Skip to main content
SpringerLink
Log in

Appearance- and Performance-Enhancing Substances Including Anabolic-Androgenic Steroids Among Boys and Men

  • Chapter
  • First Online:
Eating Disorders in Boys and Men

Abstract

Body dissatisfaction, particularly with a focus on muscularity, continues to be a pervasive issue among boys and men. It may then come as no surprise that some look to use special drugs and substances to facilitate their pursuit of an increasingly muscular physique. This chapter highlights a myriad of both legal and illegal appearance- and performance-enhancing substances (APESs) which could be sought for such functions, with a particular focus on a class of illicit APES that has received arguably the greatest empirical and clinical attention – anabolic-androgenic steroids (AASs). While AASs may be sought out to boost lean muscularity at a rate virtually impossible through conventional diet or exercise alone, our chapter first presents medical research to underscore the physical and psychological health complications connected with its use. Second, we illustrate the close relationship between problematic male body image and the motivation to use AASs, highlighting in particular its association with muscle dysmorphia, a serious psychiatric condition hallmarked by the pathological extreme pursuit of muscularity. The chapter closes by synthesizing available literature to provide an overview of important (but preliminary) considerations, guidance, and recommendations that may help support clinicians in dealing with the complexities of AAS use.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Notes

  1. 1.

    In this chapter, we use the terms males and boys/men interchangeably.

References

  1. Leit R, Gray J, Pope H. The media’s representation of the ideal male body: a cause for muscle dysmorphia? Int J Eat Disord. 2002;31(3):334–8.

    Article  PubMed  Google Scholar 

  2. Pope H, Phillips K, Olivardia R. The Adonis complex: the secret crisis of male body obsession. New York: Free Press; 2000.

    Google Scholar 

  3. McLean S, Wertheim E, Paxton S. Preferences for being muscular and thin in 6-year-old boys. Body Image. 2018;26:98–102.

    Article  PubMed  Google Scholar 

  4. Hildebrandt T, Lai J, Langenbucher J, Schneider M, Yehuda R, Pfaff D. The diagnostic dilemma of pathological appearance and performance enhancing drug use. Drug Alcohol Depend. 2011;114(1):1–11.

    Article  PubMed  Google Scholar 

  5. Bhasin S, Storer T, Berman N, Callegari C, Clevenger B, Phillips J, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996;335(1):1–7.

    Article  CAS  PubMed  Google Scholar 

  6. Begley E, Mcveigh J, Hope VD. Image and performance enhancing drugs: 2016 National survey results survey. Public Health Institute, Liverpool John Moores.

    Google Scholar 

  7. Goldman A, Pope H, Bhasin S. The health threat posed by the hidden epidemic of anabolic steroid use and body image disorders among young men. J Clin Endocrinol Metab. 2019;104(4):1069–74.

    Article  PubMed  Google Scholar 

  8. Kanayama G, Hudson J, Pope H. Illicit anabolic–androgenic steroid use. Horm Behav. 2010;58(1):111–21.

    Article  CAS  PubMed  Google Scholar 

  9. Pope H, Wood R, Rogol A, Nyberg F, Bowers L, Bhasin S. Adverse health consequences of performance-enhancing drugs: an endocrine society scientific statement. Endocr Rev. 2014;35(3):341–75.

    Article  CAS  PubMed  Google Scholar 

  10. Griffiths S, Murray S, Mitchison D, Mond J. Anabolic steroids: lots of muscle in the short-term, potentially devastating health consequences in the long-term. Drug Alcohol Rev. 2016;35(4):375–6.

    Article  PubMed  Google Scholar 

  11. Pope H, Kanayama G, Athey A, Ryan E, Hudson J, Baggish A. The lifetime prevalence of anabolic-androgenic steroid use and dependence in Americans: current best estimates. Am J Addict. 2014;23(4):371–7.

    Article  PubMed  Google Scholar 

  12. Sagoe D, Molde H, Andreassen C, Torsheim T, Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol. 2014;24(5):383–98.

    Article  PubMed  Google Scholar 

  13. Brown G, Vukovich M, King D. Testosterone prohormone supplements. Med Sci Sports Exerc. 2006;38(8):1451–61.

    Article  CAS  PubMed  Google Scholar 

  14. Van Thuyne W, Van Eenoo P, Delbeke F. Nutritional supplements: prevalence of use and contamination with doping agents. Nutr Res Rev. 2006;19(1):147–58.

    Article  PubMed  CAS  Google Scholar 

  15. Brett J, Dawson A, Brown J. Clenbuterol toxicity: a NSW Poisons Information Centre experience. Med J Aust. 2014;200(4):219–21.

    Article  PubMed  Google Scholar 

  16. Spiller H, James K, Scholzen S, Borys D. A descriptive study of adverse events from clenbuterol misuse and abuse for weight loss and bodybuilding. Subst Abus. 2013;34(3):306–12.

