Little is known about the lifetime prevalence of the various medical and psychiatric consequences of AAS use described above. It might be speculated that publication bias exaggerates the apparent magnitude of AAS-associated pathology, in that rare cases of cardiac or hepatic toxicity, or of psychiatric effects such as violence or suicide, find their way into published case reports, while the great majority of long-term illicit AAS users are healthy. Indeed, some authors have suggested that political and moral forces have demonized AAS use, and that in this atmosphere, the dangers of AAS are being greatly exaggerated (Cohen et al., 2007
; Collins, 2002
). As recently as 2005, a well-known medical ethicist has referred to “steroid hysteria,” and questioned the evidence that “steroids cause life-threatening harms” (Fost, 2005
). Certainly these arguments deserve consideration - but on the other hand, there are several reasons to suspect that we might be underestimating, rather than overestimating, the public health consequences of long-term AAS use.
First, as discussed above, a majority of individuals with a lifetime history of AAS use have yet to pass middle age, and thus the long-term effects of AAS may not have had a chance to fully declare themselves. Imagine, for example, that widespread use of cigarettes began only in 1980, and that a majority of all cigarette smokers in 2008 were still under age 45. In this scenario, one might find scattered case reports of lung cancer among cigarette smokers, but the magnitude of the association between cigarettes and lung cancer would not yet be appreciated.
Of course, some AAS users in the population are well over age 45 - especially men who competed in bodybuilding competitions or Olympic events in the 1960s and 70s, such as the Swedish sample described above (Lindqvist et al., 2007
). However our experience from interviews of numerous older weightlifters, together with published reports in the media, suggests that the doses of AAS used in the 1960s and 70s were typically much lower than those used today. It should also be remembered that most AAS users prior to 1980 were competitive athletes, presumably attempting to optimize their health and performance, and rarely using other illicit drugs for recreational purposes. For example, among the older athletes in the Swedish sample, more than 80% reported that they had never used any recreational illicit drugs in their lives. By comparison, most modern AAS users are not competitive athletes, and many use large amounts of other illicit recreational drugs (Kanayama et al., 2003b
) and other potentially hazardous body-image drugs (Kanayama et al., 2001b
; Parkinson and Evans, 2006
). Thus with advancing age, the outcomes of these individuals may be quite different from the outcomes of older elite athletes.
Second, some individuals may develop adverse effects from long-term AAS use, but the etiologic role of AAS in these cases may go unrecognized, either because the clinician fails to elicit a history of AAS use, or because the patient fails to disclose it. AAS users are particularly reluctant to disclose their AAS use to doctors. In a study from our group (Pope et al., 2004
), 20 (56%) of 36 AAS users reported that they had never disclosed their AAS use to any physician that they had seen.
Furthermore, clinicians are often much less familiar with AAS use than they are with other forms of substance abuse (Dawson, 2001
; Kanayama et al., 2007
; Kutscher et al., 2002
), and hence they may fail to seek a history of AAS exposure in an individual exhibiting medical or psychiatric problems. Such a history is easily missed when evaluating men who are older and not visibly athletic. In one recent study of 223 men admitted to a general substance abuse treatment unit (Kanayama et al., 2003a
), 29 (13%) reported a history of AAS use on a research screening interview, but in only four of these cases was this history noted in the physician’s admission evaluation.
Nondisclosure may also compromise studies comparing AAS users to non-AAS-using weightlifters, because “non-user” groups are often contaminated with occult AAS users (Brower et al., 1991
; Ferenchick, 1996
; Kanayama et al., 2003b
). Although urine testing can detect recent AAS use, individuals who have used AAS months or years earlier cannot be identified and excluded - and the inclusion of such individuals will lead to an underestimate of effect sizes.
Third, one must allow for the unknown number of AAS users who die prematurely - as suggested, for example, by the study of Parssinen and colleagues (Parssinen et al., 2000
), which found more than four times as many deaths among former likely AAS users as in an age-matched male population. Our own anecdotal experience also suggests increased premature mortality among AAS users; we are personally familiar with several deaths (primarily by suicide or by unintentional overdose of opiates) among AAS users under age 40, and colleagues have described many others (Arvary, D., personal communication, January, 2008). Premature death could cause studies to underestimate the effects of AAS in cross-sectional samples of aging men, because dead individuals would of course have exited the available study population.