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Anabolic-Androgenic Steroid Use in Sports, Health, and Society

BHASIN, SHALENDER; HATFIELD, DISA L.; HOFFMAN, JAY R.; KRAEMER, WILLIAM J.; LABOTZ, MICHELE; PHILLIPS, STUART M.; RATAMESS, NICHOLAS A.

1 Department of Medicine, Brigham and Women’s Hospital, Boston, MA

2 Department of Kinesiology, University of Rhode Island, Kingston, RI

3 Department of Physical Therapy, Ariel University, Ariel, Israel

4 Department of Human Sciences, The Ohio State University, Columbus, OH

5 InterMed, P.A., South Portland, ME

6 Department of Pediatrics, Tufts University School of Medicine, Boston, MA

7 Department of Kinesiology, McMaster University, Hamilton, ON

8 Department of Health and Exercise Science, The College of New Jersey, Ewing, NJ

Address for correspondence: Stuart M. Phillips, Ph.D., F.A.C.S.M., Department of Kinesiology, McMaster University Ivor Wynne Centre 1280 Main St, West Hamilton, Ontario, Canada L8S 4K1; E-mail: [email protected] .

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.acsm-msse.org ).

This consensus statement is an update of the 1987 American College of Sports Medicine (ACSM) position stand on the use of anabolic-androgenic steroids (AAS). Substantial data have been collected since the previous position stand, and AAS use patterns have changed significantly. The ACSM acknowledges that lawful and ethical therapeutic use of AAS is now an accepted mainstream treatment for several clinical disorders; however, there is increased recognition that AAS are commonly used illicitly to enhance performance and appearance in several segments of the population, including competitive athletes. The illicit use of AAS by competitive athletes is contrary to the rules and ethics of many sport governing bodies. Thus, the ACSM deplores the illicit use of AAS for athletic and recreational purposes. This consensus statement provides a brief history of AAS use, an update on the science of how we now understand AAS to be working metabolically/biochemically, potential side effects, the prevalence of use among athletes, and the use of AAS in clinical scenarios.

 This consensus statement is an update of the previous position stand from the American College of Sports Medicine (ACSM), published in 1987 ( 1 ). Since then, a substantial amount of scientific data on anabolic-androgenic steroids (AAS) has emerged and the circumstances of AAS use has evolved in the athletic, recreational, and clinical communities. The objective of this consensus statement is to provide readers with a brief summary of the current evidence and extend the recommendations provided in the 1987 document ( 1 ). Key topics discussed are the brief history of AAS, epidemiology, methods, and patterns of AAS use, androgen physiology and ergogenic effects, side effects of AAS, and clinical uses of AAS (see Box 1). The writing group used the rating system of the National Heart Lung and Blood Institute ( Table 1 ) and a consensus approach to synthesize the available evidence from clinical trials and case reports, narrative and systematic reviews, and meta-analyses ( 3 ). The recommendations represent the consensus of the writing panel, the ACSM, and incorporate guidance from other professional organizations with expertise in the area.

BOX 1. ACSM Consensus Statements and Recommendations Summary.

Consensus Statements and Recommendations

• 1. The administration of AAS in a dose-dependent manner significantly increases muscle strength, lean body mass, endurance, and power. The effects are primarily seen when AAS use is accompanied by a progressive training program. Evidence Category A .
• 2. Historically, AAS use was primarily seen in competitive athletes and aspiring bodybuilders and powerlifters. Recreational AAS use appears to have surpassed athletic AAS use indicated by survey prevalence estimates demonstrating that recreational trainees are the leading consumers of AAS. The ACSM deplores the illicit use of AAS for recreational purposes. Evidence Category C .
• 3. AAS are classified as schedule III drugs, banned by several sport governing bodies, and are illegal to use for athletic purposes. The ACSM deplores the illicit use of AAS for recreational use and performance enhancement in athletes. Evidence Category D .
• 4. Coaches, trainers, and medical staffs should monitor and be cognizant of visible signs of AAS use and abuse. These include (but are not limited to): a substantial increase in muscle mass, strength, and power in a relatively short period of time (or the reverse which could denote AAS withdrawal); acne that is resistant to medical treatment; development of unexplainable rash, gynecomastia, increased body hair, and prominent increases in surface vascularity; changes in temperament, mood, and aggressive behavior (severe depression or suicidality could indicate AAS withdrawal); facial masculinization and fluid retention; and muscle mass that appears disproportionate to body structure or pubertal status in young athletes. In addition, the presence of AAS-related materials (books, articles, websites, dealer information, needles, vials) on the individual could reflect intent and may warrant further dialogue from the coaching, trainer, and medical staffs. Medical staff should be aware of regulations and documentation requirements regarding use of AAS for athletes with medical indications for their use. Evidence Category C .
• 5. Use and abuse of AAS is associated with several notable adverse effects in men and women including (but not limited to) suppression of the hypothalamic-pituitary-gonadal axis, psychological changes, immunosuppression, and unhealthy cardiovascular, hematological, reproductive, hepatic, renal, integumentary, musculoskeletal, and metabolic effects. Several adverse effects may be reversible upon discontinuation but some could pose health risks beyond the duration of AAS use. Evidence Category B .
• 6. Use of AAS in prepubertal and peripubertal children may lead to early virilization, premature growth plate closure, and reduced stature. Evidence Category C .
• 7. Coaches, trainers, and medical staffs should be cognizant of the reasons for AAS use and abuse and deter use when possible. Prevention programs based on education may assist; and providing the individual with scientific nutrition and training advice is a recommended strategy to mitigate the temptation of AAS use. Evidence Category D .
• 8. Androgen replacement therapy is approved for the medical treatment of several clinical diseases and abnormalities. The ACSM acknowledges the lawful and ethical use of AAS for clinical purposes and supports the physicians’ ability to provide androgen therapy to patients when deemed medically necessary. The reader is referred to guidelines established by the Endocrine Society ( 4 ). Evidence Category C .

INTRODUCTION

Anabolic-androgenic steroids are drugs chemically and pharmacologically related to testosterone (T) that promote muscle growth and are not estrogens, progestins, or corticosteroids. An androgen is any natural or synthetic steroid hormone capable of promoting the development of male primary and secondary sexual characteristics via binding to androgen receptors at the tissue level. The term anabolic describes a hormone or other substance capable of enhancing the growth of somatic tissue, such as skeletal muscle and bone. In a sport-related setting, this is typically used to describe the enhancement of skeletal muscle. Table 2 presents nomenclature associated with AAS. In the United States, AAS are classified as Schedule III controlled substances ( 5 ). Although AAS have legitimate medicinal use, nontherapeutic use among athletes and recreationally active young men and women is performed to improve strength, power, increase muscle mass, and improve appearance. Athletic and recreational (i.e., noncompetitive) use of AAS has been widespread over the last 50 yr, creating considerable interest by the scientific and medical communities, as well as sport governing bodies, in examining the potential medical, legal, and ethical issues surrounding the use of these substances. All major national and international sports organizations have banned the illicit use of AAS by athletes.

HISTORICAL PERSPECTIVES

Anabolic-androgenic steroids use has been examined extensively in various chapters, books, meta-analyses, and reviews ( 5–12 ). The effects of testicular extracts and castration on animals and humans have been a source of fascination for thousands of years ( 13,14 ). Suggestions that the consumption of testis tissue could improve impotence were noted ~140 BC ( 13 ). The mid 1700s to late 1800s marked a time where interest in testicular endocrinology increased ( 14 ). Table 3 depicts a brief historical timeline of some key events in AAS use in athletes. Testosterone was synthesized and biochemically described in the late 1920s and 1930s, and a host of different synthetic variations have been developed since ( 5,15,16 ). Testosterone or AAS use by athletes began in the 1940s and 1950s, and increased considerably thereafter, culminating in high usage during the 1968 Olympic Games ( 5,6 ). It has been speculated that the first appearance of AAS use among female athletes dates back to the late 1950s/early 1960s in Soviet track and field athletes ( 17 ).

The sophistication of AAS use by athletes in the late 1960s was characterized by a host of different “stacking routines” (i.e., the consumption of two or more drugs in an attempt to improve the response) using various oral and injectable AAS preparations ( 5 ). Initially, many physicians did not believe AAS improved performance, and the International Olympic Committee (IOC) did not include AAS on the banned substance list. The ACSM adopted this position in their first AAS position stand in 1977 but later corrected in the 1987 publication ( 1 ). Although the 1970s marked a time where AAS use was known mostly among competitive athletes, the 1980s marked a time where AAS use spread well beyond athletics to gyms, health clubs, and public awareness of AAS use increased. The Anti-Drug Abuse Act (1988), Anabolic Steroid Control Act (1990, 2004), and Dietary Supplement Health and Education Act (1994) were enacted, in part, to stem the growing use of AAS. Only a few studies (~17) on AAS use and strength/hypertrophy increases were conducted before the 1980s, and these cumulatively showed minimal effects in untrained men, but significant responses in trained men, despite doses less than that used by many athletes ( 6,7,10 ). The sophisticated protocols and array of drugs used recreationally and by athletes remained a “black box” from a research perspective.

Of current concern is the ease by which AAS users may obtain AAS via the Internet and the proliferation of men’s health clinics. In addition to the use of AAS by competitive athletes, a growing segment of AAS users are nonathletes. Management of men with damaged hypothalamic-pituitary-gonadal regulatory pathways became a new area of medicine resulting in indiscriminate AAS use ( 18 ). Interest in AAS persists as research identifies new information regarding the performance and health aspects of the drugs and through stories of purported use in the sports world. The World Anti-Doping Agency (WADA) has developed new antidoping measures, including blood sampling, guidelines for international information gathering and sharing and revamping their “Athlete Biological Passport” guidelines. While AAS use in sports continues, increases in AAS use in the general population appear to have outpaced athletic use in the last decade ( 19 ).

EPIDEMIOLOGY OF AAS USE

Peer-reviewed studies examining the frequency of illicit AAS use have declined in the past decade despite concern over the growing AAS epidemic in the United States. These studies often rely on self-reports and are fraught with sampling bias, small sample sizes, possible confusion regarding supplement and AAS use, and suboptimal ascertainment ( 5 ). Many AAS users are secretive, with one survey finding that 56% of respondents would not disclose their physicians’ use ( 20 ). Athletes may be unwilling to discuss their use with researchers even when anonymity and confidentially are guaranteed for fear it may jeopardize their career; thus, leading to differences in what athletes reported on surveys versus their actual activities ( 21 ).

In 2014, the National Institute on Drug Abuse estimated that 1.3 million Americans were AAS users, while the Endocrine Society estimated between 2.9 and 4.0 million Americans have used AAS at some point in their lives ( 18,22,23 ). Other reports showed that the number of users might be as high as 4 million men in the United States, with ~100,000 new AAS users annually ( 6,23,24 ). The age of onset of use begins later than most drugs, with only 6% of users starting before 18 ( 23 ).

Although the general public and medical communities attribute AAS use primarily to competitive athletes ( 6 ), research does not support this misperception. Muscle dysmorphia (“megarexia”) is a dominant risk factor for illicit AAS use and indicates that AAS use is often used in pursuit of a more muscular appearance rather than for enhanced athletic performance ( 25 ). Recreationally active individuals age 15 to 24 yr are more likely to use AAS than athletes participating in organized sport ( 26 ). However, reports on the prevalence of illicit AAS use in athlete and nonathlete populations are widely variable. Anabolic-androgenic steroids have been reported in 9% to 67% of elite athletes, while reports of AAS use among gym attendees ranged from 3.5% to 80% ( 27 ). In all areas, men report higher prevalence than women, although the prevalence in women is increasing ( 28 ). Studies in girls have shown prevalence rates between 0.4% and 1.0% in adolescents, ~1.2% in collegiate athletes, and ~10.3% in elite athletes ( 27 ). Others have reported AAS use in young athletes ranging between 0.6% and 6.6% in teenage boys, 0.0% to 3.3% in teenage girls, and between 0.8% and 9.1% for collegiate male athletes ( 29–32 ). Peer-reviewed studies report the highest prevalence of use in weightlifters, powerlifters and bodybuilders, with rates ranging from 33.3% to 79.5% ( 31,33 ).

Several studies have examined sport and activity participation among self-reported AAS users. A survey study of >500 male AAS users (mean age of 29) showed ~70% were recreational exercisers versus 12% competitive bodybuilders, 8% competitive weightlifters, and 9% competitive athletes in other sports ( 34 ). Participation in high school sports was not associated with an increased risk of AAS use ( 34 ). A survey of 12 female AAS users indicated that 33% of the women were recreational users, while 67% participated in competitive bodybuilding and weightlifting. These women used a polypharmacy approach, but their weekly dose was lower than male AAS users ( 35 ). Female users were less likely to stack, more likely to pyramid and less likely to inject AAS than male users ( 35 ).

Rates of AAS use in athletes are sometimes inferred from rates of positive doping tests. However, this data has some inherent limitations, including ongoing updates to banned substances lists, variable drug testing methodologies, and variable lists of targeted substances tested by organizations that do not follow WADA protocols. It has been estimated that drug testing alone may underestimate drug use in elite athletes by 8-fold ( 21 ). The Anti-Doping Administration and Management System maintained by WADA now allows any sports body to share drug testing information. While AAS use in particular divisions, such as men’s vs women’s and underage athletes is still difficult to obtain, the testing databases now include much larger numbers of athletes than in the past. Anabolic agents constitute 87% of atypical findings reported by WADA and 46% of all adverse analytical findings (International Amateur Athletics Federation) ( 36,37 ). Stanazolol and nandrolone have the highest number of AAF at 20% and 14%, respectively, while an “unidentified anabolic agent” (e.g., “designer” AAS) was the third most common at 11% ( 36 ).

The true nature of AAS use and abuse in athletes and recreationally trained individuals is difficult to discern and is often underestimated. In addition to surveys and doping results, other sources of information on AAS use include investigated journalism and government hearings. Unfortunately, all of these methods have significant methodological issues that reduce their estimation accuracy ( 17 ). Journalists have interviewed current and former athletes, coaches, team physicians, and trainers whose estimate of AAS use in sports is much higher than survey reports. There has been an inconsistency between the number of individuals demonstrating signs of AAS use and the statistical prevalence generated via surveys. Drug testing is often limited by circumventing positive tests and has done little to quantify “real-life” use or dissuade AAS use at high levels of competition. Obtaining accurate measures of AAS use in athletes is difficult given the challenges of reducing bias; testing issues, and sincerity needed during interviews and survey completion, for example, fear of accountability, fear of loss of potential income or suspension, or fear of being perceived as a cheater or athlete who needed drugs to be successful.

Attempts have been made to identify the type of individual prone to using AAS ( 38–40 ). Hildebrandt et al. ( 39 ) reported 4 clusters of users from highest to lowest risk, each with different levels of motivation for AAS use: 1) polypharmacy (i.e., use of multiple drugs) approach with high risk (~11%); 2) fat burning (~17%); 3) muscle building (~21%); and 4) low-risk use designed to reduce fat and build muscle (~52%). Others have reported a four-level typology: 1) expert type (exemplifies controlled risk-taking, is knowledgeable about AAS and fascinated with effects on the human body, is scientific and may be focused on muscularity); 2) athlete type (interested in performance enhancement and is competitive); 3) well-being type (interested in looking and feeling good with low risk-taking); and 4) YOLO “You Only Live Once” type (is haphazard using risky behavior, quick improvements, impressing others and peer recognition is important) ( 38,40 ). Despite the typology, athletes’ motivation to use AAS is multi-faceted and influenced by many factors ( Table 4 ).

Several extensive, national studies indicate an overall downward trend in lifetime AAS use among adolescents since peaking in the early 2000s ( 42 ). Monitoring the Future (MTF) is administered annually to a sample of 8th, 10th, and 12th grade students ( 43 ). The MTF reported peak prevalence rates for lifetime AAS use in 2000 to 2002 of 3% to 4% compared with 2018 data in Table 5 (i.e., ~1%–3%). The Youth Risk Behavior Survey (YRBS) is administered annually to a sample of high school students and reports an overall prevalence of 2.9% in 2017 (See Table 6 ), after peaking in 2001 at 5% ( 44 ). Although the YRBS is widely cited, concern has been raised that the term “steroid” is vague and potentially conflated with corticosteroids or steroid-like dietary supplements ( 45 ). Surveys that delineate the type of steroid show usage rates that are markedly lower than those seen in the YRBS data ( 45 ). Although AAS use rates in adolescents are low, ~1 in 8 AAS users initiates their use before age 18 ( 23 ). Several correlates of increased AAS use risk in this group include fitness-related activity ( 46,47 ); weight-related concerns (perceptions of very underweight or overweight status) ( 48,49 ); sexual preference and gender identity ( 25,44 ); and race and ethnicity ( 43,44 ). Some view current AAS use as an epidemic given the emergence of AAS availability through internet/mail order and “backroom” laboratories ( 18,50 ).

METHODS/PATTERNS OF AAS USE

Patterns of AAS use in athletes and resistance-trained populations vary greatly and depend upon: AAS type, self-administration routes, dosages, cycling patterns and durations, and ancillary drugs. A “polypharmacy approach” is commonly used where supraphysiologic doses of injectable and oral AAS are stacked and pyramided progressively in cycles, while ancillary drugs are consumed to minimize side effects, promote other areas of health and fitness, and/or enhance T levels during off-cycles, or periods in between cycles ( Table 7 ). Figure 1 depicts survey results from two studies on usage patterns for >2400 predominately male AAS users ( 34,41 ). These studies indicated that 99.2% of users reported using injectable AAS or a combination of oral and injectable AAS, and >40% used ancillary drugs, such as antiestrogens ( 41 ). Ip et al. ( 34 ) reported that 79% of AAS users “stacked” drugs, 18% used the “pyramid” approach (i.e., where drug intake is progressively increased, plateaus, and then is decreased or tapered until the end of the cycle), and only 9% thought physicians and pharmacists were knowledgeable about AAS. Interestingly, AAS users spent an average of 268 ± 472 h researching AAS prior to use ( 34 ).

ANDROGEN PHYSIOLOGY

Testosterone is the principal androgen and has both androgenic (masculinizing) and anabolic (tissue building) effects. Testosterone is synthesized from cholesterol via the Δ-4 or Δ-5 pathways through the sequential action of several enzymes ( Fig. 2 ). In men, >95% of T is synthesized in the Leydig cells of the testes (with smaller adrenal contributions) under control of the hypothalamic-anterior pituitary-gonadal axis where gonadotropin-releasing hormone stimulates the release of luteinizing hormone (LH). Healthy men produce ~4 to 9 mg of T per day (10–35 nmol·L −1 ) whereas women have approximately 0.5 to 2.3 nmol·L −1 of circulating T in the blood ( 5 ). Gonadotropin-releasing hormone function is under the control of hypothalamic neuropeptides, such as kisspeptins, neurokinin-B, dynorphin-A, and phoenixins ( 51 ). In women, androgens are produced primarily by the ovaries and adrenal glands ( 52 ). Skeletal muscle produces small amounts of androgens ( 53 ). Testosterone circulates in the blood bound to sex hormone-binding globulin (44%–60%), albumin, orosomucoid, and cortisol-binding globulin. Testosterone and other 19-carbon androgens can be converted to 5α-dihydrotestosterone (DHT) by the action of steroid 5α-reductase or converted to estradiol or estrone by the aromatase enzyme. The liver inactivates T, and the resultant metabolites are excreted in the urine.

Androgens perform many ergogenic, anabolic, and anticatabolic functions in skeletal muscle and neuronal tissue, leading to increased muscle strength, power, endurance, and hypertrophy in a dose-dependent manner ( 54 ). A meta-analysis concluded that short-term AAS use increases muscle strength substantially more than placebo and that strength gains and muscle hypertrophy are greater in trained individuals than in nontrained individuals ( 55 ). Gains in body mass and lean body mass (LBM) of ~5% to 20% from AAS use have been reported ( 56 ). Figure 3 depicts some physiological ramifications of androgens that could affect physical performance. However, the findings of controlled clinical trials of T and other AAS may differ from the practical experience of athletes due to the inclusion of mostly untrained subjects in controlled clinical trials; the use of lower doses of T or AAS in clinical trials than those used by many athletes; the use of multiple AAS in stacks with other drugs over long periods; and differences in nutritional patterns, training programs, and study design ( 5,27 ).

