steroids in athletes research paper

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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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We would like to thank the subjects for their willing participation in this study.

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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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Participants were provided with detailed information regarding the research purpose, procedures, risks, and benefits. They provided informed consent to participate in the study and were informed that they could withdraw from the study at any time without any penalty. The confidentiality and anonymity of participants were maintained throughout the study, and the data collected were used for research purposes only. All research procedures were conducted in compliance with ethical principles as outlined in the Declaration of Helsinki, the applicable regulations, and the guidelines provided by the IRB/IEC. The authors confirm that all methods were performed following relevant guidelines and regulations. All experimental protocols were approved by the ethics committee of Research in Public Sports Board, Kermanshah, Iran. Also, all educated participants and the legal guardian of illiterate participants were asked to complete the written informed consent at the beginning 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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Introduction, implications of studies of humans for studies of nonhuman animals, conclusions, acknowledgments.

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Steroid use and human performance: Lessons for integrative biologists

From the symposium “Hormonal Regulation of Whole-Animal Performance: Implications for Selection” presented at the annual meeting of the Society for Integrative and Comparative Biology, January 3–7, 2009, at Boston, Massachusetts.

2 Present address: Department of Biology, University of South Dakota, Vermillion, SD 57069, USA

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Jerry F. Husak, Duncan J. Irschick, Steroid use and human performance: Lessons for integrative biologists, Integrative and Comparative Biology , Volume 49, Issue 4, October 2009, Pages 354–364, https://doi.org/10.1093/icb/icp015

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While recent studies have begun to address how hormones mediate whole-animal performance traits, the field conspicuously lags behind research conducted on humans. Recent studies of human steroid use have revealed that steroid use increases muscle cross-sectional area and mass, largely due to increases in protein synthesis, and muscle fiber hypertrophy attributable to an increased number of satellite cells and myonuclei per unit area. These biochemical and cellular effects on skeletal muscle morphology translate into increased power and work during weight-lifting and enhanced performance in burst, sprinting activities. However, there are no unequivocal data that human steroid use enhances endurance performance or muscle fatigability or recovery. The effects of steroids on human morphology and performance are in general consistent with results found for nonhuman animals, though there are notable discrepancies. However, some of the discrepancies may be due to a paucity of comparative data on how testosterone affects muscle physiology and subsequent performance across different regions of the body and across vertebrate taxa. Therefore, we advocate more research on the basic relationships among hormones, morphology, and performance. Based on results from human studies, we recommend that integrative biologists interested in studying hormone regulation of performance should take into account training, timing of administration, and dosage administered when designing experiments or field studies. We also argue that more information is needed on the long-term effects of hormone manipulation on performance and fitness.

One of the most widely discussed and controversial arenas of human performance concerns the use of steroid supplements to enhance athletic ability for a variety of sports, ranging from bicycling to baseball. There is strong evidence that human athletes have attempted to enhance their athletic performance using steroids since the 1950s, but whether, and in which sports, steroids are actually effective remains controversial (reviewed by Ryan 1981 ; George 2003 ; Hartgens and Kuipers 2004 ). In general, steroids used by athletes encompass a wide variety of forms of the androgen testosterone (George 2003 ), and most seem to have the classical androgenic and anabolic effects on men, although steroid use by women cannot be ignored (Malarkey et al. 1991 ; Gruber and Pope 2000 ). Alternative forms of testosterone (e.g., testosterone enanthate, methandrostenolone) are typically used by those desiring enhanced performance because ingested or injected testosterone is quickly metabolized into inactive forms (Wilson 1988 ). Thus, studies of humans that we cite involve testosterone derivatives. Early studies of the effects of steroids on human performance, however, had major flaws in design, such as lack of control groups and a double-blind procedure, the presence of confounding factors (e.g., differences in level of exercise and in motivation), and inappropriate statistical techniques (reviewed by Bhasin et al. 2001 ; George 2003 ). These problems left open for many years the question of whether, and in what capacity, steroids actually enhance athletic performance, until more recent studies conclusively showed significant effects of steroids.

The topic of steroid effects on human athletic performance is germane to an emerging field of research investigating hormonal effects on animals’ performance (e.g., sprint speed, endurance capacity, bite-force capacity) (Husak et al. 2009a ), as testosterone may exert general effects on performance across widely divergent vertebrate taxa. Our goal in this review is to interpret the effects of steroids on human performance in this broader context of hormonal effects across a wider range of taxa. We are particularly interested in drawing lessons and potential avenues of research for animal biologists from published research on humans. We have performed a selective review of studies examining how humans' use of steroids affects skeletal muscle physiology and subsequent athletic performance. While studies of performance on nonhumans have dealt extensively with the effects of morphological traits on performance and the impact of performance on individual fitness (Arnold 1983 ; Garland and Losos 1994 ; Irschick and Garland 2001 ; Irschick et al. 2007 , 2008 ; Husak et al. 2009a ), there has been relatively little synthetic discussion of how hormones affect performance in non-human animals. We also point the reader towards several recent reviews of steroid use and performance by humans for details not discussed in our review (Bhasin et al. 2001 ; George 2003 ; Hartgens and Kuipers 2004 ).

General effects of testosterone on the phenotype of males

The development of primary and secondary sexual characteristics is stimulated by testosterone in vertebrate males, and these effects can be either organizational or activational in nature (Norris 1997 ; Hadley 2000 ). Organizational effects tend to occur early in development, and during a critical window of time, thereby resulting in permanent effects. On the other hand, activational effects occur in adults, and the effects are typically temporary (Arnold and Breedlove 1985 ). The hypothalamus stimulates production of gonadotropin-releasing hormone, which in turn stimulates production of luetenizing hormone in the anterior pituitary. Luetenizing hormone then stimulates production of testosterone in the Leydig cells of the testes. Testosterone then circulates throughout the body where it exerts effects on multiple target tissues that have the appropriate receptors or appropriate enzymes (e.g., aromatase or 5α-reductase) to convert testosterone for binding to other types of receptors (Kicman 2008 ). The widespread effects of circulating levels of testosterone on aggression, secondary sexual traits, and growth of skeletal muscle in males of many vertebrate species are well-documented (Marler and Moore 1988 ; Wingfield et al. 1990 ; Ketterson and Nolan 1999 ; Sinervo et al. 2000 ; Ketterson et al. 2001 ; Oliveira 2004 ; Adkins-Regan 2005 ; Hau 2007 ; contributions in this issue). In particular, production of testosterone by males has been linked with the expression of color and behavioral display signals, as well as aggression (Marler and Moore 1988 ; Kimball and Ligon 1999 ; Hews and Quinn 2003 ; Adkins-Regan 2005 ; Cox et al. 2008 ) and increased growth (Fennell and Scanes 1992 ; Borski et al. 1996 ; Cox and John-Alder 2005 ), although this latter effect may depend on specific selective pressures on males (Cox and John-Alder 2005 ).

Effects of testosterone on the physiology of human skeletal muscle

Testosterone has multiple effects on skeletal muscle at the biochemical and cellular levels, but the direct cause-and-effect relationships among these effects are still unclear (Sinha-Hikim 2002 ; Hartgens and Kuipers 2004 ). The studies that we discuss here, and throughout the paper are from experiments or correlative studies conducted on adult individuals such that the effects seen are activational in nature, causing rather rapid changes to the phenotype. Increased testosterone causes increased protein synthesis by muscle cells (Griggs et al. 1989 ; Kadi et al. 1999 ; Hartgens and Kuipers 2004 ), which is necessary for anabolic effects and an increase in lean muscle mass. Sinha-Hikim et al. ( 2002 ) found a dose-dependent increase in the mean number of myonuclei found in skeletal muscle fibers ( vastus lateralis muscle) with testosterone supplementation, as well as in the number of myonuclei per fiber (see also Eriksson et al. 2005 ). This increase was also associated with an increase in the number of satellite cells in the muscle tissue (but see Eriksson et al. 2005 ). Satellite cells are progenitor cells found external to muscle fibers that are incorporated into fibers and promote repair and growth of the muscle (Kadi and Thornell 2000 ; Reimann et al. 2000 ). However, the mechanism by which testosterone causes an increase in the number of satellite cells is unknown and could be due to testosterone (1) promoting cell division of satellite cells, (2) inhibiting apoptosis of satellite cells, or (3) causing differentiation of stem cells into satellite cells (Sinha-Hikim 2002 ). In any case, the functional implications for these findings are clear. More satellite cells likely result in more myonuclei per fiber, which, combined with increased protein synthesis, contribute to increases in muscle growth via an increased number and hypertrophy of muscle fibers (Kadi 2000 ; Kadi and Thornell 2000 ).

