Responsible steroid use

Spanish law is unambiguous in how it defines the "doping offence" and in imposing criminal penalties on anyone who, without therapeutic justification, prescribes, provides, dispenses, supplies, administers, offers or facilitates substances intended to improve physical performance. The penalty is not confined to competitive or federated sport, where there might be some logic in stopping one athlete gaining an advantage: it extends to anyone who plays sport at all. The rule aims to "protect the athlete’s health" because, strictly speaking, using steroids to improve physical performance or for cosmetic reasons has no therapeutic justification and is unnecessary.

The law also makes clear that an athlete who uses doping substances cannot be convicted of this offence. It protects the athlete’s health against "attack by third parties", but not against themselves.

Liposculpture, blepharoplasty (eyelid surgery), breast or buttock augmentation and facelifts are likewise unnecessary medical and surgical procedures, and not free of risk. The same goes for laser hair removal and botulinum toxin injections. Invoking the principle of prescribing freedom, medicines authorised to treat diabetes are prescribed as weight-loss drugs, and there is no mechanism to prioritise access for people with diabetes.

In short, society tolerates — and in many cases promotes — medical and surgical procedures carried out for cosmetic reasons. There is nothing to object to in that: in the twenty-first century, medicine is not solely about fighting disease. Rather than "prescribing", "ordering" or "instructing", it seems sensible for the doctor’s role to be one of giving the patient all the available information about the aims, likely results and risks of a given course of action, so that decisions can be taken freely and responsibly.

And yet steroid use for sporting or cosmetic ends remains wrapped in taboo and hypocrisy.

Access to information:

As with other substances, the Internet has revolutionised access to a vast body of information on the sporting and cosmetic uses of steroids and related substances.

The biggest problem is the quality and reliability of the sources. Finding websites with information on psychoactive drug use from a harm-reduction, scientific perspective is relatively straightforward. That is not the case with steroids in particular, where two kinds of information can be told apart.

• An "official line" which holds that steroid use is, at any dose, frequency and in any circumstance, a bundle of risks, dangers and problems to be avoided.

• An "alternative line" on forums and websites recommending regimens, doses, combinations, ways of using them or ways of managing side effects that are not based on scientific studies and may predispose users to health problems. Many of the recommendations about drugs to avoid adverse effects, post-cycle therapy or adjuvant medicines rest on more or less theoretical speculation, with no sound studies backing their efficacy or safety.

Access to the substances:

The Internet is also an enormous supermarket where these substances can be bought from home. Most are medicines used in human or veterinary practice, with very low production costs, offered through "online pharmacies".

Any search engine leads to hundreds of websites where, in theory, almost any substance can be bought easily. But telling apart medicines from approved laboratories, generics made in South-East Asia or Eastern Europe, and outright counterfeits is in practice very difficult.

Some websites let users rate the pages selling these substances. Users’ subjective experience and opinion is the only assessment tool available, though it at least allows the most notorious frauds to be ruled out.

Most of the steroids and anabolic agents available on the market have been tested in humans in the treatment of various conditions, and there are enough objective data on their dosing, appropriate regimens, expected adverse effects, interactions, contraindications and so on.

In some cases, such as testosterone enanthate, there is evidence and experience of its use at moderate doses over defined periods with a very reasonable profile of adverse and toxic effects.

In others, the doses that produce a notable anabolic effect are considerably higher than those used therapeutically. Take
oxandrolone: the recommended dose is 10–20 mg, yet most
cycles recommend 30–50 mg, sometimes for more than 8–10 weeks.
The greater the gap between the dose assessed in clinical trials and
the dose actually used, the higher the likelihood of adverse effects and risks to
health.

Rigorous knowledge of the characteristics of
each preparation is therefore essential — although, as noted above, websites and forums on these substances rarely provide it.

We have set out the legal approach to prescribing steroids for sporting or cosmetic purposes, and how poorly it fits reality. Anyone can buy them online and use them according to any of the countless regimens proposed on forums and web pages.

And yet advising patients who want to use steroids is not a crime. It is, rather, an indicated and selective preventive measure aimed at protecting and preserving the health of people who are considering using them. From the classic paternalistic medical model this is hard to conceive, but from a harm-reduction standpoint a participatory, non-moralising, shared-responsibility approach reduces risks and potential health problems. The assessment is geared to advising the patient or client on the safest possible regimen.

A medical assessment before and after an anabolic cycle should be a basic principle. It should stress using steroids in a way that is limited in products, duration and dose, and as a complement to appropriate diet and exercise.
Some of the things worth assessing clinically are:

• Family and personal history (skin conditions, psychiatric conditions, heart disease, blood disorders, prostate problems and so on)

• Current and recent drug treatments

• Previous experience with steroids; goals and expectations

• Age

• Weight, height, body mass index

• Cardiovascular risk assessment (ruling out hypertension, waist circumference, index, smoking and so on)

• Blood work (glucose, kidney function, total cholesterol with HDL and LDL fractions, transaminases, bilirubin, haematocrit, thyroid hormones and so on)

• Electrocardiogram