REVIEW ARTICLE

Sports Med 2000 Jun; 29 (6): 397-405

0112-1642/00/0006-0397/$20.00/0
Adis International Limited. All rights reserved.

Risk Factors Associated With

Anabolic-Androgenic Steroid Use
Among Adolescents
Michael S. Bahrke,1 Charles E. Yesalis,2 Andrea N. Kopstein3 and Jason A. Stephens2
1 Human Kinetics, Champaign, Illinois, USA
2 Pennsylvania State University, University Park, Pennsylvania, USA
3 Substance Abuse and Mental Health Services Administration, Rockville, Maryland, USA

Contents
Abstract
. . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Methodology . . . . . . . . . . . . . . . . . . . . . . . . .
2. Identified Risk Factors . . . . . . . . . . . . . . . . . . . .
2.1 Demographic Factors . . . . . . . . . . . . . . . . .
2.1.1 Gender . . . . . . . . . . . . . . . . . . . . . .
2.1.2 Age and Grade Level . . . . . . . . . . . . .
2.1.3 Race and Ethnicity . . . . . . . . . . . . . . .
2.1.4 Socioeconomic Status . . . . . . . . . . . . .
2.1.5 Parental Characteristics . . . . . . . . . . . .
2.1.6 Geographical Location . . . . . . . . . . . .
2.1.7 City Size . . . . . . . . . . . . . . . . . . . . . .
2.2 Academic and Sports Participation Factors . . . .
2.2.1 School Size . . . . . . . . . . . . . . . . . . . .
2.2.2 Academic Performance . . . . . . . . . . . .
2.2.3 Athletic Participation . . . . . . . . . . . . . .
2.3 Personal Factors . . . . . . . . . . . . . . . . . . . .
2.3.1 Personality and Behaviour . . . . . . . . . . .
2.3.2 Body Image and Perceived Physical Health
2.3.3 Knowledge and Attitudes . . . . . . . . . . .
2.3.4 Knowing Other Steroid Users . . . . . . . . . .
2.3.5 High-Risk Behaviour . . . . . . . . . . . . . . .
2.3.6 Traumatic Events . . . . . . . . . . . . . . . .
2.4 Other Illicit Drug Use Factors . . . . . . . . . . . . . .
3. Comment . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . .

Abstract

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To identify risk factors associated with anabolic-androgenic steroid (AAS) use

among adolescents, computerised and manual literature searches were performed
and the resultant local, state, national and international reports of illicit AAS use
by adolescents that referenced risk factors were reviewed. Results indicate that
adolescent AAS users are significantly more likely to be males and to use other
illicit drugs, alcohol and tobacco. Student athletes are also more likely than non-

398

Bahrke et al.

athletes to use AAS, and football players, wrestlers, weightlifters and bodybuilders
have significantly higher prevalence rates than students not engaged in these
activities. Currently, only a partial profile can be created to characterise the adolescent AAS user. Further research will be needed before associations can be made
with a reasonable degree of confidence regarding risk factors such as athletic
participation, ethnicity, socioeconomic status and educational level. More importantly, to improve prevention and intervention strategies, a better understanding
of the process involved in initiating AAS use is needed, including vulnerability
factors, age of initiation and the use of other illicit drugs.

