Pediatric Exercise Science, 1994, 6, 149-1 58 O 1994 Human Kinetics Publishers, Inc. Anabolic Steroids: A Study of High School Athletes Charles B. Corbin, Steven A. Feyrer-Melk, Craig Phelps, and Lisa Lewis A group of 1,680 high school athletes were studied to determine factors associated with anabolic steroid use. A questionnaire assessed personal factors and steroid use, behavior of others and steroid use, and availability of anabolic steroids. Use rates were 1.1% for females and 2.4% for males. Steroids were more readily available to males, who also reported knowing more steroid users than did females. Older athletes were more likely to consider steroid use, but differences in use rate were not significant from Grade 8 to 12. Using discriminant analysis, significant differences (p <.001) were found for profiles of steroid users and nonusers for both males and females. For both males and females, personal factors such as having considered steroid use, a willingness to use them if they were legal, and a willingness to use them if they could insure success in sports were the most useful in classifying athletes as steroid users versus nonusers. Recent research indicates that an estimated 300,000 Americans engaged in anabolic steroid use during 1993 (16). Users included a significant number of teenagers who report initiating use, on the average, at age 15 (16). A larger number of people have used steroids at some point in their lives, with use particularly prevalent among athletes, depending on age, sport, and level of competition. Steroid use is most common among body builders with rates among males reported to be from 19.5 to 62% (14). Use among scholastic athletes is less than among collegiate athletes (4), though use among high school athletes has been reported to be as high as 10.9% among males and 1.1 % among females (5, 13, 14) as compared to 5.4% for males and 1.5% for females among the high school populations that include athletes and nonathletes (6). In addition to the direct harmful effects of anabolic steroids, recent reports have indicated that steroid users are more likely to use other illicit drugs, smoke cigarettes, and abuse alcohol (16). Furthermore, the use of anabolic steroids is associated with crimes against property and aggressive behavior (16). Because athletes are more likely to use steroids than those in nonathletic populations, it is important to identify those factors associated with steroid use. C.B. Corbin and S.A. Feyrer-Melk are with the Department of Exercise Science and Physical Education at Arizona State University, Tempe, AZ 85287-0701. C. Phelps and L. Lewis are with the Center for Sports Medicine and Orthopedics, 4220 North 19th Ave., Phoenix, AZ 85015.
150 - Corbin, Feyrer-Melk, Phelps, and Lewis The identification of these factors may be useful in educational efforts to reduce steroid use. Previous research has suggested that, as availability has increased, so has steroid use (12). Also, steroid use has been associated with the belief that these drugs will enhance athletic performance (3, 4, 10). Finally, use of steroids by friends and associates may be associated with personal use (9). The purpose of this study was to determine the extent to which availability of anabolic steroids, the perceived behaviors of others, and personal behaviors are factors associated with use among high school athletes. Subjects and Data Collection Methods Subjects were 1,690 students: 1,013 male and 677 female athletes in Grades 8 to 12. Testing was conducted in the summer, so subjects in the 8th grade were to be 9th graders, 9th graders to be 10th graders, and so on, at the beginning of the next school year. Twelfth graders were individuals who were entering a community college or university. The number of 12th-grade subjects was considerably lower than the other groups because of decreased post-high-school athletic participation. More than 200 male athletes were tested for all grades except Grade 12 and at least 100 female athletes were tested for all grades except Grade 12. Subject numbers were 29 males and 28 females for Grade 12. The subjects were potential or current athletes from high schools in a large city in the southwestern United States who participated in a medical evaluation conducted at a regional sports medicine facility on several weekends. Subjects were bused to the facility by school officials. A team of physicians, nurses, physical educators, and hospital volunteers provided the extensive free exam as a public service. Prior to participation, informed consent was obtained from all subjects and their parentslguardians. The project was approved by a university institutional review board and subjects were informed that they could choose not to answer any question or not to participate in the study. Of the total of 1,793 possible questionnaires, 103 were not completed or lacked sufficient answers to be included, thus 1,690 questionnaires were used for data analysis. A three-part steroids questionnaire that took approximately 5 minutes to complete was used to assess availability (four questions), behavior of others (two questions), and personal behavior in regard to anabolic steroids (four questions). Each question was designed to elicit a true or false response (see Table 1). Additional information concerning age, gender, year in school, and years participating on a school team were also included on the form. The questionnaire was included as part of a medical evaluation required for participation in sports competition. Subjects were asked to fill out the questionnaire while waiting prior to the medical evaluation. The subjects were given directions on how to fill out the form, along with assurances of anonymity. Names were not placed on the questionnaire. Completed questionnaires were placed in a sealed box to prevent identification by school officials. Only the researchers had access to the questionnaires. Subjects were aware that the box would not be opened until the end of the day. Some have suggested that questionnaire research underestimates steroid use (15);howem, recent research has
