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Image and Performance Enhancing Drugs (IPEDs) that include anabolic steroids have been a subject of growing concern over recent years, both in and out of the sporting environment. Reporting to the cross-party House of Commons Health and Social Care Committee in 2022 on the impact of body image on mental and physical health, the UK Anti-Doping Agency stated that there are more than one million, predominantly (around 98%) male, steroid users in the UK.
The Agency describe steroid abuse as “now a serious public health issue”, citing that 56% of these users took steroids for improving body image or cosmetic reasons. They describe the most common type of steroid abuser as a thirty-something white-collar professional, and not elite sportspeople as some may assume.
The taking of drugs to improve sporting performance, or ‘doping’, is not a new threat to sport but over the past 20 years the use of IPEDs, particularly anabolic steroids, has increased significantly in the UK, moving out of a narrow band of elite athletes and into amateur and recreational sport.
The use of anabolic steroids has also been linked to increases in domestic violence. In a 2021 murder case at the Old Bailey, the defence argued that the defendant had suffered from a medical illness impairing his thinking and resulting actions, but the prosecution was able to prove to the jury that the defendant in fact had become paranoid as a result of voluntarily taking anabolic steroids.
What are anabolic steroids?
Androgens are a group of sex hormones. The name is derived from the Greek andros meaning man, and gennan meaning to produce. They help start puberty and play a role in reproductive health and body development. All genders make androgens, but males make more of them. Testosterone is the most common androgen.
Anabolic steroids are androgens. They are a synthetic steroid hormone which resembles testosterone in promoting the growth of muscle.
Testosterone is the major sex hormone in males and plays a number of important roles, such as:
- The development of the penis and testes.
- The deepening of the voice during puberty.
- The appearance of facial and pubic hair starting at puberty; later in life, it may play a role in balding.
- Muscle size and strength.
- Bone growth and strength.
- Sex drive (libido).
- Sperm production.
Testosterone may also help maintain a normal mood, and there may be other important functions of this hormone that have not yet been discovered. Having too much naturally-occurring testosterone is not a common problem among men.
Anabolic steroids are drugs artificially derived from the main male hormone testosterone. They can build muscle and improve athletic performance, but they can also have significant adverse effects, especially when used incorrectly. Anabolic steroids are the most common type of Image and Performance Enhancing Drugs (IPEDs).
They are often just referred to as steroids, but other names include:
- Smart drugs.
Anabolic steroids are prescription-only medicines that are increasingly acquired and used without medical advice to increase muscle mass and improve athletic performance. They are usually injected into a muscle or taken by mouth as tablets, but they also come as creams or gels that are applied to the skin.
What are the different forms of anabolic steroids?
There are two main groups of natural steroids: anabolic steroids and corticosteroids. It is the anabolic steroids that tend to be misused, mainly because they are similar to the male hormone testosterone and they can improve endurance and performance and stimulate muscle growth.
All synthetic anabolic steroids are developed from a base of one of three parent steroids, all of which occur naturally in the human body.
- Dihydrotestosterone (DHT).
- Nandrolone (also known as 19-Nor Testosterone).
Anabolic steroids derived from DHT are typically weaker than nandrolones or testosterones in terms of their anabolic properties.
Parent steroid – Testosterone is the most potent in terms of muscle building, but also the most prone to aromatisation and androgenic side effects.
Parent steroid – Dihydrotestosterone, DHT derived anabolic steroids, are characterised by lean muscle gains, largely due to the lack of androgenic side effects including fat and water gain. They are also less likely to produce oestrogenic side effects as DHT derived anabolic steroids cannot be aromatised into oestrogen.
Parent steroid – Nandrolone exerts powerful anabolic effects but with much less androgenic activity and therefore fewer androgenic side effects than testosterone. Nandrolones also aromatise more slowly than testosterone and therefore have a reduced risk of oestrogenic side effects, although they are still possible at high doses.