Exogenous androgens are often administered orally or parenterally but are also available in cream, nasal spray, buccal, subcutaneous pellets, patches, and gel. Orally administered T is absorbed well but is degraded rapidly. The esterification of the 17-beta-hydroxyl group (e.g., T enanthate, cypionate, decanoate, undecanoate, propionate) makes the androgen more hydrophobic, causing a slow release from the muscle into circulation, increasing the duration of action. When administered intramuscularly, the androgen ester is slowly absorbed into the circulation, where it is then rapidly de-esterified by esterase enzymes to T. Intrinsic potency, bioavailability, and rate of clearance from the circulation are determinants of the biological activity. Other oral and injectable AAS are T, DHT, or 19-nortestosterone derivatives (e.g., methyltestosterone, methandrostenolone, fluoxymesterone, nandrolone decanoate, oxandrolone, trenbolone, stanozolol, and other designer-AAS).

An important and relevant question is how long the effects of a dose of AAS would last in an athlete? That is, how long would potential strength gains or gains in muscle mass persist? The answer to the question is undoubtedly complex and dependent on the AAS being used and their potency (see Fig. 1 ), the history of AAS in the athlete ( 57 ), the athlete’s training age, sex ( 58,59 ), and potentially the developmental stage of the athlete relative to puberty and adulthood (i.e., 18 yr of age). The literature in this area is, unsurprisingly, sparse, but some studies suggest that the effects of AAS persist for weeks after taking the steroids, but at ~12 wk after taking AAS that the effects, at least insofar as strength and muscle mass are concerned, are largely absent ( 55,60 ). For example, Giorgi et al. ( 61 ) showed that testosterone enanthate (TE) (3.5 mg·kg −1 ) administration for 12 wk during training resulted in greater increases in strength, muscle girth, and muscle thickness than a group given a placebo. However, after 12 wk without TE administration, but while still training, there was a reversion of strength and muscle in the TE group to levels no different from the placebo group. In contrast, others have observed preservation of AAS-induced gains in strength and LBM that persist after AAS usage has ceased, at least in the short-term ( 62 ).

Persistent and long-term (at least 5 yr) AAS use in a mixed sample of strength (strongman and powerlifters) and aesthetic sport (bodybuilding) athletes has been reported, in comparison to non-AAS, to result in persistent (i.e., in comparison to a matched group) elevations in LBM, muscle fiber area, capillary density, myonuclei density, and strength that were dose-dependent ( 57 ). The observation that long-term AAS use results in increased myonuclei density ( 57 ) suggesting that a much longer ‘muscle memory’ is perhaps possible in AAS users, particularly those who use AAS early in life. Evidence for such a mechanism comes from preclinical models ( 10 ), where young mice were exposed to AAS and subsequently increased their myonuclear content, resulting in a substantial hypertrophic advantage later in life. The authors of this work ( 63 ) even went so far as to suggest, “… the benefits of even episodic drug [AAS] abuse might be long lasting, if not permanent, in athletes. Our data suggest that the World Anti-Doping Code calling for only 2 yr of ineligibility after… [a doping violation for AAS] use… should be reconsidered.” Support for whether an AAS-induced increase in myonuclear number in humans is lacking; however, if present, then AAS-induced increases in myonuclei are theoretically advantageous to an athlete even if strength and lean mass advantages have been lost.

Residual effects of endogenous testosterone exposure in testosterone-suppressed transgender females are areas of active study and debate. These effects vary greatly depending upon the developmental stage of treatment initiation and will be much less when treatment is initiated before pubertal onset. There is a dichotomy when looking at measures of prepubertal athletic performance. Studies evaluating age-group athletic records report no significant differences in top age-group performances between boys and girls younger than 10 to 12 yr old ( 64–66 ). However, some studies evaluating more specific measures of strength and aerobic capacity reveal an 8% to 10% advantage in prepubertal biologic males relative to females, even after normalizing for body size ( 67,68 ). These performance differences may be residual effects from higher testosterone levels during early infancy (e.g., “mini-puberty”) and/or nonandrogenic genetic factors. Currently, there are no data on the durability of these performance differences in transgender females who start gender-affirming treatment before puberty.

Postpubertal testosterone suppression has variable impacts on performance-related parameters. Within 3 months of starting hormone suppression, hematocrit decreases by 4% to within normal values for cisgender females ( 69 ). A recent systematic review also evaluated evidence to date regarding treatment-related reductions in muscle size, strength, and LBM ( 70 ), summarized in Table 8 . Although the changes documented in Table 8 , along with an increase in fat mass, may contribute to significant reductions in athletic performance, the current lack of data in active or athletic populations makes the magnitude of these changes difficult to assess.

ANDROGEN SIGNALING

Androgen signaling at the tissue level occurs primarily genomically through the classical androgen receptor (AR) with multiple levels of integration with other anabolic/catabolic pathways ( 71 ). Testosterone, DHT, and other AAS bind to cytoplasmic AR ( 72 ). Androgen receptor activity is altered at various sites; phosphorylation may augment androgen/AR transcriptional action (in the presence or absence of androgens) ( 73 ). Androgen receptor signaling is activated primarily by ligand binding, but under some circumstances through ligand-independent mechanisms (e.g., insulin like-growth factor-1 [IGF-1] induced mitogen-activated protein kinase-ERK1/2, p38 and c-Jun N-terminal kinase phosphorylation) ( 74 ) that may sensitize it to anabolic signals in the presence of low androgens ( 75 ). The AR is up-regulated following resistance training and short-term androgen administration ( 54 ).

Upon androgen binding to the ligand-binding domain (LBD) of the AR, the liganded AR undergoes phosphorylation, dimerization, and conformational changes, recruits coregulators, and translocates into the nucleus, where it regulates the transcription of androgen response elements (ARE) of the androgen-responsive genes ( 76 ). Androgen binding activates and stabilizes the AR, which is selectively induced by T, DHT, and AAS ( 77 ). Greater stability is seen with DHT than T ( 78 ). Binding affinity for the AR varies between androgens. Nandrolone and metenolone have a higher binding affinity than T, while stanozolol, methandienone, and fluoxymesterone have a lower binding affinity than T; and oxymetholone has a minimal binding affinity ( 79 ). Androgen binding to the AR completes the pocket that serves as a recruiting surface for co-activators ( 80 ). Some co-activators include BAF57 and 60a, SRC1 and 3, and ARA50 and 74. The activity of these co-regulators and the role of T in ribosome biogenesis may be important in mediating the anabolic effects of AAS on skeletal muscle.

Androgen/AR binding activates signaling through the Wnt-β-catenin pathway. The presence of T (in a dose-dependent manner) increases AR-β-catenin interaction and transcriptional capacity ( 81 ). Androgens promote myogenesis via multiple pathways. Satellite cells and myoblasts express AR and androgen binding, increasing satellite cell activation, proliferation, mobilization, differentiation, and incorporation into skeletal muscle ( 82 ). Androgens increase myogenesis via increased Notch signaling of satellite cells ( 83 ) and increased expression of IGF-1 ( 84 ). Androgen binding to AR on pluripotent mesenchymal cells increases their commitment to myogenesis and inhibits adipogenic differentiation via β-catenin signaling ( 85,86 ). Testosterone upregulates follistatin expression (which blocks signaling through the TGFβ-SMAD 2/3) and increases myogenic differentiation ( 82,84,86–88 ). Androgens may be anticatabolic by decreasing glucocorticoid receptor (GR) expression, interfering with cortisol binding, or the AR-T complex may compete with the cortisol-GR complex for cis -element binding sites on DNA ( 88–91 ).

Nongenomic AR signaling is rapid, with short latency periods acting independently of nuclear receptors ( 92 ). Nongenomic effects are thought to be mediated by direct binding to a target molecule, through intracellular AR activation (i.e., Src kinase), through a transmembrane AR receptor, or via changes in membrane fluidity ( 92 ). Nongenomic signaling involving G-protein 2nd messenger system and may either increase intracellular calcium concentrations via PI3K, phospholipase C, and IP 3 signaling ( 93 ), stimulate the activation of mitogen-activated protein kinase signaling ( 94 ), and mammalian target of rapamycin pathway signaling ( 95 ). Cross-talk between IGF-1 signaling and nongenomic AR signaling appears critical to mediating some anabolic effects ( 96 ). Nongenomic signaling occurs rapidly within seconds to minutes, much faster than classic genomic signaling, which takes hours and requires the constant presence of androgens to maintain intracellular signaling.

SIDE EFFECTS ASSOCIATED WITH ANDROGEN USE AND ABUSE

Investigations examining the safety of androgen use in various populations have been largely inadequate as there is tremendous variability in androgen dosages and patterns of use, including stacking of multiple AAS and concurrent use of accessory drugs ( 5 ). Figure 4 depicts the variety of adverse physiological and psychological effects associated with AAS use. These include relatively rare effects and those that are commonly expected, particularly with long-term AAS abuse ( 30 ).

A survey of 500 AAS users (99% male) who had extensive experience (8 wk to 25 yr with 95% having >1–3 yr of AAS use) with high doses showed that 23% to 64% of respondents reported minor side effects (e.g., testicular atrophy, acne, fluid retention, insomnia, sexual dysfunction, gynecomastia) ( 97 ). Other common effects of AAS use include deleterious changes in cardiovascular (CV) risk factors: decreased plasma high-density lipoprotein (HDL) cholesterol ( 98 ), changes in clotting factors ( 99 ), and mood or psychiatric disturbances ( 79 ). Suppression of the hypothalamic-pituitary-testicular axis and spermatogenesis may result in infertility, while elevations in liver enzymes may reflect liver dysfunction ( 100–102 ). In one study, competitive athletes who used AAS during their competitive careers were more likely to die prematurely than athletes who did not ( 103 ). The use of nonsterile needles and needle sharing practices for intramuscular injections increase the risk for infection, muscle abscess, sepsis, and communicable diseases, such as human immunodeficiency virus (HIV) and hepatitis B and C ( 5 ).

Although CV effects are commonly reported with AAS use, based on an extensive review, the FDA concluded that “... the studies have significant limitations that weaken their evidentiary value for confirming a causal relationship between testosterone and adverse cardiovascular outcomes ” ( 104 ). Part of the difficulty in studying the effects of AAS on CV health is that the impacts of androgens on CV function vary with dose, method of administration, and aromatization potential ( 5 ). Parenteral administration of physiologic T replacement doses are associated with CV function and vary with dose, method of administration, and aromatization potential ( 5 ) with small decreases in plasma HDL, with little or no effect on total cholesterol, low-density lipoprotein (LDL) or triglycerides ( 105–107 ). However, supraphysiologic T doses are associated with significant reductions in HDL ( 108,109 ). Orally administered 17-alpha-alkylated, nonaromatizing AAS produce greater reductions in HDL and increases in LDL than when AAS are administered parenterally ( 110 ). Angell et al. ( 111 ) reported that self-administering AAS (median daily dose = 228 mg) for >2 yr was associated with smaller longitudinal LV strain, right ventricular (RV) ejection fraction, and altered diastolic function compared with nonusers. Others showed impaired RV free wall strain and strain rate associations with AAS abuse in competitive bodybuilders ( 112 ). D’Andrea et al. ( 113 ) showed associations between AAS use (~31 wk; weekly dose = 525 mg) and left atrial impairment (a marker of diastolic burden) in elite bodybuilders compared with nonusers. An increase in left ventricular (LV) mass occurs during resistance training ( 114–116 ); however, potential additional effects from AAS use in humans are unclear. In rats, only high T doses (up to 20 mg per kg body mass) induced cardiac hypertrophy with an impaired contractile process ( 117 ).

Deceased men who had used AAS showed greater cardiac mass than nonusers ( 118 ). Multivariate analysis indicated that increases in heart size were explained by increased body mass and by AAS use. Risk for adverse cardiac events associated with LV mass is supported by case reports detailing sudden death among power athletes who self-administered AAS ( 100,119–122 ). Case reports are largely anecdotal, and a causal relationship between AAS use and risk of sudden death has not been established. Strength/power athletes self-administering AAS have short QT intervals but increased QT dispersion compared with endurance athletes with similar LV mass who have long QT intervals but do not have increased QT dispersion ( 123 ). The interval from the peak to the end of the ECG T wave (Tp-e), Tp-e/QT ratio, and Tp-e/QTc ratio increases in AAS users, suggesting a link between AAS and ventricular arrhythmias, which may increase the risk for sudden death ( 124 ).

Increases in liver enzymes, cholestatic jaundice, hepatic neoplasms, and peliosis hepatis are associated with the use of oral, 17-alpha alkylated AAS ( 102,125,126 ), but not with parenterally administered T or its esters ( 127 ). The association between liver toxicity and AAS use is based on increases in AST and ALT. These enzymes are not liver-specific and are often elevated from muscle damage after resistance exercise ( 101,128 ); thus, possibly overstating the risk of hepatic dysfunction ( 128,129 ).

Endogenous LH and follicle stimulating hormone secretion are suppressed during AAS use, with subsequent effects on testicular T secretion and sperm count ( 130,131 ). Depending on the dose and duration of AAS use, endogenous T, LH, and follicle stimulating hormone may take weeks to months to return to homeostatic levels ( 132 ), and the long-term effects are not well understood. High-dose androgen administration in men is associated with breast tenderness and enlargement, for example, gynecomastia ( 5,133 ), thought to result from peripheral conversion of androgens to estrogens in men administering aromatizable AAS ( 134 ). The prevalence of gynecomastia is unknown, but prevalence rates as high as 54% were reported in AAS users ( 5 ). The use of nonsterile needles and needle-sharing practices for intramuscular injections increases the risk for infection, muscle abscess, sepsis, and communicable diseases, such as HIV and hepatitis B and C ( 5 ).

There is no evidence that T causes prostate cancer, but testosterone replacement therapy (TRT) is associated with a small increase in prostate specific antigen levels in older men with low T, which increases the risk of urological referral for prostate biopsy ( 5 ). Because many older men harbor subclinical prostate cancer, a prostate biopsy may lead to subclinical low-grade prostate cancer detection. Notably, however, TRT increases the risk of prostate biopsy.

The psychological effects of AAS use have garnered much publicity, especially on issues of aggression and suicide. However, the evidence is inconclusive due to the lack of sensitivity of the research instruments used to measure aggressive behavior, large variability in RT programs, preexisting personality or psychiatric disorders, and prevalence of multiple high-risk behaviors and use of other substances, such as alcohol, psychoactive drugs, and dietary supplements ( 5 ). Interestingly, physiologic T replacement in hypogonadal men may improve mood and attenuate negative aspects of mood ( 4 ). Morrison et al. ( 135 ) reported that the aggression and anxiety-provoking influences of androgens in animals are likely a developmental phenomenon and that adult exposure may be anxiolytic over the long term. However, underlying psychological dysfunction may cause a greater susceptibility to AAS use, and high doses of AAS may provoke a “rage” reaction in some individuals with preexisting psychopathology ( 136,137 ). Self-administration of AAS may increase the risk for mood disorders, such as mania, hypomania and depression ( 136,138 ). Resting T concentrations are related to posttraumatic stress (PTSD), in which higher T is associated with a lower risk for PTSD ( 139 ). Further, long-term use of AAS in former weightlifters was associated with poor cognitive function and negative changes in brain morphology ( 140,141 ). Approximately 30% of illicit AAS users will develop AAS dependence, and there is some overlap between AAS dependence and the mechanisms and risk for opioid dependence ( 142,143 ). Sudden discontinuation of exogenous AAS use in those who are dependent or have suppressed endogenous production may result in severe depression and suicidality ( 142,143 ). A multidisciplinary and medically supervised treatment program is indicated for individuals with AAS dependence.

Women self-administering AAS may undergo masculinization and experience hirsutism, deepening of the voice, enlargement of the clitoris, widening of the upper torso, decreased breast size, menstrual irregularities, and male pattern baldness ( 144 ). Some of these adverse effects may not be reversible ( 5 ).

Many of the side effects in adults may be seen in adolescents, but information on use in children is scant. Exogenous AAS exposure in preadolescence triggers pubertal onset and may result in early epiphyseal maturation and closure, leading to loss of ultimate height potential ( 40 ). Although mild acne is common during adolescence ( 40 ), AAS use may result in severe nodular acne, particularly on the back and shoulders, which is often resistant to treatment.

CLINICAL USES OF ANDROGEN THERAPY

Although athletes and recreational trainees have reported obtaining AAS from physicians for illicit purposes ( 26,33,50 ), several clinically approved uses of T exist. Of concern are potential illicit use stemming from a clinical prescription of T given the increased number of antiaging and wellness clinics. The sale of therapeutic T preparations in the United States quadrupled between 2001 and 2011 ( 145 ), and an estimated >2.3 million men received physician-prescribed T therapy as of 2013 ( 146 ). In military treatment facilities, the number of androgen prescriptions increased > twofold (23% per year) from 2007 to 2011, mainly in 35- to-44-yr-old men ( 147 ). Currently, therapeutic T is mostly used to treat primary (i.e., testicular failure) and secondary (i.e., reduced LH) hypogonadism ( 148 ). Androgen therapy has numerous clinical uses outlined in Table 9 ( 145,146 ). A substantial fraction of young men receiving T prescriptions are former AAS users trying to restore endogenous T production ( 149–151 ). The Endocrine Society Clinical Practice Guideline ( 148 ) details decision making regarding androgen therapy and the reader is referred to their specific guidelines on the diagnosis, treatment, and monitoring of hypogonadism in men ( 134 ).

Testosterone replacement therapy has been shown to improve sexual activity ( 152–155 ), vertebral and femoral bone mineral density (BMD) and microarchitecture ( 156,157 ), hemoglobin content ( 158,159 ), LBM, maximal voluntary strength and physical function ( 160–164 ), and reduces body fat and BMI ( 162,165,166 ). There have also been reports of TRT reducing neuroinflammation and depressive symptoms ( 167–169 ), reducing blood pressure and improving lipid profiles ( 166 ), and neuronal regeneration ( 154,156,170–177 ), and may not change or improve cognitive function in older men ( 174,178,179 ). There is a low frequency of adverse events associated with TRT ( 2,148,153,180–190 ). However, all TRT should be accompanied by a structured monitoring plan ( 148 ). The Endocrine Society recommends evaluating symptoms, adverse events, lower urinary tract symptoms, and measurements of T levels, hematocrit, and prostate specific antigen at baseline, 3 to 6 months after starting treatment, and annually thereafter ( 148 ).

Testosterone and free T levels decline with advancing age after peaking in the second and third decades of life ( 191–194 ), leading to increased risk of sexual dysfunction; decreased muscle mass and strength, BMD, mobility; increased falls and fractures, late-life low grade persistent depressive disorder (dysthymia), and CV mortality ( 148,195 ). Low T is associated with an increased risk of diabetes, metabolic syndrome, and increased carotid artery intima-media thickness ( 196,197 ). Whether older men with age-related T decline should receive TRT remains a matter of debate. The Endocrine Society Guideline for TRT of hypogonadal men recommends against routinely prescribing T to all men, 65 yr or older, with low T levels ( 148 ). Decisions regarding TRT should be individualized after discussing potential risks and benefits in men with both symptoms suggestive of consistent T deficiency and burden of symptoms (e.g., low libido, unexplained anemia, osteoporosis) and presence of other co-morbid conditions that increase the risk of T treatment ( 148 ). The shared decision making should weigh the patient’s and clinician’s values. In male children, physiologic doses of T are used for brief periods to initiate pubertal development in those with constitutional delay of growth and puberty. Testosterone is needed permanently for children with congenital or acquired hypogonadism.

Recent interest has focused on the role of T in athletic performance in transgender and sexual developmentally distinct athletes. Individuals transitioning to females may require a therapeutic-use exemption for spironolactone, which is often used to block the androgen receptor and lower overall testosterone levels. Currently, trans female athletes subject to WADA testing must document subthreshold T levels for at least 12 months before being allowed to compete as a female. The IOC sets this threshold at <10 nM, and World Athletics (formerly the International Amateur Athletics Federation) at <5 nM. Interested readers can obtain a much deeper discussion of this topic in several reviews ( 198–200 ).

CONCLUSIONS

Anabolic-androgenic steroids include a wide spectrum of compounds that exert their effects through various mechanisms. Anabolic-androgenic steroid use is advantageous in athletic performance predominantly through enhancements in strength, power, increases in muscle mass, reduced recovery time, and other factors. Major competitive sporting bodies ban the use of AAS; however, the predominant area of AAS usage has now expanded into clinical scenarios, persons undergoing sexual reassignment, and by those interested in AAS for purely aesthetic enhancement. Thus, it is not only athletes who are using AAS to gain performance advantages but also other individuals for various reasons. Use for AAS to enhance athletic performance is banned, and coaches, trainers, and medical staff should monitor for signs of use. The use/abuse of AAS has several notable side effects with various consequences that are, in some cases, reversible. Coaches, parents, trainers, and medical staff need to understand why athletes might use AAS and provide educational programming in a preventive capacity. The position of the ACSM is that the illicit use of AAS for athletic and recreational purposes is, in many cases, illegal, unethical and also poses a substantial health risk. Nonetheless, TRT is used in treating various conditions, and clinicians may elect to use this therapy when medically necessary. The ACSM acknowledges the lawful and ethical use of AAS for clinical purposes and supports the physicians’ ability to provide androgen therapy to patients when deemed medically necessary.

