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His own use, he emphasizes, has been extremely modest. He knows what the side effects are, and one of his goals is "to be kind to my liver.... It's when the mental image of your body is really at odds with physical reality that people run the risk of real abuse," he says. "I know someone who I am convinced is going to kill himself. He's six-foot, he's 245, and he wants to get to 260. At 260 he's going to want to get to 280. At 280 he's going to want to get to 300. Somewhere along the line he's going to fry his liver, and all hell is going to break loose. It's like any other drug. It can become an addiction."
Dr. Alberto Canas sees both faces of the Miami Beach steroid scene. More than half his practice consists of HIV-positive patients, and he prescribes steroids (or the vastly more expensive human growth hormone -- $21,000 per three-month cycle) to many of them as part of their drug regimens. He estimates that he gives steroids to about one-third of his patients, and believes that this proportion is representative of treatment for the roughly one million HIV-positive people in the United States.
Canas, a handsome man in his late thirties with plenty of gray in his dark brown hair, also knows all about the burgeoning population of HIV-negative steroid users. He dunks a slice of tuna into soy sauce and glances out Sushi Rock's front window.
"There goes one now," he murmurs as a massive man on a bicycle zips past on Collins Avenue.
Canas, like many other doctors who treat HIV patients, believes that steroids stave off the ravages of wasting syndrome. Yes, there are side effects, but irritability and the possibility of liver problems in five years pale in comparison to watching a patient's body eat itself within a matter of months. "For the most part, in the HIV-positive patient the benefits far outweigh the risks," he says.
Still, as with so many other treatments for the symptoms of HIV, the unknowns outweigh the knowns when it comes to gauging the effectiveness of steroids. Steve Fallon, director of education at CenterOne, a nonprofit HIV/AIDS service center in Fort Lauderdale, says that neither steroids nor human growth hormone has been unequivocally proven to help keep AIDS patients alive.
"A lot of gay HIV-positive men develop a more muscular physique, but it's not completely understood if that's a hedge against wasting," Fallon cautions. "The jury is still out. Has there been a major surge in getting on steroids? Yes. Are HIV doctors reluctant to tell their patients that there's no proof? Probably."
Canas is more worried about the consequences of steroid use among the HIV-negative. "We don't really know what the long-term effects of steroids are," he admits. "There are problems that can happen immediately."
He's seen mood swings result even from the carefully measured doses he gives his HIV-positive patients. "I have had people tell me, people I was treating for wasting, 'When I was on that cycle, doc, I was picking fights with my boyfriend left and right. Can we maybe try a lower dose?' These side effects are definitely real."
Canas also worries about the interaction between steroids and other drugs, legal and illegal. "Anything else that can also effect your liver, like alcohol, may cause additive damage," Canas says. "Also, weightlifting sends your blood pressure very high. If you're also doing any other kind of stimulant, like cocaine or crystal meth, you could stroke out. That's kind of indirect, but there's the potential."
The social consequences among gay men can also be severe.
"What happened was, all of a sudden you saw people who weren't doing so well at one point becoming Adonises," Canas recounts, between bites of California roll. "It's human nature to be competitive. I have a lot of patients, HIV-negative guys, who will say, 'How can I get steroids? It's not fair that I can't get them just because I'm negative.'"
He says he's had to give the same speech over and over: "Right now, if you're negative, it's not accepted medical practice to get steroids. And not legal. I don't prescribe anabolic steroids to anyone who doesn't have a chronic wasting disease."
Canas says it's impossible to quantify the illicit steroid use among gay men, in Miami Beach or anywhere else. It's all guess work at this point.
"The gym I work out in is a gay gym," says Fallon. "I was talking to somebody there, and I guessed that maybe twenty percent of the guys there were on steroids. He laughed at me and told me it was way more."
Canas is aware of the possibility that his patients might try to pass prescribed steroids along in the black market. "That's one of my biggest fears," he admits. "I do try to administer injectables within the office. But sometimes people will travel, spend summers on Fire Island or whatnot. I have to give them what they need to self-inject."
Self-injectors to whom he has not issued prescriptions also show up for treatment, and it's not a pretty sight. "I've treated people for abscesses that have formed, which is basically a big collection of pus under the skin where they inject themselves," he says.