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Muscle Dysmorphia -- Bodybuilding Gone Amuck

BELMONT, MA -- November 21, 1997 -- An international team of researchers has identified a new, '90s-style psychiatric disorder they say may be afflicting a substantial number of people -- bodybuilders in top physical shape who are chronically worried that they look puny.

They call it muscle dysmorphia. Principal investigator Harrison Pope, MD, of McLean Hospital in Belmont, MA., and his colleagues at Brown University and Keele University, England, discovered the disorder in the course of several ongoing studies of athletes. They describe the disorder and recount four case studies in the November-December issue of the research journal Psychosomatics.

For many of the muscle-bound men and women identified as having the disorder, preoccupation with their bodies was so intense they routinely gave up desirable jobs, careers and social engagements to spend hours in a gym each day. They refused to go to the beach or swimming pool for fear their bodies don't look good enough to be seen.

Many reported taking anabolic steroids to build bigger muscles, but still were unsatisfied. Typically, they weighed themselves several times a day, repeatedly checked themselves in mirrors, wore baggy sweatshirts and pants even in midsummer to conceal their bodies and experienced great distress if they had to miss even one day of weight-lifting.

"It appears that the disorder produces substantial morbidity, together with maladaptive behaviors such as anabolic steroid abuse and thus may have important implications for public health," the researchers write.

They stress, however, that for the vast majority of Americans, there is nothing pathological about working out regularly, because dedication to bodybuilding or other sports is perfectly healthy.

"This syndrome looks almost like a reverse form of anorexia nervosa," Dr. Pope said. "In a typical case of anorexia nervosa, a woman diets until she is severely underweight. Yet, when she looks at herself in the mirror, she perceives herself as fat.

"By contrast, in typical muscle dysmorphia, a muscle-bound bodybuilder will look in the mirror and see himself or herself as out of shape. We think the underlying pathology of the two conditions may be the same, since they are both disorders of body image. The preoccupations simply go in opposite directions."

The researchers speculate that more and more people may be afflicted as weightlifting increases in popularity among both men and women.

"Americans spend about $3 billion a year on commercial gym memberships," Dr. Pope said. "And this doesn't count the more than a million Americans who work out at home. With this explosion of interest, it may well be that muscle dysmorphia will become the body image disorder of the '90s, just as eating disorders leapt into public awareness in the '80s."

Expert believes mental illness drives some bodybuilders
WASHINGTON (AP) - What drives some bodybuilders is a form of mental illness that can be treated with drugs, a researcher says.

These people have a type of body dysmorphic disorder, a condition which is characterized by a preoccupation with an imagined or slight defect in appearance, said Dr. Eric Hollander of Mount Sinai School of Medicine in New York.

"Body dysmorphic disorder affects probably 1 to 2 percent of the U.S. population, but among men in particular there is a sort of subclassification called `bigorexia,' which is sort of the opposite of anorexia," Hollander said. Anorexics think they are too fat, no matter how thin they are - and bigorexics think themselves too small, no matter how big they are, he said.

Bigorexia, more properly termed muscle dysmorphia, is not yet formally recognized as a psychiatric condition, Hollander said. But the coming revision of the American Psychiatric Association's Diagnostic and Statistical Manual will describe the condition, he said.

Bodybuilding can be a healthy competition, but these people take muscle development to the point at which it interferes with ordinary living, including holding a job or staying healthy, Hollander said. "They will continue to exercise even after they have dislocated a shoulder," he said.

As an expression of body dysmorphic disorder, muscle dysmorphia is an obsessive-compulsive spectrum disorder, Hollander said. People with OCD are driven to do things such as repeatedly check their appearance in mirrors and perform ritualistic movements.

"An exaggerated sense that something doesn't look right" seems to have origins in brain chemistry, Hollander said. He and his colleagues reported in Archives of General Psychiatry on the effects of the drug clomipramine on the brain chemical serotonin.

One of serotonin's normal roles seems to be in turning off brain processes that signal when "things don't fit our conceived notions," Hollander said. If serotonin levels are abnormally low, however, it can't turn off the mental alarm bell that rings when things don't seem right, and the bell keeps on ringing even when things are right, he said. Clomipramine helps the brain raise serotonin levels by interfering with the body's ability to destroy the chemical, he said.

Hollander and his colleagues wanted to be sure clomipramine was producing improvements in the behavior of people with body dysmorphic disorder, and that the patients were not improving simply because they knew they were getting treatment and therefore expected themselves to improve. So the researchers compared clomipramine with another drug, desipramine, which had similar side effects but does not affect serotonin.

Clomipramine treatment was significantly better in reducing patients' repetitive movements and obsessive preoccupation with perceived flaws, the study found. But it is not a cure, Hollander said. "Don't think about symptoms going down to zero," he said. "They were 25 to 35 percent improved." There was, however, a significant improvement in their ability to go back to school or function at work, and a significant drop in their thoughts of suicide, he said.

Although this study did not focus on muscle dysmorphia, treatment for body dysmorphia has been shown to work on muscle dysmorphia, Hollander said. And a clinician who was not involved in the study said she found the drug to work, especially in combination with psychological therapy.

"I don't feel behavior therapy is sufficient, and certainly medications are not efficacious alone either," said Fugen Neziroglu, senior clinical director of the Bio-Behavioral Institute in Great Neck, N.Y.

Neziroglu has treated a number of people with muscle dysmorphia. "I had one who just left, an attractive, nice, 44-year-old man, he's telling me he has flab on his sides," she said. "You look at him and you know he has no flab."

Medications help to stabilize patients with muscle dysmorphia, but therapy is needed to retrain habits and thought patterns needed to make the improvements last, Neziroglu said. Clomipramine is one of the better drugs, she said.

And therapy alone may be adequate treatment, said James Rosen, a clinical psychologist and professor at the University of Vermont. The cognitive-behavioral approach teaches patients to realize when their thoughts are unrealistic, recast their self-image into more neutral terms, and adapt to situations that could set off the compulsion, he said.

For muscle dysmorphia, this could include easing away from the idea that the exercisers would lose control of themselves if they skip a workout, Rosen said.

However, one bodybuilding promoter said he couldn't tell whether bodybuilders have this condition. High-level bodybuilders are like other athletes in paying extremely close attention to what they eat, how much they exercise and where they fall short of their own goals, said James Lorimer of the Arnold Schwarzenegger Fitness Weekend, Feb. 22-27 in Columbus, Ohio.

"I can't say I place these particular athletes outside the normal range of people who are trying to be the best they can be in whatever sport they are in," Lorimer said. "You can say it's excessive, it's unusual, but (I) can't say whether it is disordered or not."

Anabolic/Androgenic Steroid Use and Aggression I: A Review of the Evidence

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November 22, 1999 (Volume 2, Number 19)

by Jack Darkes, PhD
Assistant Professor,
Department of Psychology
Director of Interventions,
Alcohol and Substance Use Research Institute
University of South Florida

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Introduction
The association between anabolic/androgenic steroid (AAS) use and aggression ("�roid rage") has been widely accepted in the culture in general, the mainstream media, and the resistance training subculture. This view has been bolstered by the use of AAS "induced" rage as a legal defense (Pope & Katz, 1990). And, although AAS use is not limited to those who perform resistance exercise, the evidence suggests that lifters using AAS are likely to use much higher doses than are those engaging in other athletic endeavors. Therefore, aggression has been both expected and reported to be more prevalent among weight trainers and this phenomenon has become part of the culture of bodybuilding, as well. More recently, naturally occurring androgen precursors have also entered the discussion (Ueki & Okano, 1999; Yesalis, 1999).

