Anabolic Steroid Abuse: Federal Efforts to Prevent and Reduce Anabolic Steroid Abuse among Teenagers
Published: 2007-10-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The abuse of anabolic steroids by teenagers--that is, their use without a prescription--is a health concern. Anabolic steroids are synthetic forms of the hormone testosterone that can be taken orally, injected, or rubbed on the skin. Although a 2006 survey funded by the National Institute on Drug Abuse (NIDA) found that less than 3 percent of 12th graders had abused anabolic steroids, it also found that about 40 percent of 12th graders described anabolic steroids as "fairly easy" or "very easy" to get. The abuse of anabolic steroids can cause serious health effects and behavioral changes in teenagers. GAO was asked to examine federally funded efforts to address the abuse of anabolic steroids among teenagers and to review available research on this issue. This report describes (1) federally funded efforts that address teenage abuse of anabolic steroids, (2) available research on teenage abuse of anabolic steroids, and (3) gaps or areas in need of improvement that federal officials and other experts identify in research that addresses teenage anabolic steroid abuse. To do this work, GAO reviewed federal agency materials and published studies identified through a literature review and interviewed federal officials and other experts.
section_title: What GAO Found
paragraphs: There are two categories of federally funded efforts that address teenage abuse of anabolic steroids. Efforts are either designed to focus on preventing the abuse of anabolic steroids among teenagers or are broader and designed to prevent substance abuse in general--which can include abuse of anabolic steroids among teenagers. Two programs that received federal funding during their development and testing, Athletes Training and Learning to Avoid Steroids (ATLAS) and Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA), are designed to focus on preventing or reducing teen abuse of anabolic steroids through use of gender-specific student-led curricula. In addition, there are various research efforts and education and outreach activities that focus on this issue. Two federal grant programs--the Office of National Drug Control Policy's Drug-Free Communities Support program and the Department of Education's School-Based Student Drug Testing program--are designed to support state and local efforts to prevent substance abuse in general and may include anabolic steroid abuse among teenagers as part of the programs' substance abuse prevention efforts. In 2007, about one-quarter of more than 700 Drug-Free Communities Support program grantees reported that they were addressing steroid abuse as one of their program's objectives. Almost half of the 16 studies GAO reviewed identified certain risk factors and behaviors linked to the abuse of anabolic steroids among teenagers. Several of these studies found connections between anabolic steroid abuse and risk factors such as use of other drugs, risky sexual behaviors, and aggressive behaviors. Most of the other studies were assessments of the ATLAS and ATHENA prevention programs and in general suggested that the programs may reduce abuse of anabolic steroids and other drugs among high school athletes immediately following participation in the programs. Experts identified gaps in the research addressing teenage abuse of anabolic steroids. Experts identified a lack of conclusive evidence of the sustained effectiveness over time of available prevention programs, for example at 1 year following participants' completion of the programs. Experts also identified gaps in the research on the long-term health effects of initiating anabolic steroid abuse as a teenager--including research on effects that may be particularly harmful in teens--and in research on psychological effects of anabolic steroid abuse.

section_title: Letter
paragraphs: The abuse of anabolic steroids by teenagers—that is, their use without a  prescription—is a health concern. Anabolic steroids are synthetic forms of  the hormone testosterone that can be taken orally, injected, or rubbed on  the skin. Although a 2006 survey funded by the National Institute on Drug  Abuse (NIDA) showed that less than 3 percent of 12th graders had abused  anabolic steroids, the survey also showed that about 40 percent of 12th  graders described anabolic steroids as “fairly easy” or “very easy” to get.  The abuse of anabolic steroids can cause serious health effects and  behavioral changes in teenagers. Under U.S. law, anabolic steroids are  controlled substances whose manufacture, possession, and use are  regulated by the federal government; they also cannot be sold legally  without a prescription.