    Article  PubMed  Google Scholar 

  17. Balasubramanian A, Thirumavalavan N, Srivatsav A, Lipshultz L, Pastuszak A. 126 testosterone imposters: an analysis of popular online testosterone boosting supplements. J Sex Med. 2019;16(4):S65.

    Article  Google Scholar 

  18. Clemesha C, Thaker H, Samplaski M. ‘Testosterone boosting’ supplements composition and claims are not supported by the academic literature. World J Mens Health. 2020;38(1):115.

    Article  PubMed  Google Scholar 

  19. Morton R, Murphy K, McKellar S, Schoenfeld B, Henselmans M, Helms E, et al. A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. Br J Sports Med. 2018;52(6):376–84.

    Article  PubMed  Google Scholar 

  20. Kreider RB, Kalman DS, Antonio J, Ziegenfuss T, Wildman R, Collins R, et al. International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport and medicine. J Int Soc Sports Nutr. 2017;14:18.

    Google Scholar 

  21. Karlic H, Lohninger A. Supplementation of l-carnitine in athletes: does it make sense? Nutrition. 2004;20(7–8):709–15.

    Article  CAS  PubMed  Google Scholar 

  22. Kanayama G, Hudson J, Pope H Jr. Anabolic-androgenic steroid use and body image in men: a growing concern for clinicians. Psychother Psychosom. 2020;89(2):65–73.

    Article  PubMed  Google Scholar 

  23. Saad F, Doros G, Haider K, Haider A. Differential effects of 11 years of long-term injectable testosterone undecanoate therapy on anthropometric and metabolic parameters in hypogonadal men with normal weight, overweight and obesity in comparison with untreated controls: real-world data from a controlled registry study. Int J Obes (Lond). 2020;44(6):1264–78.

    Article  CAS  Google Scholar 

  24. Kanayama G, Hudson J, Pope HG. Long-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: a looming public health concern? Drug Alcohol Depend. 2008;98(1–2):1–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Baggish A, Weiner R, Kanayama G, Hudson J, Lu M, Hoffmann U, et al. Cardiovascular toxicity of illicit anabolic-androgenic steroid use. Circulation. 2017;135(21):1991–2002.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. D’Andrea A, Caso P, Salerno G, Scarafile R, De Corato G, Mita C, et al. Left ventricular early myocardial dysfunction after chronic misuse of anabolic androgenic steroids: a Doppler myocardial and strain imaging analysis. Br J Sports Med. 2007;41(3):149–55.

    Article  PubMed  Google Scholar 

  27. Thiblin I, Garmo H, Garle M, Holmberg L, Byberg L, Michaëlsson K, et al. Anabolic steroids and cardiovascular risk: a national population-based cohort study. Drug Alcohol Depend. 2015;152:87–92.

    Article  CAS  PubMed  Google Scholar 

  28. Pope HG. Psychiatric and medical effects of anabolic-androgenic steroid use. Arch Gen Psychiatry. 1994;51(5):375.

    Article  CAS  PubMed  Google Scholar 

  29. ​Pope HG, Kouri EM, Powell KF, Campbell C, Katz DL. Anabolic-androgenic steroid use among 133 prisoners. Comprehensive Psychiatry. 1996;37:322–27. 

    Google Scholar 

  30. Beaver K, Vaughn M, DeLisi M, Wright J. Anabolic-androgenic steroid use and involvement in violent behavior in a nationally representative sample of young adult males in the United States. Am J Public Health. 2008;98(12):2185–7.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Griffiths S, Henshaw R, McKay F, Dunn M. Post-cycle therapy for performance and image enhancing drug users: a qualitative investigation. Perform Enhanc Health. 2017;5(3):103–7.

    Article  Google Scholar 

  32. Mosley P. Bigorexia: bodybuilding and muscle dysmorphia. Eur Eat Disord Rev. 2009;17(3):191–8.

    Article  PubMed  Google Scholar 

  33. Coward R, Rajanahally S, Kovac J, Smith R, Pastuszak A, Lipshultz L. Anabolic steroid induced hypogonadism in young men. J Urol. 2013;190(6):2200–5.

    Article  CAS  PubMed  Google Scholar 

  34. Kanayama G, Hudson J, DeLuca J, Isaacs S, Baggish A, Weiner R, et al. Prolonged hypogonadism in males following withdrawal from anabolic-androgenic steroids: an under-recognized problem. Addiction. 2015;110(5):823–31.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kaufman M, Kanayama G, Hudson J, Pope H. Supraphysiologic-dose anabolic–androgenic steroid use: a risk factor for dementia? Neurosci Biobehav Rev. 2019;100:180–207.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Bjørnebekk A, Walhovd K, Jørstad M, Due-Tønnessen P, Hullstein I, Fjell A. Structural brain imaging of long-term anabolic-androgenic steroid users and nonusing weightlifters. Biol Psychiatry. 2017;82(4):294–302.