This series will examine the support for and potential strength of the causal link between AAS use and aggression and discuss putative processes associated with it. In this installment, representative research on the AAS use and aggression relationship in humans is briefly reviewed, including limited coverage of research on endogenous testosterone levels and aggressive behavior, in order to highlight prevalent themes in the literature. For a more in-depth analysis, recent reviews by Bahrke, Yesalis, & Wright (1996) and Sharp and Collins (1998) are suggested. Further installments will evaluate the evidence for a direct causal relationship between AAS use and aggressive behavior in humans, and a model in which aggression in AAS users is moderated by distal antecedent factors, and partially mediated though proximal psychological variables, will be proposed.

This series will not discuss the pharmacology of the potential AAS/aggression relationship or potential undesirable physical effects of AAS use. Such issues are addressed in many peer-reviewed and popular periodicals, including Mesomorphosis. This series is not intended to suggest a lack of potential psychiatric or medical risk involved in AAS use, nor to endorse or condemn AAS use.

In general, although there has been tacit acceptance of the direct relationship between AAS use and aggression in most quarters, a review of the literature finds that support for this relationship is equivocal. In fact, in studies that controlled for extraneous factors through rigorous inclusion criteria and random assignment, there is little evidence to suggest that moderate AAS use leads to aggressive behavior. However, experimental research addressing real-world patterns and levels of use is needed.

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Testosterone, aggression, and dominance
The association of endogenous testosterone (T) with dominance, aggression, or aggressive behavior has a long history in the literature (see Bahrke, Yesalis, & Wright, 1990; 1996 for a full review). The role of T in dominant behavior among males is largely uncontested. However, the notion that dominance and aggression are the same phenomenon is not universally accepted (see Mazur & Booth, 1998). For instance, similar endogenous T levels have been found in both socially dominant but nonaggressive prisoners and their aggressive counterparts (Ehrenkranz, Bliss, & Sheard, 1974). In fact, most studies supporting an endogenous T and aggression link might also be interpreted as suggesting a T � dominance link (Mazur, 1976).

Studies unequivocally supporting a direct relationship between endogenous T and aggression have largely been accomplished with animals. This hypothesis is more rarely supported in humans. Some studies accomplished with "pathological" populations, such as prison inmates, have found that higher T relates to higher probabilities of committing violent crime, being viewed as dominant, and increased rule breaking while incarcerated (Dabbs, 1996). However, this could also reflect a link between T and dominance. Should studies support such a link, a major interpretive hurdle remains; incarcerated individuals are likely to differ from the general populace in many ways that might relate to aggressive behavior, T levels, or both. The generality of such findings is limited, providing little information about T and aggression in the general populace. Indeed, Dabbs (1996) noted that "Relatively few people out of the entire population engage in criminal behavior, regardless of their testosterone levels (p. 180)" suggesting crucial differences between incarcerated subjects and the general population that are not exclusively related to or a result of endogenous T. Such studies highlight the difficulty in generalizing from index cases (such as prisoners or individual "pathological" cases) to the general population.

Also of interest is the fact that the relationship between dominance and endogenous T is not uni-directional. Endogenous T levels not only predict dominant behavior, but are also predicted by it. Winning (the act of dominating) has been associated with an increase in T from pre to post-competition (see Elias, 1981; Gladue, Boehler, & McCaul, 1989; Mazur & Booth, 1998). Hence, increased levels of T in dominant samples might be a result rather than a cause, although this finding has not been universally supported (see Suay et al., 1999, for instance). In addition, some researchers have reported pre-contest rises in T, suggesting an anticipation of future need. This anticipatory rise in endogenous T suggests a system whereby a classically conditioned expectation exerts its influence, a system with implications for psychological theories of the AAS/aggression relationship.

In summary, the relationship between endogenous T and aggression is complex. As with most relationships between physiology and complex behavior, it reflects a "biopsychosocial" process, involving an interaction between the biological substrate of hormonal action, the psychology of the individual, and the social environment in which behavior occurs. Additionally, inconsistent definitions and operationalizations (e.g., discriminating dominance from aggression), the bi-directional effects of T and dominance/aggression, and the lack of longitudinal studies of the T/aggression link in large representative samples, are a few of the factors that complicate the examination of this relationship.

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AAS and aggression in humans
Even a cursory search of the psychological and psychiatric literature finds it replete with empirical reports and case studies suggesting that AAS users score more highly than the norm on personality scales measuring hostility. Regardless of this seeming consensus, it has recently been acknowledged that, although AAS use and aggression are correlated, the full extent and nature of the relationship remains unexplained and a clear inference of causality cannot be drawn (Beel, Maycock, & McLean, 1998). For instance, Riem and Hursey (1995) presaged Dabbs� (1996) sentiments regarding T and aggression, but in relation to AAS use, commenting that "In sum, not all AAS users exhibit aggressive behavior, even though all experience increases in sex steroids (p. 250)." Although AAS use is reportedly widespread (see Brower, 1992), relatively few AAS users exhibit overtly aggressive behavior (rage). Factors that might underlie this variability will be discussed later in this series.

The literature on endogenous T and aggression/hostility provides little assistance in clarifying the potential AAS/aggression relationship in humans for a number of reasons. First, in contrast to endogenous T, AAS use is a behavioral choice. Hence, it is not randomly distributed within the population and AAS users are likely to differ from nonusers. Secondly, AAS ingestion and injection are not simply physical or chemical events, but also behavioral events, part of a sub-culture and a ritual.

The literature on AAS use and aggression encompasses a range of research methods. As with most drug use literature, it is heavily laden with descriptive statistics. For example, lifetime prevalence of AAS use has been reported as 9.1% for males in Great Britain (Korkia & Stimson, 1997). Between 4% and 11% of males in the U.S. have tried AAS (Brower, 1992). And 6.3% of high school football players in Indiana are current or former AAS users (Stilger & Yesalis, (1999). [For a full review of the epidemiology of AAS use see Yesalis, Kennedy, Kopstein, & Bahrke (1993).] An abundance of anecdotal "personal stories" appear in the popular bodybuilding press (e.g., Lefavi, 1998) and case studies are also frequent in the scientific literature (e.g., Corrigan, 1996; Pope & Katz, 1990; Schulte, Hall, & Boyer, 1993; Wilson-Fearon & Parrott, 1999). These data represent naturalistic evidence of this relationship. Evidence from such reports, while rich in individual detail, contributes little to an understanding of the relationship between AAS use and aggression in the larger population. They are biased in that any number of characteristics might differentiate such individuals from the general population besides their use of AAS, again highlighting the difficulty in attempting to speculate about "normal" processes, pharmacological or psychological, in "abnormal" cases. Nonetheless, such cases constitute the majority of the evidence to which the populace is exposed.

More rigorous studies involve the observation of the concurrent correlation between variables within large groups (empirical research) or comparisons between existing groups on concurrent measures (cross-sectional research). Changes in relationships may be evaluated over time, either within or between existing groups (longitudinal or prospective studies). Lastly, treatments (i.e., the administration of AAS/placebo) may be applied to either pre-existing groups (quasi-experimental designs) or to groups of randomly assigned subjects (true experimental designs) who are then evaluated over time.