High levels of use of anabolic-androgenic steroids (AAS) have been attributed to professional
football players, weightlifters, powerlifters, bodybuilders and throwers in track and field events since
the 1960s.[1] However, until the mid-1970s, all that
was known regarding the incidence of the use of
AAS by adolescents was based on anecdotes, testimonials and rumours.[1] Use by high school athletes
was rumored to be occurring as early as 1959.[2-5]
In 1987, the first US study of AAS use at high
school level was conducted by Buckley and associates.[6] The study found that 6.6% of male high
school seniors reported having used these drugs.
There was no difference in the level of reported
AAS use between urban and rural areas, but there
was a small, but significant, difference by size of
enrolment: students at larger high schools had a
higher rate of reported AAS use. In addition, of the
self-rated AAS users, 38% had initiated use before
16 years of age and more than one-third did not
plan to participate in interscholastic sports.
Over 2 dozen US local, state and national level
studies have now confirmed the findings of Buckley et al.,[6] and show that 3 to 12% of high school
males admit to using AAS at some time in their
life.[7] Some of these studies also examined the use
of AAS among high school females, generally finding that 1 to 2% reported having used AAS.[1]
Our recent review[7] of state and national level
studies shows mixed trends for AAS use rates between 1988 and 1996. The findings of multiyear,
state level studies show a decrease in lifetime AAS
use rates between 1988 and 1994 for male and female adolescents, although no tests of statistical
Adis International Limited. All rights reserved.

significance were available. However, since 1991,

AAS use by males as measured by 2 of 3 US national surveys has been generally stable,[8-10] and
more recent data[11] indicate that AAS use by males
is now increasing. Furthermore, since 1991, data
from these same 3 national surveys point to a substantial increase in AAS use among adolescent females.
In addition, the 1997 Youth Risk and Behavior Surveillance System data[10] showed that of ninth to
twelfth graders in public and private high schools
in the US, 4.1% of males and 2.0% of females have
used AAS at least once in their lives. Based on 1997
estimates of high school students, these period prevalence rates translate to approximately 375 000 adolescent male and 175 000 adolescent female AAS
users.
It should also be noted that the use of AAS by
adolescents is not limited to the US.[12,13] Three
Canadian studies,[14-16] 2 Swedish surveys,[17,18] 2
South African investigations,[19,20] 1 British study[21]
and 1 Australian investigation[22] have reported overall prevalence rates for high school-aged students
to range between 1 and 3%. Although these rates
are slightly lower, they approximate those reported
for the US, reflecting the cross-cultural impact of
AAS on athletic performance and physical appearance.
Previous reports have shown that AAS use is
related to a wide variety of factors such as availability, behaviour of others and personal behaviour.
Unfortunately, many of these studies report conflicting findings, creating an array of possible risk
factors associated with AAS use among adolescents.
Further research is needed to better profile adolesSports Med 2000 Jun; 29 (6)

Anabolic-Androgenic Steroid Use Among Adolescents

cent AAS users regarding risk factors such as athletic participation, ethnicity, socioeconomic status
and educational level. More importantly, to improve
prevention and intervention strategies, a better understanding of the process involved in initiating
AAS use is needed, including vulnerability factors
(e.g. gender, athletic participation, specific sport
involvement), age of initiation and the use of other
illicit drugs.
Owing to the potential adverse physical, psychological and legal consequences, we must be alert to
the risk factors associated with AAS use among
adolescents. Furthermore, an awareness of these
risk factors would help differentiate the physical
and psychological changes normally occurring during adolescence from those resulting from AAS use.
The use of AAS may mask many of the changes,
such as increased body weight, muscular strength
and aggression, that occur during adolescence. This
report identifies, categorises, evaluates and summarises the risk factors from previously published
studies with the goal of providing a profile of risk
factors related to AAS use among adolescents.
1. Methodology
Computerised (MEDLINE, Focus on Sports Science and Medicine, SPORT Discus and Illinet Online) and manual (SPORT Search, Physical Education Index, Current Contents, Index Medicus and
Psychological Abstracts) literature searches were
performed, and the resultant local, state, national
and international reports of illicit AAS use by adolescents that referenced risk factors were reviewed.
Selected key words for our literature search included
adolescents, anabolic-androgenic steroids, illicit
drug use and risk factors. In addition, we contacted
government and university authorities knowledgeable about risk factors for AAS use among adolescents. All reports of illicit AAS use by adolescents
and associated risk factors identified through these
methods are described.
Studies that measure AAS use are helpful regarding risk factor analysis. Although specific methods used in each study differ, the reports we reviewed generally employed cross-sectional designs
Adis International Limited. All rights reserved.

