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Prevalence, mental health, and substance use of anabolic steroid users: a population-based study on young individuals
Sunna Gestsdottir, Hafrun Kristjansdottir, Hedinn Sigurdsson & Inga Dora Sigfu
Abstract
Aims: The use of anabolic androgen steroids to enhance performance is not a modern phenomenon. However, the majority of today’s anabolic androgen steroid users are not competitive athletes, but individuals who want to look leaner and muscular. This study aimed to examine the prevalence of anabolic androgen steroid use among young individuals and assess whether their mental health, lifestyle, and substance use differ from non-anabolic androgen steroid users.
Methods: In a population-based study conducted in secondary schools, the mean age was 17.3 years. A total of 10,259 participants (50% young women, 1% reported gender as ‘other’, 49% young men) answered questions on mental health, anabolic androgen steroid use, substance use, and sports participation. Statistical analysis included descriptive statistics, t-test, χ2, and logistic regression.
Results: The prevalence of anabolic androgen steroid use was 1.6%, and 78% of users were young men. Anabolic androgen steroid users had more anger issues, anxiety, depression, and their self-esteem were lower than among non-anabolic androgen steroid users (P<0.05). A larger proportion of anabolic androgen steroid users, 30%, had attempted suicide compared to 10% of non-users (χ2 (1, 9580) = 57.5, P<0.001). Proportionally, anabolic androgen steroid users were more likely to take medicine for mental health problems and misuse substances than non-users. Participation in non-organized sports increased anger, and body image was associated with increased odds of using anabolic androgen steroids.
Conclusions: Anabolic androgen steroid use is a public health threat. It had an alarming effect on the life of individuals who report having used anabolic androgen steroids. Authorities, healthcare workers, parents, and others working with young people need to be informed of the signs and risks of anabolic androgen steroid use to reduce future negative implications.
Introduction
The use of performance-enhancing drugs is not modern reality. It goes as far back as ancient times when Greek Olympic athletes and Roman gladiators used herbs, mushrooms, and plants to boost their performance [1]. The first known case of anabolic androgenic steroids (AAS) use to enhance performance is from a weightlifting championship in 1954 [1]. AAS contains synthetic testosterone, the male hormone, which produces the male characteristics (androgenic effect) and endorses the growth of skeletal muscle (anabolic effects) [1]. The power of AAS was, for many years, a well-kept secret among elite athletes, their coaches, and medical staff. It was not until the late 1980s that AAS use among the general population was confirmed when high school boys in the USA reported the use of them in a survey. The interesting results were that they did not only use the AAS to increase their performance in sports but also to improve their appearance [2]. The use of AAS has grown terribly among the general population, and most users today are individuals who want to look muscular and leaner [3].
Due to the widespread AAS use and the serious side effects that follow, there has been speculation about whether the use has become a public health crisis [1,3]. The particular health concern is the use of adolescents that misuse AAS during a vulnerable period in their biological and psychological growth [4]. The known physical side effects of AAS use have been found to include anatomical changes in the brain, hair loss, liver tumors, acne, sweating, injection site abscess, and cardiovascular disease [5]. Among men, the effects of AAS use are a reduction in testicle size, low sperm count, infertility, balding, prostatism, and breast development, which requires cosmetic surgery [4]. Among women, the symptoms of AAS use are facial hair growth, deepening of voice, baldness, enlarged clitoris, menstrual dysfunction, infertility, and malformation of a fetus if one becomes pregnant while using AAS [6].
Mental health and substance use among AAS users
The most common psychological effects of AAS use are mood-related. The use of AAS is most often periodically with breaks between to rebuild one’s testosterone production [6]. Hypomania, manic or psychotic symptoms correlate with AAS use. Anxiety, major depression, fatigue, impaired concentration, sleeping problems, impotence, and suicidality correlate with AAS discontinuation, resulting in about 30% of users developing an AAS dependence [1]. Aggression is problematic among AAS users, especially when combined with psychoactive substances [10]. The use of cannabis, cocaine, or other substances to reduce the side effects of AAS use is well known [1,4]. In a qualitative study, men described psychological strain as they had compromised their morals and felt guilt during the entire time they used AAS [11]. Participants also described manic-like features, praising hyperactivity, increased sexual appetite, grandiose beliefs, and euphoria [11]. Participants agreed that there is a strong psychological dependence on AAS due to the positive comments they get on their appearance [11]. The use of AAS is associated with muscle dysmorphia in both genders [12,13]. Use among young men is believed to be due to augmented emphasis in western societies on low body fat and toned muscles [14]. This preoccupation with muscularity may have led to an increase in eating disorders among young men [13], disturbed body image [6,13], and physical stature that is far beyond what can be expected by natural means [14]. Among women, AAS use is associated with an increased risk of having experienced abuse, either physical or sexual [6]. Women report using weightlifting and AAS as a defense strategy after being sexually assaulted [12]. A recent Norwegian study [5] on users who sought help to quit using AAS revealed that mental health problems were the most common motivation to quit. Both genders reported depression, anxiety, and a change in behavior, and those who used other illicit substances had a greater number of mental health problems than those who were not polysubstance abusers [5].
