"'-
0eparment of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

STE. USE 
ADOLESCENT  ROID 
f.tlVICES' 
Richard P. Kusserow 
Jr 
INSPECTOR GENERAL 
FEBRUARY 1991
1-
lt"d3a  Deparment of Health and Human Services

OFFCE OF

INSPECTOR GENERAL

ADOLESCENT STEROID USE

f.tlV'(,t$. 
Richard P. Kusserow 
INSPECTOR GENERA 
OEI-06-90-01080 
"dia  EXECUTIVE SUMMARY

PURPOSE 
To describe the non-medcal.use of steroids by adolescents and to suggest appropriate education 
neeg 
or intervention strategies as well as aras 
furter research. 
BACKGROUND 
. Anabolic-androgenic steroids ("steroids  ) are synthetic derivatives of the natial male hOrmone 
testOsterone. Most who use steroids for non-medcal reasons want to maimize the anabolic 
(growth) propertes in order to improve their muscularty, strngth, appearce, and/or capacity 
to trai. Steroids do not produce an immedate euphoria at the tie of use. Steroids are 
tie 
administered either oraly or by injection. Many users tae more than one steroid at a 
(stacking) for several months (cycles) and usually in dosages that gratly excee the therapeutic 
amounts. 
Steroid possession and distrbution for non-medcal puroses are ilegal under Federa law. 
Since the 1950's world class and professional athetes have used steroids to enhance their 
performce, but more recently evidence has shown high school, and even junior high school 
students also use steroids. At the same time researchers ar discovering the potential for serious 
health risks associated with steroid use. 
This i  spection focuses on non-medical steroid use by adolescents 
accordng to the National 
Institute on Drug Abuse (NA), professional literatu, 30 key inormants knowledgeable in 
steroid issues, and 72 curnt or former steroid users. Findigs from our companon study on 
adolescent steroid users ar avaiable in a separte repon entitled "Adolescents and Steroids: A 
User Perspective," OEI 06-90-01081. 
FINDINGS 
Over One-Quarter Million Adolescents, Primtriy Mals, Use Or Have Used Steroids, And 
Their Numbers Are Growing. 
The NIDA reponed 3 percent of the Class of 1989 (4.7% maes and 1.3% females) had used 
steroids in their lifetie. Other smaler studies show higher rates for males. Our key informants 
agree that 5 to 11 percent is an accurate range of male use, but they also say the usage rates are 
mcreasmg.  Adolescent Steroid Use Starts Early And Often Follows A Prolonged, 
Intense Pattern. 
The data also show that over hal the adolescents who use steroids have tred them for the fIrst 
time by age 16. The majority of our sample ar "heavy" users who incrased steroid dosages,
variety, and cycle length over time. 
Adolescent Steroid Use Is Motivated By Socially Acceptable Values And Life-Stage Concerns 
With Appearance And Peer Approval. 
tr 
Key informants say steroid users, in general, ar highly motivated people who  intensely to 
improve themselves or to achieve a positive goal and who believe they are health conscious. 
Adolescents, typically very concerned about their appearance and peer approval, use steroids 
primary to improve athletic performance and appearance. Key informants and users believe 
that steroids work to produce the physical effects adolescents desire. Furermore, adults and 
inditly 
famous role models  reinforce adolescent steroid use; non-using peers don t discourage 
use. 
Adolescents Are At Special Risk 
For Some Adverse Result Of Steroid Use. 
Key informants believe adolescent users are more susceptible to the health risks of stuted 
growth and adverse psychological effects including dependence. Data also suggest steroid use 
encourages adolescents to tr other drgs for enhancing performance and counterig the side 
effects of steroid use.

Although Much Remains Unknown, Experts Link Steroid Use To Serious Psychological And
Physical Health Risks. 

Prolonged use of steroids concerns our key informants because of what they do and do not know 
about their effects. Most prect that, if an adolescent uses steroids for one six-week cycle. he 
wil go on to heavy use that could possibly last for year. Intact, may of our users self-repon 
addictive thinng or behavior. The key informants li  many adverse physical and 
psychological effects to steroid use. 
Experts Recommend Educaton Of Adolescents And Adults As The Best Solution To The 
Steroid Use Problem. 
Expens do not believe adolescents ar well awar of the potenti risks of steroid use nor is 
awareness a deterrent to use. Our key infonnants say, neverteless. education is the most 
effective means of deterrg use. Honest. early. repeated and clear messages concerng steroid 
use to adolescents and responsible adults wil improve steroid education progrs. 
. ii  Testing And Controlled Substance Status Are Potential Deterrents To Non-Medical Steroid 
Use. 
Many key informants suppon drg testing as a deterrnt to adolescent steroid use, but the cost is 
a serious drwback. Some object to testing for legal or philosophical reasons. Limiting the 
black market supply could help contrl steroid use. Makng steroids a controlled substace is 
seen as beneficial, but perhaps not the only enforcement effon needed. 
RECOMMENDATIONS 
Develop A National Steroid Education Strategy. 
The Deparent should develop a national education strategy to increase adult and adolescent 
awareness of the problem and to provide educational guidelines for local progrs. An effective 
progr 
involves more than merely presentig informtion about the effects of steroids. The 
message for adolescents must come early and be reinforced in an honest. consistent way from 
their peers and responsible adults. 
Conduct Further Medical And Scientific Research. 
The Deparent, through the Public Health Service. should tae the Federal lead in expandig 
our understading of the motivap.ons for and health risks of non-medcal steroid use as a basis 
for informed policy decisions. 
COMMENTS 
dr 
We reeived Deparnta comments on the  repon frm the Offce of the Assistat 
Secretar for Planning and Evaluation (ASPE) and the Public Heath Servce (PHS). Both the 
agrd 
ASPE and the PHS generally  with the repon.  ........................ ............. .................. . ......... ...... .............. ...................... ...... .. .......................... .... ............. ................ .......... ... ................................. ..... .. ....... ................  ................  ..........................  ............. ..............  .............. .. ...................... . ...... ..... .......................... .  .. ...... ..... ...............
................ ......................... .....................................................  ........ .... ........ .... 
TABLE OF CONTENTS

EXECUTIVE SUMMARY

INTR 0 D U CTI 0 N ..............................................................................................................

Purpose........................................................................................................................

Back gronD d.......... ...... .................... 

Met hod 0 logy............ .................... .... 

.................................. .... ......00.. 

FIND IN G S 
Over One-Quarter Millon Adolescents, Primarily Males, Use Or Have 
Used Steroids, And Their Numbers Are Growing........................................

Adolescent Steroid Use Starts Early And Often Follows A Prolonged, 
In tense Pa ttern ........ ...... 

Adolescent Steroid Use Is Motivated By Socially Acceptable Values And 
Life-Stage Concerns With Appearance And Peer Approval ............................. 
Adolescents Are At Special Risk For Some Adverse Results Of Steroid Use...... 
Although Much Remains Unknown, Expert Link Steroid Use To Serious 
Psychological And.  hysica1 Health Risks ................................................................ 
Experts Recommend Education Of Adolescents And Adults As The

Best Solution To The Steroid Use Problem .............................................................

Testing And Cuntrolled Substance Status Are Potential Deterrents To

Non - M edi cal Steroi d Use.... ........ ........ 
................................ ...... .........Ot!... 

REC 0 MMEND A TI 0 NS .................................................................................................

Develop A National Steroid Education Strategy..........................................

Conduct Further Medical And Scientifc Research .....................................

CO MME NTS ............ ............ .......... .... ...... .......... ........ 

END NOTE S.. .... 
BIB L lOG RAPH Y .... .......... ............ ........ .......... .......... .... .......... 
 .............................................................................. 
APPENDIX A: Key Informant Interviews ............................................................... 
. 1

APPENDIX B:  Steroid User Interviews.................................................................... 
- 1

APPENDIX C: Steroid Incidence of Fir t:Use ................................................ C -

APPENDIX D:  Estimate of Student Steroid Use by Grade............................ D -

APPENDIX E: Departmental Comments. ................................................................ 
. 1

APPENDIX F: Public Comments 
F - 1
 INTRODUCTION

PURPOSE 
To describe the non-medical use of steroids by adolescents and to suggest appropriate education 
neeg 
or intervention strategies as well as areas  furter research. 
BACKGROUND 
Anabolic-androgenic steroids ("steroids") ar synthetic derivatives of the natual male hormone 
testosterone. The androgenic effects of testosterone ar incrased aggressiveness, the growth of 
the male reproductive tract during adolescence, and the development of seconda male 
characteristics such as increased body/facial hai. The anabolic effects ar the retention of 
dietar protein and increased muscle mass. An effect durng pubert is the s  ulation of long 
l closure. 
bone growth with subsequent epiphyseal Although separting the androgenic and 
anabolic effects is diffcult, most who use steroids for non-medcal reasons wtarIt .to  maximze the 
anabolic propertes to improve their strngt, appearce, and/or capacity to  Unlie 
recrational" drgs, such as cocaine, steroids do not produce an imedate euphoria at the time 
of use.

