Is it unethical to take steroids?

Doping in popular sport: anabolic steroids at the click of a mouse

MEDICAL REPORT

Desires for body shaping and sporting ambition are the main motives for the use of doping substances in the leisure sector. Photo: Leukotape®
There is doping not only in competitive but also in recreational sports. How can doctors react if there is a suspicion? Politicians slept through the social debate about how to deal with the desire for “self-optimization”.

The operation lasted three hours, during which the doctors removed 400 grams of breast tissue from the 36-year-old athlete. The scars, which occasionally hurt, remind the former bodybuilder Jörg Börjesson of what he says was the most painful time of his life: the phase in which the undesirable effects of long-term use of performance-enhancing substances unfolded, but the athlete himself had his problems could not pose yet. "There were signs during the training that I did not want to admit, for example the sudden rush of blood from the nose and a depressed mood," reported Börjesson at a training event of the North Rhine Medical Association on the subject of doping in recreational sports.
For a long time he also suppressed the development of the breast, which was becoming more and more feminine and painful. A “key experience” was the four-year-old son's question as to whether he was a man or a woman. By then Börjesson already had pronounced gynecomastia.
"Hundreds of thousands of German recreational athletes presumably take performance-enhancing substances, the estimates are around 200,000 amateur athletes, the number of unreported cases is high," explained Dr. med. Arnold Schüller, Vice President of the North Rhine Medical Association, and announced a series of advanced training events on the subject. “We want our medical colleagues to pay more attention to where abuse is taking place. And we want to use the mood of optimism that is currently emerging for doping-free sport, consistently: from popular to top-class sport, ”said Schüller.
The doctors would have to face the increasingly easy accessibility of performance enhancers via the Internet and dealers, emphasized Schüller. In bodybuilding circles, for example, a mix of caffeine, aspirin and ephedrine is currently being traded as a “miracle diet”; anabolic steroids and diuretics are classics. The sources of supply, dosages, use and effectiveness of the substances are discussed in relevant Internet forums.
The body becomes a projection surface
"Many adolescents and young adults have no sporting ambitions, but simply want to be better accepted through their bodies and integrated into groups," said Börjesson, who is committed to doping prevention in popular sport. The Cologne psychologist and psychotherapist Werner Hübner spoke of the desire for “self-optimization in front of you and in the mirror of others”. The body would become a savior and a projection surface to compensate for alleged deficits and restore a psychological balance.
Desires for body shaping and athletic ambition - these are the main motives behind the use of doping substances in the leisure sector, suggest the studies summarized by the Robert Koch Institute (RKI) in 2006 (RKI 2006, Issue 34: Doping in leisure and popular sports). Further research confirms this. “I was praised for my body” is typical feedback given by young users of doping substances in a study that Michael Sauer from the Institute for Biochemistry at the Sport University Cologne supervised in cooperation with the Cologne Institute for Sports Sociology.
The researchers asked 392 male adolescents from Cologne youth centers and workshops (average age 17 years) about sporting activities and consumer behavior; 45 percent said they smoked daily, 53 percent had already taken alcopops, one in three cannabis in the last twelve months (ten percent daily), and seven percent answered that they had already used anabolic steroids.
According to Sauer, interviews with the friends of the users of doping substances indicated that many teenagers and young men were actively supported by their partners - for example with intramuscular injection of anabolic steroids. Corresponding traces of injection could indicate the use of anabolic steroids, it said at the event.
Many young people are not informed about the undesirable effects of doping substances, according to the study by the Cologne sports scientists. About half of the respondents said they knew little about anabolic steroids. "After prevention events we get a lot of inquiries from young people how they should deal with the side effects of doping substances," reported Sauer. These would be downplayed in the information sources of the recreational athletes or presented as manageable. Börjesson: "The doping dealer who took care of me always said: 'I'll take the drugs myself, I've got everything under control.'"
Striving for mental and physical strength