This article is published as an official pronouncement of the American College of Sports Medicine and is an update of the 1987 ACSM position stand on the use of anabolic-androgenic steroids. Click here https://links.lww.com/MSS/C362 to download a slide deck that summarizes this ACSM pronouncement on anabolic-androgenic steroid use. This pronouncement was reviewed for the American College of Sports Medicine by members-at-large and the Pronouncements Committee.

Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from the application of the information in this publication and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. The application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.

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• Published: 01 June 2022

Anabolic–androgenic steroid use is associated with psychopathy, risk-taking, anger, and physical problems

• Bryan S. Nelson 1 ,
• Tom Hildebrandt 2 &
• Pascal Wallisch 1  

Scientific Reports volume  12 , Article number:  9133 ( 2022 ) Cite this article

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• Human behaviour

Previous research has uncovered medical and psychological effects of anabolic–androgenic steroid (AAS) use, but the specific relationship between AAS use and risk-taking behaviors as well as between AAS use and psychopathic tendencies remains understudied. To explore these potential relationships, we anonymously recruited 492 biologically male, self-identified bodybuilders (median age 22; range 18–47 years) from online bodybuilding fora to complete an online survey on Appearance and Performance Enhancing Drug (APED) use, psychological traits, lifestyle choices, and health behaviors. We computed odds ratios and 95% confidence intervals using logistic regression, adjusting for age, race, education, exercise frequency, caloric intake, and lean BMI. Bodybuilders with a prior history of AAS use exhibited heightened odds of psychopathic traits, sexual and substance use risk-taking behaviors, anger problems, and physical problems compared to those with no prior history of AAS use. This study is among the first to directly assess psychopathy within AAS users. Our results on risk-taking, anger problems, and physical problems are consistent with prior AAS research as well as with existing frameworks of AAS use as a risk behavior. Future research should focus on ascertaining causality, specifically whether psychopathy is a risk associated with or a result of AAS use.

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Introduction.

An estimated 6% of males globally 1 (including 2.9–4 million Americans 2 ) have used anabolic–androgenic steroids (AAS) such as methyltestosterone, danazol, and oxandrolone, which are a series of synthetic variants of the male sex hormone testosterone that increase lean muscle protein synthesis without increasing fat mass 3 , 4 . Although there are medical uses such as for AIDS-related wasting syndrome 5 , AAS are commonly used by individuals for the purposes of bodybuilding and appearance modification 2 , 3 , 6 . In these cases, doses are commonly 10 to 100 times higher than clinical doses and are typically “cycled” intermittently (i.e., used for a few months, stopped to minimize the stress that AAS impart on the body, then resumed shortly thereafter) 3 , 7 . AAS have a 30% dependence rate among long-term users, higher than many other prescription or illicit drugs such as cocaine and have been linked to medical issues such as liver and kidney damage, cardiovascular problems, testicular atrophy, infertility, hair loss, and gynecomastia 2 , 3 , 7 , 8 , 9 , 10 . AAS use is strongly associated with other substance abuse 8 , 9 , 11 , 12 , and users often exhibit negative, although idiosyncratic, psychological issues 8 , 13 , 14 , 15 , 16 , 17 . Some users report delusions of grandeur and invincibility, while others experience depression and various mood disturbances 8 , 18 , 19 , 20 . As dosage increases, AAS users may become impulsive, moody, aggressive, or even violent 9 , 18 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 . Recent neurobiological studies have focused on effects of AAS on central nervous system functions such as cognition, anxiety, depression, and aggression 10 , 28 , 29 . In recent imaging studies, AAS use was associated with cortex thinning as well as decreased gray matter and increased right amygdala volume 30 , 31 , 32 . AAS use seems to accelerate brain aging through oxidative stress and apoptosis 33 , 34 , 35 , is associated with lower cognitive function 36 , 37 , and may disrupt normal neuronal function in the forebrain, which can increase anxiety and aggressiveness and diminish inhibitory control 10 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 . Increased depression has been frequently observed during AAS withdrawal 32 , 46 .

One area that remains understudied among AAS users is psychopathy, a personality disorder characterized by shallow emotional affect, lack of empathy, and antisocial behavior 47 , 48 , 49 . Psychopathy research has frequently associated psychopathy with violence, repeated imprisonment, disrespect for authority, and substance misuse/abuse 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 . There is growing evidence that AAS use may be associated with psychopathy, including a direct association between AAS and psychopathy in an Iranian sample 56 as well as numerous reports of associations between AAS use and violent crime or “roid rage” 19 , 21 , 22 , 23 , 25 , 27 , 57 . Prior studies examining AAS use and elements of the “Dark Triad” and “Big Five” personality traits suggest that the relationship between AAS use and both violence and risk-behaviors may be due to self-regulatory deficits and low conscientiousness, and that AAS use is predicted by narcissism, low agreeableness, neuroticism, impulsivity, and inability to delay gratification 56 , 58 . Hauger et al. 28 recently identified significantly lower emotion recognition in AAS dependent users compared to AAS non-using weightlifters, suggesting that this lower emotion recognition may contribute to the higher frequencies of antisocial traits that AAS users have previously reported 59 , 60 . Antisocial personality disorder, which is characterized by the disregard for laws and norms, irritability, and the failure to regard the safety of self and others 61 has been suggested as the mechanism that underlies the link between AAS use and aggression 3 , 9 , 60 , 62 , 63 . Conceptually, there are overlaps between antisocial personality disorder and psychopathy 64 . We therefore argue that psychopathic traits among AAS users are worth exploring.

Thus, the present study assessed whether AAS users were more likely than nonusers to exhibit psychopathic traits, risk-taking behaviors such as sharing needles, anger problems such as getting into altercations, emotional problems such as panic attacks and depression, cognitive problems such as difficulty remembering, and physical problems such as hair loss. We hypothesized that AAS users would display heightened odds of psychopathic traits, substance use risk-taking behaviors, sexual risk-taking behaviors, anger problems, emotional stability problems, cognitive problems, depressive symptoms, anxiety symptoms, impulsivity symptoms, and physical problems, although we recognize that many of these traits are highly idiosyncratic in nature. Finally, we hypothesized there is a dose-dependent relationship between these traits and the variety of substances used as well as the number of cycles.

Participants and procedure

This study was approved by the NYU Committee on Activities Involving Human Subjects and we conducted in accordance with the Declaration of Helsinki principles. We anonymously recruited a large online sample of 492 (Mean age = 22.9, SD age = 4.3) adult biologically male bodybuilders and asked them questions about their Appearance and Performance Enhancing Drug (APED) use (if any), exercise and dietary habits, psychological states, risk-taking behaviors, and any physical problems they might have experienced. The anonymous internet survey was posted to online fitness fora in fall 2015. All participants provided informed consent prior to their participation. Participants had the option to enter an online raffle for one of twenty $50 Amazon gift cards, which were distributed via email.

The following subsections are presented in the same order as the online survey.

Diet and exercise

Participants reported how often they had exercised in the past month (every day, most days, some days, very rarely/never) and rated their caloric intake in the past month on a 5-point ordinal scale (1 = extreme restriction of calories, 5 = extreme over-consumption of calories). We measured caloric intake in terms of restriction, maintenance, or surplus rather than total calories per day because participants likely vary in caloric requirements (i.e., 3000 cal/day may be a surplus for some but a deficit for others).

Appearance and performance enhancing drugs

Each participant indicated whether he had ever used oral, injectable, or topical AAS (“yes, currently,” “yes, formerly,” “no, but considered taking,” “no, never considered taking” for each). Additionally, participants reported how many AAS cycles they had completed and responded whether they had ever used the following APEDs (each with “yes”/”no” options): Testosterone, Dianabol (Methandrostenolone), Deca Durabolin (Nandrolone Decanoate), Winstrol (Stanozolol), Anadrol (Oxymetholone), Human Growth Hormone (Somatropin), Synthol, Anti-Estrogens, Fat Burners (Insulin, Clenbuterol, Cytomel, Cynomel), Trenbolone, or Anavar.

Self-reported events

Participants rated each of the following items as “yes, currently,” “yes, formerly,” or “no, never”.

General events Participants self-reported whether they experienced the following events: depression, increased number of mood swings, getting into altercations, panic attacks, irritability, lack of frustration tolerance, aggression, difficulty focusing, racing thoughts, difficulty making decisions, difficulty remembering, suicidal thoughts, acne, trouble sleeping, water retention, hair loss, changes in appetite, and heart problems.

Risk-taking behavior Participants indicated whether they had engaged in or experienced the following: unprotected sex, sex with multiple partners, sexually transmitted disease or infection (STD), sharing needles, reusing needles, using stimulants without prescription (such as crack, powdered cocaine, methamphetamine, amphetamine, or ecstasy [MDMA]), using opiates without prescription (such as heroin, morphine, codeine, or Oxycontin), using hallucinogens without prescription (such as LSD, mescaline, and psilocybin), using depressants without prescription (such as Valium, Xanax, Librium, and barbiturates), drinking alcohol, smoking tobacco, and smoking marijuana.

Impulsivity

We used the Barratt Impulsiveness Scale to quantify impulsivity (BIS-11) 65 . Participants responded to 30 statements such as “I often have extraneous thoughts” using a 4-point ordinal rating scale (1 = rarely/never, 4 = almost always/always). The BIS-11 displayed strong reliability in this sample (Cronbach’s α = 0.84).

Psychopathic traits

We employed the Levenson Self-Report Psychopathy Scale (LSRP) to assess psychopathy 66 . The scale has 26 items graded on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) and was strongly reliable in this sample (Cronbach’s α = 0.88).

We assessed anxiety with the Generalized Anxiety Disorder 7-item Scale (GAD-7) 67 . Participants responded to each of the seven items such as “being so restless it is hard to sit still” on a 4-point ordinal rating scale (0 = not at all, 3 = nearly every day). The GAD-7 displayed excellent internal consistency (Cronbach’s α = 0.89). Possible scores range from 0 to 21.

We included the 10-item Center for Epidemiologic Studies Short Depression Scale (CES-D 10) 68 to measure depression. Participants rated statements such as “I felt lonely” on a 4-point ordinal rating scale (0 = rarely or none of the time, 3 = all the time). The CES-D 10 was highly reliable (Cronbach’s α = 0.82), with possible scores ranging from 0 to 30.

Aggravation

Participants responded to the 7-item aggravation subscale of the State Hostility Scale 69 , 70 . In the subscale, participants rate possible descriptions of their current mood (e.g., “stormy” or “vexed”) on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The aggravation subscale of the State Hostility Scale had strong reliability (Cronbach’s α = 0.90).

Demographic questions

Lastly, participants reported their age (years), height (inches), weight (pounds), body fat percentage, racial background, and level of education.

Statistical analysis

The survey was convenience sampled, with no pre-specified sample size or power calculation. For our primary analysis, we grouped participants who responded “yes, currently” or “yes, formerly” to having used AAS (oral, injectable, or topical) as AAS users (n = 154, 31.3%). We considered those who responded “no, but considered taking” or “no, never considered taking” to be AAS nonusers (n = 338, 68.7%). We also conducted a secondary analysis using all four categories (current AAS users (n = 121, 24.6%); former AAS users (n = 33, 6.7%); AAS nonuser, considered using (n = 200, 40.7%); AAS nonuser, never considered using (n = 138, 28.0%)).

Both AAS cycle experience and APED variety were self-reported. APED variety was the number of different APED types used (the number each participant responded “yes” to taking of Testosterone, Dianabol (Methandrostenolone), Deca Durabolin (Nandrolone Decanoate), Winstrol (Stanozolol), Anadrol (Oxymetholone), Human Growth Hormone (Somatropin), Synthol, Anti-Estrogens, Fat Burners (Insulin, Clenbuterol, Cytomel, Cynomel), Trenbolone, and Anavar). AAS cycle experience was the number of AAS cycles participants reported. If the participant was an AAS nonuser, then both APED variety and AAS cycle experience were scored as 0.

We grouped traits of interest into the following categories: psychopathic traits, substance use risk-taking behavior, sexual risk-taking behavior, anger problems, emotional stability problems, cognitive problems, depressive symptoms, anxiety symptoms, impulsivity symptoms, and physical problems. Following Brinkley et al. 71 , we considered participants in the top third of the LSRP distribution to have psychopathic traits. We considered any participant that reported sharing needles, reusing needles, hallucinogen use, stimulant use, depressant use, or opiate use as engaging in substance use risk-taking. Similarly, any participant that reported an STD, engaging in unprotected sex, or having multiple sexual partners was categorized as having sexual risk-taking behavior. Any participant scoring in the top half of the aggravation subscale of the State Hostility Scale, reporting physical altercations, or reporting increased aggression was categorized as having anger problems. Participants who reported mood swings, lower frustration tolerance, or irritability were considered to have emotional stability problems while participants with difficulty remembering, difficulty focusing, or trouble making decisions were considered to have cognitive problems. We considered participants with depressive symptoms as those that reported suicidal thoughts, reported increased depression, or had a CES-D 10 score greater than 10 (the established cut point 68 ). Those with anxiety symptoms either had a GAD-7 score greater than the established cut point 67 of 8 or reported panic attacks. A participant who reported racing thoughts or who scored in the top half of the Barratt Impulsiveness Scale was considered to have impulsivity symptoms. Finally, we considered participants to have physical problems if they reported heart problems, appetite changes, water retention, acne, or hair loss.

We used logistic regression to assess possible associations between these traits of interest and AAS use, number of AAS cycles, and variety of APEDs used. We computed odds ratios (OR) with 95% confidence intervals (CI). All analyses adjusted for age, race, education, exercise frequency, caloric intake, and lean BMI. Age, race, and education were included as basic demographic variables, while exercise frequency, caloric intake, and lean BMI were included to account for differences in bodybuilding goals, success, and dedication. We chose to calculate lean BMI to assess how muscular participants were. We used the standard (kg/m 2 ) BMI formula but used each participant’s lean bodyweight instead of his total bodyweight. Lean body weight was calculated by using each participant’s self-reported body fat percentage to determine how much he weighed excluding his body fat (weight in kg * (100%-bodyfat%)). Given that both psychopathy and AAS use are associated with illicit drug use 21 , we conducted a post hoc subgroup analysis among participants without history of polysubstance use (3 or more different drug classes) to ensure any association between AAS use and psychopathic traits was not confounded by polysubstance use. All analyses were conducted in R (version 3.5.1).

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of New York University.

Consent to participate

Participants provided informed consent prior to their participation in this anonymous internet survey.

Participant characteristics are listed in Table 1 . Most participants were younger than 25 years old (56.5% of AAS users; 79.0% of AAS nonusers), white (85.7% of AAS users; 77.5% of AAS nonusers), and had education beyond high school (75.3% of AAS users; 59.1% of AAS nonusers). The majority in each group exercised most days of the week (79.2% of AAS users; 74.8% of AAS nonusers) and were attempting to gain weight (51.3% of AAS users; 51.2% of AAS nonusers). For AAS users and nonusers, the median (Q1-Q3) lean BMI was 23.6 (22.3–25.4) and 21.6 (20.3–23.3) kg/m 2 . AAS users began use at a median (Q1-Q3) of 21 (20–24) years, had completed 2 (1–3) AAS cycles, and used 4 (2–5) different APED types; 78.6% (121/154) were current AAS users. Among AAS nonusers, 59.2% (200/338) had considered using AAS.

Tables 2 and 3 summarize traits of interest and specific substance use risk-taking behaviors by AAS use status; 25.8% (39/154) of AAS users and 10.2% (34/338) of AAS nonusers had a history of polysubstance use. AAS users had over twice the odds of exhibiting psychopathic traits (OR = 2.50, 95% CI 1.52–4.15), over three times the odds of engaging in substance use risk-taking behaviors (OR = 3.10, 95% CI 1.97–4.93), nearly twice the odds of engaging in sexual risk-taking behaviors (OR = 1.79, 95% CI 1.01–3.26), nearly twice the odds of experiencing anger problems (OR = 1.71, 95% CI 1.02–2.95), and over twice the odds of exhibiting physical problems (OR = 2.23, 95% CI 1.16–4.51) compared to AAS nonusers (Table 4 ). In a post hoc subgroup analysis, AAS users without history of polysubstance use had higher odds of psychopathic traits compared to nonusers without history of polysubstance use (OR = 2.73, 95% CI 1.54–4.90).

In secondary analyses with four levels of AAS use, AAS nonusers who considered using had higher odds of psychopathic traits (OR = 2.19, 95% CI 1.27–3.87), substance use risk-taking (OR = 3.51, 95% CI 2.06–6.14), sexual risk-taking (OR = 3.38, 95% CI 2.00–5.78), anger problems (OR = 3.16, 95% CI 1.86–5.42), emotional stability problems (OR = 1.87, 95% CI 1.16–3.01), depressive symptoms (OR = 2.12, 95% CI 1.32–3.44), and impulsivity symptoms (OR = 2.17, 95% CI 1.31–3.61) compared to AAS nonusers who never considered using; former AAS users had lower odds of both anxiety symptoms (OR = 0.30, 95% CI 0.08–0.84) and impulsivity symptoms (OR = 0.33, 95% CI 0.14–0.74) compared to AAS nonusers who considered using; and current AAS users had higher odds of both impulsivity symptoms (OR = 2.92, 95% CI 1.27–6.84) and physical problems (OR = 5.86, 95% CI 1.83–19.74) compared to former AAS users.

Lastly, we assessed possible relationships between (i) the number of different APED types used and (ii) the number of AAS cycles with the same traits of interest as before. Each additional type of APED used was associated with a 19% increase in the odds of psychopathic traits (OR = 1.19, 95% CI 1.07–1.33), a 24% increase in the odds of substance use risk-taking (OR = 1.24, 95% CI 1.12–1.38), an 18% increase in the odds of sexual risk-taking (OR = 1.18, 95% CI 1.02–1.38), a 15% increase in the odds of emotional stability problems (OR = 1.15, 95% CI 1.04–1.27), and a 33% increase in the odds of physical problems (OR = 1.33, 95% CI 1.12–1.66). For every one-unit increase in the number of AAS cycles, there was a 26% increase in the odds of substance use risk-taking (OR = 1.26, 95% CI 1.10–1.46) and an 85% increase in the odds of physical problems (OR = 1.85, 95% CI 1.29–3.01).

In our online survey of adult biologically male bodybuilders, we found AAS use was associated with higher odds of psychopathic traits, both for AAS users compared to nonusers as well as for increased APED variety. Importantly, this association was also present among participants with no history of polysubstance use. It is not certain whether AAS use predicts psychopathic traits or if the existence of psychopathic traits may actually be a risk factor for AAS use. We note that AAS nonusers who considered AAS use had over twice the odds of psychopathic traits compared to AAS nonusers who never considered AAS use. A recent study of 285 competitive athletes reported that Machiavellianism and psychopathy explained 29% of the variance in positive attitude toward AAS 72 . This is supported generally by the well-established association between psychopathic traits and risk-taking behaviors such as substance abuse 48 . In that case, a large proportion of bodybuilders willing to make the jump to using AAS may already have pre-existing psychopathic traits. Psychopathy is related to both antisocial personality disorder and conduct disorder, each of which is associated with AAS use 9 , 60 . Conduct disorder in particular is a major risk factor for AAS use 9 that cannot be entirely explained by use of other drugs 59 . The relationship may be dynamic; bodybuilders with psychopathic tendencies may be more willing to begin AAS in the first place. Subsequently, these traits might be amplified either chemically by AAS use or psychologically by the environment; prior work has shown the difference between psychopaths and non-psychopaths in emotional-regulatory activity in the aPFC is modified by endogenous testosterone level 73 . With this in mind, longitudinal research is needed to further explore the causal nature of this relationship.

Our study is one of many to link AAS use substance use risk-taking behaviors 74 , 75 and sexual risk-taking behaviors 59 , 76 . It is difficult to ascertain the specific relationship between AAS use and risk-taking. Unlike physical, psychological, cognitive, and anger problems, which have all had experimental and translational research done to strengthen causal interpretations of such links 16 , 77 , there has not been experimental work to test whether risk-taking behaviors are caused by AAS use. In fact, it is important to consider that AAS use is itself a risk behavior, and another form of substance use, so AAS users may already engage in many other risk-taking behaviors prior to their first use. This may be especially true in light of our findings that AAS nonusers who considered AAS use had over three-times the odds of both substance use and sexual risk-taking behaviors compared to AAS nonusers who never considered AAS use, as well as our results regarding APED variety and AAS cycle experience. AAS users willing to try more types of APEDs or willing to undergo more AAS cycles may be more likely to also engage in risk-taking behaviors. Perhaps the relationship between AAS and risk-taking behaviors is bidirectional and interactive, where athletes that engage in these risk behaviors such as illicit drug use experiment with AAS, which may lower their inhibitions to take further risks.