Use in combinations and cycles 
Steroids ar admnistere  f no!)-medical use is 
either orally or by injection. A common practice 
to "stack" steroids, i.e., to combine severa steroids, usually at least one ora and one injectable, 
in an effon to saturate receptors that can stimulate growt. Dosages often gratly excee the 
usual therapeutic amounts and may include products intended for veteri  use;"Some users 
cycle" the drgs by takng them for 4 to 18 weeks, then discontinuig them for several months; 
tae 
others  steroids continuously. 
Illegal 
activi increases 
Steroid possession and distrbution for non-medcal purses is ilegal under Fedral law. The 
Food and Drg Admnistrtion (FA) has approved steroids as drlgis twehi ch may be prescrbed 
only by a licensed physician for specifc puroses. Steroids have  approved uses, such as 
the treatment of cenain anemias, breast cancer, male hypogonadsm, and delayed adolescence in 
boys. Congress passed the Anti-Drug Abuse Act of 1988 which includes several provisions to 
control the distrbution of steroids for non-medical purposes. For a limited time in 1989 the 
Office of Inspector General (OIG) was delegated the authority to conduct investigations of 
ilegal distrbution of steroids. In November 1990 steroids were added to Schedule II of the 
Federa Controlled Substaces Act, makng steroid distrbution and possession without a 
prescription ilegal. 2 
nal!e 1
 The non-medcal use of steroids is not a new issue, but the user population seems to be 
expanding. Beginning in the early 1950's steroid use appear confIned to world class and 
professional athletes, but more recently, steroid use has incrased signifIcantly among amateurs. 
In December 1986, for example, 26 college football players, from at least 7 universities, were 
bard from post-season bowl games after testing positive for steroids. Evidence has shown that 
high school, and even junior high school, students also use steroids. 
Serious health risks suggested 
At the same time, researchers  potential for serious health risks of steroid use. 
ar discovering the 
No systematic studies of the health risks to athletes or body builders, who use steroids at higher 
than therapeutic doses, have been conducted. Health risk data do exist, however, from medical 
case studies and from a limited number of case repons on athletes. Suggested side effects range 
from acne or fluid retention to mood swings, tempora sterility, cardiovascular disease, and 
liver disease. Some risks may be even  because of their 
grater for adolescent users 
ar 
developmenta stage. Since some steroids  injected, researhers suggest an incidental health 
contanate 
effect of steroid use may be contrcting AIDS though the shared use of  needles. 
METHODOLOGY 
This inspection focuses on non-medcal steroid use by adolescents accordig to four major 
sources: the National Institute on Drg Abuse (NA), professional and origial research 
literature, interviews of 30 key informants knowledgeable in steroid issues, and interviews of 72 
current or former steroid users. Since sci ntifIc inquir in the study area has been limted, 
fIndings ar based on the compilation of the best available research information frm NIDA and 
other professional sources and of anecdotal data we gathere from key informants and users. 
Each year NIA sponsors a national high school senior surey (1). In 1989, for the fit tie, 
preliar 
the surey included questions concerng non-medcal steroid use. We examed the 
data on national steroid use as reported by the high school clas of 1989. We also completed a 
content analysis of the reent literatue (se Bibliogrphy). This analysis examned 
incidence/prevalence of steroid use, motivations for adolescent use, use patterns and trends, 
health risks associate with steroids, and education/intervention strategies. 
We collected data from 30 well-known key informants by using in-depth, strctured interviews. 
We selecte these respondents based on their promience in professional or research literature 
(16 had wrttn material we used for our content analysis), their professional afliations, or 
recommendations by other key informants. Their aras of expertse ar medcine, education 
substace abuse, drg testing, spons, and/or coaching (see Appendi A for a complete listing). 
They have been involved with the steroid issue in some way for 8 years, on average. 
Twenty-seven have personal contact with current or former steroid users in varous age groups 
and levels of athletic competition. 
We also collected detaied data on use patterns and motivations from 72 steroid users (55 current 
and 17 former). We contrcted with three key informants to complete confidential, in-depth 
e 2  interviews using our instrment (see Appendix A). The curent or former users, selecte 
judgmentaly by the  younger at the time of the 
interviewers, met three crteria: 1) age 25 or 
interview, 2) initiated steroid use in high school or younger, and 3) completed at least one steroid 
cycle of 6 weeks or longer (see Appendix B). Detaled fIndings from these interviews are 
presented in a separte repon entitled "Adolescents and Steroids: A User Perspective," OEI 
06-90-01081. 
na!!e 3
 FINDINGS

Over One-Quarter Milion Adolescents, Primarily Males, Use Or Have Used Steroids, And 
Their Numbers Are Growing. 
Mounting evidence indicates signifcant numbers of adolescents use steroids. 
The NIDA survey, the only national data base in this study area, reported 3 percent of the Class 
of 1989 had used steroids in their lifetime. Three earlier studies of high school students, not 
nationaly representative, showed similar rates ranging from 3 percent to 5.
7 percent (see Table 1 
on page 4). In 1988, Willam E. Buckley et al. reponed 6. high school seniors
6 percent of  male 
use or had used steroids in their lifetime (2). 
Using the NIDA lifetime incidence of 3 percent, we can estiate that 83,430 students from the 
3 Furer
Class of 1989 used steroids at some time.  , we calculate approximately 262 000 
students in grades 7 to 12 in 1989 used or had used steroids.  Buckley et al., at a 6.6 percent 
incidence for males, estimated 2?0,000 to 500,000 male adolescents in secondar schools 
probably use or have used steroids. 
Some key infonnants suggest, however, these rates may be unden-eponed. The NIDA data, for 
example, do not include information from school drop-outs. Dr. Charles Yesalis, a steroid 
researcher, said that the secrecy involved in steroid use is so great that it must be a 
methodological consideration when designing steroid studies (3). 
Usage rates are much higher for adolescent mals thanfemaIes. 
The NIDAdata show, as do 
TABLE 1 
other studies, that adolescent 
Summary of Steroid Usage Data 
males use steroids at a 
higher rate than adolescent 
females. The rage is 4.  STUDY  GRADE  TOTAL  MALE  FEMALE 
1 percent for 
percent to 11. 
males and only 0.5 percent  NIA - 1990  1.3 
5 percent for females 
to 2. Buckley et aI. - 1988 
(see Table 1). Two-thirds of 
Johnson et aI. - 1989  11. 
the key informants agree 5 
percent to 11 percent of high  WindsorlDumitr - 1989  9 - 12  1.4 
school males have used  Temey/McLan - 1990  9 - 12  4.4 
steroids. No one thought 
* Percent of adolescents who use or have used steroids 
this range was "very high" 
Other studies show that 
male users are usually 
athletes with 65 to 84 percent parcipating in spons (4). Ninety-six percent of our users were in 
a competitive spon or weight-trining program at the tie they began steroid use. 
page 4  " , 

Adolescent steroid use is growing according to key informants and users. 
Overall, both key informts (67%) and users (93%) believe steroid use is increasing among 
senior high school students. Supportng evidence com s from Portand, Oregon where 
researhers evaluated high school varsity football players over the thee academic years of 1987 
to 1989. In that brief time, the percentage of self-reponed steroid use more than trpled, rising 
from 1.1 percent to 3.8 percent (5). Key informants (60%) and users (57%) also believe use is 
ar 
rising among junior high school students although both groups  less sure of the use trend for 
younger students. Inclusion of steroid use questions in subsequent annual NIDA high school 
senior surveys wil yield trend data for both junior and senior high school students. 
Adolescent Steroid Use Starts Early And Often Follows A Prolonged, Intense Pattern. 
adlescents who try steroids.
First use occurs by age  16  for over half the 
the 
Many adolescents, who use steroids, have tred them for the fIrst tie by age 16. Fifty-
percent of our user sample repon they had staed at age 16 or younger; 85 percent had staed by" 
age 17. NIA reponed that 56 percent of the male users fit tred steroids by 10th gmde (age 
15 to 16) or younger (see Appendi C). Another 22 percent had staed use by 11th grde (age 
16 to 17) for a cumulative rate of 78 percent. The female incidence of fIst use follows the same 
pattern. The Buckley et al. data for males trcks our user data and NIA' s and shows 71.3 
percent stared by age 16.