Testosterone also appears to cause a dose-dependent increase in the cross-sectional area of muscle fibers, although details about which types of fibers are affected and where in the body this occurs remains equivocal. Testosterone may increase the cross-sectional area of both type I (oxidative “slow twitch”) and type II (glycolytic “fast twitch”) fibers simultaneously after administration (Sinha-Hikim 2002 ; Eriksson et al. 2005 ), but other studies have shown greater increases in type I than in type II fibers (Hartgens et al. 1996 ; Kadi et al. 1999 ; also in growing rats, Ustunelet al. 2003 ), increased size in only type I fibers (Alén et al. 1984 ; Kuipers et al. 1991 , 1993 ), or increased size in only type II fibers (Hartgens et al. 2002 ). These mixed results are intriguing, because they suggest that different parts of the body, and, hence, different performance traits, may be affected differently by elevated testosterone levels. The likely mechanism for these differences is variation in density of receptors within the myonuclei of muscle fibers in different regions of the body (Kadi 2000 ; Kadi et al. 2000 ). An alternative hypothesis is that different types of fiber have differing relationships between the number of internal myonuclei and muscle cross-sectional area during hypertrophy (Bruusgaard et al. 2003 ). That is, some types of fibers may have internal myonuclei that can serve larger “nuclear domains” than can other types of fibers (reviewed by Gundersen and Bruusgaard 2008 ). If either of these hypothesized mechanisms is correct, then circulating levels of testosterone may only explain a portion of inter-individual (or interspecific) variation in performance. Testosterone may also stimulate changes in the proportions of types of fibers in muscles (Holmang et al. 1990 ; Pette and Staron 1997 ), although evidence for this effect in humans is mixed. For example, Sinha-Hikim et al. ( 2002 ) did not observe a change in the proportions of type I and type II fibers after administration of testosterone.

Changes in lower-level traits (e.g., protein synthesis, number of satellite cells, cross sectional area of muscle fibers) after testosterone supplementation, as described above, thus, result in changes at the whole-muscle level and explain many of the classic effects of testosterone that are desired by humans using steroids. That is, increasing testosterone via steroid use increases body weight, lean body mass, as well as cross-sectional area, circumference, and mass of individual muscles (i.e., “body dimensions”); however, there are numerous studies with contradictory results, finding no change in one, or all, of these traits, depending on the drug used, the dose taken, and the duration of use (reviewed by Bhasin et al. 2001 ; Hartgens and Kuipers 2004 ). The finding that testosterone can change muscle physiology and increase whole-muscle size and/or body mass is consistent with results in nonhuman animals. For example, testosterone implants increased size and number of fibers in the sonic muscles of male plainfin midshipman fish ( Porichthys notatus ) (Brantley et al. 1993 ). Similarly, testosterone supplementation increased muscle mass and changed contractile properties of trunk muscles of male grey treefrogs ( Hyla chrysoscelis ) (Girgenrath and Marsh 2003) and of forelimb muscles of male frogs ( Xenopus laevis , Regnier and Herrera 1993 ; Rana pipiens , Sidor and Blackburn 1998 ).

Effects of testosterone on humans’ performance

Whether steroids actually enhance performance of athletes was a subject of great controversy throughout the 1980s and 1990s (Ryan 1981 ; Haupt and Rovere 1984 ; Cowart 1987 ; Wilson 1988 ; Elashoff et al. 1991 ; Strauss and Yesalis 1991 ; Hartgens and Kuipers 2004 ), largely due to flaws in design of early studies (see above). However, the past decade has seen a surge in more carefully designed studies that have convincingly tested whether, all else equal, steroids increase performance. Hartgens and Kuipers ( 2004 ) found that 21 out of 29 studies they reviewed found an increase in humans’ strength after steroid use, with improvements in strength ranging from 5% to 20%. Storer et al. ( 2003 ) found that testosterone caused a dose-dependent increase in maximal voluntary strength of the leg (i.e., amount of weight lifted in a leg press), as well as in leg power (i.e., the rate of force generation). They further tested whether increased muscle strength was due simply to increased muscle mass or to changes in the contractile quality of muscle affected by testosterone, but they found no change in specific tension, or in the amount of force generated per unit volume of muscle. This latter result suggests that, at least for leg-press performance, testosterone increases strength by increasing muscle mass and not by changing contractile properties. Rogerson et al. ( 2007 ) found that supraphysiological doses of testosterone increased maximal voluntary strength during bench presses (see also Giorgi et al. 1999 ) and increased output of work and output of power during cycle sprinting compared to placebo control subjects. Thus, “burst” or “sprint” performance traits appear to be enhanced by increased testosterone, and this is in general agreement with studies of nonhuman animals (John-Alder et al. 1996 , 1997 ; Klukowski et al. 1998 ; Husak et al. 2007 ). For example, experimentally elevated levels of testosterone caused increased sprint speed, relative to sham-implanted individuals, in northern fence lizards ( Sceloporus undulatus ) (Klukowski et al. 1998 ). These findings contrast with results for endurance events, in which no increase in performance has been detected experimentally in humans (reviewed in George 2003 ; Hartgens and Kuipers 2004 ). The finding that endurance by humans is not enhanced by testosterone is unexpected since testosterone may increase hemoglobin concentrations and hematocrit (Alén 1985 , but see Hartgens and Kuipers 2004 ) and exogenous testosterone increases endurance in rats (Tamaki et al. 2001 ) and male side-blotched lizards ( Uta stansburiana ) (Sinervo et al. 2000 ). More studies of the effects of increased testosterone on endurance would help to better clarify these seemingly paradoxical findings. One possibility that might explain species’ differences in endurance is the relative proportion of type I fibers available for enhancement, which likely varies across species (Bonine et al. 2005 ), although this hypothesis needs explicit testing. Steroid use does not seem to consistently enhance recovery time after strenuous exercise (reviewed in Hartgens and Kuipers 2004 ), although it may in non-human animals (Tamaki et al. 2001 ). Storer et al. ( 2003 ) also found no change in fatigability (i.e., the ability of a muscle to persist in performing a task) of muscle during exercise, which is consistent with other studies (George 2003 ).

One of the problems in early studies of steroid effects was that the participants’ history of training and exercise while taking steroids was not taken into account or controlled (Bhasin et al. 2001 ; George 2003 ; Hartgens and Kuipers 2004 ). Recent studies have shown that the presence or absence of exercise training during testosterone supplementation can have a marked impact on how much performance is enhanced, thus complicating results when training is not controlled. Bhasin et al. ( 2001 ) reviewed several examples of such results. They pointed out that testosterone supplementation alone may increase strength from baseline levels, but so will exercise alone with a placebo, such that strength levels with exercise alone are comparable to those with testosterone addition alone (Bhasin et al. 1996 ). Testosterone supplementation while undergoing exercise training typically has the greatest increase in strength compared to exercise only or testosterone only (Bhasin et al. 1996 , 2001 ). These findings are consistent with those of others (reviewed by George 2003 ). Indeed, George ( 2003 ) suggested that steroids will only consistently enhance strength if three conditions are met: (1) steroids are given to individuals who have been training and who continue to train while taking steroids, (2) the experimental subjects have a high protein diet throughout the experiment, and (3) changes in performance are measured by the technique with which the individuals were training while taking steroids. That is, one may, or may not, find a change in bench-press performance if individuals trained with leg presses, and not bench presses, while taking steroids. We note that the confounding effect of training is a rather intuitive finding, but it does point out potential problems in studies of non-human animals, specifically laboratory studies, which we address below.

Given the effects of steroids on physiology and performance of human muscle, what can integrative biologists take away from these findings? We suggest that they can provide some valuable insights into the mechanisms of how hormones might regulate whole-animal performance traits in nonhuman animals. The most obvious lesson is that manipulating the circulating levels of testosterone, or its derivatives, increases overall strength, which has apparent benefits for performance in bursts, such as sprint speed. In contrast, there is little evidence from studies on humans for a positive effect on capacity for endurance, which is counter-intuitive, given the known effect of testosterone on hemoglobin concentrations and hematocrit. However, these same studies of humans also raise a host of issues that merit special consideration by researchers interested in hormonal effects on nonhuman animals, including effect of training, timing of administration, and dosage administered. We also argue that more information is needed on the long-term effects of hormonal manipulation on performance and fitness. Although recent studies suggest that increasing testosterone levels can enhance certain types of performance, we are not advocating or justifying the use of steroids by humans. There are numerous side effects of prolonged steroid use in humans, including cardiovascular problems, impaired reproductive function, altered behavior, increased risk of certain tumors and cancers, and decreased immune function, among others (reviewed by Pärssinen and Seppälä 2002 ; George 2003 ). These “side-effects” are in accordance with studies of nonhuman animals where higher testosterone levels are associated with such detrimental effects as increased loads of parasites, reduced immunocompetence, decreased body condition, reduced growth, and increased use of energy, ultimately resulting in reduced survival (Marler and Moore 1988 ; Folstad and Karter 1992 ; Salvador et al. 1996 ; Wikelski et al. 1999 , 2004 ; Moore et al. 2000 ; Peters 2000 ; Klukowski and Nelson 2001 ; Wingfield et al. 2001 ; Hau et al. 2004 ). Indeed, it is the presence of these very “side-effects” that has driven a great deal of research on behavioral and life-history tradeoffs mediated by testosterone (Ketterson and Nolan 1999 ; Ketterson et al. 2001 ). Higher levels of testosterone may enhance performance and increase success at some tasks, but its widespread “pleiotropic” effects on other aspects of the phenotype may result in a net detriment to fitness (Raouf et al. 1997 ; Reed et al. 2006 ; Ketterson et al. 2009).