399

and used self-administered questionnaires. Some

reports focused on AAS use, while other reports
included alcohol, cigarettes and other drugs as well
as AAS. Most questionnaires specified steroid use
without a physicians prescription to differentiate
AAS used for performance enhancement from those
employed in prescribed medical treatment (e.g.
asthma). All surveys emphasised the confidential
nature of responses to participating students. For
some surveys, anonymity was enhanced by research
team members administering the survey (rather than
school personnel).
2. Identified Risk Factors
2.1 Demographic Factors
2.1.1 Gender

In addition to the previously mentioned reports

which examined the prevalence of AAS use by male
and female adolescents, at least 25 studies have
reported that the likelihood of using AAS is increased by being male.[14-40] Only 1 study[41] has
reported higher prevalence rates for female adolescents than male adolescents (2.8 vs 2.6%, respectively). This difference was not statistically significant. However, the relative risk of AAS use is
generally at least 2 to 3 times greater for male adolescents.
2.1.2 Age and Grade Level

While one survey found the mean age of first

use was 14 years,[36] 4 surveys have reported initial
use beginning around a mean age of 15.[6,21,30,38]
In addition, one survey of high school students reported that 7% of the AAS users began using at age
10 or younger[29] and another[41] has found use among fifth, sixth and seventh grade middle school
students, indicating that AAS use may occur at a
relatively early age.
Several state and national level studies indicate a
relationship between adolescent AAS use and age:
older adolescents have significantly higher AAS use
rates than younger adolescents.[7,15,23,28,30,34,42,43]
Conversely, other studies have found the prevalence
of AAS use not to be associated with age and/or
grade level.[16,22,24,26,27,36,44] Based on these findSports Med 2000 Jun; 29 (6)

400

ings, it would appear that there is a broad age range

among young people (including pre-adolescents)
associated with the use of AAS.
2.1.3 Race and Ethnicity

Several studies have reported that White students

had a higher usage rate of AAS than non-White
students.[23,30,45-48] However, other studies have reported no racial difference in the use of AAS by
adolescents,[26,27,38,44,49] while some report greater
use among minorities.[6,19,22,25,28,34] It seems, at this
time, that there is no clear-cut relationship between
race/ethnicity and AAS use.
2.1.4 Socioeconomic Status

Windsor and Dumitru[40] reported that affluent

students had higher AAS use rates than less affluent
students. The researchers speculated this was because affluent individuals with greater economic
resources would be better able to obtain AAS. Also,
Handelsman and Gupta[22] have found AAS use associated with higher student income. However, another investigation[30] reported that users and nonusers did not differ with regards to socioeconomic
status and no significant association existed between
socioeconomic status and AAS use when subjected
to more sophisticated statistical analysis.
2.1.5 Parental Characteristics

A 1995 survey[46] found that students who did

not live with 2 parents had slightly higher AAS use
rates compared with students who lived with 2 parents. In addition, living alone has been reported to
be associated with higher AAS use rates among
male students,[18] and an Australian study[22] found
AAS use associated with unsupervised recreation
time. With regard to parents education level, Buckley et al.[6] observed that non-users of AAS were
more likely to have a parent who completed high
school.
2.1.6 Geographical Location

It has been reported that students living in the

South of the US had the highest rates of AAS use,
followed by the Midwest and West of the US.[26]
However, Yesalis et al.[50] found no difference in
AAS use rates between sunbelt (the states of California, Florida and Texas, among others) and non Adis International Limited. All rights reserved.

Bahrke et al.

sunbelt schools. In South Africa, Lambert et al.[20]

found significant differences in the prevalence of
AAS use among adolescents in 2 geographically
separate regions.
2.1.7 City Size

One study[46] reported that students living in the

largest metropolitan areas had lower use rates than
students living in the other areas of the state. Conversely, Kindlundh et al.[18] reported higher rates
among male students reared in Swedens 3 largest
cities than boys who had grown up outside the large
cities. Other investigations[39,50] reported city size
not to be significant, but as with school sizes, definition of city size are likely to be different.
2.2 Academic and Sports
Participation Factors
2.2.1 School Size

Smaller high schools have been found to have

significantly lower AAS use rates.[6,50] However, 2
other studies did not support this conclusion. The
use of AAS was higher in smaller (enrolment < 500
students) than in larger high schools (enrolment >
1500 students) in one study[51] and, in the other,
school size was not significantly related to AAS
use.[39] It is important to note that defined school
sizes in these studies were different.
2.2.2 Academic Performance

Two investigations have reported that adolescent AAS users have lower school grades,[26,52] and
2 investigations[18,22] have found AAS use to be
associated with truancy. In addition, being dissatisfied at school has been reported to be associated
with higher AAS use rates.[18] Conversely, 2 studies have reported that academic achievement was
not significantly related to AAS use.[14,27] Although
it appears that there may be some association between AAS use and poorer academic performance,
future studies will need to examine this relationship more closely.
2.2.3 Athletic Participation

Improvement of athletic performance has been

reported by numerous adolescents as a major reason
for using AAS.[6,29,34,37,39,49] Generally, AAS users
Sports Med 2000 Jun; 29 (6)

Anabolic-Androgenic Steroid Use Among Adolescents

are significantly more likely to participate in schoolsponsored athletics than non-users.[6,23,29,34-36] The
sports most closely associated with AAS use among
adolescents are primarily the muscular strengthand size-dependent sports of football, wrestling and
track and field.[6,23,29,31,34,37,40,50] However, other investigations[26,39,40] have reported that AAS use was
not significantly associated with school-sponsored
athletics. It should be noted that there is a substantial number of adolescents who do not participate
in school-sponsored sports (approximately 30 to
40%), but who do use AAS.[6,23] These adolescents
may participate in some level of bodybuilding or
weightlifting.
2.3 Personal Factors
2.3.1 Personality and Behaviour

In a study designed to assess a broad range of

psychological characteristics in adolescent athletes
who reported AAS use, no personality variables
such as introversion, confidence and sensitivity
significantly differentiated between athletes who
used AAS and athletes who did not.[53] However,
one study[35] found AAS users more likely to report
acting violently, and another[38] found that AAS
use was significantly correlated with self-reported
aggressive behaviour and crimes against property.
2.3.2 Body Image and Perceived Physical Health

Several investigations have reported that AAS

use may be associated with poor body image.[14,21,30]
Interestingly, a considerable percentage of adolescent steroid users surveyed in other studies, ranging
from 16 to 36%, were not athletes or did not participate in any routine exercise activity.[6,26,29,34,40,46,49]
Many of these adolescents used AAS to improve
appearance (the second most popular reason for
AAS use by adolescents; improving sports performance is the most popular) as a result of dissatisfaction with body image. One investigation[52] suggested that adolescent boys, who desire weight gain
and currently abstained from AAS, may be more
likely to try AAS.
While a Canadian survey[14] found that perceived
physical health was not significantly related to AAS
use, other studies have found that AAS users are
Adis International Limited. All rights reserved.

401

more satisfied with their bodies[30] and rate their

levels of strength[6,21] and health[6,39,50] above average.
2.3.3 Knowledge and Attitudes

Several studies have reported that the more individuals knew about AAS, the more favorable was
their attitude and potential toward their use.[23,30,54,55]
Although there is evidence that providing a prevention programme that uses scare tactics to dissuade adolescents from becoming involved with
AAS may actually lead to increased use,[56] another
study[57] has shown reduced use among adolescents
following a specialised educational intervention.
This programme used a cognitive-behavioural approach in a social learning atmosphere to prevent
AAS use.
2.3.4 Knowing Other Steroid Users

Knowing other AAS users has been reported to

be significantly related to AAS use[30] and, among
athletes who found AAS to be widely available,
many knew multiple sources. Furthermore, several
studies[19,29,31,36,37,39] have reported friends of AAS
users as a primary source of AAS.
2.3.5 High-Risk Behaviour