Our finding that AAS users have higher odds of experiencing anger problems is in line with prior research 16 , 19 , 20 . Notably, anger has been previously reported as both a potential risk factor 78 as well as a potential outcome 27 . We did not observe associations between AAS use and emotional stability problems, cognitive problems, depressive symptoms, anxiety symptoms, or impulsivity symptoms. Prior research has identified various psychological and cognitive traits among AAS users such as depression, impulsivity, and mania 18 , 19 , 20 , but they are generally idiosyncratic in nature 8 , 79 , 80 , 81 . We do note that AAS nonusers who considered AAS use had higher odds of emotional stability problems, depressive symptoms, and impulsivity symptoms compared to AAS nonusers who never considered AAS use, former AAS users had lower odds of anxiety symptoms and impulsivity symptoms compared to AAS nonusers who considered AAS use, and current AAS users had higher odds of impulsivity symptoms compared to former AAS users. These findings comparing AAS nonusers who considered vs. never considered AAS use are consistent with prior research about factors relating to the decision to use AAS, including research on the “Big Five” personality traits 58 . Additionally, we observed increased odds of emotional stability problems with increased APED variety. Lastly, our hypothesis about physical problems was supported for AAS users compared to nonusers as well as the dose dependent response in relation to increased APED variety and increased AAS cycle experience. These findings are consistent with prior studies 3 , 8 , 10 , 32 .

There are several limitations. Although we successfully elicited responses from real-world users of AAS, there remain questions about how representative our sample is. AAS users in our sample were relatively new users (median of 2 prior cycles). Our findings may have been different with a group of more experienced users. It is also possible that our online survey was more likely to attract individuals with psychopathic traits or that AAS users with psychopathic traits are more willing to take an online survey than other users. We note that > 50% of AAS users and nonusers were considered to have substance use risk-taking, sexual risk-taking, anger problems, emotional stability problems, cognitive problems, depressive symptoms, impulsivity symptoms, and physical problems. Lastly, this cross-sectional study is entirely correlational and any attempts to speculate about causality should be made with extreme caution. Further prospective or experimental studies are needed. In light of the findings on Machiavellianism and psychopathy in relation to willingness to use AAS 72 , it would be interesting to also examine the link to narcissism and self-esteem/insecurity 82 . We wonder whether self-esteem or narcissistic traits could play an additional role in the motivation to begin AAS use, given the known downsides.

This study is among the first to directly assess psychopathy within AAS users. Our results on risk-taking, anger problems, and physical problems are consistent with prior AAS research as well as with existing frameworks of AAS use as a risk behavior. Increased psychopathic traits in AAS users may serve as the underlying mechanism to predict increased anger problems (see 60 regarding antisocial personality disorder as a mechanism between AAS and aggression). Although the present study highlights the relationship between AAS use and psychopathic traits, future research should emphasize possible causal explanations and try to elucidate the directionality of this relationship. Additionally, the mechanisms between AAS use and risk and violent behaviors should be further explored.

Data availability

All data generated or analyzed during this study are included in this published article’s supplementary information files. R code used in data analysis can be made available upon reasonable request to the corresponding author.

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We thank Ward Pettibone and Andre Nakkab for administrative assistance. This work was supported by the New York University Dean’s Undergraduate Research Fund.

This work was supported by the New York University Dean’s Undergraduate Research Fund.

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Nelson, B.S., Hildebrandt, T. & Wallisch, P. Anabolic–androgenic steroid use is associated with psychopathy, risk-taking, anger, and physical problems. Sci Rep 12 , 9133 (2022). https://doi.org/10.1038/s41598-022-13048-w

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• Published: 13 March 2024

Exploring the prevalence of anabolic steroid use among men and women resistance training practitioners after the COVID-19 pandemic

• Rastegar Hoseini   ORCID: orcid.org/0000-0001-8685-2471 1 &
• Zahra Hoseini   ORCID: orcid.org/0000-0002-7933-2221 1  

BMC Public Health volume  24 , Article number:  798 ( 2024 ) Cite this article

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The COVID-19 pandemic has had a significant impact on individual health and fitness routines globally. Resistance training, in particular, has become increasingly popular among men and women looking to maintain or improve their physical fitness during the pandemic. However, using Anabolic Steroids (AS) for performance enhancement in resistance training has known adverse effects. Thus, this study aimed to explore the prevalence of AS use among men and women resistance training practitioners after the COVID-19 pandemic.

A cross-sectional survey was conducted among 3,603 resistance training practitioners (1,855 men and 1,748 women) in various geographical locations impacted by COVID-19. The participants were asked to complete self-administered questionnaires, which included questions regarding demographic information, training habits, and current or prior usage of AS. The data were analyzed using SPSS statistical software and the chi-square method, with a significance level of ( P  < 0.05).

A total of 3603 men and women resistance training practitioners completed the survey. In the study, 53.05% of men and 41.99% of women used anabolic and androgenic steroids. Of those men who used steroids, 29.47% used Testosterone, while 31.20% of women used Winstrol. Additionally, 50.30% of men used steroids via injection, while 49.05% of women used them orally. According to the study, 49.99% of the participants had 6 to 12 months of experience with resistance training, and 64.25% of them underwent three training sessions per week. The analysis using the χ2 test did not reveal any significant difference between men and women in terms of duration of bodybuilding, frequency per week, and engagement in other activities.

This study shows that a significant proportion of men and women resistance training practitioners used AS, particularly among young adults with limited training experience. Thus, there is a need for targeted education and awareness campaigns to address the hazards of AS use and promote healthy training habits during the COVID-19 pandemic.

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Introduction

The coronavirus pandemic has caused significant disruption to the daily activities of individuals across the world [ 1 ]. One of the areas of life that has been significantly affected is physical exercise [ 2 ]. With the closure of gyms and other sports facilities and restrictions on outdoor exercise, resistance training practitioners have been forced to adapt to new methods of training to maintain their fitness levels [ 3 ]. This disruption to training habits may have had an impact on Anabolic Steroid (AS) usage among men and women resistance training practitioners [ 4 ]. AS are synthetic substances designed to mimic the effects of natural testosterone in the body [ 5 ]. These substances have numerous applications, including medical treatment for hormonal imbalances and muscle-wasting diseases. However, their abuse in the fitness industry, particularly among bodybuilders and other resistance training practitioners, has become widespread, primarily due to their performance-enhancing effects.

Several previous studies have explored the prevalence of AS consumption in various populations, including athletes, bodybuilders, and fitness enthusiasts [ 6 , 7 ]. These studies have demonstrated that the use of these substances is not limited to men and is consumed among women as well. According to a meta-analysis studying a wide range of samples, such as students, university students, resistance training practitioners, and the general public, the global prevalence of AS consumption was estimated at approximately 3.3% [ 8 ]. About Iran, a prevalence of 0.3% AS consumption among the adult population [ 6 , 9 ]. This percentage increased to 36.66% in 2020, which was primarily investigated among men aged between 18 and 34 years [ 10 ]. Furthermore, the prevalence of AS consumption varies widely across different countries, with rates of up to 25% reported in some cases [ 11 , 12 ]. Recent studies have raised concerns that the Coronavirus Disease 2019 (COVID-19) COVID-19 pandemic might have led to an increased prevalence of AS consumption in the resistance training community [ 4 , 13 ]. The pandemic response measures have forced many people to adjust to new, home-based training methods, with limited availability of gym and fitness facilities. This shift in training patterns may have led to increased use or abuse of AS among resistance training practitioners. However, the novelty of this study lies in its focus on resistance training practitioners, the examination of anabolic steroid use after the COVID-19 pandemic, and the inclusion of both men and women in the study population. To date, no research has explored the prevalence of AS consumption among resistance trainers after the COVID-19 pandemic in the Iranian population. Despite the growing popularity of resistance training during the pandemic, there is limited research specifically examining the prevalence of AS use among individuals engaging in resistance training. This research gap is crucial as it allows us to understand the extent of AS use and its associated risks within this specific population. By addressing this research gap, valuable insights can be provided into the prevalence of AS use and its potential implications for the health and well-being of resistance training practitioners. This study aims to address the research gap by exploring the prevalence of AS use among men and women resistance training practitioners after the COVID-19 pandemic. The novelty of this study lies in its focus on a specific population and its potential to provide valuable insights into AS use within the resistance training community. By linking the research gap to the goal of the article, the existing literature aims to be contributed to and awareness of the hazards of AS use while fostering healthy training habits during the COVID-19 pandemic aims to be promoted. Thus, this study aimed to investigate the prevalence of AS consumption among men and women resistance training practitioners after the COVID-19 pandemic.

Study design and population

The survey was conducted in Kermanshah, Iran, a city with an approximate population of 1 million. The survey obtained information on the number and location of gyms in Kermanshah from the Regional Council of Physical Education in the city between May and July 2023. A total of 356 fitness centers that offered resistance training were identified, out of which 286 centers were included in the study. With a confidence interval of 95% and assuming a p = q = 50% probability, a total of 100 resistance training centers were calculated, with an error margin of 7.9%, and used to estimate the population of resistance training practitioners in the city. The gyms were selected randomly and systematically from the five administrative regions of the city, based on the proportion of the number of gyms in each region. The gym management was contacted and explained about the study before obtaining their consent. Individuals aged 18 years and above, training for resistance exercise during morning, afternoon, or night hours were identified in each center. On average, 568 resistance training practitioners were identified per gym. A total number of 4,198 individuals were selected proportionately from each gym based on the number of resistance training practitioners, with a sampling error of 1.25% and a confidence interval of 95%. After screening out incomplete responses, 3603 individuals (1,855 men and 1,748 women) were included in the final analyses. At the commencement of the questionnaires, the participants were provided with information regarding the objectives of the study, and the confidential handling of data, and participants completed the consent form. Also, all educated participants and the legal guardians of illiterate participants were asked to complete the written informed consent at the beginning of the study. The study was conducted in adherence to the seventh and current modification (World Medical Association, 2013) of the Declaration of Helsinki. All experimental protocols were approved by the Committee of Research in Public Sports Board, Kermanshah, Iran.

Data collection

A self-administered questionnaire, consisting of 32 questions, was devised through a scholarly literature review of relevant articles [ 14 , 15 ]. The Questionnaire included the following variables: gender, age, profession, marital status, schooling, socioeconomic status, practice time of resistance training, duration, and purpose of training, nutritional monitoring, use of supplements, and use of AS. The questionnaire underwent a validation process, which determined its clarity, content, and construct indices. The questionnaire’s construction and content were evaluated and validated by professional health practitioners, while the clarity aspect was reviewed by individuals sharing the same traits, including class, age, and lifestyle of the intended research population. A pilot study was conducted to assess the questionnaire’s feasibility for use among the target populace.

To standardize the approach and application of the questionnaire, a pre-training session was conducted with the researchers. Following the pre-training, a pilot study with 40 individuals was carried out at the Kani Gym, which was not included in the survey data. Data collection was conducted throughout the working day by researchers positioned at the entrance of the gym and dressed in uniform to be easily identified. To approach participants, they were explained the research purpose, either at the beginning or end of their workout. Participants who agreed to participate in the study signed an informed consent form. The researchers provided clarification for any queries or ambiguities related to the questionnaire before allowing the participants to complete the form independently, without interference.

Statistical analysis

Statistical analysis in this study was performed using SPSS statistical software (version 21; SPSS Inc., Chicago, IL, USA) with a significance level of P  < 0.05. The normality of distribution was assessed with the Kolmogorov-Smirnov test. Both descriptive statistics, including mean, standard deviation, and percentage, and deductive statistics the Chi-square method, were utilized for analysis.

A total of 3,603 (1,855 men and 1,748 women) resistance training practitioners from various regions participated in the survey. A total of (number) participants took part in this study, of which 46% were aged between 18 and 29 years old (46.15% men and 45.08% women), 34.08% were aged between 30 and 44 years old (34.17% men and 33.98% women), 14.13% were aged between 45 and 59 years old (14.33% men and 13.90% women), and 6.16% were aged over 60 years old (5.34% men and 7.04% women). Also, 27.59% were single (30.02% men and 25.06% women), and 72.41% were married (69.98% men and 74.94% women). Furthermore, 0.72% of the participants were illiterate (0.81% men and 0.63% women), while 19.18% had a bachelor’s degree (18.01% men and 20.42% women). The majority of the participants, 80.10%, were university-educated (18.18% men and 78.95% women). Regarding employment status, 44.93% of the participants were employed (68.46% men and 19.97% women), 30.01% were enrolled as students (27.01% men and 33.18% women), and 25.06% were unemployed (4.53% men and 46.85% women). Only a small proportion of the sample, 3.99%, reported being smokers (4.96% men and 2.98% women), while 13.60% of the participants were hospitalized due to COVID-19 (15.94% men and 12.08% women) (Table  1 ).

The χ2 test was conducted to examine potential gender differences for all of these variables. The results demonstrated that employment status was the only variable with a statistically significant gender difference, with a higher proportion of men being employed compared to women ( p  < 0.05). No significant differences were found in the distribution of other variables based on gender (Table  1 ).

In this study, 49.99% of the participants had 6 to 12 months of experience with resistance training, and 64.25% of them underwent three training sessions per week. The results of analysis using the χ2 test revealed no significant difference in the duration of bodybuilding, frequency per week, and engagement in other activities between men and women. However, a significant difference in the purpose of performing resistance exercises was found, with 51.37% of men attending the gym for hypertrophy and 55.94% of women attending for weight loss. These findings suggest that men and women exhibit similar patterns of engagement in resistance training, but their motivations for doing so may differ (Table  2 ).

Table  3 presents the results showing that 53.05% of men and 41.99% of women used anabolic and androgenic steroids, with consumption methods differing between genders; 50.30% of men used it via injection, while 49.05% of women used it orally. The results of the χ2 test demonstrated a significant difference in the amount and consumption method of anabolic and androgenic steroid use between men and women. Furthermore, it was found that Testosterone was used by 29.47% of men, while Winstrol was used by 31.20% of women. These findings provide insight into gender-based differences in the use of anabolic and androgenic steroids and suggest that gender-specific strategies may be necessary to address this practice.

Resistance training is a popular form of exercise that has gained significant attention in recent years due to its numerous health benefits. The current study aims to investigate the exploring the prevalence of AS use among men and women resistance training practitioners after the COVID-19 pandemic. The results of the present study revealed a sample of 3,603 individuals, with approximately equal representation of men and women (51.42% versus 48.58%, respectively). The age distribution of participants showed that resistance training is popular among young adults, with 46% of participants aged between 18 and 29 years old. The originality of our study lies in its comprehensive analysis of the characteristics and gender differences of resistance training practitioners from various regions. This age range was nearly uniformly split between men and women; this finding is significant as it indicates that resistance training is equally popular among both genders, particularly among young adults, with 46% of participants aged between 18 and 29 years old. The findings of the present study indicate that the majority of participants were university-educated, which is consistent with previous research demonstrating that a higher level of education is associated with higher participation in exercise and sports [ 16 , 17 ]. Additionally, the results showed that the majority of participants were married, which suggests that resistance training may be a popular form of exercise for those with responsibilities such as marriage and children. In terms of employment status, these results suggest that there is a gender difference, with a higher proportion of men being employed compared to women. This finding is consistent with previous research demonstrating that men are more likely to be employed than women [ 18 ], and may reflect societal norms and gender roles. Finally, this study revealed a low prevalence of smoking among resistance training practitioners, which is encouraging given the detrimental health effects of smoking. However, a relatively high rate of hospitalization due to COVID-19 was found among the sample, which could be attributed to increased exposure to the virus in fitness facilities. This emphasizes the importance of implementing and promoting preventive measures to mitigate the risk of COVID-19 transmission in fitness facilities Overall, this study contributes to a better understanding of the characteristics and gender differences of resistance training practitioners from various regions. These findings suggest that resistance training is popular among both genders, particularly among young adults, and can be practiced by individuals with diverse educational and marital backgrounds. This is significant as it broadens our understanding of the demographic profile of resistance training practitioners. However, future research should investigate the motivations and expectations of resistance training practitioners, as well as the factors that influence how this form of exercise is adopted and maintained over time.

Also, the results of this study showed that a high percentage of participants had between 6 and 12 months of resistance training experience, and the majority underwent three weekly training sessions. Furthermore, these results showed no significant differences in the length of bodybuilding, frequency per week, and engagement in other activities between genders. These findings suggest that men and women exhibit similar exercise habits in resistance training. However, a significant difference in motivations between genders was found. The gym was attended by over half of the men (51.37%) for hypertrophy, while over half of the women (55.94%) attended for weight loss. Thus, these findings indicate that the motivations behind resistance training may differ between genders. It is worth noting that despite these differences in motivations, both men and women seem to have an equal level of engagement in resistance training. These findings have important implications for resistance training interventions. For example, hypertrophy may be less of a motivator for women in resistance training, while emphasizing weight loss may be more effective in increasing women’s participation in resistance training programs. However, more research is needed to determine the most effective ways to motivate men and women differently in resistance training interventions.

However, this study highlights the importance of considering gender differences in motivations for resistance training. While men and women exhibit similar exercise habits, their motivations may differ significantly. These findings may have important implications for resistance training interventions aimed at increasing participation and adherence in both men and women. Further research is needed to identify effective methods of motivating men and women in resistance training interventions. These results suggest that there are significant differences between men and women in terms of both the prevalence and consumption method of steroid use. Specifically, 53.05% of men and 41.99% of women reported using anabolic and androgenic steroids. This finding is significant as it highlights the need for gender-specific interventions to address steroid use. The size of the sample, participants, and gyms used in the literature varied considerably. For instance, a study conducted in Germany approximately 15 years ago involved 113 gyms and 621 individuals and reported a prevalence of AS use of 13.5% [ 14 ]. In Stockholm, Sweden, the prevalence was 3.8% with 64 gyms and 1746 individuals [ 19 ]. On the other hand, in Al-Ain, United Arab Emirates, the prevalence was 22.1% with 18 gyms and 154 individuals [ 20 ]. However, some studies had smaller sample sizes; for example, a study in El Paso, United States, evaluated three gyms and 516 individuals, revealing a prevalence of 11.0% [ 21 ]. Several factors, such as the sample distribution, the regional characteristics, and the individual characteristics of the samples, could have contributed to the variability in the prevalence of AS use among these studies. For instance, a study in the Netherlands that involved 92 gyms and 718 individuals reported a prevalence of AS use of 1% [ 22 ]. These findings are consistent with previous studies that have found that men are more likely to use anabolic and androgenic steroids than women [ 23 , 24 , 25 ]. The reason for lower consumption of AS among women is often due to their desire not to become excessively muscular or develop male characteristics [ 26 ]. On the other hand, men use AS not only to attain their desired body but also to gain status, admiration, and popularity in their social circle [ 27 ]. Furthermore, using AS helps them to be recognized and accepted by their peers [ 28 ]. These results also revealed important gender-based differences in the methods of steroid consumption, with 50.30% of men using intravenous injection and 49.05% of women using oral consumption. These differences may be due to various factors such as differences in physiology, availability, and perceived effectiveness. Of particular importance is the use of Testosterone by men and Winstrol by women, which were found to be the most commonly used steroids among the respective genders. While the reasons for these gender-based differences are unclear, they may reflect differences in physique ideals or perceived benefits or side effects.

Strength and limitations

These findings have important implications for the development of interventions to address anabolic and androgenic steroid use. The fact that gender-based differences were found in both the prevalence and consumption method of steroid use highlights the need for gender-specific interventions that take into account the unique factors driving steroid use among men and women. For instance, interventions targeting men may need to focus on reducing intravenous injection use, while interventions targeting women may need to focus on reducing oral consumption. While this study provides valuable insights into gender-specific differences in anabolic and androgenic steroid use, it is important to note that the sample used in this study was limited to a specific population and may not be representative of the broader population. Additionally, self-reported data are subject to social desirability bias and may not reflect the true prevalence of anabolic and androgenic steroid use. Future studies should aim to replicate these findings with larger, more representative samples, and employ more objective measures of steroid use such as biological markers.

