Who is using AAS?
NMAAS is largely an adult phenomenon; the median user was twenty-nine years old, agreeing with earlier reports [
25,
32]. Users were typically unmarried Caucasians in their 20s and 30s who initiated NMAAS use after reaching the age of majority. They were not active in organized sports. They were highly educated, gainfully employed, white collar workers earning an above average income; such high levels of functioning in terms of education, income, and employment are consistent findings [
9,
25] and are inconsistent with the popular view of substance abusers. In total, our findings belie the images of AAS users as mostly risk-taking teenagers, cheating athletes, and a group akin to traditional drug abusers.
One possible limitation is our use of the Internet and the potential bias toward a higher-functioning group. However, the similarities of this sample with others employing different methodologies [
25,
32,
53] minimizes this concern. Because the Internet is now a primary source for both purchasing AAS [
31] and NMAAS information [
32], a wide range of users are likely familiar and comfortable with its use. Hence, our sample likely represents the non-elite athlete, adult NMAAS using population. Further, the use of the Internet controlled for potential geographical variation in NMAAS prevalence and related behaviors [
53,
57,
58]. Finally, the Internet facilitated access to a large sample – the largest, to our knowledge, ever collected.
NMAAS use was rarely associated with athletics; most users did not compete in sports of any kind. In fact, relatively few had participated in high school sport and few reported using AAS at that time in their life. Contrary to portrayals of coaches and athletes as the primary consumers of AAS, only eight respondents were athletes or coaches by occupation; the results in this large sample agreed with those using smaller samples [
25,
32,
52,
59]; recreational weightlifters comprised almost 90% of our sample, also similar to reports from other reviewers [
24]. NMAAS may, indeed, be prevalent among elite athletes, but competitive athletes are few among NMAAS users. Cheating in sport is a rare motivation for NMAAS and the small number of professional athletes using AAS generally competed in power sport events (e.g., power lifting, wrestling, football, full contact fighting). Interestingly, NMAAS was also reported in unexpected professional sports, such as rodeo, dance and tennis.
Bias must also be considered as a possible cause for low prevalence of athletes in our sample. The extent to which athletes use the Internet, both in general and as a source for AAS or for NMAAS information or read bodybuilding magazines is unknown. Competitive athletes may be less likely to volunteer to participate and provide such sensitive information. Conversely, as noted previously, the observed consistency between our findings and those from smaller datasets [
59] suggests we have tapped the same population and we would expect that with the Internet serving as the primary source of AAS trade, athletes should be represented.
The largest yet least visible group of NMAAS users is recreational weightlifters with more varied reasons for use than competitive athletics [
51,
60]; "...a great deal of anabolic steroid use occurs in private gymnasia (non-local authority) among non-competitive recreational athletes [
51]" and "...noncompetitive recreational users make up a large portion of the AAS-using population [
25]." Our findings agree with this ubiquitous observation [
10,
25,
32,
51,
58,
60].
What is being used?
Injectable AAS were most popular and preferred, due largely to decreased liver toxicity as compared to oral agents. Almost 10% exclusively injected AAS, having never used oral agents. Contrary to traditional notions that injection reflects escalation in drug use, intra-muscular (IM) injection of AAS avoids several of the more serious potential side effects of NMAAS and may be a less risky approach. Oral AAS are associated with liver damage [
59,
61] and IM injection of AAS "...could therefore be considered a rational attempt to reduce harm rather than an element of escalating use [
9]" and may be "...more advisable... [
62]." The prevalence and preference of injecting AAS suggests that injection should be considered the normative route of administration; a positive finding, in a public health sense, due to its potential reduction of harm.
Despite having reduced hepatotoxicity, intramuscular injection is not without potential complications; a small minority reported injection-site infection. Still, unlike other groups of illicit drug users [
63‐
65], sharing of needles and multi-use vials, and reuse of needles were almost non-existent. The use of separate needles to draw and inject oil-based products was the standard approach. NMAAS users in general seemed to practice safe injection techniques [
51,
66] and NMAAS use apparently "...present [s] little risk of HIV transmission" [
66] or other blood borne pathogens [
53]. Accordingly, viral hepatitis and HIV infection were not reported by anyone in our sample.
Why are AAS being used?
Sports and competitive bodybuilding did not motivate NMAAS use in this group. Amateur sports, bodybuilding and power lifting were rarely cited as motivators. Consistent with this, few acknowledged a fear of losing athletic abilities if they ceased AAS use.
The primary motivations for NMAAS were increased muscle mass, strength and physical attractiveness. Loss of muscle and strength were important concerns should access to NMAAS cease. Negative reinforcement (avoidance motivation) was not as important as positive reinforcement (anticipated gains) in NMAAS; positive effects were endorsed more frequently and highly than were concerns about avoiding negative effects upon cessation. Overall, cessation of AAS use was not a concern for many users. Although low self-esteem certainly may motivate some AAS users, it was not a primary motivator. In fact, loss of respect was the least endorsed fear. The most parsimonious explanation seems to be that NMAAS respondents, like most people, have an idea of how they wish to appear and, as a goal-directed group, adopted a structured NMAAS regimen, along with diet, exercise and other supportive components to attain a desired physique or outcome.
NMAAS appeared to be more associated with an image of the ideal (attractive) body structure and ability as large, muscular and powerful, a view that is consistent with Western ideals, and not with an aversion towards being small. Positive changes in strength and muscularity were more highly endorsed than were avoidance of loss of these characteristics. This is a subtle but important distinction; it suggests a desire to enhance one's physique, even when it leads to use of NMAAS, as motivation, as opposed to body dissatisfaction as psychopathology which leads to AAS use [
67]. It is clear, however, that we did not measure satisfaction or dissatisfaction with current physique on our sample. Nonetheless, it has been noted that "...people actively use body image to achieve certain ends, justify particular actions and manage particular identities [
68]" and AAS-using and non-using gym goers have comparable concerns about body image [
69]. Hence, in goal-oriented NMAAS users, the desire for an improved physique may not reflect dissatisfaction with one's current physique but part of a strategy aimed at self-improvement and achieving their goals. Interestingly, even though increases in body esteem associated with NMAAS allegedly remitted after cessation of use [
70], becoming less attractive upon cessation did not concern this group.
The top three motivators among this sample replicated those in two Australian surveys [i.e., [
25,
71]]. Wright and colleagues (2001) [
62] also found increased muscle mass as the primary motivating factor. The use of AAS for fitness-related and cosmetic purposes is widely reported [
7,
8,
24,
47,
71‐
74] and NMAAS use has been discussed as a form of appearance enhancement similar to plastic surgery [
75]. Our data adds to a literature that suggests that users may consider NMAAS use as a means to enhance normal functioning, which is a growing trend in our society [
76].
Motivations for use were generally stable across age groups, consistent with the observation by Brower, Elipulos, Blow, Catlin, & Beresford [
27], (1990) that "...older and younger subjects did not appear to differ." It might have been expected that motivations for use would change with development, given the changing nature of roles across the lifespan. The minor differences that did appear primarily were associated with typical age-related biological changes (e.g., motivations for increasing endurance, decreasing fat); however, they may also reflect psychosocial development (e.g., attracting sexual partners, increases in confidence). In any case, although statistically significant, the magnitude of these age-related changes was less than might be expected.
It has been suggested [
77] that many AAS users experience a "high" from use, although others [
78] found such reports to be rare. Our results agree with the latter notion; the great preponderance of our respondents (99%) denied that immediate psychogenic effects (e.g., intoxication, arousal or euphoria) motivated their use, dose, duration or frequency of use, suggesting that they did not experience AAS as euphorigenic [
6,
72] and did not inject for a "high."
When are AAS being used?
Initiation of NMAAS use was an adult phenomenon; onset occurred in the great majority (94%) after reaching eighteen years of age and only 6% of current users initiated NMAAS prior to that age. Reports of age of onset in the literature vary; our results agree with some reports [
21] but not others [
79]. It appears, however, that the typical adult male American using AAS initiated NMAAS in his mid-twenties [see also [
24,
25]], within 5 years of beginning weight training. This does not minimize concerns about adolescent NMAAS; significant numbers of adolescents are experimenting with AAS (although surveys suggest that many more experiment with and use other drugs). But adolescent onset of use was rare among ongoing adult users, suggesting a discontinuity between adult NMAAS and adolescent experimentation. Adolescent experimentation may be qualitatively different than adult use, given the developmental issues involved in adolescent drug use/experimentation, and may not invariably lead to longer-term use. Of course, the best data to explore this issue would come from true longitudinal studies as opposed to retrospective reports of onset. Nonetheless, given the potential negative effects of adolescent use, research efforts should focus on exploring adolescents' patterns of and motivations for NMAAS to more fully inform identification of those at risk and efforts to prevent use.
Ultimately, in the absence of longitudinal studies [
80], it is impossible to make definitive statements about the relationship between patterns of initiation and long-term use. It is noteworthy that the prevalence of adult onset we observed differs from the pattern of initiation seen in other drugs [e.g., alcohol; [
81]] where early onset predicts later use. However, research has shown clear distinction between AAS users and those using other generally illicit drugs [
82].
How are AAS being used?
The overall fitness and lifestyle context in which NMAAS is embedded is likely inconsistent with widespread use; as Korkia [
58] (1994) noted, few "...are prepared to take regular and vigorous exercise like weight-training, which must accompany AS use, and therefore it is unlikely that AS use would reach epidemic proportions." This is the context of NMAAS; the majority of users maintained a strenuous regular training regimen, lifting weights 4–5 days per week, as well as a strict dietary regimen high in protein and low in fats and sugars.
AAS were used about six months per year, broken up into 3 month periods, reflecting common cycling practices employed to allow the body to return to homeostasis. Periods of use were largely planned in great detail and the necessary drugs were most often in hand ahead of time. Ancillary drugs – drugs used to prevent or treat AAS related side effects or make AAS more effective – were relatively commonplace. NMAAS users utilize SERMs (i.e., clomid [clomiphene citrate], nolvadex [tamoxifen citrate] which block estrogen receptors) or aromatase inhibitors (i.e., arimidex [anastrozole] which block the conversion of AAS into estrogen) because in an attempt to maintain homeostasis, the body converts excess androgens into estrogen, resulting in unwanted side effects. The use of peptides (i.e., HGH, IGF-1, insulin) has received little attention in the realm of NMAAS users; however the availability of recumbent forms of peptides has lead to greater use of these hormones by non-athletes [
83]. HGH, although taken with AAS, is often combined with insulin or thyroid hormones (t3/t4). Insulin, familiar to many only as a medication used in the treatment of diabetes, is a very anabolic compound that shuttles needed nutrients to muscles, produces growth factors when combined with HGH in the liver and combats insulin resistance produced by HGH. Thyroid hormones burn fat and NMAAS users may combine them with HGH to increase their levels which is reduced by HGH.
This data raises two interesting points. First, NMAAS involves more forethought and organization than other illicit drug use; it is less impulsive and more considered. The planned cycling, healthy diet, ancillary drugs, blood work, and mitigation of harm via route of administration suggest a strategic approach meant to maximize benefits and minimize harm. Second, pre-planning required users to obtain most of their planned cycle prior to beginning. Hence, unlike other illicit drugs procured by end-users in single or short-term use quantities, AAS users are likely to have substantial amounts of AAS on hand for long-term personal use. To achieve supraphysiological levels of steroid hormones, many respondents used up to 12 methandrostenolone tablets (5 mg each) per day, with a few using over 20 tablets. This reasonably necessitates an initial possession of 1,000 tablets or more for personal use (consistent with anecdotal observations of AAS purchasing patterns; [
84]). Such quantities, in the case of single-use illicit drugs, would suggest intent to distribute; in NMAAS they are more likely an on-hand quantity for personal use. The legal implications of this are that some AAS users may be improperly accused of trafficking based solely upon the quantity recovered.
AAS users are well known for being educated on the drugs they use and most seek information about AAS at least monthly [
25]. Most recognized the value of medical supervision and regular blood work, but did not trust their physician enough to inform them of their NMAAS. Consistent with other studies [
56,
69], they almost universally lacked confidence in physicians knowledge of AAS; a sentiment with which physicians seem to agree [
60]. As a result, NMAAS users seek information from various non-medical sources [
62].