With No Answers on Risks, Steroid Users Still Say 'Yes'

By GINA KOLATA

his article was reported by Gina Kolata, Jere Longman, Tim Weiner and Timothy Egan and written by Ms. Kolata.

Patrick Keogan wanted to be big, like the men with the ripped muscles he saw at the gym. "I was training like an animal," he said, working out seven days a week. But he seemed to have reached his biological limit: 5 feet 8 inches tall, 150 pounds.

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"Finally, it dawned on me," he said. Those huge men at his gym who insisted they were simply lifting weights were dissembling. "There was something they were not telling me," Mr. Keogan said. Thus Mr. Keogan, a 30-year-old salesman who lives near Boston, entered the world of anabolic steroids — testosterone and other drugs that act like it, which can build muscle, fast.

He soon was taking 4,000 milligrams of testosterone a week, which he bought from dealers at his gym. (A man his age normally produces about 35 milligrams a week.) Within 20 weeks, he weighed 200 pounds. "People would look at me," he said, and ask, "What did you do?"

Now, as more and more men, and some women, are seeking large, chiseled bodies, more are learning the bitter secret of that look: It almost always takes some chemical assistance, from drugs that are often are illegal but are readily available.

Use of steroid drugs has spread over the years from weight lifters to bodybuilders to elite athletes to high school and college athletes and to groups, like gay men and gym aficionados, who simply want to improve their appearance.

Recently, three high school boys in a prosperous community in Utah were charged with smuggling the drugs from Mexico, planning to sell them to classmates.

Steroid use is hard to quantify — federal surveys of adults' drug use do not ask about it. There is a huge underground market for anabolic steroids, including ones approved only for horses, and steady traffic by Americans to Mexico, where, as in many other countries, they are sold over the counter. Some people get prescriptions from doctors who overlook the fact that the only legal use of testosterone in the United States is to treat a real medical deficiency. Added to that is an enormous market in nutritional supplements, which are very loosely regulated and whose makers say they have the same effects as testosterone.

Prescriptions for anabolic steroids have soared in recent years, to 1.5 million in 2001 from 806,000 in 1997, according to IMS Health, a company that monitors drug sales. But it is impossible to know how much is being taken for legitimate medical needs.

By all accounts, a small minority of Americans use the drugs, but medical experts are concerned. Their concern is over their own ignorance: who uses the drugs, why, for how long, and what are the medical consequences? Is it acceptable or recklessly dangerous to use them to alter the body? There have been no rigorous medical studies to provide answers to fundamental questions about long-term safety.

"There are concerns that on the one hand there may be something good here, but on the other hand there may be a public health problem brewing," said Dr. Marc Blackman, the clinical director and chief of the laboratory of clinical investigation at the National Center for Complementary and Alternative Medicine at the National Institutes of Health. "The problem is substantial, and the chasm of ignorance is huge."

All along, there have been suspicions — but very little solid evidence — that anabolic steroids and drugs that act like them can lead to serious long-term effects, including heart attacks, strokes and cancer. There are stories that the drugs can sometimes turn placid people violent. There are concerns that in some sports, those who want to compete have little choice but to take them.

"The average guy will tell you that he hasn't had any problems and doesn't know anyone who does," said Dr. Harrison G. Pope Jr., a Harvard Medical School psychiatrist who studies bodybuilding culture. Yet, he said, there are rare individuals who "have almost a Jekyll and Hyde personality change," becoming aggressive and violent.

That was what worried Mr. Keogan — he quit after jumping out of his car to argue with another driver in a fit of rage, leaving his car to drift away. Now his body has shrunk to its former size, and he struggles to lift weights that were once a warm-up to his real lifting.

Dr. Shalender Bhasin, an endocrinologist at Charles R. Drew University in Los Angeles, says it should not be surprising that people keep taking the drugs. They do build muscle, decrease fat and improve athletic performance. In the meantime, society is sending mixed messages: no one should take steroids, but athletes should be winners and everyone should strive to be muscular.

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"There is some degree of denial and hypocrisy with the use of these compounds," Dr. Bhasin said. "We discourage it by punishing a few people now and then to show our displeasure, but we tolerate their use. We haven't taken a stand as a society, and the widespread use of these agents is reflective of our ambivalence."

A Trend Is Born
Muscles Get Bigger, and So Do Steroids

John D. Fair, a competitive weight lifter and historian of weight lifting at Georgia College and State University in Milledgeville, remembers his first foray into the world of pumping iron. He was a senior in high school, 5 feet 11 inches tall and just 129 pounds. He wore layers of shirts to make himself look bulkier. "The Charles Atlas 97-pound weakling thing is for real. I've been there," he said.

But that was 1961, a time when most men were uninterested in growing big muscles. "I was almost embarrassed to be lifting weights," Mr. Fair said. Coaches told athletes that if they lifted, they would become slow and musclebound, or develop hernias and knee injuries. But no one, except a few elite weight lifters, had even thought of using steroids, and those who did were doing it surreptitiously.