    Article  PubMed  CAS  Google Scholar 

  37. Ip E, Barnett M, Tenerowicz M, Perry P. The anabolic 500 survey: characteristics of male users versus nonusers of anabolic-androgenic steroids for strength training. Pharmacotherapy. 2011;31(8):757–66.

    Article  CAS  PubMed  Google Scholar 

  38. Cohen J, Collins R, Darkes J, Gwartney D. A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States. J Int Soc Sports Nutr. 2007;4(1):12.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Murray S, Griffiths S, Mond J, Kean J, Blashill A. Anabolic steroid use and body image psychopathology in men: delineating between appearance- versus performance-driven motivations. Drug Alcohol Depend. 2016;165:198–202.

    Article  CAS  PubMed  Google Scholar 

  40. Ridgeway R, Tylka T. College men’s perceptions of ideal body composition and shape. Psychol Men Masculinity. 2005;6(3):209–20.

    Article  Google Scholar 

  41. Murray S, Nagata J, Griffiths S, Calzo J, Brown T, Mitchison D, et al. The enigma of male eating disorders: a critical review and synthesis. Clin Psychol Rev. 2017;57:1–11.

    Article  PubMed  Google Scholar 

  42. Frederick D, Buchanan G, Sadehgi-Azar L, Peplau L, Haselton M, Berezovskaya A, et al. Desiring the muscular ideal: men’s body satisfaction in the United States, Ukraine, and Ghana. Psychol Men Masculinity. 2007;8(2):103–17.

    Article  Google Scholar 

  43. Nagata J, Bibbins-Domingo K, Garber A, Griffiths S, Vittinghoff E, Murray S. Boys, bulk, and body ideals: sex differences in weight-gain attempts among adolescents in the United States. J Adolesc Health. 2019;64(4):450–3.

    Article  PubMed  Google Scholar 

  44. Nagata J, Murray S, Bibbins-Domingo K, Garber A, Mitchison D, Griffiths S. Predictors of muscularity-oriented disordered eating behaviors in U.S. young adults: a prospective cohort study. Int J Eat Disord. 2019;52(12):1380–8.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Nagata J, Ganson K, Griffiths S, Mitchison D, Garber A, Vittinghoff E, et al. Prevalence and correlates of muscle-enhancing behaviors among adolescents and young adults in the United States. Int J Adolesc Med Health. 2020.

    Google Scholar 

  46. Pope H, Kanayama G, Hudson J. Risk factors for illicit anabolic-androgenic steroid use in male weightlifters: a cross-sectional cohort study. Biol Psychiatry. 2012;71(3):254–61.

    Article  PubMed  Google Scholar 

  47. Griffiths S, Jacka B, Degenhardt L, Murray S, Larance B. Physical appearance concerns are uniquely associated with the severity of steroid dependence and depression in anabolic-androgenic steroid users. Drug Alcohol Rev. 2018;37(5):664–70.

    Article  PubMed  Google Scholar 

  48. Greenway C, Price C. A qualitative study of the motivations for anabolic-androgenic steroid use: the role of muscle dysmorphia and self-esteem in long-term users. Perform Enhanc Health. 2018;6(1):12–20.

    Article  Google Scholar 

  49. vandenBerg P, Neumark-Sztainer D, Cafri G, Wall M. Steroid use among adolescents: longitudinal findings from project EAT. Pediatrics. 2007;119(3):476–86.

    Article  PubMed  Google Scholar 

  50. Kanayama G, Brower K, Wood R, Hudson J, Pope H Jr. Treatment of anabolic–androgenic steroid dependence: emerging evidence and its implications. Drug Alcohol Depend. 2010;109(1–3):6–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Kanayama G, Barry S, Hudson J, Pope H. Body image and attitudes toward male roles in anabolic-androgenic steroid users. Am J Psychiatry. 2006;163(4):697–703.

    Article  PubMed  Google Scholar 

  52. Griffiths S, Murray S, Dunn M, Blashill A. Anabolic steroid use among gay and bisexual men living in Australia and New Zealand: associations with demographics, body dissatisfaction, eating disorder psychopathology, and quality of life. Drug Alcohol Depend. 2017;181:170–6.

    Article  CAS  PubMed  Google Scholar 

  53. Lavender J, Brown T, Murray S. Men, muscles, and eating disorders: an overview of traditional and muscularity-oriented disordered eating. Curr Psychiatry Rep. 2017;19(6):32.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing; 2013.

    Google Scholar 

  55. Pope H, Gruber A, Choi P, Olivardia R, Phillips K. Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics. 1997;38(6):548–57.