Anabolic Steroids - 151 Table 1 Anabolic Steroid Questions by Gender Question Total Male Female p Availability 1. It is easy to get anabolic steroids if you really want them. 2. I know people who sell anabolic steroids. 3. I know a coach or school official who has helped athletes get anabolic steroids. 4. I know a doctor who has helped athletes get anabolic steroids. Behavior of others 5. I have played on school teams with athletes who have used anabolic steroids. 6. I know people on school teams with athletes that take anabolic steroids. Personal behavior 7. I have considered taking anabolic steroids. 8. I have tried anabolic steroids. 9. I would take anabolic steroids if they were legal. 10. If I knew taking anabolic steroids would guarantee me an Olympic medal, I would take them. Note. The results indicate the percentage of respondents answering true to the statements. suggested that self-report techniques are quite accurate for documenting use among adolescents when anonymity is maintained, as it was in this study (16). Though various criteria have been used to judge steroid use, in this study those subjects who had tried these drugs at least once were considered users. This criterion is one that can be compared to other reports in the literature and was one of the criteria used in a recent study of steroid use in the United States (16). Statistics and Independent Variable Calculation Chi-square statistics were used to determine differences in questionnaire responses between male and female athletes (i.e., did males differ from females in responses), as well as differences in questionnaire responses among athletes at different grade levels (did responses differ from grade to grade). Discriminant analysis is a multivariate procedure used to describe differences in profiles of multiple variables that differentiate two or more groups. In this study, the procedure was used to describe different multiple variable profiles for steroid users and nonusers. The variables included in the profiles were Availability of Anabolic
152 - Corbin, Feyrer-Melk, Phelps, and Lewis Steroids, Behaviors of Others, and Personal Behaviors as identified by questionnaire response. Scores for these three values were determined by summing the responses for appropriate questions (see Table 1). Availability was calculated by using Items 1 to 4, Behavior of Others by using Items 5 and 6, and Personal Behaviors by using Items 7, 9, and 10. Item 8 was used to determine steroid use. Chi-Square Analyses Results Gender Differences. The percentage of male and female high school athletes responding true to questions concerning anabolic steroids are presented in Table 1. Availability of anabolic steroids was higher for male athletes than for female athletes. However, the relatively high availability rate suggests that steroids were readily accessible to both males and females. Among males, 30.2% knew nonathletes who took steroids to look better, and 21.4% of females knew nonathletes taking them. Also, nearly 10% of males indicated that they have played on teams with athletes who have used steroids. This is significantly different from the nearly 3% of females that responded positively to the same question. The 2.4% use rate by male athletes was not significantly different from the 1.1% rate reported by female athletes. More than three times as many males indicated they would use steroids if they were legal. The incentive of an Olympic medal would induce 1 in 10 athletes to take anabolic steroids, including a higher percentage of males than females. Sixty-five percent of female athletes who considered using anabolic steroids did use, compared to 30% of male athletes. Grade-Level Differences. Athletes in upper grades reported significantly easier access to steroids than they had experienced at lower grade levels (see Table 2). The grade level that indicated the least availability was the 8th grade. Knowing someone who sells anabolic steroids increased progressively from 8th grade through the 12th grade (statistically significant). By Grade 12, nearly as many females as males knew steroid sellers. The chi-square values did not indicate significant differences among grade levels for Question 3 (knowing a coach or school official who helped athletes obtain steroids), or for Question 4 (knowing a doctor who helped athletes obtain steroids). Results showed an increasing number of male and female high school athletes from Grade 8 to Grade 12 who played on a team with athletes who have used steroids (Question 2) and who know nonathletes using steroids (Question 1 ). Significant grade-level differences existed among males who considered steroid use, but not among females. Specifically, there was a prominent upward trend from 3.2% in 8th grade to 17.2% in 12th grade among male athletes. There were no significant differences among users of anabolic steroids by grade level, indicating that athletes in different grades were neither more nor less likely to use steroids than at other grade levels. Males in the upper grades were significantly more likely to have considered steroid use than were males in lower grades. No -- differences existed for females in considered use among grade levels.