Anabolic steroids came to weight lifting in the 1950's, when Russians began taking testosterone and winning championships, Mr. Fair said. By 1960, a few American weight lifters had begun secretly taking them too. Within a few years, most elite weight lifters were using the drugs, said Terry Todd, a former champion weight lifter who is now a historian of weight lifting at the University of Texas at Austin.

By the end of the decade, other elite athletes had discovered the drugs. In 1969, the marathon champion Frank Shorter says, he watched a French hammer thrower, George Frenn, who died at an early age, inject a steroid into his leg.

Mr. Shorter, who is now chairman of the United States Anti-Doping Agency, which performs drug tests for Olympic-related sports, said that before the 1972 Olympics, he attended an Olympic team meeting where American athletes were cautioned not to take steroids because they did not work. "I was sitting in the back of the room with the weight guys, and they were laughing," he said. "They literally had `before' and `after' pictures with them."

Drugs came later to women's sports. In East Germany and other Eastern bloc countries, female swimmers and other athletes were secretly taking steroids in the 1960's, but almost no female athletes elsewhere were using them.

Jan Todd of the University of Texas at Austin became a competitive lifter in the 1970's when she married Terry Todd and began tagging along when he went to gyms. "I got caught up in this quest for strength," she said. Soon she was smashing world records. By the 1980's, however, many female weight lifters had begun taking steroids. Ms. Todd, who refused, saw her lifting career come to an end.

"She trained harder than anyone I've ever seen," Terry Todd said. But he added: "No matter how hard she trained, it was a foregone conclusion that these other women were going to catch her, and they did. It's frustrating. It takes the fun out of the sport."

One female power lifter, Tam Thompson, told Mr. Todd, in an interview he recorded on April 15, 1986, that she had begun taking drugs because she thought other women were taking them.

Eventually, Ms. Thompson said, her voice deepened "and I noticed these strange hairs showing up. I thought, `Well, that's no big deal. A hair here, a hair there. Big deal. I can live with it.' The next cycle it got worse. But by then, I figured the damage had already been done, and I went ahead with the full cycle of steroids because I had a meet coming up." She added, "I've been off the drugs almost two years now, but I still have to shave every day."

As steroid use seeped into sports and bodybuilding, historians say, muscles became more desirable for ordinary men and women. Steroids were classified a controlled substance by Congress in 1990, but cultural change made them seem more appealing.

Men, Mr. Fair said, became entranced with Arnold Schwarzenegger and began craving big, hard bodies. Women, who had been barred from weight-lifting rooms, found that the doors had opened with the passage of Title IX, the 1973 law that required universities receiving federal funds to provide women with equal access to athletic facilities.

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Now, Dr. Pope of Harvard said, the transformation is everywhere. Women in the centerfolds of men's magazines are increasingly muscular. Male models in advertisements and on magazine covers increasingly appear shirtless, muscles bulging.

Even G.I. Joe was affected. "G.I. Joe in the 1960's used to be perfectly ordinary looking," Dr. Pope said. But over the years, he added, the action figure pumped up.

The Black Market
Illegal to Sell, but Easy to Find

Cy Willson wanted testosterone, and he wanted his health insurer to pay for it — the pure drug, produced for human and not veterinary use, could cost $20 a month for the dose he wanted. So he needed a prescription. But the only approved use is for people with demonstrated testosterone deficiencies.

So Mr. Willson, a 21-year-old student at a large Midwestern university, set out to give himself a deficiency. In the April 2001 issue of Testosterone magazine, in an article titled "Your Doctor, Your Dealer," he explained how he did it — what symptoms to feign, what to eat (very little, and no carbohydrates or fat), what to drink (beer) and whether to exercise (yes, twice a day). A little sleep deprivation also helps, he wrote.

Mr. Willson says his testosterone levels plummeted and he got his prescription. He says he is taking testosterone "for aesthetic purposes," explaining that he gained 20 pounds of muscle.

How good is his scheme? "It is unproven, " said Dr. Blackman of the National Institutes of Health. But, he added, "each of those manipulations — excesses of diet, exercise and alcohol, as well as sleep deprivation — can lower testosterone levels."

For those who do not want to use such tactics, illicit sources of the drugs are easy to find. "It is sold by dealers, it is sold in gyms, it is sold over the Internet," said Dr. Charles E. Yesalis, a professor of health and human development at Pennsylvania State University and the author of the book "Anabolic Steroids in Sports and Exercise."

Some visit pharmacies. An American man in his 30's was recently spotted at a pharmacy in Tijuana, paying $258 for two small packets of Sostenon, an anabolic steroid. Others go to veterinary supply stores for drugs made for horses (their effects on humans have not been studied). At Viva Tijuana, a shopping center a two-minute walk from the border that has 40 pharmacies, PharmVet appears to be a pet-supply store. But a closer look reveals rows of anabolic steroids, made in Australia and Mexico.

