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Volume 15, Number 14
August 25, 2009

nature

Dr. Michael Sigler was an advertiser with The Panama News. This reporter has no grounds to complain about that business relationship. Sigler has also advertised in most of the other English-language media, and has received widespread coverage in both English- and Spanish-language publications. His talk to a community group served as the starting point for an article by this reporter on his practice and the controversial health care movement that it represents.

While that article was in gestation, there was an exchange of emails that started out in this reporter's questions about such matters as where, in fact, Sigler went to medical school. (In the autobiographical part of his advertising, the doctor danced around that question: "Dr. Sigler received his medical training both domestically and internationally, at prestigious universities including Stanford, University of California-San Francisco, University of Miami School of Medicine, University of Toronto, University of Cambridge, England, and Saint Eustatius, Netherlands.")

A suggestion not taken

In the course of that email exchange, Sigler offered free services to this reporter, who in response offered various aspects of medical history: "Do you REALLY want to hear about my medical issues? Let me say that it involves... bipolar affective disorder (the mild sort for me, although the deadly sort has also been in the family)... [and] kidney things...." Sigler responded with an emailed suggestion that: "Lets try some Testosterone for three months. I'll give it to you for free Eric. It helps with all of the below." (Sic.)

Fear of roid rage

That offer was not accepted. This reporter is not a physician, but has heard many a tale of so-called "roid rage," and personally seen some of it.

Testosterone is a natural substance created in the human body, the original version of athletic performance enhancing anabolic steroids, of which there are many synthetic varieties and relatives. You get thrown out of the Olympic movement if found taking it, but it has been a long road to get to that point. In the popular culture, the best known condemnation of steroid use was by former NFL defensive lineman Lyle Alzado, in an interview with Sports Illustrated while he was dying of brain cancer at age 43:

We're not born to be 300 lbs. or jump 30 ft. But all the time I was taking steroids, I knew they were making me play better. I became very violent on the field and off it. I did things only crazy people do. Once a guy sideswiped my car and I beat the hell out of him.

In medical parlance they don't talk about "roid rage," but of manic episodes, under the general headings of "affective" and "psychotic" symptoms. Bipolar affective disorder, also known as manic depression, is a series of conditions involving mood shifts that at their most serious can range from violent mania to suicidal depression. But one need not have a usually hereditary bipolar condition to get into a manic state. According to prestigious peer-reviewed medical literature going back more than 20 years, there appears to be a link between steroid use and affective and psychotic symptoms:

To assess the frequency of affective and psychotic symptoms in athletes taking anabolic steroids, the authors performed structured interviews of 41 body-builders and football players who had used steroids. According to DSM-III-R, nine subjects (22%) displayed a full affective syndrome, and five (12%) displayed psychotic symptoms in association with steroid use. These findings suggest that major psychiatric symptoms may be a common adverse effect of these drugs.

Pope and Katz

Affective and psychotic symptoms associated with anabolic steroid use

145 American Journal of Psychiatry 487-490 (1988)

Case reports and small studies indicate that anabolic steroids, when used in high doses, increase irritability and aggression. Some steroid abusers report that they have committed aggressive acts, such as physical fighting or armed robbery, theft, vandalism, or burglary.

Is there another side to the argument? Of course there is. There is, in fact, a pro-steroids movement, with its own published literature and websites. Moreover, the medical mainstream does not deny that there are some legitimate and recommended uses for testosterone and other anabolic steroids. However, in the fine print among the standard side effects warnings for indicated medical uses of testosterone, we find "mood changes."

And what does the self-proclaimed "World's Most Visited Anabolic Website," the steroid-celebratory Steroid.com, have to say about the "roid rage" issue?

Increased aggressiveness is often claimed to occur with anabolic steroid use. Although it's highly rare (less than 5%), significant psychiatric symptoms have been found in some steroid users, including aggression and increased violence, mania, and even psychosis.

One chance in 25 of being drugged into a violent rage? It's probably an acceptable little risk to a lot of people, but this reporter's very worst personal memory is about a man with a gun in a manic rage. This reporter also lived in a US university town in the 70s and 80s, when steroid use was prevalent in sports and athletes assaulting people was a monotonous phenomenon on campus. The fear of "roid rage" was this reporter's instinctive reason not to take up Dr. Sigler's suggestion.

Another medical opinion about testosterone and bipolar conditions

By and large, health care professionals in Panama won't help out in any journalist's effort that questions the propriety of anyone else's health care practice. There are practical reasons, including the nation's calumnia e injuria laws that can be invoked to criminalize true statements that make someone look bad, and in Dr. Sigler's case we are dealing with a clinic at the Consultorios Punta Pacifica, a flagship of the nation's medical establishment that's affiliated with Johns Hopkins University as a teaching facility. The people at Punta Pacifica can wreak havoc with a physician's career, and it has meant scant cooperation from the local medical profession in the preparation of this article.

