Brief Review ANABOLIC STEROID USAGE in ATHLETICS

Journal of Strength and Conditioning Research, 2004, 18(4), 908–917 ᭧ 2004 National Strength & Conditioning Association Brief Review

ANABOLIC STEROID USAGE IN ATHLETICS:FACTS, FICTION, AND PUBLIC RELATIONS

JOSEPH M. BERNING,1 KENT J. ADAMS,2 AND BRYANT A. STAMFORD2 1Department of Physical Education, Recreation and Dance, Exercise Physiology Laboratory, New Mexico State University, Las Cruces, New Mexico 88003; 2Health, Physical Education and Sports Studies Department, Exercise Physiology Laboratory, University of Louisville, Louisville, Kentucky 40292.

ABSTRACT. Berning, J.M., K.J. Adams, and B.A. Stamford. An- ground growth, the public viewed usage as sparse and abolic steroid usage in athletics: facts, fiction, and public rela- thought that athletes with much to lose would never risk tions. J. Strength Cond. Res. 18(4):000–000. 2004.—Anecdotal being caught. evidence suggests the widespread usage of anabolic steroids This all changed in 1988 when anabolic steroids made among athletes (20–90%), particularly at the professional and international headlines at the summer Olympics in Seoul, elite amateur levels. In contrast, scientific studies indicate that usage is rare and no higher than 6%. Conclusions from scientific South Korea. Canadian Ben Johnson set a new world rec- studies suggest that anabolic steroid usage declines progressive- ord in track and field’s premier event, the 100-m dash. ly from high school to college and beyond; however, anecdotal But his joy of victory was short lived when he was dis- evidence claims the opposite trend. In this clash between ‘‘hard’’ covered to have cheated by using a banned substance, scientific data vs. ‘‘soft’’ anecdotal information, it is natural that anabolic steroids. He was stripped of his gold medal and professionals would gravitate toward scientifically based conclu- Olympic record and was banished from competition. sions. However, in the case of anabolic steroids (a stigmatized The public’s reaction was that the system works; and illegal substance), should word-of-mouth testimony from in- cheaters are exposed; the Olympics are clean, now that dividuals closest to the issues—those who have participated in the likes of Ben Johnson have been removed from the and coached sports, those who have served as drug-testing over- seers, and journalists who relentlessly track leads and verify mix; and no one in the future will dare use anabolic ste- sources—be set aside as irrelevant? Not if a complete picture is roids for fear of being caught. to emerge. In this review, hard scientific evidence is placed on But those in the know saw things quite differently. the table side-by-side with soft anecdotal evidence, without Most insiders knew, or believed, that Ben Johnson was weighting or bias. The purpose is to allow the opportunity for hardly the only athlete bolstered by performance-enhanc- each to illuminate the other and, in so doing, potentially bring ing drugs (51). Soon after the 1988 Seoul Olympics, an us a step closer to determining the true extent of anabolic steroid anonymous Soviet coach told the New York Times, ‘‘I feel usage in athletics. sorry for Ben Johnson. All sportsmen—not all, but maybe KEY WORDS. ergogenic aids, performance enhancing drugs, dop- 90%, including our own—use drugs’’ (42). As for Ben ing, legal issues Johnson’s public humiliation acting as a deterrent, Dutch track coach, Henk Kraayenhof, offers this insight: ‘‘People like to think that things are better since Ben Johnson. I INTRODUCTION argue the opposite. If anything, Ben Johnson’s getting or over 3,000 years, drugs have been used to caught [using steroids] promoted drug use. He won!’’ (7). increase athletic performance (14, 38). In Ben Johnson was Canadian. This allowed the self- 1935, the chemical compound testosterone righteous sporting world, and particularly Americans, to was isolated and the basic understanding of point fingers of condemnation at our northern neighbor. F its anabolic (tissue building) effects was We Americans had no doubt that we were clean and that known (30). Although testosterone was not developed as we set an example for the rest of the world. Unfortunate- an ergogenic aid, Boje (9) was credited as the first to sug- ly, according to John Rugar, past chair for the U.S. Olym- gest that testosterone may enhance physical perfor- pic Athlete’s Advisory Council, the United States is far mance. This notion remained dormant in the United from pure. In fact, he stated, ‘‘Americans like to think the States until 1954 when Dr. John Ziegler, U.S. team phy- U.S. leads the ‘Sports without Drugs Crusade,’ but the sician at the World Weightlifting Championships in Vi- reality is that the U.S. is viewed as one of the dirtiest enna, learned about the usage of testosterone by Soviet nations in the world’’ (28). weightlifters from a Soviet physician (22). Upon his re- How is this possible? A recent investigative article in turn to the United States, Ziegler worked with Ciba Phar- The Mercury News (39) provides some provocative in- maceutical Company, and in 1958 they released the syn- sights into the tangled web of drug usage and potential thetic testosterone derivative Dianabol. conflicts of interest among those charged with oversight. Although rumors of Dianabol’s effectiveness spread ‘‘In a review of more than 10,000 pages of confidential rapidly among athletes, it was considered daring to ac- documents, the newspaper discovered more than 100 cas- tually take the drug because much was unknown about es in which U.S. athletes failed tests that would have dis- its effects, particularly over the long term. Such concerns qualified them at the Olympics only to have the results were soon discarded, however, as strength athletes began ruled. . . ‘inadvertent use’ by U.S. officials.’’ Darryl Seibel, making greatly accelerated gains. Usage grew, but it U.S. Olympic Committee (USOC) communications officer, grew in silence. No one admitted to drug usage, even reported, ‘‘There is no evidence the USOC ever sup- though at the time it was not illegal. Despite the under- pressed or concealed the results of drug tests.’’ This is a

908 ANABOLIC STEROID USAGE IN ATHLETICS 909 true statement, considering the following aspect of the all, is the fluidity that surrounds the philosophical ‘‘good- USOC drug policy from 1988: ‘‘Doping was taking a sub- ness-badness’’ of anabolic steroid usage among athletes. stance with the ‘sole intent’ of cheating.’’ Mr. Seibel clar- At one time it was not considered bad to use anabolic ified the USOC stance as follows: ‘‘Without proof a sub- steroids, but at some point this changed. This suggests stance was used for the express purpose of enhancing per- that the issue of using anabolic steroids is not governed formance in competition there was no doping violation.’’ by moral absolutes in the same way that, say, theft, mur- Such revelations suggest an obvious, convenient, and self- der, adultery, and so on are because the latter have al- serving catch-22. ways been considered bad. However, if the usage of ana- The Ben Johnson story underscores the clash between bolic steroids is cheating (a moral absolute), does it not anecdotes and facts and further underscores the difficul- logically follow that it is bad? And, if so, it has always ties and shortcomings associated with various methodol- been bad, whether or not it has been recognized as such. ogies used to uncover the truth about anabolic steroid us- This seems straightforward enough until one stops to age among athletes. Are athletes shunning anabolic ste- consider the notion of cheating as it applies to athletics. roids for fear of being caught? Or are they using them What exactly is it? Charlie Francis, Ben Johnson’s former more, knowing that they truly enhance performance and coach, made a profound statement in Sports Illustrated: that being caught is not likely, unless one were naı¨ve and ‘‘My definition of cheating is doing something nobody else careless—the real reason behind the demise of Ben John- is doing’’ (35). In other words, if everyone is using ana- son? And even then, is it likely that the umbrella orga- bolic steroids, how can it be construed as cheating? This nization, those charged with oversight, will bail a person viewpoint would seem to trump even the sacred ‘‘spirit of out if he or she presents a reasonable prospect of bringing sport’’ argument, if, in fact, everyone else is a user. But home the gold? are they? That is the crux of the matter and the impetus Consider the case of Jerome Young, who was one of for this review. It is also, unfortunately, only 1 component the U.S. team members awarded a gold medal in the Syd- of what can best be described as a philosophical quag- ney Olympic Games in the 1600-m relay (49). Young test- mire. ed positive for a banned steroid a year before the games Please consider, for example, the fact that athletes are but was permitted to compete. The U.S.A. Track and always seeking an edge; it is the nature of competition. Field (USATF) Doping Appeal Board had cleared him. If an athlete has state-of-the-art facilities in which to The USATF refused to disclose Young’s name to the In- train, follows a better diet, and enjoys the oversight of ternational Association of Athletics Federations (IAAF), elite coaches, is this athlete cheating if he or she competes which is a violation of IAAF rules. Finally, a joint com- against an athlete without any of these advantages? Of mission composed of members of the World Anti-Doping course not. But if not, why is taking anabolic steroids Agency (WADA) and International Olympic Committee cheating, especially if, unlike the list above, everyone has (IOC) investigated the matter and reported that it had access and is a user? ‘‘read the decision taken by the USATF and cannot un- What is the stance of professional oversight groups? derstand how, based on the facts presently available to Drugs are likely to be banned by WADA for 3 reasons: (a) the Commission, any authority could have reached the they enhance performance, (b) they are contrary to the conclusion that there was no doping offense.’’ Richard spirit of sport, and (c) they endanger health. As indicated Pound, the president of WADA, said the following about above, the first 2 reasons can (philosophically) be argued the commission’s report: ‘‘The Commission’s report makes against, thereby creating, at least seemingly, a fluidity it clear that the time has come for action in this case. that is troublesome. But the third reason (potential harm) There can no longer be any question that the IAAF and stands out and would appear, at first blush, to rise above the USOC must thoroughly investigate what happened philosophical concerns. Or does it? The rationale is if prior to the Sydney Games, and why Young was allowed drugs endanger health, they must be banned to protect to compete, and take action immediately to deal with the athletes. But should an organization take it upon itself to situation. We owe this to all Olympic athletes who com- protect athletes from themselves? Should governments peted in Sydney and, in particular, to those in the 4 ϫ 400 make it a law to wear protective seatbelts or motorcycle relay who were, perhaps, unfairly deprived of a medal.’’ helmets? Courts have ruled both ways, upholding and re- pealing such actions, adding fodder to the philosophical FACTS VS.FICTION conundrum. Methodological problems associated with attempts to ac- It is appropriate for organizations to protect athletes curately determine anabolic steroid usage have been cov- against drugs, according to Gary Wadler, a physician and ered in great detail by Charles Yesalis and colleagues (52, a U.S. representative of WADA. Hormonally based drugs 53). They provide keen insight into the daunting task of are powerful and ‘‘adverse effects may not be known for separating fact from fiction, because athletes are far from years or decades or generations later’’ (47). In other forthcoming about this issue. Assuring anonymity and words, athletes who elect to use such drugs are making confidentiality helps, but it also calls into question the naı¨ve decisions. In contrast, Norman Fost, a pediatrician accuracy and veracity of obtained data. Lack of anonym- and a medical ethicist, has grabbed headlines for his out- ity and confidentiality, on the other hand, is too risky for spokenness against the ‘‘badness’’ of performance-en- respondents, and cooperation would be unlikely because hancing drugs such as anabolic steroids. Fost sees no sports-governing bodies make it clear that using anabolic strong evidence that anabolic steroids destroy health. He steroids is a serious offense with severe consequences. says, ‘‘I think athletes should be allowed to use them if This is compounded by the fact that laws governing ille- they want, preferably under medical supervision’’ (47). gal use of anabolic steroids went into effect in the United One area of universal agreement is the need to pre- States in 1988. vent drug usage in children. Why? Are children more vul- Another factor, and perhaps the most troublesome of nerable to health problems? Do drugs enhance perfor- 910 BERNING,ADAMS, AND STAMFORD mance more in children than in adults? Is the spirit of beyond was stifling, particularly in strength and power sport violated more when children take drugs? These are events. This represented an amazing turn of events. Con- facetious questions that hint at the hypocrisy. The real sider weightlifting, for example. Before Soviet dominance, issue, most would agree, is that children are not equipped the United States won gold in nearly every weight class. to make sound decisions and therefore need to be pro- Seemingly overnight, U.S. weightlifters were fortunate to tected from themselves. medal, and eventually it was rare for a U.S. weightlifter If this is true, it harkens back to the naı¨vety issue. to break into the top 5 spots in any given weight class. Can athletes, regardless of their age, make sound deci- Was this due to the superiority of the Soviet sports sys- sions, given the pressures and the tiny window of oppor- tem? In part, yes. tunity leading to success that is open to them? An Olym- At this time in history, there was virtually no mone- pic sprinter, for example, may train slavishly to qualify tary support in the United States for weightlifting. Bob for 1 of very few slots on a national team that will com- Hoffman, a businessman who sold high-protein supple- pete only once every 4 years. If anything substantive is ments, barbells, and other resistance-training equipment to come out of the experience (fame and fortune), the and who had a keen interest in weightlifting, personally sprinter must be the one, the only one, who walks away bore much of the cost associated with training and com- with a gold medal. Can individuals mired in such psycho- petition (15). Hoffman, despite the resources he derived logically overwhelming circumstances make sound deci- from the York Barbell Company, could not compete with sions, or, like children, should they be protected from governmental support in the eastern bloc countries. Back themselves? then, the Soviet Union attracted the best athletes into its Obviously, philosophical issues run deep and wide, ranks as weightlifters, and coaches were plentiful, highly and they add mud to already heavily muddied waters trained, and well educated. Weightlifting in the United that wash over the anabolic steroid issue. As if this were States was considered a second-class sport with little or not confounding enough, public opinion must be consid- no opportunities available to competitors (e.g., no pres- ered. On the one hand, some suggest that the public is tige, no professional ranks or salaries, no endorsements). outraged at the pollution of sports with dirty drugs. In- The Soviet Union had state-of-the-art training methods deed, in his State of the Union address (43), President crafted by scientists from varying disciplines, whereas in George W. Bush condemned anabolic steroids. Bush said, the United States, much of the training was left to ‘‘The use of performance-enhancing drugs in baseball, chance. football and other sports is dangerous, and it sends the As the United States and other countries made a des- wrong message.’’ He called upon professional sports to get perate attempt to catch up, the usage of anabolic steroids rid of steroids. increased, and by the 1964 and 1968 Olympics the per- But is the public really outraged? Do they even care? ception was that most strength and track-and-field ath- Do baseball fans enjoy the incredible increase in home- letes had tried anabolic steroids (19–21). In 1972, Sylves- run production in recent years, or are they offended that ter (45) unofficially polled all male track-and-field ath- there is less bunting and base stealing? Do basketball letes at the Munich Olympic Games and reported that fans long to return to yesteryear when players were 68% of the participants had previously used anabolic ste- string beans who finessed their way to the basket? Do roids and over 60% had used them within 6 months of the football fans wish the game would slow down and that 1972 Olympic Games. players would propel themselves at each other with less Word spread, and officials feared that the issue was power? Of course not. getting out of hand and that the purity of the Olympic The issues are complex, the questions are ambiguous, Games was in jeopardy. Steps were taken, and drug test- and the answers are amorphous, if not downright contra- ing for anabolic steroids was introduced during the 1976 dictory. Even so, because the implications are so huge and Montreal Olympics. Of the 275 athletes tested, only 8 pervasive, we must make an attempt to address this sit- tested positive (29). This implied that problems were now uation. A meaningful step is to gather the best informa- under control and that the culprits were few and all had tion that is available from all potential sources. Much has been caught. Confidence was high that testing had de- been done in this direction, and this review builds on the terred athletes from using anabolic steroids, and this was excellent comprehensive work of Yesalis (51) and Yesalis supported by the 1980 Moscow Olympic Games when no et al (52–54). In addition, this review differs from the official positive drug test results were reported (46). norm because it is not limited to scientific data obtained Not everyone was convinced that the war on anabolic from well-controlled research studies. Rather, an effort steroids had been won. Manfred Donike, IOC drug-testing has been made to amass considerable anecdotal evidence from investigative reports and from individuals close to expert at the 1980 Moscow Olympic Games, was dubious the issues. and for good reason. He performed an unofficial urine test Why include both science and hearsay? Anecdotal ev- with a new drug-testing method he developed (46) and idence from those who ‘‘should’’ know, owing to their ac- found that 20% of all competitors would have failed test- cessibility to intimate knowledge, and despite inherent ing, including 16 gold medalists, if they had tested with problems associated with bias, resentment and revenge, his method. This suggested a scary trend. Athletes were social clustering, and so on is helpful, if for no other rea- beating the system, and anabolic steroid usage was likely sons than to inspire us to keep searching for the truth increasing rather than decreasing. and to continue pursuit of methodologies that ultimately Donike’s data convinced the IOC to change testing will achieve that goal. procedures, which resulted in 12 positive tests at the 1984 Olympics. This number was lower than what Donike’s ELITE AMATEUR ATHLETES ‘‘informal’’ test had revealed 4 years earlier, suggesting The dominance of the Soviet Union and eastern bloc coun- that usage was on the decline. This perception was not tries at the Olympics in the 1960s and for many years badly shaken despite the publicity tied to the Ben John- ANABOLIC STEROID USAGE IN ATHLETICS 911 son affair in 1988. Public perception continued to be that by doping tests, as serious threats to the health and safe- there were very few violators and that they were being ty of athletes, as well as detriments to the principles of caught. Further evidence of this was revealed at the 1992 fair play in sports. Any effort to veil or disguise steroid Barcelona Olympic Games when only 5 positive tests oc- usage in sports through stealth, designer, or precursor curred (7). means, puts elite, amateur and even recreational athletes Was usage really declining, or were athletes again 1 at risk.’’ The ACSM also is calling for mandatory drug step ahead of the testing procedures, even though the pro- testing in major league baseball (1). cedures had been updated by Donike? It is difficult to say, The role of governing bodies is key to progress in the and there is no concrete evidence. However, Pearson and ongoing battle, but it is hoped that history is not an in- Hansen (37) conducted a survey of 155 Olympic athletes dicator of the likelihood of future success. According to during the 1992 Winter Olympic Games and found that Jim Ferstle (16), ‘‘At the 1996 Games in Atlanta, the IOC 80% of the athletes surveyed believed anabolic steroid us- system suffered another blow. It was revealed that tests age was widespread and represented a very serious or done on the high resolution mass spectrometer (HRMS), somewhat serious problem. Unfortunately, no indication a more expensive but more ‘sensitive’ testing machine be- of direct knowledge or a factual basis was attached to ing used for the first time at these Games, had found such suspicions. traces of banned substances.’’ However, the results were Testing procedures had become more sophisticated by not used to impose sanctions. Instead, it was declared the 1996 Olympics in Atlanta, but only 2 positive tests that the results would be used for further study. ‘‘Accord- were recorded and no medals were forfeited (7). Again, ing to Catlin, the steroid testing in Atlanta was the most was usage plummeting among athletes? According to Dr. extensive at any Games. . . yet, the lingering impression Donald Catlin, director of the IOC-accredited drug-testing was that the system lacked credibility. Again, charges of lab at the University of California–Los Angeles (UCLA), a cover-up were made, as few details were made public ‘‘I don’t think everyone in Atlanta was doped, but, the about potentially positive tests’’ (16). sophisticated athlete who wants to take drugs has This revelation came on the heels of another embar- switched to things we can’t test for’’ (7). Additionally, Dr. rassing report (16). Several positive tests from the 1984 Robert Voy, the past president of drug testing for the games in Los Angeles had not been reported. Then, in USOC in 1984 and 1988, stated, ‘‘They [athletes] know August 1994, the reason was revealed. According to Jim how to beat the tests and what I am hearing from a lot Ferstel, ‘‘Several positive samples had been detected by of people is that they have a fantastic new blocking agent the UCLA lab, but nothing could be done about it because our labs cannot pick up. They [athletes] tell me our drug the code documents, which had been stored in a safe in testing program is a joke’’ (24). Such hearsay evidence de Merode’s room at the Biltmore Hotel were removed by reinforces the notion that Ben Johnson got caught be- Los Angeles Olympic Organizing Committee personnel.’’ cause he was naı¨ve and careless and rejects the notion Was this an innocent mistake or a premeditated cover- that he was a singular bad apple. up? The preponderance of evidence that has accumulated Fast forward to today’s latest developments and it over the years makes it increasingly more difficult to be- would appear as if athletes are determined to remain at lieve in innocent mistakes. least 1 step ahead of testing programs. At the time of this Obviously, objective data are hard to come by when it writing, a new ‘‘designer’’ anabolic steroid (designed to be comes to drug usage because of the severe implications. undetectable) was uncovered. The drug is tetrahydroges- And the more elite the athlete is, the greater are the risks trinone (THG), ‘‘a drug that recently was discovered by a involved (e.g., the international humiliation and ruina- testing lab at UCLA after an anonymous tipster provided tion of Ben Johnson). In addition, because so much is at a syringe of the substance’’ (50). New detection schemes stake, officials, particularly of high-profile organizations for THG have been quickly developed, and retesting of such as the IOC, likely would prefer to believe that usage hundreds of previously obtained samples taken from ath- is down, thus preserving the so-called purity of athletic letes is underway. According to the U.S. Anti-Doping competition in the eyes of the public. Agency, several positive tests have been registered from This does not necessarily mean that there are no hard samples obtained during the U.S. track championships in data from which to judge. Hard data of a sort can be con- June 2003 (50). And the IAAF reported that it will retest figured from facts that are known (or believed to be about 400 urine samples from the World Championships. known). If, for example, in any given Olympic games Positive findings will result in retroactive disqualifica- there are only 5 positive tests among the hundreds of ath- tions, loss of medals, and a 2-year ban from participation letes who compete in events where strength, power, and (50). muscular bulk are advantageous (a hard fact), and if it is This development has promise, unlike past testing assumed that all users were caught (a dubious but desir- schemes. The notion of saving samples and retesting at a able belief), the data would suggest that considerably few- future date when technologies applied by anti-doping lab- er than 1% of all Olympic athletes use anabolic steroids. oratories catch up with newly created designer drugs, We might call this interpretation the ‘‘company line.’’ plus the fear of retroactive sanctions, should give athletes Compare this remarkably low percentage with anecdotal pause. However, governing bodies must have the gump- offerings from insiders (athletes, coaches, drug-testing of- tion to proceed and press the issues, regardless of where ficials) that at least 20% and as high as 60–90% of Olym- the issues may lead. pic athletes use steroids. Combine this with the anony- Efforts by the American College of Sports Medicine mous perception from informal surveys of athletes that (ACSM) are helping keep the spotlight focused. Recently steroid usage is serious and widespread, and the gap be- (2), the ACSM issued a statement: ‘‘ACSM considers tween the scenario supported by hard facts and the one chemicals, such as the recently identified tetrahydroges- supported by anecdotal evidence is amazingly large. trinone, or THG, developed and cloaked to avoid detection Unfortunately, then, the view taken regarding the 912 BERNING,ADAMS, AND STAMFORD prevalence of anabolic steroid usage among elite amateur prevalent,’’ and that ‘‘at least a third of major leaguers athletes distills down to ‘‘who and what do you choose to are steroid users.’’ believe?’’ Do you believe the hard data or the hearsay in- What is the status of drug testing in major league formation? This option persists, and the choice is perhaps baseball? According to Gene Orza, general counsel for the even more suspect when it comes to professional sports Players Association, ‘‘the players union will never agree where the stakes are at least as high as, if not higher to random drug testing. Never.’’ The reason given is that than, those associated with the Olympics and other high- ‘‘it’s a violation of a person’s Fourth Amendment rights. profile amateur competitions. And the players maintain they have concerns about ‘mistakes’ and ‘guys getting branded for life’’’ (10). PROFESSIONAL ATHLETES Jeff Bradley’s article concludes, ‘‘The Major League Drug Policy says, ‘There is no place for illegal drug use The professional-sports circuit insists that it has taken a in Baseball, and there is need to maintain the integrity hard line against anabolic steroid usage. For proof, con- of the game’’’ (10). But 1 page later in the same document, sider its drug-testing policy. Although public perception the policy states, ‘‘Major League players are not subject is that the huge muscular bodies sprinting around the to unannounced testing for illegal drugs.’’ Obviously, this football field on Sunday afternoon are not likely to be nat- head-in-the-sand approach provides tacit approval of urally endowed and are merely the result of intensive drug usage and ensures that cheaters will not get caught. training only (particularly compared with players a few Thus, it would appear as if random drug testing in decades ago), drug testing argues otherwise. Professional baseball is between a rock and a hard place. There is athletes by and large do not get caught using anabolic great need for it on the one hand, but it represents a steroids. Are we then to assume that anabolic steroid us- perceived violation of innate rights on the other. What is age among professional athletes in reality is virtually the solution? Major league baseball announced recently nonexistent, and, of the tens of thousands of athletes who that minor league players in Latin America are going to aspire to play professional football, the few hundred who be randomly tested (8). According to Fernando Mateo, make the grade do so only because they are genetically president of Hispanics Across America, ‘‘Young players in gifted? Dominican Republic and across Latin America will now Testimonials from former professional football players enjoy the safeguards against dangerous steroids that they protest strongly against this notion (12, 19–21, 26). In deserve.’’ Players with minor-league contracts will under- 1989, Bill Fralic, Atlanta Falcons all-pro lineman, testi- go up to 3 random tests per year (8). fied before a U.S. Senate Judiciary Committee that ana- If random drug testing provides ‘‘safeguards’’ for Latin bolic steroid usage in the National Football League in- American players, why are such ‘‘safeguards’’ denied to volved at least 75% of the players (17). This supports the U.S. major leaguers? The answer is obvious. observation made earlier by Howie Long, former Los An- Although major league baseball refuses to impose ran- geles Raiders defensive end and television football com- dom drug testing, a procedure was initiated in 2003 that mentator, that 75% of offensive linemen, 40% of defensive entailed 2 announced tests per year as part of a ‘‘survey.’’ linemen, and 35% of linebackers used anabolic steroids If more than 5% of players tested positive for steroids, (55). blanket ‘‘program’’ testing would be put in place until us- A sign that anabolic steroid usage may be consider- age is decreased to less than 2.5% in 2 consecutive years. ably higher than suspected among professional athletes There is no mention of sanctions or consequences for pos- is the possible infiltration of use into major league base- itive tests. It is also a pretty safe bet that because the ball. A poll in USA Today of 75% of all major league base- tests are announced, the likelihood of catching anyone is ball players estimated anabolic steroid usage to be under remote. But at least this permits baseball to claim that it 50% (6). This suggests that usage is quite high but per- has a drug-testing policy, and that it is toughest where it haps not as high as the usage estimated by major league needs to be—among Latin American minor leaguers who baseball players Ken Caminiti and Jose Canseco. Both obviously need such safeguards to protect them against admitted using anabolic steroids and estimated preva- the dangers of anabolic steroids. lence among professional baseball players to be as high Would a get-tough drug policy clean up major league as 85% (6). Caminiti later recanted this figure but ad- baseball? Perhaps not. Another aspect of testing must be mitted that usage was ‘‘common’’ (6). considered. Legally, even if a player tests positive, can Regarding Caminiti’s admission that steroids helped this be sustained in a court of law if the player contests him win the 1996 National League Most Valuable Player the findings? Unfortunately, prosecutors can defend only award, Jeff Bradley writes in ESPN The Magazine, ‘‘Now, irrefutable results. Those associated with drug testing maybe baseball and the Players Association can acknowl- know that biochemical evidence is loose, at best, and false edge that the integrity of the game has been tampered positives are possible with any testing procedure, no mat- with’’ (10). Despite increasing evidence, this is unlikely. ter how sophisticated the approach. Thus, generating a Mike Remlinger, relief pitcher for the Atlanta Braves, is reasonable doubt is not difficult, and this knowledge quoted, ‘‘The truth is, with all the money at stake for would tend to discourage implementation of drug-testing home run hitters, it would be naı¨ve to think that some policies. And if such policies were implemented, aggres- guys aren’t using steroids. It’s just part of the game’’ (10). sive enforcement more likely than not could be challenged Richie Sexson, outfielder for the Cleveland Indians, is successfully. quoted, ‘‘Steroids are everywhere. If you want them, you It is instructive to consider the random drug-testing can get them—no problem’’ (10). Cliff Floyd, Florida Mar- procedures used in National Collegiate Athletic Associa- lins outfielder, estimates ‘‘that 40% of major leaguers are tion (NCAA) Division II baseball (34). Such testing during steroid users’’ (10). Several anonymous quotes also were the first 6 months of a pilot program found that among offered in which usage rates were estimated to be ‘‘very 148 players tested at 74 Division II schools, 0.7% tested ANABOLIC STEROID USAGE IN ATHLETICS 913

TABLE 1. Anabolic steroid usage among male college athletes. Date (study reference no.) No. of student athletes % Users 1970, 1973 (13) 4,171 15 1976, 1980, 1984 (13) 4,171 20 Division I Division II Division III 1985 (5) 2,039 4.9 4.2 2.2 1991 (4) 2,282 4.8 5.3 4.3 1993 (3) 2,505 1.9 4.3 1.9 1997 (22) 13,914 1.2 1.1 1.3 2001 (32) 21,225 1.6 1.3 1.4 positive for anabolic steroids. This is a remarkably low a very low anabolic steroid usage rate among those sur- percentage rate of cheaters, despite the NCAA’s suspicion veyed while also reporting that a very high proportion of that anabolic steroid usage among baseball players may those surveyed indicated that they have at least 1 friend be growing at an alarming rate. who is a user (27). Regardless of inherent problems, sur- What is the explanation for this huge inconsistency? veys are essentially the only vehicle that is available at Student athletes are aware that the tests will occur dur- present. ing only the competitive season and that ‘‘the effects of The following results (Table 1) reflect usage among anabolic steroids last well beyond their detection time’’ male athletes. Dezelsky et al. (13) investigated 4,171 stu- (34). An athlete can, in other words, take steroids for sev- dents at 5 U.S. universities over a 15-year period. Their eral months to increase strength and muscle mass, then surveys took place in 1970, 1973, 1976, 1980, and 1984. quit using and still carry these enhanced attributes into They found that 15% of athletes used anabolic steroids in the season without fear of detection. Thus, the rate of 1970. The percentage increased to 20% and remained con- usage may be considerably higher than revealed through stant in 1976, 1980, and 1984. testing, and unannounced testing in the off-season is In 1985, Anderson and McKeag (5) began a series of needed. Even though NCAA Division II baseball is mak- studies investigating anabolic steroid usage among ing an attempt to implement testing, the attempt likely NCAA athletes. In their first study (5) of 2,039 athletes, does nothing more than support the false premise that 4.9% in Division I, 4.2% in Division II, and 2.2% in Di- anabolic steroid usage is limited and under control. vision III used anabolic steroids. Greatest usage was Admittedly, anecdotal evidence is soft and cannot among football players at 8.4% (a consistent finding in all compare with scientific data obtained from well-con- the surveys cited in this section), followed by track and trolled research studies. But what if well-controlled re- field (4.7%), baseball (3.6%), and basketball (3.6%). Inter- search studies are essentially impossible to conduct, es- estingly, these data suggest a trend: As the stakes in- pecially at the elite-athlete level? Should we admit we creased from Division III to Division I, usage increased. have no real data upon which to rely and default to the The first follow-up survey of Anderson and McKeag conclusion that no data means no usage? Maybe, but can surveyed 2,282 NCAA athletes at 11 universities (4). Sur- we realistically cast aside observations from insiders as prisingly, the above-cited trend was reversed, as usage irrelevant? Yes, if the observations are biased. It is pos- was sustained at Division I schools at 4.8% but increased sible that some former professional athletes may have an to 5.3% in Division II and 4.3% in Division III. Another ax to grind and may delight in soiling the reputation of follow-up study (3) of 2,505 athletes from 11 universities their chosen sport by falsely claiming that steroid usage found an overall decrease in anabolic steroid usage to is common, particularly if they have been caught or have 1.9% for Division I, 4.3% for Division II, and 1.9% for admitted usage. No one likes to be singled out as the only Division III. one breaking the rules. On the other hand, this possibility In 1997, the NCAA surveyed 13,914 athletes from 637 might be more plausible if it were not for the remarkable NCAA colleges and universities (23). A drop in anabolic consistency of these ‘‘high-usage’’ observations across the steroid usage was found, with 1.2% for Division I, 1.1% board, especially among insiders who have not been for Division II, and 1.3% for Division III. Football players caught breaking the rules. Perhaps the most telling evi- again