You asked us to examine federally funded efforts to address the abuse of  anabolic steroids among teenagers and to review available research on  this issue. In this report, we  1.  describe major, federally funded efforts that address teenage abuse of  2.  describe the available research on teenage abuse of anabolic steroids,  and  3.  describe gaps or areas in need of improvement that federal officials  and other experts identify in research that addresses anabolic steroid  abuse among teenagers.
We focused our review on the abuse of anabolic steroids by teenagers in  grades 8 through 12. To describe federally funded efforts to address  anabolic steroid abuse among teenagers, we reviewed databases of federal  grant programs. We also obtained and reviewed pertinent reports and  information from the Web sites of agencies within the Department of  Health and Human Services (HHS)—the Centers for Disease Control and  Prevention (CDC), the National Institutes of Health (NIH), and the  Substance Abuse and Mental Health Services Administration (SAMHSA)— as well as the Web sites of the Department of Education (Education) and  the Office of National Drug Control Policy (ONDCP). We used these  resources to identify federally funded programs, research, and education  and outreach activities that address—through efforts to either prevent or  reduce—anabolic steroid abuse among teenagers. After identifying these  efforts, we interviewed and collected information from federal officials to  confirm that these efforts are intended to prevent or reduce anabolic  steroid abuse among teenagers. Where available, we requested funding  information on the federal efforts that we identified.
To describe the available research on teenage abuse of anabolic steroids,  we conducted a systematic review of the published literature on this topic.  We identified 16 articles that related to teenage abuse of anabolic steroids  and were published from January 1995 through June 2007. To select the  articles, we conducted a keyword search using the Dialog Database  System, a system that searches numerous database files, and reviewed the  resulting article titles and abstracts to identify whether the articles  focused on teenage abuse of anabolic steroids. We did not select articles  that were international works, based on reviews of other articles or  research, position papers, policy statements, or federal agency program  documents. The references we make to articles refer strictly to those that  we reviewed.
To describe the gaps or areas in need of improvement in research that  addresses teenage abuse of anabolic steroids as identified by experts, we  interviewed experts in anabolic steroid abuse and reviewed relevant  literature. We interviewed federal officials from CDC, NIDA, SAMHSA, and  Education, as well as other experts from universities and professional  associations. We reviewed research articles identifying gaps or areas in  need of improvement as part of our systematic review of the literature. We  conducted the work for our review from January 2007 through September  2007 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: The abuse of anabolic steroids differs from the abuse of other illicit  substances. When users initially begin to abuse anabolic steroids, they  typically are not driven by a desire to achieve an immediate euphoria like  that which accompanies most abused drugs such as cocaine, heroin, and  marijuana. The abuse of anabolic steroids is typically driven by the desire  of users to improve their athletic performance and appearance— characteristics that are important to many teenagers. Anabolic steroids  can increase strength and boost confidence, leading users to overlook the  potential serious and long-term damage to their health that these  substances can cause. In addition, the methods and patterns of use for  anabolic steroids differ from those of other drugs. Anabolic steroids are  most often taken orally or injected, typically in cycles of weeks or months  (referred to as “cycling”), rather than continuously. Cycling involves taking  multiple doses of anabolic steroids over a specific period of time, stopping  for a period, and starting again. In addition, users often combine several  different types of anabolic steroids to maximize their effectiveness  (referred to as “stacking”).
While anabolic steroids can enhance certain types of performance or  appearance, when used inappropriately they can cause a host of severe,  long-term, and in some cases, irreversible health consequences. The abuse  of anabolic steroids can lead to heart attacks, strokes, liver tumors, and  kidney failure. In addition, because anabolic steroids are often injected,  users who share needles or use nonsterile injection techniques are at risk  for contracting dangerous infections, such as HIV/AIDS and hepatitis B  and C. There are also numerous side effects that are gender-specific,  including reduced sperm count, infertility, baldness, and development of  breasts among men; and growth of facial hair, male-pattern baldness,  changes in or cessation of the menstrual cycle, and deepened voice among  women. There is also concern that teenagers who abuse anabolic steroids  may face the additional risk of halted growth resulting from premature  skeletal maturation and accelerated puberty changes.