Adolescents appear at riskfor heavy, prolonged use. 
Twenty-six key informants (87%) predct that an adolescent user who completes one 6-week 
steroid cycle is likely to go on to use for 5 cycles or more. Five cycles is a signifcant number 
because for some researchers it marks the beging of "heavy" steroid use (6). Furer, once 
users crss the 5-cycle mark, many key informants believe they wil contiue use for years 
afterwards. 
Most users in our sample ar "heavy" users accordig to ths researh definition. Six.ty.;five 
taen  5 Their 
percent of users repon they have  steroids for fIve cycles or more in their lifetie.
lifetime average is eight cycles. The average length of their last completed cycle is 11 weeks. 
Curnt users sta tag steroids 3 years ago on average; 35 percent have used steroids for 4 
years or longer. Eighty-six percent have no definite plans to stop using. 
Many users increase steroid dosages, variety and cycle length over time. 
Most of our users also say they progressively intensifed their steroid use. Over time they used 
larger dosages (89%), increased the number of different steroids per cycle (72%), lengthened 
their cycles of use (64%) and shonened the time between cycles (65%). Other signs of their 
ar:  norm 
intense steroid use  1) steroid doses  therapeutic levels, 2) 99 
gratly exceed the 
n31!e 5  ... . ,
percent of the users inject steroids, and 3) users combine an average of 5 different steroids in one

cycle.

Adolescent Steroid Use Is Motivated By Socially Acceptable Values And Life-Stage 
Concerns With Appearance And Peer Approval. 

Key informants perceive that steroid use, in genera, is uniquely motivate by values society 
normally considers "goo". They think adolescents may be more vulnerable to steroid use 
because of these societa values and their own strong concerns about appearce and peer 
approval. Although the percentage of adolescents who use or have used steroridas i s low 
compard to some other drgs,6 nearly two-thirds of the key informts still  non-megical 
steroid use as a major (27%) or moderate (37%) problem precisely because these values and

concerns lead adolescents to steroid use.

Steroid users have more positive motivatons than other drug users. 
Twenty-tWo of 29 key informants charcterize steroid use as a unique substace abuse problem. 
trg 
- . They describe steroid users, in general, as highly motivated people who are  to improve 
themselves or to achieve a positive goal. They want to be better athetes, even champions; they 
believe that they tae car of their bodes and that they are 
want to look bettr. Steroid users 
health conscious. 
Unlike other drg users, who frequently have negative or no goals, steroid users do not seek to 
escape reality or to attn instat gratifIcation. In fact, steroids do not produce an immedate

euphortadt the time of use. Athletes and appearance conscious individuals know they must trRc.

intensely to reach their goals, and they ar wiling to mae that effon. They see steroids as a

way to"i1ppioach their goal faster or to attn an even higher level of performance. If there isa
 '"C
negative motivation underlying steroid use, it is "an over-reliance on physical attbutes for

obtaining a sense of self-wort." (7)

Adolescent concerns with appearance and peer approval motivate their steroid use. 
For adolescent males, muscularty and strngt are tWo key ingrents of their perceived

importt factor. The users, key

success and favorable self-esteem. Appearance is also an 
informants and literature all say the desire to do well in sport, or its varations of increasing

Al the key inormants and nearly

strengt, size and spee, lead adolescents to steroid use. 
two-thirds of the users also repon improving appearce as a reason for stang steroid use.

Matching perceived use by competitors was also mentioned often by both groups. However,

while all the key informants say moneta rewars, such as scholarhips, ar a motivation to use

More compellng to them is the desire to

steroids, only 24 percent of the users repon this reason. 
be happier or like themselves better (53%).

Peer group involvement is very imponant during adolescence. In fact, peers are listed the most

frequently by our key informants as the key influence on adolescents to use steroids. The users

page 6  agr 
strongly  saying they were influenced to begin steroid use priary by frends or athletes at 
In most cases, the frend was 
the gym where they work out (53%) and by school frends (40%). 
a user who had achieved the results that our respondent desired. Furter, non-parcipating peers 
agr 
don t discourage use. Seventy-three percent of our users  with the statement, "My friends, 
who don t use steroids, don t car if I use. 
Steroids work, producing physical and other effects that adolescents desire. 
Almost all of our key informants believe that steroids do produce the effects adolescents 
perceive as benefIcial. In combination with a proper regimen of traiing and nutrtion, they say 
steroids are effective for incrasing muscle mass (97%), strength (97%) and traiing capacity 
(93%). Most also believe steroids and a proper regimen increase spee (67%) and enhance 
sexual capacity or enjoyment, at least initially (57%). They agree steroids do not increase 
cardiovascular endurance (60%) or prevent injuries (80%). In addition, the American College of 
Spons Medicine, which does not advocate steroid use, offcialy concedes that concurent use of 
performce. 
steroids with proper training and diet may enhance 
Currnt and former users strongly agr  that steroids work. Sixty-four users (89%) report they 
got the results they hoped for when they staed using and noxe they "realy improved 
physically." They cite large, measurble gains in weight, muscle mas and definition, strengt 
desir  agre 
and athletic accomplishments. Among users who achieved the  results, 97 percent 
that the physical effects encouraged them to continue using steroids. Improved appearance and 
increased sexual drve, prowess or pleasure are examples of unexpecte benefits mentioned by 
43 percent of users. Although former users are less enthusiastic, most curent users believe the 
emotional and social benefits of physical improvement are gettng along better with others, 
rs;- , 
greater satisfaction with life and being liked better by their pe. 
Adults andfamous role models also reinforce ster i4 U$e; 
Key informants also believe responsible adults, in addition to peers, inuence steroid use. They 
list parents, coaches/trers, successful athletes or entertptpersonalties that act as role 
models, and society in genera as sources of influence or pres ure for an adolescent. They say 
that, whether intentional or not, parnts and coaches place grat pressur on young people to 
what are acceptable ways to accomplish 
compete and wi, while sendig a mixed message of 
that goal. At other times the message is clear that using steroids to enhance performance is 
acceptable when our society prases winning, accords athletes special tratment, and overlooks 
their transgressions. 
The users' responses indicate that adults indictly encourage adolescent steroid use by sending 
mixed messages. Fifty-fIve percent agre with the statement "My parnts probably know I use 
(or used) steroids," although 93 percent also agree that "My parnts believe gettng good grades 
is more imponant than winning at sport." Only 59 percent say goo grdes are more imponant 
than winning at their schools. Of the 41 users who have coaches, 61 percent  disagree with the 
statement, " believe that steroid use is a bad idea." However, our users seldom
My coaches  really 
associate adults they know personally with motivation to begin steroid use: non-school 
page 7  coach/trner (15%), school coach/trainer (6%), personal doctor (6%). No one repons parents as 
a motivation. 
Famous role models also influence adolescents. The users believe that may high-level athletes 
sta 
have used steroids, and 42 percent say this influenced them to  using. Fifty-seven percent 
pointed to "muscle magaznes" and seven percent to entenanment personalties as source 
influence. 
A researcher/physician aptly summazes the interplay of societa influences and values on a 
potential adolescent steroid user. 

Young males with a tendency towards high risk behaviors, for whom 
physical attributes have a high personal value, ma be at most riskfor 
initial use. Social influences from peers, coaches, trainers and family 
as well as prevailng cultural values to compete, to win, to look 
good, and to be big and powerfl probably also contribute to initial 
use.(7) 
Adolescents Are At Special Risk For Some Adverse Results Of Steroid Use. 
Key informants believe adlescent users are more susceptible to some health effects. 
tae 
Twenty-seven of 30 key informants believe that adolescents who  steroids, as opposed to 
adults, ar at special risk for adverse results. Twenty say they are most worred about stunted 
dolescent steroid use may 
growth and adverse psychological effects including dependence. 
hinder long bone growth and the subsequent epiphyseal closure at pubeny. Furer, the 
developing adolescent may be especially vulnerable to the psychological effects of steroids, such 
as the possible drg-induced moo changes (8). Our key inormts ar also concerned 
generaly about the potential for serious health risks of steroid use which we discuss in detal 
beginning on page 9. 
Steroid use encourages adolescents to 
tr other drugs. 
steroid use leads adolescent users to other drugs. 
The key informants and literatu suggest 
Twenty-thee of 30 key informants believe that other drgs taken to enhance performce 
(human growth hormone, amphetanes, eryopoietin) also have the same abuse potential as 
steroids, assuming cost and availabilty are not prohibitive. Nearly hal of our key informants 
think it is  marjuana and cocaie from their steroid source. 
liely that adolescents can also obtain 
In addition, handbooks available to adolescents suggest ways to counter the side effects of 
steroid use with other drgs often available on the black market, e.g., estrogen inhibitors for 
gynecomastia, diuretics for fluid retention, human chorionic gonadotropin (HCG) to stimulate 
natura testosterone production (8). 
page 8  , "

