1. The Ethics of Performance Enhancing Drug Use Jeffrey M. Anderson, MD Director of Sports Medicine UConn Division of Athletics

2. So What Could Possibly Be Wrong With This?

3. Overview Review of anabolic steroid structure/pharmacologic action Review of anabolic steroid structure/pharmacologic action History of anabolic steroid use in sport History of anabolic steroid use in sport Ethical arguments surrounding anabolic steroid use in sport Ethical arguments surrounding anabolic steroid use in sport

5. Testosterone

6. Endogenous vs. Exogenous AAS Endogenous Endogenous –Testosterone –Androstenedione –Androstenediol –DHEA –19-norandrosterone –19-noretiocholanolone Exogenous Exogenous –Nandrolone –Norandrostenedione –Methandienone –Methyltestosterone –Stanozolol –Boldenone –Trenbolone

7. AAS Effects on muscle Most potent stimulators of protein synthesis at the cellular level Most potent stimulators of protein synthesis at the cellular level Effects are noted with supraphysiologic doses (10x-100x) Effects are noted with supraphysiologic doses (10x-100x) Clearly have a positive effect on muscle growth and hypertrophy Clearly have a positive effect on muscle growth and hypertrophy

8. History of AAS Brown-Sequard 1889 Brown-Sequard 1889 Zoth and Pregl 1920s Zoth and Pregl 1920s Late 30s-testosterone synthesized by German scientists Late 30s-testosterone synthesized by German scientists 1950s-Soviet use of testosterone in athletes 1950s-Soviet use of testosterone in athletes 1960s-John Ziegler- Dianabol 1960s-John Ziegler- Dianabol

9. History of AAS 1960s and 1970s- rampant use-not illegal or banned 1960s and 1970s- rampant use-not illegal or banned 1970s-GDR swimmers 1970s-GDR swimmers Medical establishment still noted no benefit Medical establishment still noted no benefit

10. History of AAS 1988-Ben Johnson +stanozolol test 1988-Ben Johnson +stanozolol test 1988-Underground Steroid Handbook- Duchaine 1988-Underground Steroid Handbook- Duchaine 1991-Elashoff publishes review in Annals of Internal Medicine stating that no firm conclusion can be drawn on their effects 1991-Elashoff publishes review in Annals of Internal Medicine stating that no firm conclusion can be drawn on their effects

11. History of AAS 1996-Bhasin-first study documenting anabolic effects of steroids 1996-Bhasin-first study documenting anabolic effects of steroids Late 90s-Early 2000s—baseball Late 90s-Early 2000s—baseball 2004-US Anabolic Steroid Control Act 2004-US Anabolic Steroid Control Act

12. Side Effects of AAS Hepatic Hepatic –Liver injury (temporary vs. permanent) –Hepatic tumors Cardiac Cardiac –Lowered HDL, elevated LDL and triglycerides –Increased thrombogenesis –Cardiomyopathy Genitourinary Genitourinary –Males Impotence Impotence Oligospermia/ azoospermia Oligospermia/ azoospermia Gynecomastia Gynecomastia –Females Clitoromegally Clitoromegally Menstrual disturbance Menstrual disturbance Breast atrophy Breast atrophy

13. Side Effects of AAS Dermatologic Dermatologic –Acne –Male-pattern baldness –Hirsutism Musculoskeletal Musculoskeletal –Tendon rupture

14. Side Effects of AAS Psychological Psychological –Aggressiveness –Rage –Delirium –Depression –Psychosis –Mania

15. How Common Are Side Effects? No controlled trials No controlled trials Variation in reports depending on perspective Variation in reports depending on perspective Temporary vs. permanent? Temporary vs. permanent? GDR information is concerning GDR information is concerning

16. Ethics Autonomy vs. paternalism Autonomy vs. paternalism Unnaturalness? Unnaturalness? Unfair advantage? Unfair advantage? Risk of harm? Risk of harm? –Personal harm vs. opponents harm vs. societal harm Right to privacy Right to privacy

17. Autonomy Autonomy –The principle of respect for persons, and of individual self-determination consistent with that principle. As most commonly defined, autonomy points in the direction of personal liberty of action in accordance with a plan chosen only by oneself. Paternalism Paternalism –Stance that a person’s liberty is justifiably restricted to prevent self-harm, or to promote that person’s own well-being. Paternalism is an inherently liberty- limiting principle. It is grounded in a theory of impairment, viz., that an individual lacks sufficient facts or mental capacity to make a sound choice.

18. Unnaturalness AAS are an “unnatural” way to gain advantage AAS are an “unnatural” way to gain advantage Are training, carbohydrate replacement, medications, etc. all “natural”? Are training, carbohydrate replacement, medications, etc. all “natural”?

19. Unfair Advantage If one athlete uses steroids it gives them an unfair advantage If one athlete uses steroids it gives them an unfair advantage If steroids are not banned, everyone has access If steroids are not banned, everyone has access

20. Risk of harm Harm to Self Harm to Self –Side effects Harm to Others Harm to Others –What happens to that poor kid on the previous slide? Harm to Society Harm to Society –If one has to use steroids to compete fairly, how many will be forced into using them?

21. Right to privacy Drug testing procedure Drug testing procedure –Witnessed collection –Complaints of embarrassment –Lack of trust –Invasion of privacy