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;6-
DOI: 10.1542/peds.101.5.e6

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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 re-
garding 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 re-
porting 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 eligi-
ble). 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 ste-
roids 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 be-
come increasingly more important as steroid educational
interventions for male and female middle school stu-
dents 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, Massachu-
setts.
Received for publication Sep 16, 1997; accepted Dec 12, 1997.
Reprint requests to (A.D.F) Department of Human Performance and Fit-
ness, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125.
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-
emy of Pediatrics.
http://www.pediatrics.org/cgi/content/full/101/5/e6 PEDIATRICS Vol. 101 No. 5 May 1998
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A
nabolic steroids (AS) have been used by adult
athletes since the 1950s in the hope of im-
proving 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 with-
out untoward consequences. The use of AS has been
associated with serious side effects including hyper-
tension, alterations in lipid profiles, liver dysfunc-
tion, clotting abnormalities, and psychologic effects
including changes in mood, behavior, and somatic
perceptions.17,18 AS use during adolescence poses ad-
ditional 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 in-
crease the risk of transmitting the human immuno-
deficiency virus.19,20 Many health professional orga-
nizations including the American Academy of
Pediatrics,21 the American College of Sports Medi-
cine,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 pre-
liminary reports.30,31
This study was designed to gather baseline infor-
mation 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-
1 of 6
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
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 so-
licited 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 partic-
ipate 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 adminis-
trators 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 sur-
veys 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, bas-
ketball, 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-
TABLE 1. Demographic Variables of the 965 Students Com-
pleting the Survey
Age Male Female % Reported Having Used AS
(y) (n 5 466) (n 5 499) Total
9 7 8 1.5
10 71 77 15.3
11 172 202 38.8
12 140 158 30.9
13 76 54 13.5
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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.
RESULTS
Of 1175 students who were eligible from the four
schools, 965 (82% response rate) participated volun-
tarily. 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 high-
est percentage of male and female AS users partici-
pated 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 evi-
dent (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 2. Percentage of Students by Age and Gender Who
Students Age (y)
9 10 11 12 13
Male (%) 0 0 3.5 1.4 5.3
Female (%) 0 1.3 2.5 5.1 0
All students (%) 0 0.7 2.9 3.3 3.1
TABLE 3. Percentage of Students by Gender and Activity males.2,6 –10,12,30 For example, Nutter30 noted AS prev-
Involvement Who Reported Having Used AS alence rates of 5.3% and 1.5%, respectively, for males
Sport No. of Participantsa No. of Users (% Users) and females between 12 and 16 years of age, and
Males
Komoroski and Rickert6 reported AS prevalence
Gymnastics 33 3 (9) rates of 7.6% and 1.5%, for 11th-grade males and
Weight training 85 4 (5) females, respectively.
Basketball 332 9 (3) Although AS use traditionally has been associated
Football 296 8 (3) with male-dominated strength and power sports, our
Baseball 285 7 (2)
Hockey 168 4 (2) findings suggest that an equal percentage of young
Swimming 246 6 (2) females now are using these agents. Although the
Karate 91 2 (2) specific explanations for using AS were not identi-
Tennis 91 2 (2) fied in this study, it is reasonable to conclude, al-
Track and field 86 1 (1)
Soccer 219 2 (1)
though not with complete confidence, that increased
Females pressure on young women to excel in sport has re-
Weight training 34 3 (9) sulted in a perceived need for chemical interventions
Baseball 138 9 (6) to enhance performance or to alter body size favor-
Hockey 58 3 (5) ably. Also, it is possible that young females now feel
Gymnastics 138 6 (4)
Tennis 123 5 (4) less need to be secretive about AS use. Interestingly,
Karate 49 2 (4) AS use generally increased with age in males, peak-
Basketball 272 10 (4) ing at age 13, whereas AS use in females peaked at
Track and field 112 4 (4) age 12; however, no 13-year-old females reported AS
Swimming 321 11 (3)
Soccer 168 5 (3)
use. This unanticipated decrease in AS use among
Football 95 2 (2) females may be related to the reported decrease in
a
female sports participation during the early adoles-
Students indicated all activities in which they participate.
cent years,34 or perhaps female AS users found the
virilizing effects of AS to be socially unacceptable.
school students between 9 and 13 years of age. Al- The variability in AS user rates among the partic-
though the results of this regional study may not be ipating schools is somewhat expected (1% to 5%), yet
indicative of national trends, our data provide im- it is surprising that all participating schools have AS
portant information about the magnitude and nature users. This could indicate that AS use among middle
of AS use that may be helpful to pediatricians, sport school students in Massachusetts may be more wide-
authorities, and school teachers who may design and spread than previously suspected; however, the sur-
participate in AS educational interventions. Particu- vey was administered to four schools in a region
larly noteworthy is the finding that children as with high sports participation. Although these data
young as 10 years of age reported that they had used do not represent a randomized sample, the results of
AS and that the prevalence of AS use is similar this study are of serious concern because one poten-
between young males and females. Although reports tially permanent side effect of AS use in children and
from the 1980s and early 1990s confirmed earlier adolescents is the premature closure of the epiphy-
suspicions that high school students had used AS, seal growth plates, which may result in stunted
new findings from this study suggest that AS use has growth.17 The cost and availability of AS were not
now reached the middle school level. determined in this study, yet these factors may ex-
A number of studies have used self-report surveys plain, in part, the variability in AS use among stu-
to determine the prevalence of AS use at the high dents at the four schools. In a nationwide survey of
school level, but few studies are available for com- AS use at the high school level, Buckley1 reported
parison at the middle school level. The overall prev- that students at larger schools (.700 students) had
alence of AS use among middle school students in higher rates of AS use, and it is possible that similar
this study (2.7%) was similar to prevalence rates trends may occur at the middle school level. All four
reported by Gray31 for 10- to 14-year-old youth sport middle schools that participated in our study had
participants (2.0%) and by Nutter30 for 12- to 16-year- enrollments of more than 700 students. In addition,
old middle school students (3.4%). Our findings also all students were from a middle-class socioeconomic
are consistent with data from Melia et al,32 who as- status, and sports participation rates were similar
sessed the prevalence of AS use among school-age among schools. AS educational programs were not
Canadians (2.8%), and from Yesalis,33 who reviewed offered at any of the participating schools.
AS prevalence rates among junior high school stu- Our data suggest that AS use among young males
dents in the United States (2% for 6th-grade students and females is occurring in a variety of sports and
and 2.3% to 3% for 8th-grade students). activities. Students were asked to indicate all the
Unlike findings from previous investigations, our sports and activities in which they participate; thus,
study results reveal similar overall AS prevalence the survey neither distinguished between competi-
rates between males and females (2.6% and 2.8%, tive athletics and recreational participation nor iden-
respectively). It must be emphasized, however, that tified specific school-based sports and activities. All
the students surveyed in our study were between 9 AS users in this study participated in at least one
and 13 years of age (grades 5, 6, and 7). Researchers sport or activity; however, unlike the results of other
who studied older students typically reported AS studies involving adolescents,9 –10 findings indicated
prevalence rates about three to five times higher for 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 compe-
tition 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 gym-
nastics 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 dis-
turbing, because it has been suggested that some
young gymnasts may take AS to stunt their growth
because they believe that a small stature is advanta-
geous 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 appear-
ance. 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 non-
users.6 –7 The implications of these findings are note-
worthy 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 inter-
ventions 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
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Users (%) (n 5 26) Nonusers (%) (n 5 939)
47 43
58 31
31 11
23 13
23 9
38 4
54 91
35 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 be-
cause there is no control over the illicit market sup-
ply of AS; thus, the degree of AS content or purity is
unknown.
The results of this study suggest that AS educa-
tional 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 use-
fulness of AS, current evidence indicates that
changes in muscle strength and size will be evident
after AS use if appropriate strength training guide-
lines are followed.35,36 Moreover, it has been sug-
gested recently that the side effects associated with
moderate doses of AS are primarily benign and re-
versible.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 in-
structors. 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 interven-
tions 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
prevention intervention program consisting of class-
room sessions, weight-room sessions, and a parent
evening session reduced factors that encouraged AS
use and lowered intent to use AS.39 Similar multidi-
mensional 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 ap-
proach would not be effective at the middle school
level as well.
Although the advantage of this type of study de-
sign 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. Al-
though 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 fol-
lowed (eg, assurance of anonymity and voluntary
participation). Additionally, this type of question-
naire has proven to be a valid measure of recre-
ational 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 medi-
cal and nonmedical use of AS, other studies have
used a similar question to assess AS use in adoles-
cents.3,10,13,37 It is possible, however, that some
respondents may have confused AS with similar
medications (eg, corticosteroids). In fact, nine re-
spondents answered positively to the aforemen-
tioned AS question, but noted on the questionnaire
that steroids were “in their asthma medication.” Al-
though 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 infor-
mation 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 pre-
serve a desired image of their school and student
body. Although school administrators were assured
that no school would or could be identified individ-
ually, 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 overre-
porting in this study, our data suggest that a small
but significant portion of middle school males and
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females had used AS and that a striking number of
young respondents already are aware of the poten-
tial physiologic effects of AS. These finding are of
particular concern because of the potential adverse
complications associated with AS use. Although re-
ports from other investigations suggest that students
do not rely on physicians for information about AS,
anticipatory guidance from these health profession-
als will become increasingly more important as pro-
active 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 Re-
search Foundation.
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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;6-
DOI: 10.1542/peds.101.5.e6
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