Correspondence

Review of The Adonis Complex

N Engl J Med 2001; 344:1557-1558May 17, 2001

Article

To the Editor:

We question the scientific basis for several statements in Handelsman's recent review of our book, The Adonis Complex (Jan. 11 issue).1 Handelsman dismisses anabolic-steroid–induced hypomanic syndrome (sometimes called “roid rage”) as “street folklore” and “an excuse for bad behavior,” a claim that contradicts the findings of three placebo-controlled, double-blind studies and numerous controlled field studies.2,3 He also dismisses as “an unsubstantiated claim” our suggestion that there is a natural limit to the muscularity that lean men can attain without steroids, despite the fact that our hypothesis is based on a peer-reviewed study of 157 athletes4 that has never, to our knowledge, been challenged in the subsequent literature.3 If Handelsman or others possess contrary evidence, we would urge them to publish it for scientific inspection.

Handelsman also implies that we have neglected the possibility that male body-image disorders might be “merely a variant of obsessive–compulsive disorder.” Yet we propose precisely this hypothesis in our book and in our published scientific papers.5 More generally, Handelsman states that our book provides “no specific bibliography, making it hard to examine its scientific background.” The Adonis Complex, however, cites more than 290 publications, including 200 peer-reviewed studies, more than 40 of which are from our own laboratories.

We also question the reviewer's characterization of our patients. Body-image disorders are recognized diagnostic entities that are sometimes associated with serious morbidity and even mortality. Calling these patients “pathetic men” with “narcissistic self-absorption” who are engaged in a “comic-book satire” trivializes their disabling and treatable psychiatric conditions.

Harrison G. Pope, Jr., M.D.
Roberto Olivardia, Ph.D.
Harvard Medical School, Boston, MA 02115

Katharine A. Phillips, M.D.
Brown School of Medicine, Providence, RI 02905

5 References

1. 1

   Handelsman D. Review of: The Adonis complex: the secret crisis of male body obsession. N Engl J Med 2001;344:146-147
   Full Text

2. 2

   Pope HG Jr, Kouri EM, Hudson JI. Effects of supraphysiologic doses of testosterone on mood and aggression in normal men: a randomized controlled trial. Arch Gen Psychiatry 2000;57:133-140
   CrossRef | Web of Science | Medline

3. 3

   Pope HG Jr, Brower KJ. Anabolic-androgenic steroid abuse. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's comprehensive textbook of psychiatry. Vol. 1. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2000:1085-95.
   

4. 4

   Kouri EM, Pope HG Jr, Katz DL, Oliva P. Fat-free mass index in users and nonusers of anabolic-androgenic steroids. Clin J Sport Med 1995;5:223-228
   CrossRef | Web of Science | Medline

5. 5

   Phillips KA, McElroy SL, Hudson JI, Pope HG Jr. Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? J Clin Psychiatry 1995;56:Suppl 4:41-51
   Web of Science | Medline

Author/Editor Response

Dr. Handelsman replies:

To the Editor: Reviewing a review starts a downward spiral. It is a meager defense against a critique of deficient scientific rigor in an approximately 300-page book to complain that a short review lacks scientific details. Whether scattering references among footnotes regardless of their quality constitutes a specific bibliography or not, it hinders the evaluation of the scientific validity of assertions — a task the book's popular approach often makes necessary. Semantic quibbles over how to describe the behavior of men enslaved by destructive obsessions do not warrant an argument.

The new law of nature on body composition that the authors claim to have discovered relies on evidence such as guessing body weight and height from fan-magazine photos. Does a 1.0-m-tall dwarf weighing 40 kg defy a law of nature or merely an extravagant claim? The onus of scientific proof is on the proponents and requires independent replication, the lack of which may reflect poorly on the plausibility of their claims.

The authors now defend the concept of “roid rage” by referring to placebo-controlled studies that, in fact, show no consistent effects on mood or behavior of even high doses of androgens. They unquestioningly equate the flamboyant, self-serving lifestyle depicted in the media and the courts with rare, idiosyncratic reactions observed in some but not in other studies.1-4 The variability of reactions to androgens within and between studies and the roles of personality and anticipation5 are not understood. The claim that these adverse reactions are instances of “roid rage” remains to be substantiated.

David J. Handelsman, M.D., Ph.D.
ANZAC Research Institute, Sydney, NSW 2139, Australia

5 References

1. 1

   Tricker R, Casaburi R, Storer TW, et al. The effects of supraphysiological doses of testosterone on angry behavior in healthy eugonadal men -- a clinical research center study. J Clin Endocrinol Metab 1996;81:3754-3758
   CrossRef | Web of Science | Medline

2. 2

   Anderson RA, Bancroft J, Wu FCW. The effects of exogenous testosterone on sexuality and mood of normal men. J Clin Endocrinol Metab 1992;75:1503-1507
   CrossRef | Web of Science | Medline

3. 3

   World Health Organization Task Force on Methods for the Regulation of Male Fertility. Contraceptive efficacy of testosterone-induced azoospermia in normal men. Lancet 1990;336:955-959
   CrossRef | Web of Science | Medline

4. 4

   Contraceptive efficacy of testosterone-induced azoospermia and oligozoospermia in normal men. Fertil Steril 1996;65:821-829[Erratum, Fertil Steril 1996;65:1267.]
   Web of Science | Medline

5. 5

   Bjorkqvist K, Nygren T, Bjorklund A-C, Bjorkqvist S-E. Testosterone intake and aggressiveness: real effect or anticipation? Aggressive Behav 1994;20:17-26
   CrossRef | Web of Science