Other people buy supplements that purport to have the same effects as steroids. Whether this is true is not known, said Dr. Paul Coates, director of the Office of Dietary Supplements at the National Institutes of Health. "There are a lot of anecdotes that support both benefits and harms," Dr. Coates said. "Is that evidence? That's what we're dealing with."

The result has been subcultures of American society where, with a wink and a nod, men, and some women, routinely take the drugs. Some, Dr. Pope said, are models in fitness magazines or trainers in gyms, who insist that they got their bodies just by hard work. Some are gay men who may have started taking anabolic steroids to combat the muscle wasting and low energy that can result from an H.I.V. infection or antiviral drugs. With steroids, many hope to hide signs of the disease with muscles that suggest they are bursting with health.

In the mid-1980's, they began showing up at gyms with heavily gay clienteles: men with gaunt cheeks and sunken eyes, but large pectoral muscles and a network of bulging veins.

With No Answers on Risks, Steroid Users Still Say 'Yes' (Page 4 of 4)     "I'm a poz hunk," Steve Bolerjack wrote in Poz, a magazine for people who are H.I.V. positive, describing his regimen of weight lifting and steroids to counter the skeletal look that can come from H.I.V. He said he initially obtained a prescription for steroids because he was concerned about his low energy, but found that the steroids gave him a look that drew a lot of compliments. Advertisement     But the look — a sculptured body, zero fat, shaved chest — has also drawn some derision. People with a body that looks chemically enhanced are often disparagingly called Chelsea Boys, a reference to the Manhattan neighborhood with a large gay population. "We struggle with it all the time," said Dr. Steve Becker, a San Francisco doctor who primarily treats H.I.V.-positive patients. "It's common to prescribe steroids as a way to counteract wasting. But I draw the line at giving them for purely cosmetic reasons." Rumors of steroid use persist in all sports. Major League baseball will begin testing for it next year. For athletes, the mixed messages are all too clear. Sports fans do not want to see smaller, slower linemen and backs in football or snooze through the 150th-fastest running of the 100 meters at the next Olympics, Dr. Yesalis said. "They don't give a damn. They just want to be entertained." In Search of the Truth The Street Word and the Textbooks Shalender Bhasin, the endocrinologist, used to think he knew all about anabolic steroids. He knew what was in the textbooks and the medical journals, which was very different from the word on the street. He knew that the folklore said the drugs increased muscle mass. "The scientific opinion was that that was hogwash," Dr. Bhasin said. The folklore said higher doses produced greater effects. He did not believe it. The textbooks told him there was no evidence for that notion. Then he did some research and found out that the scientists were wrong on all counts. The more he studied the drugs, the more he found himself confirming the street wisdom and not the medical textbooks. "I must say I am humbled," Dr. Bhasin said. Now, he said, he has learned not just that testosterone works, but how. It appears to act on immature cells that could develop into either fat cells or muscle cells. Under the influence of testosterone, they choose the path leading to muscle. Testosterone also produces characteristic body changes, Dr. Pope said, with the most marked muscle growth in the upper body and the biceps. Dr. Pope has published photographs of men who did not use anabolic steroids and grew as big as possible without them, and of men who used them. His goal, he says, is to show what a steroid-enhanced body looks like as a way to discourage use of the drug. "It's the lying that really gets to me," Dr. Pope said. "I'll give a lecture and show a photograph of some huge bodybuilder and someone will say, `Do you think he took steroids?' I'll say, `Do you think World War II really happened?' " But scientists say their ignorance about the array of anabolic drugs and their effects remains huge. Some of the drugs can lower levels of HDL cholesterol, the type that normally protects against heart disease. A lower HDL level may lead to an increased risk of heart attack and stroke. They may fuel the growth of some cancers, particularly those of the prostate. They suppress the body's own sex hormone production, which can cause infertility in people who are taking the drugs. But no one has done a long-term study of people who took huge doses of anabolic drugs, and for the most part, no one knows what medical problems the drugs may cause or how likely they are. Even less is known about the nutritional supplements that are advertised as mimicking the effects of drugs like testosterone. In fact, only now is a study being conducted to see if any of these supplements increase muscle size. It is a study of guinea pigs. Dr. Steven B. Heymsfield of St. Luke's-Roosevelt Hospital in New York, who is conducting the study, explained that male guinea pigs have a huge jaw muscle, but that the muscle shrinks if they are castrated. If the castrated animals are given testosterone, their jaw muscle grows back. Dr. Heymsfield's experiment is to give castrated male guinea pigs various supplements that are said to be as powerful as testosterone and see what happens to the jaw muscle. He will be testing a tiny fraction of the supplements on the market. "There are thousands of them," Dr. Heymsfield said. "They make these extraordinary claims, and they probably are right. But the actual scientific literature is extraordinarily thin. You find, like, five papers, and they are not well done."