 4. Johnson AE, Haley CA, Ward JA: Hazards of dietary supplement use. J Spec Oper Med 2007; 7(1): 30–8. will have to compete with steroid-enhanced males for these 5. Cohen J, Collins R, Darkes J, Gwartney D: A league of their own: positions. The adverse effects of steroids might preclude demographics, motivations and patterns of use of 1,955 male adult non- women from using them, which may make them less competi- medical anabolic steroid users in the United States. J Int Soc Sports tive for serving in these elite positions. The question then Nutr 2007; 4(1): 12. becomes whether this potential gender disparity is acceptable. 6. Friedl KE, Dettori JR, Hannan CJ Jr, Patience TH, Plymate SR: Comparison of the effects of high dose testosterone and 19- Finally, there is an issue of moral responsibility. Steroids nortestosterone to a replacement dose of testosterone on strength and can influence a person’s behavior, including increasing body composition in normal men. J Steroid Biochem Mol Biol 1991; aggression. It is an open question as to how much these 40(4–6): 607–IN6. effects would impact decision-making under controlled use. 7. Bhasin S, Storer TW, Berman N, et al: The effects of supraphysiologic As pointed out by Wolfendale, society already makes dis- doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335(1): 1–7. tinctions regarding whether a decision is made by someone 8. Parkinson AB, Evans NA: Anabolic androgenic steroids: a survey of who is incapacitated by drug use (e.g., tranquilizers) versus 500 users. Med Sci Sports Exerc 2006; 38(4): 644–51. the same decision made by someone who has full control of 9. Friedl KE: Effects of anabolic steroids on physical health. Anabolic their mental faculties. However, one caveat is that when peo- Steroids Sport Exercise 2000; 2: 175–224. ple know that there will be consequences to drug use, they 10. American Academy of Pediatrics: Adolescents and anabolic steroids: a subject review . Pediatrics 1997; 99: 904–8. are still held morally culpable for their actions (e.g., drunk 11. Tamir E, Ner YZ, Dayan Y, Tamir D: Knowledge and attitude regard- driving). When it comes to steroid use, the consequences are ing use of anabolic steroids among youth exercising in fitness centers. not necessarily known given the dearth of research on the Harefuah 2004; 143: 348–52. subject. Additionally, if people are not truly free to choose 12. Halikas JA, Meller J, Morse C, Lyttle MD: Predicting substance abuse to take steroids, the issue of moral responsibility is murkier. in juvenile offenders: Attention deficit disorder versus aggressivity. Child Psychiatry Hum Dev 1990; 21(1): 49–55. This also raises the question of whether asking or requiring a 13. Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in ath- person to give up their moral agency is ethical itself. letes. Sports Med 2004; 34(8): 513–54. Wolfendale argues that any technology (or steroid in this 14. Pasiakos SM, Berryman CE, Karl JP, et al: Physiological and psycho- case) that has the effect of reducing the individual’s agency logical effects of testosterone during severe energy deficit and recovery: would weaken a military’s claim to be committed to the a study protocol for a randomized, placebo-controlled trial for Optimizing Performance for Soldiers (OPS). Contemp Clin Trials 2017; laws of war and damage its reputation as a profession. 58: 47–57. Many other ethical concerns could, and should, be raised 15. Strauss RH, Liggett MT, Lanese RR: Anabolic steroid use and perceived that are outside of the scope of this paper. Given the lack of effects in ten weight-trained women athletes. JAMA 1985; 253(19): 2871–3. knowledge of the long-term effects of medically supervised 16. Wolfendale J: Performance-enhancing technologies and moral responsi- steroid use, the discussion regarding these concerns will be bility in the military. Am J Bioeth 2008; 8(2): 28–38. MILITARY MEDICINE, Vol. 183, July/August 2018 153 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

The Future of Steroids for Performance Enhancement in the U.S. Military

Peltier, Chad; Pettijohn, Kyle
Military Medicine , Volume 183 (7-8) – Jul 1, 2018
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Oxford University Press
Copyright
Copyright © 2022 The Society of Federal Health Professionals
ISSN
0026-4075
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1930-613X
DOI
10.1093/milmed/usy093
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Abstract

Downloaded from https://academic.oup.com/milmed/article/183/7-8/151/4993704 by DeepDyve user on 20 July 2022 GUEST EDITORIAL AND PERSPECTIVES MILITARY MEDICINE, 183, 7/8:151, 2018 The Future of Steroids for Performance Enhancement in the U.S. Military LT Col Chad Peltier, MSC, USN; Kyle Pettijohn, PhD Soldiers, especially those in the Special Forces, rely on elite outlined five primary concerns that the military should pursue. levels of fitness to perform their jobs. Strength, endurance, These included encouraging further exploration of steroid use, and cognition, each of which contribute to greater fitness for understanding the true prevalence of steroids, understanding duty, may be improved through the use of performance the costs and benefits of steroids, connecting users to trusted enhancing drugs (PEDs), thus PEDs could increase the like- sources of information, and collaborating with other organiza- lihood of successfully completing a mission. Despite this tions to address these concerns. The motivation for these rec- potential improvement, PEDs are generally not legally avail- ommendations partially comes from an anonymous survey of able to Soldiers, which may be a missed opportunity. This is U.S. Army Rangers that revealed that ~1/4 used an illegal ste- not to argue that Soldiers should be given PEDs, but that we roid or other PED. This is a serious issue when considering should seek to more fully understand them and arrive at a the health of these Soldiers. Because of the illegality of ster- scientifically informed decision on whether to use PEDs in oids in the U.S. military, most users do not have professional specific circumstances. medical oversight. Further, 92% of users believe that medical PED is a general term that encapsulates any drug that a professionals lack knowledge about the science of steroid use user can take to improve performance by some measure, – and they are not wrong. The scientific literature regarding whether that is mental or physical. For instance, Modafinil is steroids use is severely lacking. Methodological limitations used for cognitive enhancement, capable of maintaining and legality issues limit the ability of researchers to thoroughly wakefulness and increasing performance in several cognitive investigate steroids. Here we will outline some of the existing tasks, while recombinant human erythropoietin can be used literature on steroid use, including potential positive and nega- for cardiovascular improvement and can increase a runner’s tive outcomes. We acknowledge that some conclusions are time to exhaustion by 54%. Though there are many poten- weakly supported, or only backed by survey data, but this tial PEDs that are worthy of further discussion, the primary only reinforces the overall conclusion: the existing literature focus here is steroids, with two studies specifically referencing on steroids is limited and additional research is necessary to the steroid testosterone. Because they increase muscle strength, establish their role in the future of the military. they can be useful to improve job performance for many in the Research into the costs and benefits of steroids is limited. military, including SEALs, Marines, Paratroopers, and Rangers. Both lab-based studies and surveys of real-world users have While the discussion is centered on steroids, many of the points distinct advantages and disadvantages. In lab-based studies, raised can be applied to other PEDs that are considered con- researchers have more control: males are given a measured trolled substances that have not been thoroughly investigated. dose of a single steroid over a specified time period, calorie Current and future use of steroids in the military is an issue intake is monitored, drug purity is known, and expectations that needs to be addressed. Researchers at a 2016 Consortium are often managed by placebo-controlled designs. The of Health and Military Performance (CHAMP) symposium advantage of lab-based studies is that they are able to answer specific questions accurately. One study was performed using active duty U.S. Soldiers who received weekly injec- Naval Medical Research Unit Dayton, 2624 Q Street, Area B, Wright- tions of either 100 (n = 8) or 300 (n = 7) mg of testoster- Patterson Air Force Base, Ohio 45433-7955 The views expressed in this article are those of the author and do not one. The 300 mg group increased average lean body mass necessarily reflect the official policy or position of the Department of the by 7.5 lbs, while there was no significant change for the Navy, Department of Defense, nor the U.S. Government 100 mg group. Physical performance changes were tracked doi: 10.1093/milmed/usy093 with isokinetic knee and elbow extension/flexion and Published by Oxford University Press on behalf of Association of showed significant increases in strength for the 300 mg Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. group. While this study demonstrates that a higher dose of MILITARY MEDICINE, Vol. 183, July/August 2018 151 Downloaded from https://academic.oup.com/milmed/article/183/7-8/151/4993704 by DeepDyve user on 20 July 2022 testosterone results in increased lean body mass and strength, high incidence of side effects in steroid users could be due to the strength tests used are out of the norm for most athletes. using multiple drugs, the interaction between drugs, high doses, Bhasin et al used more conventional measures of strength impurity, duration of use, or pre-existing health issues. The last in a well-designed, placebo-controlled study that crossed tes- point is especially important for behavioral consequences of ste- tosterone injections (placebo, testosterone) and exercise (no roid use. While it appears that steroid use can increase aggres- exercise, exercise three times a week) in 43 men divided into sion, it would fit with current knowledge about illegal drug use four groups of subjects over ten weeks. The results showed that those who are aggressive are more likely to seek out that, among those who exercised, the testosterone group drugs, thus confounding any survey research suggesting ster- increased their one rep max squat 37% compared to 19% in oids are the direct cause for increased aggression. the placebo group, a significant difference. Among those Another indirect evaluation of the effects of steroids on who did not exercise, the testosterone group increased their strength can be conducted by comparing the amount of weight one rep max squat by 13%, while the placebo group only lifted in an untested lifting competition versus a drug-tested saw an increase of 3%. Though this difference was not sig- lifting competition. An untested division (Raw Unity) lifted nificant, the testosterone group significantly increased their 17% more weight than the tested division (United States of squat, even in the absence of exercise. This study demon- America Powerlifting), suggesting that among elite athletes, strates testosterone can be used to improve performance steroids may result in a large advantage. While it is possible when combined with an effective training method and main- that a steroid user could have cheated tests in the tested divi- tain, or even improve strength, while on a mission where sion, or a non-steroid user could have entered the untested strength training is not possible. division, these deviations would only serve to minimize the While the studies described above advanced our knowl- differences between the two groups, thus underestimating the edge regarding the potential benefits of testosterone, they effects of steroids. Further, this 17% benefit that is likely attrib- also demonstrated the disadvantages of lab-based studies in utable to PED use aligns with the 5–20% increase in strength that it failed to represent real-world conditions. The dose of reported in the literature. testosterone used by Bhasin et al (600 mg) was less than that Steroid use has both costs and benefits, but studies show- injected by more than 60% of real-world users, a single drug ing these effects are often correlational and unclear. Even was administered, despite 95% of users using multiple drugs, current studies cannot address the potential costs and bene- and the duration of the study was only 10 wk, while 96% of fits of steroids. For example, one ongoing study is examin- users use steroids for more than a year. These unrealistic ing whether testosterone can reduce the negative effects of conditions can lead to underestimates of both the benefits caloric restriction on physical and mental performance. This and costs of steroid use. For instance, there was not a single is a well-designed study that will address an important ques- reported side effect in these studies, but a survey of real- tion, but it does not answer whether steroids can be used to world users revealed 496 out of 500 respondents experienced maximize performance in Soldiers, nor does it tell us how a at least one side effect. While isolating the effects of a single Solider would react in a non-calorie-restricted environment. steroid over a short period of time is important to advance our Among the questions future research needs to address are knowledge of steroids, it is also important to understand usage what is the optimal dose, how long can one sustain use patterns and effects in real-world conditions. before health consequences