The list of anabolic steroids commonly used for muscle building is lengthy, but includes:
- DHEA supplements – DHEA (short for the hormone dehydroepiandrosterone) acts as a precursor to testosterone production in the body.
- Testosterone enanthate – One of the most commonly used steroids, and therefore often a first-timer’s choice.
- Testosterone cypionate – A popular synthetic form of testosterone, widely used.
- Nandrolone – Popular with bodybuilders, sportsmen and gym-goers.
- Trenbolone – Popular in UK gyms, but with serious physical side effects.
Can anabolic steroids be addictive?
Although there is not enough evidence to connect chronic anabolic steroid use with substance dependence, the positive psychological effects experienced by many users appear to reinforce the continuing use of steroids for some users.
Users can easily become psychologically dependent on anabolic steroid use, meaning they develop an increased tendency to keep taking the drug even in spite of possible harmful effects. Withdrawal symptoms have been reported by anabolic steroid users soon after stopping, including headaches, lethargy and depression.
What are anabolic steroids used for?
Anabolic steroids have limited medical uses and are not the same as corticosteroids, a different type of steroid drug that is more commonly prescribed.
Corticosteroids are mainly used to reduce inflammation and suppress the immune system.
They are used to treat conditions such as:
- Allergic rhinitis and hay fever.
- Urticaria (hives).
- Atopic eczema.
- Chronic obstructive pulmonary disease (COPD).
- Painful and inflamed joints, muscles and tendons.
- Inflammatory bowel disease (IBD) – including Crohn’s disease and ulcerative colitis.
- Giant cell arteritis and polymyalgia rheumatica.
- Multiple sclerosis (MS).
Corticosteroids can also be used to replace certain hormones that are not naturally produced by the body. This is the case in people with Addison’s disease.
Anabolic steroids can be used as performance-enhancing drugs that increase muscle mass and decrease fat. Some people take them regularly to improve their physical performance and build up their bodies. Fierce competitiveness at all levels of sport, and the huge financial rewards at the top of elite sport, can be a contributing factor to anabolic steroid use.
The use of anabolic steroids by the general public, and in particular young people, has been increasing. The constant exposure to specific body types can distort the public perception of what is normal and acceptable, leading to societal pressure to look a certain way, particularly for young people who are vulnerable to peer pressure and expectations.
Image-based sharing sites such as Instagram or Snapchat are popular among young people and filters featured on these sites, which are added to images, also add further distortion and greater ambiguity to what is real.
The role of social media influencers should also be considered. Influencers who appear on these sites can be powerful in affecting behaviour or personal morale; many demonstrate the perceived benefits of IPEDs such as anabolic steroids or supplement use without articulating the significant risks, and are often financially incentivised to do so.
How are anabolic steroids abused?
Androgenic anabolic steroid (AAS) abuse refers to the use of testosterone derivatives to improve athletic performance and/or to increase lean body mass and muscle size. Abuse differs from that of other drugs, such as heroin or cocaine, as the desire to use them does not generally come from the effects of the drug, but rather from wanting to change appearance or improve athletic performance.
Anabolic steroids are generally used in patterns called “cycling”. Here the drugs are taken for a period of time (for example 6–12 weeks) known as an “on” cycle, followed by a similar period of steroid-free training known as an “off” cycle. Such a cyclical method is practised in the belief that it prevents tolerance to the steroids and reduces the risk of side effects from prolonged use.
Users also frequently combine several different types of anabolic steroids in a process known as “stacking”. Here, two or more anabolic steroids are taken at the same time, using oral and injectable products, for example. Users believe that stacking will have specific additional or synergistic effects.
Some users gradually increase the dose of anabolic steroids to a peak, then reduce the amount; this is known as Pyramiding.
Since Viagra/sildenafil was approved for prescribed use by the Medicines and Healthcare products Regulatory Agency (MHRA), athletes and bodybuilders have been using it for another purpose, as a pre-workout supplement.
