1. No category

Anabolic Steroid Use by Male and Female Middle School Students
Avery D. Faigenbaum, Leonard D. Zaichkowsky, Douglas E. Gardner and Lyle J.
Micheli
Pediatrics 1998;101;e6
DOI: 10.1542/peds.101.5.e6
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/101/5/e6.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 1998 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Anabolic Steroid Use by Male and Female Middle School Students
Avery D. Faigenbaum, EdD*; Leonard D. Zaichkowsky, PhD‡; Douglas E. Gardner, MA‡; and
Lyle J. Micheli, MD§
ABSTRACT. Background. The prevalence of anabolic
steroid use by high school and college students has been
reported in the literature. However, rumors persist regarding the use of steroids by younger populations.
Objective. To assess the extent of steroid use by male
and female middle school students and to explore their
attitudes and perceptions about these drugs.
Methods. A confidential self-report questionnaire
was administered to 466 male and 499 female students
between 9 and 13 years of age (mean 6 SD, 11.4 6 0.9
years) in 5th, 6th, and 7th grades from four public middle
schools in Massachusetts. The number of students reporting steroid use and differences between users’ and
nonusers’ underlying attitudes and perceptions about
these drugs were evaluated.
Results. The response rate was 82% (965/1175 eligible). Results indicated that 2.7% of all middle school
students reported using steroids; 2.6% were males and
2.8% were females. When steroid users were compared
with nonusers, 47% versus 43% thought that steroids
make muscles bigger; 58% versus 31% thought that steroids make muscles stronger; 31% versus 11% thought
that steroids improve athletic performance; 23% versus
13% thought that steroids make one look better; 23%
versus 9% knew someone their own age who currently
took steroids; 38% versus 4% were asked by someone to
take steroids; 54% versus 91% thought that steroids were
bad for them; and 35% versus 2% indicated that they
would take steroids in the future. Additional analyses
determined steroid user involvement in sports and
activities.
Conclusion. The results of this study suggest that the
problem of illicit steroid use extends to children and
young adolescents and that a segment of this population
is mindful of the potential physiologic effects of steroids.
This information will be useful to pediatricians, sport
authorities, and school teachers whose guidance will become increasingly more important as steroid educational
interventions for male and female middle school students are developed. Pediatrics 1998;101(5). URL: http://
www.pediatrics.org/cgi/content/full/101/5/e6;
anabolic
androgenic steroid, drug abuse, risky behavior, children,
adolescents.
ABBREVIATION. AS, anabolic steroid(s).
From the *Department of Human Performance and Fitness, University of
Massachusetts; ‡Department of Developmental Studies, Boston University;
and §Division of Sports Medicine, Children’s Hospital, Boston, Massachusetts.
Received for publication Sep 16, 1997; accepted Dec 12, 1997.
Reprint requests to (A.D.F) Department of Human Performance and Fitness, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125.
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Academy of Pediatrics.
A
nabolic steroids (AS) have been used by adult
athletes since the 1950s in the hope of improving athletic performance. Although
weight lifters were the first consumers of these
drugs, AS now are being used by male and female
power athletes, endurance athletes, and nonathletes.
More recently, the use of AS has extended to younger
populations. In the United States, for example, it has
been reported that ;4% to 12% of male adolescents
and 0.5% to 2.9% of female adolescents have used AS
to enhance sports performance or favorably alter
body size.1–13 Although medical, legal, and ethical
issues related to the nonmedical use of AS continue
to be discussed, a growing number of adolescents
appear to be using these agents for nonmedical
purposes.14 –16
The perceived benefits from AS use are not without untoward consequences. The use of AS has been
associated with serious side effects including hypertension, alterations in lipid profiles, liver dysfunction, clotting abnormalities, and psychologic effects
including changes in mood, behavior, and somatic
perceptions.17,18 AS use during adolescence poses additional concerns because the use of these drugs
during this developmental period may result in the
premature closure of the epiphyseal growth plates.17
AS users who share contaminated needles also increase the risk of transmitting the human immunodeficiency virus.19,20 Many health professional organizations including the American Academy of
Pediatrics,21 the American College of Sports Medicine,22 and the National Strength and Conditioning
Association23 have denounced the nonmedical use of
AS.
Although the prevalence of AS use at the Olympic,
professional, college, and high school levels has been
reported,24 –28 rumors persist regarding the use of AS
by younger populations. Several researchers have
suggested that some students begin using AS before
they enter high school.1–2,10,29 Data from Tanner et al9
show that 54% of adolescent AS users started at #14
years of age, and Nutter30 recently found that ;3% of
students between 12 and 16 years of age had used or
were currently using AS. At this time, the prevalence
of AS use by children and young adolescents is
poorly understood and is limited primarily to preliminary reports.30,31
This study was designed to gather baseline information regarding the magnitude of AS use among
male and female middle school students between 9
and 13 years of age and to assess their underlying
attitudes and perceptions about AS. To our knowl-
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PEDIATRICS Vol. 101 No. 5 May 1998
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edge, no other AS survey has been administered to a
similar population. The impetus for this study was
provided by physicians and sport administrators
who suggested— based on clinical impressions and
anecdotal information—that the use of AS may have
trickled down to children and young adolescents.
METHODS
alence of AS use was ascertained with the question: Have you ever
taken steroids?
Pilot surveys were conducted to ensure that this instrument
could be used by children without difficulty. The survey was
offered in both English and Spanish. Identifying information such
as race and socioeconomic status was purposefully omitted from
this questionnaire. Descriptive statistics included means and SD
units. The tabular analysis included simple frequency counts and
percentages. The results pertaining to attitudes and perceptions
are reported to the nearest whole percentage.
Subjects
The participants in this investigation were 965 students (466
boys and 499 girls) between 9 and 13 years of age (mean 6 SD,
11.4 6 0.9 years) in 5th, 6th, and 7th grades from four public
middle schools in Massachusetts (Table 1). The four schools were
located within a 15-mile (24-km) radius of each other. Originally,
20 randomly selected middle schools in Massachusetts were solicited for participation in this study, but school administrators
declined because they stated that surveys of this nature could not
be given at their schools or that the use of AS was not a childhood
problem. Subsequently, four middle schools with which we had
worked with in the past or that expressed a willingness to participate were contacted. Informed consent was obtained from each
school principal. If requested, consent forms were sent home for
parental approval; only parents of 7 students denied permission
for their children to complete the survey. The only criteria for
inclusion in this study was that the child be currently enrolled in
middle school.
Design and Protocol
Before administering the survey, students and school administrators were informed that participation was totally voluntary and
that all responses were confidential. Students did not write their
names on the surveys, and anonymity was guaranteed. School
administrators were assured that the identity of their institution
would not be disclosed. The survey was administered to students
during 1995 and 1996. A health education teacher at each school
acted as the survey coordinator. All participants were informed
about the purpose of this study, and each survey coordinator was
given a standardized instruction sheet to read to the students
before distributing the survey. Coordinators administered the surveys to all students who were present in physical education or
health education class on the study date. Students were reminded
to answer all questions independently and honestly and to the
best of their ability. Students recorded their answers directly on
the survey sheet. When finished completing the surveys, students
were asked to fold them in half and place them in a closed box at
the front of the classroom. After all surveys were returned, the box
was then sealed by the survey coordinator and returned to the
principal investigator. Five surveys were not analyzed because of
ambiguous answers.
Instrument
A one-page self-report questionnaire was used to collect the
data. The first section obtained general information regarding age,
grade, and gender. The second section evaluated participation in
sports and recreational activities. Students were asked to mark all
sports and activities in which they participate regularly. Selections
included traditional school-sanctioned sports such as football, basketball, and soccer, as well as recreational activities such as weight
training and karate. The third section of the survey consisted of a
series of yes-or-no questions that assessed AS use, knowledge,
attitudes about AS, and intent to use AS in the future. The prev-
RESULTS
Of 1175 students who were eligible from the four
schools, 965 (82% response rate) participated voluntarily. AS use was reported by 2.7% (26/965) of all
middle school students surveyed. Of the 26 AS users,
1 (3.8%) was in 5th grade, 17 (65.4%) were in 6th
grade, and 8 (30.8%) were in 7th grade. A total of
2.6% (12/466) of the males and 2.8% (14/499) of the
females reported using AS. The prevalence of AS use
generally increased with age within a range of 11 to
13 years for males and 10 to 12 years for females. The
range of AS use among the four schools was from 1%
to 5%. A detailed prevalence of AS use is presented
in Table 2.
When the use of AS was analyzed with respect to
sport and activity participation, it was observed that
AS users on average participated in three to four
sports and activities. Our results show that the highest percentage of male and female AS users participated in gymnastics (3 users [9%], 33 participants)
and weight training (3 users [9%], 34 participants),
respectively. The activities with the lowest incidence
of AS use in males and females were soccer (2 users
[1%], 219 participants) and football (2 users [2%], 95
participants), respectively. As outlined in Table 3, no
sport or activity was secure from AS use.
In assessing attitudes and perceptions about AS,
differences between the self-identified AS users and
students who denied use of AS (nonusers) are evident (Table 4). More AS users than nonusers thought
that AS would make muscles bigger and stronger
and that AS users were more likely than nonusers to
believe that AS would improve athletic performance
or enhance appearance. Of the users, 23% knew
someone their own age who currently took AS, and
39% were asked by someone to take AS. In terms of
evaluating students’ attitudes about the potential
harm from AS, fewer users than nonusers reported
that AS are bad.“ In addition, when asked if they
would take steroids in the future, 35% of the users
reported that they would take AS, whereas 2% of
nonusers responded positively to this question.
DISCUSSION
This study represents the first attempt to assess the
prevalence of AS use among male and female middle
TABLE 1.
Demographic Variables of the 965 Students Completing the Survey
Age
(y)
Male
(n 5 466)
Female
(n 5 499)
%
Total
9
10
11
12
13
7
71
172
140
76
8
77
202
158
54
1.5
15.3
38.8
30.9
13.5
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TABLE 2.
Percentage of Students by Age and Gender Who
Reported Having Used AS
Students
Male (%)
Female (%)
All students (%)
Age (y)
9
10
11
12
13
0
0
0
0
1.3
0.7
3.5
2.5
2.9
1.4
5.1
3.3
5.3
0
3.1
ANABOLIC STEROID USE BY MIDDLE SCHOOL STUDENTS
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TABLE 3.
Percentage of Students by Gender and Activity
Involvement Who Reported Having Used AS
Sport
Males
Gymnastics
Weight training
Basketball
Football
Baseball
Hockey
Swimming
Karate
Tennis
Track and field
Soccer
Females
Weight training
Baseball
Hockey
Gymnastics
Tennis
Karate
Basketball
Track and field
Swimming
Soccer
Football
a
No. of Participantsa No. of Users (% Users)
33
85
332
296
285
168
246
91
91
86
219
3 (9)
4 (5)
9 (3)
8 (3)
7 (2)
4 (2)
6 (2)
2 (2)
2 (2)
1 (1)
2 (1)
34
138
58
138
123
49
272
112
321
168
95
3 (9)
9 (6)
3 (5)
6 (4)
5 (4)
2 (4)
10 (4)
4 (4)
11 (3)
5 (3)
2 (2)
Students indicated all activities in which they participate.
school students between 9 and 13 years of age. Although the results of this regional study may not be
indicative of national trends, our data provide important information about the magnitude and nature
of AS use that may be helpful to pediatricians, sport
authorities, and school teachers who may design and
participate in AS educational interventions. Particularly noteworthy is the finding that children as
young as 10 years of age reported that they had used
AS and that the prevalence of AS use is similar
between young males and females. Although reports
from the 1980s and early 1990s confirmed earlier
suspicions that high school students had used AS,
new findings from this study suggest that AS use has
now reached the middle school level.
A number of studies have used self-report surveys
to determine the prevalence of AS use at the high
school level, but few studies are available for comparison at the middle school level. The overall prevalence of AS use among middle school students in
this study (2.7%) was similar to prevalence rates
reported by Gray31 for 10- to 14-year-old youth sport
participants (2.0%) and by Nutter30 for 12- to 16-yearold middle school students (3.4%). Our findings also
are consistent with data from Melia et al,32 who assessed the prevalence of AS use among school-age
Canadians (2.8%), and from Yesalis,33 who reviewed
AS prevalence rates among junior high school students in the United States (2% for 6th-grade students
and 2.3% to 3% for 8th-grade students).
Unlike findings from previous investigations, our
study results reveal similar overall AS prevalence
rates between males and females (2.6% and 2.8%,
respectively). It must be emphasized, however, that
the students surveyed in our study were between 9
and 13 years of age (grades 5, 6, and 7). Researchers
who studied older students typically reported AS
prevalence rates about three to five times higher for
males.2,6 –10,12,30 For example, Nutter30 noted AS prevalence rates of 5.3% and 1.5%, respectively, for males
and females between 12 and 16 years of age, and
Komoroski and Rickert6 reported AS prevalence
rates of 7.6% and 1.5%, for 11th-grade males and
females, respectively.
Although AS use traditionally has been associated
with male-dominated strength and power sports, our
findings suggest that an equal percentage of young
females now are using these agents. Although the
specific explanations for using AS were not identified in this study, it is reasonable to conclude, although not with complete confidence, that increased
pressure on young women to excel in sport has resulted in a perceived need for chemical interventions
to enhance performance or to alter body size favorably. Also, it is possible that young females now feel
less need to be secretive about AS use. Interestingly,
AS use generally increased with age in males, peaking at age 13, whereas AS use in females peaked at
age 12; however, no 13-year-old females reported AS
use. This unanticipated decrease in AS use among
females may be related to the reported decrease in
female sports participation during the early adolescent years,34 or perhaps female AS users found the
virilizing effects of AS to be socially unacceptable.
The variability in AS user rates among the participating schools is somewhat expected (1% to 5%), yet
it is surprising that all participating schools have AS
users. This could indicate that AS use among middle
school students in Massachusetts may be more widespread than previously suspected; however, the survey was administered to four schools in a region
with high sports participation. Although these data
do not represent a randomized sample, the results of
this study are of serious concern because one potentially permanent side effect of AS use in children and
adolescents is the premature closure of the epiphyseal growth plates, which may result in stunted
growth.17 The cost and availability of AS were not
determined in this study, yet these factors may explain, in part, the variability in AS use among students at the four schools. In a nationwide survey of
AS use at the high school level, Buckley1 reported
that students at larger schools (.700 students) had
higher rates of AS use, and it is possible that similar
trends may occur at the middle school level. All four
middle schools that participated in our study had
enrollments of more than 700 students. In addition,
all students were from a middle-class socioeconomic
status, and sports participation rates were similar
among schools. AS educational programs were not
offered at any of the participating schools.
Our data suggest that AS use among young males
and females is occurring in a variety of sports and
activities. Students were asked to indicate all the
sports and activities in which they participate; thus,
the survey neither distinguished between competitive athletics and recreational participation nor identified specific school-based sports and activities. All
AS users in this study participated in at least one
sport or activity; however, unlike the results of other
studies involving adolescents,9 –10 findings indicated
that football was not the sport with the highest per-
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TABLE 4.
Percentage of Anabolic Steroid Users and Nonusers Who Answered Positively to Questions Relating to Their Attitudes and
Perceptions Toward AS
Do you think that steroids make your muscles bigger?
Do you think that steroids make your muscles stronger?
Do you think that steroids make anyone a better athlete?
Do you think that steroids make you look better?
Do you know someone your age who takes steroids?
Did someone ever ask you to take steroids?
Do you think that steroids are bad for you?
Would you ever take steroids in the future?
centage of male AS users. It is likely that several
factors, including the age of the respondents in this
study and the degrees of aggressiveness and competition in middle school football compared to high
school football, may partly explain this finding. It
also is possible that football players were fearful of
detection and therefore did not answer the survey
honestly.
The sports or activities with the highest percentage
of male and female AS users were gymnastics (9%)
and weight training (9%), respectively. Because gymnastics is a sport in which muscular strength is a
major asset, the relatively high prevalence of AS use
is not surprising. Yet this finding is particularly disturbing, because it has been suggested that some
young gymnasts may take AS to stunt their growth
because they believe that a small stature is advantageous in gymnastics. The relatively high use of AS by
young weight trainers was not unexpected, because
the use of these drugs by adolescents and adults who
weight train has been reported in the literature.4,27,28
Although no evidence indicates that weight training
in and of itself encourages AS use, when weight
training is used to enhance sports performance or
body appearance, the temptation to use AS is likely
to be greater.
The results from this study indicate that more AS
users that nonusers were knowledgeable about the
potential physiologic effects of AS (eg, increases in
muscle size and strength) and the potential influence
of AS on athletic performance and physical appearance. It is particularly distressing to report that only
54% of AS users (versus 91% of nonusers) thought
that AS were “bad,” although it is possible that some
AS users denied what they know to be true to justify
their use of these drugs. Other investigators reported
similar observations in adolescent AS users and nonusers.6 –7 The implications of these findings are noteworthy because AS education counselors should be
aware that some children and young adolescents
already believe that AS offer desirable benefits.
Equally revealing is the finding that 35% of AS users
and 2% of nonusers reported that they would take
steroids in the future. These observations suggest
that developmentally appropriate educational interventions for this population are wanting and that
positive messages children receive about the use of
AS from peers, television, and muscle magazines are
effective.
Of particular concern is that 23% of AS users and
9% of nonusers knew someone their own age who
currently took AS. Because previous reports have
4 of 6
Users (%) (n 5 26)
Nonusers (%) (n 5 939)
47
58
31
23
23
38
54
35
43
31
11
13
9
4
91
2
suggested that only a small percentage of adolescent
AS users stated that they received the drugs directly
from a physician,9,12 friends, family members, or
other individuals seem to be the primary sources of
AS.6,9 –10 Komoroski and Rickert6 reported significant
associations between AS use and the knowledge of
other male adolescents who use AS. Certainly, the
influence of peer pressure during childhood and
early adolescence should be considered one of the
primary factors associated with the initiation of AS
use. These findings are particularly troubling because there is no control over the illicit market supply of AS; thus, the degree of AS content or purity is
unknown.
The results of this study suggest that AS educational interventions should probably begin before
adolescence and should be direct toward both males
and females. Adults in contact with children need to
be aware of AS prevalence rates in this age group
and should be cognizant of children’s attitudes and
perceptions about these agents. Adults also need to
be aware of the challenges associated with changing
a behavior that results in noticeable benefits. Despite
previous reports that questioned the potential usefulness of AS, current evidence indicates that
changes in muscle strength and size will be evident
after AS use if appropriate strength training guidelines are followed.35,36 Moreover, it has been suggested recently that the side effects associated with
moderate doses of AS are primarily benign and reversible.37 This contention undoubtedly will make its
way from the scientific literature to the weight room
and may be used by some young AS users who are
trying to justify their use of these drugs.
Health care providers including pediatricians,
school nurses, and athletic trainers all can play an
important role in AS intervention strategies, but the
responsibility also should be shared by teachers,
coaches, youth sport administrators, and fitness instructors. Although many AS users may participate
in sports that are school-based, some AS users also
may belong to fitness centers (eg, local gyms) or
sport centers (eg, gymnastics clubs). AS interventions may need to be extended to public and private
centers where children exercise. Data from our study
suggest that the weight room may be a good place to
educate middle school students about AS, because a
high percentage of both male and female AS users
appear to participate in weight training, which now
is recognized as an important component of youth
fitness programs.38
At the high school level, a multidimensional AS
ANABOLIC STEROID USE BY MIDDLE SCHOOL STUDENTS
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prevention intervention program consisting of classroom sessions, weight-room sessions, and a parent
evening session reduced factors that encouraged AS
use and lowered intent to use AS.39 Similar multidimensional programs also may be effective at the
middle school level; however, this has not yet been
determined. AS interventions that focus only on the
toxic side effects of these agents (ie, scare tactics)
have been shown to be ineffective at the high school
level,40 and it is likely that this unidimensional approach would not be effective at the middle school
level as well.
Although the advantage of this type of study design is that a large number of individuals can be
questioned in a nonthreatening and inexpensive
manner, a major concern involves the possibility for
false-negative and false-positive responses. Although it is impossible to ensure the validity of every
response in this type of self-report study, it is well
established that a significant level of validity can be
achieved if appropriate research guidelines are followed (eg, assurance of anonymity and voluntary
participation). Additionally, this type of questionnaire has proven to be a valid measure of recreational drug use in adolescent populations41,42 and
has been used by other investigators who identified
AS use patterns in adolescents.7,9,10,30
The prevalence of AS use was assessed with the
question, “Have you ever taken steroids?” Although
this question did not distinguish between the medical and nonmedical use of AS, other studies have
used a similar question to assess AS use in adolescents.3,10,13,37 It is possible, however, that some
respondents may have confused AS with similar
medications (eg, corticosteroids). In fact, nine respondents answered positively to the aforementioned AS question, but noted on the questionnaire
that steroids were “in their asthma medication.” Although these false-positive responses were excluded
from the final analysis, other students may have
unintentionally reported AS use. On the other hand,
students may have underreported AS use for fear of
punishment or disqualification. Although no information is available on students who chose not to
participate or who were absent when the survey was
administered, it is reasonable to infer that a number
of those who did not participate were AS users.
Another important consideration is the prevalence
of AS use in middle schools that did not participate
in this study. School administrators who perceived
that AS use was a problem in their schools may have
been less willing to participate in this study to preserve a desired image of their school and student
body. Although school administrators were assured
that no school would or could be identified individually, it is apparent that the topic of AS use remains
sensitive and controversial.
CONCLUSION
AS use is no longer limited to the confines of
bodybuilding gyms or adult sport training centers.
Despite the probability of underreporting or overreporting in this study, our data suggest that a small
but significant portion of middle school males and
females had used AS and that a striking number of
young respondents already are aware of the potential physiologic effects of AS. These finding are of
particular concern because of the potential adverse
complications associated with AS use. Although reports from other investigations suggest that students
do not rely on physicians for information about AS,
anticipatory guidance from these health professionals will become increasingly more important as proactive educational interventions are developed for
male and female middle school students. Future
studies should examine children’s primary source of
AS, the predictors of AS use and dependency, and
effective AS prevention interventions for male and
female students.
ACKNOWLEDGMENT
This study was supported by the Boston Sports Medicine Research Foundation.
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ANABOLIC STEROID USE BY MIDDLE SCHOOL STUDENTS
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Anabolic Steroid Use by Male and Female Middle School Students
Avery D. Faigenbaum, Leonard D. Zaichkowsky, Douglas E. Gardner and Lyle J.
Micheli
Pediatrics 1998;101;e6
DOI: 10.1542/peds.101.5.e6
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