outweigh physical advantages, Surveys are one way to research steroid use in the real what can medical supervision do to mitigate side effects, world. The advantages and disadvantages of survey research what effects are unique to each sex, and what physical bene- are the opposite of the lab-based research described above. fits can be expected. These questions are only the first set of Surveys can reveal the long-term consequences of steroids, hurdles that need to be addressed before accepting steroid real patterns of steroid use, and gather data from more users use outside of the lab. If the research indicates that the bene- than can be included in a lab-based study. Whereas the pre- fits outweigh the costs, then moral and ethical questions viously mentioned studies found no side effects of steroid need to be addressed. use, surveys show there are many side effects ranging from The potential use of steroids raises several ethical con- acne to liver tumors. Some side effects are sex dependent: cerns. Perhaps the most prevalent is whether use would be males may experience testicular atrophy, decreased sperm mandatory. This is a complex issue; research will almost cer- production, or gynecomastia (breast development), while tainly show negative health consequences of steroid use in women may experience clitoral hypertrophy, breast atrophy, some individuals. Should military commands require or a deeper voice. These effects may not reverse even with Soldiers to use a potentially harmful drug? Military com- the cessation of steroid use. Steroids may also induce behav- mands already put Soldiers in dangerous situations where ioral changes. For instance, 90% of users reported increased consequences, life or death, are much more immediate con- aggression, or “roid rage.” Steroids may also result in general cerns than the potential side effects of steroids. Commanders irritability, mood swings, psychosis, and depression. make these decisions after assessing the costs and benefits. The primary disadvantage of survey research is the inability Our position is that the decision to use or not use steroids is isolate a single cause of the positive or negative effects. The similar. It may be that steroid use would have such an 152 MILITARY MEDICINE, Vol. 183, July/August 2018 Downloaded from https://academic.oup.com/milmed/article/183/7-8/151/4993704 by DeepDyve user on 20 July 2022 impact on mission success that forgoing them would jeopar- inherently incomplete. The research currently being con- dize the safety of military personnel. Conversely, there is a ducted on the effects of steroid use in a caloric-deficient pop- question as to whether steroid use can truly be optional. ulation is a well-designed study which could serve as a Even if there is no explicit order to use steroids, and use is model for future research into the efficacy of steroid use in a technically optional, environmental factors, such as peer population focused on training or performance enhancement. pressure or competitiveness, may coerce the individual who Additional research is needed to refine the problems of side might not otherwise use them. effects associated with use of a controlled, measured dose and An additional concern is how steroid use would differen- may bring additional ethical concerns to light. Steroids repre- tially affect women. While there is little to no lab-based sent a potentially useful tool to increase the performance of research on the effects of steroid use in women, there is military personnel, but the current state of knowledge makes survey-based and anecdotal evidence that testosterone-based the value of this tool, and its associated cost-benefit trade-offs, PEDs will have more adverse effects in women than men. unknown. Further research is required before any definitive One survey-based study revealed that while women taking conclusions can be reached. steroids increased lean body mass, increased strength, and decreased fat mass, they also experienced a deepened voice, REFERENCES increased facial hair, increased aggressiveness, clitoral 1. Minzenberg MJ, Carter CS: Modafinil: a review of neurochemical enlargement, menstrual irregularities, and breast atrophy. actions and effects on cognition. Neuropsychopharmacology 2008; Some of these changes are irreversible, though it is once 33(7): 1477. again impossible to isolate the effects of one drug as most of 2. Thomsen JJ, Rentsch RL, Robach P, et al: Prolonged administration of the interviewed women were taking multiple steroids. Is it recombinant human erythropoietin increases submaximal performance more than maximal