Our userdata suppon the key informants and the literature. Fort-four percent of the users 
consult a user s handbook for steroid information, apparntly the same handbook that discusses 
stag 
countering the side effects of steroids. After  steroids, 49 percent of the users staed 
other drgs for peIformance enhancement or for counterig the 
side effects of steroid use. 
Expressed as a percentage of all sampled users, they added estrogen inhibitors (31 %), HCG 
(22%), diuretics (17%), "uppers" including amphetanes (17%), pain-killers (15%) and 
recreational drgs 
other than alcohol (11 %). 
Before stang steroids, nearly two-thirds of the users repon drg use, but of a diferent type. 
They used alcohol (65%), marjuana (26%) and nicotie (14%). A few mention "uppers" (4.2%) 
and pain-killers (1.4%). None repon use of diuretics, estrogen inhibitors or HCG. 
Although Much Remains Unknown, Experts Link Steroid Use To Serious Psychological 
And Physical Health Risks. 
Key informants emphasize they do not understand enough about the effects of steroid 
use. 
Sixty-fIve percent of our key informts feel that expen understadig of the shon-term effects 
of steroid use is "goo" or "very good." On the other hand, 96 percent say expen understading 
fuer 
of the long-term effects of steroid use is "fai" to "very poor." Many strongly favor 
systematic medcal research of steroid effects as an underping for well-conceived educational 
progrs 
and futue legislation to control steroid distrbution and use. A common sentiment of 
researchers and physicians is  It would be a waste of money to put more effon into seeing if 
steroids work. We need other knowledge (about shon- and long-term) effects urgently.
" (3) 
We asked our physician/rescariTer group whether, in their professional opinon, short-term 
lied 
steroid use (less than one year) or long-term use is  either strngly, weaky or not at all to a 
lis 
wide varety of adverse heath effects. Many perceive  but carfuly qualify their answers 
overal or by each health effect being rated A summa statement from other researh that well 
describes their qualifcations also is, 
The preserzce and magnitude of anaolic or androgenic effects and 
complications of steroid use depend on the specifc drugs taken, the size 
and frequency of doses, the duration of use, the route of administration, 
and the age and health of the user. Individual responses to diferent 
steroids vary. Acute, life threatening side effects are exceedingly rare. 
Long-term deleterious effects are unknown. (8) 
The risk of steroid addiction is of partcular concern for adolescent users. 
Addiction to a substance can be a psychological and/or phy ical dependence. Many key 
informants believe adolescents who use steroids ar at a special risk for adverse psychological 
effects. In fact, the physician/researcher group, when rankig the health risks of steroid use 
page 9  repon, in their judgment, a strong link, for shon-term and long-term use, between steroid use and 
psychological dependence. To date, researh has not shown a link between steroid use and 
physical dependence, but may key informants frm the physician/researcher group believe 
physical dependence is a potential effect. Although not yet conclusive by the stadads of 
scientifIc research, in our opinion, suffcient evidence does exist in literatur to rase the serious 
ar 
possibilty that steroids  addictive. 
Buckley et al. describe the intensity and pattrn of steroid use by 226 adolescent males (2). 
Thiry-eight percent fIst used steroids at age 15 or younger; another 33 percent had staed by 
age 16. Fony percent of the users reponed 5 cycles or more of use. Fort-four percent took 
more than one steroid at a time; 38 percent used both ora and injectable forms of steroids. They 
commented, "When one considers (this data), it is clear that the potential for the development of 
long-term use patterns is real. 
To develop the dependence issue, Dr. Charles Yesalis, a principal investigator of the Buckley et 
al. research team, funher analyze the surey data (6). One-quaner of the 226 self-reponed 
users, when faced with health risk scenaros related to steroid use, state their intentions to 
continue use regardless of die health consequences such as permanent sterity, hean attcks or 
liver disease. He also noted their use of injectable steroids indicated "an increased level of 
commitment." Sixty-thre percent of the early initiators reponed 5 cycles or more and were 
more likely to exhibit symptoms consistent with habituation: unwilngness to stop use, 
perceptions of benefIts of use, rationaliztion of use and overlooking of health risks. 
Psychiatrst Kik Brower has also studied the issue of steroid addction. Hte hbelgiev es that the 
adolescent users in the Yesals analysis above show evidence of addctive  and that up to 
25 percent of adolescent steroid users- at a given tie ar possibly dependent (7). In another 
work Brower et al. interviewed 45 weightlfters who admtted steroid use for a mean of 26 
tie, 
months (including time between cy,; es) and with a mean of 2.8 dierent steroids at one 
exceeding therapeutic doses (9). A self-adnistere questionnai elicite informtion 
8 At 
standard symptoms of dependence. least one dependent symptom was reponed by 93 
percent Thee or more symptoms, consistent with a diagnosis of chemical dependency, were 
reponed by 58 percent. 
Many steroid' users in our sample exhibit adctive thinking or behavior. 
By applyig the addiction crteria from the literature to our self-reponed user data, we find 
evidence of addictive thinking and behavior. As we have seen, their use patterns are long and 
intense, i.e., 65 percent have used for 5 cycles or more, 86 percent tae 3 or more steroids at a 
time, 91 percent use both ora and injectable steroids. Funermore, quittng steroid use does not 
appear likely for many current users: most have no definite plans to stop using steroids (86%), 
many would not stop even if others do (78%), and they wouldn' t stop use even if they were 
curnt 
convinced steroids are really bad for their health (38%). One-quaner of  users tred to 
quit but couldn' t (9%), quit use completely for a while but stard again (22%) or did both. 
Ftuhnheer,y ne arhly aall dsay  sttaorn gd steerocid uisde weas  aa gogo adeicinsion  ((983%7) w%hich )th.ey  would repeat if
page 10
 The users also seem to over-look or rationalize the effects of steroid use. Fifty-three percent say 
they got along better with others while using steroids, but the same users also say they had more 
arguments or physical fIghts. Twenty-fIve percent sold steroids to pay for their own. Eighty-two 
percent of CUITent users (but only one former user) disagre with medical expens and 
professional athletes who have said steroid use can cause serious health problems. At the same 
time, many former and  repon physical changes in themselves that they attbute 
CUITent users 
directly to their steroid use: bloated appearance (75%), shrinkng testicles (61 %), breast 
development in males (42%), breast reduction in females (50%), bone/joint pain (28%), 
diffculty sleeping (22%), frequent urge to urinate (17%) and nosebleeds (10%). Finaly, 87 
percent of CUITent users agree the bad effects wil go away as soon as use is stopped, but only 41 
percent of former users agree the effects go away. 
Experts also link steroid use to other serious psychological effects. 
Other possible adverse psychological effects of steroid use include increased irrtability, violent 
behavior, depression, mania, psychosis, and suicide (or attempted suicide). All of these are to 
some degree linked to steroid use in the opinion of our physician/researcher group. They believe 
there are strong links, for shon-term and long-term use, to increased irtability and violent 
dlor manic 
behavior. Depression is strongly connected by them to long-term use. Psychotic 

