Ep 275 – Anabolic Steroids: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

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0:00:45.0 Ruth Werner: Hey, I Have A Client Who listeners, did you know I have a growing library of NCB approved one hour online self-paced continuing education courses that you can do any time, anywhere? Well, now you know. Current classes include; what's next, Covid-19 updates for massage therapists and a massage therapist introduction to pharmacology part one, and brand new, a massage therapist's introduction to pharmacology part two. Classes are $20 each and they confer one hour of continuing education credit. Wanna know more? Visit my website at ruthwerner.com and check it out. Be sure to sign up for my mailing list so you'll never miss a new class.

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0:01:38.9 RW: Hi, and welcome to, I Have A Client Who pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of a massage therapist guide to pathology and I have spent decades studying, writing about, and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks.

0:02:25.1 RW: Today's I Have A Client Who story isn't really a story, it's an issue that came up as I was discussing something entirely different with our contributor, and they mentioned this issue and I was deeply intrigued. It's a sticky one with some health-related concerns and some legal concerns and some moral and ethical concerns too. It provides a way for us to stumble right out of our scope of practice, but maybe in the best interest of the client. I don't promise to untangle this whole issue, but maybe I can help us consider this for just a moment, and there are ways that this question can affect other aspects of our work as well, and the topic is body builders who want massage and who also use anabolic steroids. Yikes! Ruth, are you sure you wanna take that on? No, but I'll do it anyway, because sometimes it's fun to climb out on a limb and take a few risks. So we have a situation, a massage therapist has a client who is a body builder, cool. This is a fun population of people who really know their bodies inside and out, and they value what massage can do to help them with training and injury recovery and just feeling wonderful after pushing their physical boundaries.

0:03:50.0 RW: Sounds terrific. And then this client informs the massage therapist that he is using anabolic steroids that he gets from a supplier online. Oh, does that change anything? Let's do a quick overview of anabolic steroids, which will dangle us precipitously over the gaping Calderon of chemistry, but I promise we won't fall in. And then we can at least start with some ideas about what's happening in the body of a person who supplements them. Then we will pick up the question of the appropriate role of the massage therapist. [chuckle] And that will be fun. I wanna give a big thanks to MedlinePlus for this. They are a resource connected to the National Library of Medicine, and they produce very accessible and easy-to-use information for people who are feeling a little out of their depth like, me. And so from them and the few other resources that I will have listed in our show notes, I learned this, anabolic steroids, technically anabolic androgenic steroids are synthetic versions of testosterone, and testosterone, of course, is the hormone connected to developing and maintaining male sex characteristics like muscle growth and facial hair and having a deep voice.

0:05:12.2 RW: Anabolic steroids have some therapeutic uses for hormonal imbalances in men, for helping to build up after muscle loss from certain diseases like HIV or types of cancer, and careful dosing with synthetic testosterone is part of treatment for transgender men too, but sometimes these medications are misused by people who just want to build muscle mass and they do not have any underlying condition. In these cases, the anabolic steroids might be taken orally or as a skin gel or a cream, which has implications for our work, or as injections. The doses might be the same as what is administered by prescription, but probably not.

0:06:00.6 RW: They're probably higher. How much higher? We don't know, it depends on the manufacturer who is not operating under any governmental supervision, drugabuse.com says online sources for anabolic steroids have doses 10 to 100 times more potent than what you would get normally. Anabolic steroids are great for building muscle mass, but of course, ha, there's a host of side effects that go along with them, including; acne, hair loss on the scalp, hair growth on the face and body, breast growth, shrinking of the testicles, erectile dysfunction, but those are just the surface issues. Synthetic testosterone use can also cause high blood pressure, heart attacks, an increased risk of prostate cancer, stroke, liver disease, and kidney damage, and of course roid rage, that aggressive behavior that is associated with steroid use. And while these drugs don't get users high, cessation of use can cause some withdrawal symptoms like decreased sex drive, fatigue, restlessness, sleep problems, and depression. In short, supplementing sketchily-sourced anabolic steroids to help with body building goals is generally speaking, probably not a great idea, and it carries a bunch of significant health risks, especially with long-term use. But what does this mean for a massage? Huh? Great question.

0:07:36.3 RW: Do you have any clients who you suspect use illicit substances, like maybe popping their partner's Ambien when they need a little extra help to get to sleep, or holding on to some heavy duty pain killers in case they might someday get a toothache over a weekend? Do you think you have any pot smokers among your clients, if you live in an area where that's still illegal? The answer is almost certainly yes, and I'm guessing that you don't report them or refuse to work with them. Is this any different from that? Uh. Maybe a little bit. The first issue is purely a legal one. If the steroid use is in a minor, that has to be reported, if the steroid use is happening on the massage therapist's premises, that has to be prevented, but aside from that, is it really our business? Definitely, yes, if it affects their ability to receive massage. This is especially true if they are using testosterone as a skin application in a gel or a cream. I have actually had a question in the past about a massage therapist getting accidentally dosed when her client suddenly remembered to tell her that he is now using a hormone cream right where she had just finished working. But if the client isn't putting us at risk for exposure, if they're happy with their results and they're not having side effects today, maybe it's none of our business.

0:09:03.9 RW: However, if our clients show signs of steroid-related side effects that disturb them, our best role is to recommend that they consult with their primary care physician absolutely as soon as possible. If they don't wanna talk about this with a doctor, we can refer them to websites that might offer some other kinds of help, and I'll put some in the show notes in case you might ever need them. But if they don't ask us for help, and if they are essentially healthy when we see them, I'm not convinced that it's in our scope of practice to bring it up. That said, if knowing your client is using steroids for bodybuilding, and if he or she wants you to help them with the same goal, you may have to evaluate how comfortable you are with that, especially if this person is doing it competitively. If it's not possible for you to clear your head and your heart about this, it may be necessary to end that therapeutic relationship. This topic opens the door to a discussion of other drugs in the context of massage therapy, and I have heard a few stories about this. One is, to me at least a specific ethical issue. A client might use a mood-altering drug like ecstasy, and then get massage to intensify the high. I've heard about this when a massage therapist attended a party specifically for that purpose to help the party goers get higher, and also when a group of people had made appointments at a local student clinic, and then they showed up high and eager to get higher. Huh?

0:10:42.3 RW: I have a strong visceral reaction to this. There are a million definitions of what massage therapy is, all of them include some kind of nod toward the idea of improving health or wellness. And I cannot make a case that massaging a person who we know is using our work to get high, fits that definition. You may disagree and that's fine, it would be interesting to have a good conversation about that. Another problematic use of medications that I've heard about is clients who are receiving very deep intrusive and maybe painful work for some kind of rehabilitation or training purpose, and they will dose up with painkiller before their session so that they can handle deeper pressure. Again, I have to ask, is this really therapeutic, does this promote health and wellness? From my own bias, I'm inclined to say no, and please don't use massage to increase the risk of injury from over-treatment. Ultimately, if we have a client who's using a substance that might be illegal or off-label or prescribed to someone else, most of the time, it's none of our business.

0:11:57.5 RW: It becomes our business when it puts us at risk, like with a topical cream, or when it affects our client's health and well-being and/or our ability to treat them with unconditional positive regard. And each of us might have a different boundary for when that occurs. This episode has probably raised more questions than it answered, but I love being challenged like that, so thanks for climbing out on this limb with me, the view from up here is great.

0:12:29.8 RW: Hey everybody, thanks for listening to, I Have A Client Who pathology conversations with Ruth Werner. Remember, you can send me your I Have A Client Who stories to ihaveaclientwho@abmp.com. That's ihaveaclientwho all one word, all lowercase @abmp.com. I can't wait to see what you send me and I'll see you next time.

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