HackTwat
MuscleChemistry Registered Member
This Article is the Kind of Bullshit that keeps AAS Illegal!!!!!!!!!!!!!!!!!
For Your Reading Non-Enjoyment.....grrrrrrrrr.....
Abstract and Introduction
Abstract
Study Objective. To contrast the characteristics of two groups of men who participated in strength-training exercise—those who reported anabolic-androgenic steroid (AAS) use versus those who reported no AAS use.
Design. Analysis of data from the Anabolic 500, a cross-sectional survey. Participants. Five hundred six male self-reported AAS users (mean age 29.3 yrs) and 771 male self-reported nonusers of AAS (mean age 25.2 yrs) who completed an online survey between February 19 and June 30, 2009.
Measurements and Main Results. Respondents were recruited from Internet discussion boards of 38 fitness, bodybuilding, weightlifting, and steroid Web sites. The respondents provided online informed consent and completed the Anabolic 500, a 99-item Web-based survey. Data were collected on demographics, use of AAS and other performance-enhancing agents, alcohol and illicit drug use, substance dependence disorder, other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses, and history of sexual and/or physical abuse. Most (70.4%) of the AAS users were recreational exercisers who reported using an average of 11.1 performance-enhancing agents in their routine. Compared with nonusers, the AAS users were more likely to meet criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001), report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010), use cocaine within the past 12 months (11.3% vs 4.7%, p<0.001), and report a history of sexual abuse (6.1% vs 2.7%, p=0.005).
Conclusion. Most of the AAS users in this study were recreational exercisers who practiced polypharmacy. The AAS users were more likely than nonusers to meet criteria for substance dependence disorder, report a diagnosis of an anxiety disorder, report recent cocaine use, and have a history of sexual abuse. The information uncovered in this study may help clinicians and researchers develop appropriate intervention strategies for AAS abuse.
Introduction
Use of anabolic-androgenic steroids (AAS) has been well documented for decades in the athletic and bodybuilding arenas. From the discovery of East Germany's government-instituted steroid doping regime during the 1960s and 1980s to the release of the 2007 Mitchell Report that implicated numerous Major League Baseball players, doping among elite athletes has been highly publicized by the media.Despite this, minimal attention has been placed on the majority of AAS users: recreational exercisers.
Most AAS users practice polypharmacy for performance enhancement by incorporating various prescription drugs, over-the-counter products, herbal medicines, and dietary supplements.However, many health care professionals are unaware of the growing trends and vast array of drugs and ergogenic agents that their patients are using. Some of these agents include fertility and breast cancer drugs such as clomiphene and tamoxifen, respectively. By understanding the various drugs being used and their intended purposes, health care providers can be better informed when caring for their patients.
The purpose of this study was to contrast the characteristics of two groups of men who participate in strength-training exercise: those who took AAS and those who did not. To our knowledge, this study represents the largest comparison of these two groups.
Methods
Study Design and Patient Population
A 99-item Web-based survey, the Anabolic 500, administered through SurveyMonkey (Palo Alto, CA), was used to assess several characteristics of men who participated in strength training. Specific variables assessed included the following: demographics; exercise patterns; AAS use, motivations for AAS use, and AAS acquisition history; use of other performance-enhancing agents (PEAs); history of illicit drug and alcohol use; behavior consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for substance dependence disorder; DSM-IV-TR psychiatric conditions diagnosed by a health care professional; and history of sexual and/or physical abuse.
Men were eligible to participate in the survey if they had Internet access, regularly participated in strength-training exercise, and documented that they were either previous or current users or nonusers of AAS. Any surveys completed by women were excluded from the final analyses, as were any data from incomplete surveys, from surveys with hoax or illogical answers, and from surveys that were filled out too quickly (< 5 min for a self-reported AAS user and < 3 min for a nonuser). A pilot test of 15 weightlifters demonstrated that the average AAS user and nonuser spent roughly 30 minutes and 10 minutes, respectively, to complete the survey.
Data Collection and Data Security
Participants were recruited from 38 online discussion boards of various fitness, bodybuilding, weightlifting, and anabolic steroid Web sites between February 19 and June 30, 2009. Previously published methods to enhance discussion board visibility and survey participation were applied.A survey Web link directed potential participants to an informed consent page that provided additional information regarding the study and detailed methods used to maintain confidentiality and anonymity. No individually identifiable data were collected, Internet provider addresses were not logged, and data transfer was encrypted. Only researchers identified in the investigational review board proposal had access to the data, and all researchers had previously completed a National Institutes of Health human subjects training program. The study received institutional review board approval from Touro University.
Statistical Analysis
All statistical analyses were conducted with use of SAS for Windows, version 9.1 (SAS Institute Inc., Cary, NC). As the survey was primarily descriptive in nature, continuous data are reported as mean ±SD, and categorical data are reported as numbers and percentages of respondents. The Student t test and Fisher exact test were used for comparisons of continuous and categoric data, respectively. For continuous variables that deviated greatly from normality (e.g., amount of money spent/year), a nonparametric Wilcoxon rank test was used. A p value of less than 0.05 was considered to indicate a statistically significant difference.