Anabolic Steroids - 153 Table 2 Anabolic Steroid Questions by Grade Level Grade Grade Gender Question Gender 8 9 10 11 12 Total p P Availability 1. It is easy to get anabolic steroids if you really want them. 2. I know people who sell anabolic steroids. 3. I know a coach or school official who has helped athletes get anabolic steroids. 4. I know a doctor who has helped athletes get anabolic steroids. Male Female Male Female Male Female Male Female Behavior of others 5.Ihaveplayedon Male 1.8 6.8 15.1 14.9 10.3 9.5.000 school teams with Female 0.7 1.5 5.7 2.6 0.0 2.8.029 athletes who have used anabolic steroids. 6. I know people who Male 21.0 25.3 31.8 42.8 44.8 30.2.000 are not athletes who Female 13.1 19.3 25.1 27.1 35.7 21.4.019 take anabolic steroids to look better. Personal behavior 7. I have considered Male 3.2 5.8 10.5 13.5 17.2 8.2 using anabolic Female 1.4 0.5 2.9 0.9 0.0 1.7 steroids. 8. I have tried anabolic Male 0.0 3.1 2.7 2.8 3.4 2.4 steroids. Female 0.7 0.5 2.3 0.9 0.0 1.1 9. I would take anabolic Male 9.1 3.1 8.5 12.6 10.3 8.6 steroidsifthey were Female 2.8 0.5 4.6 1.7 0.0 2.6 legal. 10. If I knew taking ana- Male 13.2 9.6 14.3 13.0 17.2 12.4 bolic steroids would Female 6.9 5.0 12.0 3.4 3.6 7.1 guarantee me an Olympic medal, I would take them. Note. The results indicate the percentage of respondents answering true to the statements.
154 - Corbin, Feyrer-Melk, Phelps, and Lewis No significant grade-level differences existed for either males or females for Question 3 relating to use of steroids if legal. Almost 9% of males would take them if they were legal, compared to 2.4% who actually report steroid use. For females, 2.6% would use if steroids were legal, compared to 1.1% who report use. Significantly, fewer females in upper grades reported a willingness to use steroids to gain an Olympic medal than among those at lower grade levels. No grade-level differences existed for males on this question. Discriminant Function Analysis For males, a profile of independent variables characterized primarily by personal behavior and availability scores emerged. Scores on the Behavior of Others scale was less important to the profile, as indicated by the standardized functions in Table 3. The difference in the group functions (high positive for users and negative for nonusers) indicates that the profile fits the users and not the nonusers. Thus, male steroid users in this sample can be characterized by a profile of steroid availability and personal behaviors associated with steroids, including having considered using them, especially if steroids were legal and would guarantee high-level performance. For females, a profile of independent variables that differentiated anabolic steroid users from nonusers also emerged. Personal Behavior was the principal contributor, as evidenced by the high (329) standardized function loading (see Table 3). Availability and Behavior of Others were significant contributors to the profile, but to a lesser extent. The difference in the group functions (high positive for users and almost zero for nonusers) indicates that the profile fits the users and not the nonusers. Female steroid users in this sample can be characterized by a profile of personal behaviors (having considered using steroids if they were legal and if performance were enhanced) and, to a lesser extent, steroid availability and the behavior of others. Results of the discriminant analysis can also be used to classify subjects into user groups based on multivariate profiles. Use of this procedure with this sample indicated 89.8% successful classification for males and 93.1% successful classification for females. These classification results must be viewed with caution Table 3 Discriminant Function Summary - Dependent variable Males Females Standardized function Personal behavior.638*.829* Availability.637*.296* Behavior of others -.123*.200* Function centroids Users 2.440 3.300 Nonusers -0.061-0.038 *Significant contribution to the profile.-- - -- -- - - -- -- -
Anabolic Steroids - 155 because the formulas for making the classifications were derived from the same sample that was used in making c!assifications. Before making generalizations about predicting steroid use with these formulas can be made, the formulas would need to be cross-validated on another sample of teenage athletes. Discussion Results of this study of a large sample of high school students provides a look at reported steroid use rates among both male and female athletes. The 2.4% steroid use rate for male high school athletes is within the range of.7% to 10.9% reported by others for adolescent male athletes (6, 12, 13, 14). The steroid use rate is also within the range of.9% to 5.4% reported for all high school students, whether athlete or not. Both the.9% (16) and 5.4% (6) steroid use rates were for those who have ever used these drugs and were from large, recent studies. The use rate by high school athletes in this study