In conclusion, our study significantly contributes to the understanding of resistance training practices among both genders, particularly among young adults. It underscores that resistance training is not limited to a specific demographic but is embraced by individuals with diverse educational and marital backgrounds. A key finding of our research is the distinct motivations for resistance training between men and women, with hypertrophy being a primary driver for men and weight loss for women. This divergence in motivations necessitates the development of gender-specific resistance training interventions to enhance participation and adherence. Furthermore, our study unveils critical gender differences in the prevalence and methods of anabolic steroid (AS) use. Men reported higher usage rates and a preference for intravenous injection, while women predominantly opted for oral consumption. These findings are pivotal, highlighting the need for gender-specific considerations when designing interventions and educational programs to address AS use among resistance training practitioners. Our research, therefore, provides valuable insights that can guide the development of more effective, gender-tailored strategies in the field of resistance training.

Future studies

In future studies, several suggestions can be considered to enhance the straightness of research on anabolic steroid use among resistance training practitioners. First, adopting a longitudinal approach would provide valuable insights into the changes in steroid use over time post-pandemic, identifying shifts in prevalence, patterns, and influencing factors. Also, supplementing quantitative data with in-depth interviews would offer a deeper understanding of motivations, perceptions, and experiences related to steroid use. Moreover, comparing steroid use across different training settings, such as home-based workouts, commercial gyms, or community centers, would allow for a comparison of prevalence rates and factors associated with steroid use within these environments. Additionally, exploring psychological factors such as body image dissatisfaction, social pressure, or self-esteem would provide a more comprehensive understanding of the motivations behind steroid use. Lastly, investigating the effectiveness of educational initiatives aimed at raising awareness and assessing their impact on attitudes, knowledge, and behaviors related to steroid use would assist in designing evidence-based preventive strategies. Implementing these suggestions would contribute to a more comprehensive and robust understanding of anabolic steroid use among resistance training practitioners.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Anabolic Steroid

Coronavirus Disease 2019

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RH: contributed to the study conception, design, investigation, data analysis, and writing of the manuscript. ZH: contributed to the data acquisition, interpretation, data analysis, and revision of the manuscript. All authors have approved the final version of the manuscript and agreed to be accountable for all aspects of the study.

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Hoseini, R., Hoseini, Z. Exploring the prevalence of anabolic steroid use among men and women resistance training practitioners after the COVID-19 pandemic. BMC Public Health 24 , 798 (2024). https://doi.org/10.1186/s12889-024-18292-5

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Treatments for people who use anabolic androgenic steroids: a scoping review

• Geoff Bates   ORCID: orcid.org/0000-0001-6932-2372 1 ,
• Marie-Claire Van Hout 1 ,
• Joseph Tay Wee Teck 2 &
• Jim McVeigh 3  

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A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a diverse population with varying motivations. Evidence has increased greatly in recent years to support understanding of this form of substance use and the associated health harms, but there remains little evidence regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health problems.

A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible.

In total, 109 eligible studies were identified, which included case reports representing a diverse range of disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings were limited throughout by the case report study designs and limited information was provided.

This scoping review indicates that while a range of case reports describe treatments provided to AAS users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.

Introduction

Human enhancement drug use differs from other forms of drug use by virtue of the motivation or purpose of their use. Typically, they are not consumed either for a treatment of an illness or injury nor for instant gratification through their psychoactive properties. Instead, their function is an attempt to change an individual’s appearance or improve a skill, ability or activity [ 1 , 2 ]. Characterised by man’s endeavour to gain an advantage over his competitor, their usage is by no means a new phenomenon, featured in social, ritual and sporting contexts throughout recorded history. Attempts to classify enhancement drugs have resulted in the six broad categories of drugs to increase lean muscle mass, to suppress appetite or reduce weight, to change the appearance of the hair or skin, to increase sexual desire or enhance performance, to improve cognitive function and to enhance mood or social interaction. Over the past 30 years, there has been growing media, policy and academic interest in this form of drug use, in particular the classification of drugs used to enhance musculature size and strength. Most notable within this category are the anabolic androgenic steroids (AAS) and their associated drugs [ 3 , 4 , 5 , 6 ]. Also included in this classification are a range of other hormones [ 7 , 8 , 9 , 10 , 11 ] including human growth hormone [ 12 , 13 ] and insulin [ 7 , 14 ].

While AAS doping remains a concern for sport, both at elite and recreational levels [ 15 , 16 , 17 ], the wider societal impact is now apparent [ 4 , 18 , 19 ]. Although prevalence estimates of clandestine behaviours such as AAS are notoriously difficult, a growing body of evidence has indicated that while well established in North America, northern Europe and Australia, there are concerns across the globe [ 6 , 19 ].

In recent years, research has provided a more nuanced understanding of AAS use in relation to the diverse characteristics and motivations of users [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ], together with knowledge of the variety and patterns of drug use from both academic studies [ 28 , 29 , 30 , 31 , 32 , 33 , 34 ] and other sources [ 35 ]. Extensive research and comprehensive reviews have provided details of the identified adverse health conditions experienced by users of these durgs [ 36 ], while new research has identified new and concerning health risks [ 37 , 38 ] and the potential for transmission of blood-borne viruses [ 20 , 29 , 39 , 40 , 41 , 42 , 43 ].

A body of research has discussed the risk of developing AAS dependence and it is estimated that up to 30% of AAS users may develop dependence, characterised by the simultaneous use of multiple AAS in large doses over long periods of time [ 36 , 44 ]. While AAS are not explicitly recognised in the Diagnostic and statistical manual of mental disorders (DSM 5) as one of nine classes of drugs [ 45 ], they may be considered under the tenth ‘other (or unknown) substance’ class. The DSM 5 determines the severity of a substance use disorder from mild to severe according to the presence of up to 11 criteria. It is argued that while there are differences between AAS and psychoactive drugs dependence, such as that AAS are typically used over a period of weeks and months to increase muscularity rather than to achieve a ‘high’ in the short-term, these criteria are still highly applicable to AAS dependence [ 46 ]. Criteria such as tolerance, withdrawal, use of the substance in larger amounts, unsuccessful attempts to reduce or stop using the substance, and time spent on activity related to the substance use have all been identified as features of AAS dependence [ 44 , 46 ]. A number of hypotheses to explain AAS dependence have been put forward [ 47 , 48 ] and recommendations for treating what has been described as steroid ‘abuse’ or dependence have long been proposed [ 49 , 50 , 51 ].

Recent recommendations to treat steroid dependence include a staged discontinuation, managing withdrawal symptoms, maintaining abstinence and attenuating complications of chronic use [ 51 , 52 , 53 ]. Long-term use of AAS at high doses may lead to the development of a range of withdrawal symptoms following cessation, including depression, insomnia, suicidal ideation and fatigue, which may persist for many months [ 47 , 51 , 54 ]. Withdrawal is characterised by psychiatric and neuroendocrine symptoms, with the user ultimately re-initiating AAS to alleviate or avoid their onset. Supporting discontinuation may require a multidisciplinary approach with input from health professionals such as a GP, addiction specialist, psychiatrist and endocrinologist [ 53 ]. Swedish guidelines for diagnosing and treating AAS ‘abuse’ [ 55 ] include advice around psychosocial treatments, such as cognitive behavioural therapy, counselling group therapy and motivational interviewing. These therapies address the user’s preoccupation with enhancing their muscularity, their experiences of past bullying or violence, and resulting self-esteem and confidence issues. Brower (2009) believes that these entrenched psychological issues should be addressed once acute withdrawal is resolved as part of successful treatment [ 51 ]. Muscle dysmorphia and associated drive for muscularity [ 56 , 57 , 58 ] may be risk factors for both initiating and continuing AAS use, and potentially dependence [ 52 ]. It may be necessary to identify and address such disorders through counselling or psychotherapies as part of AAS treatment to reduce likelihood of re-initiation [ 53 ].

There has been a fourfold increase in the number of English language academic papers published between 1995 and 2015 [ 59 ]. However, there remains scant evidence in relation to effective policy and practice within the topic. While we have a greater understanding of the environmental influences and risk factors for use [ 17 , 60 , 61 , 62 ], there are few robust findings to support the effective prevention of AAS use. Little progress has been made in answering the fundamental questions of how do we make AAS less attractive and how do we make these drugs less accessible to those at risk of initiating use [ 63 , 64 , 65 , 66 ].

Tensions between some AAS users and the medical community are well documented [ 26 , 67 , 68 , 69 ] and long established [ 70 ], predating anti-doping or legislative control in most countries. Although psychological harm and the potential demand for interventions to address dependence are also well recognised [ 71 , 72 , 73 , 74 , 75 ] and diagnostic tools available [ 52 , 76 ], available services are few and far between. Harm reduction programmes, in the form of needle and syringe programmes (NSP), have clearly been successful in engaging AAS users in Australia [ 42 , 43 , 77 , 78 ] and, in particular, the United Kingdom [ 5 , 30 , 79 , 80 ]. However, even where uptake of service is high, substantial numbers of AAS users do not access these services [ 26 , 68 , 80 , 81 ]. Policy guidance regarding the delivery of harm reduction services for AAS users, centred around NSP provision, is in place in the United Kingdom [ 82 , 83 ], with its importance recognised in National Drug Strategy and Treatment guidelines [ 84 , 85 ]. While these guidelines are based on well-established principles of treatment engagement and harm reduction, there is an urgent need to identify where we have evidence to support specific interventions and where the evidence gaps remain.

The overall aim of this review was to identify and describe what is known about psychosocial and medical interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health consequences. Specifically, the review aimed to identify:

What studies have examined the implementation and impact of interventions to support ASS cessation, and manage the health consequences related to cessation?

What studies have examined the implementation and impact of interventions to treat the harms or side effects associated with AAS use?

What are the implications of these findings, and what are the gaps in the evidence base that research in this area needs to address?

Methodology

The review was undertaken following Arksey and O’Malley’s guidance for scoping reviews, which informed the development of review methods and write-up of methods and findings [ 86 ].

Inclusion and exclusion criteria

Studies were eligible that included males or females with current or discontinued use of AAS alone, or AAS use alongside other substances. Use for any reason (for example, strength or sporting enhancement, aesthetic reasons) was acceptable with the exception of where AAS were prescribed or taken as part of a treatment regimen or in a controlled medical setting. Studies of any psychosocial or medical treatment interventions were eligible, including those that aimed to support individuals to discontinue AAS use or to treat the health consequences of current or past use. This included, but was not restricted to, treating AAS withdrawal, physical or psychological dependence, injuries, acute conditions, chronic conditions, side effects and blood-borne viruses. Studies that did not provide a description of the treatment given or those that did not describe any outcome following treatment at any follow-up time were excluded. Interventions that took place in any setting were eligible, including, but not restricted to, primary and secondary care, community settings such as drugs misuse services, NSPs and AAS clinics, sport and fitness environments, and prisons.

All types of study designs were considered due to the anticipated lack of high-quality controlled trials. Articles published in English were eligible with no date restrictions.

Search strategy

Initially, a comprehensive search was carried out in four bibliographic databases (Medline, PsycINFO, Sports Discus and the Social Sciences Citation Index) in January 2018. A search strategy was developed initially in Medline and adapted for the other databases. The full Medline search is provided in Additional file 2 .

The reference lists of all identified papers were screened to identify potentially eligible studies. Forward citation searches for included articles were executed in PubMed and the identified studies were assessed against the review inclusion criteria. This iterative process continued for all articles identified through these steps. Due to the nature of the evidence base, with studies likely to cover a broad range of topics and to be published in a wide variety of sources, these additional searches were expected to be important to identify relevant literature. Initially, titles and abstracts for all articles identified were reviewed against the inclusion criteria by one reviewer. A sample of 10% was independently reviewed by a second reviewer. The full texts for all articles included at this stage were retrieved and subjected to further screening against inclusion criteria.

Data extraction and synthesis

The relevant characteristics of identified studies were extracted into structured tables. This included population characteristics and details of their AAS use, the symptoms requiring treatment or reasons for seeking help, diagnosis, details of the treatment given and the outcomes of this treatment. Studies were grouped by the types of harms identified in Pope and colleagues’ review of the harms associated with AAS use [ 36 ]. A formal assessment of study quality was not undertaken, as this step is not recommended for scoping reviews [ 86 ]. However, comments on the overall nature, strengths and limitations of the evidence base are provided alongside discussion of review findings.

Identification of studies

Database searching identified 3,684 articles. Following screening of article title and abstracts against review inclusion criteria, full-text articles were accessed for 76 articles and these were again reviewed against the inclusion criteria. An additional 64 studies were identified through checking the reference lists and citations of the included articles. These were screened in the same manner. Following full-text screening, 46 articles were excluded, predominantly because no treatments were reported. The reasons for exclusion at this stage are reported in Fig. 1 .

Flow of studies through the review

Summary of findings

In total, 109 studies met the review inclusion criteria. Summaries of the included studies are provided in Table 1 , grouped by the type of condition that required treatment. The studies were carried out in 28 countries, most prominently the USA ( n = 33) and the UK ( n = 21). One study followed a retrospective chart review design with the others case report ( n = 94) or case series ( n = 14) designs. With the lack of any controlled studies, it was difficult to draw conclusions relating to the effectiveness of any treatments provided. Additionally, there were substantial variations across studies in the depth of reporting about participants, settings, condition requiring treatment, the treatments provided and outcomes. The identified studies were published in sources representing a diverse range of disciplines.

Across the included studies, all participants were male. They included a wide range of ages, with the majority in their 20s and 30s, and represented a broad range of experience using AAS from recent initiators to long-term use. Participants’ motivations and history were not reported in a consistent manner to understand factors driving AAS use, but they were frequently described as participating in bodybuilding or weight-lifting activities. The types of conditions requiring treatment included psychiatric ( n = 12), neuroendocrine ( n = 11), hepatic ( n = 25), kidney ( n = 6), cardiovascular ( n = 26), musculoskeletal ( n = 13) and infectious ( n = 7). A further eight studies were categorised as ‘other’ disorders. In a small number of studies, participants were diagnosed with multiple conditions, but they have been grouped by the primary diagnosis.

Further details on participants’ AAS use, conditions requiring treatment, the treatments provided and outcomes are provided in Additional file 1 .

Treatment to support AAS cessation

Four studies reported abstinence-focussed interventions following a diagnosis of AAS dependence. In two cases, patients participated briefly in a drug treatment programme [ 88 , 97 ] before withdrawing. In one, the patient received medication and psychosocial interventions to manage AAS and opioid withdrawal [ 93 ] and withdrawal symptoms abated over time. Detail on the nature of these treatments was not provided. In the remaining study, the patient received medication for a short period before deciding to resume their AAS use due to withdrawal symptoms [ 98 ]. There was no evidence identified here, however, regarding psychosocial interventions that have sought to address any associated psychological disorders amongst users seeking treatment for their AAS use or any other condition. Additionally, no evidence was identified on approaches to reduce risk of relapse by developing social support systems, improving self-confidence or managing stress, all identified as potentially important factors to be addressed during AAS treatment [ 51 , 52 , 55 ].

Two studies were identified in this review where individuals who discontinued AAS use needed treatment for subsequent psychiatric symptoms including depression and suicidal ideation [ 87 , 89 ]. A further 11 studies reported treatments for neuroendocrine disorders, primarily with men who had discontinued their AAS use prior to the onset of symptoms. Administering AAS suppresses the hypothalamic–pituitary testicular axis, particularly when used in large amounts and for long periods, and inhibits production of testosterone [ 195 ]. Men who discontinue long-term AAS use are at risk of hypogonadism and while this may frequently be temporary and resolve spontaneously, it may in some cases persist for long periods after cessation, requiring medical treatment [ 51 , 196 , 197 , 198 ]. Symptoms of hypogonadism may be behind the withdrawal experiences of people with a dependence on AAS [ 51 ]. These difficult experiences have been identified as an influencing factor in users’ decisions to continue or re-instate AAS use [ 52 ]. The limited evidence here shows that positive outcomes are consistently reported in the treatment of men suffering with neuroendocrine disorders following AAS cessation.

Treatment for harms associated with AAS use

The bulk of the evidence identified related to current or former users receiving treatment for an acute or chronic condition or injury associated with their AAS use. This included psychiatric disorders ( n = 12), hepatic and kidney disorders ( n = 31), cardiovascular disorders ( n = 26), musculoskeletal disorders ( n = 13) and a range of other disorders ( n = 8). The management of such conditions in the AAS-using group is similar to that of the general population [ 53 ] and details are described in the tables in the additional material provided. There was, however, limited evidence of engagement with users regarding their AAS use as part of their more general treatment. There were examples where participants were stated to have discontinued AAS following treatment and remained abstinent at follow-up [ 133 , 157 , 159 ], but patients’ AAS status at this time was not routinely reported.

Treatment as an opportunity for engagement

In a small proportion of studies ( n = 10), it was reported that some form of intervention to bring about, or maintain change in AAS use was included as part of the treatment provided. This was most commonly instruction or advice to discontinue AAS use, with a more substantial element such as counselling only reported in three studies [ 139 , 145 , 180 ]. Where reported, such efforts were based on suppling risk information associated with AAS but not support with discontinuation, such as managing withdrawal symptoms. No form of harm reduction interventions were initiated alongside or following any treatments provided. Only one study [ 145 ] reported signposting or referral to another service for further support.

In comparison to people who use other psychoactive drugs, AAS users are less likely to suffer acute adverse effects from their substance use, or to have their occupational performance or relationships impaired and are, therefore, less reliant upon health professionals [ 44 ]. Research has consistently indicated this group to be reluctant to seek medical help or engage with health professionals [ 67 , 199 , 200 , 201 ]. Where health professionals identify AAS use in a patient and are providing treatment for an associated harm, this may, therefore, provide a rare opportunity to motivate changes in behaviour. There were examples in this review of studies that included recent initiators. For example, in 12/25 studies included here reporting hepatic disorders, patients had initiated AAS use fewer than 6 months prior to treatment. Contact with a health professional at this stage could provide a valuable opportunity to engage with the individual about their motivations and substance use before habitual use develops or becomes entrenched, or identify and treat any underlying factors. In a further 5/25 studies, long-term AAS use of over 5 years was reported, and up to 15 years. For such individuals, this contact could provide opportunity to test for disorders associated with long-term use, promote behaviour change and discuss long-term plans for discontinuation of use.

Encouraging discontinuation and delivering harm reduction with patients treated for a disorder associated with AAS

Where a patient is receiving treatment, there will be a range of factors that affect the appropriateness of delivering any form of AAS intervention or investigating any other potential harms. For example, in many of the studies identified, the individuals treated had discontinued their AAS use a substantial time prior to seeking treatment. Additionally, many were diagnosed with acute conditions, for which immediate, and in some cases substantial, treatment was required. In such cases, it is not surprising that the acute harm will be the focus of the treatment. However, where AAS use is suspected or confirmed, a number of diagnostic tests may be appropriate to identify potential physiological or psychiatric harms [ 53 ]. Recommendations for general practitioners who identify AAS use in a patient include strongly encouraging cessation and management of withdrawal symptoms in those that do discontinue, as well as information on injecting practices, promoting alternatives to AAS and informing about long-term health harms for those who continue to use [ 202 ]. Continued encouragement and monitoring of psychiatric and physiological complications is recommended for those who are not prepared to consider discontinuation [ 53 ].

An instruction not to use AAS may be effective in some cases, but for individuals who are highly motivated to use AAS in response to a desire to change their appearance or performance, it may have little impact. Experiencing harm or increasing knowledge of potential risks may not only reduce motivation to use amongst users who may accept risks as a potential consequence of use, but also one that they can manage through their practices [ 60 ]. Where it is identified that users intend to continue administering AAS following treatment, it is important that they receive appropriate harm reduction advice, such as on safe injecting, blood-borne viruses (BBVs) and AAS cycles. For example, in seven studies, treatments for infectious complications associating with injecting AAS were reported. There was no indication of relevant harm reduction work included alongside treatment, such as advice or demonstration relating to injecting or injecting techniques in any of these studies, with the exception of Rich and colleagues who reported provision of counselling on the risks of BBVs [ 180 ].

Research over the past 30 years has provided a far richer understanding of the populations of AAS users, their characteristics, behaviours and motivations. While the specific risks attached to each AAS and the probability or magnitude of harm associated with highly individualised and complex drug regimens cannot be known, we now have a far greater understanding of the potential harms caused by these drugs. However, the evidence base for interventions has not kept pace. The examples of treatment identified in this review were set within primary and secondary care facilities. No studies were identified that explored the effectiveness of any approaches to encourage cessation or treat dependence within other settings where health professionals are likely to encounter users, such as steroid clinics, drugs services or NSPs. Consequently, there is a lack of any evidence on the effectiveness of such services for bringing about behaviour change in users. Within any setting there is scarce evidence on treating AAS dependence, including initiating and maintain cessation and managing withdrawal symptoms outside of case reports of former users seeking support for neuroendocrine disorders.

