The Health Threat Posed by the Hidden Epidemic of Anabolic Steroid Use and Body Image Disorders Among Young Men

Anna L. Goldman; Harrison G. Pope, Jr.; Shalender Bhasin


J Clin Endocrinol Metab. 2019;104(4):1069-1074. 

In This Article

Abstract and Introduction


Context: The prevalence of body image disorders and anabolic-androgenic steroid (AAS) use is increasing, despite the evidence of their serious adverse health effects and despite the passage of laws regulating their sales. Here we review the evolution of the dual emerging epidemics of body image disorders and AAS use, adverse health effects of AASs, and the need for an integrated health policy and regulatory response.

Evidence Acquisition: We searched for studies published prior to June 2018. Quality of evidence was low to moderate because of its observational nature; heterogeneity of eligibility criteria; variable doses; reliance on retrospective self-reported data in many studies; and variable quality of outcome ascertainment.

Evidence Synthesis: Most AAS users are nonathlete young men, who use these substances to look lean and more muscular. Some of these men suffer from "muscle dysmorphia," a form of body dysmorphic disorder. AASs has been associated with cardiovascular disorders, psychiatric disorders, AAS-withdrawal hypogonadism, infertility, neurotoxic effects, musculoskeletal injuries, liver toxicity, and needle-borne infections. Potential adverse effects may be compounded by the use of other substances (e.g., opioids) and high-risk behaviors. Unregulated Internet sales of AASs and selective androgen receptor modulators, which are easily purchased without a prescription, are of concern because of their potential to fuel the epidemic among adolescents and the military.

Conclusions: Integrated nationwide efforts are necessary to raise public awareness of this epidemic, to study long-term health effects of AASs and treatment strategies, and to reform regulations to stem the epidemics of AAS use and body image disorders.


The anabolic-androgenic steroids (AASs) are a class of pharmacological substances, sharing a cyclopenta phenanthrene steroidal ring structure, that includes testosterone and many synthetic compounds structurally related to testosterone. The anabolic effects of AASs include promotion of nitrogen retention and muscle growth, whereas the androgenic effects include the development of male secondary sexual characteristics such as facial hair, deepening of the voice, and the growth and development of external genitalia. According to the Controlled Substances Act, a substance may be classified as an AAS if it is[1] chemically related to testosterone;[2] pharmacologically related to testosterone (i.e., it produces biological effects similar to those of testosterone); and[3] not an estrogen, progestin, or a corticosteroid.[1] Another family of compounds with similar effects, the nonsteroidal selective androgen receptor modulators (SARMs), has entered development over the last two decades. SARMs are substances that bind to the androgen receptor and regulate the transcription of androgen-dependent genes in a tissue-specific manner.[2,3]

In the United States, several AASs have been approved for a limited number of medical indications, such as treatment of hypogonadism and some types of anemia.[1] Nonsteroidal SARMs have not yet been approved for human use, but are being developed for their potential anabolic applications.[2,3] However, the legitimate medical use of these compounds is overshadowed by the emerging epidemics of AAS and SARM use among weightlifters, most of whom are men and between 18 and 50 years of age.[4–7] Contrary to popular belief, most AAS users are not competitive athletes, but simply men who use these drugs to enhance personal appearance, sometimes because of underlying body image disorders.[4,6,8] Regulatory efforts have largely failed to check these substance use disorders, but instead have managed to create headwinds for the clinical use of androgens and for the pharmaceutical development of these compounds as function-promoting anabolic therapies.