Sildenafil citrate, a form of anabolic steroid, was originally developed by the pharmaceutical company Pfizer. Pfizer decided to begin selling it under the brand name Viagra for the treatment of erectile dysfunction; it increases blood flow to the penis. When Pfizer’s patent ended in 2013, it became legal for other companies to develop and market their own versions of sildenafil citrate. These other companies use the name ‘sildenafil’ in place of ‘Viagra’, as a recognisable shorthand for its active ingredient.
Viagra/sildenafil works by opening up the blood vessels, which allows blood to flow more freely to all organs. This increased blood flow is what some athletes hope to have to get them to build up their bodies faster. There is a small amount of research to support these claims.
A few studies have suggested that taking sildenafil can benefit athletes competing at high altitudes, such as cyclists or long-distance runners, by delivering more oxygen to their muscles. In 2017, the UK became the first country where Viagra/sildenafil can be bought over the counter from pharmacies, Viagra Connect is the ‘pharmacy medicine’, which means you don’t need a prescription to get it; however, Viagra Connect only comes in 50mg.
How do anabolic steroids affect the body?
People who use anabolic steroids generally experience an increase in muscle strength very quickly. This usually means that people are able to train more often and for longer periods of time, with improved recovery. This can often lead to rapid increases in lean muscle tissue. Fluid retention is also common and can lead to muscles looking soft or bloated.
Most of the harmful effects of anabolic steroids are not life-threatening, although a small number of deaths have been attributed to liver damage associated with long-term steroid use.
The range of potential harms associated with the use of anabolic steroids include:
- Cardiovascular symptoms.
- Liver problems.
- Psychological symptoms such as aggression, violence and low-level symptoms of mania called hypomania.
In young people, anabolic steroids could interfere with growth and behaviour, leading to the inappropriate development of male characteristics.
Drug use can lead to social and emotional problems and affect a person’s relationship with family and friends.
People who use anabolic steroids often report they experience:
- Mood changes.
- Increased aggression – ‘roid’ rage.
- Violent behaviour.
- Irrational behaviour.
- Addiction or dependence.
What are the risks of anabolic steroids?
Anabolic steroids bought illegally for non-medical use could be counterfeit or not meet the standard for the quality of medicines. As anabolic steroids may be injected, blood-borne infections, such as hepatitis or HIV, may also be passed between individuals if they share needles.
Regular, heavy anabolic steroid use can lead to tolerance and dependence. This means that a person needs more of the drug to achieve the same effects they did previously with smaller amounts. Their bodies become dependent on the drug and continue to use it despite the side effects and health risks. When a person stops using anabolic steroids, they may experience withdrawal symptoms.
Whilst there is little medical evidence of withdrawal symptoms, anecdotal reports indicate some people experience symptoms including:
- Decreased sexual libido.
- Suicidal thoughts.
- Muscle pain.
- Dissatisfaction with body image.
Emotional and psychological risks associated with anabolic steroid use include overreaction to events that usually would not bother the person, leading to paranoid, irritable and aggressive behaviours. Known as ‘roid’ rage, this is a term that first appeared in the 1980s in the wake of several high-profile violent crimes committed by people who used anabolic steroids.
Anabolic steroid misuse is a particular and increasing concern for those working in jobs that demand extreme fitness and physical strength as desirable attributes, such as the armed forces, and the fire and police services. Many commentators fear a correlation between steroid side effects and allegations of police violence, and steroid abuse by officers is of rising concern for UK police forces.
In 2013, a report found abuse of anabolic steroids to be a major contributing factor in cases of officer corruption. In 2018, a police officer suspected of using anabolic steroids to improve his physique was dismissed without notice after a Lincolnshire Police panel found him guilty of gross misconduct.
More recently in 2022, a Lancashire police officer resigned ahead of a misconduct hearing after reporting for duty with anabolic steroids in his system. Clearly, any substance which puts public trust and safety at risk is hugely problematic, even more so for police forces who demand scrupulous honesty and integrity from their employees.
