Examining androgenic-anabolic steroid (AAS) use with the use of a theoretical model has yet to be explored in scientific literature. Oftentimes, the authors of research studies track the epidemiology of AAS use by adolescents, athletes, and young adults and present limited trend data (2,5,10,20,22,23). Even fewer studies have researched AAS from qualitative perspective. One study attempted to qualitatively explore the phenomenon of AAS use in limited groups (17). Limited to no research has attempted to incorporate the behavior process of becoming an AAS user into a health behavior theory and/or model.
Because of the increasing media attention concerning professional athletes' use of AAS and similar performance-enhancing substances, for example, human growth hormone (HGH) and insulin growth factors, mainstream society may feel disconnected when trying to explain AAS in adolescents and young adults who are not professional athletes, because of the multitude of negative consequences. Essentially, coverage of AAS in society has existed in a dichotomous world, one of sports (professional sports and NCAA Division I athletics) and another in mainstream society (32). A primary issue may be the understanding there are many more people using AAS and other substances in mainstream society than in professional and collegiate sports (8,12,17,32). Coverage that focuses solely on AAS use in sport versus mainstream society for aesthetic purposes can be seen in recent reports and studies, such as the Mitchell Report. Elliot et al. (6) discussed AAS usage trends for aesthetic purposes in adolescents in addition to use in athletics. The social aspects of AAS use also were corroborated by Sutherland and Shepherd (29).
The Report to the Commissioner of Baseball of an Independent Investigation into the Illegal Use of Steroids and Other Performance Enhancing Substances by Players in Major League Baseball, informally known as the “Mitchell Report,” is the result of former United States Senator George J. Mitchell's 20-month investigation into the use of anabolic steroids and HGH in Major League Baseball (MLB) (20). The 409-page report, released on December 13, 2007, covers the history of the use of illegal performance-enhancing substances by players and the saliency of the MLB Joint Drug Prevention and Treatment Program. The report names 89 MLB players who are alleged to have used steroids or drugs (20).
A need for understanding adolescent AAS use often falls in the domain of the health and fitness professional (29). Sutherland and Shepherd discuss a need for health, fitness, and sports professionals to take the lead in eradicating steroids for sports or training purposes while at the same time understanding the social forces that may predispose some adolescents to use (29). Similarly, advancing research in the area of evidence-based curriculum development has been a widely discussed topic (6). Concern for what is occurring in professional sports, such as MLB pertaining to AAS use, has left many professionals and parents wondering what can be done to prevent body image disorders and the use of body image drugs (6). As it stands, few evidence-based, theory-driven programs and curricula aimed at decreasing AAS and other body image drug use have been researched and developed (6).
Personal trainers and strength and conditioning professionals often interact with clients in the general population who have questions concerning sports supplementation and possibly the use of illicit substances, such as AAS. Understanding what phase they may be in can provide the healthiest and most efficacious solution to their inquiry. One of the health education and health behavior models that can be used to address this and like issues is the transtheoretical model (TTM) proposed and developed by Prochaska (27), which will be presented in the following section. The purpose of this article is to present and discuss how the TTM can be used to explain AAS use in adolescents and young adults.
THEORETICAL FRAMEWORK: THE TRANSTHEORETICAL MODEL
TTM, also known as stage theory, was originally proposed by Prochaska in 1979 as a way to provide answers concerning stages of change people may go through in adopting (or not adopting) health behaviors. The TTM uses stages of change to integrate processes and principles of change from across major theories of intervention (7). The model originated from a comparative analysis of leading theories on psychotherapy and behavior change (27). Behavior change, for the positive or negative, unfolds through a series of steps or changes (26). At its core, the TTM has 5 core “constructs”: precontemplation, contemplation, preparation, action, and maintenance, although some models include a sixth stage (termination). For the sake of completeness, we have chosen to use the 6-stage model because of the fact that AAS termination (cessation) is highly desirable. In addition to these constructs, the TTM also involves decisional balance, such as pros and cons, self-efficacy, and various processes of changes, for example, consciousness raising, dramatic relief, and re-evaluation of self (13,14,27).
