A New League of US Steroid Users?

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In 2005, an ambitious psychology graduate student named Jason Cohen contacted me to ask for help. Jay, now Dr. Cohen, wanted to conduct an online survey of adult Americans who are using anabolic steroids non-medically. He was concerned that potential distrust among the target population might reduce participation. And he was probably right; while the survey was anonymous, it sought answers admitting criminal conduct (anabolic steroids are Schedule III controlled substances under federal law and illegal to possess without a valid medical prescription). That’s where I came in.

At the time, I had been a columnist in the popular Muscular Development magazine for several years and the author of the steroid treatise Legal Muscle. I had long before established a name for myself among hardcore bodybuilders as someone you could trust. I was busy successfully representing bodybuilders and fitness enthusiasts on legal matters nationwide, but I went to Washington, DC, and met with Jay in person. After speaking with him, I whole-heartedly signed on to the project. I promoted the survey on my website www.steroidlaw.com, in Muscular Development, and in online forums. I recruited University of South Florida psychology professor Jack Darkes, PhD, and fellow Muscular Development columnist Dan Gwartney, MD, to form a research team to analyze and publish the data. It was my honor and privilege to work closely with all three of them on the project – brilliant minds and terrific guys – over the span of nearly two years.

The number of respondents was unprecedented: We drew our nearly 2,000 male, adult, non-medical, US steroid users from a larger sample of 2,663 people from 81 countries – to my knowledge, the largest sample of this population ever surveyed in-depth. The results of our efforts were published in 2007 in the peer-reviewed Journal of the International Society of Sports Nutrition as a paper called “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.” We spelled out the who, why and how of non-medical steroid use in America.

But the data is now a decade old. How much have things changed? In 2015, a new team of researchers launched a survey of their own. Using a similar approach to ours, they recruited from online forums and steroid websites, garnering 231 male respondents who met the criteria for inclusion. While representing a much smaller sample size (despite equal time in the field) and focusing on testosterone, the findings, published in the Mayo Clinic Proceedings as a paper called “Heavy Testosterone Use Among Bodybuilders: An Uncommon Cohort of Illicit Substance Users,” beg review and comparisons to our work. Here’s a quick snapshot of a few things that jump out.

When it comes to the typical American steroid user, not much has changed. In 2005, our typical subject was a white male about 30 years old, highly educated, gainfully employed and earning an above-average income in a white-collar occupation. In 2015, the Mayo Clinic researchers found the typical subject to still be a white male over 25 years old with an above-average educational level and income. The biggest motivator for use was, and still is, increasing muscle mass.

In terms of testosterone dosages, we found that only 2.4% used less than 200 mg weekly, with 52% using between 200 and 599 mg weekly and 31.8% using between 600 and 999 mg weekly (only 10.3% used over a gram per week). The Mayo Clinic researchers found that 15.6% used less than 400 mg weekly, 26.8% used between 400 and 600 mg weekly, 17.7% used between 600 and 800 mg weekly, and 19.5% used between 800 mg and a gram weekly (16.5% used over a gram weekly). The average weekly dosages in the two studies are pretty close, somewhere between 600 and 800 mg. Not much change there.

In our survey, while 66% expressed a willingness to seek medical supervision, less than half had sufficient trust in their physician to report their steroid use; still, 61% obtained blood work at least once a year to assess the effects of steroid use on their physical health. The Mayo Clinic survey showed that 69.2% regularly see a physician, and 77.1% have routine laboratory tests performed – overall, a positive trend

As for adverse health consequences, the Mayo Clinic researchers report that “nearly all” experienced subjective adverse effects. But while the mainstream media may seize upon that finding to highlight the health risks of steroid use, a review of the data is in order. The “nearly all” refers to the 86% of those who said they experienced subjective adverse effects while using testosterone. What were these subjective effects? The most common were testicular atrophy (52.5%), acne (43.9%) and fluid retention (43.4%). Some 87% of the respondents used ancillary medications (clomiphene citrate, tamoxifen, anastrozole, letrozole) to avoid or ameliorate adverse effects. While this “polypharmacy” is often criticized among steroid users, controlling undesired but expected effects of a drug with other adjunct medications is accepted in standard clinical practice. Further, continued use despite subjective adverse effects cuts both ways – critics may claim it shows addiction, but a more rational assumption may be that the conditions were minor / tolerable as compared to the self-perceived benefits of steroid use.

More significantly, the Mayo Clinic researchers found abnormal lab tests among 37.9% of those undergoing regular testing, with 51.6% of that group reporting elevated liver and/or kidney markers. Of those reporting cholesterol abnormalities (18.8%) while using steroids, most (75%) were taking oral C-17 alkylated steroids. Interestingly, despite the fact that 58.7% of respondents reported using oral C-17 alkylated steroids, only about 2% of respondents indicated that they had ever experienced any liver or kidney problems relating to use (aside from elevated liver and/or kidney markers). Dr. Gwartney has noted that elevation in liver enzymes such as elevated AST and ALT are seen in athletes not using steroids, particularly those involved in strenuous training, due to training-induced muscle damage, and that kidney markers can be slightly elevated due to large muscle mass, creatine supplementation, or high protein diets.

So what have we got? Well, first, I’m glad that our findings were confirmed. The same people are still using steroids for the same reasons and in the same doses. While the behavior incorporates illegality, the majority of users exhibit responsibility – few if any other categories of illicit drug users would monitor their use through regular blood work. The Mayo Clinic researchers note that they found “no associations between longer duration or dose of testosterone and higher rates of illegal drugs, comorbid conditions, or criminal convictions. In contrast, our data indicate that those using testosterone for longer durations had higher incomes, were older, and were more likely to be married, all factors that are traditionally not associated with higher rates of illicit behaviors.” Users, including higher does users, are not scary monsters on society’s fringe, but rather ordinary, productive folks – something to consider in assessing our current regulatory and criminal justice framework on this issue. As for health consequences among these respondents, the adverse effects appear to be minor and benign, and are exactly what you would expect for androgenic drugs.

Obviously, there’s a lot more to look at in this new study, including some important findings worthy of comment. Look for an upcoming issue of Muscular Development magazine for further comments in my “Busted!” column.