Empirical and Case Studies.

A substantial amount of empirical research supports the AAS/aggression relationship. For instance, AAS users report higher levels of anger-arousal and hostile outlook than a group that never used AAS (Lefavi, Reeve, & Newland, 1990). Interestingly, data collected from former AAS users was not reported, so it is uncertain if they differed reliably from either group. AAS users exhibit increased instances of mood disorder (Pope & Katz, 1994), higher scores on aggression scales on personality measures (Galligani, Renck, & Hansen, 1996; Yates, Perry, & Murray, 1992) and measures of mood (Bond, Choi, & Pope, 1995). Nonetheless, as with the T/aggression relationship, findings of reliable differences in psychometrically assessed psychological characteristics between AAS users and non-users are not universal (e.g., Malone, Dimeff, Lombardo, & Sample, 1995; Swanson, 1989).

Several case studies (e.g., Pope & Katz, 1990) and retrospective evaluations of forensic records (e.g., Thilbin, Kristiansson, & Rajs, 1997) have also reported associations between AAS and aggression or other psychopathology. However, as noted previously, generalizing from case study data or criminal index cases to the larger population is, at best, a tenuous proposition.

The majority of the empirical and case studies suffer from methodological flaws, such as inconsistent operationalizations of aggression and differing psychometric measures (Bahrke, Yesalis, & Wright, 1996), making comparisons across studies difficult. Most rely exclusively on self-report measures of aggression, a method susceptible to several sources of bias. And, as mentioned earlier, inferring causation using such data is problematic in that AAS use is not randomly distributed in the population. The choice to use AAS, potentially at high doses, is likely to be confounded with a number of predisposing individual differences. For example, current or past AAS users might value aggression and consider aggressive responding a desirable outcome.

Ultimately, the data are largely inconsistent and inconclusive (Uzych, 1992) and a causal relationship between AAS use and aggression has not been established (Isacsson & Bergman, 1993).

Prospective and Longitudinal Studies

Choi, Parrott, & Cowan (1990) followed current AAS users and a non-using control group over a period of several months in a prospective and to some extent quasi-experimental design. The AAS group was evaluated both when using and not using AAS (an ABBA design) and non-users where evaluated at the same times, but never used AAS. A significant group (user/non-user) by drug phase (on/off) interaction for aggression, assessed by the Buss-Durkee Hostility Inventory (BDHI) resulted. Subsequent tests found no reliable effect for drug phase or user status. On the other hand, although there was no significant interaction for hostility (BDHI), there was a reliable effect for group: AAS users were more hostile than non-users, regardless of drug phase. This longitudinal (prospective) quasi-experimental (self-selected and administered treatments - used or did not use) study suggests that those who chose to use AAS were more hostile over time, whether using or not. The assessment of hostility prior to first ever drug use (difficult to accomplish given the low base rate of AAS use) would be more illuminating.

This study was quasi-experimental; there was no random assignment to conditions. Users self-selected drug use and had a prior history of use, and the controls chose not to use AAS and were lifetime nonusers. AAS users and nonusers have, in other empirical studies, differed in their mean scores on a variety of self-report and psychometric measures of personality and aggression (e.g., Galligani, Renck, & Hansen, 1996; Moss, Panzak, & Tarter, 1992). Therefore, any between group effects (as compared to "cycling on or off" differences) merely replicate the cross-sectional findings and might represent dispositional factors related to self-selection, rather than AAS use.

In a within subject, double-blind, prospective design, Su et al., (1993) examined four within subject drug phases: placebo baseline, low dose (40 mg/day) and high dose (240 mg/day) Methyltestosterone and placebo withdrawal. Each phase lasted 3 days. Significant increases in positive mood, negative mood, and cognitive impairment during high dose administration resulted. One out of twenty-nine (approximately 3.4%) participants exhibited a hypomanic episode (an atypical, but non-severe elevation of mood). Although changes in hostility across time showed a dose response relationship, the only reliable differences were between placebo and high dose time periods. These authors note that "The increased symptoms we noted during anabolic steroid administration, while significant, were subtle, reflecting several factors. First, the response to anabolic steroids across members of the subject group was highly variable, ranking from negligible to dramatic (p. 2763)." They acknowledged that marked increases in a small number of subjects were sufficient to create significant differences across time periods and, perhaps most interestingly, noted that "Symptomatic differences did not, however, reflect differences in plasma anabolic steroid levels (p. 2763)." It must be noted that this dosing pattern, a single AAS used at relatively low doses for a very short period of time, does not generalize to typical use in a naturalistic setting. In fact, as the quote above suggests, any behavioral or psychological response in this sample had less to do with blood levels of AAS than with other apparently unmeasured variables.

Gradually increasing doses of testosterone cypionate (150, 300 and 600 mg/week) or placebo were injected, in blocks of two weeks, into eight normal male volunteers, including both prior AAS users and nonusers (Kouri, Lukas, Pope, & Oliva, 1995). Aggression was operationalized as the number of button pushes chosen in order to subtract points from a fictitious opponent. The fictitious opponents� subtraction of points from participants represented provocation. Two participants failed to believe the sham opponent deception and were dropped, leaving six participants for subsequent within subject comparisons. Increased "aggressive responding" in response to provocation, as compared to both placebo administration and baseline measures, followed testosterone administration. Higher scores were also reported on the Aggression Questionnaire at post testosterone as compared to baseline, largely due to increases in the Physical Aggression score. Whether the participants included (five lifters and 3 non-lifters: 3 with a prior history of AAS use) and the measure of aggression used provide much insight into the AAS/aggression relationship is uncertain. It was not clear which participants were excluded or, in light of the exclusions, how to interpret the statement "Since many of the subjects could not discriminate the testosterone treatment from the placebo treatment� (pp. 77-78)" in view of the small number of participants included in the analyses.

Quasi-experimental studies

Swanson (1989) examined concurrent differences between current AAS users, non-AAS using athletes, and non-using non-athletes on aggressive behavior. Group membership was verified by urinalysis. A sham reaction time competition was used and the participants� choice of a noise level to which their "opponent" was exposed if the opponent were slower on the task constituted the measure of aggression. Participants also completed the BDHI. No between group differences were found in behavioral or self-report indices. This study is subject to the previous caveats regarding self-selection when using pre-existing groups, as well as issues related to the operationalization of aggression. Even so, while certain correlations were significant within the AAS using group, there were no differences reported between AAS users, non-using athletes, and non-using non-athletes.

Experimental Studies

Several true experimental studies, incorporating random assignment of non-using participants to AAS or placebo treatments, have recently appeared. Although the ability of such studies to generalize to self-initiated and self-maintained AAS use can be limited, they address a number of the problems associated with the cross-sectional, prospective, and quasi-experimental designs reviewed above. They constitute a true test of the AAS/aggression relationship while controlling for biases associated with self-selection and the existence of predisposing characteristics.

Bjorkqvist, Nygren, Bjorklund, and Bjorkqvist (1994) randomly assigned twenty-seven male participants to receive no-treatment control, placebo, or 40 mg/day orally administered testosterone (Panteston) over a seven day period. Both self-reported and observer-rated mood showed no effect of drug treatment. In fact, the only reliable differences reported, for self-reported anger, irritation, frustration, and impulsivity and for observer ratings of frustration, indicated that the placebo group scored higher than the no-treatment or testosterone treated groups. While, as in earlier studies, the low dose level certainly impacts the applicability of these results to real world AAS use, it is clear that anticipation and expectation played a part in participants� observer rated behavior and self-report. However, as these authors point out "What is surprising and calls for an explanation, is the absence of a placebo effect in the group receiving testosterone (p. 24)."

Tricker et al. (1996), reported on mood and behavioral changes in a sample in which physical performance changes were reported separately by Bhasin et al., (1996). Testosterone administration (600 mg/week testosterone enanthate in 3 ml. sesame oil or a placebo of 3 ml. of sesame oil, IM) and exercise (strength training v. no exercise) were completely crossed to create four treatment cells. Forty-three males were randomly assigned to the four conditions and evaluated over a 30-week period in the following order � 4-week control period, 10-week treatment period, and 16-week recovery period. Forty participants completed the study. Attrition was unrelated to adverse drug effects. No between group difference in mood or behavior assessed via psychometric instrument, self-report, or observer (significant other) ratings were reported. As before, both dose and the use of a single drug may not accurately reflect naturalistic practice. Nonetheless, the administration of a supraphysiological dose of AAS over a 10-week period to randomly assigned participants found no reliable differences in aggression between those receiving AAS and those receiving placebo.

A recent study (Yates, Perry, MacIndoe, Holman, & Ellingrod, 1999) reported similar results. Of 42 participants randomly assigned to receive either 100, 250, or 500 mg/week of testosterone cypionate, 31 completed the study. The design included a 2-week period of placebo injections for all participants, followed by 14 weeks of injections at their assigned dose. Attrition was largely related to failure to attend weekly visits, although two 100 mg. dose dropouts were excluded due to psychological exclusions (personality disorder and high BDHI prior to treatment). One 250 mg. participant dropped out due to gynecomastia and one was lost to follow-up. One 500 mg. subject dropped out due to worsening acne and another withdrew due to adverse psychological effects (increased irritability, sleep-onset insomnia, and concentration problems � but no aggressive behavior). Analyses indicated no significant differences in attrition across the groups and no effect of non-completion on the results found with those who completed the study.

No reliable effects of any dose were found for measures of aggression, whether self-report or collateral ratings. Several quotes from these authors are noteworthy. First, they noted "�testosterone cypionate at doses of up to 500 mg/week is associated with minimal psychological effects for the majority of subjects in the study (p. 258)." However, "�the entry criteria were extremely rigorous. More than half of the potential subjects were excluded because of evidence of Axis I or II disorders or elevated psychometric measures of aggression (p. 259)." Again, the use of a single AAS and the range of doses administered do not reflect real world use, but neither do the exclusion criteria. Nonetheless, through the use of random assignment and rigorous exclusionary criteria, most potentially confounding variables (self-selection and pre-existing psychological factors) were controlled for in this study. The results suggest that, when such factors are controlled for, there is relatively little evidence to link AAS use with aggression at the doses used.

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Summary
This brief review of the literature finds no clear, consistent, and unequivocal support for the hypothesis that AAS use causes aggression. Does this refute the anecdotal reports and case studies that depict heavy steroid users as aggressive? No. Not only can such idiographic results not be generalized to the larger population, but also the normative data cannot account for all individual cases. In addition, ethical concerns regarding the use of higher dose levels and multiple AAS in experimental studies, confounds the pattern of use with the method of data collection (naturalistic, empirical, or experimental). It certainly does not refute the existing evidence for the modulation of neurotransmitter systems associated with aggression by androgens (e.g., Cologer-Clifford, Simon, Richer, Smoluk, & Lu, 1999). Does the inconsistency call into question the reflexive and widespread assumption that the use of AAS inevitably leads to aggressive behavior in humans or that such behavior is a result of purely pharmacological events? It would seem so, at least to some extent, and within the limits set by issues of dose and simultaneous use of multiple AAS. Certainly the null hypothesis, that AAS use is not necessarily causally related to aggression, cannot be rejected.

In short, as Beel et al. (1996) suggested, the literature reveals a rather complex relationship between AAS use and aggressive behavior. Perhaps this complexity has been over-simplified for mass distribution, an occurrence that is common in such instances. If so, there may be several reasons for it. The complexities of the relationship may be distilled down to imprecise bits of information for dissemination to a populace that deals best and most comfortably with short, easily digestible answers. People often desire easy to grasp dichotomies, preferring simple and clear-cut conclusions even when faced with decidedly complicated and uncertain realities. Perhaps this simplification reflects the desire to curtail the potential abuse of AAS. Such statements, that a certain drug causes undesirable behavior, often become an integral part of "scare tactic" approaches, presenting extreme or worse case scenarios to enhance negative expectations. Unfortunately, such messages mean little to ongoing users, whose experiences might disconfirm the assertion. And, conversely, such statements may heighten the drug�s appeal, should the outcome (e.g., increased aggression) be desirable to the individual contemplating use or lead to negative outcomes, when the taking of the drug facilitates the expected outcome.

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"Lean, mean" and feeling "powerful": Premature osteoporosis among young female athletes: Experiences and feminist sociological analyses
Joyce Sherlock

De Montford University, Bedford, England

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This paper focuses on issues of being in control and being out of control of one's behaviour raised through research which gathered accounts of the experience of overtraining amongst young sportswomen. The initial purpose was to understand the processes involved in overtraining in order to educate others: young sportswomen, parents, teachers, coaches, doctors and sporting officials. In triathlon, the young women's sporting ambitions were accompanied by training regimes which absorbed, with work and sleep, their whole way of life. The culture of the sports club proved to be absolutely central to their social world and sense of personal identity, so that injury meant being unable to be the person they saw themselves as being. Training to become faster was accompanied by almost excluding eating or rationalising a low fat diet to reduce body fat and excess weight. Long term lack of menstruating was not an unwelcome fact of life. Together, the intensity of training and imbalance between energy intake and expenditure, combined with amenorrhea, would seem to have contributed to premature low bone density in these extremely thin females (Drinkwater,1992; Wilmore, Wambgans, Brenner, Broeder, Paijmans, Volpe & Wilmore, 1992) (although, osteoporosis could be more connected with reproductive function than diet). Through their sporting involvement these young women became thinner and faster, but also fragile. Their disciplined behaviour signified self-control and yet they recognised an obsessiveness which was a loss of that control. They experienced being driven to irrational behaviours, of being unable to choose the sensible and healthy option even if able to recognise it, such as to rest instead of training when on the edge of injury, or to eat without guilt.
This was articulated thus by one triathlete:

I laugh at myself over some things but at the same time am concerned at the power of all this. Sometimes when I've felt hungry I have even had second thoughts about having a banana. At the back of my mind and nagging me has been the knowledge that its fat content is higher than other fruits, so an apple would really be a better choice wouldn't it? Invariably I 'refrain' and choose the apple. Control and self discipline are definitely key factors in all of this. Just as sticking to training programmes, I...felt satisfaction in being able to 'say no' to certain foods, to discipline myself into the attitude that these were things that I 'didn't eat'. A part of this is to be regarded as someone who is 'healthy', has a 'healthy life style' and the association with this of avoiding fat and sweet foods. Now I know all too well that with both diet and training, what is 'healthy' should be seen as the top of a curve, not the end of a straight line-there are certainly very real dangers in going too far and as I indicated above, I can now see a 'power' of influence over attitudes and rationality that does 'get a grip' on you, so that you are arguably no longer in control...(I've)...got as far as being aware of 'the problem', that what started as a move towards a healthier diet became a health risk in itself... I'm finding increasing difficulty knowing what tense to use-past or present?, because it isn't something I'm totally over by any means...getting into this situation and patterns of behaviour was progressive and took time, changing them does too, but awareness is certainly a critical first step...awareness alone isn't going to change anything and...you can only change if you really want to and believe in the benefits that will arise as a result. I'm not sure how far down the line I've gone..a little way but not far and it is difficult....

What follows is a socio-cultural analysis which extends research for overtrained female athletes and which began in 1995 with an interdisciplinary focus. Research into osteoporosis tends to be of a medical nature and overtraining is often analysed in psychological terms (see, for example, De Souza & Metzer, 1991). Of the few sociological studies which have any direct relevance, Nixon 11 (1989) extends Yates, Leehay and Shisslaker's (1983) observations on the similarities in character, adaptive qualities and background between American males addicted to distance running and anorexic women. The males are perceived as "obligatory runners", whose behaviour might be glorified, but females exercising to keep thin are more likely to be considered sick. Nixon 11 (1989) concentrates on the differences between them, but both frame behaviours in terms of problems of identity and role adjustment, "positive deviance" and pathology on the part of participants fitting into American society. He emphasises the importance of his recognition that these subjects are very successful adherents to, and practioners of, behaviours designed to achieve the American dream. They demonstrate values of individualism which may lead to asocial behaviour. He also recognises that the contemporary meaning of success may be ambivalent and for females, bringing ambiguities such as unpopularity generally and with males in particular. Males may not find the kind of satisfaction in work they had anticipated. Both males and females may turn, for security, to gender appropriate ways of finding alternative success in a time of loosening patriarchy, which yet retains equivocal responses to female power. Their obsessive preocccupation with running and anorexia may be further exacerbated by the severance of links with significant others in a sub-culture whose taken for granted competitiveness does not challenge such compulsive behaviours. As such, why these people behave the way they do is because socialisation into the values of the American Dream has been adhered to in unrealistic ways which do not take structural obstacles into account, thus creating unstable identities which need social support and control to bring them out of their uncontrollable behaviour. The existence of females who become very serious about running is acknowledged by Nixon,11 (1989), but they are not seen as addictive, rather pursuing routes to traditional femininity through keeping weight down for an attractive appearance.
Analysing accounts of the osteoporotic young women in my sample showed that they recognised the compulsive nature of their training making them "obligatory runners", not recognised in the research above. They showed a strong commitment to the club sub-culture of triathlon which does not challenge continued compulsive behaviour, much as the males above had done. Since these are "obligatory runners" who are female, and there exist male anorexics (Waugh,1993), an explanation for their behaviour cannot be entirely, if at all, that traditional gender behaviours are providing coping strategies for identity problems. Further, the female runners say that significant others during the growing up process at one point or another were far from supportive, in expecting them to aspire to a model at odds with their perception of themselves, whether of traditional femininity, or academic achievement, which the running behaviour challenged with a different body image or sporting success preferred to academic success. Rather than traditional femininity and sex-appropriate behaviours being the only gender aspirations available to contemporary British young women, feminist discourses may have encouraged so-called unisex sports like triathlon and perhaps aspirations towards gender equity, while the current popularity of females taking part in traditionally male sports such as football and rugby, may be a way of challenging traditional femininity.

Although a high incidence of anorexia amongst female British runners has recently come to light (Hulley, cited in Bee,1997), and Seaton (1997) talks about a crisis in women's running, my subjects did not present themselves as anorexic. What they share with anorexics is the belief that the social power their physical state imbued them with provided important ways for each of them to present her own idea of herself, her own desires, giving her a sense of control over destiny. There is a strong sense in each account of a belief in the freedom to become what she desires. Research on premature osteoporosis is strictly contemporary, coinciding with the increased competitiveness of sport as scientific training techniques become taken for granted. As osteoporosis, usually considered a disease of old age, seems more prevalent in women than men, so in young athletes, it is being presented as connected with female reproduction. Hormone replacement therapy has been a form of treatment for both age groups. McSween (1993) in her feminist and sociological perspective on Anorexic Bodies suggests that

in the anorexic symptom women try to synthesise contradictory elements in their social position through the creation of an 'anorexic body' (p.2).
Here we have an analysis which discerns a logic in behaviour which, popularly, and in much medical practice, seems nonsensical and devoid of any positive characteristics. Contradictions between being rational and educated on the one hand and domesticated and caring on the other, between being modest and chaste in contrast to being sexual, being constantly surveyed while supposedly having a right to survey, to be sexually active and choosing rather than only available to men's desires, to be independent and separate, while at the same time dependent and responsive, these are some of the common dilemmas related to control over her destiny reiterated by and for the contemporary female. Place (1989) saw this as resulting for her in a "battle to find words to express the world as it is -full of paradoxes and not the narrow, simple place some parents describe it to be" (286: cited in Eckerman, 1997, p.151). Self starvation was for her a means of trying to resolve the paradoxes, through the creation of a body on which the signs of the paradoxes could be read. A dilemma for the feminist analyst is whether she abrogates responsibility for intervention. Does a young woman have the right to starve herself to death? McSween (1993) makes it clear that she applies a feminist and sociological analysis to the accounts which she has gathered. It is her interpretation of what her subjects are saying that we hear.

Similarly to the way that osteoporosis is generally treated, McSween (1993), defines anorexia as a woman's disease. She says that the central features of anorexia are recognised by contemporary psychiatry, just as they were in the nineteenth century when Gull and Lasegue, quite independently in England and France respectively, introduced 'anorexia nervosa' and 'hysterical anorexia' to the medical establishments. These features are:

emaciation, occurring without organic causation; a specific distribution by age and by gender (although the class distribution was not noticed by Gull and Lasegue); the denial by the patient that she was ill, and the corresponding recognition of a degree of conscious choice in anorexia; and a view of anorexia as a non-organic disorder (McSween,1993, p.15)".
There is a contemporary consensus that 'anorexia'-lack of appetite-is a misnomer, as the anorexic woman still experiences hunger, and her appetite remains 'normal'. Through a critical debate with Turner's (1984) sociology of the body and others, significantly Marx, McSween (1993) argues that

we can identify the dominant bourgeois body-concept as that of an individualized and completed possession of the self which is finished (in normal circumstances) after the integration and separation of the formative years of infancy, and through which we pursue pleasure and satisfy our (internal) desires in the expropriation of the separated environment....desires form the 'core' of the person. The autonomous pursuit of individual interests is, then, the model for both the body and the self" (p.153-4).
She continues, showing that Turner's (1984) rendition is not gender neutral, but more applicable to masculinity than femininity,

masculine bodily integrity -or closure, or separation-is constructed in relation to, and depends on the maintenance of feminine bodily openness; and...masculine bodily instrumentality is defined in relation to the construction of the feminine body-as- environment...dominant(masculine) and subordinate (feminine) body concepts are created through a set of oppositions-open/closed, active/passive, hard/soft, muscle/flesh-and... consequently resistance to or changes in one affects or undermines the other (159).

For my purposes, what Turner's (1984) analysis does, which Nixon11 (1989) and McSween (1993) do not do, is to indicate the possibility of an individual perceiving themselves as a candidate for social success in consumer culture, without considering gender to be an issue. But the point McSween (1993) makes in bringing a feminist dimension into a criticism of Turner, is that broad tenets of feminism, such as doing what men can do and doing things for your own pleasure, have so much permeated popular consciousness, or at least the social milieu of the formally educated (and such is the inflexibility of functionalist analyses like Nixon11's, which can talk easily about deviance, as though we had clear ideas about normality and health) that we have to recognise that subjects can see anorexia as a positive strategy for them, struggling for their individuality on their own terms against continuing perceptions of male surveillance acting upon them both sexually and authoritatively.

In her application of a bodily analysis to interviews with anorexic women, McSween (1993) shows how the feminine body is created as an object on which the masculine subject acts, and which he owns: women maintain bodies as objects through dietary, cosmetic and behavioural practices rather as caretakers than owners. She argues that Turner's (1984) assertion that women have a 'phenomenological possession' of their bodies sits uneasily with women's alienation from their bodies as the objects of masculine sexual desire and site of personally controlled reproduction.

As a step towards evaluating the usefulness of McSween's (1993) method for more deeply understanding the overtraining drive in prematurely osteoporotic sporting females, I now outline what she says about the fitness boom. She sees this as part of an increased concern with bodily health. Initially a middle-class phenomenon, capital, the mass media and the state have taken it up and the market is still expanding. She cites Turner's (1984) reference to associated behaviours as 'forms of secular asceticism' or 'calculating hedonism' and anorexia is one of these. So these non-oppositional 'body-maintenance' practices are ways in which we enable ourselves to consume more sex, work and achieve longevity. This is of benefit to the state and the medical profession and the healthy jogger becomes the healthy citizen. McSween (1993) extends this, pointing out that as well as treating the body as a vehicle for consumption and individuation, it can also be a 'last resort' of a sense of individual control in the absence of believing that we can impact upon our environment. This is an idea of living in rather than through the body. Seeing this as gendered, through the ideology of femininity, the female is acted upon rather than acting, consumed rather than consuming. Chapkis (1986) is cited as arguing that 'the exercise of control over the body compensat(es) for a basic sense of a life out of control' (McSween, 1993,p.156) and that the pursuit of beauty is more attainable than such male controlled desires like jobs and promotion. Chapkis is also said to argue that fitness for women is fit to be looked at rather than fitness to act.

In spite of the reluctance of British governments to become deeply involved in centralising sport (Hargreaves,1986), a governmentally funded British Academy of Sports is a response to the emergent, arguably, global consumer culture of sport. This puts the emphasis on the nurturing of talent, performance rather than participation, and the creation of national champions. As such, the significance of sporting success is designed to indicate the health of the nation in not only physical, but political and economic terms, as the success of the Australian Institute for sport has done. Training for the osteoporotic subjects, as they put it in their own words, epitomises such practice where desire to achieve performance goals, to become a better performer, are tied in with a severe rejection of acceptance of the 'body as it is', for a self-immolatory set of short term and long term aims in running, swimming and cycling distances and sprints, in a highly structured way. For example:

I wanted "to be a runner" and be recognised and recognisable as such-and..(A)nother characteristic of these people that I was impressed by and...desired was that they 'looked fit'-and themselves desired...being 'lean and mean'. The aim ...was to minimise body fat... in losing any 'excess' weight which would...slow down their running in...(10km upwards) races. The relationship between 'thinness' and running identity and performance was something that I was aware of but..became increasingly conscious of and influenced by. Running magazines and television reinforced...what I now see as a dangerous message: 'the thinner- the faster'.
Another subject talked about a coach pursuing this "dangerous message". This philosophy was embraced by participants at both elite and below elite level, where the ruthless competitive values of high level sport are internalised by individuals as members of clubs, but not necessarily being monitored for self-inflicted and potentially dangerous excesses. The individualism of fulfilling potential manifest by these subjects can be related to 'calculating hedonism' because of the pleasure derived in the pursuit of desire, to be identifiable as an athlete, through physical abilities and body image. The extent to which this can be seen as oppositional is in the degree to which one sees sport and femaleness as a legitimate combination in contemporary culture. The purpose of the sporting endeavour would seem to be for its own sake rather than to consume more, as McSween's (1993) reading of Turner (1984) suggests. Yet it is also living through the body rather than in the body since the clear purpose is an instrumental one. As a subject put it:

..Gradually I think I felt myself developing an identity from my participation -as 'someone who ran, and..running started to become 'part of my life'..like my running and my training, my commitment to a low fat diet was something that in time became far more structured and disciplined.
Whereas the state may seem to benefit from a politically docile, self-absorbed athletic population, which at the highest level will be championed as a product of liberal democracy to bring national glory, the politics of women's sport as an equity issue is a slow struggle against hegemonic masculinity and not an issue voiced by the subjects themselves. The medical profession may suffer rather than benefit, as with the sportswomen I interviewed getting viruses regularly, stress fractures, broken limbs from cycling accidents, needing bone scans and experimental treatment, all of which take up precious resources. This is how two subjects articulated their experiences:

over-training...develops very gradually, it's that pattern of that hard, sustained, constant training that I got into...over a matter of years...that gradually your body is saying, hang on a minute, I need a break from this..what that gave rise to was repeated sore throats, eye infections, as well as problems with...pulled muscles. As soon as I started to train it seemed that something would go... I experienced increased circulatory type problems,...I lost a big toenail on two two occasions simply because that circulation had been cut off for so many hours and I remember the pain...of this and the misery of feeling the cold which thin people tend to do.
At 28 years of age, I have the bone density (in my spine and hips) of an 80-90 year old woman. Each day I take 3 different drugs in an attempt to curb further bone loss, one of which is considered a poison and has not been clinically accepted for routine prescription within the UK.....Women of my age are normally building bone rather than losing it. The threat and fear of fracture has become so prominent that I have been forced to undergo a complete change of lifestyle-from that of a competitive and successful athlete, to a relatively "sedate" individual.....I guess that one of the frustrating facts is that my "condition" might have been avoidable and is, to some extent self-inflicted.... While she was training hard "Despite my thinness, I felt strong and powerful". Yet a bone scan revealed bone density of a woman in her 70s. Incredibly, I managed to convince myself that it didn't matter; to blot it out of my mind and tell no-one else....Two months later, whilst "storming along" on an early morning training cycle ride...I swerved to avoid a pothole, failed to hear a fast approaching car and was knocked flying. This resulted in a broken pelvis and three months off training. Within 2 weeks of the accident I was hopping around on crutches...Another 2 weeks on, I still couldn't walk, but found that I could pedal, almost pain free on my turbo trainer...My mind was saying "do it" even if my body said "no". I became a "driven woman" again, determined to regain "fitness" and this continued for another two years, with "some good times in cycle time trials, but (I) was pushing my body very hard and constantly suffered upper respiratory tract infections". After contracting the Epstein Barr virus while feeling "like death", yet cycling 150 miles a week and swimming 4 hours each week "my body "packed in" and despite extreme motivation, I couldn't exercise..I'd reached rock bottom and it was time to quit.

Much of the treatment for sports injuries has to be privately funded and the specialism of sports injuries has opened up another career avenue for doctors. This is not to mention the relatively new career of sports scientist and the development of exercise physiology in both an understanding of general exercise on the body and also training regimes for committed athletes. But for females this is relatively marginal terrain. Lottery finance for sport, most markedly influencing gender equity as a criterion for acceptance, has been seen as a positive financial intervention, with interesting consequences as in the recent case of cricket and the MCC. In this context women's sport has yet to throw off the vestiges of separate organisation and largely amateur ethos and become truly integrated on either terms of equity or of women themselves. At the same time, the perceived affluence of women in the consumer market, and the success of companies like Reebok, prompting Nike in America to win the market sector of sporty young women, may have consequences in UK.

With regard to triathlon and the osteoporotic subjects I want to gain a better understanding of, it can be observed, and one subject has pointed out, that the masculine model of testing the limits of endurance are the aspiration of strong and less strong women and men, with the standard being set by the most powerful men and the organisation of the sport. This is far from being the unisex sport of the millenium, being hierarchical and administered mostly by males. So, with regard to the issue of control for my subjects, there has been no definite move towards the openness of femininity but clear aspirations towards the closed ideology of masculinity and individuation. This is not necessarily how the osteoporotic subjects perceive their behaviour, but sociologically, it has taken place in a context of control literally by males and ideologically heterosexually bounded (as by media invisibility and the kinds of representations of women in sport) so that sport is defined as competitive, aggressive, needing total dedication, a closed structure. McSween (1993) makes the point that the definition of feminine in bourgeois culture operates through the concepts of discipline, object and chaos. She also goes on to say that self-control is part of being feminine-we watch how we sit, walk and what we eat. I'd say that my subjects do not easily watch these, one at least openly rejecting the idea that gender has much to do with her behaviour. As in the film A League of Their Own, the sports business world, sporting institutions like physical education and national governing bodies of sport today, regulate dress codes and behaviour in a way generally taken for granted. Players in the film trained in functional clothing of their own choice, but then had to be groomed for the market to wear short 'girlie' dresses, be socially graceful, womanly, poised and decorous. Their exhuberance, on the other hand, was at first a surprise to audiences and then a necessity to draw the crowds. It had to be kept under control when it broke out in a dance hall. McSween (1993) recognises a reworking of such issues in different social contexts and 1990s UK is obviously very different from 1940s US. The question is whether osteoporotic female athletes, like anorexics, use their bodies in sport as a 'site of image production': objectifying, disciplining and coping with chaos.

McSween's (1993) emphasis on a bodily analysis, which indicates that as well as treating the body as a vehicle for consumption and individuation, it can also be a 'last resort' of a sense of individual control in the absence of believing that we can impact upon our environment, could be applied to sport in the sense that, as an institution, it is more renouned for its conservative tendencies than its critical edge. In the case of sportswomen's accounts this would not seem to apply, for they have clearly aimed for individuation and to an extent achieved it. As professional young women, they are financially independent, and have a strong sense of resistance to being consumed. As such they may well pose a threat, in challenging and undermining the ideology of male competency and heroism. This is far from the threat of feminine openness, discussed by McSween (1993). If women can do what have been seen as the mythical physical feats of humanity, then these can hardly have the social currency they once had. Chapkis (1986) is cited as arguing that 'the exercise of control over the body compensat(es) for a basic sense of a life out of control' (McSween, 1993,p.156). This certainly might apply in the case of the osteoporotic subjects, but they do not speak of the pursuit of physical beauty at all. They are ambitious to attain such male controlled desires like jobs and promotion. If endurance sport is the last bastion of hypermasculinity, then they have gone for it full tilt. There seems at first glance no sense in which we can apply Chapkis' comments that fitness for women is fit to be looked at, rather than fitness to act, from what our sporting subjects say about themselves. That is, except for the reference above by a subject to a desire to be like new acquaintances, triathletes, whose image and lifestyle was 'lean and mean' and by another, to athletic training making her 'feel powerful'.

There seem to be some distinctions between prematurely osteoporotic female runners with obvious eating disorders and anorexics. Remember that McSween (1993) argues, in explanation of anorexic behaviour that the feminine body is created as an object on which the masculine subject acts, and which he owns: women maintain bodies as objects through dietary, cosmetic and behavioural practices rather as caretakers than owners. She argues that Turner's (1984) assertion that women have a 'phenomenological possession' of their bodies sits uneasily with women's alienation from their bodies as the objects of masculine sexual desire and site of personally controlled reproduction. If we take each point in relation to the triathletes, there is much more of a tendency for women to behave like men, in the sense that the desire is not for a feminine body on which a masculine subject acts, but rather for a sporting body which is owned by the female herself in the pursuit of her desires, which are to be lighter and faster, but which have made her fragile. The social context of the running club is relentlessly competitive, not in the sense of competing for a male, but in the sense of becoming a better athlete, improving performance times, training harder and in a more dedicated way, gaining satisfaction from self-discipline, countering lack of control and lack of self-discipline. This is both not feminine in the sense that masculine desire would, at first sight seem to be absent in sexual terms, and it would seem gender neutral in the sense of simply being, to the subjects themselves, as rational as possible, as efficient as possible, as professional in the sense of being as ruthlessly competitive as possible. It is, however, from a sociological perspective, clearly a masculine model adopted by females driving their bodies as though the female reproductive system were of no consequence, and as though the quasi-neuter body was inviolate. Also, for one subject, answering: "Why the dedicated participation, why the overtraining, why the level of commitment..." says

..I think this all hinges on the sort of issue of insecurity, the need for an identity for recognition and the security that that can offer, and the absence of that otherwise in one's life. And certainly in my case I trace it back to my childhood and what I regard as particularly from my father a sort of essential rejection of who I was, of the character I was and that I wasn't the daughter that he'd hoped I would be and that I think left a very big impression on me....I was a swot at school, I wore glasses...and if you add that to a situation at home...of great insecurity and uncertainty because of my father's mental illness....I didn't have any control over the situation I was living in and that's left me very scared of being out of control of anything, and so being out of control of my life....He essentially wanted me to be a glamorous, slim, a woman who's basic priority would be marrying someone successful and bringing up a family.
There a strong sense of closure here, an instrumentality, little sense of openness, and a rejection of the body-as-environment. Dominant (masculine) and subordinate (feminine) body concepts are revealed in the emphasis on the need for activity over passivity in training, its consequences in creating a hard, muscular (lean and mean) look-and that consequent resistance to femininity brings in a celebration of the woman she desires to be, regardless of whether masculinity undermines femininity. Women are controlling their reproductive processes, and pleased to be without the nuisance of menstruation, controlling their desired image in relation to expected images from childhood, while ironically, at the same time they are being controlled by the ideology of ruthless competitiveness, a belief in bourgeois competitive individualism for status as recognisably a runner, not a woman. Whilst acting as though she owns her body and self, the triathlete is owned and controlled in the sense of, 'being in the power of', the institution to which she has committed herself. She acts as a caretaker of her body for her own pleasure in competition, for the satisfaction of her own desires.

The irony is that in finding her own path to control, away from confessed deeply negative and traumatic experiences in adolescence, she has become deeply committed to a culture of achievement which arguably controls her unless she changes her way of life fundamentally. One subject talked about self- destruction, both of her body and her way of life: the dominance of exercise(her daily run) to the exclusion of interest in its effects: sexual abuse and sexual avoidance: training making her feel "powerful" and as a displacement for relationships: "runorexia" rather than anorexia: low bone density: physical and emotional pain: maturity. She is a researcher and, as part of wanting to help others avoid the mistakes she has made, has appeared on national television, carefully negotiating a role as informant, not victim. She has advised the National Osteoporosis Association on this subject group and written for women's magazines. For her there has been a shift towards concentrating on professional achievement and also an approach to a social life which is calculated to be more rational than previously. She is different from another subject in making an unsuccessful love affair a central aspect of her obsessiveness. A desire for a fulfilling domestic life seems to be more important to her in the account and from other observations. Another subject talked about the difficulty of admitting what she had got into: wanting to be a runner with a "lean and mean" look: differences in competitive levels of swimming and cycling, increasingly structuring activities, discipline and stress: changes in food tastes: overtraining and thinness: lack of structural support: explanations for her behaviour. Her considerable professional and sporting achievements consume her entire existence. Control of her life through personal achievement is the way she continues to live. She has not changed her punishing lifestyle and seems more concerned with maintaining some equilibrium that enables her to maintain present achievements than prepare for future health. The first subject tells us about an identity shift while the second has become her idea of a successful woman, in spite of what her father wanted her to be.

Both subjects tell in their accounts that they became part of athletic club cultures which were experienced as feeling good, right and natural for them. One describes in detail how she became acculturated:

The social aspects of clubs...is a really big thing in terms of the...stress associated with over-training and perhaps being forced by either injury or illness in not being able to train. It's not just the fact that you can't train, it's the impact that that has on your whole lifestyle, your whole confidence, your identity, everything because when you're training at these sorts of levels and you're working, you've got a job which you're committed to and working hard as well, apart from those two things and generally carrying out the sort of everyday mundane things in life there's not a lot of time for anything else and inevitably your social life revolves around the people you train with and know through the sport and if suddenly you're not actively participating in that sport you're missing out on a lot more than just the sport. And it leads to isolation, loneliness and I think when you are injured or something, I mean I'm the last person who'd want to go along and spectate, or even necessarly be with those people who I'd normally train with, because that just rubs in the fact that you're injured or you're ill and can't do it and, therefore, as I say, there is this loneliness and isolation, and I don't think that people who aren't in that situation realise the impact that it does have on people....it's a major part of your life that isn't there and it's very, very difficult to cope with....
For the other, her osteoporosis put her at such risk that she had to give up exercise almost altogether and had to break away from club culture, a fundamental change involving deep pain, having to learn that other less active pastimes, previously considered inferior, can be learned and eventually enjoyed, but not without a sense of loss: "I feel that I've lost part of my "identity" as well as my self-esteem". It would seem that McSween (1993) has much to contribute to an understanding of these particular women when she says "Reconciling the hidden incompatibilities between individualism and femininity is the central task of growing up female in contemporary Western culture" (p.3).

Pressures to be surveyed, to compete for a man, are deeply embedded in heterosexual discourses from childhood socialisation through to adolescence, and in the idea of sport as a morally worthy and healthy pursuit. But, in an environment of a traditional incompatability of sport and femininity, there have been many challenges to deep-seated cultural prejudices against female freedom to choose sport. In the context of female sporting success often being undermined with lesbian inuendos unable to accept that women can be successful and skillful in sport in their own right, such as has been so blatently revealed in the case of Theresa Harrild's treatment by, and subsequent condemnation of cricketers' attitudes at Lord's (Daily Express, Mar.12th, 1998) the idea of individuation to which some females, such as my triathlete subjects aspire seems incomprehensible. It also seems to be just one in many competing discourses surrounding femininity and sport.

A conclusion from the previous discussion is that clearly the homogenous image of femininity implied by McSween (1993) and psychoanalytic cultural analysis does not apply to the triathlete subjects. Like anorexic women, they are very thin, without organic causation; they are in their late twenties and early thirties and undeniably middle-class and highly educated; they confess to recognising a problem which they did not or will not confront fully; they view their obsessive overtraining behaviour as having social, psychological and physiological influences and consequences. But in the context of sport, the gendered nature of their behaviour is more towards a 'masculine' than 'feminine' end, with similar consequences. Furthermore, male athletes can suffer from low bone density (Bennell, Brukner & Malcolm,1996) and Waugh(1993) writes about anorexic males, who need to be accounted for. In the case of the latter, taking up sport as a means to better self esteem and social solace, can play a part in becoming anorexic. Biological essentialism, which might be implied by physiologists focusing on female athletes and hormone replacement therapy as a cure, does not account for the social and psychological aspects of an understanding of overtraining, sought by my subjects.

It is easy to read McSween (1993) as implying a kind of feminine essentialism through her method and conclusions. Certainly many healthy women in contemporary society would appear to choose a recognisably feminine image, and there is little challenge to this in many media images. But, other women do challenge the image by looking different, and also, not only sportswomen, but many professional women challenge traditional expectations everyday in their workplace. They may or may not subscribe to stereotypical femininities, but, I would concede that they are ultimately governed by seemingly rational, professional, gender neutral discourses, which can be aligned with middle-class, white, heterosexual, masculine, achievement orientated values. So while there is more choice being enacted by many people, there is still a dominant standard of attainment which is ultimately sexist in its expectations. McSween (1993) does recognise this, but my example of women who may well be anorexic, but who are or have been also seriously sporting and academic, does show that thinking only in 'feminine' terms does not answer the question of why they would prefer to continue. That lies in the meaning the lifestyle they have chosen offers them as a legitimation of their desired perception of themselves. This way of life provides the means of them controlling what they can be.

These subjects are female "obligatory runners" (Yates et al, cited in Nixon11, 1989) the existence of whom has only been recognised in the past decade. They have been or are taking part compulsively in an activity which still signifies virility but which is becoming more acceptable as pleasurable and a worthwhile enterprise for women, in spite of continuing media ambiguity. They also have silences on food or recognise an eating disorder, still signified as a woman's disease. If they are thin, whether they have an eating disorder or not, the fact of others reading their body as possibly anorexic, may undermine their legitimacy to some extent. Both sets of behaviour signify being out of control, and they interpret their own behaviour as an attempt to control their own lives. In the individualistic 1990s to argue that they are deviant and have unstable identities, is definitely, from a feminist and current sociological analysis, inadequate. But the importance of identity and appearance are by no means absent from an explanation of their behaviour, either a personal interpretation or a feminist or sociological one. McSween (1993) is right when she identifies "hidden incompatibilities between individualism and femininity" (p.3) in contemporary Western culture.

Like anorexics some of these women may wish to produce neuter bodies as a sign of not wishing to be acted upon by masculinity. But this is countered by some females wishing to produce a body desirable because it is a sporting body and not a traditionally feminine one which might imply, to the subjects themselves, not being intelligent, or being passive. To produce this body means belonging to a subculture of like-minded people, emulated for their lifestyle and their appearance. This gives meaning until the need to be the best, a standard presented socially and ostensibly neutrally, takes control. Although they do not necessarily forefront their femaleness as important to their identity, and they show disinterest in either promoting or challenging femininity, their behaviour appears rational and professional, but they are in an arena dominated by extreme male physical standards. In their life histories they reveal a number of incompatibilities between their perception of themselves and how significant others wanted them to be. Their bodies do reveal a surface which indicates something of this, but each life history is different and provides a different explanation for the way the creation and maintenance of identities has intersected with discourses of achievement, desires of image and temptations of fantasies compelling them out of control. Osteoporotic female athletes, like anorexics, use their bodies in sport as a 'site of image production': objectifying, disciplining and coping with chaos, but the difference is that in sport they have chosen an ambiguous goal for a female: glorious sport: glorious if you are a woman? That lies at the heart of the personal and the cultural dilemma.

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