Application of the TTM has ranged from smoking cessation to weight loss; however, the TTM has not been used to explore negative health behaviors, such as AAS use or the use of other illicit drugs. Using the model in reverse (see Table 3) to explain AAS use is the primary aim of this article. An understanding of the epidemiology of AAS use in adolescents and young adult populations is important when considering using theory to explain behaviors. Trends of AAS use are presented in the following section.
ANDROGENIC-ANABOLIC STEROID USE IN ADOLESCENTS AND YOUNG ADULTS
Anabolic agents, such as AAS, are substances that promote tissue growth through nitrogen sparing and protein synthesis (25). The use and abuse of AAS and other performance-enhancing substances is not new to sports (31,33). What is a newer trend is the use of AAS on a broader scale in mainstream society, likely for aesthetic purposes versus just strength and size (16,22,23). The period of adolescence and early adulthood is a particularly influential period of one's life when making choices concerning health (27,32). People who struggle with poor self-image, coupled with the confluence of social forces, may be at risk for developing negative health practices, such as AAS use, to compensate for poor body image (32).
People who are unable to achieve personal goals or handle pressures from peers, parents, coaches, and others regarding an unrealistic ideal body image may turn to AAS or other dangerous substances to satisfy their aspirations (18). In an older, but telling study (2), the authors noted that adolescent AAS users are at risk for several adverse psychobehavioral consequences, such as addiction, violence and aggression, and social conduct disorder. It has also been suggested that AAS users form a “risk behavior syndrome,” which encompasses the use of other harmful drugs and substances, such as cigarettes, smokeless tobacco, marijuana, alcohol, and cocaine (20). Risk-taking is not a surprise with AAS users and is exemplified by risky behavioral practices as with hypodermic needle use and abuse of addictive drugs, such as nalbuphine hydrochloride, a narcotic for pain control (16,20,30).
The enigma of AAS use by adolescents and young adults continues to be popularized by current media but understudied in theory. Tracking the epidemiology of use is confounded by self-report bias, recall bias, and issues of social desirability, which may affect truthfulness. Most recent data suggest younger males are most susceptible to use, with an overall national trend being 3-6% (4-6,20,22,25). Causes likely stem from sport performance pressures, but also deficits in self-esteem and body image (3,4,12,32). Because of the widespread and understudied explanations concerning AAS, theories and models, such as the TTM, can effectively be used to address some of the former issues.
USING THE TRANSTHEORETICAL MODEL TO EXPLAIN ANDROGENIC-ANABOLIC STEROID USE
As previously discussed, TTM provides a theoretical framework that crosses many disciplines in medical, health, and behavioral sciences (27). Being that AAS use has been presented from all of these perspectives, the TTM can be used to propose explanations as to why adolescents and young adults may elect to begin using AAS and other performance-enhancing drugs. The following sections present each stage of the TTM with a brief overview of its concepts, followed by the application of the TTM for explaining AAS use and behaviors (also see Table 3). Rather than viewing each stage as separate and distinct, often there is considerable overlap among all 6 stages (27). For a more detailed view of the TTM, see Table 1.
Persons in the precontemplation stage of the TTM have no intent to take action in the upcoming 6-month period. Failure to take action may be the result of a variety of factors, but most notably a lack of overall awareness of an issue or a low perception of risk or threat for a particular behavior (27). Users of AAS are often described as being part of a particular “culture,” a social construct characterized by daily behaviors centered around strength training, strict dieting (high protein and low fat), and immersion in discussions pertaining to fitness, magazines, and means to obtain performance-enhancing drugs (14). This “culture” often is preceded by changes within one's perception of one's body, most notably his or her body image (28,32). Many people, particularly adolescents and young adults, become aware of their changing body and their image of it between the ages of 13-25 years, with great variability between ages (32).
Adolescents and young adults who begin using AAS often do so after an initial exposure to the AAS culture or if there is a breach in their self-esteem, which may call their body image into question (3). As people developmentally advance into adolescence and young adulthood, the homogeneity of body types greatly varies and differentiates. This differentiation process may lead one to become dissatisfied with his/her body type and take measures to change it (32). The use of “body image” drugs, such as AAS, HGH, and ephedra derivatives, often tempt people to use with hopes of changing their body for the better (12). A goal for AAS educational strategies is to keep adolescents and young adults in this stage. To borrow from the health belief model, which assesses a person's intent to act, establishing or clarifying reasons of why not to use AAS, that is, having more barriers than benefits, and encountering more risks than rewards, are critical in preventing AAS use (27).