led the field but with a usage rate of only 2.2%. A dence of all is that insiders en masse have not stood up 2001 NCAA study involved 713 NCAA institutions and and proclaimed condemnation of the observations (made 21,225 athletes (33). Overall, anabolic steroid usage was by relative few) that steroid usage is common. up, but it was only at 1.6% for Division I, 1.3% for Divi- sion II, and 1.4% for Division III, with a 3% usage rate COLLEGE ATHLETES among football players. The prevalence of anabolic steroid usage among college Results recorded in Table 1 demonstrate a dramatic athletes has been the subject of numerous well-controlled shift from 1970–84 to 1985–2001. What accounts for this survey studies; however, in contrast to elite amateur and shift? A number of factors are possible influences. In the professional athletes, there is considerably less anecdotal earlier period, anabolic steroids, although an occult phe- evidence. Thus, considerable hard data are available. Or nomenon, were not stigmatized to the degree that oc- are there? Surveys must guarantee anonymity and con- curred in the latter period. Also, anabolic steroid usage fidentiality to respondents and must rely upon percep- was not considered illegal until 1988. These factors could tions and factors that can inspire creativity and hearsay. dampen visibility and drive users further into the under- For example, it is not uncommon for researchers to report ground scene, making them less forthcoming about their 914 BERNING,ADAMS, AND STAMFORD

TABLE 2. Anabolic steroid usage among female college a breakout of those who participated in athletics vs. those swimmers. who did not, the ratio of users who were athletes to users Date (study reference no.) % Users who were nonathletes was typically at least 2:1. The in- tended purpose for usage in the vast majority of cases was 1985 (5) 0.7 improved athletic performance, with improved appear- 1991 (4) 1.0 1993 (3) 0.6 ance a distant second and injury prevention or rehabili- 1997 (22) 0.8 tation third. This is consistent throughout the range of 2001 (32) 1.3 high school and college athletes. The Monitoring the Future Study (27) reported anabolic steroid usage for 8th-, 10th-, and 12th-grade boys

TABLE 3. Anabolic steroid usage among high school stu- and demonstrated a trend toward increased usage with dents.* advancing age for 2.3, 3.3, and 3.8%, respectfully, whereas usage rates among girls were flat at 1.0, 1.0, and 1.1%, % Users Date (study respectfully. Trend data from 1999 to 2002 demonstrated reference no.) No. of students Boys Girls an increase of approximately 0.5% for boys, with the ex- 1988 (11) 3,403 6.4 NA ception of a 1.2% increase for 12th graders (27). 1989 (25) 1,757 11.1 Ͻ0.1 Anecdotal evidence is scare on this population. How- 1989 (42) 901 5.0 1.4 ever, it has been reported that despite an overall usage 1994 (17) 3,047 3.0 0.9 rate of only 6.4%, 60% of anabolic steroid users believed 1995 (30) 1,907 3.3† 3.3† that 10 or more of their fellow high school seniors used 1995 (31) 3,054 5.7 1.7 the drug (54). However, this finding may suggest a clois- 1996 (38) 4,722 4.5 0.8 tered effect (users congregate with users) because only 1997 (34) 265 5.3 1.5 26% of nonusers believed that 10 or more fellow students *NAϭ not applicable. used anabolic steroids (54). † Percentage of all students; no separate data for boys or girls. COMMENT usage even though surveys are anonymous and confiden- Anecdotal evidence suggests that steroid usage among tiality is guaranteed. Another factor is the researchers elite athletes is widespread, despite purported get-tough themselves. Different researchers used different ap- policies among governing bodies backed by sophisticated proaches to perform the groups of studies. And, of course, drug-testing regimens. Unfortunately, reliable research there is the possibility that anabolic steroid usage greatly data on elite athletes are unavailable, and the only hard declined over the 30-year span of these studies. indicator is the number of positive test results, which, if Some of the studies listed in Table 1 also included fe- the system were failsafe, would argue that usage is ex- male athletes. In the 1985 study (5), 0.7% of female swim- tremely rare. Anecdotal evidence suggests that the drug- mers used anabolic steroids, with no representation from testing system is far from failsafe and that those who get a wide variety of other sports surveyed. In each of the caught are guilty of naı¨vety and carelessness while the studies that included women, female swimmers were rep- masses get away simply because they do not make mis- resented and offered the only consistent variable avail- takes. Real data are not likely to come to light in the near able for tracking chronologically (see Table 2). future, as there is too much at stake for all concerned In 1991 (4), the steroid usage rate was 0.8% for female parties. Athletes do not want to get caught, and there is basketball players and 1.2% for female track-and-field suspicion that governing bodies may very well prefer not athletes. In 1993 (3), usage among women had increased to catch them and be forced to admit that drug usage is to 2.7% for track-and-field athletes, with a 1.7% rate for a problem. softball players. In 1997 (23), the usage rate for female Data on college athletes appear to be dichotomized: softball players was 0.9% and 0.6% for track-and-field before 1985 and after 1985. Before 1985 and ranging back athletes. And in 2001 (33), the usage rates were 0.7% for to 1970, usage was pegged at 15–20% among male ath- female basketball players and 0.8% for softball players. letes. The same researchers collected all these data on the Overall, the usage rate for female athletes competing in same respondents over time (13). Post-1985 data suggest sports other than swimming was similar to the rate for a marked reduction in usage, down to an average of ap- swimmers, with a slightly higher usage rate for track- proximately 4.5% through 1993 and then, beginning in and-field athletes. 1997, dropping farther to approximately 1.5%. Less data are available on female college athletes, but the rate of HIGH SCHOOL ATHLETES AND NONATHLETES usage from 1985 onward appears to be flat at approxi- Although anabolic steroid usage started with Olympic mately 1%. and professional athletes, most prevalence studies have Although the apparent remarkable reduction in ste- focused on high school adolescents (Table 3). Data indi- roid usage among male college athletes is encouraging, cate that the majority of college students who use ana- the issue is not as clear as it might be, given the number bolic steroids started in high school (33). Unfortunately, of studies conducted over the years. The social climate for studies on high school students do not provide a clear steroids has changed considerably since 1970, and steroid contrast between athletes and nonathletes (18, 25, 36, 40, usage has been stigmatized in many ways. Sports-govern- 48). This may be because, at this level, distinction being bodies have imposed career-ending penalties on users, tween the 2 groups is not as firm as it is in college and and there are now legal implications because steroids are beyond. As such, the review of studies in this section in- illegal. These factors may inspire respondents to be less cludes nonathletes and athletes. In studies that included than forthcoming about usage when compared with the ANABOLIC STEROID USAGE IN ATHLETICS 915 earlier era, even though they are guaranteed anonymity roids from Mexico and European countries, especially and confidentiality. Russia and Romania, are flowing into this country in bulk Most anabolic