madman
Super Moderator
Recent decades have seen increasing attention to disorders of body image [1]. In the past, most body-image studies have focused on women [2], and especially women with eating disorders [3], but now a growing literature has also begun to address body image disorders in men [4]. In particular, it appears that today’s men have become increasingly preoccupied with having a lean and muscular body, perhaps as a result of constant exposure to lean and muscular male images in movies, television, advertising, and elsewhere [1, 5]. Modern mental health professionals are very likely to encounter male patients who harbor such concerns. Importantly, many of these men use drugs (or “dietary supplements” containing drugs) in order to gain muscle or lose body fat. The use of these “body image drugs” had already surfaced as a clinical issue 20 years ago [6] and has generated increasing attention in recent years [7]. From a public health standpoint, the most concerning of these substances are the anabolic-androgenic steroids (AAS) – the family of hormones that includes testosterone and its synthetic derivatives. In this paper, we present a clinical update on AAS use.
Drugs in the AAS family all possess both anabolic (muscle-building) properties and androgenic (masculinizing) properties [8]. Soon after the identification of testosterone in the late 1930s, athletes discovered that AAS could allow them to greatly increase muscle mass, and attain levels of performance beyond that previously attained by “natural” athletes [9]. Consequently, AAS use spread rapidly through the elite athletic world from the 1950s through the 1970s, especially in sports requiring muscle strength, such as field events, weightlifting, and bodybuilding. However, it was not until the 1980s that AAS use began to spill out of the elite athletic world and into the general population. Nowadays, most AAS users are not competitive athletes, but simply men using these drugs primarily for personal appearance [10, 11]. About 98% of AAS users are male [12], in part because women rarely desire to be extremely muscular, and are also vulnerable to the androgenic effects of these drugs, such as beard growth, deepening of the voice, and masculinization of secondary sexual characteristics [13]. Consequently, the discussion below is focused on male AAS users.
AAS users frequently use several AAS simultaneously (a practice called “stacking”), often combining both injectable AAS and orally active AAS [8]. For example, a typical stack might include injected testosterone cypionate 400 mg per week plus injected nandrolone decanoate 400 mg per week plus oral methenolone 50 mg per day. Users may also add other appearance- performance-enhancing drugs to the stack (e.g., human growth hormone, clenbuterol, insulin, etc.), as well as drugs to counteract the side effects of AAS, such as anti-estrogens to prevent gynecomastia. Discussion of these other classes of drugs can be found elsewhere [8, 14–16]. Although AAS and these other drugs are illegal without a prescription in most developed Western countries, the drugs are readily available through local underground drug dealers and through numerous Internet sites. In addition, many “nutritional supplements,” purchased over the counter or online [17], may contain surreptitious AAS or other ingredients of uncertain efficacy and toxicity [18].
In the 21st century, AAS use has continued to spread widely among men around the world, especially in Nordic countries, the United States, British Commonwealth countries, and Brazil, with many other Western countries following not far behind. AAS use remains rare in east Asia, however, apparently because the Confucian and related traditions in these societies place little value on musculature as a measure of masculinity [19, 20], whereas in the West, muscularity has been celebrated since ancient times, with a particular emphasis in the last several decades [21, 22]. At present, some tens of millions of men worldwide have used AAS, and thus AAS use arguably represents the youngest of the world’s major substance use disorders.
Because AAS use is so new, science has only begun to appreciate the potential adverse effects of these substances. Other drugs, such as alcohol, cannabis, and opioids, have been used for thousands of years, and many decades of research have now evaluated the effects of these substances. By contrast, most of the world’s older AAS users, those who first tried these drugs as youths in the 1980s or The 1990s are only now reaching middle age. Consequently, it is only in the last decade or two that it has become feasible to study the long-term effects of AAS [23]. For further discussion of the current state of knowledge, we refer the reader to our earlier comprehensive review [8]. Below, we briefly summarize this literature, with emphasis on effects most likely to be encountered by mental health clinicians
*Medical Effects
-Cardiac Effects
-Hypogonadism
-Other Organ Systems
*Psychiatric Effects
-Major Mood Disorders
-Muscle Dysmorphia
-AAS Dependence
*Clinical Evaluation
*Treatment
-The Body Image Pathway
-The Neuroendocrine Pathway
-The Hedonic Pathway
*In summary, then, at the present limited state of knowledge, much of the treatment of AAS users must be based on the clinician’s assessment of each individual case. Now that AAS use has risen to become one of the world’s major substance use disorders, it will become increasingly important for mental health professionals to stay abreast of evolving knowledge in this area.