We encourage researchers to complete more detailed studies of the interactions among hormones, morphology, and performance, especially across different types of performance traits (dynamic versus regulatory, see Husak et al. 2009a ). Comparative data on whether the same, or different, hormones affect the same performance traits in different taxa (e.g., burst speed in fish, sprint speed in lizards) would be useful for understanding how different species have evolved unique, or conserved, endocrine control of morphology and function. A comparative approach is important, as other studies have shown different effects of testosterone on performance in different taxa (e.g., an increase in endurance for rats and lizards, but none for humans), and more research is needed to determine whether such differences are valid or purely methodological. Even though testosterone is confined to vertebrates, it is possible that studies with invertebrates may reveal similar effects on performance via different hormones, e.g., recent work showing a seemingly similar role of juvenile hormone for invertebrates as testosterone has for vertebrates (Contreras-Garduno et al. 2009 ; see also Zera 2006 ; Zera et al. 2007 ; Lorenz and Gäde 2009).

Correlative studies relating endogenous circulating hormone levels to natural variation in performance traits can provide valuable insight into potential mechanistic regulators of performance, but manipulations allow a more detailed examination of cause-and-effect relationships. Whether performance can be manipulated by reduction (castration) or supplementation (implants) of testosterone in nonhuman animals will depend on the type of performance and how it is affected by circulating levels of the androgen. Many dynamic performance traits, especially maximal performance, may show different responses to exogenous hormone in the laboratory versus field, compared to coloration or “behavioral” traits. For example, supplementation with testosterone may rapidly increase display behavior or aggression in the laboratory (Lovern et al. 2001 ; Hews and Quinn 2003 ) compared to control animals, or corticosterone supplementation may decrease sexually selected color patterns (reviewed by Husak and Moore 2008 ). These examples are in contrast to supplementing testosterone in the laboratory and testing for an effect on performance. Aggression and coloration will not likely require training of the target trait to reveal an observed effect, whereas some performance traits may require training. Furthermore, regulatory performance traits (e.g., regulation of ions in seawater), on the other hand, may respond more directly to hormonal manipulation (see McCormick 2009), and will likely not require any training, but more empirical data are necessary to make generalizations.

It is also important to more closely inspect those traits that show no significant effect of testosterone on dynamic performance after manipulation in the laboratory. Such a “noneffect” may be due to numerous possibilities, the most obvious of which is that testosterone simply has no effect on a particular type of performance. However, a second possibility is that muscles involved in performance were not adequately trained during administration of supplemental testosterone, or there was no control of exercise during the period of testosterone administration. As an hypothetical example, one might not expect to see a large increase in the maximal flight speed of birds that were never allowed to fly following administration of exogenous testosterone. Indeed, Gallotia galloti lizards given exogenous testosterone were compared to lizards given sham implants and there was no difference in maximal bite force at the end of the experiment (K. Huyghe, J.F. Husak, R. Van Damme, M. Molina-Borja, A. Herrel, in review), despite increases in mass of the jaw muscles in testosterone-supplemented males. One possible explanation for this result is that these lizards did not “train” their jaw muscles enough while in captivity to increase muscle mass sufficiently to result in a measurable enhancement of performance. It is also possible that receptor density is very low or becomes low in trained muscles. Nevertheless, while training in animals seems straightforward in principle, in practice it is far trickier, and there also appear to be striking differences among species in the effects of training. Whereas some studies of mammals have successfully increased performance through training in a laboratory (Brooks and Fahey 1984 ; Astrand and Rodahl 1986 ), similar studies with lizards have found no effect (Gleeson 1979 ; Garland et al. 1987 ). In addition, while training might be successful with animals acclimated to a laboratory setting, inducement of stress, with a concomitant effect on corticosterone (Moore and Jessop 2003 ), and potentially circulating testosterone levels, is a significant confounding factor. Another complementary option is to use field studies, where experimental groups are released into the wild to “train” themselves while accomplishing their day-to-day tasks and performing naturally. Of course, this approach also cannot take into account variation in “training” within experimental groups, as individuals will likely use their performance traits in different ways when left to their own devices. Consequently, this approach could result in unpredictable results in how hormones impact performance, unless one accepts the unlikely assumption that all experimental animals are performing in the same ways. Further, a field approach also does not take into account other “pleiotropic” effects of increased (or decreased) testosterone on the phenotype (e.g., increased activity or conspicuousness to predators), which can eliminate potential benefits to fitness from enhanced performance due to testosterone supplementation.

Studies seeking to manipulate performance with testosterone supplementation should also consider the timing of experiments. For example, testosterone should ideally be increased or decreased during times when the hypothalamic–pituitary–gonad (HPG) axis is responsive and receptors are expressed in the appropriate target tissues. Seasonal sensitivity of the male HPG axis is well documented (Fusani et al. 2000 ; Jawor et al. 2006 ; Ball and Ketterson 2008 ), and such effects should be considered. For example, male green anoles ( Anolis carolinensis ) given exogenous testosterone after the end of the breeding season in a laboratory setting did not increase head size or bite-force performance (J. Henningsen, J. Husak, D. Irschick, and I. Moore, unpublished data), presumably because some or all of the relevant target tissues were no longer sensitive to androgens. On the other hand, male brown anoles ( Anolis sagrei ) did show enhanced maximal bite force when testosterone was supplemented at the beginning of the breeding season when the target tissues are presumably sensitive to androgens (Cox et al., in press). Timing of experimentation is thus critical for designing studies examining hormonal effects, and the interaction between timing and training should also be considered, as training effects may be relevant for some seasonal periods, but not for others.

A related issue concerns how much hormone to administer to experimental subjects. Studies of human steroid use typically involve supraphysiological doses of testosterone, as this is the typical regimen for steroid-abusing athletes (George 2003 ; Hartgens and Kuipers 2004 ). Indeed, many studies of steroid use by humans have been criticized for having experimental groups using physiological doses of testosterone. However, such criticism of seemingly unrealistic dosages highlights the differing goals of studies on human and non-human animals. Whereas studies of humans are focused on the role of supraphysiological doses on performance, those of nonhuman animals are more broadly interested in whether circulating testosterone affects performance within more natural bounds of variation (reviewed by Fusani et al. 2005 ; Fusani 2008 ). Supraphysiological doses can result in unexpected, or even counterintuitive, effects because endocrine systems tend to be homeostatic and compensatory after disruption via up- or down-regulation of various components within the system (Brown and Follett 1977 ).

There are few data on how testosterone affects dynamic performance during different stages of development, either in humans or in non-human animals. Practically all studies examining the effects of exogenous testosterone on humans have been on adults (reviewed by Hartgens and Kuipers 2004 ), but an increasing area of concern is steroid use by teenagers (Johnston et al. 2005 ). Because they are still developing physically, steroids may have dramatically different effects on dynamic performance in developing juveniles versus older adults. For example, steroid use is known to cause closure of growth plates of long bones (George 2003 ), potentially preventing growth to full height. Any manipulative hormone study examining effects on dynamic performance should also take baseline circulating levels into account, as there may be striking differences among age groups. For example, among sexually mature male green anole lizards in a well-studied New Orleans, Louisiana (USA) population, smaller “lightweight” males have lower circulating testosterone levels (Husak et al. 2007 , 2009b ), relatively smaller heads, and lower bite forces than do larger “heavyweight” males (see Lailvaux et al., 2004; Vanhooydonck et al., 2005a), with the difference apparently due to age (Irschick and Lailvaux 2006). Smaller males with low testosterone levels seem unable to produce higher levels (Husak et al. 2009b ), suggesting that testosterone levels are likely suppressed until a critical body size when the individuals become competitive with larger males. At this body size, elevated testosterone levels may accelerate growth of the head and increase bite force, although more data are needed to test this hypothesis. This ontogenetic increase in testosterone levels suggests that exogenous administration will have quite different effects on different age groups. For example, many hormones exert threshold effects (reviewed in Hews and Moore 1997 ) in which increased amounts above a threshold level produce little noticeable effect, suggesting that exogenous administration may accomplish little for larger lizards already with high testosterone levels, but may have substantial effects on smaller lizards with low testosterone levels.

In this context, long-term studies in animal species that focus on younger individuals (see Cox and John-Alder 2005 and references therein) might be useful for understanding the potential costs and benefits of hormones in improving or decreasing dynamic performance. Scientists are well-aware of some of the short-term activational effects of testosterone in humans and nonhuman animals, but while some long-term effects of supraphysiological doses on human health are recognized (see Hartgens and Kuipers 2004 ), we know far less about long-term effects of elevated (but not supraphysiological) testosterone levels on longevity and lifetime reproductive success of nonhuman animals. Ethical considerations may preclude long-term hormone implantation in humans and nonhuman animals, but correlating natural variation in testosterone levels both with performance traits and with other demographic features, such as longevity and lifetime reproductive success, would be useful for understanding chronic effects. Elegant studies with the dark-eyed junco ( Junco hyemalis ) (Ketterson et al. 2001 ; Reed et al. 2006 ) show complex trade-offs between different components of reproductive success (e.g., investment in extra-pair fertilizations versus parental care) as a result of testosterone supplementation; other similar trade-offs might be occurring over longer time spans in other animal species.