aerobic capacity. Eur J Appl Physiol 2007; 101(4): ethical to put women at greater risk if the availability of ster- 481–6. oids creates an atmosphere in which their use is necessary 3. Givens ML, Deuster PA, Kupchak BR: CHAMP symposium on andro- for career advancement? In 2013, a 3-yr phase-in began to gens, anabolic steroids, and related substances: what we know and what open all combat roles to women. If the use of steroids we need to know. Mil Med 2016; 181(7): 680–6. becomes a de-facto necessity to serve in certain roles, women 4. Johnson AE, Haley CA, Ward JA: Hazards of dietary supplement use. J Spec Oper Med 2007; 7(1): 30–8. will have to compete with steroid-enhanced males for these 5. Cohen J, Collins R, Darkes J, Gwartney D: A league of their own: positions. The adverse effects of steroids might preclude demographics, motivations and patterns of use of 1,955 male adult non- women from using them, which may make them less competi- medical anabolic steroid users in the United States. J Int Soc Sports tive for serving in these elite positions. The question then Nutr 2007; 4(1): 12. becomes whether this potential gender disparity is acceptable. 6. Friedl KE, Dettori JR, Hannan CJ Jr, Patience TH, Plymate SR: Comparison of the effects of high dose testosterone and 19- Finally, there is an issue of moral responsibility. Steroids nortestosterone to a replacement dose of testosterone on strength and can influence a person’s behavior, including increasing body composition in normal men. J Steroid Biochem Mol Biol 1991; aggression. It is an open question as to how much these 40(4–6): 607–IN6. effects would impact decision-making under controlled use. 7. Bhasin S, Storer TW, Berman N, et al: The effects of supraphysiologic As pointed out by Wolfendale, society already makes dis- doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335(1): 1–7. tinctions regarding whether a decision is made by someone 8. Parkinson AB, Evans NA: Anabolic androgenic steroids: a survey of who is incapacitated by drug use (e.g., tranquilizers) versus 500 users. Med Sci Sports Exerc 2006; 38(4): 644–51. the same decision made by someone who has full control of 9. Friedl KE: Effects of anabolic steroids on physical health. Anabolic their mental faculties. However, one caveat is that when peo- Steroids Sport Exercise 2000; 2: 175–224. ple know that there will be consequences to drug use, they 10. American Academy of Pediatrics: Adolescents and anabolic steroids: a subject review . Pediatrics 1997; 99: 904–8. are still held morally culpable for their actions (e.g., drunk 11. Tamir E, Ner YZ, Dayan Y, Tamir D: Knowledge and attitude regard- driving). When it comes to steroid use, the consequences are ing use of anabolic steroids among youth exercising in fitness centers. not necessarily known given the dearth of research on the Harefuah 2004; 143: 348–52. subject. Additionally, if people are not truly free to choose 12. Halikas JA, Meller J, Morse C, Lyttle MD: Predicting substance abuse to take steroids, the issue of moral responsibility is murkier. in juvenile offenders: Attention deficit disorder versus aggressivity. Child Psychiatry Hum Dev 1990; 21(1): 49–55. This also raises the question of whether asking or requiring a 13. Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in ath- person to give up their moral agency is ethical itself. letes. Sports Med 2004; 34(8): 513–54. Wolfendale argues that any technology (or steroid in this 14. Pasiakos SM, Berryman CE, Karl JP, et al: Physiological and psycho- case) that has the effect of reducing the individual’s agency logical effects of testosterone during severe energy deficit and recovery: would weaken a military’s claim to be committed to the a study protocol for a randomized, placebo-controlled trial for Optimizing Performance for Soldiers (OPS). Contemp Clin Trials 2017; laws of war and damage its reputation as a profession. 58: 47–57. Many other ethical concerns could, and should, be raised 15. Strauss RH, Liggett MT, Lanese RR: Anabolic steroid use and perceived that are outside of the scope of this paper. Given the lack of effects in ten weight-trained women athletes. JAMA 1985; 253(19): 2871–3. knowledge of the long-term effects of medically supervised 16. Wolfendale J: Performance-enhancing technologies and moral responsi- steroid use, the discussion regarding these concerns will be bility in the military. Am J Bioeth 2008; 8(2): 28–38. MILITARY MEDICINE, Vol. 183, July/August 2018 153

Journal

Military Medicine – Oxford University Press

Published: Jul 1, 2018

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