Self-harm and suicide attempts are also known effects of AAS use, especially during the withdrawal stage [15]. Eight medicolegally cases of suicide in 21–33-year-old men using AAS revealed five suicides committed during AAS use and two suicides during withdrawal of AAS [15]. Lindqvist et al. [16] indicated that studies on former elite athletes in power sports revealed that suicide was increased two to four times, and the mortality rate was 4.6 times higher compared to non-users.
Strengths, limitations, and directions for future research
To the best of our knowledge, this is among the first population-based studies on AAS use among young individuals that compares users’ mental health to that of non-users. It gives a good description of use among the general public and their mental health. The questions on AAS were self-reports and a part of a comprehensive questionnaire and were thus less specific. It could well be that the prevalence of AAS use is under-reported as it is an illegal act.
In the future, it would be interesting to get answers to more detailed questions on AAS use; for example, on the motivation for intake, whether intake is monitored, how users obtain their AAS, for how long they have been using, and if they believe AAS use is harmless.
Conclusion
AAS use is a public health threat. Although the use among elite athletes has received the most debate, they are clearly no longer used only for performance enhancement in sports. They are more likely to be used for appearance enhancement by young individuals. AAS use has had an alarming effect on the lives of individuals who report having used them. As found in this study, the mental health of AAS users was worse than that of non-users, they were more likely to have attempted suicide and used other substances. Increased education about the adverse health effects of AAS use is needed for the general public; for example, for parents to monitor their youngsters for rapid weight gain or muscle growth and other biological changes, as well as extreme fluctuations in their mental health. To reduce future negative implications of AAS use, increased awareness is vital among authorities, physicians, psychologists, and others in the medical community of the signs, symptoms, and dangers of AAS use.
Sunna Gestsdottir, Hafrun Kristjansdottir, Hedinn Sigurdsson & Inga Dora Sigfu
Abstract
Aims: The use of anabolic androgen steroids to enhance performance is not a modern phenomenon. However, the majority of today’s anabolic androgen steroid users are not competitive athletes, but individuals who want to look leaner and muscular. This study aimed to examine the prevalence of anabolic androgen steroid use among young individuals and assess whether their mental health, lifestyle, and substance use differ from non-anabolic androgen steroid users.
Methods: In a population-based study conducted in secondary schools, the mean age was 17.3 years. A total of 10,259 participants (50% young women, 1% reported gender as ‘other’, 49% young men) answered questions on mental health, anabolic androgen steroid use, substance use, and sports participation. Statistical analysis included descriptive statistics, t-test, χ2, and logistic regression.
Results: The prevalence of anabolic androgen steroid use was 1.6%, and 78% of users were young men. Anabolic androgen steroid users had more anger issues, anxiety, depression, and their self-esteem were lower than among non-anabolic androgen steroid users (P<0.05). A larger proportion of anabolic androgen steroid users, 30%, had attempted suicide compared to 10% of non-users (χ2 (1, 9580) = 57.5, P<0.001). Proportionally, anabolic androgen steroid users were more likely to take medicine for mental health problems and misuse substances than non-users. Participation in non-organized sports increased anger, and body image was associated with increased odds of using anabolic androgen steroids.
Conclusions: Anabolic androgen steroid use is a public health threat. It had an alarming effect on the life of individuals who report having used anabolic androgen steroids. Authorities, healthcare workers, parents, and others working with young people need to be informed of the signs and risks of anabolic androgen steroid use to reduce future negative implications.
Introduction
The use of performance-enhancing drugs is not modern reality. It goes as far back as ancient times when Greek Olympic athletes and Roman gladiators used herbs, mushrooms, and plants to boost their performance [1]. The first known case of anabolic androgenic steroids (AAS) use to enhance performance is from a weightlifting championship in 1954 [1]. AAS contains synthetic testosterone, the male hormone, which produces the male characteristics (androgenic effect) and endorses the growth of skeletal muscle (anabolic effects) [1]. The power of AAS was, for many years, a well-kept secret among elite athletes, their coaches, and medical staff. It was not until the late 1980s that AAS use among the general population was confirmed when high school boys in the USA reported the use of them in a survey. The interesting results were that they did not only use the AAS to increase their performance in sports but also to improve their appearance [2]. The use of AAS has grown terribly among the general population, and most users today are individuals who want to look muscular and leaner [3].