Short-term and long-term effects of anabolic steroids
The effects of anabolic steroid use can differ from person to person.
Some people may experience:
- Difficulty sleeping.
- Damage to nerves from injecting steroids.
- Irritability, mood swings, aggression or depression.
- Increased sex drive (libido).
- Skin changes – Acne that results in scarring.
- More colds.
Men may experience:
- Testicle and penis shrinkage.
- Reduced sperm count.
- Erectile dysfunction (or impotence).
- Prostate problems.
- Gynaecomastia (breast development).
- Baldness (patterned hair loss).
- Involuntary and long-lasting erection.
Women may experience:
- Irregular menstrual cycle or loss of periods (amenorrhoea).
- Shrunken breasts.
- Deepened voice.
- Facial and body hair growth (such as hirsutism).
- Abnormal growth of the clitoris.
Young people may experience:
- Stunted growth.
- Premature balding.
- Acne scarring.
- Injury caused by excessive, intense workouts.
- Stretch marks on the chest and arms.
- Prematurely aged or ‘leathery’ skin.
Anabolic steroids can produce many unpleasant and often permanent side effects, including:
- Damage to the testicles or ovaries.
- Liver disease.
- Malfunctions of the kidneys, liver or heart.
- ‘Roid rage’, which is characterised by uncontrollable outbursts of psychotic aggression.
- Paranoia and mood swings, including deep depression.
- Severe acne, which can cause scarring.
- High blood cholesterol levels.
- High blood pressure (hypertension).
- Injuries to tendons that can’t keep up with the increased muscle strength.
- Delusional feelings of being superhuman or invincible.
- Trembling and muscle tremors.
- Nerve damage from needle use, which may lead to conditions such as sciatica.
- Unsafe needle use can increase the risk of contracting infections such as hepatitis B and C, HIV and tetanus.
Anabolic steroids and the law
A drug or other substance is tightly controlled by the UK government because it may be abused or cause addiction. The Misuse of Drugs Act (MDA) 1971 established the system by which illicit drugs or controlled substances are classified. Its fundamental purpose is to provide a regulatory framework which controls the availability of, and access to, certain substances.
Within this Act, criminal penalties are set with reference to the risk or to the harm caused by a drug and the type of illegal activity undertaken, for example, possession or supply / trafficking.
There are three categories of drugs: Class A, Class B and Class C. Anabolic steroids are a Class C drug, which can only be sold by pharmacists with a prescription. It is legal to have anabolic steroids for personal use with a prescription, which means it is illegal to have them for yourself without prescription, or to give away or sell. Illegal possession can get you up to 2 years in prison, an unlimited fine or both. Supplying someone else, even your friends, can get you up to 14 years in prison, an unlimited fine or both.
Many sporting organisations, both professional and amateur, have banned the use of certain steroids. These organisations carry out tests for the banned steroids. If someone tests positive, they can be disqualified from competing for certain periods of time, or even banned for life.
The responsibility of regulating the use of, and access to, IPEDs including anabolic steroids in the UK crosses a number of bodies including UKAD, the Food Standards Agency (FSA), the Medicines and Healthcare products Regulatory Agency (MHRA), Trading Standards, police forces, the National Crime Agency (NCA) and Border Force.
UKAD prosecutes athletes and any support personnel against the UK Anti-Doping Rules. Successful prosecutions are called Anti-Doping Rule Violations (ADRV). Between 2012 and 2017, there were 185 ADRVs issued by UKAD across 23 sports. 46% of those related to the use of anabolic agents and 30% to the use of stimulants.
The use of IPEDs including anabolic steroids in sport is cheating. For anyone who is concerned about drugs and anabolic steroids in particular, whether this is your own use of substances, or you feel under pressure to take drugs, or if you are worried about a friend or family member taking drugs there is confidential help and advice.