Several studies[22,28,30,58] have found AAS use

to be associated with such high risk activities as
using injectable drugs, sharing needles and driving
too fast. Middleman et al.[58] reported that driving
after drinking, carrying a gun, number of sexual
partners in the last three months, not using a condom, history of sexually transmitted diseases, injury sustained in a physical fight requiring medical
attention, not wearing a helmet on a motorcycle,
not wearing a seatbelt and suicide attempts requiring
medical attention were all associated with AAS use.
2.3.6 Traumatic Events

One report[59] has suggested a possible causal

link between the occurrence of a traumatic event
in ones life (brothers stabbing death, son run over
by car, or childhood obesity and delayed sexual
development) and the subsequent decision to use
AAS. However, the limited sample size of this group
(n = 3) requires great caution in interpreting this
observation.
Sports Med 2000 Jun; 29 (6)

402

2.4 Other Illicit Drug Use Factors

An interesting hypothesis that has been proposed

several times is that AAS users are less likely to use
other illicit drugs.[25,26,28,39,55] This hypothesis was
based on the assumption that AAS users are attempting to improve their appearance and strength
and will therefore not jeopardise their health or athletic performance by using other drugs. However,
no currently available study supports this theory.
In fact, unanimous support is given to the alternative hypothesis, that AAS users are poly-drug users. Several studies show a statistically significant
association of AAS use with other illicit drug
use.[14,16-18,25-28,31,34,35,38,39,60] These studies have reported that the likelihood of using AAS was associated with the use of several other drugs including
marijuana, cocaine, stimulants, relaxants, heroin,
caffeine, alcohol, cigarettes and smokeless tobacco.
One more important drug trend in adolescent
AAS users that deserves considerable attention is
the use of injectable drugs. Studies have reported a
strong association between injectable drug use and
AAS use.[25-28] Some of these same studies have
also observed a significant association with injectable drugs and the use of shared needles.[25,26,28]
3. Comment
Identified risk factors for illicit AAS use by adolescents in the present report include being male,
use of other illicit drugs and participation in strengthdependent sports such as football, wrestling and
weightlifting. In addition, results from 3 national
surveys, the National Household Survey on Drug
Abuse, the Monitoring the Future Study and the
Youth Risk Behavior Surveillance Survey confirm
many of these same factors: the majority of adolescent AAS users are males who participate in a variety of risky behaviours including the use of other
illicit drugs, fighting and driving while under the
influence of alcohol and drugs.[61]
Identifying risk factors associated with AAS use
among adolescents helps us differentiate the physical and psychological changes such as increases in
weight, strength and aggression normally occurring
Adis International Limited. All rights reserved.

Bahrke et al.

during adolescence from those resulting from AAS

use. It is also possible that changes frequently attributed to AAS use may reflect changes resulting
from weight training, the concurrent use of other
substances such as alcohol, cocaine, amphetamines
or other stimulants such as ephedrine and caffeine,
and from dietary manipulation including nutritional
supplements.[62] Possible indicators of AAS use include rapid or disproportionate increases in muscle
size or strength that are unexpected with ordinary
training, obsessive focus with weightlifting and diet,
preoccupation with body image, increased appetite
and mood swings.[61]
The association between AAS use and the use
of other illicit drugs, alcohol and tobacco is an important issue that deserves attention. As noted previously, several studies show a statistically significant association of AAS use with other illicit drug
use among adolescents.[14,16,17,25-28,31,34,35,38,39,60]
However, these studies employed a cross-sectional
design. Therefore, neither the direction of the relationship nor causality can be established. Moreover, confounders could be operating and, for example, the common ground between AAS use and
other illicit drug use could merely reflect a propensity to take risks, as seen in other studies.[22,28,30,58]
It is also reasonable to assume that a response bias
exists whereby individuals comfortable enough to
report that they have used an illicit drug are more
likely to report the use of other drugs.
The effects of purified sex hormones, including
those on mood and mental disorders, began to be
experimentally and clinically explored during the
last half century and were found to be generally
positive.[63] However, more recently, in contrast to
earlier findings, clinical reports of individuals using AAS in sport and exercise have suggested that
affective and psychotic syndromes, some of violent
proportions, may be associated with the use of AAS
in particular individuals. Several cases have been
reported wherein defendants alleged behavioural
effects of AAS significantly influenced the commission of criminal acts.[63] In addition, one previous
study[35] found adolescent AAS users more likely
to report acting violently and another[38] that AAS
Sports Med 2000 Jun; 29 (6)

Anabolic-Androgenic Steroid Use Among Adolescents

use was significantly correlated with self-reported

aggressive behaviour and crimes against property.
In the wake of the doping scandal among competitors in the 1998 Tour de France bicycle race,
the revelation that baseball slugger Mark McGwire
used androstenedione and creatine in his quest for
a new home run record, the admission of AAS use
by the new governor of the state of Minnesota[64]
and the suspension of several former Olympic gold
medalists for drug use, what can be done to combat
the risks associated with AAS use among adolescents?
Several education and prevention programmes
utilising information dissemination of the adverse
effects of and alternatives to AAS use have been
effective. Goldberg et al.[57] have used a successful
cognitive-behavioural approach in a social learning atmosphere to prevent AAS use. This programme
has focused, in part, on positive educational initiatives related to nutrition and strength training. Increasing adolescents awareness of the types of social pressures they are likely to encounter to use
AAS and attempts to inoculate them against these
pressures are major components of the programme.
Adolescents are taught specific skills for effectively
resisting both peer and media pressures to use AAS.
Periodic monitoring and reporting of actual AAS
use among adolescents was conducted in an effort
to dispel misinformation concerning the widespread
use of AAS among peers. Using peers as programme
leaders was an additional component. This programme has been successful in significantly affecting attitudes and behaviours related to steroid use
and has remained effective over several years. However, the Goldberg et al.[57] programme is directed
toward male athletes, and gender-specific and nonathlete strategies may be required to arrest the
growing use of AAS by adolescent females and
non-athletes.
Drug testing, for many years the mainstay of
drug prevention efforts among elite athletes, is being increasingly examined as a potential AAS reduction strategy at the secondary school level. Since
the US Supreme Court ruled in 1995 that a school
districts random drug testing of its students is con Adis International Limited. All rights reserved.

403

stitutional under the Fourth Amendment to the

Constitution, drug testing as a way to discourage
the use of AAS and other performance enhancing
drugs among adolescents is beginning to occur.[65]
However, drug testing as a method of detecting
AAS abuse is flawed and testing is often circumvented by the user. In addition, testing for AAS is
expensive (approximately $US120 per test) and prohibitive for the vast majority of secondary schools.[11]
Only a handful of school systems may be able to
incur the costs of testing for AAS.[65]
4. Conclusion
Only a partial profile can be created to characterise the adolescent AAS user. Steroid users are
significantly more likely to be males and to use
other illicit drugs, alcohol and tobacco. Student athletes are also more likely than non-athletes to use
AAS, and football players, wrestlers, weightlifters
and especially bodybuilders have significantly
higher prevalence rates than students not engaged
in these activities. However, the effects of race/
ethnicity, age/grade level, body image and other
factors on AAS use are not fully understood. In
addition, several other areas, such as academic performance and socioeconomic status, require further investigation before associations can be made
with a reasonable degree of confidence.
Risk factors associated with illicit AAS use among
adolescents have been identified. Physicians, parents and teachers should be aware of these risk factors in the effort to identify and deter AAS use by
adolescents.
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Correspondence and offprints: Dr Michael S. Bahrke, Human

Kinetics, 1607 North Market Street, Champaign, IL 618255076, USA.
E-mail: mikeb@hkusa.com

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