Due to the widespread AAS use and the serious side effects that follow, there has been speculation about whether the use has become a public health crisis [1,3]. The particular health concern is the use of adolescents that misuse AAS during a vulnerable period in their biological and psychological growth [4]. The known physical side effects of AAS use have been found to include anatomical changes in the brain, hair loss, liver tumors, acne, sweating, injection site abscess, and cardiovascular disease [5]. Among men, the effects of AAS use are a reduction in testicle size, low sperm count, infertility, balding, prostatism, and breast development, which requires cosmetic surgery [4]. Among women, the symptoms of AAS use are facial hair growth, deepening of voice, baldness, enlarged clitoris, menstrual dysfunction, infertility, and malformation of a fetus if one becomes pregnant while using AAS [6].
Mental health and substance use among AAS users
The most common psychological effects of AAS use are mood-related. The use of AAS is most often periodically with breaks between to rebuild one’s testosterone production [6]. Hypomania, manic or psychotic symptoms correlate with AAS use. Anxiety, major depression, fatigue, impaired concentration, sleeping problems, impotence, and suicidality correlate with AAS discontinuation, resulting in about 30% of users developing an AAS dependence [1]. Aggression is problematic among AAS users, especially when combined with psychoactive substances [10]. The use of cannabis, cocaine, or other substances to reduce the side effects of AAS use is well known [1,4]. In a qualitative study, men described psychological strain as they had compromised their morals and felt guilt during the entire time they used AAS [11]. Participants also described manic-like features, praising hyperactivity, increased sexual appetite, grandiose beliefs, and euphoria [11]. Participants agreed that there is a strong psychological dependence on AAS due to the positive comments they get on their appearance [11]. The use of AAS is associated with muscle dysmorphia in both genders [12,13]. Use among young men is believed to be due to augmented emphasis in western societies on low body fat and toned muscles [14]. This preoccupation with muscularity may have led to an increase in eating disorders among young men [13], disturbed body image [6,13], and physical stature that is far beyond what can be expected by natural means [14]. Among women, AAS use is associated with an increased risk of having experienced abuse, either physical or sexual [6]. Women report using weightlifting and AAS as a defense strategy after being sexually assaulted [12]. A recent Norwegian study [5] on users who sought help to quit using AAS revealed that mental health problems were the most common motivation to quit. Both genders reported depression, anxiety, and a change in behavior, and those who used other illicit substances had a greater number of mental health problems than those who were not polysubstance abusers [5].
Self-harm and suicide attempts are also known effects of AAS use, especially during the withdrawal stage [15]. Eight medicolegally cases of suicide in 21–33-year-old men using AAS revealed five suicides committed during AAS use and two suicides during withdrawal of AAS [15]. Lindqvist et al. [16] indicated that studies on former elite athletes in power sports revealed that suicide was increased two to four times, and the mortality rate was 4.6 times higher compared to non-users.
Strengths, limitations, and directions for future research
To the best of our knowledge, this is among the first population-based studies on AAS use among young individuals that compares users’ mental health to that of non-users. It gives a good description of use among the general public and their mental health. The questions on AAS were self-reports and a part of a comprehensive questionnaire and were thus less specific. It could well be that the prevalence of AAS use is under-reported as it is an illegal act.
In the future, it would be interesting to get answers to more detailed questions on AAS use; for example, on the motivation for intake, whether intake is monitored, how users obtain their AAS, for how long they have been using, and if they believe AAS use is harmless.
Conclusion
AAS use is a public health threat. Although the use among elite athletes has received the most debate, they are clearly no longer used only for performance enhancement in sports. They are more likely to be used for appearance enhancement by young individuals. AAS use has had an alarming effect on the lives of individuals who report having used them. As found in this study, the mental health of AAS users was worse than that of non-users, they were more likely to have attempted suicide and used other substances. Increased education about the adverse health effects of AAS use is needed for the general public; for example, for parents to monitor their youngsters for rapid weight gain or muscle growth and other biological changes, as well as extreme fluctuations in their mental health. To reduce future negative implications of AAS use, increased awareness is vital among authorities, physicians, psychologists, and others in the medical community of the signs, symptoms, and dangers of AAS use.
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