Daily-Dose

Contents

From New Yorker

From Vox

Covid-19 has very much disrupted schools in the past year and a half. And while the coronavirus’s risk to kids is relatively low, it’s still killed nearly 600 children in the US, according to federal data. Kids can also spread the virus to people who are more vulnerable, including parents, grandparents, teachers, and other school staff.

The research on past school and other mandates, meanwhile, suggests that mandates successfully increase vaccination rates among children. More than 80 percent of kids are inoculated for other diseases, including polio, measles, and chickenpox, by age 2 — so serious outbreaks are very rare and almost never disrupt schools.

All of that, plus the high effectiveness of the Covid-19 vaccines, adds up to a compelling case that schools should require Covid-19 vaccines for students.

Yet there are reasons that schools might want to wait. The Pfizer/BioNTech Covid-19 vaccine is authorized for kids only for emergency use. It’s not fully approved, which creates some legal uncertainty around school mandates. There are also legitimate questions about the possible side effects for kids, including myocarditis (inflammation of the heart muscle). And while the research generally supports mandates, it also suggests that mandates are less effective if there’s not sufficient public buy-in.

To date, only California has said it will require Covid-19 vaccines for schoolchildren once the vaccines get full approval from the Food and Drug Administration.

“I don’t expect schools to move totally in this direction until [full approval],” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told me. “Some may, but they’ll get pushback.”

The process could ultimately work like an expedited version of what we saw earlier this year: When the shots were approved for adults, officials, by and large, relied on enthusiasm for the inoculations and persuasion to get people vaccinated. Then they tried to incentivize shots through financial payouts and other benefits, albeit with disappointing results. Only once those measures proved to be not enough (about 70 percent of people 18 and older in the US are fully vaccinated) did employers, businesses, and different levels of government start mandating the vaccines.

Schools should be ready for this same chain of events. They should want to get kids vaccinated — it’s the best way to guarantee Covid-19 will stop disrupting the classroom. Chances are, though, that persuasion and incentives won’t be enough. And if that’s the case, mandates are a proven way to get vaccination rates up.

School mandates work

The empirical research on school vaccine mandates isn’t very expansive. But there are some studies, and they’re consistently positive for vaccination requirements.

A review of the research published in CMAJ Open in 2019 found that school mandates are “largely associated with increased vaccination coverage.” The review called for more studies, particularly with methodology that can better discern causation from correlation. But the studies reviewed, in elementary and middle school settings, showed that mandates seem to boost vaccination rates.

The chickenpox vaccine offers a recent example. The vaccine was approved in 1995, but initial uptake among children wasn’t great — in part because, like the coronavirus in kids, chickenpox carries a relatively low risk of death or serious complications for younger children. So in the late 1990s and 2000s, as vaccination rates stagnated, states began mandating the shot.

It worked. A 2005 study in Vaccine found that states with chickenpox vaccination requirements for day cares and school entry had greater coverage: 85 percent in the states with mandates compared to 77 percent for those without. The researchers also found that states with mandates didn’t appear to have higher vaccination rates prior to the requirements, suggesting the mandate is what made the difference.

A 2011 study in the Journal of Health Economics looked at the impact of school and day care mandates, broken down year by year. They found that the mandates increased vaccination rates, with the strongest effect in the second year after the mandate began.

A chart looking at the effect of school and daycare mandates on chickenpox vaccination rates.

German Lopez/Vox

Studies have also found evidence for mandates in other settings. A 2015 review of the research in Human Vaccines and Immunotherapeutics found that mandates in health care settings were the most effective intervention for boosting vaccination rates compared to softer requirements, increased awareness, and better access.

In recent weeks, there’s also been real-world evidence that Covid-19 vaccine mandates in particular are effective. As more workplaces and government agencies have mandated the shots, the requirements have consistently pushed up vaccination rates — to 90 percent or more in specific settings — while leading to very few, if any, resignations.

One telling example: Novant Health in North Carolina initially suspended 1 percent of its workforce — nearly 400 people — for not getting the vaccine, only for more than half of those workers to get the shot and go back to work within a week. What was once vaccine hesitancy and apathy quickly melted away as people got immunized.

Schools might want to wait

Despite the evidence, some experts remain skeptical that schools nationwide will embrace mandates — and note that there are some legitimate reasons to wait.

First, there’s the legal concerns. Since the vaccines are only authorized for emergency use for kids and lack full approval, there’s a worry that mandates now would fall to legal challenges.

