A competitive spirit is an indispensable aspect of human life, where it could be argued that a failure to compete only results in participating in a competition to fail. Over a very long period of time, humans have relied on various kinds of performance-enhancing substances. It has been suggested, for example, that the ancient Greeks turned to potions to improve performance.
Today, these substances range from “soft” or legal substances such as energy drinks to “hard” substances such as steroids and amphetamines, and other more “natural” methods, including blood doping to increase the number of rich red blood cells in the bloodstream.
In the exercise or athletic world, anabolic-androgenic steroids or anabolic steroids are a very popular performance-enhancing substance. But over the past 40 years they have increasingly been used for aesthetic or “beauty” reasons. This is what we found in a recent study, published in Annals of Epidemiology, that suggested that 3.3% of the world’s population have used anabolic steroids at least once, most of whom were male (around 6.4% of males and 1.6% of females).
The biggest users were in the Middle East, followed by South America, Europe, North America, Oceania, Africa, and Asia. Use was highest among recreational sportspeople followed by athletes, prisoners and arrestees, drug users, high school students, and non-athletes.
Our finding suggests that use of anabolic steroids is now a serious global public health problem. Not confined to athletes, the spread of their use into the general population means millions of individuals across the world, many of whom have no athletic ambitions, are using them to increase and improve their physical strength and appearance.
A recent Australian survey suggested that two thirds of young men who began injecting drugs in the past three years were using steroids (rather than methamphetamine or heroin).
Anabolic steroids are a group of hormones that include the natural male sex hormone testosterone and a set of synthetic versions. Early scientific forays into the effects of testosterone included one Harvard professor injecting himself with a “rejuvinating elixr” that included extract from dog and guinea pig testicles in 1889. It wasn’t until the mid-1930s, however, that human testosterone was first “discovered” and then synthesised by Adolf Butenandt and Leopold Ruzicka (independently of each other) in 1939. Both were awarded the Nobel Prize for their work.
All anabolic steroids – natural and synthetic – have two essential results: a “muscle building” effect that results in muscle growth, and an androgenic or virilising effect that results in masculinising characteristics such as deepening of the voice. Anabolic steroids increase the production of protein within cells, which decreases body fat as well as increasing muscle growth beyond natural limits.
Steroids are used in medicine for several purposes including the treatment of male hypogonadism, a condition where the body doesn’t produce enough testosterone and which can limit the production of sperm. It is also used to treat delayed puberty, enhance appetite and stimulate growth.
Many “steroids” prescribed by medics are not anabolic, but corticosteroids which have neither anabolic nor addictive potential. But other people who use these steroids for fitness or aesthetic purposes clearly do it outside of these health reasons.
Spread to general population
Around the 1960s and 1970s, anabolic steroids were mainly used by elite athletes and bodybuilders motivated by the desire to develop bigger muscles and enhance their athletic performance. In the past three or four decades however, millions of non-competitive athletes such as recreational sportspeople and adolescents have been using them, motivated by the desire to look more attractive. This means their use has spread from the athletic community into the general population. While it has been suggested that athletes comprise the smallest group of anabolic users, in our study they were the second biggest.
Until recently, several questions over the global use estimates were largely unanswered. The aim of our study was to estimate the global prevalence of use. Putting together findings from 187 studies (and subject to some limitations such as the paucity of anabolic steroid prevalence research in especially Africa and Asia), we estimate the problem is gradually increasing. Between 1990 and 1999 prevalence was about 2.9% but post 2000, this has risen to 3.2%.
These findings should attract the attention of global public health officials because of the associated serious harmful effects of long-term use. These include high blood pressure, heart attack, stroke, acne and skin infections, liver damage, tendon rupture, premature baldness, stunted bone growth in adolescents, syringe exchange infections such as HIV and hepatitis, and death. There are psychosocial implications too. Users can become violent or aggressive, cause mood syndromes, and addiction.
There are also other gender-specific effects. In males, these include low sperm count, shrunken testicles, infertility and growth of breasts. In females, these include roughening of the skin, decreased breast size, deepening of the voice, growth of body hair, changes to the menstrual cycle and enlargement of the clitoris.
It has to be noted that the effects and harms of anabolic use are dose-dependent. So higher and longer term use leads to bigger muscles but more harmful effects.
Laying down the law
Since the 1990s there has been increasing legislation to combat the problem. Anabolic steroid use is illegal in the US, the UK, Australia, Argentina, Brazil, Portugal, and Saudi Arabia. Though the US passed their Anabolic Steroid Control Act in 1990, and Sweden the Act Prohibiting Certain Doping Substances in 1991, other countries have been a bit slower – Norway only banned use in 2013. In many places they are unregulated and can be bought in some pharmacies.
An amendment to the US act in 2004 also added prohormones to the list of controlled substances. These substances, a kind of precursor to a hormone (rather than a hormone itself), can amplify the effect of existing hormones.
But as the internet makes obtaining substances easy, even if illegal, it’s clear that better ways of dealing with the problem – and the probable harmful effect on population health – will need to be found.