Mclean Hospital

Podcast: Let’s Talk About Steroids

December 24, 2019

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Trevor talks to Harrison G. Pope, MD, MPH, director of McLean’s Biological Psychiatry Laboratory. Dr. Pope talks about men’s misuse of anabolic steroids—drugs which have been used by millions to gain muscle or lose body fat—with potential long-term dangers.

Dr. Pope is arguably the leading researcher in the world on the misuse of anabolic steroids. He discusses some of the reasons men use steroids, the dangers of using these drugs, and the relationship to men’s body image.

Episode Highlights

  • The growth in popularity of the muscular body form among males in the 1970s is discussed (07:09)
  • Dr. Pope shares a basic definition of what an anabolic steroid is (10:22)
  • The ease with which one can acquire anabolic steroids (without a prescription) is described (28:29)

Relevant Content

Episode Transcript

Harrison: When I first became interested in steroids, it was because there were two guys who were admitted to McLean Hospital, who—

Trevor: What year?

Harrison: This would have been approximately 1986.

Trevor: Okay.

Harrison: ‘85 to ‘86.

Trevor: Okay.

Harrison: And there were two guys admitted to McLean Hospital who developed psychotic symptoms after taking anabolic steroids. And I was asked to see them, because people knew that I was a weightlifter and was familiar with steroids from my experience in the gym. And I found in the literature that no scientist had written any papers to say that this could happen with anabolic steroids. And after seeing the second case, I said, this is sufficiently striking that it really ought to be written up. It should be reported. And so I wrote just a short presentation about it. And, well actually I didn’t first write a short presentation. I then collaborated with another guy at McLean Hospital and we recruited about 40 other weightlifters who had used anabolic steroids and interviewed them and found to our surprise that quite a number of them had experienced psychiatric symptoms.

And so we then published an initial paper, just as a brief report in a fairly prestigious journal, actually, the Lancet. And at first, when those results came out, the ... Virtually all of the community of people who were knowledgeable about steroids rejected the findings, said there’s no evidence that steroids can do that, and we—

Trevor: That was their claim. There’s no evidence.

Harrison: Right. And they had never seen it, they said. And the reason was that the people who were knowledgeable about steroids were sports medicine people, other sports associated people, but none of them were psychiatrists. And as a result, they were unfamiliar with performing psychiatric interviews or evaluating psychiatric symptoms. And so there was great skepticism about the paper when it came out. We then got a grant from NIH to do a larger study where we interviewed 160 guys of whom there were 80 or 90 who had used anabolic steroids and then a comparable group who were also experienced weight lifters who had never used steroids. And we found that the prevalence of the psychiatric syndromes in the steroid group was significantly higher than in the non-steroid group, particularly with regard to so-called manic or hypomanic syndrome. A manic syndrome is where you developed exaggerated feelings of self-confidence, decreased need for sleep, racing thoughts, sometimes pressured speech, hyperactivity.

Trevor: Pressured speech?

Harrison: Pressured speech is sometimes called verbal diarrhea, where you can’t interrupt the person and they just go on continuously from one thought to the next.

Trevor: Gotcha.

Harrison: And we see naturally occurring manic episodes all the time, here at McLean Hospital and elsewhere in patients with bipolar disorder, but the idea that anabolic steroids could produce comparable symptoms was essentially unknown as of the late 1980s, and it took really until maybe 10 years ago, before the scientific community had finally sort of admitted that these drugs really could do this, in a minority of people, admittedly, but that they really could do this in certain predisposed individuals.

Trevor: I want to back up to something, you found 160 men in this study?

Harrison: We, yes. We advertised in gymnasiums, in the Boston area and the Los Angeles area, and offered them $60 to come in for an interview and some related laboratory tests. And in inflation adjusted terms, that would probably be more like $150 today, and that’s how we got them to come in.

Trevor: I want to touch on something. I want to get back to what you were talking about, but I wanted to touch on something that you made me aware of when I was doing research on you, was the growing body politics for men, that in ... Most people thought it was an issue among women. Do you think the fact that there were, that it was that easy, I don’t know if it was easy. I’m assuming it was easy, that it was that easy to find 160 men for this study was in itself a clue that men were starting to have body image issues and were going to the gym and contending with that issue?

Harrison: Well, it’s hard to know how much of it was attributable to body image and how much of it was attributable to simple concerns about being fit or being healthy.

Trevor: Yeah, I don’t know though. But, I mean, it was around the ... Wasn’t it around the 70s and the 80s when the universe contest started getting televised and those muscle magazines started growing? Like the image of ... I remember, or my parents told me that when they were kids it was a George Reeves or Steve Reeves who played Superman, that was the ideal body for the men. It wasn’t a very defined musculature. Now, you have Ferrigno and Schwarzenegger and these images are coming out in these magazines and people are developing all these muscle groups. Am I way off on this?

Harrison: The distinction between Steve Reeves and bodybuilders starting even 10 years later was that Steve did his weightlifting in the era before anabolic steroids. With the advent of anabolic steroids, it became possible to create men with far more muscle than any naturally occurring man had ever had.

Trevor: Okay. I did not know that.

Harrison: And that was the inflection point.

Trevor: Okay.

Harrison: And after that, when you could have huge bodybuilders as a result of steroids, there was increased interest in bodybuilding contests and televising and even in the movies. By the 1980s, we see more steroids appearing in the movies with actors who have obviously taken steroids, and—

Trevor: Well, not only that, you literally saw Mr. Universe become the biggest movie star in the world. I mean, what does that say?

Harrison: Well, the idea of muscular bodies being desirable probably came from several sources. One of them was the advent of steroids and the fact that it became possible to do that.

Trevor: Right.

Harrison: But then another aspect of it may be that corporations who had made money off of women’s insecurity about their bodies, recognize that if they could prey upon the other 50% of the population, that there was a market to be had.

Trevor: Right.

Harrison: And so there was increasing influences on males, especially in Western societies, to look leaner and more muscular and to buy products that were advertised to help make them leaner and more muscular.

Trevor: Right.

Harrison: So, I think that that was a parallel force and it caused an increasing focus on body image among men that began to gather steam in the 1970s and especially the 1980s, and has continued up to the present. For example, my father or my grandfather never worried that they had a six pack of abdominals. It would never have occurred to them to even think about such a thing.

Trevor: Sure.

Harrison: And that they would never go to a gym. And even when I first went to the gym, which would’ve been in 1980, it was still in those days, mostly construction workers and truck drivers who went to the gym and somebody who was a faculty member at Harvard Medical School would not normally be someone seen at a gym. Whereas now, I would guess that probably two thirds of our faculty has had a gym membership at one time or another. So it has been a quite striking trend that dates back about 40 years.

Trevor: Out of those 160 subjects that you interviewed, were any of them recreationally abusing drugs on top of the antibiotic steroids?

Harrison: Absolutely, yes. Many anabolic steroid users—

Trevor: Specifically cocaine.

Harrison: Many anabolic steroid users use other drugs. The one that gets them, creates the most trouble is actually opiates, although many of them have used cocaine, marijuana, and other drugs as well. And that brings up an interesting issue, that the bodybuilding magazines and some of the publicity surrounding bodybuilding has portrayed the bodybuilder as someone who is a highly self-disciplined person who eats a very careful diet, exercises rigorously, and a very careful schedule, avoids alcohol, cigarettes, et cetera, and takes anabolic steroids. But in fact, people who take anabolic steroids are simply drug users, like other types of drug users, and they use other types of drugs as well as anabolic steroids, so that it is not as if steroid use is somehow a unique, noble type of drug use. It’s just simply another form of drug use that that has both subjective rewards to the user and potential dangers, just like other drugs that we see.

Trevor: For the audience, what is a very basic, clean definition of an anabolic steroid?

Harrison: That’s an important question. Anabolic steroids comprise testosterone, which is the male hormone, which is nature’s own anabolic steroid, so to speak, plus a couple of hundred, several hundred derivatives of testosterone where there have been modifications of the testosterone molecule to create drugs that have properties similar to testosterone. The anabolic steroids should not be confused with corticosteroids. Corticosteroids, drugs like prednisone and cortisone and dexamethasone and so on, are drugs that are manufactured primarily in the adrenal gland and they are used to treat inflammation, like a doctor gives you corticosteroids for poison Ivy or you hear about somebody getting a shot of corticosteroids in their shoulder, but corticosteroids have no muscle building properties. In fact, they actually decrease muscle volume and therefore they are not drugs of abuse at all. Anabolic steroids, on the other hand, have huge effects on muscle building and as a result, are widely used.

Trevor: What effects have you found anabolic steroids to have specifically on the brain and maybe the nervous system?

Harrison: That’s an area that we are investigating right now.

Trevor: Right now.

Harrison: In a ... We have a five year grant from the National Institute of Drug Abuse looking at this issue, and the origin of this was about a little over 10 years ago, some researchers found that if you expose human brain cells to very high levels of testosterone, levels much higher than natural levels of testosterone, that the cells seem to die off prematurely. It’s a process called apoptosis, A-P-O-P-T-O-S-I-S. And the speed with which they died off increases as the testosterone level increases. And the investigators suggested that maybe human beings taking testosterone or other comparable anabolic steroids might have some loss of brain cells as a result. And that theoretically, at least, that anabolic steroid use in very high doses might lead to the onset of dementia at an early age.

After these findings came out, we did a preliminary study in Middlesbrough, England, where one of our colleagues rounded up a group of steroid users and a comparison group of weightlifters who had not used steroids, and we gave them a battery of tests that they did on an iPad, on a touchscreen computer.

Trevor: Right.

Harrison: And on most of the tests, there was no difference between the steroid users and the non-steroid users. But interestingly, on two of the tests, which were tests of visual, spatial memory, there were quite striking differences between the groups, with the steroid users performing worse than the non-users. For example, on one of the tests, called pattern recognition memory, the computer presents you with a series of 12 or 18 little squiggles of different shapes and colors.

Trevor: Right.

Harrison: And after you have seen all of this group of squiggles, the computer then presents you with two squiggles side by side and says, “Touch the one of these two that you saw before.” One of them is a novel image and the other is one that hopefully you remember.

Trevor: Right.

Harrison: And we found that, on that test, the steroid users more often made mistakes. But what was more striking was that the number of mistakes they made was correlated with their total lifetime exposure to steroids. The longer you had been taking the stuff, the worst you did on pattern recognition memory. And we then had data that had been collected on the entire United Kingdom population. We were able to standardize the scores, like an IQ test, with a mean of a hundred and a standard deviation of 15, and we calculated using this transformation, that the steroid users were losing about one and a half IQ points of visual spatial memory for every year of steroid exposure, so that in theory if you’d been taking steroids for a total of 10 years, that you were on the drugs for a total of 10 years, your visual spatial IQ would drop to an 85. That finding was quite scary. And we next came back to the United States and did a comparable study here in the United States, and in the American group, the deficits of visual spatial memory were much less, although there was still a trend in the same direction on one of the two visual spatial tests.

Trevor: What was the discrepancy?

Harrison: The pattern recognition memory failed to distinguish the users from the non-users in the American pilot study, even though it had distinguished the groups in the—

Trevor: England.

Harrison: UK study. However, we then did neuroimaging on the subjects. We put them in the MRI machine here at McLean, and one of the things that the machine can do is called magnetic resonance spectroscopy, where the machine can detect the chemical signatures of chemicals deep inside your brain without having to enter your brain in any way. And we found that there was one particular chemical called scylloninositol, S-C-Y-L-L-O-I-N-O-S-I-T-O-L. Scylloninositol. And the scylloninositol levels in the steroid users were significantly low in comparison to the otherwise similar non-users. And that’s bad, because scylloninositol helps to detoxify poisons in your brain. It helps to to detoxify beta-amyloid, which is one of the principle culprits in the development of Alzheimer’s disease. And so if you don’t have enough scylloninositol, that potentially would mean that you might be at greater risk for dementia. Based on those preliminary findings, we then got a large grant to do a study of a hundred guys, and so far, we’ve done 54 of them and hopefully the results will be available by about late 2021 at the rate that we’re going.

Trevor: What else besides dementia are you seeing? Is there anything else?

Harrison: Well—

Trevor: I guess I’m talking specifically about issues with sudden outbursts of anger, that sort of stuff.

Harrison: Well, you and I have discussed two different brain effects in the course of this conversation and it’s important to distinguish them, as you just suggested. The acute effects, effects that happen right now if you’re taking steroids right at this moment, are effects, such as hypomanic or manic symptoms that I described earlier in our conversation, feelings of increased irritability, increased aggressiveness, sometimes greater tendency to violence. And those are effects that are present when you actually taking steroids and they tend to disappear fairly promptly when you stop taking the drugs. Whereas the neurological effects, so the neuropsychiatric effects that I was just talking about, there, we’re talking about a long-term effect, which is presumably related to your total lifetime exposure to anabolic steroids, especially if you’ve been taking them at very high doses. So the ... It is now well-established, scientifically, that anabolic steroids can produce acute psychiatric effects in a subpopulation of individuals. Only a minority of users, mind you, but in a significant minority, experience these psychiatric effects.

Trevor: What do they have in common?

Harrison: We don’t know.

Trevor: Okay.

Harrison: The ... It was once thought that the people most likely to get these effects were people who were maybe angry or irritable to begin with, or people who were suggestible and where they learned from the gym subculture that you’re supposed to act that way.

Trevor: Or is it possible maybe they have a psychiatric condition already, or a mood disorder or something?

Harrison: One could argue that as well.

Trevor: Okay.

Harrison: However, to address that question, there were four double blind studies that were performed, where investigators took ordinary guys and gave them either an anabolic steroid or a placebo under blinded conditions, where neither the study participant nor the scientist was aware of when they were getting the real stuff and when they were getting the inert placebo.

Trevor: Neither ... The scientists didn’t know either?

Harrison: That’s why it’s called double-blind, for that reason, because neither the investigator nor the subject knows what they are getting.

Trevor: Okay.

Harrison: And in three of those four studies, there were individuals who exhibited prominent mood changes, that were hypomanic or manic symptoms, whereas none of the people getting the placebo exhibited comparable symptoms. And when I say ... When I refer to four studies, I mean four studies where the doses that were administered were above 500 milligrams of testosterone equivalent per week, which is up in the range toward the lower end of the range, of doses used by actual steroid users in the field. If you do a study where you give only 200 or 300 milligrams of testosterone a week, then it’s too low to produce much of any effect, whereas users out in the field, maybe taking a thousand or 1500 milligrams of testosterone equivalent per week, and hence are more vulnerable to these effects. Having observed this in the double blind studies, we know that you can’t write it off as purely attributable to somebody’s underlying personality or purely attributable to the power of suggestion, or cultural influences from the gym. And we know that therefore there has to be some biological phenomenon that is going on and that some people, apparently carry some sort of biological susceptibility to these effects from anabolic steroids, whereas a majority of people don’t have that biological susceptibility and don’t have any particular psychiatric changes.

Trevor: I’m not going to lie to you, I’ve stressed over this interview for weeks, because it’s extremely dense. Where should we go next?

Harrison: Well, you had begun by asking me about the nervous system.

Trevor: Right.

Harrison: But if we were to back up and you asked me to rank, well, what worries me the most about these drugs? If you asked me that question, I would say the effects on the heart would be number one.

Trevor: I assume there’s been studies on this, yes?

Harrison: Yes.

Trevor: Yeah.

Harrison: And we just completed the largest study to be performed, that was published back in 2017.

Trevor: Right.

Harrison: And the reason that I worry the most about the effects of steroids on the heart is because the heart is a muscle. Steroids affect muscles. The heart is, in fact, the strongest muscle in the body. And it’s the only muscle that never rests. And so it’s perhaps not surprising that you would see bad things potentially happen to the heart in people taking anabolic steroids, especially over the long term. What we did, again, we got two or 3 million bucks from the National Institute of Drug Abuse, and we got 86 men who had used anabolic steroids for at least two years out of their lives. And 54 other men who were—

Trevor: How recent was this study?

Harrison: This study was published in 2017.

Trevor: Okay.

Harrison: We got 54 other men who were comparable weight lifters, equally experienced at lifting weights, capable of bench pressing 275 pounds or more, but who had no history of using steroids. And we then gave them a detailed cardiac evaluation. And one of the things that we found was that many of the steroid users showed signs of a cardio, so-called, cardiomyopathy. And in a cardiomyopathy, what happens with these guys is that when the heart contracts, when the ventricle contracts and sends the blood shooting out through your body, it should expel at least 52% of its contents, when it contracts and beats.

Trevor: Right.

Harrison: And in some of the steroid users, the ventricle became very flabby and was expelling only 40% or sometimes even in the 30s, percent of its contents, when it should have been well over 50. And then the other measure is how fast does the heart fill back up with blood so that after the ventricle is contracted, it has to fill back up in preparation for the next contraction.

Trevor: Next ... Right.

Harrison: And we can, you could measure that with a technique called, so-called, echocardiography. And we found that the steroid users did not fill their hearts back up efficiently. That instead of being flexible and rubbery the way it was supposed to be, the walls of the ventricle were stiffer and did not respond as flexibly. This cardiomyopathy is obviously a cause for concern, but somewhat to our relief, we found that when these guys had been off steroids, individuals who had not used, who were steroid users, but were not currently using steroids at the time that we tested them, that the degree of cardiomyopathy was greatly reduced.

This suggests that steroids can do bad things in terms of cardiomyopathy, but that if you stop, that most of it will recover. However, there is still bad news that goes with that good news, namely there is another effect and that is hardening of the arteries. Steroids mess up the balance of your cholesterol fractions and lead to accelerated, greatly accelerated, hardening of the artery, so-called atherosclerosis. And the way that we test that is you get in a CAT scan machine and you get a shot of an agent that has a high molecular weight so that the X-rays of the cat scan can see it.

Trevor: Right.

Harrison: And as the material goes shooting through the arteries of your heart, the machine with the aid of a computer can actually look to see if there’s any occlusion in any of the various coronary arteries. And when we did that, we found that the men who’d used steroids had significantly greater occlusion, and the ones who had used steroids for long periods of time had markedly greater occlusion of the coronary arteries. And that obviously is quite worrisome, because that’s not easily reversible. It doesn’t go away when you stop your drugs.

Trevor: So, silly question, but what does that mean? Does that mean the heart is working harder or it’s not expelling out enough, so it’s backing up? What does this mean?

Harrison: No. It means that if your arteries of your heart are getting more blocked, it means you’re at greater risk for a heart attack.

Trevor: Okay.

Harrison: And indeed, of the 86 men that I recruited for the study, three of the 86 had had a heart attack already prior to the age of 45.

Trevor: Oh my God.

Harrison: Prior to the age of 45, and then a fourth one had a heart attack just after participating in the study a few months later. And none of the people in the comparison group, the non-steroid comparison group, had a history of a heart attack at the time that they were interviewed. This is a serious concern and one worries that we’re going to see more of this as time goes by.

Trevor: Sure.

Harrison: The reason that I say that you’re going to see more of this is that anabolic steroids were discovered in the late 30s and early 40s, and by the 50s, they had started to find their way into the top echelons of sport, into Olympic weight lifting, other Olympic sports, Mr. Universe contest, et cetera. But they remained in the prominence of elite athletes up through the 70s, and it was not until about 1980 that we see steroids spilling out of the elite athletic world and onto the street, so to speak. As a result, the vast majority of American steroid users began after 1980, and in other countries of the world, that beginning was probably in the 1990s for most other countries. And what that means is that the oldest members of this group, somebody who was say, 20 years old when they first used steroids in 1985, is only now into middle age and entering the period of risk for getting a heart attack or getting other complications of use. We may be just seeing an increasing public health problem that is going to get worse, just over the horizon.

Trevor: We’re talking specifically weightlifting, but we’ve seen in sports that anabolic steroids has been used in cycling, swimming, all sorts of stuff. Does it make a difference what sport you’re doing? I mean, is there something specific about weightlifting?

Harrison: We doubt that it’s specific about weightlifting, because in the study that I just described to you, the comparison group were also weightlifters.

Trevor: Okay.

Harrison: So if there’s any effect of weightlifting, it would be neutralized by the fact that everybody in the study were weightlifters.

Trevor: Right.

Harrison: And therefore any differential between the two groups could not be ascribed to weightlifting and therefore, by default, was presumably attributable to the steroids themselves. You’re quite correct though, that may be if you are a non-weightlifter and you take steroids for swimming or cycling—

Trevor: Or something that’s more cardio related.

Harrison: That in theory you might be less vulnerable to the atherosclerotic disease. That has not been systematically studied.

Trevor: When anabolic steroids spilled out among everybody in the 70s, where are they coming from? Are there street cooks making these steroids? Like what, how are they meeting the demand that’s outside of the upper echelon and among your every day user who just goes to the gym?

Harrison: Well, the availability of steroids has shifted as the years have gone by. When I first started lifting weights myself in the 1980s, it was only a misdemeanor for people to use anabolic steroids. And therefore there were quite a lot of guys in my gym who used steroids. And they had the names of various doctors where you could go down to the doctor and slap a $50 bill on the desk and he’d write you prescriptions for all the steroids that you wanted, and then you could go to the local drug store and buy them. But then Congress wised up about this and it became a felony, and in 1991, Congress passed the so-called Steroid Trafficking Act, which puts steroids under the jurisdiction of the Drug Enforcement Agency, the DEA. And as a result, the controls were much tighter, and as the lawmakers had anticipated, this caused the domestic production of anabolic steroids by pharmaceutical companies to dry up to a substantial degree.

But what they had not anticipated is that by the mid 1990s that that void was filled up by the internet and it became possible to get steroids over the internet as—

Trevor: Yeah, but who’s making them?

Harrison: Well, steroids, unlike many drugs, for example, heroin is illegal in every country, but anabolic steroids are perfectly legal in many countries around the world.

Trevor: Okay.

Harrison: And so, as a result, you could buy them at a pharmacy in Mexico or many Latin American countries or many former Eastern bloc countries, or in Thailand or China. And so as a result, someone can have large amounts of steroids and sell them over the internet where they get shipped into the country, into the United States, and it’s very, very difficult to perform interdiction of this flow of drugs coming in, so that the great majority of people who ordered these drugs actually get them. Now, of course, you could ask, well surely there must be websites that are selling fake steroids and so on.