symptoms and suicide are linked, with no consensus in degree, to both shon and long-term use. 
Similar to addiction, evidence does exist in literatue to suppon a real possibilty that steroids 
cause other psychological effects. Drs. Harson Pope and David Katz questioned 41 
bodybuilders and football players who had used steroids (10). Having no histories of past 
psychiatrc diffIculties, five subjects met the criteria for psychotic episodes and 5 for manic 
, episodes during periods of steroid use. No subject descrbed comparble behavior-when they 
were not using steroids.  Dr. Mark Humben found a relationship between steroid use and mood 
states (11). Mood scores of athlete users changed signifIcantly after 4 weeks of st Joid,use and 
. approached pretest measurs 4 weeks after discontiuing use. Whle using steroid , athetes 
reponed to Humben a decrease in vigor and increases in hostility, anxiety, confusion, depression, 
and fatigue. 
Users repon indications of adverse psychological effects. Fifty-one percent k?d;J.ilOre arguments 
or physical fIghts while using steroids. Twenty-fIve percent repon doing serious damge to 
propeny or a person either in anger or "for fun  . Someties they were very sad (28 %); 3 users 
even seriously considered suicide. Finally, 6 of the 17 former users say one of the main reasons 
they stopped was they experienced undesirable behavioral or emotional effects. 
Key informants link several negative physical health effects to steroid use. 
We asked our physicians/researchers about links between steroid use and physical health 
problems just as we asked about psychological health problems. With the same qualifIcations 
described on page 9, they do believe adverse physical health effects stem from steroid use. For 
both long-term and shon-term use they consistently see strong linkages between steroids and 
acne, fluid retention, gynecomastia (breast development in males), masculinization in females, 
page 11
 reversible sterility (males), incrased LDL (bad cholesterol), decreased HDL (goo cholesterol), 
and high bloo pressure. They also perceive strong links between long-term use and baldness, 
increased chance of injury to muscles, tendons and ligaments, and liver problems. They see no 
link between shon -term stero d use and permanent sterility in males. 
For other physical health effects, expen opinion is somewhat less cenan.  ough there is no 
consensus as to the degr of linkage, they do perceive links between shon- and long-term 
steroid usage and sexual problems/impotence, stunted growth and prostate problems. The same 
is true for their opinion of shon-term use and incrased chance of injur to muscles, tendons and 
ligaments and Ilver problems. For long-term use, they see links, without a consensus on degree, 
to cardiovascular disease, kidney problems and cancer. No consensus emerged for long-term 
steroid use and possible links to permanent male sterility, or for any linage between  roid use 
and accelerated aging of the skin or immune system problems. ' 
Despite the dear of research on the effects of steroids, a fInal thought offered by a key 
informant is noteworty: 
daging 
These drugs are too powerfl not to have some  effects 
associated with long-term use, and it is imprudent to assume that 
athletes are immune to the deleterious effects that are seen in 
animals.(3) 
Experts Recommend Education Of Adolescents And Adults As The Best Solution To The 
Steroid Use Problem. 
Key infonnants do not believe adolescents are well aware of the risks of steroid use. 
' Adolescents ar not perceived as knowledgeable about the potential dagers of steroids: 
Two-thirds of our key inormts believe junior high school students ar "somewhat unaware 
(33%) or "very unaware" (33%) of the potential risks of steroid use. They rate senior high 
school students' knowledge better with 27 of 30 key informants sayig the older students are 
somewhat aware" (47%) to "somewhat unawar" (43%). Terney and McLai refox;d nearly 
55 percent of the high school students they surveyed were not awar of the medical risks 
associated with steroid use (12). Johnson et al. found 22 percent of male, high-school users did 
complications associated with steroid use (13). 
not know of  any 
Our users, with an average age of 20, know more about the medcal risks of steroid use than the 
the 
above subjects. All could name at least  serious health problems medcal expert and 
professional athletes say may be caused by steroids. Two-thirds could name more than thee 
health problems. 
page 12
 Knowledge of potential health risks alone is not a deten'ent to steroid use. 
A frustrting aspect of adolescents' knowledge of steroids is that, even when they ar aware of 
potential health risks, that awarness does not deter steroid use. Eighteen of 30 key informants 
rate knowledge of risks as ineffective in stering adolescteantgs  away from the drgs. The primar 
reason given is the general tendency for incrased risk- by adolescents  the "it can 
happen to me" syndrome. Other impottt reasons offere by our key informants ar adolescent 
perceptions that the rewar of steroid use outweigh the risks and that the medcal community 
was wrong previously in saying steroids don t work. 
The medical community s loss of credibilty is impottt when discussing adolescent steroid use 
and possible strategies for deterrng use. Pror to 1984, expert repeatedy denied, based on 
mixed results from earlier steroid studies, that steroids enhanced performance. In 1984, 
however, the American College of Spons Medcine revised its position on steroids to say that 
concurrent use of steroids with proper trning and diet may enhance performance. Also in 1984 
Haupt and Rovere reviewed the steroid literatu and concluded that  :msistent improvements in . 
muscle strengt and size could result frm steroid use in athetes who followed proper training 
and dieta regiens. Many physicians and scientists, however, sti insiste any weight gained 
while takng steroids was maily the result of fluid r tention and that any strengt gain was 
largely psychological. 
diagr 
As we mentioned earlier, 82 percent of current users  with medcal expens and 
professional athletes who say steroid use can cause serious health problems. They disagree 
because neither they, nor other users they know, are experiencing health problems. Many also 
cite the lack of "hard evidence" to back up warngs (56%), their suspicion the warngs are 
merely scar tactics (38%) and previous statemepts by expert who say steroids don t work 
agr 
(27%). In shar contrast, 16 of 17 former users  with the expert that steroid use poses 
Actualy experiencing the negative he;vtO effects was a strong motivation for over 
serious risks. 
tang 
half the former users to stop  steroids. 
Nevertheless, experts say educaton is 'the most effective means of deterrng steroid use. 
Nineteen of 28 key informants say that, ovemH, ooucation is sti the most effective means of 
deterrng steroid use among junior and senior high school students. The adolescents themselves 
are mentioned most often by key informants as the appropriate taets of the educational effon. 
However, they say coaches, trners, and parents should also be included Only one former user 
repons disapproval by a coach or parnt as a reason for stopping steroid use. Whether the adults 
didn t object to the steroid use or the objection was not hear seems imaterial next to fact that 
adults apparently ar not playing as strong a role as they could in deterrg use. Education was 
also suggested for other school personnel  and health care professionals, including physicians. 
Coaches should be a specifIc taget group for education accordng to literature and key 
informants. Coaches have special influence on a young person s life, yet sometimes they do not 
appear well informed or alen to the steroid problem. In 1988 Dr. E. James Swenson et al. 
published a surey of 474 high school varsity coaches (14). The coaches did not generaly 
page 13
 gy 

consider steroid use to be a problem, with only 11 percent to 14 percent (for different school 
years) reportng some use among their athletes. This incidence rate is the inverse of the result 
reponed by Buckley et al. who found evidence of use at 85 percent of their sample schools. 
Swenson et al' also reponed that, although about 70 percent of coaches felt informed about 
steroids, may, in fact, had misconceptions. . For example, 45 percent felt steroids are effective in 
preventing injur. While most coaches would look for strngth increase as an early sign of 
steroid use, less than half would look for intabilty or fluid retention. 10 Thus, most coaches 
would be more liely to miss the early signs of steroid use. The researhers concluded the 
coaches were most likely uninformed and unaware of the tre incidence of steroid use, but 
commented that possibly the coaches did not want to know the extent of the problem, as "it may 
cause them to tae action that would effect their win-loss reord. 
Honest, early, repeated, and clear messages improve steroid educaton programs. 
If steroid education is imponat but currnt effort ar not deterrng steroid use, then what makes 
progr 
a steroid education  more effective? Our key informants say, more than anything else, 
we should tell adolescents honestly what we do and do not know about the effects and risks of 
steroid use. Scare tactics and continuing to say that steroids do not work are major en-ors 
because of the prior loss of  medcal community and because adolescents know 
credbilty by the 
that steroids do work for the goals they have in mid, namely improved strngt, muscularty 
and appearce. 
We also need to recognize for educational 
puroses that adolescent steroid users ar, in 
sociological terms, a "deviant sub-cultur." Users are so secetive that some athetes would 
rather confess to cocaine use than to steroid use (3). , lnfpnnation about the drawbacks of use that 
comes from outside this cultu has litte influence on its members. In fact, in the past, the 
curling drg 
varous educational and preventive measurs s_eem 10 have been effective only in 
furer 
use to a degre, if at all, and drving it  underground-(l5). Our users say people who 
motivated them to use steroids and provide informtion about the drgs are preomiantly their 
school and  frends. Johnson et al. suggest that, since peers provide a major soure of 
information concernng steroids, peer advice and educ tion, which has been used effectively in 
lit 
other settgs, may provide an effective interventiQ'. to  steroid use (13). 
Another strtegy for improving the effect of steroid education is to deliver the message "early 
sta 
and often." As we have discussed, the data show that some adolescentS  steroids at young 
ages and continue though high school. This suggests that junior high school or earlier is an 
appropriate time to begin steroid education. In addition, one educational session wil probably 
not be a deterrnt according to Dr. Linn Goldberg et al. (16). They assesse the steroid 
knowledge and atttudes of six varsity high school football team before and after an education 
intervention. Four teams were included in the intervention and two teams were controls. 
Although students showed increased awareness of the adverse effects of steroid use afer the 
education progr, no differences in atttudes toward steroid use occured as compard to the 
controls. 
page 14
 - . 
Simply supplying informtion about steroids is not enough. Dr. Mimi Johnson summzed a

study by Gordon and McAlister which said that informational approaches to drg and alcohol

use in the school systems have failed with no apparent decrase in use (8). "It is felt that these

approaches do not address the reasons teenagers use the chemicals." Key informts and the

agr 
National Consensus Meeting of Anabolic/Andrgenic Steroids (17)  regarding steroid

progr 
education. They suggest an education  should:

clearly and consistently send a message from coaches, parents, educators and 
physicians that they don t want adolescents to use steroids. 
help adolescents develop realistic expectations and goals for themselves and 
alternatives to steroid use, such as improved weight trning methods, n.utrtion 
or training techniques, 
using steroids, including a 
advocate and encourage social suppon for  not 
de-emphasis of winning at all costs and the socialmoneta rewards attached to 
wmmng, 
encourage positive role modeling by elite and professional athetes, 
emphasize the moral and ethical aspects of steroid use, i.e., steroid use is 
cheating and destroys fai play.