Despite popular interest in steroids and their effects on human athletic performance, we still lack a broad understanding of the effects of testosterone on performance in different animal species.

Our review of the literature on human steroids highlights several issues that could prove useful for integrative biologists interested in determining links among hormones, morphology, performance, and fitness in nonhuman animal species. First, studies of steroid use by humans reveal many caveats related to experimental design and interpretation that should be considered by those studying nonhuman animals (e.g., training, diet, dosage effects). Second, because of conflicting results of testosterone on different performance traits (e.g., burst performance versus endurance), more data are needed for such biomechanically opposing performance traits; testosterone may enhance multiple kinds of performance in some species, and only one kind in another. Third, while testosterone may have some general effects on dynamic performance in vertebrates, are there other hormones (e.g., juvenile hormone) that play a similar role in invertebrates? Finally, human steroid abusers often use various systems of “stacking”, where multiple drugs are taken in a specific order (George 2003 ), and such regimens are believed, by those who use them, to markedly increase dynamic performance. However, few studies have specifically examined how these regimes affect performance, or how the different regimes may be more, or less, effective in enhancing performance, either in humans or in non-human animal species. Furthermore, such practices are not restricted to multiple androgens, but may also include other hormones, such as growth hormone and insulin-like growth factor-I, which may, when taken exogenously, also enhance athletic performance and other aspects of the phenotype (Gibney et al. 2007 ). In this manner, the interactive effects of different hormone regimens for increasing animal performance are highly understudied. In conclusion, we have advocated an integrative approach for studying the evolution of morphology, function, and endocrine systems, and increased collaboration between researchers interested in human and in other animal systems may prove fruitful for both groups.

Financial support was provided by the National Science Foundation (IOS 0421917 to DJI and IOS 0852821 to I. T. Moore, JFH and DJI).

We are thankful to the symposium participants for fruitful discussions about hormones and performance. We thank the Society for Integrative and Comparative Biology, especially the Divisions of Animal Behavior, Comparative Endocrinology, and Vertebrate Morphology, for providing logistical and financial support.

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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.

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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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Effects of Androgenic-Anabolic Steroids in Athletes

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• Published: 23 September 2012
• Volume 34 , pages 513–554, ( 2004 )

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Androgenic-anabolic steroids (AAS) are synthetic derivatives of the male hormone testosterone. They can exert strong effects on the human body that may be beneficial for athletic performance. A review of the literature revealed that most laboratory studies did not investigate the actual doses of AAS currently abused in the field. Therefore, those studies may not reflect the actual (adverse) effects of steroids. The available scientific literature describes that short-term administration of these drugs by athletes can increase strength and bodyweight. Strength gains of about 5–20% of the initial strength and increments of 2–5kg bodyweight, that may be attributed to an increase of the lean body mass, have been observed. A reduction of fat mass does not seem to occur. Although AAS administration may affect erythropoiesis and blood haemoglobin concentrations, no effect on endurance performance was observed. Little data about the effects of AAS on metabolic responses during exercise training and recovery are available and, therefore, do not allow firm conclusions.

The main untoward effects of short- and long-term AAS abuse that male athletes most often self-report are an increase in sexual drive, the occurrence of acne vulgaris, increased body hair and increment of aggressive behaviour. AAS administration will disturb the regular endogenous production of testosterone and gonadotrophins that may persist for months after drug withdrawal. Cardiovascular risk factors may undergo deleterious alterations, including elevation of blood pressure and depression of serum high-density lipoprotein (HDL)-, HDL2- and HDL3-cholesterol levels. In echocardiographic studies in male athletes, AAS did not seem to affect cardiac structure and function, although in animal studies these drugs have been observed to exert hazardous effects on heart structure and function. In studies of athletes, AAS were not found to damage the liver. Psyche and behaviour seem to be strongly affected by AAS. Generally, AAS seem to induce increments of aggression and hostility. Mood disturbances (e.g. depression, [hypo-]mania, psychotic features) are likely to be dose and drug dependent. AAS dependence or withdrawal effects (such as depression) seem to occur only in a small number of AAS users. Dissatisfaction with the body and low self-esteem may lead to the so-called ‘reverse anorexia syndrome’ that predisposes to the start of AAS use. Many other adverse effects have been associated with AAS misuse, including disturbance of endocrine and immune function, alterations of sebaceous system and skin, changes of haemostatic system and urogenital tract. One has to keep in mind that the scientific data may underestimate the actual untoward effects because of the relatively low doses administered in those studies, since they do not approximate doses used by illicit steroid users.

The mechanism of action of AAS may differ between compounds because of variations in the steroid molecule and affinity to androgen receptors. Several pathways of action have been recognised. The enzyme 5-α-reductase seems to play an important role by converting AAS into dihydrotestosterone (androstanolone) that acts in the cell nucleus of target organs, such as male accessory glands, skin and prostate. Other mechanisms comprises mediation by the enzyme aromatase that converts AAS in female sex hormones (estradiol and estrone), antagonistic action to estrogens and a competitive antagonism to the glucocorticoid receptors. Furthermore, AAS stimulate erythropoietin synthesis and red cell production as well as bone formation but counteract bone breakdown. The effects on the cardiovascular system are proposed to be mediated by the occurrence of AAS-induced atherosclerosis (due to unfavourable influence on serum lipids and lipoproteins), thrombosis, vasospasm or direct injury to vessel walls, or may be ascribed to a combination of the different mechanisms. AAS-induced increment of muscle tissue can be attributed to hypertrophy and the formation of new muscle fibres, in which key roles are played by satellite cell number and ultrastructure, androgen receptors and myonuclei.

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Acknowledgements

Preparation of this manuscript was financially supported by a grant from the Netherlands Centre for Doping Affairs, Capelle aan den IJssel, The Netherlands. The authors did not receive any (financial) support or other benefits from a commercial entity, nor any agreement to provide such benefits from a commercial entity. The authors do not have a relationship with any company or manufacturer of any commercial product mentioned in this manuscript or with companies or manufacturers that might benefit from this manuscript.

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Hartgens, F., Kuipers, H. Effects of Androgenic-Anabolic Steroids in Athletes. Sports Med 34 , 513–554 (2004). https://doi.org/10.2165/00007256-200434080-00003

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Anabolic steroids and the athlete: a case study

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Expert Commentary

Performance-enhancing drugs in athletics: Research roundup

2015 roundup of research on the use of performance-enhancing drugs in athletics and academics as well as their potential health effects.

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by Leighton Walter Kille, The Journalist's Resource June 9, 2015

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Performance-enhancing drugs have a long history in sports, of course, but pharmacological research has led to a surge in the number of substances available, each with its own potential for misuse.

Given the potential financial rewards of athletic success, it’s no surprise that we’ve been witness to a seemingly endless procession of allegations and scandals. Sluggers Barry Bonds (steroids) and Alex Rodriguez (human growth hormone); cyclists Lance Armstrong (EPO),  Floyd Landis (testosterone) and Alberto Contador (clenbuterol); runners Tyson Gay (steroids) and Justin Gatlin (testosterone); and golfer Vijay Singh (IGF-1) are only some of the more prominent professionals implicated in such behavior. The complicity of medical professionals and shadowy labs is often involved, and a 2015 report from the International Cycling Union (UCI) found the sport’s own governing body bore significant responsibility.

Not surprisingly, hard numbers on rates of usage are difficult to come by, but anecdotal evidence isn’t lacking and anonymous surveys have provided some insight. Questionable use of medications and supplements have also been reported in the U.S. armed forces , fire and police departments , amateur athletics , and even high schools .

Below is a selection of studies on a range of issues related to performance-enhancing drugs. It has sections on their potential economic impacts, prevalence , health effects and athletes’ attitudes . For additional studies on these topics, you can search PubMed , which is the federal clearinghouse for all medical research. At bottom, we have also included some studies relating to cognitive-enhancing drugs and the related academic dimensions of this issue.

—————————-

“The Economics of Corruption in Sports: The Special Case of Doping” Dimant, Eugen; Deutscher, Christian. Edmond J. Safra Working Papers, No. 55, January 2015.

Abstract: “Corruption in general and doping in particular are ubiquitous in both amateur and professional sports and have taken the character of a systemic threat. In creating unfair advantages, doping distorts the level playing field in sporting competition. With higher stakes involved, such distortions create negative externalities not only on the individual level (lasting health damages, for example) but also frictions on the aggregate level (such as loss of media interest) and erode the principle of sports. In this paper, we provide a comprehensive literature overview of the individual’s incentive to dope, the concomitant detrimental effects and respective countermeasures. In explaining the athlete’s motivation to use performance enhancing drugs, we enrich the discussion by adapting insights from behavioral economics. These insights help to understand such an athlete’s decision beyond a clear-cut rationale but rather as a product of the interaction with the underlying environment. We stress that in order to ensure clean sports and fair competition, more sophisticated measurement methods have to be formulated, and the respective data made publicly available in order to facilitate more extensive studies in the future. So far, the lack of data is alarming, especially in the area of elite sports where the stakes are high and doping has a substantial influence.”