Trevor: Of course.

Harrison: There are in turn websites that review the other websites and tell you which ones to buy and give you—

Trevor: Websites that review the other illegal websites.

Harrison: And give you commentary as to what’s out there and what’s best. And then, there are still cooks, as you had mentioned in your previous question, where you could arrange for a Teddy bear to be sent to you from China, and inside the Teddy bear, in powder form, is a bunch of anabolic steroids, which you can then take to your basement laboratory and—

Trevor: How do you know about this Dr. Pope?

Harrison: From my study subjects who have described it to me in great detail.

Trevor: Gotcha.

Harrison: And so you can take this to your underground laboratory and make up thousands of doses of anabolic steroids. And if you’re a real professional dealer, you would have a label making machine that will make labels that look exactly like a genuine pharmaceutical company label and a bottling machine and a bottle capping machine that will make sealed bottles that look exactly like a legitimate pharmaceutical bottle that you would buy at a local drug store. And you can then sell them with the ... Giving the appearance that they’re legitimate pharmaceutical drugs from overseas, when in fact you have made them in your basement.

Trevor: Right. What do you think about the belief, and I’ve heard some people have this belief, that steroids in sports is just the next natural step of competition? That this is just taking it to the next level, so the game can be more exciting to watch and therefore would boost ratings and boost money and revenue and stuff like that? What do you think about people that buy into that theory?

Harrison: Well, there are two parts to your question.

Trevor: Okay.

Harrison: The second part of your question is that you’re absolutely correct, people like 300 pound linemen and people like people who can hit home runs repeatedly out of Fenway Park.

Trevor: Sure.

Harrison: And as a result, the public effectively is supporting the use of anabolic steroids, because it does make for more entertaining athletes.

Trevor: The public is not across the board, but you found have been more supportive of this?

Harrison: Well, the public is not explicitly supporting guys use of steroids, but is unknowingly—

Trevor: They’re not crying foul.—

Harrison: Supporting the use of steroids. Now, the other part of your argument is more the—

Trevor: Not my argument.

Harrison: The other part of your question is more the question of well, why not just let people do what they want. Just take our hands off of this and—

Trevor: I’ve heard that plenty of times—

Harrison: Abandon these feudal efforts to try to control it, and just say, yep, you can take whatever you want and may the best man win with all of his pharmaceutical assistance. But the problem with that of course is that it can be very dangerous and that the larger amounts of these drugs you take, the greater the odds that you will develop some serious complication.

Trevor: And then you would, I think, so it’s fair across the board, you would have to come up with some sort of controlled way to administer it so everybody gets the same fair amount, the same fair dosage. I mean, now it would become a part of the sport.

Harrison: Yes. Now the problem of course is that despite vast amounts of effort and money spent doing testing to try to ensure clean, athletic competition, the athletes are always a step ahead of the testers, and in a paper that we published back in 2015 or 2016, we did a study, this was an international group of people, not just myself at McLean, where we used a technique called the randomized response technique. And this is a technique where I present the question to you on a laptop computer in such a way that I cannot possibly know when you answer yes. I cannot possibly know whether you’re saying yes that you have taken the drugs or that you’re answering yes to a different question. Without going into great detail, just take my word for it, that this is a method where it is obvious to the athlete that it guarantees his anonymity. There’s no way that I could bust you.

Trevor: Sure.

Harrison: And we took this technique to the World Games in Daegu, Korea in 2011, and hired a group of six different people who collectively spoke 15 different languages to approach all of the athletes with their iPads and administer this so-called randomized response technique question. And at the games, urine testing that was performed on about 400 people. Well, I’m not sure whether it was 400 people, but on several hundred people, and it found a rate of 0.5% who got busted for having illicit substances, whereas with the randomized response technique, where the athletes were guaranteed anonymity, the number who admitted to having used illicit substances was closer to 40%. And we were so astonished of the results that we then took our technique to the Pan Arab Games in Qatar later that same year, and in Qatar, the number who were busted with urine testing was about 3% and the number who admitted to using illicit doping methods on the randomized response technique was closer to 50%. Many of us in the field are very cynical about whether one can—

Trevor: Yeah, I’d imagine so.

Harrison: Actually, control for this, so that one can have any number of agreements and so on. But the fact is that people will go to great lengths to win.

