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Roid Rage," The Pistorius Murder Case & the Roots of Ignorance

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'Roid Rage," The Pistorius Murder Case & the Roots of Ignorance
by Dan Gwartney, M.D.

Was "'Roid Rage" Involved? Why is testosterone now being blamed in the Pistorius murder case?

The advent of DNA testing has revolutionized forensic science. In addition to its ability to identify perpetrators from trace evidence left at crime scenes, DNA analysis has also determined the innocence of wrongly convicted individuals. After a false conviction and some period of unimaginably horrific confinement in prison, many exonerated individuals have difficulty returning to their former homes due to the taint upon their reputation.

Science offers a sense of confidence through concrete evidence proving facts or dispelling fallacies; it is not influenced by theological beliefs, political aspirations, greed, or favoritism. Unfortunately, the same cannot be said of many judges, prosecutors, and jurors (and defense attorneys to be complete). Even the public perception of independence in truth-seeking by established media has been diminished, as reactions to the events surrounding the WikiLeaks organization and founder Julian Assange demonstrate.

Though trivial in comparison to wrongful convictions, a similar legacy has colored the history of testosterone and other anabolic-androgenic steroids (AAS).

The Roots of Ignorance: Prohibition and Reefer Madness

Over 150 years ago, morality-based groups rampaged against the use of strong drink, pointing to scallywags (stereotypically Irish immigrants) who invariably embarked on alcohol-fueled rampage or sought the charms of harlots after imbibing whiskey lustfully. Later, zealots such as Carry Nation swept across the United States smashing barrels and bars. This resulted in the passage of the 18th Amendment (prohibition)— later repealed by the 21st Amendment as influential men argued that restricting alcohol consumption strangled the economy. The claim that alcohol abuse is harmful to individuals and society is absolutely accurate. For adults not affected by alcohol dependence, a drink or two per day is actually healthier than abstinence.1

The witch-hunt for AAS users in sports has recreated the “social experiment” of prohibition by creating a black market, inspiring the creation of designer drugs, and immediately casting doubt on any athlete who outperforms his/her peers.

Nearly a century ago, marijuana was not considered to be a matter of social consequence. Again, morality-based groups took offense at the use of the drug, primarily by migrant Mexican workers at the time, typified by the movie “Reefer Madness.” This resulted in marijuana being classified as a narcotic and criminalized. Some states have passed laws allowing the prescribed medical use of marijuana. Last year, attempts to legalize public use of marijuana regained national attention, particularly in California where the proposition failed. The strongest argument for the passage may have been the same as that resulting in the 21st Amendment— economic gain. Financial network CNBC aired a feature titled, “Marijuana Inc.: Inside America’s Pot Industry” that presented an economic argument for decriminalizing marijuana for the purpose of increasing the revenue tax base in this cash-strapped nation, especially the state of California.2

There is very little support for any health claims associated with marijuana. However, the palliative relief many cancer patients or chronic pain sufferers experience is considerable.3 One has to acknowledge subjective benefits claimed by recreational users. Is it an American right to be able to access a drug like marijuana; is society better served by regulating and taxing a drug used by 25 million people instead of devoting resources necessary to enforce standing laws? Are these laws protecting our vulnerable youth? Apparently not— the most recent National Institute of Drug Abuse survey, “Monitoring the Future,” shows more teens smoke pot than tobacco.4

AAS as performance-enhancing drugs were introduced to the U.S. during the 1950s, according to accepted lore. Originating in powerlifting circles, use gradually spread to other sports, particularly bodybuilding. Little attention was paid to AAS until the short-lived 1988 gold medal 100-meter effort by Jamaican-born sprinter Ben Johnson. Racing as a member of the Canadian team, he easily outpaced the rest of the field, including media darling, American Carl Lewis. When the results of Johnson’s urine drug screen revealed stanozolol (Winstrol) use, Johnson was demonized as the embodiment of cheating in sports, and AAS were branded as inherently evil and harmful to individuals and society.5

A recent study of prisoners showed that aggressive and moderately-aggressive inmates have testosterone concentrations on the low end of the normal range.