Results
When the survey closed on June 30, 2009, there were 2380 survey attempts. Among these, 861 surveys were excluded for the following reasons: 842 were incomplete, 10 reported hoax or illogical responses or were completed too quickly, and 9 were completed by individuals not involved in strength-training exercise. This resulted in a final analytic cohort of 1519 subjects who fully completed and submitted a valid survey. Among the 1519 subjects, 518 were self-reported AAS users (current or previous use) and 1001 were nonusers (no history of AAS use). Among the 518 reported AAS users, 506 were male and 12 were female. Among the 1001 nonusers, 771 were male and 230 were female. The female AAS users have been previously described, [SUP][12][/SUP]and their data were not included in this analysis. Thus, 506 male AAS users and 771 male nonusers were included in this analysis.
Demographics
The demographic data comparing the male AAS users and nonusers are summarized in Table 1. The AAS users were significantly older (29.3 vs 25.2 yrs, p<0.001) and weighed more (96.8 vs 88.8 kg, p<0.001) with a corresponding greater body mass index ([BMI] 29.9 vs 27.8 kg/m [SUP]2[/SUP], p<0.001) than the nonusers. Most of the AAS users were Caucasian (88.6%), heterosexual (97.2%), and single (53.2%). However, AAS users were more likely to be married (27.7% vs 17.7%, p<0.001), divorced or separated (7.6% vs 3.0%, p<0.001), or living with a partner (11.6 vs 5.4%, p<0.001) than the predominantly single (73.9%) nonusers. With regard to education, 43.4% of AAS users who were at least 25 years old completed a bachelor's degree or higher compared with 27.2% of the United States population in the same age range. [SUP][13][/SUP]
The AAS users tended to have more years of strength training experience than nonusers (9.4 ± 7.6 vs 5.3 ±6.2 yrs, p<0.001) and also differed in the number of days/week and hours/week spent strength training. The AAS users underwent strength training significantly more days/week (4.6 ±0.9 vs 4.1 ±1.1 days, p<0.001) and hours/week (6.8 ±3.2 vs 6.0 ±3.5 hrs, p<0.001) compared with the nonusers.
The respondents were asked to classify themselves as recreational exercisers, competitive bodybuilders, competitive weightlifters, or competitive athletes. The majority of both AAS users and nonusers classified themselves as recreational exercisers (70.4% vs 69.0%, p=0.620). Only 61 AAS users (12.1%) were competitive bodybuilders, 42 (8.3%) were competitive weightlifters, and 47 (9.3%) were competitive athletes. Also, a history of participation in high school sports was not associated with an increased risk of being an AAS user.
Characteristics of Performance-enhancing Agent Use
As shown in Table 2, both AAS users and nonusers practiced polypharmacy related to PEAs. For analytic purposes, PEAs included both AAS and non-AAS agents. On average, AAS users incorporated over 2.5 times more PEAs into their routine than the nonusers (11.1 vs 4.3 agents, p<0.001). The AAS users used an average of 2.3 AAS agents and 8.9 other PEAs, and they spent more than twice the amount of money on PEAs per year than did nonusers ($1428.92 ± 1570.24 vs $599.76 ±875.14, p<0.001).
Characteristics of Anabolic-androgenic Steroid Use
The AAS users spent a large amount of time researching AAS before starting use (267.8 ± 472.0 hrs; Table 2). The mean ± SD starting age of AAS use was 24.5 ±7.2 years (range 13–69 yrs). Most users (95.8%) strategically planned their AAS duration, doses, and compounds that would be used before starting their AAS regimen. The AAS users administered or ingested an average weekly AAS dose of 1188.2 ±1077.1 mg. Most (87.6%) administered their AAS in drug cycles (preplanned periods of use and nonuse). The average AAS cycle length was 10.7 ±4.6 weeks whereas the average off-period from AAS use was roughly twice as long (20.4 ±28.3 wks). Most AAS users (78.6%) practiced "stacking," a dosing technique that refers to combining more than one AAS agent at a time. Only 17.6% of AAS users practiced "pyramiding," which refers higher dose, then tapering down the dose.
Most of the AAS users utilized injectable forms of AAS (90.9%). Testosterone enanthate was the most commonly used AAS agent (41.1%), followed by oral methandrostenolone (27.7%), trenbolone (20.8%), testosterone cypionate (20.2%), nandrolone (19.0%), testosterone propionate (16.0%), boldenone (15.0%), testosterone blend (14.4%), and oral oxandrolone (8.7%). Regarding injection practices, none of the AAS users shared the same syringes or needles with another person.
Motivations for Use Primary motivations for starting AAS were examined by using a 5-point Likert scale, as described in Table 3. The AAS users rated the following motivations—to increase muscle mass (score of 4.56 ±0.80), improve physical appearance (4.31 ±0.96), and increase strength (4.29 ± 0.89)—as important or very important reasons for starting AAS. Increasing aggression, personal protection, acceptance by peers, pressure to perform, and increasing sex drive or sexual function were not highly rated reasons for using AAS.
Acquisition Most users (54.9%) obtained their AAS supply from local sources (friends, training partners, gym members, or dealers); 51.8% acquired the drugs from Internet suppliers (not registered pharmacies). Roughly 20.4% of the users obtained their AAS supply through foreign mail order (from Mexico, China, Romania, Thailand, greece, or Iran). Smaller percentages acquired their AAS by transporting it from a foreign country (Mexico, Thailand, or greece [7.3%]), receiving it from a physician clinic (5.9%), or self-manufacturing it (1.8%). Twenty-two respondents (4.3%) declined to provide acquisition information.