“The Frequency of Doping in Elite Sport: Results of a Replication Study” Pitsch, Werner; Emrich, Eike. International Review for the Sociology of Sport , October 2012, Vol. 47, No. 5, 559-580. doi: 10.1177/1012690211413969.

Abstract: “The difficulty of measuring the prevalence of doping in elite sport is a recurring topic in the scientific literature on doping. The Randomized Response Technique is a method for asking such embarrassing or even threatening questions while allowing the respondents to answer honestly. It was used to measure the prevalence of doping among German squad athletes by Pitsch et al. (2005, 2007). In a replication study with better sampling control, it was possible to replicate the general trend of the data from the 2005 study…. The paper-based survey resulted in a rate of 10.2% ‘honest dopers,’ irrespective of the disciplines, obtained with the question: ‘Have you ever knowingly used illicit drugs or methods in order to enhance your performance?’ By adding the rate of cheaters (24.7%), whose behaviour the researchers know nothing about, one can calculate the interval (10.2%, 34.9%), which should include the true rate of dopers throughout their career among German elite athletes. In contrast, this means that the larger proportion of athletes, namely, 65.2%, represents ‘honest non-dopers.’ In the 2008 season, this figure was 65%.”

“Growth Hormone Doping in Sports: A Critical Review of Use and Detection Strategies” Baumann, Gerhard P. Endocrine Reviews , April 2012, Vol. 33, No. 2 155-186. doi: 10.1210/er.2011-1035.

Abstract: “[Growth hormone] is believed to be widely employed in sports as a performance-enhancing substance. Its use in athletic competition is banned by the World Anti-Doping Agency, and athletes are required to submit to testing for GH exposure…. The scientific evidence for the [performance-enhancing characteristics] of GH is weak, a fact that is not widely appreciated in athletic circles or by the general public. Also insufficiently appreciated is the risk of serious health consequences associated with high-dose, prolonged GH use. This review discusses the GH biology relevant to GH doping; the virtues and limitations of detection tests in blood, urine, and saliva; secretagogue efficacy; IGF-I doping; and information about the effectiveness of GH as a performance-enhancing agent.”

“Supplements in Top-Level Track and Field Athletes” Tscholl, Philippe; Alonso, Juan M.; Dollé, Gabriel; Junge, Astrid; Dvorak, Jiri. American Journal of Sports Medicine , January 2010, Vol. 38, No. 1, 133-140. doi: 10.1177/0363546509344071.

Abstract: “Analysis of 3,887 doping control forms undertaken during 12 International Association of Athletics Federations World Championships and one out-of-competitions season in track and field. Results: There were 6,523 nutritional supplements (1.7 per athlete) and 3,237 medications (0.8 per athlete) reported. Nonsteroidal anti-inflammatory drugs (NSAIDs; 0.27 per athlete, n = 884), respiratory drugs (0.21 per athlete, n = 682), and alternative analgesics (0.13, n = 423) were used most frequently. Medication use increased with age (0.33 to 0.87 per athlete) and decreased with increasing duration of the event (from sprints to endurance events; 1.0 to 0.63 per athlete). African and Asian track and field athletes reported using significantly fewer supplements (0.85 vs. 1.93 per athlete) and medications (0.41 vs. 0.96 per athlete) than athletes from other continents. The final ranking in the championships was unrelated to the quantity of reported medications or supplements taken. Compared with middle-distance and long-distance runners, athletes in power and sprint disciplines reported using more NSAIDs, creatine, and amino acids, and fewer antimicrobial agents. Conclusion: The use of NSAIDs in track and field is less than that reported for team-sport events. However, nutritional supplements are used more than twice as often as they are in soccer and other multisport events; this inadvertently increases the risk of positive results of doping tests.”

“Alcohol, Tobacco, Illicit Drugs and Performance Enhancers: A Comparison of Use by College Student Athletes and Nonathletes” Yusko, David A.; et al. American Journal of Sports Medicine, August 2010. doi: 10.3200/JACH.57.3.281-290.

Abstract: Compares the prevalence and pattern of substance use in undergraduate student athletes and nonathletes from 2005-2006. Data was collected using questionnaires from male (n = 418) and female (n = 475) student athletes and nonathletes from 2005-2006 to assess prevalence, quantity, and frequency of alcohol and drug use, and to determine patterns of student athletes’ alcohol and drug use during their athletic season versus out of season. Male student athletes were found to be at high risk for heavy drinking and performance-enhancing drug use. Considerable in-season versus out-of-season substance use fluctuations were identified in male and female student athletes. Additional, and possibly alternative, factors are involved in a student athlete’s decision-making process regarding drug and alcohol use, which suggests that the development of prevention programs that are specifically designed to meet the unique needs of the college student athlete may be beneficial.”

Health effects

“Performance Enhancing Drug Abuse and Cardiovascular Risk in Athletes” Angell, Peter J.; Chester, Neil; Sculthorpe, Nick; Whyte, Greg; George, Keith; Somauroo, John. British Journal of Sports Medicine , July 2012. doi:10.1136/bjsports-2012-091186.

Abstract: “Despite continuing methodological developments to detect drug use and associated punishments for positive dope tests, there are still many athletes who choose to use performance- and image-enhancing drugs. Of primary concern to this review are the health consequences of drug use by athletes…. We will address current knowledge, controversies and emerging evidence in relation to cardiovascular (CV) health of athletes taking drugs. Further, we delimit our discussion to the CV consequences of anabolic steroids and stimulant (including amphetamines and cocaine) use. These drugs are reported in the majority of adverse findings in athlete drug screenings and thus are more likely to be relevant to the healthcare professionals responsible for the well-being of athletes.”

“Illicit Anabolic-Androgenic Steroid Use” Kanayama, Gen; Hudson, James I.; Pope Jr., Harrison G. Hormones and Behavior , Volume 58, Issue 1, June 2010, Pages 111-121. doi: 10.1016/j.yhbeh.2009.09.006.

Abstract: “The anabolic-androgenic steroids (AAS) are a family of hormones that includes testosterone and its derivatives. These substances have been used by elite athletes since the 1950s, but they did not become widespread drugs of abuse in the general population until the 1980s. Thus, knowledge of the medical and behavioral effects of illicit AAS use is still evolving. Surveys suggest that many millions of boys and men, primarily in Western countries, have abused AAS to enhance athletic performance or personal appearance. AAS use among girls and women is much less common. Taken in supraphysiologic doses, AAS show various long-term adverse medical effects, especially cardiovascular toxicity. Behavioral effects of AAS include hypomanic or manic symptoms, sometimes accompanied by aggression or violence, which usually occur while taking AAS, and depressive symptoms occurring during AAS withdrawal. However, these symptoms are idiosyncratic and afflict only a minority of illicit users; the mechanism of these idiosyncratic responses remains unclear. AAS users may also ingest a range of other illicit drugs, including both “body image” drugs to enhance physical appearance or performance, and classical drugs of abuse. In particular, AAS users appear particularly prone to opioid use. There may well be a biological basis for this association, since both human and animal data suggest that AAS and opioids may share similar brain mechanisms. Finally, AAS may cause a dependence syndrome in a substantial minority of users. AAS dependence may pose a growing public health problem in future years but remains little studied.”

“Adverse Health Effects of Anabolic-Androgenic Steroids” Van Amsterdama, Jan; Opperhuizena, Antoon; Hartgensb, Fred. Regulatory Toxicology and Pharmacology , Volume 57, Issue 1, June 2010, Pages 117-123. doi: 10.1016/j.yrtph.2010.02.001.

Abstract: “Anabolic-androgenic steroids (AAS) are synthetic drugs derived from testosterone. Illegally, these drugs are regularly self-administered by body builders and power lifters to enhance their sportive performance. Adverse side effects of AAS include sexual dysfunction, alterations of the cardiovascular system, psyche and behavior, and liver toxicity. However, severe side effects appear only following prolonged use of AAS at high dose and their occurrence is limited…. The overwhelming stereotype about AAS is that these compounds cause aggressive behavior in males. However, the underlying personality traits of a specific subgroup of the AAS abusers, who show aggression and hostility, may be relevant, as well. Use of AAS in combination with alcohol largely increases the risk of violence and aggression. The dependence liability of AAS is very low, and withdrawal effects are relatively mild. Based on the scores for acute and chronic adverse health effects, the prevalence of use, social harm and criminality, AAS were ranked among 19 illicit drugs as a group of drugs with a relatively low harm.”

“Effects of Growth Hormone Therapy on Exercise Performance in Men” Triay, Jessica M.; Ahmad, Bushra N. Trends in Urology & Men’s Health , July/August 2012, Vol. 3, Issue 4, 23-26. doi: 10.1002/tre.274.

Conclusions: “In the athletic arena, [growth hormone] doping is considered to be widespread and used in combination with other agents, and regimens vary depending on individual preferences and cost implications…. It must be recognised that the effects of GH administration in adults with a normal GH/IGF-1 axis are not comparable to those in GH deficiency and that the complexity of processes influencing GH release and peripheral actions means that overall performance should be considered as opposed to isolated effects. Although studies to date have been small in both subject numbers and treatment times, they have demonstrated measurable changes in GH and IGF-1 levels, as well as possible deleterious effects on exercise performance that should be taken seriously.”

“Performance-Enhancing Drugs on the Web: A Growing Public-Health Issue” Brennan, Brian P.; Kanayama, Gen; Pope Jr., Harrison G. American Journal on Addictions , March-April 2013, Vol. 22, Issue 2, 158-161. doi: 10.1111/j.1521-0391.2013.00311.x.

Abstract: “Today’s Internet provides extensive “underground” guidelines for obtaining and using illicit substances, including especially anabolic-androgenic steroids (AAS) and other appearance- and performance-enhancing drugs (APEDs). We attempted to qualitatively characterize APED-related Internet sites. We used relevant Internet search terms [and] found thousands of sites involving AAS and other APEDs. Most sites presented an unabashedly pro-drug position, often openly questioning the qualifications and motivations of mainstream medical practitioners. Offers of AAS and other APEDs for sale, together with medical advice of varying legitimacy, was widespread across sites. Importantly, many sites provided detailed guidelines for exotic forms of APED use, some likely associated with serious health risks, which are probably unknown to most practicing clinicians.”

“Doping in Sport: A Review of Elite Athletes’ Attitudes, Beliefs and Knowledge” Morente-Sánchez, Jaime; Zabala, Mikel. Sports Medicine , March 2013. doi: 10.1007/s40279-013-0037-x.

Abstract: “Although most athletes acknowledge that doping is cheating, unhealthy and risky because of sanctions, its effectiveness is also widely recognized. There is a general belief about the inefficacy of anti-doping programmes, and athletes criticise the way tests are carried out. Most athletes consider the severity of punishment is appropriate or not severe enough. There are some differences between sports, as team-based sports and sports requiring motor skills could be less influenced by doping practices than individual self-paced sports. However, anti-doping controls are less exhaustive in team sports. The use of banned substance also differs according to the demand of the specific sport. Coaches appear to be the main influence and source of information for athletes, whereas doctors and other specialists do not seem to act as principal advisors. Athletes are becoming increasingly familiar with anti-doping rules, but there is still a lack of knowledge that should be remedied using appropriate educational programmes. There is also a lack of information on dietary supplements and the side effects of [performance-enhancing substances].”

“Age and Gender Specific Variations in Attitudes to Performance Enhancing Drugs and Methods” Singhammer, John. Sport Science Review , December 2012. doi: 10.2478/v10237-012-0017-3.

Abstract: “Using a population-based cross-sectional sample of 1,703 Danish men and women aged 15-60 years, the present study examined age and gender variation in attitudes to performance enhancing drugs and methods…. Overall, participants held negative attitudes to drugs and methods enhancing predominantly cognitive-abilities-enhancing performance drugs and to appearance-modifying methods, but were positive to drugs for restoring physical functioning conditions. However, attitudes varied nonlinearly across age. Lenient attitudes peaked at around age 25 and subsequently decreased. Lenient attitudes to use of drugs against common disorders decreased in a linear fashion. No gender differences were observed and attitude did not vary with level of education, self-reported health or weekly hours of physical activity.”

“Drugs, Sweat and Gears: An Organizational Analysis of Performance Enhancing Drug Use in the 2010 Tour De France” Palmer, Donald; Yenkey, Christopher. University of California, Davis; University of Chicago. March 2013.

Abstract: “This paper seeks a more comprehensive explanation of wrongdoing in organizations by theorizing two under-explored causes: the criticality of a person’s role in their organization’s strategy-based structure, and social ties to known deviants within their organization and industry. We investigate how these factors might have influenced wrongdoing in the context of professional cyclists’ use of banned performance enhancing drugs (PEDs) in advance of the 2010 Tour de France….. We find substantial support for our prediction that actors who are more critical to the organization’s strategy-based structure are more likely to engage in wrongdoing. Further, we find that while undifferentiated social ties to known wrongdoers did not increase the likelihood of wrongdoing, ties to unpunished offenders increased the probability of wrongdoing and ties to severely punished offenders decreased it. These effects were robust to consideration of other known causes of wrongdoing: weak governance regimes and permissive cultural contexts, performance strain, and individual propensities to engage in wrongdoing.”

“Elite Athletes’ Estimates of the Prevalence of Illicit Drug Use: Evidence for the False Consensus Effect” Dunn, Matthew; Thomas, Johanna O.; Swift, Wendy; Burns, Lucinda. Drug and Alcohol Review , January 2012, Vol. 31, Issue 1, 27-32. doi: 10.1111/j.1465-3362.2011.00307.x.

Abstract: “The false consensus effect (FCE) is the tendency for people to assume that others share their attitudes and behaviours to a greater extent than they actually do…. The FCE was investigated among 974 elite Australian athletes who were classified according to their drug use history. Participants tended to report that there was a higher prevalence of drug use among athletes in general compared with athletes in their sport, and these estimates appeared to be influenced by participants’ drug-use history. While overestimation of drug use by participants was not common, this overestimation also appeared to be influenced by athletes’ drug use history.”

“The Role of Sports Physicians in Doping: A Note on Incentives” Korn, Evelyn; Robeck, Volker. Philipps-Universitat, Marburg, March 2013.

Abstract: “How to ban the fraudulent use of performance-enhancing drugs is an issue in all professional — and increasingly in amateur — sports. The main effort in enforcing a ‘clean sport’ has concentrated on proving an abuse of performance-enhancing drugs and on imposing sanctions on teams and athletes. An investigation started by Freiburg university hospital against two of its employees who had been working as physicians for a professional cycling team has drawn attention to another group of actors: physicians. It reveals a multi-layered contractual relations between sports teams, physicians, hospitals, and sports associations that provided string incentives for the two doctors to support the use performance-enhancing drugs. This paper argues that these misled incentives are not singular but a structural part of modern sports caused by cross effects between the labor market for sports medicine specialists (especially if they are researchers) and for professional athletes.”

“Socio-economic Determinants of Adolescent Use of Performance Enhancing Drugs” Humphreys, Brad R.; Ruseski, Jane E. Journal of Socio-Economics , April 2011, Vol. 40, Issue 2, 208-216. doi: 10.1016/j.socec.2011.01.008.

Abstract: “Evidence indicates that adolescents (athletes and non-athletes use performance enhancing drugs. We posit that adolescent athletes have different socio-economic incentives to use steroids than non-athletes. We examine adolescent steroid use using data from the Youth Risk Behavior Surveillance System. Multi-sport upperclassmen and black males have a higher probability of steroid use. Steroid use is associated with motivations to change physical appearance and experimentation with illicit substances. These results suggest there are different socio-economic motivations for adolescent steroid use and that steroid use is an important component of overall adolescent drug use.”

Cognitive-enhancing drugs

“Randomized Response Estimates for the 12-Month Prevalence of Cognitive-Enhancing Drug Use in University Students” Dietz, Pavel; et al. Pharmacotherapy , January 2013, Vol. 33, Issue 1, 44-50. doi: 10.1002/phar.1166.

Results: “An anonymous, specialized questionnaire that used the randomized response technique was distributed to students at the beginning of classes and was collected afterward. From the responses, we calculated the prevalence of students taking drugs only to improve their cognitive performance and not to treat underlying mental disorders such as attention-deficit-hyperactivity disorder, depression, and sleep disorders. The estimated 12-month prevalence of using cognitive-enhancing drugs was 20%. Prevalence varied by sex (male 23.7%, female 17.0%), field of study (highest in students studying sports-related fields, 25.4%), and semester (first semester 24.3%, beyond first semester 16.7%).”

“The Diversion and Misuse of Pharmaceutical Stimulants: What Do We Know and Why Should We Care?” Kaye, Sharlene; Darke, Shane. Addiction , February 2012, Vol. 107, Issue 3, 467-477. doi: 10.1111/j.1360-0443.2011.03720.x.

Results: “The evidence to date suggests that the prevalence of diversion and misuse of pharmaceutical stimulants varies across adolescent and young adult student populations, but is higher than that among the general population, with the highest prevalence found among adults with attention deficit-hyperactive disorder (ADHD) and users of other illicit drugs. Concerns that these practices have become more prevalent as a result of increased prescribing are not supported by large-scale population surveys…. Despite recognition of the abuse liability of these medications, there is a paucity of data on the prevalence, patterns and harms of diversion and misuse among populations where problematic use and abuse may be most likely to occur (e.g. adolescents, young adults, illicit drug users). Comprehensive investigations of diversion and misuse among these populations should be a major research priority, as should the assessment of abuse and dependence criteria among those identified as regular users.”

“Adderall Abuse on College Campuses: A Comprehensive Literature Review” Varga, Matthew D. Journal of Evidence-Based Social Work , 2012, Vol. 9, Issue 3. doi: 10.1080/15433714.2010.525402.