Rather than focusing on an ethnic group in this now-diverse nation, anti-AAS crusaders could point out individuals who were clearly different from “normal” Americans due to their size and muscularity. Associating AAS use with clearly unethical sports-doping made “juicing” less of a social trait, and more of a character flaw. People with impressive physiques or physical performance were no longer admirable— they were suspect. In fact, the witch-hunt for AAS users in sports has recreated the “social experiment” of prohibition by creating a black market, inspiring the creation of designer drugs, and immediately casting doubt on any athlete who outperforms his/her peers.

To further dispel any appeal of AAS, a multitude of adverse effects have been associated with AAS abuse. As with alcohol, there is no question that abusive AAS practices can cause harm, and possibly death in susceptible individuals or over the long-term. However, it is just as clear that low-normal or deficient testosterone is associated with certain conditions, disease, and earlier death.6 Of the adverse effects attributed to testosterone, many are being challenged. Abraham Morgentaler, M.D., is a urologist who has published very convincing evidence countering the long-held assumption that testosterone causes prostate cancer as incorrect.7 Once thought to be an overt cardiovascular risk, testosterone replacement actually improves the lipid profile of otherwise healthy, testosterone deficient men.8

The most worrisome immediate effects of AAS are psychogenic. When testosterone concentration is very high, studies show increased aggression.9 Very low concentrations, occurring during the post-cycle period while natural production remains suppressed, are associated with depression and even suicidality.10 However, it remains to be shown that AAS use in humans can directly and reliably cause either of these states. This is complicated by the many different AAS available, variability in dosing, and individual response.

The limited research does show that supraphysiologic testosterone can increase the aggressiveness of a provoked response in some men.9 In those predisposed to violence, especially domestic violence, this may be a very real issue. Adolescents, those who have underdeveloped socialization, and those raised in cultures that glamorize violence may then have a lower threshold to respond to any (putative) aggression/violence promoting effect.10 Interestingly, a recent study of prisoners showed that aggressive and moderately-aggressive inmates have testosterone concentrations on the low end of the normal range.11 Those who have underlying or diagnosed personality disorders, psychopathology, or sociopathology might be very vulnerable to any such effects, or view aggression as socially positive.10

Is this analogous to the “mean drunk?” There is much that remains to be studied before coming to any conclusion, but one can make a reasonable “reach” and presume that negative mood effects of AAS in those affected would be more specific than alcohol, less episodic as androgen concentrations remain elevated for weeks to months, and may be influenced by social interactions as people react to an AAS user’s change in appearance/social status.

The media has tagged the term “roid rage” despite the absence of any such emotional state or set of behaviors being acknowledged by mental health professionals.

The media has tagged the term “roid rage” despite the absence of any such emotional state or set of behaviors being acknowledged by mental health professionals. The term elicits a clear image of a wild-eyed behemoth, bulging with vein-laced muscle, rampaging through a zone of destruction. There might as well be a soundtrack repeating, “Hulk smash!” as the raging juicer mantra. Certainly, there have been many cases of violence involving AAS users— some of these occur on the sports field; others in social arenas such as the workplace or taverns; and tragically, also in the home.9 However, the prevalence of violence in American society is very common; this dilutes the relevance of AAS-associated violence. Also, the use of other drugs is essentially the American way of life, whether prescribed or illicit. Nonetheless, it is important to acknowledge that violence or unrestrained outbursts can and do occur in AAS-users. Like most adverse effects, it is likely that the emergence of such an event relates to the specific AAS used, the total androgen load, individual susceptibility, environment, physical conditions, sleep deprivation, other drugs in the system, etc.