The findings of this scoping review are characterised by missed opportunities. While the failure to report good practice or supplementary activity is not proof that it does not occur, without confirmation we cannot make assumptions. The extensive literature outlining the symptomatic treatment of AAS-related harms within numerous medical and surgical specialisms fails to provide evidence of intervention or referral to address the major causative factor, the patients’ AAS use. This scoping review has reported only a sample of the myriad of case reports involving the treatment of AAS-related harms. These case reports not only demonstrate the lack of evidence of intervention effectiveness to support the cessation of AAS use or reduce the associated harms, they also fail to show that actual activity occurred. As a minimum, future case reports should report if any assessment for AAS dependence were conducted. Details of advice or interventions provided to AAS users or any referral or signposting are also essential information. Referrals to primary care, endocrinologists, addiction specialists or harm reduction providers are essential building blocks in identifying care pathways and potential effective interventions. Case reports are published predominantly in clinical journals, often relating to medical or surgical specialisms. The publication of reports in broader health or public health journals or journals related to drug use, addiction or harm reduction would facilitate the inclusion of clinical experiences within a wider approach to addressing the harms associated with AAS use.

Despite the comprehensive research and literature relating to AAS dependence, there remains little evidence regarding effective interventions to support cessation of use or management of withdrawal. It is hoped that the development diagnostic tools [ 46 ], guidelines for clinical management [ 85 ] and harm reduction [ 82 ] or the commissioning of health services [ 83 ] will be accompanied by robust research and evaluation. Evaluations to date have been small scale and lack generalizability.

In addition to the need to ensure accurate and consistent reporting of activity and an upscaling of research and evaluation, there is a need to ensure that interventions are culturally appropriate to the target groups. Much of the work to date has focused on the bodybuilding communities of North America, Northern Europe and Australia. It is clear that AAS use is a global issue, with research emerging from low–middle income countries around the world in addition to industrialised high-income states. Of added significance is the diversity of individual AAS users. Interventions will need to be tailored to meet the varied characteristics and motivations of users, going beyond those looking to achieve a stylised “bodybuilding appearance” or excel at sport or even the young males attempting to bulk up. Evidence from the United Kingdom indicates that there are as many AAS users over 40 years of age as there are those under the age of 25 years [ 31 ]. It is well established that AAS use is not restricted to men and while rates amongst women are much lower [ 203 ], the complexities of treatment and care are undoubtedly much higher [ 23 , 204 , 205 ]. Prevalence of AAS use is higher amongst groups with specific characteristics such as professions where size or strength is an asset [ 206 , 207 , 208 , 209 ], amongst gay and bisexual men [ 20 , 22 , 29 , 210 , 211 ] and those using or who have previously used other drugs [ 212 ] [ 30 , 33 , 67 , 212 , 213 , 214 ]. These “sub groups” may or may not require specific interventions and may merely illustrate the complexities of human nature. The majority of AAS users will not initiate or continue AAS by virtue of membership of one of these groups but will have a range of susceptibilities and motivations for use.

Beyond these challenges, to develop effective services for users of AAS is the ongoing lack of confidence that some communities of AAS users feel towards health care professionals and primary care in particular [ 30 , 67 , 199 ] and a feeling that reliable and relevant health information can be gained elsewhere [ 215 ]. Built on the long-standing dismissive approach towards the effectiveness of anabolic steroids by elements of the health profession [ 216 , 217 ] and an ongoing ‘just say no’ stance amongst some practitioners, it is evident that establishing trust through listening to the AAS-using communities will be an essential element of intervention and service development [ 26 ].

Conclusions

This scoping review of the literature has identified treatments given to AAS users for a wide range of physiological and psychological harms. Despite the large number of articles identified, the evidence base consists of case reports of predominantly treatment of physiological harms and there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

• Anabolic androgenic steroids

Blood-borne virus

Diagnostic and statistical manual of mental disorders

Needle and syringe programme

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Kanayama G, Pope HG, Hudson JI. Associations of anabolic-androgenic steroid use with other behavioral disorders: an analysis using directed acyclic graphs. Psychol Med. 2018:1–8.

Salinas M, Floodgate W, Ralphs R. Polydrug use and polydrug markets amongst image and performance enhancing drug users: Implications for harm reduction interventions and drug policy. Int J Drug Policy. 2019;67:43–51.

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Bates, G., Van Hout, MC., Teck, J.T.W. et al. Treatments for people who use anabolic androgenic steroids: a scoping review. Harm Reduct J 16 , 75 (2019). https://doi.org/10.1186/s12954-019-0343-1

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6 Serious Health Risks of Steroid Drug Use to Boost Athletic Ability

Taking anabolic steroids for muscle and performance enhancement is illegal. And doctors want you to know they can also pose significant risks to health.

Next up video playing in 10 seconds

In sports, the use of performance-enhancing drugs is illegal and has led to a fall from grace for some big athletes.

In 2007, the Olympic runner Marion Jones was stripped of five medals won during the 2000 Olympic games after she admitted to using anabolic steroids. The scandal around Major League Baseball’s Barry Bonds’s steroid use lasted years during the early 2000s, and resulted in his being convicted of perjury.

But some social media users may have forgotten these high-profile downfalls, as they boast of the fitness and muscle gains from taking the same illegal drugs.

The bodybuilder and TikToker David Rau (25,600 followers) has been open about his experience. In videos, he’s shared how-tos , comparison photos of physiques attained naturally versus with steroids , and the purported benefits of being on anabolic steroids, according to him (confidence, mental sharpness, and increased muscle mass).

Others, like the TikToker Caroline Mathias (34,000 followers) are calling out steroid drug use by popular social media personal-trainer influencers.

Doctors warn people not to be duped by the attention and praise social media influencers are gathering for these drugs. Anabolic steroids and other performance-enhancing drugs can come with some serious and irreversible health risks and consequences.

What Are Anabolic Steroids?

Anabolic-androgenic steroids (AAS) are man-made versions of testosterone, which is the primary sex hormone in men, according to MedlinePlus . Testosterone is responsible for the appearance of features we associate with masculinity — a deep voice, facial hair, and bulging muscles. The steroids can be taken orally, as injections, or applied topically to the skin.

These hormones are widely misused in high doses because people want large muscles and improved athletic performance, according to a review published in December 2022 in Frontiers in Endocrinology .

“Anabolic steroids greatly enhance muscle mass and increase metabolism and fat breakdown,” says Diederik Smit, an internist specializing in endocrinology and the use of anabolic steroids in Tilburg, Netherlands, and a coauthor of the review. “Besides larger muscles and increased strength, men using AAS usually are leaner. This makes the steroids very suitable for bodybuilding purposes because this is all about muscle size and definition.”

Some anabolic steroid drugs include:

• Testosterone
• Fluoxymesterone
• Mesterolone
• Methyltestosterone
• Nandrolone deconoate
• Nandrolone phenpropionate
• Oxandrolone
• Oxymetholone

Anabolic steroids have been used in this way since the 1950s, according to research . But since then they’ve been banned by several athletic organizations as performance-enhancing drugs (more on that below).

Anabolic steroids can serve a medical purpose. According to the Department of Justice’s Drug Enforcement Administration (DEA) , they’re called on as treatments for:

• Testosterone deficiency
• Delayed puberty
• Breast cancer
• Low red blood cell count
• AIDS-related tissue wasting

They can also be prescribed to help people gain weight after illness, injury, or infection, or to those who have trouble gaining weight for unknown reasons, according to the Mayo Clinic .

A few anabolic steroids are approved for medical use in humans and pets for the aforementioned conditions with a valid prescription, but by and large these are illegal and classified as Schedule 3 substances under the Controlled Substances Act, according to the DEA.

They’ve also been banned by the International Olympic Committee since the mid-1970s, and subsequently by most athletic organizations, per previous research. 

It’s when these steroids are used for the wrong reasons (and at doses of 10 to 100 times higher than doses that would be used to treat medical conditions), such as for bodybuilding or enhancing athletic performance, that they become dangerous and illegal, according to MedlinePlus.

Anabolic steroids are different from general steroids, known as corticosteroids, which are anti-inflammatory drugs such as prednisone and cortisone, according to the Cleveland Clinic .

6 Risks of Anabolic Steroids When Used for the Wrong Reasons

Not only are they illegal when taken outside of the care of a medical professional to treat specific medical conditions, but they can be dangerous. Side effects can start after about two or three weeks of use, generally around the same time that the positive effects reveal themselves, Smit says.

Here are six potential side effects of anabolic steroids when they're taken at high doses and absent a clear medical indication.

1. Heart and Liver Trouble

“The increased risk of cardiovascular disease is one of the most serious consequences of steroid use,” says Sean Byers, MD , a medical adviser in Los Angeles for Health Report Live.

The DEA reports the steroids could heighten cholesterol levels, which may lead to stroke, heart attack, or coronary artery disease.

A study published November 2018 in the International Journal of Sports and Exercise Medicine found that anabolic steroids decrease HDL cholesterol (so-called “good cholesterol”) by more than 90 percent and increase LDL cholesterol (“bad cholesterol”) by about 50 percent. The researchers found levels returned to normal about four months after participants stopped taking them.

“Long-term use [of steroids] predisposes to heart attacks and strokes, much like smoking, hypertension, and bad cholesterol do,” Smit says. “The heart muscle also increases in size, and not particularly in a good manner. This so-called hypertrophy may decrease cardiac function and cause dangerous arrhythmias.”

Oral steroids can also lead to liver trouble, including the development of tumors, according to research published in May 2020 in LiverTox .

2. Stunted Growth in Young People

These steroids could impact adult height if they're taken in adolescence, according to the DEA. This happens because the bones end up maturing too quickly and then stop growing, according to Nemours KidsHealth .

3. Aggressive Behavior

Ever heard the term “roid rage”? This is the personality change one may experience as a result of taking anabolic steroids. Many people find themselves becoming hostile, experiencing major mood swings, and engaging in aggressive behavior, per the DEA. This can sometimes lead to depression and suicide once the steroids have been stopped.

4. Physical Changes

Many of the side effects are the same for men and women, Smit says. But not all. Men on anabolic steroids may experience baldness, breast growth, and shrinking testicles, according to MedlinePlus.

Women, on the other hand, may find themselves with a deeper voice, more hair on the face and body, male pattern baldness, changes to their menstrual cycle, and a lengthening of the clitoris, according to the DEA . And while many of the side effects for anabolic steroids go away once the drugs are stopped, some of these changes to women can become permanent, Smit says.

5. Male Infertility

Steroids can negatively impact a man’s fertility. Testosterone plays an important role in male reproductive organs and sexual function, according to research , but taking testosterone through steroids can inhibit two other reproductive hormones — FSH and LH.

Steroids can also lead to abnormalities in sperm motility and morphology. It’s possible this can be reversed — the previous study showed sperm can return to normal after four months or so.

Smit adds, though, that other studies haven’t been so promising, so it’s unknown if male fertility always rebounds. “This may have consequences if they still desire to have children later in life,” he says.

Acne tends to appear along the chest, face, neck, back, and arms in response to high doses of steroids, according to the DermNet . The chest is the most common area, and steroid acne tends to be more uniform than usual acne. While not the most serious of side effects, it’s worth noting because it can affect about half of steroid abusers, according to previous research . “Acne can be disfiguring but is manageable,” Smit says.

For men, many of these side effects can be reversed once the steroid is stopped, according to the Cleveland Clinic . But it can be hard to stop, with more than 50 percent of users becoming dependent, per previous research.

Anabolic Steroids - Abuse, Side Effects and Safety

Medically reviewed by Leigh Ann Anderson, PharmD . Last updated on July 16, 2024.

What are Anabolic Steroids?

Androgens and anabolic steroids include the endogenous male sex hormone testosterone and dihydrotestosterone, and other agents that behave like these sex hormones. Androgens stimulate the development of male sexual characteristics (such as deepening of the voice and beard growth) and development of male sex organs. Anabolic steroids stimulate growth in many other types of tissues, especially bone and muscle. Anabolic effects also include increased production of red blood cells.

Medically, androgens and anabolic steroids are used to treat:

• delayed puberty in adolescent boys
• hypogonadism and impotence in men
• breast cancer
• osteoporosis
• weight loss disease in HIV
• endometriosis
• other conditions with hormonal imbalance

Anabolic steroids can be given by injection, taken by mouth, or used externally. In the U.S. they are primarily classified as Schedule III Controlled Substances due to the possibility of serious adverse effects and a high potential for abuse.

Are Anabolic Steroids Prohibited in Sports?

Some athletes may abuse anabolic steroids to build muscle, prolong endurance and enhance performance. Anabolic agents are prohibited at all times, both in- and out-of-competition in collegiate and professional sports and appear on both the World Anti-Doping Agency (WADA) and U.S. Anti-Doping Agency (USADA) Prohibited Lists . Anabolic steroid use is also prohibited by the International Olympic Committee (IOC) as well as the National Collegiate Athletic Association (NCAA). 1,2

Anabolic steroids include all synthetic derivatives of testosterone, both oral and injectable. Examples of anabolic steroids include testosterone, methyltestosterone, danazol, and oxandrolone. Anabolic steroids are performance-enhancing drugs and act by increasing lean muscle protein synthesis and body weight, without increasing fat mass. 3

What is the Extent of Illicit Anabolic Steroid Use in the U.S?

Illegal use and street purchase of anabolic steroids is risky. Illicit steroids may be sold at gyms, sporting competitions, and via mail order. Buyers may be at risk of purchasing adulterated or contaminated products.

Often, illicit steroids are smuggled into the U.S. from countries that do not require a prescription for the purchase of steroids. Steroids may also be illegally sourced from U.S. pharmacies or synthesized in backroom laboratories.

Anabolic steroids were made illegal to purchase or sell without a prescription in the Anabolic Steroids Control Act of 1990. 9

Common street names that are used to refer to anabolic steroids may include:

Abuse of anabolic steroids can occur in any age group, but statistics on their abuse is difficult to determine because many surveys on drug abuse do not include steroids. According to the National Institute on Drug Abuse (NIDA), scientific evidence indicates that anabolic steroid abuse among athletes may range between 1 and 6 percent. 2 , 5

Not surprisingly, prevalence of steroid use is higher in males than females. Laboratory drug testing can usually detect the presence of anabolic steroids, and athletes in higher level sports are frequently monitored for abuse of a large number of drugs, including steroids.

In the 2023 Monitoring the Future Survey , high school seniors reported a 0.7% use of steroids in the last 12 months, a drop from 1.3% in 2022. 7,9 Reported anabolic steroid use was 0.6% in 8th  graders and 0.5% in 10th graders in the past 12 months for the 2023 survey. In 2023 the lifetime prevalence of anabolic steroid use was 1% in all grades. 9 

Steroid use for grades 8-12 reached a peak in 2001-2002 (ranging from 1.6% to 2.5% in the last 12 months) and have since declined substantially.

Steroidal dietary supplements can be converted into testosterone or other androgenic compounds in the body. Steroidal over-the-counter dietary supplements such as androstenedione and tetrahydrogestrinone (THG) were previously available without prescription through health food stores, however, these supplements are now classified as controlled substances. 3,8

Dehydroepiandrosterone (DHEA), another steroidal dietary supplement is still available legally; however, it does appear on the U.S. Anti-Doping Agency’s list of prohibited agents for both in- and out-of-competition. In almost all countries except the U.S., DHEA is treated as a controlled anabolic steroid. Clinical research reports indicate that these agents are ineffective or lack evidence of performance-enhancing effects, and can be linked with many serious side effects and drug interactions. 3,4 ,6

Related : Explore the World Anti-Doping Agency (WADA) list of prohibited agents in sports

What are the Most Common Side Effects That May Occur with Anabolic Steroid Use?

There is a wide array of serious side effects associated with abuse of anabolic steroids - an example list can be found here. 4

Steroid use can alter the normal hormonal production in the body. Most side effects can be reversed if the drugs are stopped, but some, such as a deepened voice in women may persist. Data on long-term side effects primarily come from case reports and not from well-controlled, long-term epidemiological studies, which might be more reliable. 4

Common side effects with anabolic steroids may include:

• severe acne , oily skin and hair
• l iver disease , such as liver tumors and cysts
• kidney disease
• heart disease, such as heart attack and stroke
• altered mood, irritability, increased aggression, depression or suicidal tendencies
• alterations in cholesterol and other blood lipids
• high blood pressure
• gynecomastia (abnormal development of mammary glands in men causing breast enlargement)
• shrinking of testicles
• azoospermia (absence of sperm in semen)
• menstrual irregularities in women
• infertility
• excess facial or body hair (hirsutism), deeper voice in women
• stunted growth and height in teens
• risk of viral or bacterial infections due to unsterile injections

Are Anabolic Steroids Addictive?

Users of anabolic steroids can become both physically and psychologically dependent upon the drugs, as evidenced by:

• a drug-seeking behavior
• continued use even with adverse effects
• physical withdrawal symptoms such as mood swings, fatigue, restlessness, loss of appetite, insomnia, reduced sex drive, and steroid cravings.

Severe withdrawal can lead to depression and possible suicide. Depressive symptoms can persist for up to one year after the user stops taking the steroid. 4

Supportive treatments and medication interventions may be needed for severe addiction. Medications that have been used for treating anabolic steroid withdrawal allow the natural hormonal system to restore. Other medications target specific withdrawal symptoms.

For example, antidepressants may be prescribed to treat depressive episodes and analgesics , such as acetaminophen or ibuprofen, may be used for headaches and muscle and joint pains. Some patients may also undergo behavioral therapies. 4

What is Being Done to Combat Anabolic Steroid Abuse?

Awareness and educational efforts are working to help prevent anabolic steroid abuse in schools and communities. The Adolescents Training and Learning to Avoid Steroids (ATLAS) and the Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) programs are scientifically-proven programs that teach athletes they do not need steroids to build powerful muscles and improve athletic performance.

These programs provide:

• weight-training and nutrition alternatives
• increase healthy behaviors
• less likelihood to try steroids
• less likelihood to engage in other dangerous behaviors such as drinking and driving, use of marijuana and alcohol , and and improved body image.
• education on ways to refuse an offer of illicit drugs

Both Congress and the Substance Abuse and Mental Health Services Administration endorsed these model prevention programs. 4,7

Learn more : The Risks for Teenagers of Using Steroids

• Blood Doping: Lance Armstrong & Pro Cycling
• Can a Drug Test Lead to a False Positive?
• Drug Testing FAQs
• The Risks for Teenagers of Using Steroids
• Toxicology Drug Testing
• U-47700 (Pink)

Treatment options

• Medications for Substance Abuse

Symptoms and treatments

• Sedative, Hypnotic or Anxiolytic Drug Use Disorder
• United States Global Drug Reference Online. Drug Search. Accessed July 16, 2024 at https://www.globaldro.com/us/search
• The World Anti-Doping Agency (WADA) Website. 2020 List of Prohibited Substances and Methods. Accessed July 16, 2024. https://www.wada-ama.org/en/prohibited-list
• Jenkinson DM, Harbert AJ. Supplements and sports. Am Fam Physician. 2008 Nov 1;78(9):1039-46. PMID: 19007050. Accessed July 16, 2024.
• National Institute on Drug Abuse (NIDA). Anabolic steroids and other Appearance and Performance Enhancing Drugs (APEDs). Accessed July 16, 2024 at https://nida.nih.gov/research-topics/anabolic-steroids
• Dehydroepiandrosterone (DHEA). NPP. Drugs.com. Accessed July 16, 2024 at https://www.drugs.com/npp/dehydroepiandrosterone.html
• ATLAS and ATHENA Program Materials. Oregon Health and Science University. Accessed July 16, 2024 at https://www.ohsu.edu/ortho/high-school-athlete-program
• Monitoring the Future: National Survey Results on Drug Use 1975-2021. Jan. 2022. Institute for Social Research The University of Michigan. 
• Controlled Substances. DEA. April 12, 2022. Accessed July 16, 2024 at https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf
• Miech, R. A., Johnston, L. D., Patrick, M. E., et al. (2024). Monitoring the Future national survey results on drug use, 1975–2023: Overview and detailed results for secondary school students. Monitoring the Future Monograph Series. Ann Arbor, MI: Institute for Social Research, University of Michigan. Accessed July 16, 2024 at https://monitoringthefuture.org/data/bx-by/drug-prevalence/#drug=%22Steroids%22

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How Dangerous Are Anabolic Steroids?

What Are Anabolic Steroids?

Anabolic steroids are drugs made in a lab that mimic the naturally occurring male sex hormones called androgens. Testosterone is the primary type of androgen. Doctors prescribe anabolic steroids to promote the growth of skeletal muscle and the development of male sexual characteristics for conditions such as low testosterone (male hypogonadism), certain cancers , or acquired immunodeficiency syndrome (AIDS).