Trevor: Yeah. And I’m not the first one, far from the first one to suggest it, but when you look at the whole picture, you see just a big circle of business. You see the production, the distribute, the distribution, the purchase, but then the business of controlling it and checking to see who’s using it, there’s a lot of money going around in this.

Harrison: Yes. And because of the fight—

Trevor: To fight it, to produce it and to fight it.

Harrison: Yes. Because of the large sums of money in international sports that it’s obviously there are strong pressures both to use the drugs and to prevent the public from becoming too worried about the use of the drugs, to minimize the public perception of the drug use, even though the athletes are surreptitiously making every possible effort to use them.

Trevor: Right.

Harrison: And as a corollary of that, you and I are sitting here as Westerners in the United States and we sort of accepted as axiomatic that obviously you’ve got to have a level playing field, so that you expect everybody to have to be honest in competition. But suppose that you’re in the Olympics for some other country somewhere. In your country, you might feel that you really should take the anabolic steroids, for your country. That even if you feel that they are dangerous to you, you might feel as a matter of simple patriotism, that you should take them.

Trevor: Oh, I absolutely believe that’s a thing—

Harrison: And it might not occur to you that these Western notions of a level playing field would be meaningful, so that one has to take into account the cultural lens through which we see all of this.

Trevor: What do you think? Should we just legalize it and be on with it?

Harrison: I don’t know a solution.

Trevor: Oh, stop it. You ... I didn’t ask you for a solution. I asked you what you thought—

Harrison: All I can tell you is that there is no way that you can stop the use of elicit performance enhancing drugs. Not just anabolic steroids, but there’s numerous other performance enhancing drugs.

Trevor: No way to stop it.

Harrison: There’s no hope of stopping it anytime in the foreseeable future. And therefore, my reaction is that the best that we can do is to do the sort of thing that I and other scientists do, which is to look at the potential dangers of these drugs and—

Trevor: And educate.

Harrison: Make sure that the people who use these drugs know what they might be in for if they take them, especially if they take them over the long term.

Trevor: Right.

Harrison: For example, one area that you and I have not talked about at all so far has been what is known as hypogonadism. Hypogonadism is the term that means that you’re not having enough testosterone in your system.

Trevor: Right.

Harrison: Now, I’m talking in terms of males. 98% of all anabolic steroid users are male. Only 2% are female. If you’re female, and you use anabolic steroids, you’ll start to grow a beard and your voice will go down by two octaves and you will develop masculinization of secondary sex characteristics.

Trevor: Okay.

Harrison: And furthermore, women don’t usually aspire to be extremely muscular in the first place. As a result—

Trevor: I think that part of it is growing, though. I mean, we are seeing female bodybuilding growing, are we not? I mean, at least it has in my lifetime.

Harrison: Yeah, well actually female bodybuilding has not been doing very well financially.

Trevor: Really?

Harrison: As far as I know, but not nearly to the extent that male bodybuilding has.

Trevor: Okay.

Harrison: But anyway, so to go back, my following discussion is confined to males. So if you’re a male and you are taking testosterone from the outside or any other anabolic steroids from the outside, your hypothalamus in your brain looks around and it says, well, we already have tons of steroids available here. There’s no need for us to manufacture anymore. And so your hypothalamus tells your pituitary gland to shut down and the pituitary gland makes two hormones called FSH and LH and the pituitary accordingly reduces its production of FSH and LH. And the LH tells the testis to manufacture testosterone and the FSH tells it to manufacture sperm cells. And so with the FSH and the LH turned off, the testis goes to sleep and the production of testosterone in sperm cells goes way, way down. Then, if you stop your steroids, especially if you stop them after having taken them for a prolonged period of time, the testis does not immediately wake up. It can take months for it to come back online.

And more recently, in the course of our more recent studies, we’ve been seeing an increasing number of guys where it appears that it may never completely come back online, and that there may be some permanent loss of testicular function, even in people who have been off of steroids for several years. And these findings are not coming merely from my laboratory, but other ... There was another group in Denmark who had almost identical findings to ours and then other reports coming in from around the world. And that is the sort of thing that if you’re an 18 year old guy who has decided to take steroids and get muscular quickly, you might not be deterred by the thought that you might get a heart attack when you’re 60, but you might get deterred by the thought that you might have no sex drive by the time that you’re 35. And so that the more that we can explore the potential dangers of the drugs, the more people may think twice about using them now that science finally is beginning to get some answers to these questions.

Trevor: You started bodybuilding in 1980, did you try anabolic steroids?

Harrison: No, I never tried anabolic steroids.

Trevor: Were you ever offered them?

Harrison: I was never actually offered them. I could easily have gotten them, if I had had wanted to, but the—

Trevor: Is the gym the way to ... Is the gym the place to get them?

Harrison: Well, people usually—

Trevor: Without a prescription—

Harrison: Yeah. People are usually introduced to anabolic steroids by meeting other guys in the gym who have used them. And as a result, they learn the ropes from an underground network of information, so to speak. And as I said in the 1980s, that was hardly even underground, because in those days steroids were merely a misdemeanor, and so people talked openly about them all the time.

Trevor: Right.

Harrison: But now, it’s much more on a need to know basis, and that people don’t talk about steroids except to selected people when they absolutely have to.

Trevor: Sure. Before we wrap up, is there anything that we should touch on or anything you want to bring up?

Harrison: Well, I suppose if I were going to try to summarize—

Trevor: Yeah, that would be good.

Harrison: Some of the things that I just said to you. As you remember, I had pointed out that widespread use of steroids in the United States did not begin until the 1980s.

Trevor: Sure.

Harrison: And therefore that means that the oldest of America’s steroid users are only now in their fifties. Someone who started steroids when they were 20 years old, in 1985, is now going to be in their 50s, and as a result, we still don’t know just how much long-term dangers there may be, that over the next decade, as this pool of people moves into their 60s and 70s, we don’t know whether there are other long-term effects of steroids, such as more heart disease, possible dementia, et cetera, that may still be waiting to fully declare themselves. And imagine by analogy that widespread cigarette smoking did not occur in the United States until the mid 1980s.

Trevor: Sure.

Harrison: And that the vast majority of cigarette smokers were still under the age of 55 or 60 today. In that scenario, there would be the occasional case report of lung cancer, a small case series of emphysema and so on, but we still would have no idea of what was about to hit us. And I worry that we may see a somewhat similar phenomenon with anabolic steroids, and that a decade from now, that we may see more of these long-term effects than we have known up to this point.

Trevor: Are you scared?

Harrison: Well, I’m worried, yes. I cannot predict the magnitude of this problem, because we still don’t have enough data to be able to fully project what’s going to happen 10 years from now.

Trevor: Yeah. How many more peer reviewed papers do you have left in you?

Harrison: Well, I will obviously write up the neurological results that we are doing now, and I’m just finishing a paper on anabolic steroids and violence and people who engage in crime, including often individuals who had no prior history of aggression or violence or criminality prior to using steroids and then had a Jekyll and Hyde personality change when taking steroids, and went out and killed somebody or committed some other crime.

Trevor: Some other crime, but it’s all ... It’s a crime that’s rooted in violence?

Harrison: Yes.

Trevor: Well, for the most part?

Harrison: Typically.

Trevor: Typically, yeah.

Harrison: But remember this is only a small minority of people, but we don’t know why this small minority is vulnerable to these effects, but there is just no question that there are some people who are very vulnerable to these psychiatric effects who get into serious trouble, including committing murders, coincident with having used anabolic steroids.

Trevor: Did O. J. Simpson use steroids?

Harrison: Again, we have no data one way or the other.

Trevor: I know some people are saying that his violence might be attributed to possible concussions and everybody has a theory, I guess.

Harrison: Yeah. Concussions don’t usually predispose people to become violent. With the history of concussions—

Trevor: But that is a growing concern. You have been hearing about that? I’ve been hearing about it and I don’t even look for that kind of news.

Harrison: Yeah. The first paper that I published about the potential psychiatric effects of head injury, I wrote in 1983, so I’ve been in this business for—

Trevor: So you ... Yeah, you know.

Harrison: 40 years or close to 40 years, but what typically happens over the long term is dementia or mood disorders, vulnerability to depression or even to bipolar disorder, but not particularly to violence.

Trevor: Okay. Is there anything we should add before we wrap up.

Harrison: No, I think we’ve covered most of the bases.

Trevor: This was really ... I was so nervous about this interview. You look at me, wait, no, we ... Our pre-interview, we did it and I was like, I’m way in over my head on this one. I feel like this is a very dense subject. There’s a lot of branches and how are we going to bring it together in an hour and then I realized, let him lead and he’ll take you there and you did, Dr. Pope. I really appreciate it. You are really great interview—

Harrison: My pleasure.

Trevor: It was really great. Thank you so much. Thank you for listening to Mindful Things, the official podcast of McLean Hospital. Please subscribe to us and rate us on iTunes or wherever you listen to podcasts. If you have any suggestions for special topics or future guests, email us at mindfulthings@mclean.org. And don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at .877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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