Testing And Controlled Substance Status Are Potential Deterrents To Non-Medical Steroid 
Use. 
Most key'infor;nants would favor drug testing as a deterrent were it not for high costs. 
Many key informants would advocate testing as a deteITnt to adolescent steroid use, but cost is 
a serious drwback. Twenty of 30 say, if cost were not a factor, they would advocate a large or 
moderate deterrnt role for drg testig. When the 20 key inormants considere cost, 16 then 
withdrw their suppon of steroid testig, sayig it should have a sma role or no role. Dr. 
Roben Voy, former diector of spons medicine for the United States Olympic Commttee, has 
said regardig testig and subsequent sanctions, 
Some risk has to be associated with (steroid use).... Drug education in 
and of itself wil not work. Without testing nobody's going to listen to 
education. The penalties don t have to be draconian, but there must be 
some penalties.(18) 
The National Consensus Meeting of Anabolic/Androgenic Steroids parcipants went so far as to 
recommend encourging the liabilty insurace industr to develop coverage for schools ' drg 
testing progrs in order to make drg testig more readily avaiable at all levels of athletic 
page 15
 competition (17). They also suppon drg testing as an effective deterrent, but only in 
progr 
conjunction with a comprehensive  of education and rehabilitation. 
Our key informants and other expens ar also concerned about what constitutes an effective drg 
progr.  progr ar 
testing  They say the essentials of a testing  unannounced, random test 
times (possibly year-round and for all team members), assurances of accurcy, rehabiltation or 
counseling progrs for "positives" and defInite, pre-determned crteri for who wi be tested. 
Many of these essential elements ar expensive, plus, these elements and others rase legal and 
philosophical issues. In fact, the National Collegiate Athletic Association (NCAA) was legally 
challenged on these issues after their drg testig program went into effect in the fall of 1986. 
While expert say radom, unannounced testing is tlYe only sur way to detect drg abuse, it is 
also one of the most controversial points. "It may be that random testing is appropriate for 
athletes at some level of competition, but not for others. drg testing 
" (18) Furter, the timing of 
corresponds poorly with drg taing and a signifcant number of users don t face drg testing at 
all (3). On the issue of accuracy, access to qualfIed laboratories is a problem. The advanced 
International Olympic Committee (lOC) testig techniques aren t available everywhere, and 
some believe "there s a clear dierence in testig abilties between the lac approved 
laboratories and private, commercial laboratories. " (19) 
Nine key informts opposed a substatial role for drg testing as a deterrnt to steroid use even 
if cost were not a factor. Besides questioning the accurcy of testig, they also object to testing 
as an invasion of privacy, and a discrmiatory practice that singles out one drg population. 
They also believe education is more imponat than testing. 
upp()' could help control non-medical steroid use. 
Limiting the 

Data on the growth of steroid use and the possible health consequences has produce effons 
priar 
shut down the steroid supply for non-medcal use. The key inormants believe the 
steroid sources for young users ar peers and drg deers, maiy in a commercia 
ll Users agr  ma 
setting.  while adding pharacists (31 %) and  order sources (28%). In 
November 1990 the Congrss addressed the problem of non-medcal steroid use by scheduling 
them under the Controlled Substaces Act, makng it ilegal under Federa law to distrbute and 
possess steroids without a prescription. 
Twenty-one of 30 key informants and other expert see benefIt in controllng steroids. The key 
informants believe controllng steroids holds physicians accountable for the drgs they prescribe, 
limits the supply of steroids manufactured in this  strcter 
countr, and allows imposition of 
penalties for use violations. Because of the record-keeping required, other expens believe 
diversion of supplies from legitimate domestic maufacturs (theft, resale by consumers, fIling 
of fraudulent prescrptions)(4) to black markets wil be harder (20). 
Some key informants and other expens doubt scheduling wil have much effect on the black 
market (20). For example, according to the Deparent of Justice, besides diversion from 
legitimate manufacturers, other sources of black market steroids are clandestinely manufactured 
goods, including counterfeits, and smuggled products (4). Other enforcement effons, however, 
page 16
 appear to limit these black market sources. For example, during the 6 months the OIG had 
authority to conduct investigations of ilegal distrbution of steroids, 25 arsts and convictions 
resulted. Besides diversion of steroids from legitimate domestic manufacturers, OIG 
investigators identifIed criminal activities of counterfeiting brand-name steroids, smuggling 
steroids into the United States and domestic underground. laboratories. 
Sixty-thre percent of our users say steroids ar becoming harder to obtan. However, the 
var 
perceptions of our key informants concerning the steroid supply  widely. Some key 
informants believe all steroids are harder to obtan; others say high qualty or real 
(non-counterfeit) steroids are more scarce. Of the 12 sayig steroids ar more scare, the 
majority believe restrctive state laws and incrased enforcement ar the causes. An additional 
concern is that a declining supply is temporar, parcularly if illcit drg dealers are including 
steroids in their operations. 
page 17
 . .
RECOMMENDATIONS

Overall, our key informants, steroid users and literature review indicate that no single approach 
wil solve the problem of adolescent steroid use. Rather, a solution lies within a strategy to 
improve education for adults as well as adolescents and to conduct additional medcal and 
scientifIc research. 
Develop A National Steroid Education Strategy 
The Public Health Service is currently developing a national strategy for addressing the problem 
of non-medcal steroid use. We recommend that it include  following elements: a national 
drg 
public awareness campaign using credble spokespeople, addition of steroid information to 
education currcula on al levels and issuance of guidelines for effective steroid education 
intervention at the local level. We also recommend aggressive testig by the NCAA, National 
Footbal League and other amateur and professional spons associations to promote steroid-free 
athletic competition at the college and professional levels, as this should have a signcant 
educational impact on adolescents. 
Key informants believe that education is the most effective means of deterrng steroid use even 
though it doesn t always work. Education involves more, however, than merely presenting 
information about the effects of steroids to adolescents. The educational tagets should include 
coaches, trainers, parents and medical professionals as well as adolescents. The educational 
message for adolescents must come early and be reinforced often in an honest, consistent way 
from their peers and responsible adults. We must find ways to overcome adolescent resistace to 
the message based on their own sense of immonaity, the high degree of secm;y involved in 
steroid use, and the previous loss of crbilty by the medcal communty. Finaly, the 
educational intervention must be talored to several audiences  the responsi1?le'adult vs. the 
adolescent, the potential user vs. the curnt user, the appearce user vs. the athetic user, the 
nee. 
non-dependent user vs. the dependent user in conjunction with rehabiltation 
Conduct Further Medical And Scientifc Research 
The Deparent, though the Public Health Service, should tae the Federal lead in conducting 
medical and scientific research on steroids. Curnt understading of the racations of 
non-medcal use of steroids is very limited. A pressing nee exists to accurtely identiy the 
potential adverse health effects of shon-term and long-term steroid use, parcularly for 
effects, 
adolescents. Such research should focus on adverse physical and psychological 
especially, the risk of addiction. Because of the secrey surounding steroid use, innovative and 
unconventional researh methods may be reuired. Another imponant need is to expand the 
available information on trnds in the incidence and prevalence of adolescent steroid use and 
information on the knowledge, atttudes, beliefs, use patterns and motivations of adolescents. 
NIA 
Continued, or even expanded, coverage of steroids in the  annual surey of high school 
seniors is one means of buildig useful trend data on adolescent use. 
page 18
 COMMENTS

We received comments on the draft repon from two Deparent of Health and Human Services 
entities - the Office of the Assistant Secretar for Planning and Evaluation and the Public Health 
Service. Our responses to their technical comments as well as the full text of their comments 
in Appendix E. Public Comments are in Appendix F. 
Offce of the Assistant Secretary for Planning and Evaluation (ASPE) 
The ASPE agreed with the repon. In paricular, they think "the repon s highlighting of the fact 
that steroid use is motivated by socially acceptable values is very benefIcial and should 
contrbute to bringing this factor to the attention of those developing educational materials. 
Public Health Service (PHS) 
The PHS generally agred with the findings and recommendations of the report They believe 
-ecommeridations would be inappropriate since the Interagency 
hasty implementation of the 

ar 
Task Force on Anabolic Steroid Abuse, in which they  active pancipants, has not fmalized its 
repon and recommendations for steroid regulation/enforcement, prevention/education, and 
research. The PHS specifIcally notes that while we stressed the PHS role in an education 
campaign, "it is imponant to recognize that any effon in this area wil require coordiation 
across Depanments. 
We agree with the PHS. In addition, we appreciate the opportunity they provided us to present 
our findings to the Interagency Task Force on Anaolic Steroid Abuse and to review the draft 
reports from the Task Force sub-committees on preventon/education and research. Their 
proposed activities match our recommendations. Like the PHS we believe a well-planned and 
coordinated approach to the problem of adlescent steroid use should take into account the 
work, now underway, of the Task Force. In addition, after we issued our draft report, Congress 
passed the Anabolic Steroids Control.Act of 1990. Besides making steroids a controlled 
substance, this Act amend the Public Health Service Act to include the development and support 
innovative demonstration program designed to identify and deter improper use or abuse of 
of "
anabolic steroids by students, especially students in secondary schools." The implementing 
regulations are not yet written, but obviously these demonstration programs must also be 
considered in the Department s steroid prevention/education and research strategy. 
page 19
 ENDNOTES

1. 
Refers to the end of a long bone (epiphysis) composed of cartilage or separated from the

bone shaft by a disk of canlage; after the period of growth, bone tissue replaces the

cartilage at the epiphysis to form a single bone with the shaft.