Adverse Effects Adverse effects most commonly reported by the AAS users included acne (52.4%), testicular atrophy (51.0%), injection site pain (42.5%), edema (33.8%), increased blood pressure (32.4%), mood changes (23.9%), insomnia (23.1%), striae (19.0%), gynecomastia (15.6%), sexual dysfunction (13.4%), abnormalities in lipid levels (10.9%), and hair loss (10.1%). Only 11.5% of AAS users reported no adverse effects from AAS. Over half (56.0%) of AAS users were concerned about possible negative effects of AAS on their long-term health. Despite these adverse effects and concerns, an overwhelming majority (93.3%) reported plans to continue AAS use in the future.
Disclosure of Use Use of AAS was not clandestine. Most AAS users had informed a friend (72.5%) and/or family member or spouse (53.0%) regarding their use. This was followed by informing a physician or health care provider (33.0%); colleague, teammate, and/or gym member (29.3%); trainer or coach (9.5%); and priest, pastor, or religious authority (0.8%). Only 8.9% of users were secretive about their AAS use and informed no one.
Use of Performance-enhancing Agents Other Than Anabolic-androgenic Steroids
Various types of non-AAS PEAs as well as their usage are listed in Table 4. The AAS users were much more likely to use certain agents than were nonusers. These included tamoxifen, anastrazole, ephedrine, clomiphene, clenbuterol, human chorionic gonadotropin, triiodothyronine, human growth hormone, tadalafil, sildenafil, insulin, and finasteride.
Alcohol, Tobacco, and Illicit Drug Use
The AAS users were not more likely to binge drink alcohol (≥ 5 drinks on the same occasion; 47.2% vs 52.0%, p=0.097), take part in heavy alcohol use (≥ 5 drinks on the same occasion ≥ 5 days within a 30-day period; 24.1% vs 24.9%, p=0.791), smoke cigarettes (22.9% vs 19.8%, p=0.207), use marijuana (30.6% vs 26.9%, p=0.145), or use heroin (3.0% vs 1.7%, p=0.170) within the past 12 months compared with nonusers. However, AAS users were more likely to have used cocaine (11.3% vs 4.7%, p<0.001) within the past 12 months.
Substance Dependence Disorder and Diagnosed Psychiatric Conditions
Substance dependence disorder is a pattern of substance use that leads to significant impairment or distress. As noted in the DSM-IV-TR, substance dependence disorder is marked by three or more symptom criteria, as shown in Table 5. Among the symptoms listed, the most commonly reported among the AAS users were the need to use increased amounts (29.7%), a decreased effect with the same dose (29.4%), withdrawal problems (22.3%), and escalated and prolonged use than originally intended (19.4%) regarding their PEAs. The AAS users in the study were more likely than the nonusers to meet the DSM-IV-TR criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001).
Among the AAS users, 17.4% reported a health care professional psychiatric diagnosis compared with 13.9% of nonusers (p=0.095; Table 6). The psychiatric diagnoses consisted of major depressive disorder, anxiety disorder (generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, or social phobia), attention-deficit–hyperactivity disorder, anorexia nervosa, or bulimia nervosa. Among these psychiatric diagnoses, the AAS users were more likely than the nonusers to report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010).
Sexual and Physical Abuse
The AAS users were more likely than nonusers to report a history of sexual abuse (6.1% vs 2.7%, p=0.005). With regard to reporting physical abuse, no significant difference was noted between AAS users and nonusers (10.0% vs 7.3%, p=0.097).
Discussion
This analysis confirms the presence of AAS use in the strength-training population. The typical male AAS user in this survey was 29 years old, single, heterosexual, Caucasian, and had a bachelor's degree or higher. Similar to previous studies, most AAS users classified themselves as recreational exercisers. [SUP][3–5][/SUP]This supports the concept that AAS use is not merely limited to competitive bodybuilders, weightlifters, and athletes, but is more commonly used among the general male population.
Both male AAS users and nonusers had a mean BMI greater than the normal range (18.5–24.9 kg/m [SUP]2][/SUP]).The AAS users had even higher BMIs and body weights than their non-AAS counterparts, as might be expected due to increased lean body mass with AAS administration. Despite these findings, a majority of both AAS users and nonusers were attempting to "gain weight." The AAS users were also primarily motivated to use AAS in order to increase muscle mass, increase strength, and improve appearance. The preference for a larger and more muscular body among the male subjects in our study seems to correspond with another investigation that found that men from various parts of the world would prefer their own bodies to be more muscular than their current state.Furthermore, the societal representation of the male body (e.g., male magazine photos and toy action figures) has become more muscular in appearance over the past few decades, which may be the impetus for body image issues in men.
Although both the AAS users and nonusers in this analysis practiced polypharmacy by using multiple PEAs at a time, the AAS users incorporated a significantly greater number of PEAs and spent much more money on these agents than did the AAS nonusers. The AAS users also took supraphysiologic doses of AAS. The weekly dose of 1188.2 ±1077 mg administered by the AAS users in this study is more than 10 times greater than the recommended dose for testosterone replacement therapy in patients with clinical hypogonadism.A dose-response relationship with AAS dose and its anabolic effects on muscle mass and strength has been demonstrated. Thus, AAS users are likely stacking AAS agents and administering supraphysiologic doses of AAS to aid them in "getting big."