Second, there are genuine concerns about the side effects of the vaccines. While all the experts I spoke to said they would get their kids vaccinated, they acknowledged legitimate concerns about the Pfizer vaccine causing myocarditis, particularly in boys. Coupled with the data showing that kids are at relatively low risk of Covid-19 to begin with, it’s not unreasonable for parents to wonder if the benefits of vaccines outweigh the risks.

An analysis by the Food and Drug Administration estimated that once Covid-19 is under greater control — which is not the case today but will be in the future — the vaccine could lead to higher hospitalization rates for children than the SARS- CoV-2 virus itself. The FDA suggested that the vaccine would still be worth it even in that scenario; the vaccine-linked myocarditis cases are almost all minor and resolve with very few, if any, lasting problems, while Covid-19 is far more likely to cause serious myocarditis and other significant health issues, including death, in the first place.

Still, the data presents a genuine challenge for school mandates. “You’re going to get pushback from parents that you’re actually putting their child at more risk by requiring them to be vaccinated,” Céline Gounder, an epidemiologist at New York University, told me.

The experts I spoke to said their own concerns were addressed by Pfizer moving to use a smaller vaccine dose for kids — those ages 5 to 11 get one-third of the dose given to people 12 and up. But myocarditis cases and other side effects continue to be something to watch for as vaccines are administered and more real-world data comes in.

Finally, there’s public buy-in. A recent survey from the Kaiser Family Foundation found just 27 percent of parents of kids 5 to 11 are eager to get their kids vaccinated, with 33 percent planning to wait and how the vaccines work and 30 percent saying they “definitely won’t” get their kids vaccinated. That’s more than six in 10 parents unwilling to get their kids vaccinated right away.

The level of skepticism can make mandates less effective. CMAJ Open’s 2019 research review found that mandates for HPV vaccines — which, like the Covid-19 vaccines, have been caught up in political controversy and safety concerns — “were notably ineffective.”

One way to build public support may be to tie vaccination rates or access to the vaccines — after a certain period of time — to the end of Covid-related restrictions, such as closures and masking. Some research suggests people are more likely to get vaccinated if it allows them to ease up on restrictions.

Monica Gandhi, a doctor and an infectious disease expert at UC San Francisco, told me that she rescinded her support for California’s school vaccine mandate after finding out it wasn’t linked to the end of school masking requirements. But she’d support a vaccine mandate if it came with an off-ramp for other restrictions.

“It’s not that I think children shouldn’t be vaccinated, because I do,” Gandhi said. But “there needs to be an off-ramp for children masking in schools.”

The vaccines are still the way out of the pandemic, and the ability to vaccinate kids is a crucial step to getting the world back to something closer to the pre-Covid normal. But the authorization of vaccines for kids is only the first part of that final step — and mandates will very likely be needed to finish the job.

In defending the discriminatory treatment of Vaello-Madero and of similarly vulnerable Puerto Ricans, the Justice Department points to a legal rule known as the “rational basis” test — and here’s the part where Vaello-Madero becomes a difficult case. This rational basis test defines much of the relationship between an elected Congress and an unelected judiciary. It is the reason why much of the New Deal and the Great Society survived contact with the Supreme Court.

Indeed, the rational basis test is probably the single most important check on judicial power. It is not something to be cast aside lightly, especially in an era when the Supreme Court’s conservative supermajority would love to get its hands on more power.

Vaello-Madero’s lawyers argue that this is one of the rare cases where the rational basis standard, which I will explain in more detail below, should not apply. They tell a story in their brief about how Puerto Ricans were systematically denied the full rights of citizenship, and how this denial justifies giving them heightened constitutional protection.

So Vaello-Madero is a case about a very poor man who seeks only a pittance from the most powerful nation on Earth. But it asks some of the most fundamental questions that a person can ask about their nation. Does the federal government owe certain obligations to all Americans, or can it vary those based on where someone lives? And is Vaello-Madero’s suffering the price of democracy?

Rational basis, briefly explained

Vaello-Madero is not the first time the Supreme Court considered whether it is unconstitutional to deny SSI benefits to people living in Puerto Rico. In Califano v. Torres (1978), the Court rejected a similar lawsuit challenging the program’s discrimination against Puerto Rican residents.