The abuse of anabolic steroids may also lead to aggressive behavior and  other psychological side effects. Many users report feeling good about  themselves while on anabolic steroids, but for some users extreme mood  swings also can occur, including manic-like symptoms leading to violence.  Some users also may experience depression when the drugs are stopped,  which may contribute to dependence on anabolic steroids. Users may also  suffer from paranoia, jealousy, extreme irritability, delusions, and  impaired judgment stemming from feelings of invincibility.
Two national surveys showed increasing prevalence in teenage abuse of  steroids throughout the 1990s until about 2002 and a decline since then  (see fig. 1). One of these two national surveys, the Monitoring the Future  (MTF) survey, is an annual survey conducted by the University of  Michigan and supported by NIDA funding. The MTF survey measures drug  use and attitudes among students in grades 8, 10, and 12, and asks several  questions about the use of and attitudes towards anabolic steroids, such as  perceived risk, disapproval, and availability of anabolic steroids. The  survey’s questions are designed to assess respondents’ use of steroids in  the last 30 days, the past year, and over the course of the respondent’s  lifetime. Questions about steroid use were added to the study beginning in  1989. The most recent results from this survey showed that in 2006,   2.7 percent of 12th graders said they had used anabolic steroids without a  prescription at least once. The second national survey, the Youth Risk  Behavior Survey (YRBS), is a biennial survey conducted since 1991 by  CDC. The YRBS is part of a surveillance system consisting of national,  state, and local surveys of students in grades 9 through 12. These surveys  collect information about a wide variety of risk behaviors, including sexual  activity and alcohol and drug use. The most recent available national  YRBS survey—conducted in 2005—asked one question related to lifetime  steroid use without a prescription, which showed that 3.3 percent of 12th  graders had used steroids at least once.
The MTF and YRBS surveys indicate a low abuse rate for anabolic steroids  among teenagers when compared with the abuse rates for other drugs.  However, the reported easy availability of steroids and the potential for  serious health effects make anabolic steroid abuse a health concern for  teenagers, particularly among males. In general, the reported rates of  anabolic steroid abuse are higher for males than for females (see fig. 2).  Data from the 2006 MTF survey showed that 1.7 percent of teenage males  reported abusing anabolic steroids in the past year, as compared with   0.6 percent of females. Data from the 2005 YRBS survey showed that   4.8 percent of high school males reported abusing steroids in their lifetime,  as compared with 3.2 percent of females.
section_title: Some Federally Funded Efforts Are Designed to Focus on Preventing Teenage Steroid Abuse, While Other Efforts Designed to Address Substance Abuse in General May Include Teenagers
paragraphs: There are two categories of federally funded efforts that address teenage  abuse of anabolic steroids. Efforts are either designed to focus on  preventing the abuse of anabolic steroids among teenagers or are broader  and designed to prevent substance abuse in general—which can include  abuse of anabolic steroids among teenagers. Two programs that received  federal research funding for their development and testing, ATLAS and  ATHENA, are designed to focus on preventing or reducing teen abuse of  anabolic steroids. In addition, there are various research efforts and  education and outreach activities that focus on this issue. Two federal  grant programs—ONDCP’s Drug-Free Communities Support program and  Education’s School-Based Student Drug Testing program—are designed to  support state and local efforts to prevent substance abuse in general and  may include anabolic steroid abuse among teenagers as part of the  programs’ substance abuse prevention efforts. See appendix I for a list of  the federally funded efforts discussed below.
subsections: section_title: Some Federally Funded Programs, Research, and Activities Are Designed to Focus on Preventing Teenage Anabolic Steroid Abuse
paragraphs: There are various federally funded efforts—programs, research, and  educational activities—that address teenage abuse of anabolic steroids.  Some of these efforts are designed to focus on preventing or reducing  anabolic steroid abuse among teenagers. As part of our review we  identified two programs, the ATLAS and ATHENA programs, which  received federal research funding during their development and testing  and are designed to focus on preventing the abuse of anabolic steroids  among male and female high school athletes, respectively.
