The population of AAS users is disparate from that of other drugs of abuse. Laboratory test abnormalities and adverse effects are common and should be taken into account when counseling patients who may be using AASs.

A total of 231 male respondents met the inclusion criteria. Most were white, were older than 25 years, were employed with above average income, and had received a formal education beyond high school. Ninety-three percent began using AAS after the age of 18 years, and 81% reported using 400 mg or more of testosterone per week. Factors associated with longer duration of use (>5 years) included higher incomes (≥$75,000, P=.003), increased testosterone dosages (>600 mg per week, P=.007), older age (≥35 years, P<.001), being married (P<.001), and being self-employed (P<.001). The Internet was the most common source of testosterone (53%). Ninety-three percent used at least one additional performance-enhancing drug. Seventy-seven percent had routine laboratory tests performed, and 38% reported laboratory abnormalities at some point. Nearly all experienced subjective adverse effects while using and not using testosterone. Fifty-three percent reported use of other illegal substances, most commonly (90%) beginning before AAS initiation. Ten percent had a criminal conviction, 91% of which preceded AAS use. Fifty percent were felonies.

An anonymous, self-administered, 49-item questionnaire was posted on message boards of Internet websites popular among AAS users and administered via SurveyMonkey from February 1, 2015, to June 1, 2015. Thirty-seven questions were analyzed for this study.

Testosterone, first isolated in 1935, is the principal androgen controlling the development of the male body.Testosterone exerts its virilizing effects on the androgen receptor directly and indirectly via reduction to 5α-dihydrotestosterone.In addition, testosterone has anabolic effects, in which nitrogen is differentially retained in lean body mass, resulting in increased muscle size and bone metabolism.Significant anabolic effects occur at supraphysiologic testosterone levels (>1000 ng/dl), which generally requires weekly doses of 300 mg or more.Pharmacologic agents have long been used for performance enhancement in high-level athletic competition.However, since the 1980s, illicit use of anabolic-androgenic steroids (AASs) has spread from elite athletes into the general population.Current estimates place the number of AAS users in the United States between 1 million and 3 million.Most of these users are believed to be recreational bodybuilders and weightlifters who use these drugs for cosmetic purposes rather than to enhance sports performance.

However, despite the high prevalence of use, little is known about this population. In the United States, AASs are a Schedule III controlled substance; therefore, AAS users rarely disclose their drug-taking habits. In recent studies, up to 56% of users admit they have never informed their personal physician of their drug use.Prior studies examining this population are limited by small sample size and recall bias.Therefore, we sought to describe a population of current AAS users and characterize the pattern of performance-enhancing drug use.

The t test and Mann-Whitney test were used to compare continuous variables, whereas the Fisher exact test and Pearson χ 2 test were used to compare categorical variables. Statistical significance was defined as P≤0.05, with all reported P values 2-sided. Statistical analyses were performed using the SAS JMP version 10.0 software package (SAS Institute Inc).

Demographic information included age, employment status, current income, level of education, and athletic participation in high school and college. Drug use characteristics included age of first use, duration of use, and specific AAS and performance-enhancing drug regimen, including weekly dose, number of weeks per year and agents used, and cycling practices. Participants were asked to select symptoms they had experienced from a list of known testosterone-related adverse effects. Other questions assessed medical comorbidities and routine laboratory testing. Participants were also asked about high-risk behaviors, such as illicit drug use and criminal activities.

The 49-item questionnaire was designed to elicit single-answer responses with the option of providing additional information where indicated. Branching logic questions were used to limit responses to personally relevant items on the basis of prior responses, thereby varying the total number of questions presented to each participant. In addition, not all participants responded to all relevant questions, and the opportunity to decline to answer was provided for all questions. The survey required approximately 10 to 15 minutes to complete. Of the 49 questions, 37 were analyzed for this report. See Supplemental Table 2 for a list of survey questions analyzed in the study.

Surveys were administered via SurveyMonkey, a secure third-party data collection system. All information was gathered in an anonymous fashion, and no specific participant identifiers were obtained, including Internet provider addresses or email information. Informed consent was obtained electronically.

After institutional review board approval, recruitment postings were placed on popular bodybuilding forums from February 1, 2015, to June 1, 2015. See Supplemental Table 1 (available online at www.mayoclinicproceedings.org ) for the recruitment posting used. Participants were requested to participate in an online, anonymous survey on patterns of testosterone use. Inclusion criteria were age of 18 years or older, male sex, and prior or current testosterone supplementation. Websites were identified using the Google ( www.google.com ) search terms bodybuilding forum and anabolic steroid forum. Moderators of several websites were contacted regarding the aims, confidentiality, inclusion criteria, and survey questions of the study. After discussion, 9 websites permitted inclusion of an anonymous survey link along with a brief study description and inclusion criteria ( Supplemental Table 1 ).

Results

A total of 321 respondents initiated the survey, of whom 61 did not meet initial screening criteria, and 29 were excluded for blank or surveys that lacked information on frequency, duration, and dose of testosterone use. The remaining 231 participants met criteria for analysis.

Table 1 a a AAS = anabolic-androgenic steroid. Demographic Characteristics of 231 AAS Users Characteristic No. (%) of respondents Age group (y) 18-24 50 (21.6) 25-34 83 (35.9) 35-44 52 (22.5) 45-54 28 (12.1) 55-64 17 (7.2) ≥65 1 (0.4) Race/ethnicity White 197 (85.3) Hispanic/Latino 14 (6.1) Asian/Pacific Islander 6 (2.6) Black/African American 5 (2.2) American Indian/Alaskan 2 (0.9) Prefer not to answer 7 (3.0) Employment status Employed 142 (61.5) Self-employed 38 (16.5) Student 32 (13.9) Retired 8 (3.5) Unemployed 6 (2.6) Prefer not to answer 5 (2.2) 2014 Pretax income ($) <25,000 35 (15.2) 25,000-34,999 14 (6.1) 35,000-49,999 17 (7.2) 50,000-74,999 44 (19.1) 75,000-99,999 25 (10.9) 100,000-149,999 48 (20.9) ≥150,000 27 (11.7) Prefer not to answer 20 (8.7) Missing b b Missing values were not calculated in the total. 1 Marital status Single 106 (46.5) Married 105 (46.1) Divorced 14 (6.1) Prefer not to answer 3 (1.3) Missing b b Missing values were not calculated in the total. 3 Highest level of education Graduate degree/professional 35 (15.2) Bachelor's degree 62 (26.8) Associate or technical degree 34 (14.7) Some college, no degree 61 (26.4) High school diploma 24 (10.4) 12th grade or less (no diploma) 11 (4.8) Prefer not to answer 4 (1.7) A total of 133 of the 231 respondents (57.6%) were between 18 and 34 years old, and 105 of 228 (46.1%) were married. A total of 192 of 231 men (83.1%) had completed at least some college, and 100 of 210 (47.6%) earned $75,000 or more in pretax income. Sixteen of 228 (7.0%) had started using AASs by 18 years of age, whereas 145 of 228 (63.6%) began using AASs after 22 years of age. Although 143 of 231 (61.9%) played sports in high school, only 36 of 231 (15.6%) participated in collegiate sports. The demographic characteristics of the survey participants are summarized in Table 1

A total of 137 of 230 respondents (59.6%) used testosterone at least half the year, and 102 of 230 (44.3%) used for more than 50 weeks per year. Ninety of 231 (39.0%) had been using AAS for at least 3 years, whereas 29 of 231 (12.6%) had been using for more than 10 years. Thirty-nine of 56 men (69.6%) using testosterone for more than 5 years earned $75,000 or more in pretax income in 2014 compared with 81 of 174 men (46.6%) using testosterone for 5 years or less (P=.003). In addition, those supplementing for more than 5 years were significantly more likely to use higher testosterone doses, with 39 of 54 (722%) using more than 600 mg per week vs 85 of 168 (50.6%) of those using for 5 years or less (P=.007). They also saw a physician more regularly (47 of 55 [85.5%] vs 106 of 166 [63.9%], P=.002), were older (42 of 57 [73.7%] were ≥35 years old vs 56 of 174 [32.3%]; P<.001), and were married (38 of 57 [66.7%] vs 67 of 171 [39.2%]; P<.001) more commonly than men using testosterone for 5 years or less. On the other hand, men using testosterone for shorter periods (≤5 years) more often believed that testosterone use in sports was fair (101 of 159 [63.5%] vs 21 of 54 [38.9%]; P=.002) and used testosterone less frequently (49 of 174 [28.2%] vs 6 of 57 [10.5%] used <20 weeks per year; P=.004) compared with those using for longer durations (>5 years). Men using testosterone for 5 years or less were also less likely to be self-employed than those using for more than 5 years (13 of 174 [7.5%] vs 25 of 57 [43.9%]; P<.001).

Thirty-eight of 231 men (16.5%) had used more than 1000 mg per week, whereas 36 of 231 (15.6%) had never exceeded 400 mg. Men using higher doses (>600 mg per week) were more likely to have more than 5 years of use (39 of 124 [31.5%] vs 15 of 98 [15.3%]; P=.007) and to spend more than $100 per month on AASs (83 of 121 [68.6%] vs 30 of 96 [31.3%]; P<.001). Three individuals (1.3%) spent more than $1000 per month, all of whom were using more than 600 mg of testosterone per week. Men using 600 mg or less per week were more likely to use testosterone less than 20 weeks per year (32 of 98 [32.7%] vs 20 of 124 [15.1%]; P<.001) and have a total duration of use less than 3 years (71 of 98 [72.4%] vs 65 of 124 [52.4%]; P<.001) compared with those using more than 600 mg per week.

Table 2 a a AAS = anabolic-androgenic steroid; PCT = post-cycle therapy. Summary of Descriptors of Testosterone Use Among 231 AAS Users Descriptor No. (%) of respondents Starting age of testosterone use (y) <14 1 (0.4) 14-18 15 (6.6) 19-22 67 (29.4) ≥23 145 (63.6) Missing b b Missing values not calculated in total. 3 <400 36 (15.6) 400-600 62 (26.8) 600-800 41 (17.7) 800-1000 45 (19.5) >1000 38 (16.5) Alternative/other 9 (3.9) Duration of testosterone use (y) <1 51 (22.1) 1-3 90 (39.0) 3-5 33 (14.3) 5-10 28 (12.1) >10 29 (12.6) Time per year using testosterone (wk) <10 13 (5.7) 10-20 42 (18.3) 21-30 38 (16.5) 31-40 21 (9.1) 41-50 14 (6.1) >50 102 (44.3) Missing b b Missing values not calculated in total. 1 Antiestrogens 201 (87.4) Human growth hormone 60 (26.1) 17-α-alkylated oral hormones 135 (58.7) Research peptides 83 (36.1) Cutting agents 110 (47.8) Other anabolic steroids 100 (43.5) Use of PCT Yes 125 (55.6) No 100 (44.4) Missing b b Missing values not calculated in total. 6 Amount per month spent on performance-enhancing drugs ($) <100 111 (49.1) 100-500 104 (46.0) 501-1000 8 (3.5) 1001-1500 1 (0.4) >1500 2 (0.9) Missing b b Missing values not calculated in total. 9 Source of testosterone c c Total greater than 100% because of the possibility of multiple responses. Internet supplier 119 (52.7) Physician 63 (27.9) Overseas pharmacy 43 (19.0) Friend 42 (18.6) Antiaging clinic 16 (7.1) Underground/black market 5 (2.2) Missing b b Missing values not calculated in total. 5 A total of 119 of 226 respondents (52.7%) used the Internet as a source for obtaining testosterone, whereas 63 of 226 (27.9%) received testosterone from a physician. In addition, 43 of 226 (19.0%) received testosterone from an overseas supplier, and 16 of 226 (7.1%) used antiaging clinics (total >100% due to ability to indicate more than one source for obtaining testosterone). Table 2 summarizes the patterns of testosterone use.

Increasing muscle mass was the most common reason for starting use of testosterone (82 of 231 [35.5%]). Forty-two of 231 (18.2%) of men started using testosterone to help lose adipose tissue, whereas 35 (15.2%) and 22 (9.5%) took testosterone to augment self-diagnosed low testosterone levels and for bodybuilding competitions, respectively. Only 16 (6.9%) of men took testosterone to improve overall aesthetics of their physique. Attracting women, peer pressure, improving sports performance, depression, difficulty gaining muscle, improving endurance, and enhancing overall quality of life were given as reasons less than 5% of the time.

Of the 231 respondents, 213 (92.6%) used substances in addition to testosterone. A total of 201 of 231 (87.0%) used antiestrogens (clomiphene citrate, tamoxifen, anastrazole, letrozole), 135 of 230 (58.7%) used 17-α-alkylated hormones (methylepitiostanol, oxandrolone, stanozolol), 110 of 230 (47.8%) used cutting agents (clenbuterol, T3/T4, 2,4-dinitrophenol, drostanolone), and 100 of 230 (43.5%) used additional anabolic steroids such as trenbolone, 19-nortestosterone, and methenolone. Finally, 60 of 230 (26.1%) supplemented with other accessory anabolic agents, such as insulin-like growth factor 1 and/or human growth hormone (total >100% due to ability to select all that applied). A total of 125 of 225 men (55.6%) used postcycle therapy between periods of testosterone use, presumably to mitigate adverse effects of testosterone, such as reduced testicular volume and infertility.

Of the respondents, 153 of 221 (69.2%) regularly see a physician, and 172 of 223 (77.1%) have routine laboratory tests performed. Men 35 years or older were more likely to see their physician regularly (80 of 95 [84.2%] vs 73 of 126 [57.9%]; P<.001). Similarly, men using testosterone for more than 5 years also were more likely to see their physician regularly (47 of 55 [85.5%] vs 106 of 166 [63.9%]; P=.002). Men who see their physician regularly were more likely to be married (83 of 152 [54.6%] vs 17 of 66 [25.8%]; P<.001), make $75,000 or more annually (94 of 152 [61.8%] vs 21 of 68 [30.9%]; P<.001), and were less likely to use other illegal substances (71 of 151 [47.0%] vs 42 of 65 [64.6%]; P=.02) compared with those who do not see a physician regularly.

Of respondents undergoing routine laboratory testing, 64 of 169 (37.9%) reported having laboratory test abnormalities, including 33 of 64 (51.6%) with abnormally elevated liver and/or kidney markers. Twelve of 64 (18.8%) reported cholesterol abnormalities while using AASs, 9 of whom were taking 17-α-alkylated agents. Interestingly, and despite the elevated laboratory test levels, 2 of 223 participants (0.9%) indicated that they had ever experienced any hepatic or renal injury relating to use. In contrast, 21 of 215 respondents (9.3%) reported personally knowing someone who had been directly harmed by testosterone use. Overall, 126 of 224 participants (56.3%) reported at least one medical condition (median, 1; interquartile range [IQR], 1-2), including hypertension (38 of 224 [17.0%]), self-diagnosed low testosterone (62 of 224 [27.7%]), psychiatric conditions (19 of 224 [8.5%]), diabetes (7 of 224 [3.1%]), chronic kidney disease (3 of 224 [1.3%]), obesity (10 of 224 [4.5%]), cardiac disease (5 of 224 [2.2%]), and liver disease (2 of 224 [0.9%]).