“We deal here with a constitutional attack upon a law providing for governmental payments of monetary benefits,” the Court explained in its unsigned opinion in Torres. Such a law, the opinion continued, “is entitled to a strong presumption of constitutionality.” As long as Congress’s “judgments are rational, and not invidious, the legislature’s efforts to tackle the problems of the poor and the needy are not subject to a constitutional straitjacket.”

This judgment may seem cruel, but it is the product of one of President Franklin Roosevelt’s most hard-fought victories against a reactionary Supreme Court that actively pushed the poor and the vulnerable into desperation.

For the first third of the 20th century, and much of Roosevelt’s early years as president, the Supreme Court routinely sabotaged progressive legislation — often relying on highly dubious legal reasoning in the process. The Court struck down federal child labor laws. It invalidated minimum wage laws, stripped workers of their right to unionize, and struck down laws prohibiting employers from overworking their employees.

Meanwhile, a series of cases involving Roosevelt’s efforts to take the United States off the gold standard threatened to cause such widespread economic disruption — if the government had lost these cases, private debt would have increased by as much as 69 percent, and most of the railroads that the country relied on to ship goods could have gone bankrupt — that Roosevelt prepared a speech announcing that the government would not obey the decision.

In the end, the Court blinked. Roosevelt’s undelivered speech was filed away in an archive, and the Court reversed course on many of its anti-worker decisions. It even upheld a New Deal law protecting workers’ right to organize.

The culmination of the Court’s turn toward restraint was United States v. Carolene Products (1938), which held that, with a handful of important exceptions, economic legislation “is not to be pronounced unconstitutional unless in the light of the facts made known or generally assumed it is of such a character as to preclude the assumption that it rests upon some rational basis within the knowledge and experience of the legislators.”

This is the “rational basis” test that forms the core of the DOJ’s argument in Vaello-Madero. It establishes that nearly all policy questions are none of the judiciary’s business and that the courts should be especially reluctant to strike down legislation touching on fiscal and economic policy.

This doctrine emerged not as an excuse to uphold cruel policies but as a safeguard against cruelty and overreach by judges. Especially as the Court became dominated by Roosevelt’s own appointees, its members wanted to prevent a repeat of the early 20th-century decisions harming workers and undercutting Roosevelt’s efforts to lift the nation out of the Great Depression. And so the Court decided to check itself.

In the decades that followed the Court’s decision to take its foot off the neck of democracy, the United States became the richest and most powerful nation in the world. But democracy also comes at a price, for a democratically elected legislature can enact laws that favor some groups and disfavor others. They can, for example, vote to deny an economic safety net to people in Puerto Rico.

The case for judicial intervention

Although Carolene Products held that Courts should begin every constitutional case with a presumption in favor of democracy, deferring to elected legislatures in nearly all cases, it did lay out a few exceptions to this rule. If a law violates a “specific prohibition of the Constitution,” such as the right to free speech or the right to be free from unreasonable searches and seizures, then it should still be struck down. So too should laws that undermine democracy itself, such as voter suppression laws or partisan gerrymanders (although the Roberts Court has largely abandoned this pro- democracy prong of Carolene Products).

J. Scott Applewhite/AP

The US Supreme Court building is seen at dusk in Washington, DC, on October 22.

Additionally, Carolene Products said that laws rooted in “prejudice against discrete and insular minorities” are also constitutionally suspect and should ordinarily be struck down. Such laws, the Court explained, are suspect because they tend “to curtail the operation of those political processes ordinarily to be relied upon to protect minorities.” If a minority group is transformed into a legal underclass, like African Americans in the Jim Crow South, then they are unlikely to wield enough political power to lobby for the repeal of laws that disfavor them.

This last prong of the Carolene Products framework forms the bulk of Vaello-Madero’s legal argument.

The Constitution forbids the government from denying “any person within its jurisdiction the equal protection of the laws.” As the Court explained in City of Cleburne v. Cleburne Living Center (1985), this Equal Protection Clause primarily protects groups that have “experienced a `history of purposeful unequal treatment’ or been subjected to unique disabilities on the basis of stereo-typed characteristics not truly indicative of their abilities.” Thus, courts view discrimination on the basis of characteristics like race and gender with great skepticism, because racial minorities and women have historically faced the kind of unequal treatment described in Cleburne. Before former President Donald Trump remade the Supreme Court, the Court also hinted that discrimination on the basis of sexual orientation is also the kind of “unequal treatment” disfavored by Cleburne.

Vaello-Madero’s lawyers spend the lion’s share of his brief arguing that people residing in Puerto Rico have also experienced a “history of purposeful unequal treatment” and been subject to discrimination rooted in racial stereotypes. Although Puerto Rico became a United States territory in 1898, the federal government has historically treated it as “outside the United States,” Vaello-Madero’s brief explains, and even held that certain constitutional rights do not apply in Puerto Rico.

Puerto Rico, the Philippines, and Guam were all annexed by the United States as part of the Spanish-American War, and this annexation produced a political crisis in the minds of the racist leaders who still dominated American politics and the legal profession in the late 19th century. Many American elites, including members of Congress, presidents, and Supreme Court justices, viewed the people of these new territories as too alien from American culture and too unfamiliar with our system to be subject to the same laws or afforded many constitutional rights.

These sentiments culminated in a group of Supreme Court decisions known as the “Insular Cases,” which divided the United States’ territorial possessions into two categories. Residents of “incorporated” territories enjoyed full constitutional rights, and incorporated territories were often understood to be on a path to statehood. “Unincorporated” territories, meanwhile, were deemed too foreign in character to enjoy the full blessings of the Constitution.

At least some of the justices who heard these cases were quite open about their racism. Justice Henry Billings Brown, best known as the author of the pro-segregation decision Plessy v. Ferguson (1896), wrote that the United States’ acquisition of Puerto Rico raised “grave questions” about the “differences of race, habits, laws, and customs of the people” of this island from the people of the mainland. And that these questions justified denying Puerto Ricans “the rights to citizenship, to suffrage, and to the particular methods of procedure pointed out in the Constitution which are peculiar to Anglo-Saxon jurisprudence.”

Although Congress made Puerto Ricans US citizens in 1917, the Court embraced Brown’s view of the Puerto Rican people five years later, in Balzac v. Porto Rico [sic]. Written by Chief Justice William Howard Taft, a former US president and colonial governor of the Philippines, Balzac held that Puerto Ricans were not protected by the constitutional right to a jury trial because “the jury system postulates a conscious duty of participation in the machinery of justice which it is hard for people not brought up in fundamentally popular government at once to acquire.”

In so holding, Taft distinguished Puerto Rico from the incorporated territory of Alaska. Alaska, he claimed, “was an enormous territory, very sparsely settled and offering opportunity for immigration and settlement by American citizens,” and thus it “involved none of the difficulties which incorporation of the Philippines and Porto Rico presents.” Alaska, in other words, was sufficiently empty that it could be filled up with white settlers who would bring with them American sensibilities. But the people already living in Puerto Rico were simply too alien to be afforded full constitutional rights.

Vaello-Madero’s brief draws a straight line from these decisions treating Puerto Ricans as legally inferior to other Americans, to Congress’s decision to exclude people living in Puerto Rico from SSI benefits. And it also makes another, closely related, argument that is firmly grounded in Carolene Products. “Because of Puerto Rico’s ‘unique’ status and ‘unparalleled’ relationship with the United States” — it is an island of United States citizens with no representation in the federal government — “Congress can discriminate against the island’s residents without regard to the heightened protection ordinarily afforded to politically powerless groups that have experienced a history of discrimination.”

Puerto Ricans, Vaello-Madero argues, are the very sort of people that the Equal Protection Clause protects. They’ve experienced a history of purposeful discrimination, been subject to racial stereotypes, and have little recourse to the political process. It’s an elegant argument, rooted in longstanding legal doctrines.

So how should this case turn out?

The government’s strongest argument against Vaello-Madero is that, while residents of Puerto Rico bear some resemblance to other groups that have been afforded special protection under the Constitution, it is not a perfect fit. The Equal Protection Clause, the DOJ notes, prohibits the government from denying equal rights “to any person.” It has been ordinarily understood to prevent “unequal treatment of classes of persons, not unequal treatment of regions.”

SSI’s exclusion for people living in Puerto Rico does not disable people of Puerto Rican descent from receiving SSI benefits. Vaello-Madero received those benefits when he lived on the mainland. Similarly, a white Nebraskan who moves to Puerto Rico would also be ineligible for SSI.

A similar concern animated the Court’s decision in Torres, the 1978 decision denying SSI benefits to people in Puerto Rico. A court decision requiring equal benefits for all Americans, regardless of where they live, “would apply with equal force to any benefits a State might provide for its residents, and would require a State to continue to pay those benefits indefinitely to any persons who had once resided there.”