The contemplation stage involves planning on initiating change within the upcoming 6 months. People may be very aware of the benefits but also acutely aware of the costs. Balancing the costs versus the benefits can produce a lengthy contemplation stage (27).
Many adolescents participate in athletics, which may expose them to heightened pressures to be bigger, stronger, and faster (10). Others may view AAS as a means to produce a pleasing aesthetic appearance (18). The phenomenon of the “sheep mentality,” may prevail during these ages, particularly if role models, and members of the peer group, are found to be using banned substances (10). Moreover, exposure to social pressures may provoke internal conflict for an adolescent or young adult contemplating the use of AAS. When media, among other social pressures, reaches a critical level in terms of decision making, an external motivation may develop, which can lead to preparation for obtaining and using AAS (9).
In the preparation stage, people have the intent to take action on an issue in the immediate future (approximately 1 month). Some actions have lead up to this point, such as self-education and involvement with other people who are already involved in the process; that is other AAS users (27).
Accordingly, people who have been considering the use of AAS and other substances have gathered information on the logistics ranging from finding credible substances and dealers to financing the whole process (27). In many gymnasiums, the possibility of finding a person who has access to AAS is generally not problematic (32). Many AAS users will come up with the financial resources to afford this behavior through working more hours at the expense of social obligations (school, personal relationships, etc.), selling personal items, or simply becoming dealers themselves (2,8). In some instances, reports have focused on men who become sex workers to pay for their habit, but who do not identify as being homosexual (8,11,15,16). Essentially, the preparation stage ranges from figuring out the financial costs associated with AAS to finding out how to best dose and administer the AAS product. There may also continue to be an inner dialogue evaluating the associated physical risks and side effects, but the likelihood of using will continue (2).
The action stage is encompassed by overt modifications in one's behavior and/or lifestyle within the past 6 months (27). For purposes of this article, action means the person has begun using AAS or other substances. For use of AAS to begin, the person must have resolved the inner conflict discussed in the contemplation and preparation stage of this model. In the action stage, the person is intent on finding supplies, such as hypodermic needles and pills, as well as supportive treatments for side effects encountered with AAS. Side effects have been reported to range from severe body acne and breast tissue development to psychological effects, such as aggression and potentially violent behavior as with “roid rage” (16,32,33). Supportive treatments may include products to minimize the side effects of AAS (see Table 2), including a common cancer drug called tamoxifen, which is used to halt tissue growth in the breast (12). Users of AAS may use tamoxifen to minimize or hide the resulting gynecomastia (excessive breast tissue) that accompany mid- to longer term use (12,16). Other drugs, such as nalbuphine hydrochloride, may be used to combat the severe pain encountered with muscle tears from overtraining of muscle and tendon tissue (30). Finally, the threat of infection from injectable AAS is an ever-present possibility (8,11,12). It is not uncommon for AAS users to share needles in their subculture or to use needles more than once on themselves. These latter facts pose several public health and individual risks, from septic infection of the individual to transmission of HIV/AIDS viruses to others who share needles (11,16).
On the basis of the latter examples of potential risks of using AAS, users often will maintain usage for a variety of intrinsic and extrinsic reward systems. The inherent nature of the maintenance stage is based on the premise that people are less likely to be tempted to stop using a substance or enacting a behavior because of increasing confidence (27). User confidence is problematic in that the user will likely see and feel the results of AAS use. Androgenic-anabolic steroids do in fact cause muscle hypertrophy, an increase in lean mass, and notable strength increases (1,8,10,11,15,16,24,25,31). These intrinsic factors remind the user that their choice of AAS use behavior is working. The user sees his/her results each day in the mirror or in the increasing size of weight stacks they lift at their local workout facility.
Users also may maintain their behaviors and use of AAS based on social or external reinforcement they receive (27). People, such as personal/athletic trainers, friends, coaches, parents, or any other influential people in the adolescence's or young adult's life may inadvertently compliment the results of the person's negative behavioral choices in using AAS or other potentially harmful substances. These unhealthful, but often unintended, social reinforcements from others may lead to continued AAS use. The adolescent or young adult does not want to revert back to a previous stage, which may be viewed as less physically competent or weaker (1). Therefore, without proper education on the adverse effects (see Table 2) of AAS in this population, or if the person experiences a traumatic side effect themselves, use will likely continue (6).