Abstract: “Prescription stimulant abuse has dramatically increased over the past 10 years, but the amount of research regarding college students and illicit prescription stimulant use is still very limited. This has important implications for college mental health professionals and higher education administrators. In this comprehensive literature review the author explores factors contributing to illicit use, self-medication, and recreational use of controlled prescription stimulants; discusses the potential consequences for those students abusing stimulants; and provides recommendations for educating, combating, and assisting students who illicitly use prescription stimulants on college campuses.”

“A Comparison of Attitudes Toward Cognitive Enhancement and Legalized Doping in Sport in a Community Sample of Australian Adults” Partridge, Brad; Lucke, Jayne; Hall, Wayne. AJOB Primary Research , November 2012. doi: 10.1080/21507716.2012.720639.

Abstract: “This article compares public attitudes toward the use of prescription drugs for cognitive enhancement with the use of performance enhancing drugs in sport. We explore attitudes toward the acceptability of both practices; the extent to which familiarity with cognitive enhancement is related to its perceived acceptability; and relationships between the acceptability of cognitive enhancement and legalized doping in sport. Of 1,265 [survey] participants, 7% agreed that cognitive enhancement is acceptable; 2.4% of the total sample said they had taken prescription drugs to enhance their concentration or alertness in the absence of a diagnosed disorder, and a further 8% said they knew someone who had done so. These participants were twice as likely to think cognitive enhancement was acceptable. Only 3.6% of participants agreed that people who play professional sport should be allowed to use performance-enhancing drugs if they wanted to. Participants who found cognitive enhancement acceptable were 9.5 times more likely to agree with legalized doping.”

Keywords: drugs, youth, sports, cheating, higher education, corruption, ADHD, research roundup

About The Author

Leighton Walter Kille

Steroids, Sports and the Ethics of Winning

• Markkula Center for Applied Ethics
• Focus Areas
• Bioethics Resources

Steroid use by athletes is a form of cheating.

Why, ethically, does the use of steroids in sports bother us? The medical issues are fairly straightforward. The use of anabolic steroids increases the athlete's chance of getting liver cancer. Heavy or prolonged use can cause psychological and emotional problems—so-called "steroid rage."

Men will have testicular atrophy and libido problems, and women will have abnormal periods and changes in their normal hormonal balance.

Because steroids enable heavy lifting, tendon tears and osteoarthritis are common ailments. I could tell you about guys who do what their bodies weren't designed to do—such as benching 400 pounds—and by the time they are 35, they cannot lift their arms.

So, why do people use them? The answer to that question is also straightforward. They make you bigger, faster, and stronger. And they work perfectly well in anybody who's training heavily.

Should athletes be allowed to make this trade-off? Many say, "It hurts only me, so why does society care?"

Society cares because steroid use is a form of cheating. Since steroids work so well, they create an unfair advantage for those who take them, and this breaks the social contract athletes have implicitly agreed to: We are going to have a fair contest. There are things we can and cannot do. Even if there were a safe performance-enhancing substance, if it weren't available to everybody, using it would still be cheating.

Unfortunately, steroids are still ubiquitous, and one of the problems is that we let people use them. Society loves sports and tends to look the other way when they become dangerous. We tolerate boxing, where you have two guys beating each other's brains out; we tolerate sports that have severe lifetime side effects like some elements of track and field.

The conspirators in this are everywhere—coaches, institutions, even some parents. We see parents who are in complete denial when their kids—college athletes with eating disorders—have stress fractures of their tibias or patellas because their bones are fragile from anorexia. The parents are living through the children's achievements, so it's very difficult to break this pattern.

Steroid use is part of this whole youthful delusion that says, "If I just do this for a period of my life, I'll be fine. I'll smoke until I'm older; I'll only binge drink in college; I'll be anorexic or bulimic so I can run, and then I'll stop being that way and I'll go on and have a wonderful life."

That's playing Russian roulette, which is not a game I think we want to encourage.

The only things that work to discourage doping are testing and penalties. You can talk about personal responsibility until you're blue in the face, but to stop steroid use, testing is necessary. Cocaine and steroids have ceased to be big problems in professional football because of testing.

In most other professional sports, the inmates are running the asylum. There is no effective testing, and the penalties are pitiful. If Congress pushes this issue, and if professional sports and unions stop obstructing, and if some of the professionals get busted, we may get somewhere. I'm hopeful.

Wednesday, August 25, 2004

EDUCATIONAL INTERVENTION ON ANABOLIC STEROIDS IN HIGH SCHOOL FOOTBALL STUDENTS IN LOS ANGELES, CALIFORNIA

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• April 29, 2024
• Maddox, Madison
• The usage of anabolic steroids (AS) among high school athletes in the United States is becoming an increasingly pressing concern. According to surveys conducted in the late 1980s, between 3 and 11% of male high school students admitted to having used AS at some point, with only 22% of them initiating usage before the age of 20. A recent study estimated that between 2.9 and 4.0 million Americans aged 13 to 50 years have used AAS, with one million individuals experiencing AAS dependence. Lack of education regarding the potential side effects of AAS is a contributing factor to the misuse of anabolic steroids in high school athletes. 85% of teenage athletes have no knowledge of the negative effects of steroids. High school athletes face immense pressure to get recruited into Division 1 college sports, and some believe that using AAS is essential for achieving this goal. Teenagers often look up to professional athletes who have admitted to using AAS, making them susceptible to influence. Four out of ten teens claim their decision to take steroids was inspired by professional athletes who took them. It's essential to provide student-athletes with educational opportunities to learn about the adverse effects of AAS use, as well as appropriate pre and post-workout fueling, and the safe use of legal sports supplements. I am proposing an implementation plan for an educational intervention aimed at the top ten high school football teams in Los Angeles, CA. This intervention entails a series of six 50-minute classes designed to educate football players on anabolic steroids. The classes will be scheduled during the six weeks preceding the football season and will be led by coaches in collaboration with a dietitian. These educational sessions will be conducted after their preseason weightlifting sessions, with a final class including the parents. Approximately 60% of the class will involve peer-led discussions. The program will encompass information and activities related to the misuse of anabolic steroids, the lasting side effects associated with them, nutritional education concerning vitamins and supplements, as well as strategies for fueling both pre and post-practice or workouts. Before and after the intervention, I will administer surveys to students to assess their knowledge regarding anabolic steroids.
• https://doi.org/10.17615/ts71-r238
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• Agrawal, Seema
• Master of Public Health

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Local cannabis industry leaders say move to reclassify weed will benefit businesses, customers

The move would in part ease tax burdens on pot shops, which are currently prohibited from deducting expenses from income associated with schedule i or ii substances. savings on those costs could be passed on to customers, industry leaders said..

A manicured medical marijuana flower is shown during a tour of Illinois Grown Medicine in Elk Grove Village.

Ashlee Rezin/Sun-Times file

Local cannabis industry leaders lauded the U.S. Drug Enforcement Administration’s plan to reclassify marijuana as a less dangerous drug, saying the move will be a boon to businesses and customers alike.

“It’s giant,” said Charlie Bachtell, CEO of Chicago-based weed giant Cresco Labs and chairman of both the National Cannabis Roundtable and United States Cannabis Council.

The DEA’s proposal would recognize marijuana’s medical uses and reclassify it from a Schedule I drug, alongside heroin and LSD, to Schedule III, alongside ketamine and some anabolic steroids, according to the Associated Press. However, it would not legalize marijuana outright for recreational use.

Section 280E of the Internal Revenue Code prohibits marijuana businesses from deducting what would be considered common business expenses — such as advertising and wages — from income associated with “trafficking” Schedule I or II substances. The move would remove that restriction.

“For this entire existence of this industry, we’ve all had to pay taxes at the gross profit level not actual profit. It’s a crazy burden,” said Bachtell, adding that at Cresco that amounts to $70 to $80 million in extra costs per year.

Bachtell said without the burden of that cost, smaller operators and social equity license holders — chosen with an eye toward increasing diversity in the industry — will have an easier time opening shops.

“Being able to take business deductions and hold on to more of the revenue and profit that comes into the business is going to be incredibly impactful,” Bachtell said. “I think greater accessibility, greater number of operators, is all better for the consumer.”

Reclassification would also make it easier to research marijuana, Bachtell said. It’s very difficult to conduct authorized clinical studies on Schedule I substances. It will also change legislative opinion, since some legislators are reluctant to pass laws on substances classified as Schedule 1, he said.

Dominique White, director of people and operations at Ivy Hall, the first dispensary to operate under Illinois’ Social Equity program, said customers will benefit from the reduction of the extra costs associated with taxes.

“It’ll make a huge difference in consumers’ pockets and their ability to go into a store and get what they want,” White said.

She said reclassification will also help further reduce stigma attached to pot, potentially leading to more customers and more Black- and Brown-owned weed businesses.

Aaron Smith, co-founder and CEO of the National Cannabis Industry Association, said the reduction in taxes could be “potentially huge” for businesses.

“Right now, it’s incredibly costly for legal businesses to produce cannabis in part because of 280E, and hopefully, it will allow business to provide product at a price that’s more competitive with the underground market,” Smith said. “I think it’s going to be very good for consumers and the industry alike.”