ATLAS is a student-led curriculum designed to prevent male high school  athletes from abusing anabolic steroids and other performance-enhancing  substances. The program’s intervention strategy relies on peer pressure  and providing information on healthy alternatives for increasing muscle  strength and size. The ATLAS curriculum is typically delivered during a  sport team’s season in a series of 45-minute sessions scheduled at the  coaches’ discretion and integrated into the usual team practice activities.  The athletes meet as a team in groups of six or eight students with one  student functioning as the assigned group leader. Coaches, group leaders,  and student athletes all work from manuals and workbooks, which  provide brief, interactive activities that focus on drugs used in sports,  sport supplements, strength training, sport nutrition, and decision making.
The ATHENA program is designed to prevent the abuse of body-shaping  substances such as diet pills and anabolic steroids, although abuse of the  latter is less common in females than in males. Like ATLAS, the ATHENA  curriculum is integrated into a sport team’s usual practice activities and  uses workbooks and student group leaders. The ATHENA curriculum  takes into account that female athletes are less likely than males to abuse  anabolic steroids but are more likely to have problems with eating  disorders and to use drugs such as diet pills and tobacco. As a result,  ATHENA’s curriculum gives more attention than ATLAS’s to addressing  these behaviors.
The ATLAS and ATHENA curricula were developed and tested with  funding provided by NIDA. From fiscal years 1993 through 2001, NIDA  provided more than $3.4 million to fund the research that developed and  tested the effectiveness of the ATLAS curriculum. Similarly, from fiscal  years 1999 through 2003 NIDA provided $4.7 million in research funding to  develop and test the effectiveness of the ATHENA curriculum. While  ATLAS and ATHENA were developed and tested with federal funding, the  programs are implemented at the local level. Schools in at least 25 states  have chosen to implement the programs with local and private funds, and  the National Football League and Sports Illustrated magazine together  have supported the programs in more than 70 schools nationwide.
In addition to the ATLAS and ATHENA programs, there are various  federally funded research efforts that focus on preventing or reducing  anabolic steroid abuse among teenagers. NIDA has funded several  research projects examining the factors that influence teenagers to abuse  anabolic steroids and the effectiveness of interventions used to prevent  teenage steroid abuse. From fiscal years 2000 through 2006, NIDA awarded  nearly $10.1 million in grants to support an average of four research  projects each year related to anabolic steroid abuse with a specific focus  on adolescents. In fiscal year 2006, for example, NIDA awarded a total of  nearly $638,000 to three research projects that examined risk factors for  anabolic steroid abuse among teenagers or the effects of steroid abuse in  this population. Like NIDA, the United States Anti-Doping Agency  (USADA)—an independent, nonprofit corporation funded primarily by  ONDCP—supports research related to the abuse of anabolic steroids and  other performance-enhancing drugs by athletes, including teenage  athletes. In fiscal year 2006, USADA spent $1.8 million for research, and  an ONDCP official estimated that about one-third of that research funding  was directed to anabolic steroids and another performance-enhancing  drug, human growth hormone.
In addition to research, there are various education and outreach activities  that focus on preventing anabolic steroid abuse among teenagers. Many of  these efforts have been supported by NIDA. Since 2000, NIDA has  provided nearly $500,000 in funding for a variety of education and  outreach efforts in support of this goal. For example, in April 2000, in  response to an upward trend in steroid abuse among students, NIDA  launched a multimedia educational initiative intended to prevent anabolic  steroid abuse among teenagers. Along with several national partners,  including the National Collegiate Athletic Association, the American  College of Sports Medicine, and the American Academy of Pediatrics, the  initiative produced a Web site, a research report on steroid abuse, and  postcard-sized messages about steroids for placement in gyms, movie  theaters, shopping malls, bookstores, and restaurants in selected areas. By  2007, NIDA funding for this particular initiative totaled about $124,000.
In addition to NIDA, other federal agencies and organizations have  supported educational and outreach activities that focus on preventing  anabolic steroid abuse among teenagers, as the following examples  illustrate.
ONDCP has funded six informational briefings since 2001 to encourage  journalists, entertainment writers, and producers to accurately cover  anabolic steroids and drug abuse among teenage athletes. ONDCP also has  Web sites for teens and parents with information about anabolic steroids  and links to NIDA resources.
Since 2003, USADA has produced written publications and annual reports  on anabolic steroid abuse and has distributed those publications through  high schools and state high school associations. In addition, some USADA  public service announcements to be aired during televised sports events  and movie trailers have targeted anabolic steroid abuse.
In fiscal years 2007 and 2008, SAMHSA expects to spend a total of $99,000  under a contract to develop and disseminate educational materials  addressing the abuse of anabolic steroids by adolescent athletes. These  materials, which are intended for use by high school athletic and health  science departments, include brochures, a video, and 10 high school  outreach seminars.
section_title: Two Federal Grant Programs Designed to Address Substance Abuse May Address Teenage Anabolic Steroid Abuse
paragraphs: As part of our review, we identified two federal grant programs that are  designed to support state and local efforts to prevent various forms of  substance abuse and that may include teenagers. Grantees of these  programs may address teenage anabolic steroid abuse as part of the  programs’ general substance abuse prevention efforts. The Drug-Free  Communities Support program, funded by ONDCP and administered by  SAMHSA under an interagency agreement, provides grants to community  coalitions to address drug abuse problems identified in their  communities. Many community coalitions choose to implement school- based drug prevention programs with their grant funding and are allowed  to tailor these programs to address the drug prevention needs of their  communities. In 2007, about one-quarter of more than 700 grantees  reported that they were addressing steroid abuse as one of their program’s  objectives. Each community coalition is eligible for grants of up to  $125,000 per year, renewable for up to 4 more years, and requiring dollar- for-dollar community matching funds. In 2007, the Drug-Free  Communities Support program is providing about $80 million in grants to  709 community coalitions for drug prevention activities based on the  needs of the communities.
Another federal grant program that supports substance abuse prevention  efforts for teenagers and that may also include efforts to address anabolic  steroid abuse in this population is the School-Based Student Drug Testing  program in Education’s Office of Safe and Drug-Free Schools. Since 2003,  this program has provided grants to school districts and public and private  entities to establish school-based drug-testing efforts. For fiscal years 2003  through 2007, the Office of Safe and Drug-Free Schools awarded   $32.2 million in grants to 87 individual School-Based Student Drug Testing  grantees. According to information provided in the grantees’ grant  applications, 34 of the grantees (representing 180 middle, junior, and high  schools and at least 70,000 students) proposed using their grant-supported  drug testing to test for anabolic steroids in addition to other substances  such as amphetamines, marijuana, and cocaine. Education officials told  us that although grantees generally identify the drugs for which they are  testing in their annual performance reports, there has been no  independent verification by Education staff that confirms that the 34  grantees actually have implemented anabolic steroid testing or whether  additional grantees have included steroid testing in their efforts.
section_title: Research Shows Teenage Anabolic Steroid Abuse Is Linked to Certain Risk Factors and That Prevention Programs May Have Some Short-term Effectiveness
paragraphs: Of the 16 studies we reviewed, nearly half focused on linking certain risk  factors and behaviors to teenagers’ abuse of anabolic steroids, including  the use of other drugs, risky sexual behaviors, and aggressive behaviors.  Most of the other studies we reviewed were assessments of the ATLAS and  ATHENA prevention programs and in general suggested that the programs  may reduce abuse of anabolic steroids and other drugs among high school  athletes immediately following participation in the programs. Appendix II  is a list of the articles we reviewed.