However, the reality is different. Even after two to three years of consuming anabolic-androgenic steroids (AAS), undesirable physical effects can manifest themselves, for example increased sweating (64.4 percent), acne (57.8 percent), gynecomastia (15.6 percent), skin streaks and cracks (31 percent), testicular atrophy (29 percent), hand tremors (35.6 percent) and spontaneous nosebleeds (22 percent) (source: RKI brochure, in each case self-reported by male users).
Pathological changes in lipid and liver metabolism are also observed. Psychological effects include aggressiveness, anxiety, depression and sleep disorders. "The desired ideal of mental and physical strength is taken ad absurdum with such symptoms," explained Sauer, "those affected suffer considerably."
What should the doctor do if he has evidence that a patient may be taking performance-enhancing substances? "A good doctor speaks up what he notices - but in such a way that he also offers the patient a consultation with his formulation," said Hübner, who advises the person concerned. "Ideally, the doctor has known the patient for a long time and can inform him of the changes he has noticed." He should critically question a sharp increase in muscle mass, changes in the skin and blood pressure values ​​as well as profuse sweating during the examination.
The patient's reaction determines the further course of the conversation. “Either the advice from the doctor works like a 'door opener' and the patient is happy to be able to talk about the subject,” said Hübner, or the patient remains stuck in his addictive behavior and prefers to remain silent. "Then the doctor could express that he is currently unable to explain the findings, but can imagine that the patient could contribute to the clarification with his own information," said Hübner. It is important to signal readiness to talk at any other time. Serious advice is difficult for "one-time customers" who consult any doctor in order to gain access to doping substances.
Education and advice on site, “where young people are on the move”, should be promoted more than before, according to Hübner. Doctors should also be critical of the prescription of substances that could be used to improve performance, for example asthma drugs such as Clenbuterol, which also have anabolic effects, according to Dr. med. Petra Jasker from the Institute for Pathology at the Evangelical Hospital Bethesda in Duisburg. If possible, the diagnosis of asthma should be preceded by the consultation of a pulmonologist. The red list indicates effective asthma medication without the risk of abuse.
Even if breast cancer patients asked to be prescribed increased amounts of tamoxifen, this could indicate the passing on to anabolic drug users who wanted to prevent or treat gynecomastia, Jasker said. Tamoxifen inhibits estrogen receptors and stimulates progesterone receptors.
Around six percent of Germans are members of fitness facilities. In studies from 1998, 2001 and 2006, between 13.5 and 19 percent of fitness center visitors stated that they dope. 14 to 50 percent of users named the doctor as the source for the medication. "Family doctors are often unknowingly involved," said Prof. Dr. med. Herbert Löllgen, Head of the Cardiology / Pneumology Department at the Sana Clinic Remscheid and President of the German Society for Sports Medicine.
A look at the Red List helps to minimize the risk of a violation of the Medicines Act. If the doctor was treating a patient who he believed was using doping substances, it was important to document where the drugs came from and that he had advised against the victim for ethical and medical reasons. A “gray area” is where doctors treat doping drug users in order to “prevent worse things from happening”.
Like many other doctors and medical lawyers, Löllgen is of the opinion that politicians have slept through the debate in society as a whole about how much “self-optimization” to increase physical or mental performance (enhancement) with the help of the doctor is acceptable. In addition to doping, the medical enhancement methods also include cosmetic surgery and the use of psychotropic drugs under certain circumstances - but under which circumstances? How are the benefits and risks to be assessed?
Solidarity burdened
The Tübingen lawyer Susanne Beck said that it should first be “discussed in general whether the autonomy over one's own body justifies taking health risks for the purpose of improvement, although their unwanted consequences could later put a financial burden on the solidarity community” (Medizinrecht 2006; 2: 95-102 ). The discussion should initially be limited to enhancement. Because a comparison with other health-damaging behaviors does not make it possible to include the intention of the individual improvement and its consequences in the weighing of whether a possible impairment of personal freedom seems justified. Dr. rer. nat. Nicola Siegmund-Schultze
Doping in popular sport: anabolic steroids at the click of a mouse

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