According to Prochaska's original model of the TTM, people may progress to a termination stage where they do not give any thought to their new behavior because it has become second nature based on temporal events (27). The use of AAS and other substances, compared with positive health behaviors, often does not reach a termination stage. Drug use produces dependence and addictive type of qualities that stay with the individual throughout his/her life, thus terminating the thoughts of the dangers of use (11). As with other types of drug and alcohol treatment approaches, many AAS users encounter similar dependence issues, such as withdrawal and mood disturbances. Withdrawal from AAS, however, remains a controversial theory (24,33). The lure of drug use will always remain; how it is managed through self-control and treatment becomes the main goal of intervention and treatment strategies.
It has become increasingly important to address performance-enhancing substance use as with androgenic-anabolic steroids in the strength and conditioning profession. Not only is this a contemporary issue relevant to athletes and those who are physically active but also for populations who use these drugs for enhancing appearance with hopes of achieving an aesthetic sociocultural ideal. Identifying behaviors, such as secrecy, ritualistic exercise patterns, change in affect, and issues with money, among other behaviors indicative of AAS use should be noted by the strength and conditioning professional. Understanding how to use health theory and health behavior models (see Table 3), such as TTM, to explain AAS use may help improve communication among strength and conditioning professionals and also among the clients they work with each day. Effective communication will hopefully parlay into further discussions and interventions curtailing the use of performance-enhancing substances, such as AAS.
Much of the discussion surrounding AAS use and other performance-enhancing substances stems from examples in professional sports, such as the National Football League and MLB. Only a fraction of this discussion in the popular media has addressed this issue from a public health perspective. Clearly, more people use AAS and like substances for aesthetic purposes versus sport performance (12). Being that strength and conditioning professionals are on the front lines of this issue and are often called upon to be resource persons, a clear understanding of the psychobehavioral processes people experience related to AAS use is needed. Part two of this theoretical and conceptual model will present effective theory-based strategies to help identify and curtail the use of performance-enhancing drugs, such as AAS.
1. Berning JM, Adams KJ, and Stamford BA. Anabolic steroid usage in athletics: Facts, fiction, and public relations. J Strength Cond Res
18: 908-917, 2004.
2. Burnett KF and Kleiman ME. Psychological characteristics of adolescent steroid users. Adolescence
29: 81-90, 1994.
3. Cohane G and Pope HG. Body image
in boys: A review of the literature. Int J Eat Disord
29: 373-379, 2001.
4. Drewnowski A, Kurth CL, and Krahn DD. Effects of body image
on dieting, exercise, and anabolic steroid use in adolescent males. Int J Eat Disord
17: 381-386, 1995.
5. Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris WA, Lowry R, Mcmanus T, Chyen D, Shanklin S, Lim C, Grunbaum J, and Wechsler H. Youth risk behavior surveillance: United States 2005. Surveillance Summaries
55: SS-5, 2005.
6. Elliot DL, Moe EL, Goldberg L, Defrancesco CA, Durham MB, and Hix-Small H. Definition and outcome of a curriculum to prevent disordered eating and body-shaping drug use. J School Health
76: 67-73, 2006.
7. Ficke DL and Farris KB. Use of the transtheoretical model in the medication use process. Ann Pharmacother
39: 1325-1330, 2005.
8. Halkitis PN, Moeller RW, and Deraleau LB. Steroid use in gay, bisexual, and non-identified men-who-have-sex-with-men: Relations to masculinity, physical, and mental health. Psych Men Masc
9: 106-115, 2008.
9. Hargreaves D and Tiggemann M. The effect of television commercials on mood and body dissatisfaction: The role of self-schema activation. J Soc Clin Psych
10. Hoffman JR, Faigenbaum AD, Ratamess NA, Ross R, Kang J, and Tenebaum G. Nutritional supplementation and anabolic steroid use in adolescents. Med Sci Sport Exerc
40: 15-24, 2008.