But Smith noted that much of the industry will remain the same because the drug remains illegal at the federal level, and rescheduling is a small step toward broader cannabis reform.

Tiffany Chappell Ingram, executive director of the Cannabis Business Association of Illinois, echoed Smith’s thoughts in a statement applauding the DEA’s move.

“While this decision does not legalize marijuana on a federal level, it recognizes the medical benefits of cannabis and eases the tax burden on marijuana companies by allowing them to take federal tax deductions,” Igram said. “This is a huge step in the right direction for the cannabis industry and our society at large, and we hope this continues to pave the path towards federal legalization.”

Federal drug policy has lagged behind many states in recent years, with 38 having already legalized medical marijuana and 24 legalizing its recreational use.

That’s helped fuel fast growth in the marijuana industry, with an estimated worth of nearly $30 billion. Illinois pot shops sold more than $1.6 billion worth of recreational marijuana in 2023.

But among groups opposed to legalization, the plan to reschedule the drug is a step in the wrong direction. Kevin Sabet, president of Smart Approaches to Marijuana, a group that advocates for health and scientific guidance toward marijuana policies, said the move was made to benefit “deep-pocketed” investors.

“This industry, which has lobbied heavily to sell demonstrably harmful products, will now use this announcement to drive even more deliberate misinformation about these high-potency drugs to expand use and addiction,” Sabet said in a statement.

The proposal to reschedule weed follows a recommendation from the U.S. Department of Health and Human Services. It would still have to be reviewed by the White House Office of Management and Budget.

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Meet the Men Who Eat Meat (and Only Meat)

With the help of Joe Rogan, a social media trend with staying power emerged from a 2018 book, “The Carnivore Diet.”

By Steven Kurutz

“ Girl dinner ” this is not.

In a social media trend that won’t stop, ravenous meat eaters, mostly men, show themselves chomping on rib-eye steaks, bacon and innards.

In a recent online video, a popular TikTok user who posts as @carnivoreray unveiled a new snack recipe. After sliding sheet pans packed with fatty bacon strips into the oven, he melted two sticks of butter from grass-fed cows. Once the bacon was crisp, he poured the melted butter into the sheet pans. Then he popped the concoction into the freezer.

The next morning, the influencer bit into the frozen treat while filming himself for his roughly 170,000 TikTok followers. “This tastes like candy,” he said . (The person behind the account did not reply to requests for comment.)

The video belongs to an enduring social media genre quarterbacked largely by muscular fellows who claim that a meat-heavy diet is the key to mental and physical well-being.

A stricter version of high-fat, low-carb regimens like the Atkins diet and keto , the carnivore diet consists of meat, seafood and eggs — period. While some add dairy and a little fruit to the mix, the strictest proponents adhere to what they call B.B.B.E — that is, beef, bacon, butter and eggs.

TikTok and Instagram are awash in videos of these men (and some women ) feasting on a petting zoo’s worth of meat products. Some boast about having not consumed a vegetable in months. They also claim health benefits including drastic weight loss and sharpened mental acuity. Some of the so-called “meatfluencers” forgo not only carbs but also dishware, eating straight from the cutting board .

Health experts are skeptical of the health benefits of the carnivore diet — indeed, it “really bucks nutrition science,” said Whitney Linsenmeyer , an assistant professor of nutrition and dietetics at Saint Louis University in Missouri. But the lack of endorsement from the medical establishment may add to its appeal.

The protein-and-fat-heavy eating regimen has been promoted by the podcasters Joe Rogan and Lex Fridman, influential figures in a testosterone-fueled segment of the media often called the “ manosphere .”

“I feel by far the best when I eat only meat,” Mr. Fridman, a computer scientist, said during a 2023 episode of “The Lex Fridman Podcast.”

His guest that day was the psychologist, author and fellow podcast host Jordan Peterson — also a carnivore — who credited the diet with having healed his chronic psoriasis and gum disease.

“ I don’t like to talk about this much, because it’s so bloody radical, and I don’t like to propagate it, but this diet seems to have stopped all of that,” Mr. Peterson said on the show.

The paeans to meat have come in the wake of a 2017 appearance by Shawn Baker, a buff orthopedic surgeon, on “The Joe Rogan Experience.”

In an interview for this article, Dr. Baker said he had turned 50 the year before he went on Mr. Rogan’s show, a time when he was dissatisfied with his health, experiencing chronic knee pain and gut issues. Although he had recently shed 50 pounds by limiting his intake of carbohydrates and calories, he suffered from a general I’m-getting-older malaise.

Then he encountered “this crazy group of people online who were eating an all-meat diet,” he said. He decided to try it for 30 days, despite concerns that a person’s “colon would fall out from lack of fiber” on the regimen.

“I do the diet and feel fantastic,” said Dr. Baker, speaking by phone from his home in suburban Seattle. “And then I go back to my old low-carb diet and feel worse.”

He wrote about the diet that he had embraced — and also named, he said — in a 2018 book, “The Carnivore Diet.” This manner of eating had another surge in online popularity last June, when Mr. Rogan tried it and told his millions of listeners , “The best I ever felt — like, literally, the best I ever felt all throughout the day — was when I was on the carnivore diet.”

In recent years, a number of online fitness influencers have risen to fame promoting animal-based eating. They include Brian Johnson, who is known as the Liver King . A Texan with a bushy beard, Mr. Johnson amassed millions of social media followers after claiming that he ate raw meat, testicles, animal organs and bone marrow to achieve his powerful physique. (Mr. Johnson has since admitted to using steroids .)

A plant-free, low-fiber diet goes against accepted views of what constitutes healthy, balanced eating, Professor Linsenmeyer said. Meat and butter are “very high in saturated fat,” she said. “That increases the risk for cardiovascular disease. If this were my patient following this diet, I would be very concerned.”

There is also the matter of contributing to the warming climate, since meat and dairy production are linked to emissions of methane , a potent greenhouse gas.

Promoters of the carnivore diet argue that our ancestors subsisted on animals almost exclusively. Carnivorism, in their view, represents a return to a supposed hunter-gatherer golden age, long before the advent of Cap’n Crunch’s Ocean Blue Maple Syrup and other highly processed foodstuffs.

Paul Saladino , a medical doctor and the author of “The Carnivore Code,” has claimed that most plants are “ inedible if not toxic to humans .” “Forget the leaves and fibrous tubers, we’re going hunting!” he commands in the book. (Since publishing “The Carnivore Code” in 2020, Mr. Saladino has reintroduced carbohydrates into his diet, with fruit and honey.)

As a 2023 New Yorker article detailing the carnivore craze pointed out, however, studies of Neanderthals have turned up evidence that their diets included dates, tubers and other leafy foods in addition to meat. According to Herman Pontzer, an evolutionary anthropologist at Duke University quoted in the article, humans are “opportunistic omnivores” who will “eat whatever’s available, which is almost always a mix of plants and animals (and honey).”

The New Yorker also noted a study by the biologists David Raubenheimer and Stephen J. Simpson, who found that protein-loaded diets had a detrimental effect on animals’ life spans. “Our sexy, lean mice who ate high-protein, low-carb diets were the shortest lived of all,” the scientists wrote in 2014. “They made great-looking middle-aged corpses.”

Dan Buettner , an author who identified five regions around the world where people have especially long life spans, said that a diet of predominantly whole food, plant-based meals, among other practices, is what leads to a long, healthy life.

“I know of no long-lived culture in the history of the world that were mainly meat eaters,” Mr. Buettner said by phone from Italy, where he was conducting further research on the places he has dubbed “blue zones.”

For some, going carnivore appears to be a facet of the optimization culture that seeks self-improvement through so-called bio hacking and other methods. For others, there may be an aspect of flexing one’s masculinity and success through the consumption of beefsteak, a luxury in much of the world. It is notable that online promoters almost exclusively post videos eating red meat, though fish is part of the diet.

Dr. Baker, who planned to eat a rib-eye steak and eight ounces of salmon for his main meal on the day he was interviewed, said he kept two freezers in his garage, which at that moment contained “half a side of beef from a local rancher.”

Rib-eye steak, even when eaten every day, “is viscerally and primitively satisfying to me,” he said. “I get to eat stuff that only royalty would have eaten through history.”

Dr. Baker, who runs a nutrition and lifestyle company and no longer practices medicine, said he usually recommended that people adopt the carnivore diet for a limited time to reset their digestive systems. After that, they may reintroduce other foods or stay carnivore as he has.

“If somebody wants to turn it into a lifestyle and call themselves Carnivore Carl, that’s up to them,” he said.

That people have embraced a way of eating referred to as “crazy” and “radical” even by its evangelists may say something about the Western diet of processed foods and its effect on the populace.

On this point, at least, Mr. Buettner can agree with the carnivores.

“We live in an environment where 95 out of 100 food decisions presented to us are bad,” he said. “So in desperation, to turn to an extreme diet, I don’t blame any overweight and unhealthy American.”

Steven Kurutz covers cultural trends, social media and the world of design for The Times. More about Steven Kurutz

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