steroid users in college started using in and are easily obtained with little or no risk involved (44). high school. The rate of usage among high school students In addition, clandestine laboratories are springing up and appears to be flat in boys and girls from 1988 onward, cashing in on the demand. The Internet has become a with usage among boys in the 5–6% range and among conduit for mail-order steroids, and it is not difficult to girls at approximately 1.5%. Although the rate of usage find someone at large commercial gyms and competitions among boys is not high, it suggests that usage among with an automobile trunk full of drugs. high school athletes is considerably higher today than Athletes are reluctant to reveal their involvement among college athletes. The fact that data on high school with anabolic steroids for a number of reasons. Steroids students were often diluted with data from nonathletes procured from a black-market operation no doubt put an- may be a factor, whereas studies on college students re- other insulating layer on the issues. They also raise is- stricted their populations to athletes. However, if this is sues surrounding drug purity and potency that are par- a factor, it could artificially reduce the reported incidence ticularly frightening, because athletes who will risk ev- among high school athletes, for there is no reason to be- erything to succeed are not likely to worry about such lieve that nonathletes would be more likely to use ana- matters. bolic steroids. On the contrary, the data suggest that athlete users outnumbered nonathlete users at least 2 to 1. THE FUTURE Thus, the reported gap between high school and college Unfortunately, despite considerable effort, it is possible could be even greater than it appears. that we know little about the true extent of anabolic ste- If these trends are real, they raise interesting ques- roid usage among athletes. Compounding all the prob- tions. Why would the rate decline when athletes reach lems cited above is development of new designer anabolic college and the competition for playing time increases steroids that are designed to escape detection, helping dramatically? Does increased maturity lead to better de- athletes stay 1 step ahead of the authorities. This em- cision making? Is it because there is greater oversight phasizes the lengths to which athletes will go and the and fear of drug testing, leading to the loss of an athletic risks they will take to gain an edge. scholarship? And why would the rate drop even farther Such lengths have no bounds when one considers a to nearly 0 (according to hard data) among elite amateur new threat that is Orwellian in scope and makes designer and professional athletes while tens of thousands of hope- drugs look like child’s play. Researchers at the University ful participants fail to make the grade because competi- of Pennsylvania have conducted experiments on mice tion is so intense? Is it because there is even more acute that produce substantial increases in muscle size and oversight and more sophisticated testing procedures and strength that are not lost with age and are sustained even because the stakes are higher still? Or are elite athletes when training is discontinued (41). The research entails so genetically gifted that they need not bother with arti- the use of gene therapy to produce increased levels of in- ficial performance boosters? sulin-like growth factor-1—a protein that enhances mus- If these trends are not real, do athletes, despite guar- cle growth and repair. Dr. H. Lee Sweeney, the researcher antees of anonymity and confidentiality, simply deny ste- in charge, is excited about the potential of this work to roid usage as a key to their success as they move up the help the elderly and those with muscle-wasting diseases. ranks from high school to college and beyond? Moreover, Dr. Sweeney also has become acutely aware that a it is difficult to ignore the fact that as hard data sup- population unrelated to his work has its eye on him and porting usage declines from high school to college and be- eagerly awaits further results. Shortly after presenting yond, anecdotal evidence proclaiming widespread usage some of his results at a meeting of the American Society increases. for Cell Biology, Dr. Sweeney received many e-mail mes- sages. A particularly alarming one was from a high school Procuring Illegal Drugs football coach who ‘‘wanted [Dr. Sweeney] to treat his An argument in favor of very low usage rates, especially whole team.’’ Dr. Sweeney responded that his results among younger amateur athletes, is that anabolic ste- were preliminary and applicable only to animals, and if roids are illegal, and therefore they should be hard to he did what the coach requested, they would all end up obtain. Would wholesome high school or college athletes in jail (41). One has to wonder if such a coach would pro- risk going after an illegal drug, thus setting up a 2-tiered mote the use of anabolic steroids to his young players. It risk for themselves (breaking the law and violating sport- is difficult to imagine that he would resist. It is also dif- ing rules)? At one time it was assumed that the only way ficult to imagine that he alone is driven by such danger- these athletes could procure anabolic steroids was ous blind ambition. through an unethical physician who would write a pre- This review and the ominous clouds that hang over scription. Nowadays, however, with all the heat and pub- the future of athletics underscore the need for more re- licity focused on anabolic steroids, it is hard to imagine search in this area and exploration of new, creative, and that many physicians would put themselves in such a unique approaches to research. The works of Yesalis (51) compromised position. This means that the perceived dif- and Yesalis and colleagues (52–54) indicate that such ef- ficulty of procuring illegal anabolic steroids serves as an forts are underway. This review also underscores the internal policing mechanism. valuable role of anecdotal evidence provided by insiders Those in the know, however, quickly point out the na- that is neither quantifiable nor verifiable, and yet, with- ¨ıvety of this thinking, because the black market in ana- out it, the issue of anabolic steroid usage among athletes bolic steroids has blossomed into a huge profitable busi- likely would be glossed over as an insignificant concern. ness with no shortage of clients, and physician prescrip- (At the time of this writing, indictments were handed tions are no longer the gatekeeper. Illegal anabolic ste- down by the Justice Department against individuals in- 916 BERNING,ADAMS, AND STAMFORD volved with development of THG, the new designer anabolic 23. GREEN, G.A., F.D. URYASZ, T.A. PETR, AND C.D. BRAY. NCAA steroid, and others from the same commercial laboratory, study of substance use and abuse habits of college student- as well as the personal trainer of professional baseball su- athletes. Clin. J. Sport Med. 11:51–56. 2001. perstar, Barry Bonds. This suggests the possibility that if a 24. JANOFSKY, M. Drug cheaters may be winning the battle of wits sport cannot police itself, law-enforcement groups may step with testers. New York Times. September 15, 1988:D29, 2. 25. JOHNSON, M.D., S. JAY,B.SHOUP, AND V.I. RICKERT. Anabolic in. Once the law puts the squeeze on these individuals, steroid use by male adolescents. Pediatrics. 83:921–924. 1989. those turning state’s evidence could blow the lid off and re- 26. JOHNSON, W.O., S. COURSON, AND C.J. RADLER. Steroids: A veal under oath in depth what has really been going on. problem of new dimensions. Sports Illustrated. May 13, 1985. Stay tuned for potentially explosive developments.) pp. 38–61. 