Media Thrives on Dramatic Headlines

The media thrives on grabbing the public’s attention through dramatic headlines, and few drugs have the buzz-value held by AAS. When AAS are linked to public figures and violence— especially homicide or suicide— the media willingly tosses aside professional standards to engage in frenzied speculation. The hallmark of this is the extremely tragic murder of the wife and son of professional wrestler Chris Benoit, followed by his suicide.12 Clearly, Benoit was not rational at the time of these events, a state that likely progressed over the course of years or months— as demonstrated by comments left by Benoit in his diary, as related by his father on “Larry King Live.”13 In that episode, airing just weeks after the Benoit family loss, neurosurgeon Dr. Robert Cantu commented on the post-mortem brain exam of Chris Benoit, noting damage consistent with multiple concussions and sub-concussive trauma, as evidenced by abnormal proteins in the brain cells. Dr. Cantu compared this with four other brains examined, all from former NFL football players, who had the same lesions.

When asked by Larry King if this damage could have affected Chris Benoit’s behavior or personality, Dr. Cantu responded that it was the likely cause. Of the other four brains from the deceased NFL players, three were obtained after the individuals committed suicide. Larry King then asked about the role of steroids and Dr. Cantu explained how Chris Benoit’s actions, occurring over three days, was not consistent with an impulsive act; he then explained how “roid rage” is a controversial term, not identified as a medical diagnostic term. Even today, over three years later, the definitive manual of psychiatric conditions, the DSM-IV, does not include AAS dependence or “roid rage.”

A quote from that interview by Dr. Cantu was quite telling, “There -- most importantly, Larry, there is no evidence in the medical literature or science to suggest that the steroids lead to the traumatic encephalopathy brain damage changes that were present in Chris’s brain.”13

The condition that Dr. Cantu was referring to in the cases of Chris Benoit and the four NFL players is called “chronic traumatic encephalopathy” or CTE.14 Dr. Sanjay Gupta, also a neurosurgeon, responded to the question posed by Larry King if the trauma and neuro damage could lead to the acts of Chris Benoit, “I don't know, Larry. It's that -- establishing that cause and effect relationship -- I guess I'm not prepared to say that for sure.” Dr. Gupta later added, “And, most likely, this is not due to steroids…”13

To his credit, Dr. Gupta has been following the effects of repeated concussions to athletes; an issue he continues to monitor and report upon. Recently, he aired a segment titled “Concussion Crisis in Football,” with cases of players ranging from former NFL quarterback Kurt Warner to 17- and 13-year old student-athletes who suffered multiple hits to the head resulting in neurological damage.15 In concluding his interview with 12-year NFL veteran Fred McNeill of the Minnesota Vikings (retired)— who suffers memory loss, rage, depression, even suicidal thoughts— Gupta states, “It's called chronic traumatic encephalopathy. And here's the kicker: those changes are directly associated with rage, memory problems and depression.”

Of course, head trauma happens in many sports besides American football; soccer, boxing, mixed martial arts, and so many others involve intentional or incidental contact.14 And then there is everyday life— many young men and boys get into fights; some are forced to endure beatings as part of initiation into a gang. Our bravest enter the military, and our finest serve in branches of law enforcement. Even the most insulated in our society risks a fall on ice or down a set of stairs; the most vulnerable may be subject to abuse.

Where Did the Concept of “Roid Rage” Come From?

The symptoms attributed to “roid rage” are strikingly similar to the features seen in these men (though women are not immune to the same processes) who have suffered repetitive head trauma. CTE may in fact be the ignored factor, long hidden behind the curtain of “roid rage.” Where did the concept of “roid rage” come from, then? Is it like oompa-loompa land from “Charlie and the Chocolate Factory,” wherein Willy Wonka replies to the challenge by Mike Teevee’s mother that there is no such place, after she asserts her credentials as a history teacher, with “Oh well, then you know all about it…” The existence of “roid rage” goes far in legitimizing the agenda against testosterone and AAS.

Sadly, many forget that do not harm means more than avoiding risk. It also means not misleading or misspending resources to prove one’s campaigning issue at the neglect of other possible causes. This tactic has allowed the devastating effects of impacts to the head to be ignored, and continue, to the detriment of millions of potential victims over the course of the decades.