Table 3 Adverse Effects Reported by 231 Study Participants While Using Testosterone and After Discontinuation of Testosterone Use Adverse effect No. (%) of respondents a a Total greater than 100% because of the possibility of multiple responses. Receiving testosterone Testicular atrophy 116 (52.5) Acne 97 (43.9) Fluid retention 96 (43.4) Overconfidence 47 (21.3) Painful nipples or gynecomastia 30 (13.6) Fatigue 15 (6.8) Angry or violent tendencies 10 (4.5) Depression 8 (3.6) No adverse effects 31 (14.0) Other 8 (3.6) Not receiving testosterone Decreased energy 133 (60.2) Loss of muscle 129 (58.4) Decreased libido 127 (57.5) Gain of adipose tissue 98 (44.3) Loss of interest in working out 90 (40.7) Depression 68 (30.8) Erectile dysfunction 60 (27.1) No adverse effects 30 (13.6) Other 9 (4.1) A total of 190 of 221 respondents (86.0%) reported subjective adverse effects with testosterone use. Users reported a median of 2 adverse effects (IQR, 1-3), with the most common being testicular atrophy (116 of 221 [52.5%]), acne (97 of 221 [43.9%]), and fluid retention (96 of 221 [43.4%]). Similarly, 191 of 221 (86.4%) experienced subjective adverse effects during periods when not taking testosterone. Respondents reported a median of 4 adverse effects (IQR, 2-6) when not undergoing therapy, most commonly decreased energy (133 of 221 [60.2%]), loss of muscle mass (129 of 221 [58.4%]), and reduced libido (127 of 221 [57.5%]). See Table 3 for a summary of adverse effects experienced while taking and while not taking testosterone.

A total of 116 of 219 respondents (53.0%) stated they had taken other illegal drugs, with 103 of 115 (89.6%) indicating that the illegal drug use preceded testosterone. Men using illegal substances were younger (<35 years old) (75 of 116 [64.7%] vs 49 of 103 [47.6%]; P=.01) and less likely to be married (43 of 115 [37.4%] vs 59 of 101 [58.4%]; P=.003) compared with those who did not report other illegal substance use. Those taking illegal substances were more likely to be convicted of a crime (19 of 115 [16.5%] vs 3 of 101 [3.0%]; P=.001) and were less likely to see a physician regularly (71 of 113 [62.8%] vs 80 of 103 [77.7%]; P=.02) compared with nonusers.

Twenty-two of 216 men (10.2%) reported being convicted of or pleading no contest to a crime, with 20 (90.9%) of those occurring before starting use of testosterone. Eleven (50%) of the crimes were felonies, whereas 9 (40.9%) were misdemeanors, and 2 (9.1%) were minor infractions. In reviewing associated characteristics of men convicted of a crime, 16 of 22 (72.7%) made less than $75,000 per year compared with 86 of 193 (44.6%) of those not convicted or who plead no contest (P=.01). Men convicted of a crime were more likely to use other illegal substances (19 of 22 [86.4%] vs 96 of 194 [49.5%]; P=.001) and were less likely to have played high school sports (8 of 22 [36.4%] vs 127 of 194 [65.5%]; P=.01) compared with those not convicted of a crime.

Family dynamics, including being the oldest child, being the only child, or having an older sister or brother, did not affect outcomes and was not associated with any relevant features related to AAS use. Similarly, high school sociality and high school extracurricular involvement was not significantly associated with any factors related to AAS use.

Finally, regarding the role of AAS in sporting activities, 91 of 213 respondents (42.7%) believed that AAS use in competitive sporting activities was unfair. In subgroup analysis, 78 of 122 men younger than 35 years (63.9%) and 101 of 159 (63.5%) of those using testosterone for 5 years or less considered AAS use fair vs 44 of 91 men 35 years or older (48.4%) (P=.03) and 21 of 54 (38.9%) of those using testosterone for more than 5 years (P=.002). Of interest, 85 of 133 men (63.9%) who played high school sports considered AAS use fair vs 37 of 80 men (46.3%) who did not play high school sports (P=.01). Conversely, only 14 of 35 men (40.0%) who played sports at the collegiate level believed that AAS use was fair compared with 108 of 178 men (60.7%) not playing college sports (P=.03).