was considerably lower, however, than those reported for groups of older athletes including body builders (14), whose use rates range from 19.5 to 62% (4, 14, 15), and Division I collegiate athletes, whose use rates range from 6.2 to 35%. Research is more limited concerning steroid use rates by adolescent female athletes. The 1.1 % use rate reported in this study is identical to the rate reported by Labergem and Thibault (10) and similar to the 1.5% use rate for adolescent athletes and nonathletes studied by the Center for Disease Control (6). The steroid use rate among female athletes in this study was higher than both the.l% nationwide rate reported for all females (athlete and nonathlete) in a recent study (6) and the.6% use rate reported for Division I college female athletes (1). It was, however, lower than the 4.8% projected use rate for Division I female athletes (15). The fact that anabolic steroids were more available to male than to female athletes is not surprising considering the higher use rate by males. One report (12) has shown that over a 2-year period, the availability of steroids among male high school football players increased from 38.8 to 59.9%, similar to those for males in this study. Although females were less likely to find steroids available at most grade levels, by the 12th grade they were almost as likely to know a steroid seller as males were. Nearly half of all athletes of both sexes found steroids accessible by Grade 12. At least two studies (2, 12) have reported increases in steroid use over a several year period that parallels increased availability. As athletes progress through school, they are increasingly more likely to know someone who uses anabolic steroids and are more likely to have played on a team with someone who uses them. Like other athletes (9), a third of the athletes in this study knew nonathletes who used steroids. These findings about steroid use by others were of little importance when characterizing profiles of male users and were only modestly important for females. Given that male athletes were more likely to consider using steroids with each increase in grade level and that they were more likely to consider use than females, it is not surprising that personal behaviors were important to the use profile of male athletes. Though personal behaviors-including considered use, considered use if legal, and considered use if performance success was guaranteed-were behaviors endorsed by 12% or fewer of all athletes, these behaviors
156 - Corbin, Feyrer-Melk, Phelps, and Lewis were very important to profiles to steroid use for both males and females. The relatively small group of athletes who have considered or who would consider using steroids appears to be more at risk of use than are other athletes. It is interesting to note that older female athletes (Grades 1 I and 12) were less likely to consider steroid use, even if it guaranteed them athletic success. In total, the evidence for females suggests that 10th-grade girls are particularly vulnerable. The fact that they are much more likely to consider use if an Olympic medal was guaranteed is interesting. Younger girls (8th and 9th graders) know fewer people who use steroids, are less likely to have availability, and have a low rate of use and considered use compared to 10th-grade girls. Older girls (12th graders) have similar availability and know a similar number of people who use steroids but report zero incidence of use or considered use. It may be that young girls simply have less exposure to steroids and that older girls have developed either more realistic athletic expectations or more accurate perceptions of the dangers of steroids than 10th graders have. It does seem that educational efforts to prevent steroid use may be especially necessary for female athletes in the middle years of high school. Clearly more males consider using anabolic steroids as they progress through school, a phenomenon that is accompanied by increased availability and greater exposure to use by others. The discriminant function analysis results indicate that availability and personal characteristics are most useful in characterizing users. Considered together, these data suggest that athletes are most vulnerable when availability is high and when they have considered use for one reason or another, a finding that is consistent with the findings of others (12). Though the use rates reported in this study are not particularly high, they are still of concern. The 1.9% overall steroid use rate in this sample was higher than a national study of the normal population (16). That study indicated that more than one million Americans had used steroids at one time or another and 300,000 were currently using them. The direct negative health effects of anabolic steroids are themselves of concern, but when the recent findings that steroid use is positively associated with illicit drug use and abuse of both tobacco