Almost half of the studies we reviewed identified certain risk factors and  behaviors linked to the abuse of anabolic steroids among teenagers. Risk  factors, such as antisocial behavior, family violence, and low academic  achievement, are linked to youths’ likelihood of engaging in risky  behaviors, including drug abuse. Several studies found that the use of  alcohol and other drugs—such as tobacco, marijuana, and cocaine—is  associated with the abuse of anabolic steroids among teenagers, including  teenage athletes and non-athletes. One 2005 study found that the use of  other drugs was more likely to predict anabolic steroid abuse than  participation in athletic activities. Several studies we reviewed found no  difference between athletes and non-athletes in their abuse of anabolic  steroids, and one 2007 study of teenage girls found that female athletes  were less likely than female non-athletes to abuse anabolic steroids. A few  studies we reviewed found a positive correlation between anabolic steroid  abuse and risky sexual behaviors such as early initiation of sexual activity  and an increased number of sexual partners. Some studies found that  aggressive behaviors such as fighting were related to anabolic steroid  abuse by both males and females. Moreover, one 1997 study found that  adolescents (both male and female) who reported abusing anabolic  steroids in the past year were more likely to be perpetrators of sexual  violence. However, the cause-and-effect relationships between anabolic  steroid abuse and other risky behaviors, such as violence, have not been  determined.
About half of the studies we reviewed were assessments of the ATLAS and  ATHENA prevention programs, and in general these studies suggested that  these programs may reduce abuse of anabolic steroids and other drugs  among high school athletes immediately following participation in the  programs. Researchers assessing the ATLAS program reported that both  the intention to abuse anabolic steroids and the reported abuse of steroids  were lower among athletes who participated in the ATLAS program than  among athletes who did not participate in the program. The most recent  study found that although the intention to abuse anabolic steroids  remained lower at follow-up 1 year later for athletes who participated in  the ATLAS program, the effectiveness of the program in reducing reported  use diminished with time. Similarly, researchers assessing the ATHENA  program found that girls who participated in the program reported less  ongoing and new abuse of anabolic steroids as well as a reduction in the  abuse of other performance-enhancing and body-shaping substances. The  authors note that these results are short term, and the long-term  effectiveness of the ATHENA program is not known.
The authors of the one study in our review that looked at student drug- testing programs found that the abuse of anabolic steroids and other illicit  drugs and performance-enhancing substances was decreased among  athletes at schools that implemented mandatory, random drug-testing  programs. However, this group of athletes also showed an increase in risk  factors that are generally associated with greater abuse of illicit drugs,  including anabolic steroids. For example, athletes at schools with drug- testing programs were more likely to believe that peers and authority  figures were more tolerant of drug abuse, had less belief in the negative  consequences of drug abuse, and had less belief in the efficacy of drug  testing. Based on these seemingly inconsistent findings, the study’s  authors called for caution in interpreting the findings.
section_title: Experts Find There Are Gaps in Research on the Sustained Effectiveness of Prevention Programs and on the Long-term Health Effects for Teenagers
paragraphs: Experts identified gaps in the research that addresses anabolic steroid  abuse among teenagers. Experts identified gaps in the current research on  the outcomes of prevention programs that focus on anabolic steroids.  Experts also identified gaps in the research on the long-term health effects  of initiating the abuse of anabolic steroids as teenagers.
According to experts, available research does not establish the extent to  which the ATLAS and ATHENA programs are effective over time in  preventing anabolic steroid abuse among teenage athletes. Experts  acknowledge that both programs appear promising in their ability to  prevent the abuse of anabolic steroids among teenage athletes  immediately following participants’ completion of the programs.  Assessment of the effectiveness of the ATLAS program 1 year later,  however, found that the lower incidence of anabolic steroid use was not  sustained, although participants continued to report reduced intentions to  use anabolic steroids. The long-term effectiveness of the ATHENA  program has not been reported. The effectiveness of these programs has  been assessed only in some schools in Oregon, and therefore experts  report that the effectiveness of the programs may not be generalizable. In  another example, experts identified the need for additional research to  assess the effectiveness of drug-testing programs, such as those funded  under Education’s School-Based Student Drug Testing program, in  reducing anabolic steroid abuse among teenagers.