However, one prominent local physician noted another risk to this reporter. Bipolars, the doctor said, are notorious for a tendency to "self medicate" by way of substance abuse, and their compulsive use of drugs is an often cited risk related to anabolic steroids. "Whether addiction to these steroids can occur is debatable, but there is evidence for dependence and a withdrawal syndrome," the above-cited British doctors noted. The local physician pointed to the potential for abuse as a reason for any conscientious doctor to be quite cautious about prescribing testosterone to somebody with a bipolar condition.

The kidney issue with testosterone

One of the standard counter-indications listed with respect to approved medical uses of testosterone is that "men with heart, liver or kidney disease may experience heart failure while on testosterone therapy."

Medical research suggests that on a cellular level testosterone can harm kidneys, and biochemistry studies in mice suggest that testosterone is the reason for males being more vulnerable than females to certain types of kidney conditions.

So what's the risk to a reporter who once had a complicated kidney stone attack, has had occasional kidney infections, has occasional gout attacks (which are a kidney function related problem) and takes the commercially available kidney tea from time to time when that part of the body becomes tender? Maybe something that bears further scrutiny before accepting an emailed suggestion of testosterone use.

Revisiting old ground

This reporter looked askance at Dr. Sigler's suggestion, but just reported the outlines of the controversy with a central aspect of his business, the theories behind Cenegenics in general and the assertion that human growth hormone is useful to manage aging in particular and then left the subject alone.

However, since the June 2008 article several sources have brought up certain matters with respect to Dr. Sigler, and in following up on those, other sources have made other relevant statements. Still, both in the health care professions and in the government, people have been reticent to talk about the issues raised.

Shortly after last year's article appeared, a prominent businessman warned this reporter that not only does Dr. Sigler lack a medical license in Panama --- as a non-citizen, it would be very hard for him to get one of those --- but that his lack of a medical license in the United States is worse than it looks at first glance. (At first glance, a Google search turns up 2007 hearings in which Sigler's application for a reconsideration of Florida's denial of a medical license was first delayed and then withdrawn. One must dig deeper for the 2006 public record quoted above.)

Then a former patient told this reporter that Sigler was dispensing medications imported from China without labels, and that one substance that came in unmarked blue vials given to him by Sigler caused his heartbeat and blood pressure to shoot up and resulted in his hospitalization for a heart condition.

Probably due to that former patient's complaint, the Cenegenics Medical Institute denounced Sigler's practice and demanded that he stop using the name Cenegenics. This reporter was able to confirm the broken off --- or, from another side's claim, never existing --- relationship with the Cenegenics people.

Another former patient noted that, while the testosterone and human growth hormone that Sigler had provided him made him feel and look better, it distorted the results of blood tests that are part of his ordinary physical check-ups and made further and somewhat painful other tests necessary.

Apprised of what this reporter has learned, one licensed Panamanian physician said that it appears that, notwithstanding claims that at his clinic in the Consultorio Punta Pacifica all medical work is done by licensed Panamanian physicians, the reality is that Sigler is practicing medicine without a license.

Faced with a stone wall of silence from governmental authorities --- as in, being told to call a number to make an appointment, and when calling that number for that purpose, the repeated response is a hung-up telephone --- and the reticence of both MDs and alternative health care system practitioners to talk, this reporter encountered, seeping out from the cracks in those walls of silence, some things about imported medicinal substances:

• If it's not in the standard medical pharmacopoeia, the governmental authorities in charges of overseeing the quality of medicines that Panama imports pay no attention to a substance. That means that herbalists, homeopaths, and apparently to a certain extent "age management specialists" are overlooked, with the things they prescribed treated as "food supplements" not subject to anyone's regulation.

• If such substances are food products, Panamanian law requires that foods be labeled in Spanish. However, except when there's a great hue and cry in the wake of an international scandal this has not been enforced.

• There is great suspicion of medical or health care substances coming from China. Go to a Chinese herbalist in Panama and it's much more likely that you will be treated with plants from the United States than plants from China, because even in the Chinese community --- maybe especially so --- the quality control problems in the People's Republic of China are frightening.

• Those alternative practitioners who will talk about the sources of the medicinal substances that they use cite bureaucracy in licensing and corruption at Customs and elsewhere as common obstacles that a scrupulous alternative health care provider is likely to face.

Dr. Jeffry Life, the new 60-something Cenegenics chief medical officer,
before (right) and after (left) he got into human growth hormone

Cenegenics may have certain unique protocols, but it's one of several schools in an "age management" movement that centers around the use of human growth hormone and steroids to increase muscle mass at the expense of fat, increase bone density, restore gray hair to more youthful colors and generally create a more youthful appearance and feeling.

Yes, those chemicals do pump you up. In some of Dr. Sigler's advertising, since withdrawn from the Internet, there is a photo of the founder of Cenegenics, Dr. Alan P. Mintz, at age 67 in a bodybuilder's pose. But Mintz died of a stroke at age 69, and now the new Cenegenics poster boy is Dr. Jeffry Life.