2. Each controlled drug is on one of fIve schedules depending on its potential for abuse and 
dependence. Schedule I drgs have the highest abuse potential and no accepted medical 
uses, e.g. heroin. Schedule ill includes, besides steroids, stimulants, depressants, and 
narcotic drgs like codeine. Penalties for the ilegal possession or distrbution of scheduled 
drugs are prison sentences and/or fInes. 
83,430 = 3% of 2,781 000  the estimated number of graduates in the Class of 1989, 
according to the U.S. Depanment of Education. 
4. Computed from 1989 enrollment data from the U.S. Depanent of Education and NIDA

data on incidence of fIrst steroid use by grade (see Appendices C and D).

or longer. 
5. We  one cycle of six weeks
collected data only from those usersrwho had completed 	 at least 
6. NIDA reponed for the Class of 1989 that the lifetime prevalence of use was 90.7% for 
. alcohol, 43.7% for marjuana, 19. 1 % for amphetamines, 18.6% for inhalants, 10.3% for 
cocaine and 8. 3% for LSD. 
7. For similar and/or compatible results-fiom' ot..her work, see Goldstein (29), and Fuller and

Lafountain (27).

8. The American Psychiatrc Association s DIagnostic and Statistical Maual of Mental 
ll-
Disorders (DSM- R). Examples are withdrawal symptoms, contiued use despite 
tie 
drg taen 
problems from use, more  than intended, large  expenditure on drg-related 
activity, usual activities replacecl by drug use, unable to cut down or control use. 
9. 
Also see Pope and Katz (31) for a smaller case study in violent crimes linked to steroid use. 
10.	 A complicating factor is steroid use may increase aggrssiveness and tolerance of stress, 
both positives for some competitive sport. 
11. According to Buckley et al. (2), Yesalis et al. (37), and Frankie et al. (26) the major source 
of steroids for non-medical use is the black market. 
page 20  ,,  "" , "  , "

BIBLIOGRAPHY

A. PRIMARY

. National Institute on Drug Abuse, Epidemiology Research Brach, Floor 11A, Parklawn 
grt 
Building, 5600 Fishers Lane, Rockvile, MD 20857 by  to the Institute for Social 
Research, University of Michigan, Ann Arbor, MI. 
2. 
Buckley, Wiliam E. et al., "Estimated Prevalence of Anabolic Steroid Use Among Male

High School Seniors,  The Journal pfthe American Medical Association  vol. 260, n. 23,

pp. 3441-3445, December 16, 1988. 
3. Cowar, Virginia, "National Institute on Drug Abuse May Join in Anabolic Steroid

Research  vol. 261 , n. 13,

The Journal of the American Medical Association, 

pp. 1855-1856, April 7, 1989.

4. 
United States General Accounting Offce, "Drg Misu e: Anabolic Steroids and Human

HR-
Growth Hormone," GAO- 89-109, 1989.

5. 
Boyea, Steven et al.  Ergogenic Drg Use Among High School Athletes: A Three Year

" abstract of work accepted for pr sentation at the annual meeting of the

Sequential Study,
American College of Spons Medicine, May 1990.

6. 
Yesalis, Charles E. et al., "Anabolic Steroid Use: Indications of Habituation Among

Adolescents,  vol. 19(2), pp. 103-116, 1989.

Journal of Drug Education, 

7. " . Bruvver, Kik J.  Rehabiltation for Anabolic-Androgenic Steroid Dependence," based Q"!Hl:"":" 
paper presented at the National Consensus Meeting on Anabolic Androgenic Steroids, Los 
Angeles, CA, July 30- , 1989. 
8. 
Johnson, Mimi  Anabolic Steroid Use in Adolescent Athetes," scheduled for publication 
vol. 37, n. 5, October 1990.
in  Pediatric Clinics of North America, 
9. Brower, Kik J. et al., "Physical and Psychological Dependence on Anabolic-Androgenic

Steroids," Deparment of Psychiatr, University of Michigan, Ann Arbor, MI, for the

Workshop Conference on Androgen Therapy: Biologic and Clinical Consequences

sponsored by Penn State College of Medcine, Marco Island, FL, Januar 17-20, 1990.

10. 
Pope, Harson G. and David L. Katz  Affective and Psychotic Symptoms Associated with 
Anabolic Steroid Use,  American Journal of  vol. 145, n. 4, pp. 487-490, April 
Psychi,!tr, 
1988. 
page 21  , ," " , "	 , "

11. Humben, Mark D., "Psychological Effects of Self-:Administered Anabolic Steroids on Male 
Athletes: Hostilty, Depression, Vigor, Fatigue, Anxiety and Confusion " doctoral 
dissenation, United States International University, San Diego, CA 1990. 
Lar 
12. Terney, Rise and  McLain, "The Use of Anabolic Steroids in High School Students, 
American Journal of Diseases of Children, 
Loyola University, May 1988; published in 

vol. 144, Januar 1990. 
13. Johnson, Mimi et aI.  Anabolic Steroid Use by Male Adolescents,  voL 83, n.
Pediatrics, 
6, pp. 921-924, June 1989. 
14. Swenson, E. James et aI., "Perspectives on Anabolic Stero ds: Survey of High School

Varsity Football Head Coaches," Deparment of Family Practice, Michigan- State

University, a paper of 40 pages, May 1988.

15. Wright, James E. and Michael H. Stone	 Anabolic Drg Use by Athletes Literature

Review " position paper on anabolic drg use by athletes, National Strength and

Conditioning Association, 1985.

16. Goldberg, Linn et al., "Effect of an Anabolic Steroid Education Program on Knowledge and 
Attitudes of High School Footbal Players,  Journal of Adolesce 
t Health Care, 
 vol. 11
n. 2, March 1990. 
17. Repon of the National Consensus Meeting of Anabolic/Androgenic Steroids, July 30
1989, Los Angeles, CA, sponsored by the USOC, NCAA, National Federation of State 
High School Associations and the Amateur Athletic Foundation of Los Angeles. 
18_  war, Virginia, "Drug Testing Programs Face Snags and Legal Challenges,  The 
vol. 16, n. 2, pp. 165-172, Februar 1988. 
Physician and Sportsmedicine, 

19. Cowar, Virginia, "Reflections on the Medcal Aspects of the 1988 Olympic Summer 
Games,  vol. 16, n. 12, pp. 118-123, December 1988. 
The Physician and Sportsmedicine, 

20. Cowar, Virginia, "Would Controlled Substace Status Affect Steroid  The 
Trafcking?" 
vol. 15, n. 5, pp. 151-154, May 1987. 
Physician and Sportsmedicine, 

SUPPLEMENTAL 
21... Amsel, Zili et al.  Anabolic Steroid Use Among Male High School Seniors -To the Editor, 
ol. 261, n. 18, p. 2639, May 12, 1989. 
The Journal of the American Medical Association, 

22. Costill, D.L. et aI.  Anabolic Steroid Use Among Athletes: Changes in HDL-C Levels, 
The Physician and Sportsmedicine, 
 vol. 12, n. 6, pp. 113-117 , June 1984. 
page 22  , "  , "

23. Cowan, Virginia, "Physician-Competitor s Advice to Colleagues: Steroid Users Respond to 
Education, Rehabilitation  vol. 257,
The Journal of the American Medical Association, 

n. 4, pp. 427-428, Jan 23/30, 1987. 
24. Cronin, Bar, "The Steroid Menace  Chicago Sun- special reprint, Februar 1989. 
Times 
25. Duda, Mar, "NCAA: Only 4 Percent of Athletes U ed Steroids,  The Physician and 
vol. 13, n. 8, p. 30, August 1985.
Sportsmedicine, 
26. Frakie, Mark et al., "Use of Androgenic Anabolic Steroids by Athletes - To the Editor 
vol. 252, n. 4, p. 482, July 27, 1984. 
The Journal of the American Medical Association, 