And there’s also good reason why liberals and leftists should recoil from a court decision requiring the same legal rules to be applied to every American, regardless of where they live. The Court’s decision in Shelby County v. Holder (2013), which struck down a provision of the Voting Rights Act imposing special obligations on states with a history of racist election practices, was rooted in similar concerns that the rules in one part of the country should be the same as the rules in other parts.

Similarly, Democrats in Congress appear likely to pass legislation permitting poor people in states that refused the Affordable Care Act’s Medicaid expansion to receive cost-free insurance through a different government program. But that means that a poor person in, say, Florida, would receive different federal benefits than a poor person, in say, Virginia. Such a regime could be vulnerable if the Court determines that geographic discrimination can violate the Constitution.

It’s easy to see, in other words, how a conservative Supreme Court could wield a legal doctrine requiring geographic equality to do considerable violence to progressive legislation.

Carolene Products’ core insight is that an unelected judiciary should not be trusted with too much power. We saw, in the Court’s early-20th-century decisions, how democracy can spin off its axis if the courts are too powerful. The rational basis test exists to prevent that from happening again.

Ultimately, the correct answer to the Vaello-Madero comes down to an extraordinarily difficult question. Mr. Vaello-Madero is the victim of a terrible injustice. The question is whether, if a conservative Supreme Court steps in to cure that injustice, it can be trusted not to seize even more power in the process.

And it’s often easy to find them.

According to doctors, Hollywood insiders, and regular gym-going sources, anabolic steroids are the cheapest and most common of all PEDs. Doctors see misuse among civilian gym-goers. Meanwhile, medical-grade HGH is harder to find because of prescription controls and expense.

“Under ordinary circumstances, physicians shouldn’t be prescribing hormones for normal adult males,” said Ruth Wood, a neuroscientist who researches steroid abuse at the University of Southern California. But they are.

Across the country, you can find clinics advertising hormone replacement therapy to men diagnosed with low testosterone. Testosterone is also used in gender-affirming hormone therapy for transgender men and nonbinary people.

Testosterone is itself an anabolic steroid, its presence in the body monitored in athletic competitions, but it is usually prescribed to men over a certain age since testosterone levels decline as men get older. As a CBS investigation found in 2019, the regulation surrounding said clinics is spotty, with clinics prescribing hormones like testosterone to people with normal levels.

Testosterone prescribed to American men tripled between 2001 and 2011, the BBC reported. After the 10 years of growth, a research letter published in the Journal of the American Medical Association found that prescriptions decreased from 2013 to 2016, which coincided with a safety warning from the FDA about testosterone being linked to increased cardiovascular “adverse events” and stroke risks. (It should be noted that the researchers wrote that one of the limitations of the study is that testosterone procured without insurance was not studied.)

Because HGH prescriptions are both required and usually difficult to procure in the US, Wood said, HGH is one of the drugs that commonly go “missing” between manufacturing and shipping. The doses that never make it to pharmacies are very likely resold on the black market.

Amy, the actress with deep connections in the industry, has seen actors get what they need through “friendly” doctors and extralegal means. Procuring PEDs, Timothy said, is usually done by word of mouth, and through physicians who are willing to flout the rules.

“There’s a doctor and it’s like a two-year fucking waiting list to get with him,” Timothy said. “And this guy gives out HGH like candy — you just have to get on that list. And you have to get into his little fucking circle, which I never got through to.”

Fearing trouble, Timothy didn’t go through his business contacts when he started his regimen. Instead, he asked a friend with an impressive muscle-to-height ratio if he was on steroids. That friend put Timothy in touch with his contact, whom we’ll call David. David got him his first cycle of steroids.

David (who isn’t an actor) didn’t want to be named in this story because unauthorized steroid distribution is illegal. He began experimenting with steroids after his doctor diagnosed him with low testosterone around a decade ago.

“I never really thought about shooting myself in the butt with hormones. But here I was, doing it every week in a clinical setting,” David said. After digging around, he found that other anabolic steroids were not only a cheaper alternative to the $40 per week he was spending on testosterone but also more effective at building muscle. For example, a steroid like Trenbolone, which is used to fatten livestock and is not approved by doctors for human use, has a much more powerful muscle- building effect than testosterone in humans.

“I’ve purchased steroids from a couple different mediums. I’ve lived in the United States and Europe and done it in both places,” he told me, explaining that in America, the substances are probably created or procured across the border in Mexico, brought in, and shipped. Experts I spoke to confirmed that the legality of substances varies from country to country and that drugs can be brought across the border from Mexico. (David said he also knows a scientist who creates anabolic steroids in his own batches.)

David said it wouldn’t be impossible to find HGH on the black market or for resale, but that it comes at a high price.

“That’s just a lot more of a difficult channel and they’re far, far, far more expensive. That would be out of reach when you’re just an average person with an average expendable income to be using on steroids,” he said. People I spoke to said that the dollar amounts can range wildly, but medical-grade HGH is at least a few thousand US dollars per month.

While David and Timothy’s relationship was cultivated in person, it’s not hard to find the same conversations happening online. It happens in Reddit threads, bodybuilding forums, and even Instagram pages discussing PEDs. Some online businesses advertise supposed PEDs for purchase. It’s gotten to the point where steroids and other PEDs function as memes.

According to the scientists I spoke to who study steroids, determining how widespread their use is can be hard.

“There is a lack of extensive studies on steroid use in the US. This contributes to the sense among public health leaders that steroid use isn’t a real problem. If you don’t study the problem, you are less likely to observe it,” Wood told me.

The National Institute on Drug Abuse wrote in 2018 that it’s difficult to ascertain “the true prevalence of steroid misuse in the United States because many surveys that ask about illicit drug use do not include questions about steroids,” and that usage studies in the past have focused on youths in high school and middle school, leaving out broad swaths of the population.

An illustration of a man working out with a ball and a dotted line connecting them to a muscled torso.

Rabin said that WADA has seen a decrease in positive PED tests among athletes because of how frequently testing occurs. WADA has, with each year, increased the number of tests on athletes and improved the technology needed to detect them. The testing isn’t perfect. WADA and the Olympics were criticized over some of their decisions, including disqualifications on two Namibian female sprinters for having high amounts of natural testosterone. But, Rabin thinks, the extensive testing has helped deter the use of PEDs and made the sport cleaner.

With the public, though, there is no such protocol.

Rabin said people seeking steroids “have got access to a lot of different drugs on the internet. And it’s so easy, you’re just a couple of clicks away from ordering all sorts of substances, legal or illegal.”

Thanks to my school’s D.A.R.E. program, steroids conjured up a nightmare kaleidoscope of shrunken testicles, premature balding, excessive acne, uncontrollable rage, and death. These effects, the program taught, happen quickly — you basically get buff and then you die.

That kind of education is misleading, and even detrimental to preventing use.

“It’s like the way that we were told as kids that if you smoked weed once you would be a drug addict for the rest of your life. They lie to us,” Timothy, the actor, said of how he was taught about steroids and whether he’s nervous about the risk involved. “Like, movie stars do steroids all the time. More and more of my friends are taking steroids; they’re not dead yet.”

Drug education in the US has historically used fear to drive the point home, but that can lead to skepticism when the fears are revealed to be exaggerated. PEDs can lead to grim consequences, but they usually don’t happen instantly. Not every nightmare scenario happens, and not all at the same time.

The illegality of some PEDs is part of the problem in determining side effects and how dangerous they may be. While there are studies of anabolic steroid use in patients, it does not extend to the wide array of PEDs, nor can you conduct a study simulating heavy use over time. Pumping volunteers full of steroids isn’t ethical and would put them in danger. People can be hesitant to disclose their use, as they’d be admitting to breaking the law. When doctors like Harrison Pope study steroids and PEDs, then, they rely on volunteers with past or current drug use coming forward, sometimes to varying degrees.

The use of anabolic steroids is still fairly new, Pope said. The bodybuilders who popularized them in the ’80s and ’90s were mostly in their 20s and 30s. That means the first batch of heavy steroid users are just now coming out of middle age, and Pope and his cohort have only been able to study long-term effects for the past decade or so, and only with this select group of people. HGH is even more difficult to study, as its use as a PED is even more recent.

Pope uses smoking to illustrate our relative lack of knowledge. In 2021, it’s impossible to consider smoking without thinking about its connection to lung cancer. This was not always the case, however. Even though lung cancer had surged alongside the popularity of cigarettes at the turn of the 20th century enough to become an epidemic, it would take decades until scientists in the 1950s and ’60s found a concrete connection and made the public aware of it.

PEDs have barely begun that arc, and what doctors and scientists are seeing now, he fears, is akin to pulmonary doctors finding the first few cases of lung cancer in heavy smokers, having “no idea of what was about to hit us.”

“We may see a substantial increase in cases of cardiac complications over the next decade or two, as this group moves into older ages,” Pope said.

Steroids make muscles in your body stronger and bigger, but something funny can happen to your heart, arguably your most important muscle. With heavy steroid use, your heart may become weaker, more inefficient at pumping blood. Inefficient hearts can lead to heart failure. Steroids can also harden arteries and increase the risk of heart attacks and stroke.

Pope and his colleagues recently completed a study involving long-term steroid-using weightlifters and weightlifters who didn’t use steroids, to establish the risks of long-term use.

“Of the 86 steroid users, three had a heart attack prior to the age of 45. Whereas of the 54 comparison weightlifters, none of them had had a heart attack,” Pope said.

New research may also lead to reversals of what doctors thought they knew about steroids, with often-discussed side effects having a more permanent effect than expected. It’s well-known that steroid use causes natural testosterone production to shut down, makes testes shrink, and can lead to a loss of sex drive and erectile dysfunction. But, Pope said, “if you asked me 20 years ago if the testes would rebound back to normal, I would have assured you that, yes, after a certain amount of time, testicular function would come back online and the testosterone levels will come back to normal. It turns out I was wrong.”

Another wrinkle with steroids is that desired results are tied to long-term use. Steroid users could quit cold turkey, but quitting abruptly throws testosterone levels into chaos and causes the user to lose any physical gains they’d made. Bodies and brains may not rev up testosterone production instantly.

Wood, the USC researcher, said that consistent users may not completely wean themselves off the drugs they’re using, and instead switch to a lower dosage. When studying athletes who used PEDs, users needed to continue their regimen to maintain their physical prowess while at the same time making up for their bodies shutting down their natural production of testosterone.

Without extensive medical trials, one of the methods doctors employ to study steroids is to test them on rodents. Wood is using this method to study the cognitive effects of steroids, including whether they’re habit-forming. Unlike humans, animals don’t seem to have body dysmorphia and aren’t swayed by the promise of getting stronger or looking better. Her initial research has found that rodents will self- administer both testosterone and anabolic steroids, possibly indicating that there is an addictive quality to them.

Her research has also shown that animals given steroids have shown less cognitive flexibility and exhibit more risk-taking behavior — a pattern that mirrors the “roid rage” symptoms sometimes seen in humans.

Wood, Pope, and their colleagues may also have to contend with emerging drugs that are more effective, seemingly with less immediate negative impact.

The full side effects of HGH as a PED are still being studied, but research suggests they include insulin resistance, increased risk of certain cancers, and increased breast tissue in men. Still, one of the hyped talking points of HGH is that it comes with fewer or less serious side effects than anabolic steroids.

And while HGH seems like the cutting edge in performance enhancement, there are even newer drugs on the rise. “We’ve also seen a new class of substances that has been called selective androgen receptor modulators (SARMs) that are anabolic-like substances, but they are said to be without some of the side effects and undesirable effects of steroids,” said Rabin, the WADA expert. “We’ve seen these new kinds of substances coming to the market, in particular the illegal market.”

The problem, said Wood and Pope, is that because these side effects don’t happen immediately, they’re not perceived as scary enough to outweigh the benefits of PEDs. Shorter- term side effects appear to be less common with new PEDs, and long-term effects — including cardiovascular, liver, and kidney issues — don’t show up until later in life. It’s hard for users to conceptualize drawbacks. The thought of getting stiff arteries in 40 years or having a heart attack at 60 might not faze someone who wants to look muscular in two months.

“I think there’s a study where they asked Olympic-level athletes if they would do something that would give them a gold medal but kill them in 10 years, and a fairly substantial fraction said, ‘Yep, I’d do it,’” Wood said, putting PEDs’ risk-reward trade-off in perspective. It’s difficult to argue instant gratification against future risk.

Roberto Olivardia, a psychologist who lectures at Harvard Medical School and specializes in treatment of body dysmorphia in boys and men, said that the combination of social media, trends in popular culture, and increased steroid use has coincided with an increase in muscle dysmorphia. The term primarily refers to boys and men who are dissatisfied with their appearance because they perceive their muscles as too small, no matter their size.

“Doing this work for 21 years, I saw a real shift in my practice when the internet and social media took off,” Olivardia told me, explaining that muscle idolization has always been a part of American culture but has exploded in the past few years. “Now young boys are getting information about the substances and have access to imagery — and it’s not only just celebrities now. It’s their peers, and they’re Photoshopping pictures of themselves. It’s definitely increasing.”

Olivardia said that his patients are getting younger and younger, which he finds worrisome. For muscle dysmorphia, the youngest patients he sees are 15 and 16 years old. The oldest patients he sees are in their 50s.

Body dysmorphia is a discussion we’ve been having culturally for decades, but mostly as it concerns women and girls. Standards of beauty for the female body have long been exacting and unrealistic. This same kind of specificity and harm may be more novel for men. One of the narratives surrounding famous women’s bodies is on using the artificial — plastic surgery, Photoshop, Instagram filters — to achieve the unrealistic. With men’s bodies, the narrative is often that unrealistic results are solely a product of hard work.

His younger patients often look up celebrities’ workout routines in the hope they can copy them. The hard part, Olivardia said, is making it clear to boys that it’s unrealistic to achieve those kinds of bodies without the chefs, trainers, money, and sometimes substances that those actors have access to.

“There are a number of people that I’ve worked with in Hollywood who have said steroids and PEDs are a little secret, but they see it as a necessary component of their jobs,” he said. “A lot of these young boys and young men look at this imagery, and they’re frustrated as to why they can’t look like that. They’re not taking into consideration all those factors.”

A barrier to this is that the framework to talk about mens’ and boys’ body issues doesn’t exist. There’s a lack of attention to problems like body dysmorphia and eating disorders in men and boys. Coupled with the lack of transparency around steroids and other PEDs, it raises the question of what we all think the male body is supposed to look like.

“For people who are within gym culture, it becomes very obvious what is and is not achievable without help,” Michael Collins, a bodybuilder and podcaster, told me. “These are unnatural bodies; these are not the way humans are meant by nature to look like. I don’t see a problem with that — Botox is unnatural. If you want to get Botox, go ahead. But let’s be clear, in terms of our biology, we have this trick in order to look like that.”

An illustration of a man working out in a circle of muscle images.

Collins grew up idolizing the bodies of ’80s action heroes like Jean-Claude Van Damme or Arnold Schwarzenegger. He found them sexy, and he wanted to get the same look. It’s what made him get into bodybuilding and shaped his view on steroids; he knew the only way to get the body he wanted was with PEDs.

“I think a lot of the misery that comes from our current situation [is that] steroids are everywhere, but you can’t talk about them,” he told me, explaining that he has been using steroids for four years and compared the danger to going out and taking drugs at parties. It’s a risk he’s willing to take.

“Taking some MDMA is a choice that someone can make. As far as I’m concerned, that is a perfectly fine lifestyle choice if that’s what you want to do with your life. There’s use and there is abuse. It’s similar with steroids,” he argued.

Collins gets at a bigger question of harm reduction — the way we approach substance abuse in respect to other recreational substances — with steroids and other PEDs. If abstinence-only education on PEDs hasn’t stopped people from taking them, and steroids and PEDs have risen in popularity, is there a better way to approach this subject?

Wood and Pope don’t believe there’s a risk-free experience. Pope said one of the big risks he fears is that as PEDs’ efficiency becomes more well- known, it may actually increase usage. Olivardia agreed, and said that with the patients he sees, the only path to safety is quitting the drugs.

“When I’m working with these patients with muscle dysmorphia, my position is there is no safe use available with anabolic steroids,” Olivardia said, pointing to several psychological consequences he’s seen — hypomania, psychosis, and depressive states during withdrawal — in addition to the physical risks PEDs present.

Olivardia and others in his field said there’s just too much risk with even mild use of PEDs. Plus, it’s hard to convey to young men that they’re playing Russian roulette with their health.

“You’re doing something that’s messing with your hormones,” Olivardia told me. “There’s some people that smoke cigarettes and never develop lung cancer, but we know if you smoke, you’re increasing your risk of lung cancer. For some people, that might be lung cancer in their 60s, and some people might get it in their early 40s. And so it’s painting a more accurate picture to them about the risks.”

What troubles Pope isn’t just the risk but the possibility that education would encourage even more usage. The more a layperson learns about PEDs, the more they’ll learn that the drugs are effective. That’s dangerous, experts say.

“The problem with many educational campaigns is that when guys find out just how effective these drugs really are, it may actually backfire. They’re even more tempted to take them,” Pope said. “If you’re going to educate, you have to begin by conceding that, you know, these drugs really do work.”

If you want to see what he means, open up Instagram, head to your local multiplex, or pop by the gym. The results are unmistakable.

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