By Commander Kim R. Humphrey, Professional Standards Bureau, Phoenix, Arizona, Police Department; Kathleen P. Decker, M.D., U.S. Air Force; Linn Goldberg, M.D., Oregon Health and Science University, Portland, Oregon; Harrison G. Pope Jr., M.D., Harvard Medical School; Joseph Gutman, M.D., Practicing Endocrinologist, Tempe, Arizona; and Gary Green, M.D., University of California at Los Angeles (UCLA)
Although physical fitness is an essential part of policing, as described in the previous article, some officers go too far to ensure their strength—endangering not only themselves but also the public they are sworn to defend.
n officer crashes a police car and seriously injures an innocent bystander. The investigation reveals that the officer was acting erratically, had bloodshot eyes, and slurred his speech. The officer’s supervisor is called, and the decision is made to test for alcohol consumption. The test results determine that the officer was in fact intoxicated. Disciplinary action is taken, resulting in the officer’s termination for drinking alcohol while driving on duty. Though exposed to liability, the department recognizes the dangers of alcohol abuse and appropriately responds when a dangerous situation presents itself.
Another officer, involved in several shootings and use-of-force incidents, garners significant attention within his agency and the media. Investigations reveal that the unrelated incidents were questionable but lawful and, according to the officer, justified based on perceived threats. The agency’s use-of-force review reluctantly finds the officer within policy but awaits the next incident. How many police leaders would recognize that this officer could have a problem similar to the one in the first example? If the officer’s appearance indicated he was exceptionally muscular, would they consider the possible abuse of anabolic steroids? What would prompt them to believe that excessive use of force could be associated with “’roid rage,” a hyperaggressive, violent state of mind supposedly brought on by steroid use? When and how would they confirm that their suspicions are true? What if a defense or civil attorney proposed that an officer was a steroid abuser based on the officer’s appearance and witnessed behaviors? Compared with alcohol and other illicit drugs, anabolic steroids (also known as anabolic-androgenic steroids, or AASs) are not easily detected. Supervisors typically are trained to look for inappropriate behaviors that might justify a “just cause” drug screen; however, with AASs the behaviors and other indicators might not be as easily recognized.
Recently, accounts of major league baseball’s steroid era have come to light, Olympic athletes have admitted use, and many other major sporting icons have been stripped of their titles after being caught using performance-enhancing drugs such as AASs and human growth hormone (HGH). Unfortunately, growing evidence suggests a similar abuse of AASs and other performance-enhancing drugs by law enforcement professionals. Across the United States, several investigations associated with Internet pharmacies and “antiaging” clinics in association with unscrupulous physicians have revealed officers caught up in this web of illicit drug use.
Although the traditional reason for the use of AASs is to improve athletic performance, AASs also appeal to officers wanting a tactical edge or an intimidating appearance. Unlike with other forms of drug abuse, steroid users do not take their drug recreationally; on the contrary, some state they need these drugs in order to do their job effectively or improve their “job performance.” From street officers who consider themselves vulnerable to bigger, more aggressive criminals to special-assignment officers who are regularly tested for their physical abilities, officers are turning to performance-enhancing drugs such as AASs and HGH as a shortcut to improved performance. This article will not delve into the abuse of HGH, which is not a controlled substance but is obtained by prescription only and has very limited use—none for normal adults.
In addition to the normal health concerns, there is one further issue when discussing abuse of steroids by those in the law enforcement profession. Officers carry weapons, are authorized to use lethal force, and are often involved in physically controlling or restraining people. If the stories of ’roid rage are true, how often are the officers who use anabolic steroids involved in unnecessary use-offorce incidents that could become a major liability for their agencies? Considering the legal issues, health effects, and commensurate costs associated with inappropriate use, agencies should proactively address this issue. Rather than look back on what could be an embarrassing “steroid era” of law enforcement—one in which the profession might be riddled with lawsuits, corruption, and claims of heavy-handedness—it is critical to address the current and future impact of this issue head-on.
Over the past few decades, several stories have surfaced regarding law enforcement personnel involved with anabolic steroids. The U.S. Drug Enforcement Administration (DEA) recently led Operation Raw Deal, considered the largest international steroid investigation to date. The operation discovered several links to current or former law enforcement officers. This was predicted almost 20 years ago by an article in the FBI Law Enforcement Bulletin that stated, “Anabolic steroid abuse by police officers is a serious problem that merits greater awareness by departments across the country.”1 In addition, a story on the television program 60 Minutes in 1989 titled “Beefing up the Force” featured three police officers who admitted steroid use and claimed that their resulting aggression got them in serious trouble.
In the past year, a book titled Falling Off the Thin Blue Line was written and published by former Texas police officer David Johnson, who describes his addiction to steroids and speaks about the prevalence of steroid abuse in the law enforcement community.2 Recently, investigations into illegal steroid purchases revealed the names of several officers on pharmacy distribution lists, garnering national media attention. Unfortunately, agencies looking for methods to confront steroid abuse find few examples of effective policies and practices. This article summarizes the Phoenix, Arizona, Police Department’s experience in this area over the past several years and suggests policy and testing considerations for anabolic steroids in the law enforcement community.
Problems with Testing
In 2005, the Phoenix Police Department (PPD) investigated several incidents either directly or indirectly involving officers accused of abusing anabolic steroids. As a result, the city formed a committee to determine policy changes and address the issue with public safety agencies (that is, police and fire departments) as well as all other city employees. Due to the demands of the law enforcement profession and the legal precedent supporting random drug testing, policies are naturally more stringent for police than for other city departments. The police department, with support from its labor organization, added anabolic steroids to the random testing process for all officers and the preemployment screen. Research is clear that significant health risks result from nontherapeutic uses of anabolic steroids. 3 For this reason, the PPD’s focus on prevention revolved around a prevention video with questions and answers from a local endocrinologist who specializes in steroid abuse treatment.
Regarding testing, the task seemed simple enough: contact a local laboratory and test officers for performance-enhancing substances. However, implementation proved less than simple. First, adding AASs to the PPD’s random test tripled its drug testing costs. Additionally, local laboratories were able to provide only an initial urine screen that tested for a handful of the growing number of AASs. Furthermore, compounding the difficulty of the task, testing for anabolic steroids goes beyond looking for the specific synthetic AAS; it also needs to detect compounds naturally created by the human body, such as testosterone. This entails an analysis of an individual’s ratio of testosterone to epitestosterone (abbreviated T/E); when this value is found to be out of normal range, it may indicate the use of illegal substances. Additionally, as noted previously, HGH does not fall under the Anabolic Steroid Control Act, and currently there is no reliable test to detect it in the human body.
Testing for performance-enhancing substances presents a myriad of challenges:
- How can an agency test for “all” illegal AASs, and what does it do if a T/E ratio is not normal?
- How can an agency prove that someone is illegally or inappropriately using anabolic steroids?
- What if an officer who tests positive provides a prescription, and the prescribing physician indicates that the officer has a condition that necessitates the use of these drugs? Additionally, what constitutes abuse of prescribed drugs?
- Do ’roid rage and other psychiatric disturbances claimed to result from steroid abuse actually exist, and do they present a liability to an abuser’s organization?
Jumping into a testing policy before answering these questions will lead agencies to the realization that testing for these substances is not as straightforward as, say, discovering heroin in a drug screen. Officers might present a prescription or might have ordered something over the Internet in what they believe is a legal transaction. The DEA works regularly to shut down numerous unscrupulous doctors who seek to make money by connecting with pharmacies and engaging in illegal distribution, using the few very specific legitimate uses for AASs as cover for their operation. In these cases, ignorance is a common excuse from officers, who typically state that a doctor prescribed the drug, so it must be “okay.”
The PPD sought out answers to these and other questions. Below is a description of the issue and some policy considerations.
What Are Steroids?
Steroids are a group of chemical substances that have certain structural similarities. AASs constitute a subgroup of this category that includes the physiological (normal) human male hormone testosterone as well as related compounds with similar functions. These compounds have legitimate medical uses but are frequently abused for illegitimate, recreational uses (bodybuilding, weightlifting, or “bulking up,” as well as athletic performance enhancement). AASs should not be confused with other types of “steroids,” such as corticosteroids. This latter group of drugs, including hydrocortisone and prednisone, is prescribed widely for legitimate medical purposes (for example, skin creams to treat rashes, in asthma inhalers, and so on). Corticosteroids do not cause increases in muscle mass, have almost no abuse potential, and are almost never sold on the illicit market. Therefore, for the purposes of this article, references to steroids mean specifically AASs, which are the type of steroids that are used illicitly.
AASs are controlled substances. They are prescribed by physicians for certain specific, legitimate medical reasons, such as treatment of a condition known as hypogonadism (abnormally low testosterone production in men), cancer (to suppress certain kinds of tumors), a rare genetic condition called angioneurotic edema, AIDS wasting syndrome, and some forms of anemia (low red blood cell counts). The U.S. Federal Drug Administration (FDA) lists specific allowable “indications,” or uses, for all regulated drugs. The legitimate uses of AASs are minimal as noted; for example, an officer who states that a physician provided them for “elbow pain” would be using them inappropriately.
Medical investigators also perform research studies on human volunteers to better understand the benefits and risks of AASs. To be considered legitimate, such a study must be approved by an institutional review board operated according to the standards of the U.S. National Institutes of Health (NIH), Office for Human Research Protections, and registered with the FDA and/or the NIH Clinical Trials Registry (clinicaltrials.gov).
Illicit “Benefits” of AASs
AASs can be taken orally, by injection, as a skin patch or cream, or sometimes by placing them between the cheek and gum. When combined with a high-protein diet and vigorous weightlifting, AASs “work.” That means that they stimulate the formation of muscle tissue and are known to cause enlargement of muscle fibers. It is widely understood that testosterone (the major natural male AAS hormone in normal, healthy men) stimulates an increase in fat-free muscle mass while at the same time decreasing fat. Doses of AASs that exceed the normal production rate of testosterone can amplify this effect, resulting in supernormal gains in lean muscle mass and strength.
Patterns of Illegitimate Use
Abusers of AASs often follow a particular pattern of use, as discovered in one study of AAS users:4
- Many users reported taking a weekly dose in excess of (the equivalent of) 1,000 mg of testosterone. For comparison, adult human testicles normally produce 5–10 mg of testosterone per day—generally less than 100 mg/week.
- Most AAS users reported self-administering by injecting the drug directly into their muscles.
- Some studies reveal that approximately 25 percent of those who inject AASs share needles or vials, increasing the risk of HIV infection, viral hepatitis, or other infections.
- Over 95 percent of AAS users reported self-administering multiple substances, with 25 percent taking growth hormone and/or insulin in addition to AASs.
- Users have been found to move on to illegal drugs other than athletic performance enhancers.
- Nearly 100 percent of AAS users reported noticeable side effects—but most users claim that these effects are mild and do not deter them from continuing to use AASs.
- Users often become fixated on their muscularity and are reluctant to stop using AASs for fear that they will get smaller again.
General Medical Effects of Use
Anabolic steroids can cause temporary or permanent medical problems. Some known medical problems associated with AAS use follow:
- Decreased sperm production
- Abscess at the site of injection
- Increased or even severe acne
- Increased blood pressure
- Increased “bad” (LDL) and lower “good” (HDL) cholesterol, with attendant increased risk of heart attack
- Thickening of the wall of the heart (especially in the left ventricle)
- Increased or decreased sex drive (libido)
- Increased appetite
- Liver disease, especially with AASs taken orally (infrequent)
- Death from several causes, including suicide, atherosclerosis (hardening of the arteries leading to heart attacks or strokes), and cardiac complications
- HIV and similar risk issues associated with the sharing of needles or the use of nonsterile needles
Researchers still do not know a great deal about the long-term dangers of AAS use in individuals, but the evidence of potential dangers has been steadily increasing with new scientific publications in recent years. For example, one study of older champion power lifters (most or all of whom had likely used AASs) found that their death rate was almost five times as great as that of a comparison group of men of the same age in the general population. The reasons for death in the older power lifters included both medical problems such as heart disease and psychiatric problems such as suicide.5
Users of AASs can experience psychiatric symptoms during use, abuse, or withdrawal. Symptoms differ depending on the drug’s absence or presence in the body. Symptoms tend to correlate with the size of the weekly dose and can worsen with long-term use. Importantly, the psychiatric symptoms are idiosyncratic; some men taking a given dose of AASs may show no psychiatric effects at all, whereas a few men taking an identical dose might show extreme effects.6 The reasons for this variability are not known, but it is clear that reactions to AASs cannot be predicted on the basis of an individual’s baseline personality. In other words, even if a man has a mildmannered, gentle personality when not taking AASs, there is still a risk that he might develop a sudden personality change and become uncharacteristically aggressive and violent while taking AASs.7
Symptoms Associated with Use or Abuse:
- Mania or hypomania (high energy levels associated with increased self-confidence, increased activity, impaired judgment, and reckless behavior)
- Psychosis—loss of touch with reality (for example, paranoia or delusions of grandeur; infrequent)
- Personality changes
Symptoms Associated with Withdrawal:
- Long-term AAS abusers can develop symptoms of dependence and withdrawal on discontinuation.
- Withdrawal sometimes leads to severe depression and thoughts of suicide, in addition to medical effects, especially in individuals who have taken AASs for months or years.
Laws and Regulations Associated with AASs
The use of AASs for performance enhancement is banned by all major sports bodies, including the International Olympic Committee, the National Basketball Association, the National Hockey League, the National Football League, Major League Baseball, the Union of European Football Associations, and Fédération Internationale de Football Association.
In the late 1980s, the U.S. Congress considered listing AASs in the Controlled Substances Act. Based on evidence of widespread abuse, AASs are now classified by the FDA and DEA as Schedule III controlled substances. The Crime Control Act of 1990, approved on November 29, 1990, includes provisions for control of these drugs and penalties for inappropriate trafficking in them. The Anabolic Steroid Control Act of 2004 further amended this law to increase the number of AASs that were included and make it easier to add additional drugs. A Schedule III substance is defined as follows:
- The drug or other substance has a potential for abuse that is less than the drugs or other substances in Schedules I and II.
- The drug or other substance has a currently accepted medical use in treatment in the United States.
- Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence.
Schedule III drugs are available only by prescription, although control of wholesale distribution is somewhat less stringent than that of Schedule II drugs. Prescriptions for Schedule III drugs may be refilled up to five times within a six-month period.
The Controlled Substances Act defines AASs as any drug or hormonal substance chemically and pharmacologically related to testosterone other than estrogens, progestins, and corticosteroids.8 This means that federal and most state laws dictate that the sale of steroids, possession of steroids, and possession of steroids with intent to sell are all classified as felonies. Any individual who is convicted of the sale of steroids or possesses steroids unlawfully with intent to sell may under federal law be penalized by up to five years in prison. That same individual may face more than five years of punishment depending on the applicable state law. Almost every state has sanctioned various laws placing AASs in the controlled-substance category, in addition to the federal law.
Due to users’ sharing and redistribution habits, one can easily be charged with possession with the intent to sell or deliver AASs based simply on the quantity involved. Physicians dispensing such substances without an appropriate medical diagnosis, a treatment plan, or indications are subject to criminal penalties as well as disciplinary action by the appropriate medical licensing board, including the possible loss of their license.
In addition to the illegal use of these substances, in the last decade a significant number of cases involved counterfeit AAS preparations. These preparations can be simply useless (such as vegetable oil), or they can be dangerous if they are used for injection and turn out to be not sterile.
Negligent Retention: Agencies have a duty and a right to maintain fit officers and to protect the public from impaired officers. They must exercise reasonable means at their disposal to ensure that officers are fit. Both national and local standards regarding the use of AASs support the idea that officers abusing such substances could be at risk for impairment and could even be involved in criminal activity related to the use of these substances.
Employees’ Rights: National Treasury Employees v. Von Raab is a landmark U.S. Supreme Court case in which employees carrying firearms were required to submit to drug testing.9 The Court approved the testing program due to the extraordinary hazards of drug use in these officers. No specific guidelines for testing were put forth, but purely random testing is constitutional according to various courts. However, in the mid-1980s the Boston Police Department adopted a random drug-testing program that was struck down in 1991 by the Massachusetts Supreme Judicial Court.10 Therefore, the acceptability of random drug testing is highly variable in different jurisdictions and likely depends on union and/or employment contracts.
Detection: To act against an officer, an agency must have reasonable suspicion that the officer is abusing substances or must have an agency-wide random drug-testing schedule. Agencies may not single out an officer for “random” drug testing in the absence of information to suggest use, dealing, and/or impairment.
Testing: Virtually all testing for AASs is on urine specimens. Courts have accepted gas chromatography/mass spectrometry (GC-MS) urine test results. Levels of most AASs in the blood are generally too low to be easily tested. Detection of AASs in hair samples appears possible but is still in an experimental stage of development.
Collection: Although most of the focus of drug testing is on sample analysis, proper collection and chain-of-custody procedures are also of paramount importance. It does not make sense to employ high-quality, expensive laboratories to analyze samples that have been improperly collected. In drug testing appeal cases, the first challenge is usually to the collection process. Collection procedures should be thorough enough to withstand legal scrutiny and accurate enough to ensure that drug-using officers are properly identified.
Determination of Legitimate Use: If an individual is found using an illicit substance and cannot provide evidence of a legitimate prescription for a medically necessary condition, a fitness-for-duty evaluation is likely needed to ascertain whether the officer is using or abusing the substance in such a way as to jeopardize public safety. The most likely legitimate uses in which a working officer might be prescribed AASs would be for treating hypogonadism. The standard treatment of hypogonadism is the use of a testosterone patch or gel, both of which are highly unlikely to be abused. Injectable and sometimes oral preparations are the common choices of AAS abusers.
Research suggests that individuals taking AASs in excess of 100–200 mg of testosterone per week are outside the bounds of therapeutic use. Upon reaching a dose of 300 mg of testosterone per week, they are somewhat more likely to exhibit aggressive behaviors, which start to take place more frequently.11 Determining the amount taken may be difficult; therefore, it might be necessary to establish a policy that disallows any level of use above therapeutic levels, since it would be difficult to predict aggressive, inappropriate behaviors.
The following key points should be included in policy statements for law enforcement personnel:
- Use of illegal substances or improperly prescribed controlled substances represents both legal and disciplinary issues for officers and can pose threats to the officer and public safety.
- If the agency has reasonable cause to suspect illegitimate drug use, it may require substance use testing, including but not limited to random urinalysis (for alcohol and drugs), blood work for a toxicology panel, and/or hair analysis.
- Where feasible, supervisors should consult with internal affairs/professional standards and/or the appropriate personnel department before acting on a suspicion of abuse of anabolic steroids.
- Employees found to be using illegal substances will be immediately placed on administrative leave (if not already on such leave) pending further investigation and/or an independent medical review or fitness-for-duty evaluation, and they will hand in their weapons.
- Employees found to have controlled substances that are not illegal but can impair performance, such as (but not limited to) opiate analgesics, controlled substances used as sleep aids or muscle relaxants, or anabolic steroids, may be required to submit to an independent medical review or fitness-for-duty evaluation by the appropriate medical specialist (whether an internist, cardiologist, endocrinologist, or psychiatrist, or a combination thereof) to ascertain whether these officers are using such substances appropriately and/or whether their use of such substances is impairing performance.
- If an employee is found to be possibly illegally using controlled substances and/or medications prescribed by a health-care provider, the agency shall report the case (representing potential illegal activity) to an outside agency for investigation of the officer (by a federal or separate state agency) for misconduct, wherever possible. The agency must also follow the required federal and state reporting procedures for legal proceedings against the health-care professional and the officer, if appropriate.
Reasonable Cause: Several symptoms can indicate that someone is abusing AASs. Symptoms may include the following:
- Visible increase in body mass over a short period of time (usually months)
- Fluid retention (bloating)
- Noticeable acne and/or oily skin
- Mood swings, particularly if aggressive
- Unreasonable emotional responses to situations
- Voice changes (such as deepening voices in women)
- Facial hair growth in women
- Multiple incidents of “use of force” or complaints of improper outbursts and attitude
Testing Process: Anabolic steroid testing is expensive compared to other illicit drug testing. There are literally hundreds of variations of AASs. Local laboratories used for an initial urine screen can test for a small number of typical steroids and can also screen the T/E ratio.12 An elevated T/E ratio signifies possible abuse, as it is affected by the intake of AASs.
Proper collection and chain-of-custody procedures are critical. Agencies hiring a specimen collection service, using their healthcare providers, or collecting samples using their department personnel should ensure that sample collection procedures are standardized. Immediate testing after notification and observed collection provide the strongest assurance against tampering. Examples of collection procedures can be obtained from the National Center for Drug Free Sport as well as other agencies.
If working with a local laboratory, an agency should consider a dual notification procedure in its laboratory contract. With dual notification, the laboratory will notify the agency as well as a medical review officer (MRO) of the results. If an individual who tests positive has a seemingly valid prescription, the MRO may consider the test negative; however, the agency might want to follow through with an independent medical review or fitness testing as noted earlier and would need to know that the initial test was positive.
Additionally, using an MRO who has expertise in performance-enhancing drug testing should be considered. If follow-up on a positive initial screen test is needed, the sample can be sent to a laboratory certified by the World Anti-Doping Agency for further analysis. Currently, the University of Utah and the University of California at Los Angeles are the only certified laboratories in the United States. Their analysis consists of a full panel for AASs and, if possible, can determine specifically what types and levels are present. In addition, certified laboratories have further testing capabilities that can determine if substances in the sample are naturally occurring or synthetic drug substitutes. The expense is significant, and these tests should be used for increased scrutiny, particularly when results are disputed or can be disputed by an individual.
The PPD is currently working with the Arizona Peace Officer Standards and Training organization to consider a state rule disallowing the use of AASs by police officers unless a medical exception is granted.
Preventing anabolic steroid abuse requires a multifaceted approach. After understanding the challenges associated with testing and deciding on appropriate discipline, it is critical for agencies to educate their officers and provide alternatives for health and fitness. The challenges are many, but failure to act now could cause significant suffering for law enforcement agencies in the future and mandates for action. For the safety of the community and the health of an agency’s employees, it is essential to act to prevent the abuse of these drugs.
The authors thank Kris Arnold, M.D., of the Occupational Health Division of the Boston Police Department and member of the IACP Police Physicians Section for his assistance in moving this issue forward; S. Mitchell Harman, M.D., Ph.D., director and president of the Kronos Longevity Research Institute, for information on identifying legitimate research and treatments with anabolic steroids; Chris Nordby, director of the National Center for Drug Free Sport, for his expertise and direction in the testing field; and Robert Jones, M.D., regional medical director, Phoenix Concentra, for his work on policy development. ?
1Charles Swanson, Larry Gaines, and Barbara Gore, “Abuse of Anabolic Steroids,” FBI Law Enforcement Bulletin 60, no. 8 (August 1991): 19.
2David Johnson, Falling Off the Thin Blue Line: A Badge, a Syringe, and a Struggle with Steroid Addiction (iUniverse, 2007).
3See Kirk J. Brower, “Anabolic Steroid Abuse and Dependence,” Current Psychiatry Reports 4, no. 5 (October 2002): 377–87; and Harrison G. Pope Jr. and Kirk J. Brower, “Anabolic-Androgenic Steroid Abuse,” in Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed., eds. Benjamin J. Sadock and Virginia A. Sadock (Philadelphia: Lippincott, Williams, and Wilkins, 2004), 1318–28.
4Andrew B. Parkinson and Nick A. Evans, “Anabolic Androgenic Steroids: A Survey of 500 Users,” Medicine and Science in Sports Exercise 38, no. 4 (2006): 644–51.
5M. Parssinen et al., “Increased Premature Mortality of Competitive Powerlifters Suspected to Have Used Anabolic Agents,” International Journal of Sports Medicine 21, no. 3 (April 2000): 225–27.
6See Ryan C. W. Hall et al., “Psychiatric Complications of Anabolic Steroid Abuse,” Psychosomatics 46, no. 4 (July–August 2005): 285–90; and Harrison G. Pope Jr. and David L. Katz, “Psychiatric Effects of Exogenous Anabolic-Androgenic Steroids,” in Psychoneuroendocrinology: The Scientific Basis of Clinical Practice, eds. Owen M. Wolkowitz and Anthony J. Rothschild (Washington, DC: American Psychiatric Publishing, 2003), 331–58.
7Women can suffer from the same effects. However, because AASs are known to have noticable masculinizing effects in women (such as increased body hair and a deepening of the voice), they are considerably less likely to take excessive doses and therefore also less likely to demonstrate overly aggressive behaviors.
8More information on drug schedules and related issues is available at http://www.usdoj.gov/dea/pubs/csa/812.htm (accessed May 8, 2008).
9National Treasury Employees Union v. Von Raab, 489 U.S. 656 (1989).
10Guiney v. Police Comm’r of Boston, 411 Mass. 328 (1991).
11Hall et al., “Psychiatric Complications of Steroid Abuse,” 285–86.
12Christophe Saudan et al., “Testosterone and Doping Control,” British Journal of Sports Medicine 40, Supplement 1 (2006): i21–i24.