27. Fuller, John R. and Marc LaFountain; "Performance-Enhancing Drugs in Spon: A 
Different Form of Drug Abuse,  vol. XXII, n. 88, pp. 969-976, Winter 1987.
Adolescence, 
The Body Press, Tucson, AZ, 371 pages, 1984.
28. Goldman, Bob,  Death in the Locker Room, 

29. Goldstein, Paul  Anabolic Steroids: An Ethnogrphic Approach " Narcotic and Drug 
Research, Inc., a paper of 36 pages, submitted to NIDA )989. 
30. National Institute on Drug Abuse, agency contact for steroid issues: Lynda Erioff, Ph.D., 
Room 10A-31, 5600 Fishers Lae, Rockvile, MD, 20857. 
31. Pope, Harson G. and David Katz, "Homicide and Near-Homicide by Anabolic Steroid 
Users,  , pp. 28-31, Januar 1990. 
Journal of Clinical Psychiatry,  vol. 51, n. 1
32. Pope, Harson G. et al., "Anabolic-Androgenic Steroid Use Among 1010 College Men, 
vol. 16, n. 7, pp: 75- , July 1988.
The Physician and Sportsmedicine, 

33. Struss, Richard H. et al., "Anabolic Steroid Use and Perceived Effects in Ten 
Weight-Traned Women Athetes,  The Journal of the American Medical Association, 
vol. 253, n. 19, pp. 2871-2873, May 17, 1985. 
34. Taylor, Wiliam N., "Synthetic Anabolic-AruiIogeJ.iic Steroids: A Plea for Controlled 
Substace Status,  vol. 15, n. 5, pp. 140-150, May 1987.
The Physician and Sportsmedicine, 

35. Telander, R. and M. Noden  The Death of an Athlete,  vol. 70, n. 8, 
Sports Illustrated,

Februar 20, 1989. 
36. Windsor, Roben and Daniel Dumitr, "Prvalence of Anabolic Steroid Use by Male and 
Female Adolescents,  vol. 21, n. 5,
Medicine and Science in Sports and Exercise, 

pp. 494-497, Februar 1989. 
37. Yesalis, Charles E. et al., "Incidence of the Non-Medical Use of Anabolic-Androgenic 
Steroids," a paper submitted to NIDA, 1989. 
page 23  . .
- -
Simon McNeely, Secretary-Treasurer 
Society of State Directors of Health, Physical Education and Recreation 
9805 Hilridge Drive

Kensington, MD 20895 
Robert E. "Skip" Morris, Executive Oirector 
National High School Athletic Coaches Association 
O. Box 941329 
Maitland, FL 32794 
Dick Stickle, Executive Director 
National Federation TARGET Program Inc. 
11724 Plaza Circle 
O. Box 20626 
Kansas City, MO 64195 
Professional  Affiliate of National Federation of State High 
da: 
School Associations .

Frank Uryasz

Director of Spons Sciences 
National Collegiate Athletic Association (NCAA) 
6201 College Boulevard 
Overland Park, KS 66211 
Paul Zeek 
Lamar University 
O. Box 10115 
Beaumont, TX 77710 
Tra
Acting Executive Dirctor, National Athletic 
Professional data: 

ers Association  . ,

APPENDIX 
STEROID USER INTERVIEWS 
Steroid users ar diffcult to identify and contact for interviews. We initialy tred to-complete 
the interviews ourelves by instaling a toll-fre "800" telephone number and circulatig our 
request for user interviews though our key informants. This prouced ontlyh fiv e qualifed 
interviews despite assurances of confidentiality. We then contrted with  key informants, 
Neil Carolan, Dr. James Wright and Dr. Mark Humben, to conduct in-depth interviews of steroid 
the 
users who met  crteria: 1) age 25 or younger at the tie of the interview, 2) initiated steroid 
use in high school or earlier, and 3) completed at least one steroid cycle of 6 weeks or longer; 
Otherwise, the interviewers judgmentally selected the users to intervew. 
Seventy-tWo steroid users (55 curent + 17 former) provided informtion about themselves by 
completing a confIdential, strctured intervew of 39 questions. All intervewers captued the 
self-reponed user data on the instrment we designed and pre-tested, but they did not attempt to 
verify the factual accuracy of the users ' answers. All personally conducted the interviews either 
face to face or by telephone. 
The CUITent and former users were 93 percent male with an average curent age of 20 and an 
average initiation age of 16. They come from 10 states and frm vared settgs and locations 
within those states. Dr. Wright pointed out that he visite several counties for his 11 interviews 
in one state. Neither he, nor Dr. Humbert simply concentrate on one commercial gym which 
caters to "hard core" bodybuilding and weightliftng trning. Mr. Carolan, a substace abuse 
drg  progrs, curnt 
therapist  interViewed users who were refe1Ts from other  counseling 
clients, and word-of-mouth contacts limited to this project. Most were parent- or self-refeITed; 
none wele court-referrd.  APPENDIX 

STEROID INCIDENCE OF FIRST USE 
National High School Senior Survey, Class of 1989 
Sponsored by the National Institute on Drug Abuse 
Grade  Total  Male  Female 
6 or below  0.3  0.2 
0.3 
7 to 8 
0.4 
1.0 
1.0  0.4 
1.0 
Never Used  97.  95.3  98. 
*For further infprmtion. contact Chief. Epidemiology Research Branch. National 
A. ParklawnBuilding. 5600 Fishers Lane, 
Institute on Drug Abuse, Floor  11 
Rf/ckvile, MD 20857. 
C - 1
 ' ,

APPENDIX D

ESTIMATE OF STUDENT STEROID USE BY GRADE 
If we assume that the incidence of fIrst use for the Class.of 1989 is typical (see Appendix C), 
then we can estimate student steroid use by grade. Using enrollment data from the U. 
Deparent of Education, we calculate, that in the 1989 school year approximately 97,000 
students tred steroids for the fIrst time and that by the end of the 1989 school year 
approximately 262 000 students in grades 7 to 12 used or had used steroids. 
Grade/Class  % First Use  # Students  Cumulative  Cumulative 
# Enrolled  By Grade  First Use  School Year  All Grades 
By Grade 
or below  354* 
353,837 (grade 6) 
to  8 - Class of'  800  13, 154  13, 154 
293,000 per class 
(approximate) 
9 - Class of  0.5  17,821  30,975  129 
564 104 
10 	 Class of'  16,657 .  47,632  761 
331 358 
11 -	 Class of '  25,293  72,925  164 686 
161,609 
12 -	 Class 0/'  172  97,097  261 783 
021 532 
*Based on enrollment data for grade  6;  data for incidence of first use by grades 1 through  individually is nor 
available. 
D - 1  ...
. '! 
APPENDIX 

PUBLIC COMMENTS 
Charles E. Yesalis, Sc.D., Depanment of Health Policy and Admnistrtion, Pennsylvania State 
University, is a nationally recognized steroid researcher. Below ar excerpts from a letter he 
wrote us after he reviewed the draft repon. 
Overall the reports are well done and represent a valuable contribution 
however, have a concern with the report's conclu
to the literature. I do, 
sions on strategies to deal with this problem. Once again the central 
focus appears to be directed at the education of users or potential users 
of anabolic steroids. Much less attention is given to our social environ
ment which, in my opinion, gives strong signals to our children to use 
these drugs. Your report states that anabolic steroids are not mood al
tering at the time of administration. You fail, however, to proceed to 
what I believe is the only logical conclusion: the appetite for these 
drugs ha  been created by our  and physical appear-
fiation on sport 
innate  desire to look like Mr. Universe
ance. Children do not have an 

by nature 
nor do they  play games for the sole purpose of winning 
teach them this. Our youngsters look around and see numerous exam
pIes, both inside and outside of sport, of win at any cost, winner take 
wil help you win and they 
all, and bigger is better. Anabolic steroids 

wil make you bigger. 
Our children are influenced by the adulation offans and material re
wards which often accompany success at the Olympic, collegiate and 
professional levels of sport. Moreover, because of reports in the news 
media as well as written and verbal testimonials by athletes, adoles
aware of the role anabolic steroids play in the success of
cents are 

many so called role-model athletes. 
Although the report acknowledges that anabolic steroids are capable of 
enhancing strength, size and capacity to train, the report once again 
stops short of an obvious conclusion:  do not use these .drugs, all 
if you 
else being equal, YOU WILL NOT WIN AS OFTEN.... This conclusion 
also has signifcant implications for strategies to solve the. problem of 
steroid use among adolescents. If coaches are not wiling to say with 
sincerity to their athletes, My opposition to steroids is so great that I 
am wiling to lose every game rather than have any of you use steroids. 
this problem wil continue. Ifparents, athletic directors and principals 
continue.  this problem wil
are not wiling to support such a stance by coaches, 
F - 1