Androgen misuse and abuse

The Nobel prize-winning identification of testosterone as the mammalian male sex hormone in 1935 was the culmination of an ancient pursuit to learn how the testis was responsible for masculine virility and superior muscular strength. Within two years, testosterone was being used clinically, and within a decade much of the clinical pharmacology and many applications were recognised (1, 2). Given its weighty historical legacy as the archetypal virilizing substance, testosterone was soon being evaluated to boost pharmacologically the muscular size and strength of healthy men beyond physiological development. In the years following the Second World War, the pharmaceutical industry undertook an extensive quest to identify an ‘anabolic steroid’, an androgen without virilizing properties. Although this proved futile, with the search abandoned, the now meaningless term ‘anabolic steroid’, perpetuating a distinction without a difference, has persisted long beyond its scientific obsolescence largely as a journalistic device for sensationalism and demonization (3). Systematic androgen abuse first appears an epidemic, with an epicentre among Eastern European elite athletes, in the mid 1950s (4). This timing coincided with the golden age of steroid pharmacology in the postwar pharmaceutical industry boom years, which produced the oral contraceptive and synthetic glucocorticoids, and with the early years of the Cold War. This fortuitous intersection of industrial means, unscrupulous operators, and political goals shaped the emergence of systematic androgen abuse as a convenient tool by which sociopolitically dysfunctional Eastern bloc countries could gain short-cut ascendancy through symbolic victories over Western political rivals, a challenge quickly reciprocated by athletes and trainers from the advanced noncommunist countries. This bidding war escalated into national sports doping programs operated covertly by Eastern European communist governments. These organized programs of unscrupulous cheating mixed competitive fraudulence with callous ruination of their athletes’ welfare for national political goals. Of these, only the East German program, with its dire consequences for athletes’ health, has so far been fully disclosed (5). Over the next 4 decades, androgen abuse became endemic in countries where the population is sufficiently affluent to support this consumer variant of drug abuse. Once entrenched in the community, androgen abuse spreads beyond elite sports, where it remains as a low level endemic, to nonsporting users with recreational, cosmetic, and occupational motivations for body-building, such as seeking to promote a fearsome muscular image (6).