According to experts, there are several gaps in research on the health  effects of teenage abuse of anabolic steroids. Experts report that while  there is some research that has examined the health effects of anabolic  steroid abuse among adults—for example, the harmful effects on the  cardiovascular, hormonal, and immune systems—there is a lack of  research on these effects among teenagers. There is also a lack of research  on the long-term health effects of initiating anabolic steroid abuse during  the teenage years. Some health effects of steroid abuse among adults, such  as adverse effects on the hormonal system, have been shown to be  reversible when the adults have stopped abusing anabolic steroids.  Experts point out, however, that it is not known whether this reversibility  holds true for teenagers as well. While some experts suggest that anabolic  steroid abuse may do more lasting harm to teenagers, due to the complex  physical changes unique to adolescence, according to other experts there  is no conclusive evidence of potentially permanent health effects. Experts  also report that the extent of the psychological effects of anabolic steroid  abuse and, in particular, of withdrawal from steroid abuse, is unclear due  to limited research. Some experts we consulted noted a need to better  inform primary care physicians and pediatricians about anabolic steroid  abuse among teenagers, so these providers would be better able to  recognize steroid abuse in their patients and initiate early intervention and  treatment.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS and Education for comment and  received technical comments only, which we incorporated into the report  as appropriate.
As arranged with your offices, unless you publicly announce the contents  of this report earlier, we plan no further distribution of it until 30 days  after its issue date. At that time, we will send copies of this report to the  Secretary of Health and Human Services and to the Secretary of  Education. We will also provide copies to others upon request. In addition,  the report is available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staff members have any questions regarding this report,  please contact me at (202) 512-7114 or ekstrandl@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be found  on the last page of this report. GAO staff members who made major  contributions to this report are listed in appendix III.
section_title: Appendix I: Selected Federally Funded Efforts That Address or Can Address Anabolic Steroid Abuse among Teenagers
paragraphs: Table 1 lists selected federally funded efforts—including programs,  research, and educational and outreach activities—that are designed to  focus on preventing or reducing the abuse of anabolic steroids by  teenagers (focused efforts), as well as other broader efforts that may  address teenage abuse of anabolic steroids as part of the programs’  general substance abuse prevention efforts. The list includes programs  funded by two departments and the Office of National Drug Control Policy  (ONDCP), in the Executive Office of the President.
section_title: Appendix II: Articles Included in GAO’s Review
paragraphs: Borowsky, I.W., M. Hogan, and M. Ireland. “Adolescent sexual aggression:  risk and protective factors.” Pediatrics, vol. 100, no. 6 (1997): e71-e78.
Dukarm, C.P., R.S. Byrd, P. Auinger, and M. Weitzman. “Illicit substance  use, gender, and the risk of violent behavior among adolescents.” Archives  of Pediatric & Adolescent Medicine, vol. 150, no. 8 (1996): 797-801.
DuRant, R.H., L.G. Escobedo, and G.W. Heath, “Anabolic-steroid use,  strength training, and multiple drug use among adolescents in the United  States.” Pediatrics, vol. 96, no. 1 (1995): 23-28.
Elliot, D., J. Cheong, E.L. Moe, and L. Goldberg. “Cross-sectional study of  female students reporting anabolic steroid use.” Archives of Pediatric &  Adolescent Medicine, vol. 161, no. 6 (2007): 572-577.
Elliot, D., and L. Goldberg. “Intervention and prevention of steroid use in  adolescents.” American Journal of Sports Medicine, vol. 24, no. 6 (1996):  S46-S47.
Elliot, D.L., L. Goldberg, E.L. Moe, C.A. DeFrancesco, M.B. Durham, and H.  Hix-Small. “Preventing substance use and disordered eating: Initial  outcomes of the ATHENA (Athletes Targeting Healthy Exercise and  Nutrition Alternatives) program.” Archives of Pediatric & Adolescent  Medicine, vol. 158, no. 11 (2004): 1043-1049.
Elliot, D.L., E.L. Moe, L. Goldberg, C.A. DeFrancesco, M.B. Durham, and H.  Hix-Small. “Definition and outcome of a curriculum to prevent disordered  eating and body-shaping drug use.” The Journal of School Health, vol. 76,  no. 2 (2006): 67-73.
Fritz, M.S., D.P. MacKinnon, J. Williams, L. Goldberg, E.L. Moe, and D.L.  Elliot. “Analysis of baseline by treatment interactions in a drug prevention  and health promotion program for high school male athletes.” Addictive  Behaviors, vol. 30, no. 5 (2005): 1001-1005.
Goldberg, L., D. Elliot, G.N. Clarke, D.P. MacKinnon, E. Moe, L. Zoref, E.  Greffrath, D.J. Miller, and A. Lapin. “Effects of a multidimensional anabolic  steroid prevention intervention: the Adolescents Training and Learning to  Avoid Steroids (ATLAS) program.” JAMA, vol. 276, no. 19 (1996): 1555- 1562.
Goldberg, L., D. Elliot, G.N. Clarke, D.P. MacKinnon, L. Zoref, E. Moe, C.  Green, and S.L. Wolf. “The Adolescent Training and Learning to Avoid  Steroids (ATLAS) prevention program: background and results of a model  intervention.” Archives of Pediatric & Adolescent Medicine, vol. 150  (1996): 713-721.
Goldberg, L., D.L. Elliot, D.P. MacKinnon, E. Moe, K.S. Kuehl, L. Nohre,  and C.M. Lockwood. “Drug testing athletes to prevent substance abuse:  Background and pilot study results of the SATURN (Student Athlete  Testing Using Random Notification) study.” Journal of Adolescent Health,  vol. 32, no. 1 (2003): 16-25.
Goldberg, L., D.P. MacKinnon, D.L. Elliot, E.L. Moe, G. Clarke, and J.  Cheong. “The Adolescents Training and Learning to Avoid Steroids  Program: Preventing drug use and promoting health behaviors.” Archives  of Pediatric & Adolescent Medicine, vol. 154, no. 4 (2000): 332-338.
MacKinnon, D.P., L. Goldberg, G. Clarke, D.L. Elliot, J. Cheong, A. Lapin,  E.L. Moe, and J.L. Krull. “Mediating mechanisms in a program to reduce  intentions to use anabolic steroids and improve exercise self-efficacy and  dietary behavior.” Prevention Science, vol. 2, no. 1 (2001): 15-28.
Miller, K.E., J.H. Hoffman, G.M. Barnes, D. Sabo, M.J. Melnick, and M.P.  Farrell. “Adolescent anabolic steroid use, gender, physical activity, and  other problem behaviors.” Substance Use & Misuse, vol. 40, no. 11 (2005):  1637-1657.
Naylor, A.H., D. Gardner, and L. Zaichkowsky. “Drug use patterns among  high school athletes and nonathletes.” Adolescence, vol. 36, no. 144 (2001):  627-639.
Rich, J.D., C.K. Foisie, C.W. Towe, B.P. Dickinson, M. McKenzie, and C.M.  Salas. “Needle exchange program participation by anabolic steroid  injectors.” Drug and Alcohol Dependence, vol. 56, no. 2 (1999): 157-160.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Laurie Ekstrand, at (202) 512-7114 or ekstrandl@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this report  were Christine Brudevold, Assistant Director; Ellen M. Smith; Julie  Thomas; Rasanjali Wickrema; and Krister Friday.