Around 3 to 4 million people in the U.S. use anabolic steroids without a prescription for nonmedical purposes. They're the most common appearance- and performance-enhancing drugs (APEDs). Some athletes and bodybuilders may use them as a way to enhance their physical appearance. 

Anabolic steroid street names

Slang words for steroids are hard to find. Most people just say steroids. 

The scientific name for this class of drugs is anabolic-androgenic steroids. Anabolic refers to muscle building . Androgenic refers to increased male characteristics. But even scientists shorten it to anabolic steroids.

Although the nicknames for anabolic steroids change over time, some of the current common names according to the United States Drug Enforcement Administration include:

• Weight gainers

Anabolic steroids vs. corticosteroids

Corticosteroids are general steroid medications that reduce inflammation and dampen the activity of your immune system. They're lab-made to work like cortisol, a hormone made by your adrenal glands. 

Doctors prescribe corticosteroids much more often than anabolic steroids. You may need them to treat conditions such as  asthma , eczema, muscle and joint conditions, lupus, or multiple sclerosis.  

How Do Anabolic Steroids Work?

Anabolic steroids activate androgen receptors in your body. That means they create the same effect that androgens do in the body. This makes them an ideal treatment for people dealing with low testosterone levels. 

They can also help lower estrogen levels, which can help treat estrogen receptor positive breast cancer by blocking the growth of cancer cells that use estrogen to grow. For people with cancer or AIDS who are losing muscle, anabolic steroids increase the number of androgen receptors in skeletal muscle and increase it in size and strength.

Anabolic Steroid Types

Anabolic steroid pills

Anabolic steroids you take by mouth are available in tablet or capsule form. Some you take sublingually, which means under the tongue. 

Other forms of anabolic steroids

• Creams or topical gels
• Pellets you implant under the skin

List of anabolic steroids

The different types of anabolic steroids a doctor can prescribe include:

• Danazol (Danocrine)
• Fluoxymesterone (Androxy, Halotestin)
• Mesterolone (Proviron)
• Methyltestosterone (Android, Methitest, Testred, Virilon)
• Nandrolone Decanoate (Deca-Durabolin)
• Nandrolone Phenpropionate (Durabolin)
• Oxandrolone (Oxandrin)
• Oxymetholone (Anadrol)
• Testosterone buccal system (Striant)
• Testosterone capsules (Jatenzo)
• Testosterone injection (Andro-L.A., Aveed, Delatestryl, Depo-Testosterone, Virilon, Xyosted)
• Testosterone nasal gel (Natesto)
• Testosterone patches (Androderm, Testoderm)
• Testosterone skin solution (Axiron)
• Testosterone subcutaneous pellets (Testopel)

Anabolic Steroid Uses

Doctors use these drugs to help treat delayed puberty, and improve muscle mass and strength in people who have conditions that reduce muscle tissue. Some doctors prescribe it for testosterone supplementation therapy to improve mood and sexual performance in older men. 

Anabolic steroids for muscle growth

The misuse of anabolic steroids is common among athletes because it increases lean muscle mass more quickly and dramatically when combined with weight lifting than weight lifting alone. Many people who take it deal with a body dysmorphic disorder called muscle dysmorphia, which is a preoccupation with muscle size and the fear that muscles are too small.  

Cycling and stacking

Some people "cycle" their anabolic steroid use by taking the drugs for a while and then pausing for a while before they start them again. Another method called "stacking" involves taking more than one type of anabolic steroid at a time in hopes that this will make the drugs work better. 

"Pyramiding" is another type of anabolic steroid usage people try to prevent harmful side effects. This involves a combination of both stacking and cycling. You start by taking a low dose of one or more anabolic steroids, and then increase your dosage over time. Once you get to a maximum dose, you stop taking them for a rest period before starting again. 

When anabolic steroids are staggered, overlapped, or substituted with another type of steroid to avoid developing tolerance, this is called "plateauing." There's no scientific research that shows any of these methods improve the drugs or reduce the risk of negative effects. 

Anabolic Steroid Effects

To use anabolic steroids safely, you need a prescription and supervision of a doctor. 

Some of the typical side effects of the drug include:

• Ankle swelling
• Problems peeing
• Breast enlargement in people assigned male at birth
• Reduced breast size in people assigned female at birth
• Worse sleep apnea, if you have it
• Decrease in testicle size
• Vaginal dryness, burning, itching, or bleeding
• Changes to your period

The average nonprescription dose of anabolic steroids is 10–100 times stronger than one a doctor would prescribe. This makes side effects much more severe when you use them without a prescription. Some can be reversed, but some are permanent. 

Anabolic Steroid Side Effects

If you take anabolic steroids outside of a doctor's care, you may have serious side effects that can have a negative impact on your health. You're at risk of:

• High blood pressure
• Blood clots
• Heart issues, including heart attack
• Liver damage
• Short stature (if you're an adolescent)
• Male-pattern baldness
• Major depressive disorder.

Are anabolic steroids addictive?

Nearly one-third of people who misuse anabolic steroids become dependent on them. That means over time it starts to take higher and more frequent doses to get the same effects. 

People who become dependent on anabolic steroids can also have withdrawal symptoms if they stop taking them. Without the drug in their system, they may feel tired and restless, stop eating and sleeping, lose their sex drive, and crave the drug. In some cases, withdrawal causes depression and thoughts of suicide.

Anabolic Steroid Complications

Your moods and emotions are balanced by the limbic system of your brain. Steroids act on the limbic system and may cause irritability and mild depression. Eventually, steroids can cause mania, delusions, and violent aggression, or "roid rage."

When steroids get into the body, they go to different organs and muscles. Steroids affect individual cells and make them create proteins. These proteins cause issues such as:

• Tumor growth in the liver
• Peliosis hepatis (blood-filled cysts on the liver that can rupture and cause internal bleeding)
• Atherosclerosis , which causes fat deposits inside arteries to disrupt blood flow. When blood flow to the heart is blocked, a heart attack can occur. If blood flow to the brain is blocked, a stroke can result.
• Weakened immune system, which increases your risk of infection and illness

If you inject anabolic steroids and share a needle with others, you're at great risk of getting HIV, hepatitis B, and hepatitis C. 

Can you overdose on anabolic steroids?

Anabolic steroids aren't a drug you can overdose on. The negative effects of the drug are ones that develop over time. 

 Treatment for Anabolic Steroid Misuse

Studies show that few people who misuse anabolic steroids seek treatment to stop using them. To treat steroid use, the most effective methods involve uncovering the underlying causes of the misuse.

Treatment options include:

• Therapy and possibly medication for muscle dysmorphia
• Endocrine therapies to help treat low testosterone levels after stopping anabolic steroids to help prevent and reduce symptoms of depression
• Antidepressants 
• Drug and psychosocial treatments for people who are also dependent on opioids. These methods may work to reduce dependence on anabolic steroids

Are Anabolic Steroids Illegal?

Anabolic steroids are Schedule III substances under the Controlled Substances Act. That means it's illegal to use them without a prescription. Only a small number of anabolic steroids are approved for either human or veterinary use.

Legal anabolic steroids

The only way to use steroids legally is to have a prescription for them.

Preventing Anabolic Steroid Misuse 

Research on high school athletes shows they're less likely to misuse anabolic steroids if their friends and family disapprove. Peer pressure has a strong effect. 

But simply educating students about the dangers of anabolic steroid misuse doesn't have the same preventive results. Studies show it's more effective to talk about the whole picture of anabolic steroids: the risks and the benefits. Often, this helps them believe the negative aspects are true (and that they should avoid them).  

Other research shows that focusing on the prevention of high-risk behavior in general can be a catchall to help ward off anabolic steroid use. 

Doctors prescribe anabolic steroids to help with skeletal muscle and the development of male sexual characteristics. Around 3 to 4 million people in the U.S., however, use anabolic steroids without a prescription for nonmedical purposes, including as appearance- and performance-enhancing drugs (APEDs). If you take anabolic steroids outside of a doctor's care, you may have serious side effects that can have a negative impact on your health. Talk to your doctor about possible treatment plans if you're worried about misusing steroids.

Anabolic Steroids FAQs

• What are anabolic steroids mainly used for? Around 3 to 4 million people in the U.S. use anabolic steroids without a prescription for nonmedical purposes. They're the most common appearance- and performance-enhancing drugs (APEDs).
• Are anabolic steroids ever safe? Doctors prescribe anabolic steroids to help with skeletal muscle and the development of male sexual characteristics for conditions like low testosterone (male hypogonadism), certain cancers, or acquired immunodeficiency syndrome (AIDS).
• Are anabolic steroids illegal? It's illegal to use anabolic steroids without a prescription.

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Newsroom / MC students study use of anabolic agents in livestock production

Colby Huffman ’25 and Ellie Jaynes ’26 work to trace anabolic agents from the farm to the kitchen

Aug. 13, 2024

EDITOR’S NOTE: This is the sixth in an ongoing series spotlighting summer research projects and internships by Maryville College STEM students , made possible through a $645,000 Fund to Improve Post-Secondary Education (FIPSE) grant, administered through the U.S. Department of Education. The grant was earmarked for the expansion of MC’s Scots Science Scholars program and build on STEM initiatives provided by the College to “increase access to hands-on experiences and industry exposure, with a focus on addressing emerging technologies and scientific innovation in natural sciences, computational science and engineering.” 

The use of anabolic agents in agriculture, specifically by farmers who raise beef cattle, has been a topic of much debate for years, to the point that some European countries banned them decades ago.

It was in BIO-412, MC Biology Professor Dr. Drew Crain ’s Animal Physiology class, that Colby Huffman ’25 first became aware of them, and he found the subject so fascinating that he asked to work with Crain over the summer to research the amount of those agents — steroid hormones, in most cases — can be found in beef.

“This is important, because most producers use beef enhancement that makes their cows develop more muscle quicker, which is great for the farmer because it’s economical, but maybe not so much for the people eating the meat,” Huffman said. “That question is still up in the air, though, so hopefully this project will shed some light on the situation. I’m asking the question, ‘How much of these enhancers are staying in the meat?’ This is the first step to determining if there are potential impacts on the consumer.”

“When discussing the endocrine system, I mentioned in passing about how we do not know much about the impact of hormone supplements for cattle,” Crain added. “For instance, do any of the hormones end up in the meat, and does cooking the meat impact this? Colby’s family owns a beef cattle farm, and Colby approached me inquiring if he could pursue this question with me. When we heard that Ellie Jaynes (’26) , who has a very quantitative and mathematical mind, could help us, this project was born.

“I act as a faculty mentor to Colby and Ellie. As I explained to them, I am treating this like a graduate school research project. I meet with them regularly giving advice and direction, and then they do the research.”

The first experiment with anabolic agents to support livestock growth took place in 1948, according to the National Institute of Health , and over the next several decades, they’ve been explored for use in both agriculture and pharmaceuticals. The misuse of growth stimulants in livestock, however, led to a ban in the Netherlands in 1961. Other European countries followed suit, and that decision spurred Huffman’s interests in determining whether the presence of such steroid hormones might have an effect on people. Like their peers in the labs and fields this summer, Huffman and Jaynes can afford to spend their summer doing research thanks to compensation via the FIPSE grant.

“The process for doing so is to get a sample of beef for the grocery store, extract the steroids from the meat, and then measure them using a very sophisticated instrument called High-Performance Liquid Chromatography-tandem Mass Spectrometry (HPLC-MS/MS or LC-MS/MS),” he said.

Jaynes, a rising junior Mathematics major, then analyzes the resulting data to determine the specificity and the amount of the anabolic agents discovered in those grocery store samples. Collecting that data is the first step, Huffman said, and determining the effects of those agents on people rather than livestock is a much more complex scientific feat.

“Another exciting portion is that this is a pretty big project, but it has so much potential to keep evolving and taking on more and more to study,” Huffman said. “An example would be analyzing waterways because the cows also urinate some of these substances out, and most water treatment plants, to my knowledge, do not filter these substances, which could be another way they are consumed by people.

“Needless to say, I am extremely interested in this project and often get lost in planning the crossroads and different avenues. However, I would like to keep working on this through my senior thesis and explore some more avenues that this project and protocol can offer at Maryville.”

Up next: Jonathan Yost ’26 mines marigolds for repellent !

After Colby Huffman '25 gathers samples of meat sold to the public, Ellie Jaynes '26 works to analyze it.

Colby Huffman '25 (left) and Ellie Jaynes '26 work together in the lab.

Colby Huffman '25 analyzes data on anabolic agents used to promote livestock growth.

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• v.5(2); 2006 Jun

Medical Issues Associated with Anabolic Steroid Use: Are They Exaggerated?

For the past 50 years anabolic steroids have been at the forefront of the controversy surrounding performance enhancing drugs. For almost half of this time no attempt was made by sports governing bodies to control its use, and only recently have all of the major sports governing bodies in North America agreed to ban from competition and punish athletes who test positive for anabolic steroids. These punitive measures were developed with the primary concern for promotion of fair play and eliminating potential health risks associated with androgenic-anabolic steroids. Yet, controversy exists whether these testing programs deter anabolic steroid use. Although the scope of this paper does not focus on the effectiveness of testing, or the issue of fair play, it is of interest to understand why many athletes underestimate the health risks associated from these drugs. What creates further curiosity is the seemingly well-publicized health hazards that the medical community has depicted concerning anabolic steroidabuse. Is there something that the athletes know, or are they simply naïve regarding the dangers? The focus of this review is to provide a brief history of anabolic steroid use in North America, the prevalence of its use in both athletic and recreational populations and its efficacy. Primary discussion will focus on health issues associated with anabolic steroid use with an examination of the contrasting views held between the medical community and the athletes that are using these ergogenic drugs. Existing data suggest that in certain circumstances the medical risk associated with anabolic steroid use may have been somewhat exaggerated, possibly to dissuade use in athletes.

• For many years the scientific and medical communities depicted a lack of efficacy and serious adverse effects from anabolic steroid use.
• Clinical case studies continue to link anabolic steroid administration with myocardial infarct, suicide, and cancer, evidence to support a cause and effect relationship is lacking.
• It may be other contributing factors (i.e. genetic predisposition, diet, etc.) that play a substantial role and potentiate the harmful effects from anabolic steroids.

Introduction

Anabolic-androgenic steroids (herein referred to as only anabolic steroids) are the man-made derivatives of the male sex hormone testosterone. Physiologically, elevations in testosterone concentrations stimulate protein synthesis resulting in improvements in muscle size, body mass and strength (Bhasin et al., 1996 ; 2001 ). In addition, testosterone and its synthetic derivatives are responsible for the development and maturation of male secondary sexual characteristics (i.e. increase in body hair, masculine voice, development of male pattern baldness, libido, sperm production and aggressiveness).

Testosterone was isolated in the early 20 th century and its discovery led to studies demonstrating that this substance stimulated a strong positive nitrogen balance in castrated dogs and rats (Kochakian, 1950 ). Testosterone, because of its rapid degradation when given through either oral or parenteral administration, poses some limitations as an ergogenic aid. Although its potency is rapidly observed, the high frequency of administration needed becomes problematic. In addition, testosterone has a therapeutic index of 1 meaning there is similarity in the proportion between the anabolic and androgenic effects. As a result it becomes necessary to chemically modify testosterone to retard the degradation process and reduce some of the negative side effects. This allows for maintenance of effective blood concentrations for longer periods of time, may increase its interaction with the androgen receptor, and achieves the desired anabolic and androgenic changes.

Boje, 1939 was the first to suggest that exogenous testosterone administration may enhance athletic performance. By the late 1940’s and 1950’s testosterone compounds were experimented with by some west coast bodybuilders (Yesalis et al., 2000 ). The first dramatic reports of anabolic steroid use occurred following the 1954 world weightlifting championships (Yesalis et al., 2000 ). Use of these drugs spread quickly through the 1960’s and became popular among athletes in a variety of Olympic sports (Dubin, 1990 ). Wide spread use has also been reported in power lifters (Wagman et al., 1995 ), National Football League players (Yesalis et al., 2000 ), collegiate athletes (Yesalis, 1992 ), and recent claims of wide spread use in many sports including Major League Baseball players has made anabolic steroids the number one sports story of 2005 in some markets (Quinn, 2006 ). The ergogenic effects associated with anabolic steroids are presented in Table 1 .

Ergogenic effects associated with anabolic steroid use.

Athletes typically use anabolic steroids in a “stacking” regimen, in which they administer several different drugs simultaneously. The rationale for stacking is to increase the potency of each drug. That is, the potency of one anabolic agent may be enhanced when consumed simultaneously with another anabolic agent. They will use both oral and parenteral compounds. Most users will take anabolic steroids in a cyclic pattern, meaning the athletes will use the drugs for several weeks or months and alternate these cycles with periods of discontinued use. Often the athletes will administer the drugs in a pyramid (step-up) pattern in which dosages are steadily increased over several weeks. Towards the end of the cycle the athlete will ‘step-down’ to reduce the likelihood of negative side effects. At this point, some athletes will discontinue drug use or perhaps initiate another cycle of different drugs (i.e., drugs that may increase endogenous testosterone production to prevent the undesirable drop in testosterone concentrations that follows the removal of the pharmaceutical agents). A recent study has shown that the typical steroid regimen involved 3.1 agents, with a typical cycle ranging from 5 – 10 weeks (Perry et al., 2005 ). The dose that the athlete administers was reported to vary between 5 - 29 times greater than physiological replacement doses (Perry et al., 2005 ). These higher pharmacological dosages appear necessary to elicit the gains that these athletes desire. In a classic study on the dose-response curve of anabolic steroids, Forbes, 1985 demonstrated that the total dose of anabolic steroids have a logarithmic relationship to increases in lean body mass. These results exacerbate the athlete’s philosophy that if a low dose is effective, then more must be better.

Adverse effects associated with anabolic steroid use are listed in Table 2 . For years, the medical and scientific communities attempted to reduce anabolic steroid use by athletes by underscoring their efficacy and focusing on the unhealthy side effects (Biely, 1987 ; Darden, 1983 ; Fahey and Brown, 1973 ; Fowler et al., 1965 ; Golding et al., 1974 ). For the most part, this may have proved to be ineffective and caused athletes to lose trust in the physician’s knowledge of anabolic steroids thereby forcing them to seek advice from friends, internet sites or drug suppliers (Pope et al., 2004 ). However, recent literature has suggested that the medical issues associated with anabolic steroids may be somewhat overstated (Berning et al., 2004 ; Sturmi and Diorio, 1998 ; Street et al., 1996 ) considering that many of the side effects associated with anabolic steroid abuse are reversible upon cessation. It is important to note that there are differences in the side effects associated with anabolic steroid use (i.e.under medical supervision) versus abuse (i.e. consumption of many drugs at high doses).

Adverse effects associated with anabolic steroid use.

The clinical examination of anabolic steroid use is quite limited. Much of the problem in prospectively examining the effects of anabolic steroids on the athletic population is related to the unwillingness of institutional review boards to approve such studies in a non-clinical population. As a result, most of the investigations concerning medical issues associated with anabolic steroid administration have been performed on athletes self-administering the drugs. Anecdotally, it appears that a disproportionate magnitude of use and incidence of adverse effects are evident in bodybuilders (who are also known for consuming several other drugs that relieve some side effects but potentiate other risk factors as well, i.e. diuretics, thyroid hormones, insulin, anti-estrogens, etc.) compared to strength/power athletes. The mindset and motivation of these two types of athletes can be quite different. The strength/power athlete will typically use anabolic steroids to prepare themselves for a season of competition. They will generally cycle the drug to help them reach peak condition at a specific time of the training year. In contrast, bodybuilders use anabolic steroids to enhance muscle growth and definition. Their success is predicated on their aesthetic appearance. As a result many of these athletes may use anabolic steroids excessively for severalyears without cycling off or perhaps minimizing the length of “off cycles” depending on their competition schedule. Recent research has indicated that those athletes exhibit behavior that are consistent with substance dependence disorder (Perry et al., 2005 ). Although the medical issues associated with anabolic steroids may be quite different between these two types of athletes, the scientific literature generally does not differentiate between the two. The following sections will discuss adverse effects on specific physiological systems associated with anabolic-androgenic steroid use. It is important to note that many athletes consume multiple drugs in addition to anabolic steroids. Thus, the unhealthy side effects could be potentiated by the use of drugs such as human growth hormone or IGF-1.