and alcohol (16), educators and sports medicine experts have even more reason for concern. Further, recent evidence has indicated that users often share needles, increasing risk of diseases such as HIVIAIDS (6). Though school officials cannot totally limit availability and exposure to users, they can take steps to make sure that school facilities used by students to enhance performance and physical attractiveness, such as weight rooms, are not frequented by steroid users or sellers. If school weight rooms are used by the community, it would seem wise to limit use by community members to times when student athletes are not present. At least one study (1 1) has shown that weight room users in healthlfitness clubs are especially likely to use steroids and to know people who sell them. Recent arrests of 33 individuals for illegal steroid sales and the closing of three gyms in the city in which this study was conducted (7, 8) also suggest that more than a few gyms or "health clubs" are frequented by steroid users and sellers. Limiting contact between athletes and sellers and users seems especially important during this vulnerable age. Further, the supervision of weight facilities by a knowledgeable person seems important. Student athletes interested in improved performance and enhanced muscle development may be likely to listen to users/sellers if they are weight room-users, especially if they
Anabolic Steroids - 157 have good muscle development. Informed supervisors can help prevent the dissemination of incorrect information by these people and perhaps discourage steroid use. The fact that 2.8% of all athletes knew a coach or school official who helped athletes get steroids and 4.2% knew a doctor who helped athletes get these drugs is particularly distressing. If these reported rates are accurate, it is apparent that hiring school officials to supervise weight rooms is not enough. Efforts must be made to find ways to identify those who aid students in steroid use and to help students find advisors who will help them avoid use and, of course, help those who have already used them. References 1. Anderson, W.A., M.A. Albrecht, D.B. McKeag, D.O. Hough, and C.A. McGrew. A national survey of alcohol and drug use by college athletes. Phys. Sportsrned. 19(2):91-104, 1991. 2. Boyea, S., E. Bosworth, R. Folkert, R. Bents, D. Elliot, and L. Goldberg. A longitudinal study of trends in knowledge and use of anabolic steroids. Med. Sci. Sports Exerc. 22:s 18 1, 1990. (Abstract) 3. Buckley, W.E., C.E. Yesalis, K.E. Fried], W.A. Anderson, A.L. Streit, and J.E. Wright. Estimated prevalence of anabolic steroid use among high school seniors. JAMA 260:3441-3445, 1988. 4. Chng, C.L., and A. Moore. A study of steroid use among athletes: Knowledge, attitude and use. Health Education. 2 l(6): 12-1 7, 1990. 5. Dezelsky, T.L., J.V. Toohey, and R.S. Shaw. Non-medical drug use behavior at five United States universities: A 15-year study. Bull. Narcotics. 37:47-53, 1985. 6. Durant, R.H., V.I. Rickert, C.S. Ashworth, C. Newman, and G. Slavens. Use of multiple drugs among adolescents who use anabolic steroids. N. Eng. J. Med. 328:922-926, 1993. 7. Goodykoontz, B., and D. Cannella. Severe blow to steroids. The Arizona Republic, 1991 July 1: Al, All. 8. Goodykoontz, B., and D. Cannella. Six indicted in alleged smuggling of steroids. The Arizona Republic, 1991 July 12: B4. 9. Johnson, M.D., M.S. Jay, B. Shoup, and V.I. Rickert. Anabolic steroid use by male adolescents. Pediatrics 83(6):921-924, 1989. 10. Labergam, S., and G. Thibault. Prevalence of banned drugs used by young male and female athletes and identification of potential users. Med. Sci. Sports Exerc. 22:S64, 1990. (Abstract) 11. Munro, R., and C.B. Corbin. Steroid related behaviors of weight room users. Manuscript submitted for publication. 12. Trevisan, L., R. Bents, E. Bosworth, D. Elliot, and L. Goldberg. A sequential study of anabolic steroid use among high school athletes. Med. Sci. Sports Exerc. 21:S25, 1989. (Abstract) 13. Welch, M.J., and R.F. Priest. Anabolic steroid use among high school athletes. Med. Sci. Sports Exerc. 21:S25, 1989. (Abstract) 14. Yesalis, C.E. Incidence of anabolic steroid use: A discussion of methodological issues. In: Anabolic Steroids in Sport and Exercise, C.E. Yesalis (Ed.). Champaign, IL: Human Kinetics, 1993, pp. 49-70.
158 - Corbin, Feyrer-Melk, Phefps, and Lewis 15. Yesalis, C.E., W.A. Buckley, W.A. Anderson, M.O. Wang, J.A. Norwig, G. Ott, J.C. Puffer, and R.H. Strauss. Athletes' projections of anabolic steroids use. Clin. Sports Med. 1655-171, 1990. 16. Yesalis, C.E., Kennedy, N.J., Kopstein, A.N., and Bahrke, M.S. Anabolic-androgenic steroid use in the United States. JAMA. 270: 1217-1221, 1993. Acknowledgements We would like to acknowledge the assistance of Dr. Richard Emerson, of the Center for Sports Medicine and Orthopedics, and Dr. Paul Steingard, of the Steingard Orthopedics and Sports Medicine Center, Phoenix, AZ.