Certain things are intuitive to expect. If you have increased bone density, the chances of meeting one's maker as a consequence of having fallen down and broken a hip in one's old age would appear to be reduced. However, the Cenegenics Medical Institute is careful not to claim that its age management techniques increase longevity. While the steroid connection down at the bodybuilders' gym might make extraordinary claims that would demand extraordinary proofs, what seems so unusual in the case of Cenegenics --- sometimes in contrast with rival age management groups --- is, when shorn of the strongman poses and essentially meaningless verbal fluff, how ordinary the claims turn out to be. It's just a variation on a relatively modest steroid dealer's pitch.

Like the larger argument about steroid use, those who talk honestly and seriously about the issues raised by the use of human growth hormone and steroids to manage the ravages of age talk of risks and benefits, in terms of health, economics and social factors.

A 2002 editorial in the Journal of Gerontology didn't dismiss hormone-based anti-aging therapies out of hand, but took a skeptical view:

While the concept of antiaging therapies is intriguing, there is clearly little evidence-based medicine to support most of the generally touted approaches. While research needs to go forward, it is important that gerontologists do not provide support for the large number of inappropriate antiaging therapies.

The American physician and medical journalist Dr. Sanjay Gupta has incurred the wrath of human growth hormone advocates with this take on the substance:

It's not quite as popular, hasn't quite gotten to the same levels as steroids, but it's been touted as, you know, the fountain of youth. It'll turn your gray hair back black. It'll make the skin of you -- your skin more elastic again to try and make you look younger. But it probably has some significant problems as well.

Another physician who often appears on US television, Dr. Andrew Weil, opines:

All of the anti-aging doctors are into giving growth hormone. I would not do that myself. I have concerns about the side effects of growth hormone. It's expensive. It may increase risk of heart disease. It may increase risks of prostate cancer. I'm nervous about giving people hormones if they don't need them and I don't think there is a chemical fountain of youth that's going to make people younger or live forever. Sorry.

However, the expense of "age management" through hormone and steroid approaches --- expect to pay $12 grand or more for your first year of care at Dr. Sigler's clinic, much of it for the initial battery of tests --- perversely becomes one of its selling points. It's what Hollywood stars do to look young, and if most working people can't afford it, the upper middle class can. Figure that, in a time when a screaming crowd that doesn't want the government getting involved in its Medicare can be unleashed on a member of Congress, the snob appeal of elite medical care just like Michael Jackson got would be a selling point in its own right.

Figure that, just as it took decades of use by many women to get a strong statistical base of knowledge about the risks associated with the most commonly taken hormone --- estrogen taken by women for contraception --- that process is going to take awhile with human growth hormone. The people using chemicals to manage their aging processes will be long gone before we have any base of knowledge comparable to what is now know about estrogen for birth control. Strip away all of the issues about the personalities involved, all of the conflicting prejudices and all of the imagery brought to bear, and the medical controversy will remain with us for years to come. Even when there comes to be a medical consensus about the age management movement's claims about hormones and steroids, there will still be arguments about balancing public health and individual choice.

And at every step along the way, one important question will be in whom to place one's trust. Your physician? A specialist? An activist for a movement? A hormone and steroids vendor? An unlicensed physician who makes his living importing and selling hormones and steroids? Trust gets placed or misplaced for all sorts of good or bad reasons, but the starting point for any healthy sort of trust would have to be full disclosure.


A sports postscript

The controversy over human growth hormone and anabolic steroids in sports derives most of all from the fact that they enhance performance. It's considered a form of cheating, and in professional sports where there is a lot of money involved or US intercollegiate sports in which scholarships are at stake, that can be seen as a form of fraud that has pecuniary consequences. If everybody does it, that might not be a big problem, except that if there are health risks then that would mean that athletes would have to take those risks in order to compete and it adds another dimension of urgency to the question.

But consider the consequences of what we have here: human growth hormone and steroids posed as a means for senior citizens to improve the quality of their lives.

The Panama News has had a very occasional contributor and good friend over the years, Earl Watson. He's a retired maintenance supervisor from the old Gorgas Hospital complex in its US Army days, and he and his wife Minga (who's a retired nurse) have from time to time made a suggestion that this reporter has no really good excuse to reject: they advise a morning routine that includes time in the national swimming pool, as in joining the over-50 swimming club of which they are avid members. After the death of the club's founder and coach last year, Earl took over as coach of the swim team, which will compete early next year in the Floral Games, this country's senior citizen sports competition.

As director of PANDEPORTES, Omar Moreno has not been willing to talk to me about steroids in this context or any other. He has plenty of controversies as it is. But what does Earl Watson have to say? If somebody is on human growth hormone and testosterone for "age management," is that person eligible to compete in the Floral Games? "I don't think so," Watson said, adding that at his level of swimming competition there has never been any definite word one way or another from the Panamanian Swimming Federation. Whatever the rules --- and international standards would suggest that Dr. Sigler's patients would be banned from the Floral Games --- Panama has not had the resources to test participants in senior citizen competitions for the use of performance enhancing substances.

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