Cardiovascular System

In both the medical and lay literature one of the principal adverse effects generally associated with anabolic steroid use is the increased risk for myocardial infarction. This is primarily based upon several case reports published over the past 20 years describing the occurrence of myocardial infarctions in young and middle-aged body builders or weight lifters attributed to anabolic steroid use and/or abuse (Bowman, 1989 ; Ferenchick and Adelman, 1992 ; Gunes et al., 2004 ; Kennedy and Lawrence, 1993 ; Luke et al., 1990 ; McNutt et al., 1988 ). However, direct evidence showing cause and effect between anabolic steroid administration and myocardial infarction is limited. Many of the case studies reported normal coronary arterial function in anabolic steroid users that experienced an infarct (Kennedy and Lawrence, 1993 ; Luke et al., 1990 ), while others have shown occluded arteries with thrombus formation (Ferenchick and Adelman, 1992 ; Gunes et al., 2004 ; McNutt et al., 1988 ). Still, some of these studies have reported abnormal lipoprotein concentrations with serum cholesterol levels nearly approaching 600 mg·dl -1 (McNutt et al., 1988 ). Interestingly, in most case studies the effects of diet or genetic predisposition for cardiovascular disease were not disseminated and could not be excluded as contributing factors.

Alterations in serum lipids, elevations in blood pressure and an increased risk of thrombosis are additional cardiovascular changes often associated with anabolic steroid use (Cohen et al., 1986 ; Costill et al., 1984 ; Dhar et al., 2005 ; Kuipers et al., 1991 ; LaRoche, 1990 ). The magnitude of these effects may differ depending upon the type, duration, and volume of anabolic steroids used. Interesting to note is that these effects appear to be reversible upon cessation of the drug (Dhar et al., 2005 , Parssinen and Seppala, 2002 ). In instances where the athlete remains on anabolic steroids for prolonged periods of time (e.g “abuse”), the risk for developing cardiovascular disease may increase. Sader and colleagues ( 2001 ) noted that despite low HDL levels in bodybuilders, anabolic steroid use did not appear to cause significant vascular dysfunction. Interestingly, athletes participating in power sports appear to have a higher incidence of cardiovascular dysfunction than other athletes, regardless of androgen use (Tikkanen et al., 1991 ; 1998 ). Thus, a strength/power athlete with underlying cardiovascular abnormalities that begins using anabolic steroids is at a much higher risk for cardiovascular disease. However, anabolic steroid-induced changes in lipid profiles may not, per se, lead to significant cardiovascular dysfunction.

The risk of sudden death from cardiovascular complications in the athlete consuming anabolic steroids can occur in the absence of atherosclerosis. Thrombus formation has been reported in several case studies of bodybuilders self-administering anabolic steroids (Ferenchick, 1991 ; Fineschi et al., 2001 ; McCarthy et al., 2000 ; Sahraian et al., 2004 ). Melchert and Welder, 1995 have suggested that the use of 17α-alkylated steroids (primarily from oral ingestion) likely present the highest risk for thrombus formation. They hypothesized that anabolic steroid consumption can elevate platelet aggregation, possibly through an increase in platelet production of thromboxane A 2 and/or decreasing platelet production of prostaglandin PgI 2, resulting in a hypercoagulable state.

Left ventricular function and anabolic steroid use/abuse has been examined. Climstein and colleagues ( 2003 ) demonstrated that highly strength-trained athletes, with no history of anabolic steroid use exhibited a higher incidence of wave form abnormalities relative to recreationally-trained or sedentary individuals. However, when these athletes self-administered anabolic steroids, a higher percentage of wave form abnormalities were exhibited. Further evidence suggestive of left ventricular dysfunction has been reported in rodent models. A study on rats has shown that 8 weeks of testosterone administration increased left ventricle stiffness and caused a reduction in stroke volume and cardiac performance (LeGros et al., 2000 ). It was hypothesized that the increased stiffness may have been related to formation of crosslinks between adjacent collagen molecules within the heart. Others have suggested that anabolic steroid use may suppress the increases normally shown in myocardial capillary density following prolonged endurance training (Tagarakis et al., 2000 ). However, there are a number of interpretational issues with this study. The changes reported were not statistically significant. In addition, the exercise stimulus employed (prolonged endurance training) is not the primary mode of exercise frequently used by anabolic steroid users. Resistance training, independent of anabolic steroid administration, has been shown to increase left ventricular wall and septal thickness due to the high magnitude of pressure overload (Fleck et al., 1993 ; Fleck, 2003 ; Hoffman, 2002 ). This is known as concentric hypertrophy and does not occur at the expense of left ventricular diameter. In general, cardiac hypertrophy (resulting from a pressure overload, i.e. hypertension) may not be accompanied by a proportional increase in capillary density (Tomanek, 1986 ). Therefore, the potential for a reduction in coronary vasculature density exists for the resistance- trained athlete. However, it does not appear to pose a significant cardiac risk for these athletes. Recent observations have shown a dose-dependent increase in left ventricular hypertrophy (LVH) in anabolic steroid users (Parssinen and Seppala, 2002 ). This may have the potential to exacerbate the reduction in coronary vasculature density. However, the authors have acknowledged that their results may have been potentiated by a concomitant use of human growth hormone by their subjects. Other studies have failed to show additive effects of anabolic steroid administration and LVH in resistance-trained athletes (Palatini et al., 1996 ; Dickerman et al., 1998 ).

Hepatic System

An elevated risk for liver tumors, damage, hepatocellular adenomas, and peliosis hepatitis are often associated with anabolic steroid use or abuse. This is likely due to the liver being the primary site of steroid clearance. In addition, hepatic cancers have been shown to generally occur with higher frequency in males compared to females (El-Serag, 2004 ). It is thought that high endogenous concentrations of testosterone and low estrogen concentrations increase the risk of hepatic carcinomas (Tanaka et al., 2000 ). However, this appears to be prevalent for men with pre-existing liver disease. In normal, healthy men the relationship between testosterone concentrations and liver cancer has not been firmly established. Additional reports of liver cancer and anabolic steroids have been reported in non- athletic populations being treated with testosterone for aplastic anemia (Nakao et al., 2000 ). In regards to liver cancer and disease in athletes consuming anabolic steroids, many concerns have been raised based primarily on several case studies that have documented liver disease in bodybuilders using anabolic steroids (Cabasso, 1994 ; Socas et al., 2005 ; Soe et al., 1992 ).

A few studies have recently questioned the risk to hepatic dysfunction from anabolic steroid use (Dickerman et al., 1999 ). A recent study examining the blood chemistry of bodybuilders self-administering anabolic steroids reported elevations in aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase (CK), but no change in the often-regarded more sensitive gamma- glutamyltranspeptidase (GGT) concentration (Dickerman et al., 1999 ). Thus, some experts have questioned these criteria tools because of the difficulty in dissociating the effects of muscle damage resulting from training from potential liver dysfunction. This has prompted some researchers to suggest that steroid-induced hepatotoxicity may be overstated. Another study involved a survey sent to physicians asking them to provide a diagnosis for a 28-year-old anabolic steroid using bodybuilder with abnormal serum chemistry profile (elevations in AST, ALT, CK, but with a normal GGT) (Pertusi et al., 2001 ). The majority of physicians (63%) indicated liver disease as the primary diagnosis as 56% of physicians failed to acknowledge the potential role of muscle damage or disease thereby increasing the likelihood of overemphasized anabolic steroid-induced hepatotoxicity diagnoses. Many case reports involving anabolic steroid administration and hepatic cancers examined individuals who were treated with oral steroids (17α-alkylated) for many years. No cysts or tumors have been reported in athletes using 17β-alkylated steroids. Thus, evidence appears to indicate that the risk for hepatic disease from anabolic steroid use may not be as high as the medical community had originally thought although a risk does exist especially with oral anabolic steroid use or abuse.

Bone and Connective Tissue

The issue of anabolic steroids and bone growth has been examined in both young and adult populations. In both populations, androgens have been successfully used as part of the treatment for growth delay (Albanese et al., 1994 ; Bagatell and Bremner, 1996 ; Doeker et al., 1998 ), and for osteoporosis in women (Geusens et al., 1986 ). Androgens are bi-phasic in that they stimulate endochondral bone formation and induce growth plate closure at the end of puberty. The actions of androgens on the growth plate are mediated to a large extent by aromatization to estrogens (Vanderschueren et al., 2004 ; Hoffman, 2002 ). Anabolic steroid use results in significant elevations in estrogens thought to impact premature closure of the growth plate. The acceleration of growth in adolescents treated with testosterone has raised concern for the premature closure of the epiphyseal plate (NIDA, 1996 ; Sturmi and Diorio, 1998 ). However, there does not appear to be any reports documenting the occurrence of premature stunted growth inadolescents taking anabolic steroids. Interesting, anabolic steroid administration in colts has been reported to delay epiphyseal plate closure (Koskinen and Katila, 1997 ). Although comparisons between humans and animals are difficult to make, suprapharmacological dosages that most athletes use may pose a greater risk than the doses studied to date. Thus, for the adolescent athlete using anabolic steroids the risk of premature epiphyseal plate closure may exist.

Anabolic steroids have been suggested to increase the risk of tendon tears in athletes (David et al., 1994 ; Stannard and Bucknell, 1993 ). Studies in mice have suggested that anabolic steroids may lead to degeneration of collagen (proportional to duration of steroid administration) and potentially lead to a decrease in tensile strength (Michna, 1986 ). In addition, a decrease in collagen synthesis has been reported from anabolic steroid administration in rats (Karpakka et al., 1992 ). The response in humans has been less clear. Mechanical failure has been suggested as a mechanism in anabolic steroid-using athletes. Skeletal muscle adaptations (i.e. hypertrophy and strength increases) take place rather rapidly in comparison to connective tissue. Therefore, tendon injuries in athletes are thought to occur from a rapid increase in training intensity and volume where connective tissue fails to withstand the overload. However, case reports of spontaneous tendon ruptures of weightlifters and athletes are limited.Although experimental data from animal models suggest that anabolic steroids may alter biomechanical properties of tendons, ultrastructural evidence supporting this claim is lacking. One study has shown that high doses of anabolic steroids decrease the degradation and increase the synthesis of type I collagen (Parssinen et al., 2000 ). Evans and colleagues ( 1998 ) performed an ultrastructural analysis on ruptured tendons from anabolic steroid users. They concluded that anabolic steroids did not induce any ultrastructural collagen changes that would increase the risk of tendon ruptures. Although the incidences of tendon rupture in anabolic steroid users should not be discounted, it is important to consider it in relation to the mechanical stress encountered from the rapid increases in muscular performance. Prospective research on anabolic steroid use and connective tissue injury is warranted.

Psychological and Behavioral

An issue that is often raised with anabolic steroid use is the psychological and behavioral effects. Increases in aggressiveness, arousal and irritability have been associated with anabolic steroid use. This has potentially beneficial and harmful implications. Elevations in arousal and self-esteem may be a positive side effect for the athlete. The increase in aggressiveness is a benefit that athletes participating in a contact sport may possess. However, increased aggressiveness may occur outside of the athletic arena thereby posing significant risks for anabolic steroid users and those they come in contact with. Anabolic steroids are associated with mood swings and increases in psychotic episodes. Studies have shown that nearly 60% of anabolic steroid users experience increases in irritability and aggressiveness (Pope and Katz, 1994 ; Silvester, 1995 ). A recent study by Pope and colleagues ( 2000 ) reported that significant elevations in aggressiveness and manic scores were observed following 12 weeks of testosterone cypionate injections in a controlled double-blind cross-over study. Interestingly, the results of this study were not uniform across the subjects. Most subjects showed little psychological effect and few developed prominent effects. A cause and effect relationship has yet to be identified in anabolic steroid users and it does appear that individuals who experience psychological or behavioral changes do recover when steroid use is discontinued (Fudula et al., 2003 ).

Additional Adverse Effects Associated with Anabolic Steroid Use

Other adverse events generally associated with anabolic steroid use include acne, male pattern baldness, gynecomastia, decreased sperm count, testicular atrophy, impotence, and transient infertility. Acne is one of the more common side effects associated with anabolic steroid administration. One study reported that 43% of users experienced acne as a consequence from androgen use (O’Sullivan et al., 2000 ). Few other investigations have been able to prospectively determine the occurrence of side effects associated with androgen administration. Increases in acne are thought to be related to a stimulation of sebaceous glands to produce more oil. The most common sites of acne development are on the face and back. Acne appears to disappear upon cessation of androgen administration.

Male pattern baldness does not appear to be a common adverse effect, but is often discussed as a potential side effect associated with androgen use. This is likely related to the role that androgens have in regulating hair growth (Lee et al., 2005 ). An abnormal expression of a specific cutaneous androgen receptor increases the likelihood of androgenic alopecia (Kaufman and Dawber, 1999 ; Lee et al., 2005 ). Thus, it is likely that androgenic alopecia observed as a result of exogenous androgen use is more prevalent in individuals that have a genetic predisposition to balding.

Gynecomastia is a common adverse effect associated with anabolic steroid use. Research has demonstrated a prevalence rate of 37% in anabolic steroid users (O’Sullivan et al., 2000 ). Gynecomastia isa benign enlargement of the male breast resulting from an altered estrogen-androgen balance, or increased breast sensitivity to a circulating estrogen level. Increases in estrogen production in men are seen primarily through the aromatization of circulating testosterone. Many anabolic steroid users will use anti-estrogens (selective estrogen receptor modulators) such as tamoxifen and clomiphene or anastrozole which is a nonsteroidal aromatase inhibitor to minimize side effects of estrogen and stimulate testosterone production. Once gynecomastia is diagnosed cosmetic surgery is often needed to correct the problem.

Changes in libido appear to be the most common adverse event (approximately 61% of users) reported in a small sample of anabolic steroid users (O’Sullivan et al., 2000 ). Although testosterone is often used in hypogonadal men to restore normal sexual function, increasing testosterone above the normal physiological range does not appear to increase sexual interest or frequency of sexual behavior in healthy men administered anabolic steroids in supraphysiological dosages (up to 500 mg·wk -1 ) for 14 weeks (Yates et al., 1999 ). Other studies confirm unchanged libido following 10 weeks of anabolic steroid administration in dosages ranging up to 200 mg·wk -1 (Schurmeyer, et al., 1984 ). However, reports do indicate that towards the end of an androgen cycle some men may experience loss of libido (O’Sullivan et al., 2000 ). It was thought that the decreased libido was related to the transient hypogonadism which typically occurs during exogenous androgen administration. Decreases in libido as a result of hypogonadism appear to be a function of high baseline levels of sexual functioning and desire (Schmidt et al., 2004 ). This may explain the conflicting reports seen in the literature. Regardless, changes in libido do appear to normalize once baseline endogenous testosterone concentrations return (Schmidt et al., 2004 ).

Another frequent adverse event relating to sexual function in males administering anabolic steroids is reversible azoospermia and oligospermia (Alen and Suominen, 1984 ; Schurmeyer et al., 1984 ). As exogenous androgen use increases, endogenous testosterone production is reduced. As a result, testicular size is reduced within three months of androgen administration (Alen and Suominen, 1984 ). In addition, sperm concentration and the number of spermatozoa in ejaculate may be reduced or eliminated by 7 weeks of administration (Schurmeyer et al., 1984 ). During this time risk for infertility is elevated. However, the changes seen in testicular volume, sperm count and concentration are reversible. Anabolic steroid-induced hypogonadism returns to baseline levels within 4 months following discontinuation of androgen use (Jarow and Lipshultz, 1990 ), and sperm counts and concentration return to normal during this time frame (Alen and Suominen, 1984 ; Schurmeyer et al., 1984 ).

Medical Issues Associated with Female Steroid Use

In female anabolic steroid users the medical issues are quite different than that shown in men. Deepening of the voice, enlargement of the clitoris, decreased breast size, altered menstruation, hirsutism and male pattern baldness are all clinical features common to hyperandrogenism in females (Derman, 1995 ). Androgen excess may occur as the result of polycystic ovary syndrome, congenital adrenal hyperplasia and possibly Cushing’s syndrome (Derman, 1995 ; Redmond, 1995 ). However, these clinical symptoms are seen in young, female athletes that are self-administering anabolic steroids. In contrast to men, many of these adverse events in the female anabolic steroid user may not be transient (Pavlatos et al., 2001 ).

Long Term Health Issues Associated with Anabolic Steroid Administration

The acute health issues associated with anabolic steroid use appear to be transient and more prevalent in individuals with genetic predisposition (e.g. hair loss, heart disease). It is the long-term effects that become a larger issue. However, limited data are available. In one study in mice, anabolic steroids were administered in relative dosages typically used by bodybuilders. However, the duration of the study was 1/5 the life span of the mouse which is relatively greater than that experienced by most athletes self-administering androgens. The results demonstrated a shortened life span of the mice with evidence of liver, kidney and heart pathology (Bronson and Matherne, 1997 ). In a study on Finnish power lifters, investigators examined 62 athletes who finished in the top 5 in various weight classes between the years 1977 and 1982 (Parssinen et al., 2000 ). These investigators reported that during a 12-year follow-up, the mortality rate for the power lifters was 12.1% compared to 3.1% in a control population. They concluded that their study depicted the detrimental long-term health effects from anabolic steroid use. Others have suggested that prolonged anabolic steroid use may increase the risk for premature death, but this may be more relevant in subjects with substance abuse or underlying psychiatric disease (Petersson et al., 2006 ).

The use of anabolic steroids in strength/power athletes has been reported for more than 50 years in North America. As discussed in the beginning of this review, during the 1970’s and 1980’s anecdotal reports on the rampant use of anabolic steroids in professional athletes were prevalent. However, little information is available concerning steroid-related diseases or associated deaths in these former strength/power athletes who are now well into middle age. Regardless, research should focus on these former athletes to ascertain possible long-term effects from androgen use.

Is There a Clinical Role of Androgenic Anabolic Steroids?

The efficacy of anabolic steroids in enhancing muscle strength and lean tissue accruement is no longer an issue for debate. While the issue of medical risks in individuals self-administering anabolic steroids is still being hotly debated, the medical community is no longer denying the potential clinical use of these androgens (Dobs, 1999 ). In recent years clinical treatment with anabolic steroids has increased lean tissue and improved daily functional performance in AIDS patients (Strawford et al., 1999 ) patients receiving dialysis (Johansen et al., 1999 ), patients with chronic obstructive pulmonary disease (Ferreira et al., 1998 ), and patients recovering from a myocardial infarction (Nahrendorf et al., 2003 ). In addition, research has demonstrated a positive effect on healing from muscle contusion injuries (Beiner et al., 1999 ). Although the medical community has generally taken a conservative approach to promoting anabolic steroids as part of a treatment plan in combating diseases involving muscle wasting, the body of knowledge that has developed indicates the potential positive effects of androgen therapy for certain diseased populations.

Conclusions

For many years the scientific and medical communities depicted a lack of efficacy and serious adverse effects from anabolic steroid use. However, competitive athletes continued to experiment with, use, and abuse anabolic steroids on a regular basis to enhance athletic performance despite the potential harmful side effects. The empirical evidence that the athletes viewed may have led to the development of distrust between the athletic and medical communities. Science has been lagging several years behind the experimental practices of athletes. In fact, most athletes consume anabolic steroids on a trial and error approach based on information gained from other athletes, coaches, websites, or gym “gurus.” Science has lacked in its approach to study anabolic steroids because only few studies have examined long-term cyclical patterns, high doses, and the effects of stacking different brands of steroids. These practices are common to the athletic community and not for the medicinal purposes of anabolic steroid therapy. In addition, some athletes (especially bodybuilders) have experimented with drugs unbeknown to the medical community, i.e. insulin, thyroid hormones, and site-specific enhancers such as Synthol and Esiclene to name a few.

When examining the potential medical issues associated with anabolic steroid use, evidence indicates that most known side effects are transient. More so, few studies have been able to directly link anabolic steroids to many of the serious adverse effects listed. Although clinical case studies continue to link anabolic steroid administration with myocardial infarct, suicide, and cancer, the evidence to support a cause and effect relationship is lacking and it may be other contributing factors (i.e. genetic predisposition, diet, etc.) play a substantial role and potentiate the harmful effects from anabolic steroids. Consistent physician monitoring is critical to the athlete who consumes anabolic steroids. However, many athletes may not undergo extensive medical exams prior to androgen administration and few physicians may be willing to provide such monitoring.

The purpose of this review was not to support or condone anabolic steroid use. Rather, the aim was to discuss pertinent medical issues and provide another perspective in light of the fact that many anabolic steroids users do not appear to prioritize the health/safety hazards or potential adverse medical events. In order to maintain credibility with the athlete, it is important to provide accurate information to the athlete in regards to these performance enhancing drugs, and provide education about alternative means and potential risks. Finally, anabolic steroids have been used legitimately for several clinical purposes such as muscle wasting or hypogonadal related diseases.

Biographies

Jay R. HOFFMAN

The College of New Jersey.

Research interests

Sport supplementation, resistance training, eExercise endocrinology.

E-mail: ude.jnct@jnamffoh

Nicholas A. RATAMESS

Sport supplementation, resistance training, exercise endocrinolgy.

E-mail: ude.jnct@ssematar

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