    Article  PubMed  Google Scholar 

  56. Pope H, Katz D, Hudson J. Anorexia nervosa and “reverse anorexia” among 108 male bodybuilders. Compr Psychiatry. 1993;34(6):406–9.

    Article  PubMed  Google Scholar 

  57. Cafri G, Olivardia R, Thompson J. Symptom characteristics and psychiatric comorbidity among males with muscle dysmorphia. Compr Psychiatry. 2008;49(4):374–9.

    Article  PubMed  Google Scholar 

  58. Olivardia R, Pope H, Hudson J. Muscle dysmorphia in male weightlifters: a case-control study. Am J Psychiatry. 2000;157(8):1291–6.

    Article  CAS  PubMed  Google Scholar 

  59. Murray S, Rieger E, Touyz S. Muscle dysmorphia symptomatology during a period of religious fasting: a case report. Eur Eat Disord Rev. 2011;19(2):162–8.

    Article  PubMed  Google Scholar 

  60. Murray S, Rieger E, Touyz S, De la Garza García Lic Y. Muscle dysmorphia and the DSM-V conundrum: where does it belong? A review paper. Int J Eat Disord. 2010;43(6):483–91.

    Article  PubMed  Google Scholar 

  61. Pope C, Pope H, Menard W, Fay C, Olivardia R, Phillips K. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2(4):395–400.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Kanayama G, Pope H, Hudson J. Associations of anabolic-androgenic steroid use with other behavioral disorders: an analysis using directed acyclic graphs. Psychol Med. 2018;48(15):2601–8.

    Article  PubMed  Google Scholar 

  63. Griffiths S, Murray S, Mond J. The stigma of anabolic steroid use. J Drug Issues. 2016;46(4):446–56.

    Article  Google Scholar 

  64. Kimergård A. A qualitative study of anabolic steroid use amongst gym users in the United Kingdom: motives, beliefs and experiences. J Subst Abus. 2014;20(4):288–94.

    Google Scholar 

  65. Dunn M, Henshaw R, McKay F. Do performance and image enhancing drug users in regional Queensland experience difficulty accessing health services? Drug Alcohol Rev. 2016;35(4):377–82.

    Article  PubMed  Google Scholar 

  66. Pope H, Kanayama G, Ionescu-Pioggia M, Hudson J. Anabolic steroid users’ attitudes towards physicians. Addiction. 2004;99(9):1189–94.

    Article  PubMed  Google Scholar 

  67. Cunningham M, Griffiths S, Mitchison D, Mond J, Castle D, Murray S. Muscle dysmorphia: an overview of clinical features and treatment options. J Cogn Psychother. 2017;31(4):255–71.

    Article  PubMed  Google Scholar 

  68. Brower K. Anabolic steroid abuse and dependence in clinical practice. Phys Sportsmed. 2009;37(4):131–40.

    Article  PubMed  Google Scholar 

  69. Vassallo M, Olrich T. Confidence by injection: male users of anabolic steroids speak of increases in perceived confidence through anabolic steroid use. Int J Sport Exerc Psychol. 2010;8(1):70–80.

    Article  Google Scholar 

  70. https://www.drugabuse.gov/publications/research-reports/steroids-other-appearance-performance-enhancing-drugs-apeds/how-are-anabolic-steroids-used.

  71. https://en.wikipedia.org/wiki/Androgen_prohormone.

  72. https://en.wikipedia.org/wiki/Essential_amino_acid.

Download references

Author information

Authors and Affiliations

  1. School of Psychology, The University of Sydney, Sydney, NSW, Australia

    Mitchell L. Cunningham

  2. School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia

    Scott Griffiths

Authors
  1. Mitchell L. Cunningham
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Scott Griffiths
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mitchell L. Cunningham .

Editor information

Editors and Affiliations

  1. Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA

    Jason M. Nagata

  2. Department of Psychiatry, University of California, San Diego, San Diego, CA, USA

    Tiffany A. Brown

  3. Department of Psychiatry and Behavioral Sciences, USC Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Stuart B. Murray

  4. Department of Medicine, Military Cardiovascular Outcomes Research (MiCOR) Program, Uniformed Services University of the Health Sciences, The Metis Foundation, Bethesda, MD, USA

    Jason M. Lavender

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Cunningham, M.L., Griffiths, S. (2021). Appearance- and Performance-Enhancing Substances Including Anabolic-Androgenic Steroids Among Boys and Men. In: Nagata, J.M., Brown, T.A., Murray, S.B., Lavender, J.M. (eds) Eating Disorders in Boys and Men. Springer, Cham. https://doi.org/10.1007/978-3-030-67127-3_12

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-67127-3_12

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-67126-6

  • Online ISBN: 978-3-030-67127-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation