Soldiers, especially those in the Special Forces, rely on elite levels of fitness to perform their jobs. Strength, endurance, and cognition, each of which contribute to greater fitness for duty, may be improved through the use of performance enhancing drugs (PEDs), thus PEDs could increase the likelihood of successfully completing a mission. Despite this potential improvement, PEDs are generally not legally available to Soldiers, which may be a missed opportunity. This is not to argue that Soldiers should be given PEDs, but that we should seek to more fully understand them and arrive at a scientifically informed decision on whether to use PEDs in specific circumstances. PED is a general term that encapsulates any drug that a user can take to improve performance by some measure, whether that is mental or physical. For instance, Modafinil is used for cognitive enhancement, capable of maintaining wakefulness and increasing performance in several cognitive tasks,1 while recombinant human erythropoietin can be used for cardiovascular improvement and can increase a runner’s time to exhaustion by 54%.2 Though there are many potential PEDs that are worthy of further discussion, the primary focus here is steroids, with two studies specifically referencing the steroid testosterone. Because they increase muscle strength, they can be useful to improve job performance for many in the military, including SEALs, Marines, Paratroopers, and Rangers. While the discussion is centered on steroids, many of the points raised can be applied to other PEDs that are considered controlled substances that have not been thoroughly investigated. Current and future use of steroids in the military is an issue that needs to be addressed. Researchers at a 2016 Consortium of Health and Military Performance (CHAMP) symposium outlined five primary concerns that the military should pursue.3 These included encouraging further exploration of steroid use, understanding the true prevalence of steroids, understanding the costs and benefits of steroids, connecting users to trusted sources of information, and collaborating with other organizations to address these concerns. The motivation for these recommendations partially comes from an anonymous survey of U.S. Army Rangers that revealed that ~1/4 used an illegal steroid or other PED.4 This is a serious issue when considering the health of these Soldiers. Because of the illegality of steroids in the U.S. military, most users do not have professional medical oversight. Further, 92% of users believe that medical professionals lack knowledge about the science of steroid use5 – and they are not wrong. The scientific literature regarding steroids use is severely lacking. Methodological limitations and legality issues limit the ability of researchers to thoroughly investigate steroids. Here we will outline some of the existing literature on steroid use, including potential positive and negative outcomes. We acknowledge that some conclusions are weakly supported, or only backed by survey data, but this only reinforces the overall conclusion: the existing literature on steroids is limited and additional research is necessary to establish their role in the future of the military. Research into the costs and benefits of steroids is limited. Both lab-based studies and surveys of real-world users have distinct advantages and disadvantages. In lab-based studies, researchers have more control: males are given a measured dose of a single steroid over a specified time period, calorie intake is monitored, drug purity is known, and expectations are often managed by placebo-controlled designs. The 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 injections of either 100 (n = 8) or 300 (n = 7) mg of testosterone.6 The 300 mg group increased average lean body mass by 7.5 lbs, while there was no significant change for the 100 mg group. Physical performance changes were tracked with isokinetic knee and elbow extension/flexion and showed significant increases in strength for the 300 mg group. While this study demonstrates that a higher dose of testosterone results in increased lean body mass and strength, the strength tests used are out of the norm for most athletes. Bhasin et al7 used more conventional measures of strength in a well-designed, placebo-controlled study that crossed testosterone injections (placebo, testosterone) and exercise (no exercise, exercise three times a week) in 43 men divided into four groups of subjects over ten weeks. The results showed that, among those who exercised, the testosterone group increased their one rep max squat 37% compared to 19% in the placebo group, a significant difference. Among those who did not exercise, the testosterone group increased their one rep max squat by 13%, while the placebo group only saw an increase of 3%. Though this difference was not significant, the testosterone group significantly increased their squat, even in the absence of exercise. This study demonstrates testosterone can be used to improve performance when combined with an effective training method and maintain, or even improve strength, while on a mission where strength training is not possible. While the studies described above advanced our knowledge regarding the potential benefits of testosterone, they also demonstrated the disadvantages of lab-based studies in that it failed to represent real-world conditions. The dose of testosterone used by Bhasin et al (600 mg) was less than that injected by more than 60% of real-world users, a single drug was administered, despite 95% of users using multiple drugs, and the duration of the study was only 10 wk, while 96% of users use steroids for more than a year.8 These unrealistic conditions can lead to underestimates of both the benefits and costs of steroid use. For instance, there was not a single reported side effect in these studies, but a survey of real-world users revealed 496 out of 500 respondents experienced at least one side effect.8 While isolating the effects of a single steroid over a short period of time is important to advance our knowledge of steroids, it is also important to understand usage patterns and effects in real-world conditions. Surveys are one way to research steroid use in the real world. The advantages and disadvantages of survey research are the opposite of the lab-based research described above. Surveys can reveal the long-term consequences of steroids, real patterns of steroid use, and gather data from more users than can be included in a lab-based study. Whereas the previously mentioned studies found no side effects of steroid use, surveys show there are many side effects ranging from acne to liver tumors.9 Some side effects are sex dependent: males may experience testicular atrophy, decreased sperm production, or gynecomastia (breast development), while women may experience clitoral hypertrophy, breast atrophy, or a deeper voice. These effects may not reverse even with the cessation of steroid use.10 Steroids may also induce behavioral changes. For instance, 90% of users reported increased aggression, or “roid rage.” Steroids may also result in general irritability, mood swings, psychosis, and depression.11 The primary disadvantage of survey research is the inability isolate a single cause of the positive or negative effects. The high incidence of side effects in steroid users could be due to using multiple drugs, the interaction between drugs, high doses, impurity, duration of use, or pre-existing health issues. The last point is especially important for behavioral consequences of steroid use. While it appears that steroid use can increase aggression, it would fit with current knowledge about illegal drug use that those who are aggressive are more likely to seek out drugs,12 thus confounding any survey research suggesting steroids are the direct cause for increased aggression. Another indirect evaluation of the effects of steroids on strength can be conducted by comparing the amount of weight lifted in an untested lifting competition versus a drug-tested lifting competition. An untested division (Raw Unity) lifted 17% more weight than the tested division (United States of America Powerlifting), suggesting that among elite athletes, steroids may result in a large advantage. While it is possible that a steroid user could have cheated tests in the tested division, or a non-steroid user could have entered the untested division, these deviations would only serve to minimize the differences between the two groups, thus underestimating the effects of steroids. Further, this 17% benefit that is likely attributable to PED use aligns with the 5–20% increase in strength reported in the literature.13 Steroid use has both costs and benefits, but studies showing these effects are often correlational and unclear. Even current studies cannot address the potential costs and benefits of steroids. For example, one ongoing study14 is examining whether testosterone can reduce the negative effects of caloric restriction on physical and mental performance. This is a well-designed study that will address an important question, but it does not answer whether steroids can be used to maximize performance in Soldiers, nor does it tell us how a Solider would react in a non-calorie-restricted environment. Among the questions future research needs to address are what is the optimal dose, how long can one sustain use before health consequences outweigh physical advantages, what can medical supervision do to mitigate side effects, what effects are unique to each sex, and what physical benefits can be expected. These questions are only the first set of hurdles that need to be addressed before accepting steroid use outside of the lab. If the research indicates that the benefits outweigh the costs, then moral and ethical questions need to be addressed. The potential use of steroids raises several ethical concerns. Perhaps the most prevalent is whether use would be mandatory. This is a complex issue; research will almost certainly show negative health consequences of steroid use in some individuals. Should military commands require Soldiers to use a potentially harmful drug? Military commands already put Soldiers in dangerous situations where consequences, life or death, are much more immediate concerns than the potential side effects of steroids. Commanders make these decisions after assessing the costs and benefits. Our position is that the decision to use or not use steroids is similar. It may be that steroid use would have such an impact on mission success that forgoing them would jeopardize the safety of military personnel. Conversely, there is a question as to whether steroid use can truly be optional. Even if there is no explicit order to use steroids, and use is technically optional, environmental factors, such as peer pressure or competitiveness, may coerce the individual who might not otherwise use them. An additional concern is how steroid use would differentially affect women. While there is little to no lab-based research on the effects of steroid use in women, there is survey-based and anecdotal evidence that testosterone-based PEDs will have more adverse effects in women than men. One survey-based study revealed that while women taking steroids increased lean body mass, increased strength, and decreased fat mass, they also experienced a deepened voice, increased facial hair, increased aggressiveness, clitoral enlargement, menstrual irregularities, and breast atrophy. Some of these changes are irreversible, though it is once again impossible to isolate the effects of one drug as most of the interviewed women were taking multiple steroids.15 Is it ethical to put women at greater risk if the availability of steroids creates an atmosphere in which their use is necessary for career advancement? In 2013, a 3-yr phase-in began to open all combat roles to women. If the use of steroids becomes a de-facto necessity to serve in certain roles, women will have to compete with steroid-enhanced males for these positions. The adverse effects of steroids might preclude women from using them, which may make them less competitive for serving in these elite positions. The question then becomes whether this potential gender disparity is acceptable. Finally, there is an issue of moral responsibility. Steroids can influence a person’s behavior, including increasing aggression. It is an open question as to how much these effects would impact decision-making under controlled use. As pointed out by Wolfendale,16 society already makes distinctions regarding whether a decision is made by someone who is incapacitated by drug use (e.g., tranquilizers) versus the same decision made by someone who has full control of their mental faculties. However, one caveat is that when people know that there will be consequences to drug use, they are still held morally culpable for their actions (e.g., drunk driving). When it comes to steroid use, the consequences are not necessarily known given the dearth of research on the subject. Additionally, if people are not truly free to choose to take steroids, the issue of moral responsibility is murkier. This also raises the question of whether asking or requiring a person to give up their moral agency is ethical itself. Wolfendale argues that any technology (or steroid in this case) that has the effect of reducing the individual’s agency would weaken a military’s claim to be committed to the laws of war and damage its reputation as a profession. Many other ethical concerns could, and should, be raised that are outside of the scope of this paper. Given the lack of knowledge of the long-term effects of medically supervised steroid use, the discussion regarding these concerns will be inherently incomplete. The research currently being conducted on the effects of steroid use in a caloric-deficient population14 is a well-designed study which could serve as a model for future research into the efficacy of steroid use in a population focused on training or performance enhancement. Additional research is needed to refine the problems of side effects associated with use of a controlled, measured dose and may bring additional ethical concerns to light. Steroids represent a potentially useful tool to increase the performance of military personnel, but the current state of knowledge makes the value of this tool, and its associated cost-benefit trade-offs, unknown. Further research is required before any definitive conclusions can be reached. References 1 Minzenberg MJ , Carter CS : Modafinil: a review of neurochemical actions and effects on cognition . Neuropsychopharmacology 2008 ; 33 ( 7 ): 1477 . Google Scholar CrossRef Search ADS PubMed 2 Thomsen JJ , Rentsch RL , Robach P , et al. : Prolonged administration of recombinant human erythropoietin increases submaximal performance more than maximal aerobic capacity . Eur J Appl Physiol 2007 ; 101 ( 4 ): 481 – 6 . Google Scholar CrossRef Search ADS PubMed 3 Givens ML , Deuster PA , Kupchak BR : CHAMP symposium on androgens, anabolic steroids, and related substances: what we know and what we need to know . Mil Med 2016 ; 181 ( 7 ): 680 – 6 . Google Scholar CrossRef Search ADS PubMed 4 Johnson AE , Haley CA , Ward JA : Hazards of dietary supplement use . J Spec Oper Med 2007 ; 7 ( 1 ): 30 – 8 . 5 Cohen J , Collins R , Darkes J , Gwartney D : A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States . J Int Soc Sports Nutr 2007 ; 4 ( 1 ): 12 . Google Scholar CrossRef Search ADS PubMed 6 Friedl KE , Dettori JR , Hannan CJ Jr , Patience TH , Plymate SR : Comparison of the effects of high dose testosterone and 19-nortestosterone to a replacement dose of testosterone on strength and body composition in normal men . J Steroid Biochem Mol Biol 1991 ; 40 ( 4–6 ): 607 – IN6 . Google Scholar CrossRef Search ADS PubMed 7 Bhasin S , Storer TW , Berman N , et al. : The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men . N Engl J Med 1996 ; 335 ( 1 ): 1 – 7 . Google Scholar CrossRef Search ADS PubMed 8 Parkinson AB , Evans NA : Anabolic androgenic steroids: a survey of 500 users . Med Sci Sports Exerc 2006 ; 38 ( 4 ): 644 – 51 . Google Scholar CrossRef Search ADS PubMed 9 Friedl KE : Effects of anabolic steroids on physical health . Anabolic Steroids Sport Exercise 2000 ; 2 : 175 – 224 . 10 American Academy of Pediatrics : Adolescents and anabolic steroids: a subject review . Pediatrics 1997 ; 99 : 904 – 8 . CrossRef Search ADS PubMed 11 Tamir E , Ner YZ , Dayan Y , Tamir D : Knowledge and attitude regarding use of anabolic steroids among youth exercising in fitness centers . Harefuah 2004 ; 143 : 348 – 52 . Google Scholar PubMed 12 Halikas JA , Meller J , Morse C , Lyttle MD : Predicting substance abuse in juvenile offenders: Attention deficit disorder versus aggressivity . Child Psychiatry Hum Dev 1990 ; 21 ( 1 ): 49 – 55 . Google Scholar CrossRef Search ADS PubMed 13 Hartgens F , Kuipers H : Effects of androgenic-anabolic steroids in athletes . Sports Med 2004 ; 34 ( 8 ): 513 – 54 . Google Scholar CrossRef Search ADS PubMed 14 Pasiakos SM , Berryman CE , Karl JP , et al. : Physiological and psychological effects of testosterone during severe energy deficit and recovery: a study protocol for a randomized, placebo-controlled trial for Optimizing Performance for Soldiers (OPS) . Contemp Clin Trials 2017 ; 58 : 47 – 57 . Google Scholar CrossRef Search ADS PubMed 15 Strauss RH , Liggett MT , Lanese RR : Anabolic steroid use and perceived effects in ten weight-trained women athletes . JAMA 1985 ; 253 ( 19 ): 2871 – 3 . Google Scholar CrossRef Search ADS PubMed 16 Wolfendale J : Performance-enhancing technologies and moral responsibility in the military . Am J Bioeth 2008 ; 8 ( 2 ): 28 – 38 . Google Scholar CrossRef Search ADS PubMed Author notes The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government Published by Oxford University Press on behalf of Association of 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.
Military Medicine – Oxford University Press
Published: Jun 28, 2018
It’s your single place to instantly
discover and read the research
that matters to you.
Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.
All for just $49/month
Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly
Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.
Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.
Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.
All the latest content is available, no embargo periods.
“Hi guys, I cannot tell you how much I love this resource. Incredible. I really believe you've hit the nail on the head with this site in regards to solving the research-purchase issue.”Daniel C.
“Whoa! It’s like Spotify but for academic articles.”@Phil_Robichaud
“I must say, @deepdyve is a fabulous solution to the independent researcher's problem of #access to #information.”@deepthiw
“My last article couldn't be possible without the platform @deepdyve that makes journal papers cheaper.”@JoseServera