The prevalence of the use of androgenic
anabolic steroids by adolescents in a county
of Sweden
SVERKER NILSSON, AMIR BAIGI, BERT1L MARKLUND, BENGT FRJDLUND •
Background: The prevalence of the use of androgenic anabolic steroids has been poorly studied in Europe. This
study was undertaken to examine the prevalence of the misuse - the non-medical use - of androgenic anabolic
steroids among adolescents in a county of Sweden. Methods: The total population of 16 and 17 year old male and
female adolescents in a county on the south-west coast of Sweden was studied. The investigation was done by an
anonymous multiple-choice questionnaire. The questionnaire was completed by 5,827 pupils and statistically
analysed. The participation rate was 95%. Results: Among male adolescents 16 and 17 years old, 3.6% and 2.8%
had misused androgenic anabolic steroids, respectively. These male adolescents had also misused alcohol, growth
hormones and narcotic drugs more than the steroid hormone non-users. Among female adolescents there was no
recorded misuse of these drugs (0.0%). Conclusions: The misuse of androgenic anabolic steroids Is a reality in both
small and large municipalities in Sweden. The prevalence figures are higher among 16 year old compared to 17
year old male adolescents. There is an association between this drug misuse and other substance misuse such as
narcotic drugs. Female adolescents do not misuse steroid hormones. The findings indicate the need for preventive
work among male adolescents in order to induce adolescents not to start misusing androgenic anabolic steroids.
Keywords: adolescents, androgenic anabolics, appearance, drug misuse, prevention
he use of androgenic anabolic steroids in order to improve sports performance has been known about since the
1950s.1'2 During the 1980s evidence emerged that the use
of these steroid hormones had spread to non-athletic
adolescents in die USA. 3 " 5 Misuse (non-medical use) of
androgenic anabolic steroids among male adolescents in
the USA has been reported continuously ever since. 6 " 16
Studies in the USA have proved a variety of prevalence
figures for misuse of steroid hormones. The average figure
in a range of states in 1988 was 6.6 % 3 among male
adolescents. Figures from individual states included Texas
(5.0%) 5 and Arkansas (11%) 4 during the same period.
The prevalence figures were in the same range during the
1990s
and have been similar in urban and rural
areas. ' Misuse in the USA has been shown not only
among male adolescents, but also among female adolescents ranging from 0.5"* to 5%. The prevalence of the
misuse of androgenic anabolic steroids in the rest of the
world has been poorly studied, with only a few studies
from Great Britain, 17 ' 18 Australia, 19 South Africa,20
Canada and Sweden. The side-effects of androgenic
anabolic steroids are dangerous both physically and
* S. Nlbson1, A. Baigi2, B Marklund3, B. Frldlund3
1 Department of Primary Health Care. Falkenberg, Sweden
2 Research and Development Unit, Primary Hearth Care Halland, Falkenberg,
Sweden
3 Centre for Hearth Promotion Research, Halrratad University, Halmstad,
Sweden
Corrapondenc*: Dr Sverker Nirsson, Department of Primary Hearth Care,
Neptun klinlken, S6dra Hamnvagen 4, 43244 Varberg, Sweden,
tel. +46 34016016, fax +46 340644816, e-mail: nlbsonsveftcerOhotmail.com
mentally.
Psychiatric side-effects can occur among
healthy people without a predisposition to psychiatric
disease. • ^ • i The side-effects of androgenic anabolic
steroids can be harmful not only to the misuser but also
to people in contact with violent offenders.25'27 For these
reasons it is important to investigate the prevalence figures not only in the USA, but also in European countries.
The aim of this study was to examine the prevalence of
misuse of androgenic anabolic steroids among adolescents
in a county of Sweden.
METHODS
Design and setting
A descriptive explorative study design was carried out in
schools in a county on the south-west coast of Sweden
with a catchment area of 240,000. The study was approved by local politicians as well as by the headmasters
of each participating school.
Population
In the catchment area all 16 and 17 year old males and
females, termed adolescents in the current study, were
examined, i.e. all adolescents in the ninth classes of
school (16 years old) and in the first form (17 years old)
in colleges. Attendance in the ninth class is compulsory
and almost everyone (98%) continues studies in the first
form of college, according to the school authorities. 29
Consequently, this study can be considered to cover the
entire population of 16 and 17 year old adolescents in this
region of Sweden. Adolescents living in both urban and
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 11 2001 NO. 2
rural areas were studied and the sample was representative
of the population of Sweden in this age group in terms of
social class.30
Instrument
The study used an anonymous multiple-choice questionnaire designed by the Centre of Alcohol and Narcotic
information (CAN) in Sweden, which is a department
founded by the government in order to investigate the
misuse of drugs and alcohol and to stimulate preventive
work to decrease this misuse. CAN evaluated the questionnaire and found it valid and reliable. The 32-item,
multiple-choice questionnaire included questions regarding the usage of androgenic anabolic steroids, such as
'Have you ever used androgenic anabolic steroids other
dian prescribed by doctors?1 and other questions asking
about growth hormones, alcohol and narcotic drugs, exploring type of drug and route of administration. For
example, 'If you have taken androgenic anabolic steroids,
how have you taken them: as pills or by injections or
both?1 Other questions asked about frequency and duration of use ('How often have you taken androgenic
anabolic steroids and for how long?1) and the reason why
('Why do you or did you use androgenic anabolic
steroids?')- The questionnaire with responses on an
ordinal scale also included questions designed to detect
false answers. It was pre-tested on 20 teenagers as well as
on 20 personnel in schools and primary health care
centres.
Dam collection
The questionnaires were distributed to each school form
by trained personnel. The teacher responsible for each
class administered them to every adolescent in the class.
The questionnaires were completed individually and
anonymously, placed in an envelope and sealed. Teachers
collected the envelopes and the study personnel returned
them to the Research and Development Unit in die
county where diey were analysed. All adolescents in this
Table 1 Frequency of drugs reported tested in a county of Sweden
among 84 male androgenic anabolic steroid users and 2,701 male
non-users respectively
Drugs
Alcohol regulary
Home-made
alcohol often
Narcotic drugs
overall
Amphetamine
Ecstasy
Hashish
Marijuana
Morphine
Cocaine
LSD
Steroid users
n
%
Steroid non-users
n
%
57
68
769
28.0
37
44
130
4.8
55
27
22
42
37
10
14
24
65
32
26
50
44
12
17
29
217
54
20
141
113
22
15
21
8.0
2.0
0.7
5.2
4.2
0.8
0.6
0.8
All the differences are statistically significant (p<0.001)
area were examined in the same week in dieir schools,
which means that all adolescents participated in the
study except those who were absent due to illness. The
investigation was completed by 5,827 adolescents out of
a total population of 6,120, i.e. a participation rate of 95%.
The sample was almost equally divided between 16 and
17 years old and between males and females.
Data analysis
Frequency and percentage distributions were used to
describe the data. Cross-tabulation was used in data
presentation and statistical analysis. Student's t-test was
used to test differences between sexes and ages and die
basic data were regarded as normally distributed. The
level of significance was set at 5%. 32
RESULTS
In this study, misuse of androgenic anabolic steroids
among female adolescents was not detected (0.0%), while
among male adolescents 2.9% (n=84) had misused steroid
hormones. The prevalence rates were 3.6% among 16 year
old boys and 2.2% among 17 year old boys. The rates were
higher among 16 year old boys dian among 17 year old
ones (p<0.01). Among those male adolescents (n=84)
who used androgenic anabolic steroid pills, 25% (n=21)
also injected ampoules of the steroid hormones. Of male
adolescents which had used androgenic anabolic steroids,
43% (n=36) had done so over at least 1 year. They bought
their drugs at gyms, in die street or in die school yards.
The main reason offered for drug misuse was to improve
their appearance, (73%, n»61). A comparison of boys
who used androgenic anabolic steroids showed diat diey
differed from others in several ways (table 1 and 2); diey
trained more at gyms to build up dieir muscle volume
(p<0.001), drank more alcohol (p<0.001) more often
(p<0.001) and witli more on each occasion (p<0.001),
used more home-distilled alcohol (p<0.001) and used
more illicit drugs overall (p<0.001) as well as for each
substance, for example amphetamine (p<0.001), ecstasy
(p<0.001), hashish/marijuana (p<0.001), morphine
(p<0.001), cocaine (p<0.001) and LSD (p<0.001). Of
these boys, 33% (n=28) stated diat androgenic anabolic
steroids were not harmful while die rest did (p<0.001).
These male adolescents believed diat girls prefer boys
widi big muscles more dian the others did (p<0.001). Of
Table 2 Attitudes to androgenic anabolic steroids and lifestyles in
a county of Sweden among 84 male androgenic anabolic steroid
users and 2,701 male non-users respectively
Questions asked
Train at gym
often
Anabolics
harmful
Girls prefer big
muscles
Steroid users
n
%
Steroid non-users
n
%
29
35
94
3.5
37
44
2,459
91.0
49
58
780
29.0
All the differences are statistically significant (fXO.001)
Misuse of androgenic anabolics by adolescents
the male adolescents who had used androgenic anabolic
steroids, 64% (n=54) consumed alcohol at the same time.
One percent (n=30) had injected growth hormones, all
of whom had also misused androgenic anabolic steroids.
DISCUSSION
This study was designed to investigate the misuse of
androgenic anabolic steroids among all 16 and 17 year old
adolescents in the south-west of Sweden. The sample was
representative of the rest of Sweden in terms of social
class. The findings show that the non-medical use of these
hormones among male adolescents is a reality not only in
the USA,3"15 but also in Sweden. They also show that the
misuse of these drugs is essentially a male problem, as no
female adolescents in this study reported misuse of androgenic anabolic steroids. However, as the side-effects of the
drugs can be very harmful because of changes in personality to a more aggressive manner23'24i26>28 particularly
in combination with alcohol,"~2° both sexes and all ages
are in danger. Although the prevalence figures of the
misuse of androgenic anabolic steroids among male adolescents are not as high as in the USA3" the findings
describe an existing problem, requiring urgent action.
Previous studies •• have shown that boys who use these
drugs are more likely to misuse alcohol and narcotic drugs,
findings which are supported in this study. The reported
misuse is higher among 16 than 17 year old male adolescents, which needs to be studied further, in order to
establish the causes of this phenomenon.
CONCLUSIONS AND IMPLICATIONS
In a study examining the prevalence figures of the misuse
of androgenic anabolic steroids in a county of Sweden,
misuse of androgenic anabolic steroids was found among
male but not among female adolescents. As this study
showed that the main reason for this drug misuse among
male adolescents is to improve their appearance, it may
be important to discuss ideas about appearance and
behaviour in future preventive work. The key task for
future preventive health work is to identify those at risk
of misuse in order to influence their attitudes before they
start misusing androgenic anabolic steroids and other
drugs. An effective intervention can save adolescents
from unnecessary suffering due to side-effects, while at
the same time saving money for the community. Future
studies are needed in order to evaluate both the effectiveness and the cost-effectiveness of intervention
programmes.
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Received 27 July 1999, accepted 13 January 2000