27. JOHNSTON, L.D., P.M. O’MALLEY, AND J.G. BACHMAN. Monitor- REFERENCES ing the Future National Survey Results on Drug Use, 1975– 2001. Volume I: Secondary School Students (NIH Publication 1. AMERICAN COLLEGE OF SPORTS MEDICINE (ACSM). The use of No. 02–5106). Bethesda, MD: National Institute on Drug anabolic-androgenic steroids in sports. Med. Sci. Sports Exerc. Abuse, 2002. 19:534–539. 1987. 28. KETEYIAN, A. Mass deception: Today’s athlete is getting bigger, 2. AMERICAN COLLEGE OF SPORTS MEDICINE (ACSM). Steroids stronger, faster. . . unnaturally. Sport. August: 38–39. 1998. threaten health of athletes and integrity of sports performance. 29. KIRSHENBAUM, J. Steroids: The growing menace. Sports Illus- News release. October 23, 2003. Available at: www.acsm.org. trated. November 12, 1979. p. 33. Accessed October 25, 2003. 30. KOCHAKIAN, C.D. Testosterone and testosterone acetate and 3. ANDERSON, W.A., M.A. ALBRECHT, AND D.B. MCKEAG. Second the protein and energy metabolism of castrated dogs. Endocri- replication of a national study of the substance use/abuse hab- nology. 21:750–755. 1937. its of college student athletes. Final Report. NCAA News. 1993. 31. LUETKEMEIER, M.M., C.N. BAINBRIDGE,J.WALKER, D.B. 4. ANDERSON, W.A., M.A. ALBRECHT, D.B. MCKEAG, D.O. HOUGH, BROWN, AND P.A. EISENMAN. Anabolic-androgenic steroids AND C.A. MCGREW. A national survey of alcohol and drug use prevalence, knowledge and attitude in junior and senior high by college athletes. Physician Sports Med. 19:91–104. 1991. school students. J. Health Educ. 26:4–9. 1995. 5. ANDERSON, W.A., AND D.B. MCKEAG. The substance use and 32. MIDDLEMAN, A.B., A.H. FAULKNER, E.R. WOODS, S.J. EMARS, abuse habits of college student athletes. Research paper No. 2. AND R.H. DURANT. High-risk behaviors among high school stu- Mission, KS: NCAA, 1985. dents in Massachusetts who use anabolic steroids. Pediatrics. 6. ANTONEN, M. USA polls. 79% of players want drug testing. 96(2):268–272. 1995. USA Today. July 8, 2002: 1A. 33. NATIONAL COLLEGIATE ATHLETIC ASSOCIATION (NCAA). The 7. BAMBERGER, M., AND D. YAEGER. Over the edge. Sports Illus- NCAA study of substance abuse habits of college student ath- trated. 86:60–70. 1997. letes. The NCAA Committee on Competition Safeguards and 8. Baseball to start testing Latin American players. Available at: Medical Aspects of Sports: NCAA research staff, 2001. www.sportsillustrated.cnn.com. Accessed September 4, 2003. 34. NCAA NEWS. Championships panel seeking to extend baseball 9. BOJE, O. Doping. Bulletin of the Health Organization of the drug study. Available at: www.ncaa.org. Accessed July 22, League of Nations. 8:439–469. 1939. 2002. 10. BRADLEY, J. Gen XXL. ESPN: The Magazine. April 3, 2000. pp. 35. NODEN, M. A dirty system. Sports Illustrated. December 17, 84–90. 1990. 73 (25): 27. 11. BUCKLEY, W.E., C.E. YESALIS, K.E. FRIEDL, W.A. ANDERSON, 36. NUTTER, J. Middle school students’ attitudes and use of ana- A.L. STREIT, AND J.E. WRIGHT. Estimated prevalence of anabolic steroids. J. Strength Cond. Res. 11:35–39. 1997. bolic steroid use among male high school seniors. JAMA. 260: 37. PEARSON, B., AND B. HANSEN. Survey of U.S. Olympians. USA 3441–3445. 1988. Today. February 5, 1992. p. 10C. 12. COURSON,S.False Glory. Stanford, CT: Longmeadow Press, 38. PROKOP, L. The struggle against doping and its history. J. 1991. Sports Med. Phys. Fitness. 10:45–48. 1970. 13. DEZELSKY, T., J. TOOHEY, AND R. SHAW. Non-medical use be- 39. REID, S.M., W. HEISEL AND T. SAAVEDRA. Tainted U.S. Glory. havior at five United States universities: A 15-year study. Bull. The Mercury News. April 16, 2003. Available at: www. Narc. 27:45–53. 1985. bayarea.com/mld/mercurynews/sports. Accessed November 7, 14. EMMANOUEL,E.Isteria Pharmakeutikis [History of Pharmacy]. 2003. Athens: Pryssos, 1947. pp. 126–127. 40. SCOTT, D.M., J.C. WAGNER, AND T.W. BARLOW. Anabolic ste- 15. FAIR, J.D. Muscletown USA—Bob Hoffman and the Manly Cul- roid use among adolescents in Nebraska schools. Am. J. Health ture of York Barbell. University Park, PA: Pennsylvania State Syst. Pharm. 53(17):2068–2072. 1996. University Press, 1999. 41. SOKOLOVE, M. The lab animal. The New York Times Magazine. 16. FERSTLE, J. Evolution and politics of drug testing. In: Anabolic January 18, 2004; sect 6. pp. 28–33, 48, 54, 58. Steroids in Sport and Exercise. C.E. Yesalis, ed. Champaign, 42. SPEAKING OUT. The New York Times. October 3, 1988. p. C11. IL: Human Kinetics, 2000. p. 384. 43. State of the Union (President G.W. Bush). Office of Press Sec- 17. FRALIC,W.Testimony Before U.S. Senate, Committee on the Ju- retary. Available at: http://www.whitehouse.gov/news/releases/ diciary. Hearings on Steroids in Amateur and Professional 2004/01/20040120-7.html. Accessed January 20, 2004. Sports: The Medical and Social Costs of Steroid Abuse, 101st 44. STEJSKAL, G. They shoot horses don’t they? Anabolic steroids Cong, 1st Sess (April 3, May 9, 1989). and their challenge to law enforcement. The FBI Law Enforce- 18. GAA, G.L., E.H. GRIFFITH, B.R. CAHILL, AND L.D. TUTTLE. Prev- ment Bulletin. 63(8):1–6. 1994. alence of anabolic steroid use among Illinois high school stu- 45. SYLVESTER, L.J. Anabolic steroids at the 1972 Olympics. Scho- dents. J. Athletic Training. 29(3):216–222. 1994. lastic Coach. 43:90–92. 1973. 19. GILBERT, B. Drugs in sport: Part 1. Problems in a turned-on 46. TODD, J., AND T. TODD. Significant events in the history of drug world. Sports Illustrated. June 23, 1969. pp. 64–72. testing and Olympic movement: 1960–1999. In: Doping in Elite 20. GILBERT, B. Drugs in sport: Part 2. Something extra on the Sport: The Politics of Drugs in the Olympic Movement. W. Wil- ball. Sports Illustrated. June 30, 1969. pp. 30–42. son and E. Derse, eds. Champaign, IL: Human Kinetics, 2001. 21. GILBERT, B. Drugs in sport. Part 3. High time to make some pp. 65–128. rules. Sports Illustrated. July 7, 1969. pp. 30–35. 47. WALKER, D. To UW doctor, steroids aren’t so bad—‘‘False 22. GOLDMAN, B., R. KLUTZ, AND P. GOLDMAN. Death in the Locker claims’’ at root of issue. Sentinel. Available at: http://www. Room: Steroids, Cocaine, and Sports. Tucson, AZ: The Body Press, jsonline.com/sports/gen/jan04/201972.asp. Accessed January 1987. 22, 2004. ANABOLIC STEROID USAGE IN ATHLETICS 917

48. WINDSOR, R.E., AND D. DIMITRU. Prevalence of anabolic steroid 53. YESALIS, C.E, A.N. KOPSTEIN, AND M.S. BAHRKE. Difﬁculties use by males and female adolescents. Med. Sci. Sport Exerc. in estimating the prevalence of drug use among athletes. In: 21(5):494–497. 1989. Doping in Elite Sport: The Politics of Drugs in the Olympic 49. WORLD ANTI-DOPING AGENCY (WADA). WADA/IOC Commis- Movement. W. Wilson and E. Derse, eds. Champaign, IL: Hu- sion Issues Further Report on Young Case. Montreal, Canada. man Kinetics, 2001. pp. 43–56. September 30, 2003. 54. YESALIS, C.E., K.L. STREIT, J.R. VICARY,K.FRIEDL,D.BRAN- 50. UNITED STATES ANTI-DOPING AGENCY. USADA statement. NEN, AND W. BUCKLEY. Anabolic steroid use: Indication of ha- Available at: www.usantidoping.org. Accessed October 16, bituation among adolescents. J. Drug Educ. 19(2):103–116. 2003. 1989. 51. YESALIS, C.E., ed. Anabolic Steroids in Sports and Exercise 55. ZIMMERMAN, P. The agony must end. Sports Illustrated. No- (2nd ed.). Champaign, IL: Human Kinetics, 2000. vember 10, 1986. pp. 17–21. 52. YESALIS, C.E., M.S. BAHRKE, A.N. KOPSTEIN, AND C.K. BAR- SUKIEWICZ. Incidence of anabolic steroid use: A discussion of methodological issues. In: Anabolic Steroids in Sport and Ex- ercise. C.E. Yesalis, ed. Champaign, IL: Human Kinetics, 2000. Address correspondence to Kent J. Adams, kent@ pp. 73–106. louisville.edu.