Drugs in the AAS family all possess both anabolic (muscle-building) properties and androgenic (masculinizing) properties [8]. Soon after the identification of testosterone in the late 1930s, athletes discovered that AAS could allow them to greatly increase muscle mass, and attain levels of performance beyond that previously attained by “natural” athletes [9]. Consequently, AAS use spread rapidly through the elite athletic world from the 1950s through the 1970s, especially in sports requiring muscle strength, such as field events, weightlifting, and bodybuilding. However, it was not until the 1980s that AAS use began to spill out of the elite athletic world and into the general population. Nowadays, most AAS users are not competitive athletes, but simply men using these drugs primarily for personal appearance [10, 11]. About 98% of AAS users are male [12], in part because women rarely desire to be extremely muscular, and are also vulnerable to the androgenic effects of these drugs, such as beard growth, deepening of the voice, and masculinization of secondary sexual characteristics [13]. Consequently, the discussion below is focused on male AAS users.
AAS users frequently use several AAS simultaneously (a practice called “stacking”), often combining both injectable AAS and orally active AAS [8]. For example, a typical stack might include injected testosterone cypionate 400 mg per week plus injected nandrolone decanoate 400 mg per week plus oral methenolone 50 mg per day. Users may also add other appearance- performance-enhancing drugs to the stack (e.g., human growth hormone, clenbuterol, insulin, etc.), as well as drugs to counteract the side effects of AAS, such as anti-estrogens to prevent gynecomastia. Discussion of these other classes of drugs can be found elsewhere [8, 14–16]. Although AAS and these other drugs are illegal without a prescription in most developed Western countries, the drugs are readily available through local underground drug dealers and through numerous Internet sites. In addition, many “nutritional supplements,” purchased over the counter or online [17], may contain surreptitious AAS or other ingredients of uncertain efficacy and toxicity [18].
In the 21st century, AAS use has continued to spread widely among men around the world, especially in Nordic countries, the United States, British Commonwealth countries, and Brazil, with many other Western countries following not far behind. AAS use remains rare in east Asia, however, apparently because the Confucian and related traditions in these societies place little value on musculature as a measure of masculinity [19, 20], whereas in the West, muscularity has been celebrated since ancient times, with a particular emphasis in the last several decades [21, 22]. At present, some tens of millions of men worldwide have used AAS, and thus AAS use arguably represents the youngest of the world’s major substance use disorders.
Because AAS use is so new, science has only begun to appreciate the potential adverse effects of these substances. Other drugs, such as alcohol, cannabis, and opioids, have been used for thousands of years, and many decades of research have now evaluated the effects of these substances. By contrast, most of the world’s older AAS users, those who first tried these drugs as youths in the 1980s or The 1990s are only now reaching middle age. Consequently, it is only in the last decade or two that it has become feasible to study the long-term effects of AAS [23]. For further discussion of the current state of knowledge, we refer the reader to our earlier comprehensive review [8]. Below, we briefly summarize this literature, with emphasis on effects most likely to be encountered by mental health clinicians
*Medical Effects
-Cardiac Effects
-Hypogonadism
-Other Organ Systems
*Psychiatric Effects
-Major Mood Disorders
-Muscle Dysmorphia
-AAS Dependence
*Clinical Evaluation
*Treatment
-The Body Image Pathway
-The Neuroendocrine Pathway
-The Hedonic Pathway
*In summary, then, at the present limited state of knowledge, much of the treatment of AAS users must be based on the clinician’s assessment of each individual case. Now that AAS use has risen to become one of the world’s major substance use disorders, it will become increasingly important for mental health professionals to stay abreast of evolving knowledge in this area.
Last edited:
