Page 111 - Journal of Special Operations Medicine - Fall 2015

biological activity, many physicians soon administered recreational athletes and high school and college ath-
them as the “elixir of life.” This set the stage for Oscar letes represent a large portion of users, with the majority
1,2
Zoth to publish an article in 1896 suggesting testicular of these users resorting to polypharmacy. 10–12
injections improved strength; he was likely the first to
introduce injecting athletes with hormones to improve The prevalence of use among military members is un-
performance.3 Several decades later, Koch was the first known, but a recent study regarding substance use among
to isolate sex steroid, followed by Ruzicka’s discovery of military members found a surprisingly large number of
cholesterol manipulation for synthesis. androgen users (16 of 50) among a small study popula-
4
tion. In 1999, a survey of 2,212 men (aged 18 to 47
13
In the late 1930s, numerous testosterone derivatives be- years) undergoing Ranger and Special Forces training
gan to be produced and clinical trials were initiated. It revealed that 64% were using training supplements, and
was rumored that German soldiers were given testos- it is likely that some percentage of these supplements
terone to increase their aggressiveness in battle; how- are anabolic related. Further studies explored anabolic
ever, no data substantiate the use of steroids by either use specifically with sequential Department of Defense
German soldiers or athletes during this time frame. At surveys showing an increase in lifetime prevalence of use
5
the 1954 World Weightlifting Championships in Vi- from 1.6% to 5.6% from 2002 through 2011. A 2007
14
enna, Austria, a Russian weightlifting coach disclosed survey of US Army Rangers revealed 37% of respon-
to Dr John Ziegler (the US team physician) that Russian dents used dietary supplements, with androstenedione
athletes were using steroids, and after a short period of reported in 27% and anabolic steroids in 1.8%. Per-
15
time, likely in the York Barbell Club, US weightlifters sonal communication between the authors and several
also began experimenting with testosterone and its de- sources suggests the survey data underrepresent the true
rivatives. Bob Hoffman founded the York Barbell Club prevalence of use in the SOF community. A case series
in 1932 and over a long period of time he developed by Hughes highlights several cases of suspected anabolic
exercise equipment and introduced various nutritional use among approximately 500 Special Operations men
supplements (protein powders) to include an energy bar over a 2-year period. Five of the patients reported use
16
in 1966. It is important to note that from 1932 through of anabolics or anabolic precursors, and another four
6
the 1970s, the York Barbell team members dominated cases exhibited highly suspicious signs and symptoms
the Olympic scene with national championships and consistent with anabolic use. All of these cases resulted
Olympic Gold Medalists. It was Dr John Ziegler, likely in lost training time for evaluations, and some even re-
influenced by the Russians using testosterone, who in- quired redeployment from theater. 16
troduced Dianabol to the York Barbell Club, and the
subsequent success of the lifters gained rampant atten- One surrogate for current and prior use of anabolic ste-
tion. Dianabol (methandrostenolone) was developed by roids is dietary supplement patterns. Kao et al. noted
17
17
Germans for use in burn patients and certain geriatric that military members using body building/performance
cases and later introduced into the United States by Ciba enhancing supplements were about 5 times more likely
Specialty Chemicals. 3,6,7 to have used anabolic steroids in the past year than those
not using such supplements. Importantly, a system-
After Dianabol was introduced to the York Barbell team, atic review by Knapik revealed a trend of high DS use
androgen use increased and a schism between the medical among elite military forces (US Army Rangers, Special
community and athletes began to form. Medical opinions Forces, and Navy SEALs). These trends toward higher
18
were incongruent with athletes’ perception as to how an- use among SOF than the general military population are
drogens affected them based on some early flawed studies. concerning given the association between supplement
8
Many of the early research trials did not find performance and anabolic steroid use. 17
or body composition benefits, which may be attributed
to study design, such as low dosing or choice of outcome Given the paucity of data regarding the true nature of
measures. In contrast, the athletes using steroids were no- anabolic use among SOF, it is important to explore the
ticing gains, and the denial by the medical community that complex issues surrounding the use of these substances.
steroids work fueled distrust by athletes. Steroid use grew The discussion below highlights questions or comments
and spread from the strength community into other sports that represent themes encountered by the authors in
as athletes tried to gain a competitive edge. It was not until investigating the nebulous issue of androgen use in the
the 1970s that the International Olympic Committee pro- military community. Although not all the questions are
posed sanctions and began testing for testosterone, which amenable to answers based on scientific data, a reason-
was first listed as a banned substance in 1982. Since that able attempt will be made to tackle the topics objectively
9
time, regulatory efforts and testing have evolved, but an- by highlighting available evidence, current policy, and
drogen use in sport continues to be ubiquitous, and use has expert opinion and identifying gaps in knowledge ame-
bled outside of elite athlete circles. Noncompetitive adult nable to future research.

Androgens and Androgen Derivatives 99