AAS will not be “rescued” with an economic argument, as alcohol and marijuana. In fact, economic factors weigh against exonerating testosterone and AAS as their void in the pharmacopeia drives demand for new SARM drugs by affluent pharmaceutical companies; drug testing has become a multi-multi-million dollar industry, sapping insolvent municipalities and school districts (though lawmakers, doctors, and lawyers are oddly exempt); and the “shock value” of AAS in news stories would be lost. Further, acknowledging sports-related CTE may place some burden of liability on schools and professional teams, resulting in six- to seven-figure settlements per case.16

There is no lab test or imaging technique that can prove AAS “innocence.” However, as evidence continues to point to other, more viable, “suspects,” it is past time to re-evaluate the potential for testosterone and AAS to be considered for appropriate clinical indications.


References:

1. Saremi A, Arora R. The cardiovascular implications of alcohol and red wine. Am J Ther, 2008;15(3):265-77.

2. CNBC – hosted by Trish Regan. Marijuana Inc. Inside America’s Pot Industry. http://www.cnbc.com/id/15840232/?video=1185791780&play=1, accessed December 14, 2010.

3. McCarberg BH. Cannabinoids:their role in pain and palliation. J Pain Palliat Care Pharmacother, 2007;21(3):19-28.

4. Walker EP. Teen marijuana use grows. MedPage Today 14 December 2010. http://www.medpagetoday.com/PublicH...DailyHeadlines&utm_source=mSpoke&userid=87398, accessed December 14, 2010.

5. Johnson WO, Moore K. The Loser. Sports Illustrated 1988 October 3. http://sportsillustrated.cnn.com/vault/article/magazine/MAG1067804/1/index.htm, accessed December 14, 2010.

6. Cunningham GR, Toma SM. Why Is Androgen Replacement in Males Controversial? J Clin Endocrinol Metab, 2010 Sep 29. [E-pub, ahead of print]

7. Morgentaler A, Schulman C. Testosterone and prostate safety. Front Horm Res, 2009;37:197-203.

8. Traish AM, Saad F, et al. The dark side of testosterone deficiency: III. Cardiovascular disease. J Androl, 2009;30(5):477-94.

9. Midgley SJ, Heather N, et al. Levels of aggression among a group of anabolic-androgenic steroid users. Med Sci Law, 2001;41(4):309-14.

10. Talih F, Fattal O, et al. Anabolic steroid abuse: psychiatric and physical costs. Cleve Clin J Med, 2007;74(5):341-52.

11. Chichinadze KN, Domianidze TR, et al. Possible relation of plasma testosterone level to aggressive behavior of male prisoners. Bull Exp Biol Med, 2010;149(1):7-9.

12. Donaldson-Evans C. Wrestler Chris Benoit Double Murder-Suicide: Was It 'Roid Rage'? FoxNews.com 2007 Jun 27. http://www.foxnews.com/story/0,2933,286834,00.html, accessed December 15, 2010.

13. CNN Larry King Live 2007 September 6. Why Did Wrestler Kill Wife, Son, Self? http://transcripts.cnn.com/TRANSCRIPTS/0709/06/lkl.01.html, accessed December 15, 2010.

14. Gavett BE, Stern RA, et al. Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clin Sports Med, 2011;30(1):179-88.

15. CNN SANJAY GUPTA MD 27 November 2010. Concussion Crisis in Football. http://edition.cnn.com/TRANSCRIPTS/1011/27/hcsg.01.html, accessed December 15, 2010.

16. Smart’s California Insurance Report 1 May 2010. Pro football head trauma claims may be heading for California. http://www.pcllp.net/NFL_CT_Claim.pdf, accessed December 15, 2010.

photo: miqu77/shutterstock.com http://www.shutterstock.com/gallery-667537p1.html?cr=00&pl=edit-00">miqu77
 
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