Despite using multiple agents and administering large doses of AAS, most AAS users were methodic in their approach. In fact, AAS users spent over 260 hours of research on the topic before taking their first AAS dose. An over-whelming majority also strategically planned the duration, doses, and compounds that would be used before starting an AAS cycle. A majority also had a regular primary care provider and had routine laboratory work performed while using AAS. Finally, the AAS users were not reckless regarding injection practices, as not a single AAS user reported ever sharing a used needle or syringe with another person. These traits, which seem to focus on planning and safety, differ dramatically from that of a typical user of intravenous street drugs.
Various adverse effects were noted with AAS use. In particular, gynecomastia, testicular atrophy, sexual dysfunction, and hair loss are likely contributing to the polypharmacy and higher frequency of PEAs taken by AAS users. For example, AAS users were much more likely to report taking tamoxifen, anastrazole, clomiphene, human chorionic gonadotropin, tadalafil, sildenafil, and finasteride compared with AAS nonusers. Tamoxifen and anastrazole, antiestrogens used in the treatment of breast cancer, are commonly taken by AAS users to treat or prevent AAS-induced gynecomastia.Clomiphene and human chorionic gonadotropin, fertility-enhancing agents, are used to treat or prevent AAS-induced testicular atrophy and withdrawal.Tadalafil and sildenafil are agents commonly used to treat erectile dysfunction, and finasteride is used to treat male pattern baldness associated with AAS. Despite most AAS users in this study reporting some AAS-related adverse effect, this did not deter them from future AAS use.
No significant differences were noted between AAS users and nonusers with regard to binge drinking, heavy alcohol use, cigarette smoking, and marijuana or heroin use. However, AAS users were more than twice as likely than nonusers to have used cocaine within the past 12 months. A previous study also demonstrated that AAS use was positively correlated with cocaine use.
The substance dependence disorder diagnostic assessment, completed by 479 of the 506 AAS users, found that male AAS users met DSM-IV-TR criteria for substance dependence disorder in almost one fourth of the subjects (112 [23.4%]). The rate of substance dependence disorder among AAS users in this study was similar to that of another study published in 2000 (23%)but was less than that in a 2005 study (33%). The differences observed between the studies may indicate a change in substance dependence disorder among AAS users, or may be the result of different sample sizes and study population demographics. Regardless, substance dependence disorder represents a significant problem among AAS users as the frequency was more than twice as high as that in the nonusers (11.2%).
Another group of authors recently performed an intriguing study comparing 20 AAS-dependent men with 42 non–AAS dependent men and 72 non–AAS-using men. They found that AAS-dependent men, compared with the other two groups, were more likely to report a history of conduct disorder as well as a lifetime prevalence of opioid abuse and dependence. Future studies would benefit from exploring characteristics of AAS-dependent men on a larger scale, as the information obtained will be able to aid clinicians in recognizing patient characteristics and to provide this subset of individuals with appropriate medical treatment.
Among various psychiatric diagnoses, AAS users in our analysis were more likely than nonusers to report a health care professional diagnosis of an anxiety disorder. However, it is not possible to determine if the reported increase in anxiety disorders was a result of AAS use or if the anxiety disorder was present before starting AAS. It is interesting to note that AAS administration has been shown to increase anxiety levels in male rats. The AAS users also reported a history of sexual abuse more often than did nonusers. An intriguing hypothesis worth investigating is determining whether the underlying cause of AAS initiation is a history of an anxiety disorder or abuse.
There is an apparent disconnect between AAS users and health care providers. Despite most of the AAS users having a regular primary care provider and undergoing routine health visits, only a minority (33.0%) disclosed their AAS use to a health care provider. A possible explanation for this behavior may be precipitated by the users' perceived lack of confidence in their health care provider's knowledge of PEAs and AAS. Only 8.8% of respondents believed that physicians and pharmacists were knowledgeable regarding AAS and PEAs. A similar bias was found in another study where AAS users rated physicians lower on knowledge and advice regarding AAS and nutritional supplement expertise versus health or disease, cigarette smoking, or alcohol drinking.It would be instructive to know how health care providers perceive their own knowledge of AAS and PEAs. If their confidence in this area were at odds with their patients, continuing education programs in the areas of AAS and PEAs would be indicated to aid in bridging the communication gap between AAS users and health care providers.
Limitations
There are limitations to this study. First, survey studies by nature lend to information bias as participants must recall their experiences. Second, although surveys are a useful and an efficient tool in obtaining general information about a target population, it is difficult to assess causality. Third, the length and number of questions in the survey may have limited survey participation. Finally, Internet discussion boards were the source for recruitment and survey administration. The possibility of selection bias exists since individuals who do not have Internet access or do not access online discussion boards would, by definition, be excluded. Still, consistencies of information with this study and other surveys support the current results. Various sources have also demonstrated the validity and reliability of online data collection for research when compared with traditional methods.
Conclusion
The average AAS user in the Anabolic 500 survey was a 29-year-old, single, Caucasian male who attended college and acquired at least a bachelor's degree. Most of the AAS users classified themselves as recreational exercisers, practiced polypharmacy with PEAs (often to counter adverse effects of AAS), and were motivated to use AAS in order to increase muscle mass, increase strength, and improve appearance. The AAS users were more likely than nonusers to have met criteria for substance dependence disorder, have been diagnosed with an anxiety disorder, admit to recent cocaine use, and have a history of sexual abuse. The information presented in this study can help clinicians and researchers understand and recognize potential AAS users and help develop appropriate intervention strategies.