11. Kanayama G, Cohane GH, Weiss RD, and Pope HG. Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: An underrecognized problem? J Clin Psychiatry
64: 156-160, 2003.
12. Kanayama G, Pope HG, and Hudson JI. “Body image
” drugs: A growing psychosomatic problem. Psychother Psychosom
70: 61-65, 2001.
13. Kiefluk D. Success strategies-Part 1. Strength Cond J
25: 21-22, 2003.
14. Kiefluk D. Success strategies-Part 2. Strength Cond J
25: 12-13, 2003.
15. Klein AM. Little Big Men: Bodybuilding Subculture and Gender Construction
. New York: State University of New York Press, 1993. pp. 7-31.
16. Lenehan P. Anabolic Steroids and Other Performance Enhancing Drugs
. London: Taylor and Francis, 2003. pp. 53-82, 117-134.
17. Leone JE and Fetro JV. Perceptions and attitudes toward androgenic-anabolic steroid usage in among two age categories: A qualitative inquiry. J Strength Cond Res
21: 532-537, 2007.
18. Leone JE, Sedory EJ, and Gray KA. Recognition and treatment of muscle dysmorphia and related body image
disorders. J Athl Train
40: 352-359, 2005.
19. Maravelias C, Dona A, Stefanidou M, and Spiliopoulou C. Adverse effects of anabolic steroids in athletes: A constant threat. Toxicol Lett
158: 167-175, 2005.
20. Middleman AB, Faulkner AH, Woods ER, Emans SJ, and Durant RH. High-risk behaviors among high school students in Massachusetts who use anabolic steroids. Pediatrics
96: 268-272, 1995.
21. Mitchell GJ. Use of performance-enhancing drugs in Major League Baseball (MLB). Office of the Commissioner of Baseball. December 13, 2007. Available at: http://mlb.mlb.com/mlb/news/mitchell/index.jsp
. Accessed: February 2, 2008.
22. Nilsson S, Baigi A, Marklund B, and Fridlund B. Trends in the misuse of androgenic anabolic steroids among boys 16-17 years old in a primary healthcare area in Sweden. Scand J Prim Health Care
19: 181-182, 2001.
23. Nilsson S, Spak F, Marklund B, Baigi A, and Allebeck P. Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden. Substance Use Misuse
39: 1183-1197, 2004.
24. Pope HG and Katz DL. Psychiatric effects of anabolic steroids. Psych Ann
22: 24-29, 1992.
25. Powers M. Performance-enhancing drugs. In: Principles of Pharmacology for Athletic Trainers
. J. Houglum, G. Harrelson, and D. Leaver-Dunn, eds. Thorofare, NJ: Slack, 2005. pp. 327-332.
26. Prochaska JO and Diclemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Counsel Clin Psych
51: 390-395, 1983.
27. Prochaska JO, Redding CA, and Evers KE. The transtheoretical model and stages of change. In: Health Behavior and Health Education: Theory Research, and Practice
. K. Glanz, B.K. Rimer, and F. Marcus-Lewis, eds. San Francisco, CA: Jossey-Bass, 2002. pp. 99-120.
28. Sondhaus EL, Kurtz RM, and Strube MJ. Body attitude, gender and self-concept: A 30-year perspective. J Psychol
135: 413-429, 2001.
29. Sutherland I and Shepherd JP. Social dimensions of adolescent substance abuse. Addiction
96: 445-458, 2001.
30. Wines JD, Gruber AJ, Pope HG, and Lukas SE. Nalbuphine hydrochloride dependence in anabolic steroid users. Am J Addict
8: 161-164, 1999.
31. Wright JE and Cowart VS. Anabolic Steroids
. Carmel, IN: Benchmark Press Inc., 1990. pp. 45-71.
32. Wroblewska AM. Androgenic-anabolic steroids and body dysmorphia in young men. J Psychosom Res
42: 225-234, 1997.
33. Yesalis CE, Vicary JR, and Buckley WE. Anabolic steroid use among adolescents: A study of indications of psychological dependence. In: Anabolic Steroids in Sport and Exercise
. C.E. Yesalis, ed. Champaign, IL: Human Kinetics, 1993. pp. 216-229.
Keywords:© 2008 National Strength and Conditioning Association
epidemiology; body image; performance-enhancement drugs; public health