For Your Reading Non-Enjoyment.....grrrrrrrrr.....
Abstract and Introduction
Abstract
Study Objective. To contrast the characteristics of two groups of men who participated in strength-training exercise—those who reported anabolic-androgenic steroid (AAS) use versus those who reported no AAS use.
Design. Analysis of data from the Anabolic 500, a cross-sectional survey. Participants. Five hundred six male self-reported AAS users (mean age 29.3 yrs) and 771 male self-reported nonusers of AAS (mean age 25.2 yrs) who completed an online survey between February 19 and June 30, 2009.
Measurements and Main Results. Respondents were recruited from Internet discussion boards of 38 fitness, bodybuilding, weightlifting, and steroid Web sites. The respondents provided online informed consent and completed the Anabolic 500, a 99-item Web-based survey. Data were collected on demographics, use of AAS and other performance-enhancing agents, alcohol and illicit drug use, substance dependence disorder, other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses, and history of sexual and/or physical abuse. Most (70.4%) of the AAS users were recreational exercisers who reported using an average of 11.1 performance-enhancing agents in their routine. Compared with nonusers, the AAS users were more likely to meet criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001), report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010), use cocaine within the past 12 months (11.3% vs 4.7%, p<0.001), and report a history of sexual abuse (6.1% vs 2.7%, p=0.005).
Conclusion. Most of the AAS users in this study were recreational exercisers who practiced polypharmacy. The AAS users were more likely than nonusers to meet criteria for substance dependence disorder, report a diagnosis of an anxiety disorder, report recent cocaine use, and have a history of sexual abuse. The information uncovered in this study may help clinicians and researchers develop appropriate intervention strategies for AAS abuse.
Introduction
Use of anabolic-androgenic steroids (AAS) has been well documented for decades in the athletic and bodybuilding arenas. From the discovery of East Germany's government-instituted steroid doping regime during the 1960s and 1980s to the release of the 2007 Mitchell Report that implicated numerous Major League Baseball players, doping among elite athletes has been highly publicized by the media.Despite this, minimal attention has been placed on the majority of AAS users: recreational exercisers.
Most AAS users practice polypharmacy for performance enhancement by incorporating various prescription drugs, over-the-counter products, herbal medicines, and dietary supplements.However, many health care professionals are unaware of the growing trends and vast array of drugs and ergogenic agents that their patients are using. Some of these agents include fertility and breast cancer drugs such as clomiphene and tamoxifen, respectively. By understanding the various drugs being used and their intended purposes, health care providers can be better informed when caring for their patients.
The purpose of this study was to contrast the characteristics of two groups of men who participate in strength-training exercise: those who took AAS and those who did not. To our knowledge, this study represents the largest comparison of these two groups.
Methods
Study Design and Patient Population
A 99-item Web-based survey, the Anabolic 500, administered through SurveyMonkey (Palo Alto, CA), was used to assess several characteristics of men who participated in strength training. Specific variables assessed included the following: demographics; exercise patterns; AAS use, motivations for AAS use, and AAS acquisition history; use of other performance-enhancing agents (PEAs); history of illicit drug and alcohol use; behavior consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for substance dependence disorder; DSM-IV-TR psychiatric conditions diagnosed by a health care professional; and history of sexual and/or physical abuse.
Men were eligible to participate in the survey if they had Internet access, regularly participated in strength-training exercise, and documented that they were either previous or current users or nonusers of AAS. Any surveys completed by women were excluded from the final analyses, as were any data from incomplete surveys, from surveys with hoax or illogical answers, and from surveys that were filled out too quickly (< 5 min for a self-reported AAS user and < 3 min for a nonuser). A pilot test of 15 weightlifters demonstrated that the average AAS user and nonuser spent roughly 30 minutes and 10 minutes, respectively, to complete the survey.
Data Collection and Data Security
Participants were recruited from 38 online discussion boards of various fitness, bodybuilding, weightlifting, and anabolic steroid Web sites between February 19 and June 30, 2009. Previously published methods to enhance discussion board visibility and survey participation were applied.A survey Web link directed potential participants to an informed consent page that provided additional information regarding the study and detailed methods used to maintain confidentiality and anonymity. No individually identifiable data were collected, Internet provider addresses were not logged, and data transfer was encrypted. Only researchers identified in the investigational review board proposal had access to the data, and all researchers had previously completed a National Institutes of Health human subjects training program. The study received institutional review board approval from Touro University.
Statistical Analysis
All statistical analyses were conducted with use of SAS for Windows, version 9.1 (SAS Institute Inc., Cary, NC). As the survey was primarily descriptive in nature, continuous data are reported as mean ±SD, and categorical data are reported as numbers and percentages of respondents. The Student t test and Fisher exact test were used for comparisons of continuous and categoric data, respectively. For continuous variables that deviated greatly from normality (e.g., amount of money spent/year), a nonparametric Wilcoxon rank test was used. A p value of less than 0.05 was considered to indicate a statistically significant difference.
Results
When the survey closed on June 30, 2009, there were 2380 survey attempts. Among these, 861 surveys were excluded for the following reasons: 842 were incomplete, 10 reported hoax or illogical responses or were completed too quickly, and 9 were completed by individuals not involved in strength-training exercise. This resulted in a final analytic cohort of 1519 subjects who fully completed and submitted a valid survey. Among the 1519 subjects, 518 were self-reported AAS users (current or previous use) and 1001 were nonusers (no history of AAS use). Among the 518 reported AAS users, 506 were male and 12 were female. Among the 1001 nonusers, 771 were male and 230 were female. The female AAS users have been previously described, [SUP][12][/SUP]and their data were not included in this analysis. Thus, 506 male AAS users and 771 male nonusers were included in this analysis.
Demographics
The demographic data comparing the male AAS users and nonusers are summarized in Table 1. The AAS users were significantly older (29.3 vs 25.2 yrs, p<0.001) and weighed more (96.8 vs 88.8 kg, p<0.001) with a corresponding greater body mass index ([BMI] 29.9 vs 27.8 kg/m [SUP]2[/SUP], p<0.001) than the nonusers. Most of the AAS users were Caucasian (88.6%), heterosexual (97.2%), and single (53.2%). However, AAS users were more likely to be married (27.7% vs 17.7%, p<0.001), divorced or separated (7.6% vs 3.0%, p<0.001), or living with a partner (11.6 vs 5.4%, p<0.001) than the predominantly single (73.9%) nonusers. With regard to education, 43.4% of AAS users who were at least 25 years old completed a bachelor's degree or higher compared with 27.2% of the United States population in the same age range. [SUP][13][/SUP]
The AAS users tended to have more years of strength training experience than nonusers (9.4 ± 7.6 vs 5.3 ±6.2 yrs, p<0.001) and also differed in the number of days/week and hours/week spent strength training. The AAS users underwent strength training significantly more days/week (4.6 ±0.9 vs 4.1 ±1.1 days, p<0.001) and hours/week (6.8 ±3.2 vs 6.0 ±3.5 hrs, p<0.001) compared with the nonusers.
The respondents were asked to classify themselves as recreational exercisers, competitive bodybuilders, competitive weightlifters, or competitive athletes. The majority of both AAS users and nonusers classified themselves as recreational exercisers (70.4% vs 69.0%, p=0.620). Only 61 AAS users (12.1%) were competitive bodybuilders, 42 (8.3%) were competitive weightlifters, and 47 (9.3%) were competitive athletes. Also, a history of participation in high school sports was not associated with an increased risk of being an AAS user.
Characteristics of Performance-enhancing Agent Use
As shown in Table 2, both AAS users and nonusers practiced polypharmacy related to PEAs. For analytic purposes, PEAs included both AAS and non-AAS agents. On average, AAS users incorporated over 2.5 times more PEAs into their routine than the nonusers (11.1 vs 4.3 agents, p<0.001). The AAS users used an average of 2.3 AAS agents and 8.9 other PEAs, and they spent more than twice the amount of money on PEAs per year than did nonusers ($1428.92 ± 1570.24 vs $599.76 ±875.14, p<0.001).
Characteristics of Anabolic-androgenic Steroid Use
The AAS users spent a large amount of time researching AAS before starting use (267.8 ± 472.0 hrs; Table 2). The mean ± SD starting age of AAS use was 24.5 ±7.2 years (range 13–69 yrs). Most users (95.8%) strategically planned their AAS duration, doses, and compounds that would be used before starting their AAS regimen. The AAS users administered or ingested an average weekly AAS dose of 1188.2 ±1077.1 mg. Most (87.6%) administered their AAS in drug cycles (preplanned periods of use and nonuse). The average AAS cycle length was 10.7 ±4.6 weeks whereas the average off-period from AAS use was roughly twice as long (20.4 ±28.3 wks). Most AAS users (78.6%) practiced "stacking," a dosing technique that refers to combining more than one AAS agent at a time. Only 17.6% of AAS users practiced "pyramiding," which refers higher dose, then tapering down the dose.
Most of the AAS users utilized injectable forms of AAS (90.9%). Testosterone enanthate was the most commonly used AAS agent (41.1%), followed by oral methandrostenolone (27.7%), trenbolone (20.8%), testosterone cypionate (20.2%), nandrolone (19.0%), testosterone propionate (16.0%), boldenone (15.0%), testosterone blend (14.4%), and oral oxandrolone (8.7%). Regarding injection practices, none of the AAS users shared the same syringes or needles with another person.
Motivations for Use Primary motivations for starting AAS were examined by using a 5-point Likert scale, as described in Table 3. The AAS users rated the following motivations—to increase muscle mass (score of 4.56 ±0.80), improve physical appearance (4.31 ±0.96), and increase strength (4.29 ± 0.89)—as important or very important reasons for starting AAS. Increasing aggression, personal protection, acceptance by peers, pressure to perform, and increasing sex drive or sexual function were not highly rated reasons for using AAS.
Acquisition Most users (54.9%) obtained their AAS supply from local sources (friends, training partners, gym members, or dealers); 51.8% acquired the drugs from Internet suppliers (not registered pharmacies). Roughly 20.4% of the users obtained their AAS supply through foreign mail order (from Mexico, China, Romania, Thailand, greece, or Iran). Smaller percentages acquired their AAS by transporting it from a foreign country (Mexico, Thailand, or greece [7.3%]), receiving it from a physician clinic (5.9%), or self-manufacturing it (1.8%). Twenty-two respondents (4.3%) declined to provide acquisition information.
Adverse Effects Adverse effects most commonly reported by the AAS users included acne (52.4%), testicular atrophy (51.0%), injection site pain (42.5%), edema (33.8%), increased blood pressure (32.4%), mood changes (23.9%), insomnia (23.1%), striae (19.0%), gynecomastia (15.6%), sexual dysfunction (13.4%), abnormalities in lipid levels (10.9%), and hair loss (10.1%). Only 11.5% of AAS users reported no adverse effects from AAS. Over half (56.0%) of AAS users were concerned about possible negative effects of AAS on their long-term health. Despite these adverse effects and concerns, an overwhelming majority (93.3%) reported plans to continue AAS use in the future.
Disclosure of Use Use of AAS was not clandestine. Most AAS users had informed a friend (72.5%) and/or family member or spouse (53.0%) regarding their use. This was followed by informing a physician or health care provider (33.0%); colleague, teammate, and/or gym member (29.3%); trainer or coach (9.5%); and priest, pastor, or religious authority (0.8%). Only 8.9% of users were secretive about their AAS use and informed no one.
Use of Performance-enhancing Agents Other Than Anabolic-androgenic Steroids
Various types of non-AAS PEAs as well as their usage are listed in Table 4. The AAS users were much more likely to use certain agents than were nonusers. These included tamoxifen, anastrazole, ephedrine, clomiphene, clenbuterol, human chorionic gonadotropin, triiodothyronine, human growth hormone, tadalafil, sildenafil, insulin, and finasteride.
Alcohol, Tobacco, and Illicit Drug Use
The AAS users were not more likely to binge drink alcohol (≥ 5 drinks on the same occasion; 47.2% vs 52.0%, p=0.097), take part in heavy alcohol use (≥ 5 drinks on the same occasion ≥ 5 days within a 30-day period; 24.1% vs 24.9%, p=0.791), smoke cigarettes (22.9% vs 19.8%, p=0.207), use marijuana (30.6% vs 26.9%, p=0.145), or use heroin (3.0% vs 1.7%, p=0.170) within the past 12 months compared with nonusers. However, AAS users were more likely to have used cocaine (11.3% vs 4.7%, p<0.001) within the past 12 months.
Substance Dependence Disorder and Diagnosed Psychiatric Conditions
Substance dependence disorder is a pattern of substance use that leads to significant impairment or distress. As noted in the DSM-IV-TR, substance dependence disorder is marked by three or more symptom criteria, as shown in Table 5. Among the symptoms listed, the most commonly reported among the AAS users were the need to use increased amounts (29.7%), a decreased effect with the same dose (29.4%), withdrawal problems (22.3%), and escalated and prolonged use than originally intended (19.4%) regarding their PEAs. The AAS users in the study were more likely than the nonusers to meet the DSM-IV-TR criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001).
Among the AAS users, 17.4% reported a health care professional psychiatric diagnosis compared with 13.9% of nonusers (p=0.095; Table 6). The psychiatric diagnoses consisted of major depressive disorder, anxiety disorder (generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, or social phobia), attention-deficit–hyperactivity disorder, anorexia nervosa, or bulimia nervosa. Among these psychiatric diagnoses, the AAS users were more likely than the nonusers to report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010).
Sexual and Physical Abuse
The AAS users were more likely than nonusers to report a history of sexual abuse (6.1% vs 2.7%, p=0.005). With regard to reporting physical abuse, no significant difference was noted between AAS users and nonusers (10.0% vs 7.3%, p=0.097).
Discussion
This analysis confirms the presence of AAS use in the strength-training population. The typical male AAS user in this survey was 29 years old, single, heterosexual, Caucasian, and had a bachelor's degree or higher. Similar to previous studies, most AAS users classified themselves as recreational exercisers. [SUP][3–5][/SUP]This supports the concept that AAS use is not merely limited to competitive bodybuilders, weightlifters, and athletes, but is more commonly used among the general male population.
Both male AAS users and nonusers had a mean BMI greater than the normal range (18.5–24.9 kg/m [SUP]2][/SUP]).The AAS users had even higher BMIs and body weights than their non-AAS counterparts, as might be expected due to increased lean body mass with AAS administration. Despite these findings, a majority of both AAS users and nonusers were attempting to "gain weight." The AAS users were also primarily motivated to use AAS in order to increase muscle mass, increase strength, and improve appearance. The preference for a larger and more muscular body among the male subjects in our study seems to correspond with another investigation that found that men from various parts of the world would prefer their own bodies to be more muscular than their current state.Furthermore, the societal representation of the male body (e.g., male magazine photos and toy action figures) has become more muscular in appearance over the past few decades, which may be the impetus for body image issues in men.
Although both the AAS users and nonusers in this analysis practiced polypharmacy by using multiple PEAs at a time, the AAS users incorporated a significantly greater number of PEAs and spent much more money on these agents than did the AAS nonusers. The AAS users also took supraphysiologic doses of AAS. The weekly dose of 1188.2 ±1077 mg administered by the AAS users in this study is more than 10 times greater than the recommended dose for testosterone replacement therapy in patients with clinical hypogonadism.A dose-response relationship with AAS dose and its anabolic effects on muscle mass and strength has been demonstrated. Thus, AAS users are likely stacking AAS agents and administering supraphysiologic doses of AAS to aid them in "getting big."
Despite using multiple agents and administering large doses of AAS, most AAS users were methodic in their approach. In fact, AAS users spent over 260 hours of research on the topic before taking their first AAS dose. An over-whelming majority also strategically planned the duration, doses, and compounds that would be used before starting an AAS cycle. A majority also had a regular primary care provider and had routine laboratory work performed while using AAS. Finally, the AAS users were not reckless regarding injection practices, as not a single AAS user reported ever sharing a used needle or syringe with another person. These traits, which seem to focus on planning and safety, differ dramatically from that of a typical user of intravenous street drugs.
Various adverse effects were noted with AAS use. In particular, gynecomastia, testicular atrophy, sexual dysfunction, and hair loss are likely contributing to the polypharmacy and higher frequency of PEAs taken by AAS users. For example, AAS users were much more likely to report taking tamoxifen, anastrazole, clomiphene, human chorionic gonadotropin, tadalafil, sildenafil, and finasteride compared with AAS nonusers. Tamoxifen and anastrazole, antiestrogens used in the treatment of breast cancer, are commonly taken by AAS users to treat or prevent AAS-induced gynecomastia.Clomiphene and human chorionic gonadotropin, fertility-enhancing agents, are used to treat or prevent AAS-induced testicular atrophy and withdrawal.Tadalafil and sildenafil are agents commonly used to treat erectile dysfunction, and finasteride is used to treat male pattern baldness associated with AAS. Despite most AAS users in this study reporting some AAS-related adverse effect, this did not deter them from future AAS use.
No significant differences were noted between AAS users and nonusers with regard to binge drinking, heavy alcohol use, cigarette smoking, and marijuana or heroin use. However, AAS users were more than twice as likely than nonusers to have used cocaine within the past 12 months. A previous study also demonstrated that AAS use was positively correlated with cocaine use.
The substance dependence disorder diagnostic assessment, completed by 479 of the 506 AAS users, found that male AAS users met DSM-IV-TR criteria for substance dependence disorder in almost one fourth of the subjects (112 [23.4%]). The rate of substance dependence disorder among AAS users in this study was similar to that of another study published in 2000 (23%)but was less than that in a 2005 study (33%). The differences observed between the studies may indicate a change in substance dependence disorder among AAS users, or may be the result of different sample sizes and study population demographics. Regardless, substance dependence disorder represents a significant problem among AAS users as the frequency was more than twice as high as that in the nonusers (11.2%).
Another group of authors recently performed an intriguing study comparing 20 AAS-dependent men with 42 non–AAS dependent men and 72 non–AAS-using men. They found that AAS-dependent men, compared with the other two groups, were more likely to report a history of conduct disorder as well as a lifetime prevalence of opioid abuse and dependence. Future studies would benefit from exploring characteristics of AAS-dependent men on a larger scale, as the information obtained will be able to aid clinicians in recognizing patient characteristics and to provide this subset of individuals with appropriate medical treatment.
Among various psychiatric diagnoses, AAS users in our analysis were more likely than nonusers to report a health care professional diagnosis of an anxiety disorder. However, it is not possible to determine if the reported increase in anxiety disorders was a result of AAS use or if the anxiety disorder was present before starting AAS. It is interesting to note that AAS administration has been shown to increase anxiety levels in male rats. The AAS users also reported a history of sexual abuse more often than did nonusers. An intriguing hypothesis worth investigating is determining whether the underlying cause of AAS initiation is a history of an anxiety disorder or abuse.
There is an apparent disconnect between AAS users and health care providers. Despite most of the AAS users having a regular primary care provider and undergoing routine health visits, only a minority (33.0%) disclosed their AAS use to a health care provider. A possible explanation for this behavior may be precipitated by the users' perceived lack of confidence in their health care provider's knowledge of PEAs and AAS. Only 8.8% of respondents believed that physicians and pharmacists were knowledgeable regarding AAS and PEAs. A similar bias was found in another study where AAS users rated physicians lower on knowledge and advice regarding AAS and nutritional supplement expertise versus health or disease, cigarette smoking, or alcohol drinking.It would be instructive to know how health care providers perceive their own knowledge of AAS and PEAs. If their confidence in this area were at odds with their patients, continuing education programs in the areas of AAS and PEAs would be indicated to aid in bridging the communication gap between AAS users and health care providers.
Limitations
There are limitations to this study. First, survey studies by nature lend to information bias as participants must recall their experiences. Second, although surveys are a useful and an efficient tool in obtaining general information about a target population, it is difficult to assess causality. Third, the length and number of questions in the survey may have limited survey participation. Finally, Internet discussion boards were the source for recruitment and survey administration. The possibility of selection bias exists since individuals who do not have Internet access or do not access online discussion boards would, by definition, be excluded. Still, consistencies of information with this study and other surveys support the current results. Various sources have also demonstrated the validity and reliability of online data collection for research when compared with traditional methods.
Conclusion
The average AAS user in the Anabolic 500 survey was a 29-year-old, single, Caucasian male who attended college and acquired at least a bachelor's degree. Most of the AAS users classified themselves as recreational exercisers, practiced polypharmacy with PEAs (often to counter adverse effects of AAS), and were motivated to use AAS in order to increase muscle mass, increase strength, and improve appearance. The AAS users were more likely than nonusers to have met criteria for substance dependence disorder, have been diagnosed with an anxiety disorder, admit to recent cocaine use, and have a history of sexual abuse. The information presented in this study can help clinicians and researchers understand and recognize potential AAS users and help develop appropriate intervention strategies.
