Research Report European Addiction Research

Published online: June 19, 2015

Eur Addict Res 2015;21:321–326 DOI: 10.1159/000433580

Anti-Social Behaviors Associated with Anabolic-Androgenic Steroid Use among Male Adolescents Mats Hallgren a Harrison G. Pope Jr d Gen Kanayama d James I. Hudson d Andreas Lundin c Håkan Källmén b  

 

 

a

 

 

 

Department of Public Health Sciences, Section for Epidemiology and Public Health Intervention Research (EPHIR), Karolinska Institutet, b Department of Clinical Neuroscience, Karolinska Institutet, and c Institute of Environmental Medicine, Unit of Occupational Medicine, Karolinska Institutet, Stockholm, Sweden; d Biological Psychiatry Laboratory, McLean Hospital, Belmont, Mass., and Department of Psychiatry, Harvard Medical School, Boston, Mass., USA  

 

 

 

Abstract Anabolic-androgenic steroids (AAS) have been linked to a range of problematic behaviors, but AAS use is still sometimes portrayed as more benign than other forms of classical drug abuse. To address this issue, we compared the prevalence of anti-social behaviors among adolescent AAS users, non-AAS illicit drug users, and drug non-users. We examined 3 waves (2004, 2008, and 2012) of self-reported cross-sectional data from a secondary school survey conducted in Stockholm, Sweden (total n = 19,773; response percentage, 79.6%). Across all survey years, the risk ratios for virtually all measured anti-social behaviors were significantly higher among AAS users compared to non-AAS illicit drug users and to drug non-users. © 2015 S. Karger AG, Basel

© 2015 S. Karger AG, Basel 1022–6877/15/0216–0321$39.50/0 E-Mail [email protected] www.karger.com/ear

Introduction

Anabolic-androgenic steroids (AAS) are a family of drugs that includes the male hormone, testosterone, together with its synthetic derivatives. Although non-medical use of AAS has been illegal in Sweden since the 1990s, many young people nevertheless use these drugs [1]. National estimates (2000–2013) indicate that the lifetime prevalence of AAS use among 18-year-old Swedish males ranges between 1 and 1.9% [1], and some regional studies have reported figures of 2.8–3.6% [2]. Some media reports and other publications in the United States and elsewhere suggest a perception that AAS use is less harmful than ‘traditional’ non-AAS illicit drug use because it is not thought to be associated with significant social problems, such as violence and anti-social behavior [3–6]. Such beliefs may perpetuate the notion that AAS use is relatively benign with few serious social consequences. However, these notions are contradicted by studies linking AAS use to use of other illicit Mats Hallgren Department of Public Health Sciences Section for Epidemiology and Public Health Intervention Research (EPHIR) Karolinska Institutet, SE–17176 Stockholm (Sweden) E-Mail mats.hallgren @ ki.se

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Key Words Anabolic-androgenic steroids · Adolescent · Anti-social behavior · Drug dependence

Methods The Stockholm Student Survey The survey used in this study is a repeated cross-sectional selfreport survey completed every second year by school students in year 9 (aged about 15) and year 11 (aged about 17) in the Stockholm municipality. The survey was developed by the Research and Development Unit within the Stockholm City Council. The goal was to implement a school-based survey to monitor changes in adolescent substance use. It was envisaged that the survey would be used to inform prevention policy by identifying locally relevant risk factors for adolescent drug use. The survey includes questions about a range of issues known to be associated with delinquency and drug use (e.g. school and community connectedness, relationships with parents and peers, impulsivity, etc.). It also assesses the frequency and quantity of alcohol and other drug use using a questionnaire developed to measure national drug trends [1]. Development of the survey was theory driven and influenced by the Social

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Eur Addict Res 2015;21:321–326 DOI: 10.1159/000433580

Development Model [16], Control Theory [17], and the Theory of Inter-connected Influences [18]. Questions about criminality were inspired by a National Crime Prevention Council survey [19]. The extensive international literature on risk and protection was also consulted before determining the final questions. Detailed information about the survey has been reported previously [20]. Conducted during the season of Spring, the survey was completed anonymously by students during class time before being returned to teachers in a sealed envelope. Participation in the survey was mandatory for all public schools, which in 2012 comprised about 53% of all schools in Stockholm. Private schools participated voluntarily. Stockholm is a multicultural city with a diverse student population. Questions about ethnicity were not included in the survey. The authors received permission from the Department of Social Affairs, Stockholm City Council (Socialförvaltningen) to analyze and report results from the survey. Participants Preliminary analyses of the student data revealed that many year 9 students had answered the AAS questions inconsistently, for example, by indicating use of testosterone but not use of AAS. Including these respondents in the analyses would increase the number of false-positive cases. Therefore, to maximize the integrity of the data, we restricted our analyses to the year 11 students, who provided more reliable responses. We also excluded year 11 girls, since they very rarely reported AAS use, and even these few cases may often have represented false-positive responses [21]. We analyzed the year 11 boys in 3 survey years (2004, 2008, and 2012). The total number respondents each year were 3,436, 2,368, and 3,533, respectively. The overall response percentage was 79.6%. Categories of Drug Use We compared 3 categories of substance use: (1) AAS users, (2) non-AAS illicit drug users, and (3) drug non-users, as defined below. Anabolic-Androgenic Steroid (AAS) Users. One item assessed the use of any doping preparations: ‘have you ever used a doping product (without a doctor’s prescription)?’ A second item then asked about the type of doping preparation used, with 4 response alternatives: (1) ‘anabolic steroids’, (2) ‘testosterone’, (3) ‘growth hormone’, and (4) ‘other’. Participants answering ‘yes’ to the first question (current or past doping) and indicating ‘anabolic steroids’ as the type of preparation used were coded as AAS users. No other response alternatives were included in this category (for example, adolescents indicating ‘testosterone’ or ‘growth hormone’ only). This category included adolescents who had used other illicit drugs in addition to AAS. Non-AAS Illicit Drug Users. One item assessed lifetime drug use: ‘have you ever used an illicit drug?’ A second question then asked: ‘what type of drug(s) have you used (without a doctor’s prescription)?’ The respondent could then indicate one or several drugs from a list of 16 other illicit drugs: cannabis (hash, marijuana), khat, amphetamine, crack, smoking heroin, injecting heroin, morphine, psilocybin (magic) mushrooms, methadone, cocaine, LSD, ecstasy, GHB, subutex, metabolite, hypnotics/tranquilizers or benzodiazepines, other drug (e.g. Rohypnol, Imovane, Stilnoct). Participants denying all doping but acknowledging use of at least one illicit drug were coded as non-AAS illicit drug users. Drug Non-Users. Drug non-users were defined as adolescents who denied use of both doping products and all illicit drugs.

Hallgren/Pope Jr/Kanayama/Hudson/ Lundin/Källmén

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drugs [7], hazardous alcohol consumption [8], and antisocial behaviors such as truancy [9] and criminality [10]. In a general population survey of Swedish men aged 15– 64 years, Hakansson et al. [11] reported that AAS use was strongly associated with a lifetime history of illicit drug use and the misuse of prescription drugs. Similarly, in 2  related studies conducted in Sweden, Skårberg and colleagues found significant associations between AAS use, poly-substance dependence and serious criminality (violence and weapons offences) [12, 13]. What remains unclear in the scientific literature is whether these antisocial behaviors are more common among AAS users compared with other non-AAS illicit drug users. Understanding these relationships may provide a more realistic assessment of the social and behavioral problems associated with AAS use. To date, studies investigating AAS use have focused mainly on young adults in their 20s and 30s, the age group exhibiting the highest prevalence of doping [14]. However, as developmental research has shown, patterns of drug use established during adolescence are of particular concern because they predict drug habits in adulthood and are associated with negative social and occupational outcomes [15]. As the vast majority of AAS users are male [1], this study focuses on the behavior of adolescent boys in upper secondary schools in Stockholm, Sweden. Taking advantage of a unique cross-sectional survey designed specifically to assess changes in youth substance abuse and related factors, we compared the prevalence of antisocial behaviors among AAS users, other non-AAS illicit drug users, and drug non-users. We hypothesized that rates of anti-social behavior would be highest among AAS users.

ment in 2004 and 2008 and Conduct Problems in 2004 due to low numbers of participants meeting the criteria for these variables. All analyses were performed using SPSS version 20.0 and Stata version 9.0. We chose the risk ratio in favor of other possible measures of effect (e.g. the odds ratio), since risk ratios seemed most easily interpretable when comparing the prevalence of various behaviors across the drug use categories. Our use of the risk ratio does not imply any causal structure for the associations.

Results

The prevalence of reported AAS use was 0.7% in 2004, 0.9% in 2008, and 0.9% in 2012 among grade 11 males. Throughout the 3 study years, the prevalence of antisocial behaviors was almost invariably highest among AAS users, moderate among non-AAS illicit drug users, and lowest among drug non-users (table 1; see further details in online suppl. table  1; for all online suppl. material, see www.karger.com/doi/10.1159/000433580). The resulting risk ratios showed markedly higher risks among AAS users vs. non-AAS illicit drug users on almost all variables in every year, with the latter group in turn almost always showing markedly higher risk than the drug non-users (fig. 1; see detailed numerical data in online suppl. table  2). For example, on the variables of Bullying, Criminality, and Conduct Problems, risk ratios for AAS users relative to drug non-users ranged from 4.4 to 6.9 (p < 0.001 in all cases). For AAS users relative to non-AAS illicit drug users, risk ratios ranged from 1.7 to 3.4 (p < 0.03 in all cases). Here also, striking differences were found on many variables, including Bullying, Conduct Problems, Contact with Social Services, Criminality, and Poor School Adjustment.

Discussion

Data Analysis The proportion of students meeting the criteria for each antisocial behavior was calculated across drug use categories (AAS user, non-AAS illicit drug user, and drug non-user). For each variable, we calculated risk ratios for the AAS group and for the nonAAS illicit drug user group relative to the drug non-user reference group in each of the 3 study years. We omitted Poor School Adjust-

We found that among adolescent boys, AAS use was associated with a significantly higher prevalence of antisocial behavior compared to non-AAS illicit drug users and drug non-users, respectively. The results were consistent across all 3 survey years, suggesting that the finding is robust. Importantly, our findings contradict the popular view that AAS doping is a ‘mild’ form of substance abuse [22]; on the contrary, young male AAS users appear considerably more anti-social than non-AAS illicit drug users as a whole. Of particular concern is the high proportion of adolescent AAS users who engaged in serious criminal activities, including rape, burglary, and the use of weapons.

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Measures of Anti-Social Behavior Polysubstance Use. Poly-substance use was coded if the respondent indicated that he had used 2 or more non-AAS illicit drugs without a doctor’s prescription. Bullying. Bullying was assessed with a single item: ‘during the past school year, how often have you bullied other pupils at school?’ The 5 response alternatives ranged from ‘never’ to ‘several times a week’. Any response other than ‘never’ was coded as Bullying. Criminality. Students were asked if they had been involved in a range of criminal activities during the past 12 months. Items included: ‘forced someone to give you money, a mobile phone or anything of value’; ‘raped someone’; ‘committed burglary’; ‘struck someone who later needed hospitalization’; and ‘carried an illegal weapon’ (e.g. a gun or knife). The 5 response alternatives ranged from ‘no’ to ‘more than 10 times’. Criminality was coded if the respondent reported one or more of these criminal acts. Poor School Adjustment. School adjustment was assessed by the question: ‘I get along well in school’ with responses given on a 4-point scale ranging from ‘describes me very badly’ to ‘describes me very well’. The first 2 alternatives (‘describes me very badly’ and ‘describes me quite badly’) were coded as Poor School Adjustment. Conduct Problems. To assess conduct problems, students were asked to respond to 6 statements, rated on a 4-point scale from ‘describes me very badly’ to ‘describes me very well’. These statements were: ‘I do the opposite of what people tell me to do, only to make them angry’; ‘I like to do exciting and dangerous things even if it’s not permitted’; ‘I don’t like to be provoked, but if I am, I will hit someone’; ‘if I get angry at someone it is easy to hurt him/her’; ‘I don’t care about rules that stop me from doing what I want’; and ‘if a person makes me angry, I will hit him/her – even if that person did not hit me first’. These items were summed for each student and the cumulative frequency was calculated. As the distribution of the summed responses was skewed, with many students answering yes to one or more questions, we selected the 90th percentile as the cut-off for a Conduct Problem. This helped to ensure the identification of adolescents with more severe behavioral problems. Contact with Support Services. Students were asked to indicate if they had been in contact with the health care system or social services during the current school year due to use of alcohol or drugs. The response alternatives were ‘yes’ or ‘no’. Truancy. One question asked whether students had taken a day off school during the current school year without permission. The response alternatives were: ‘never’, ‘once’, ‘2–3 times’, ‘4–10 times’, ‘10–20 times’, and ‘more than 20 times’. Responses of 2–3 times through to more than 20 times were coded as Truancy because they indicated regular non-approved absences from school. Cheating at School. A single item asked whether students had cheated on their homework assignments or an exam during the current school year, with 6 response alternatives: ‘no’, ‘once’, ‘2–3 times’, ‘4–10 times’, ‘10–20 times’, and ‘more than 20 times’. Responses of 2–3 times or greater were coded as Cheating at School.

behaviors Behavior

Survey year

AAS users

Non-AAS illicit drug users

Drug nonusers

Bullying

2004 2008 2012

65.2 55.6 63.0

25.5 21.4 18.4

14.5 12.5 9.1

Criminality

2004 2008 2012

69.6 81.0 70.0

40.7 35.9 32.2

15.3 15.1 12.0

Truancy

2004 2008 2012

60.9 66.7 59.4

76.0 53.2 42.9

49.0 31.4 20.8

Cheating at school

2004 2008 2012

47.8 81.0 56.3

45.4 32.8 31.7

30.1 21.6 19.9

Contacts with social service

2004 2012

36.4 36.7

11.8 9.3

1.8 1.0

Conduct problems

2008 2012

45.0 56.7

22.1 17.0

8.8 9.4

Poor school adjustment

2012

36.7

9.1

8.0

Polysubstance use

2004 2008 2012

71.4 78.6 82.8

28.2 25.7 22.0

– – –

Total numbers in 2004: AAS users – 23; non-AAS drug users – 795; drug non-users – 2,586. Total numbers in 2008: AAS users – 21; non-AAS drug users – 613; drug non-users – 1,701. Total numbers in 2012: AAS users – 32; non-AAS drug users – 906; drug non-users – 2,382. Note that denominators used to calculate these percentages are sometimes. Less than the total number because of missing data (suppl. table 1).

Previous research has demonstrated associations between doping and violent crime among adults in the Swedish forensic (prison) system [23]. Our results extend this work using a general population survey and indicate that many adolescents who use AAS are prone to engage in similar acts of aggression. Also noteworthy is the high proportion of poly-substance abuse among AAS users, a finding that has been reported previously [9, 12, 13, 24]. Indeed, only 2 of the AAS users in our study had not used at least one other type of illicit drug – so that it was not feasible for us to adjust for other illicit drug use when performing analyses of the AAS-user group in this study. The association between AAS use and antisocial behaviors was recently assessed in another Swedish study by 324

Eur Addict Res 2015;21:321–326 DOI: 10.1159/000433580

Lundholm et al., which examined the association between AAS use and violent crime among Swedish men aged 20–47 years using national register data (n = 10,365) [25]. These authors found a strong association between any lifetime use of AAS and a conviction for violent crime. However, this association was substantially attenuated and no longer reached significance when adjusting for other illicit drug use. Although this finding may at first seem at odds with the findings of the present study, the results of the 2 studies are not incompatible. Specifically, AAS use, other illicit drug use, and antisocial behaviors do not fall on a simple causal pathway, but are likely intertwined in a more complex causal structure. Consequently, the adjusted analysis by Lundholm et al. might ‘adjust out’ part of the actual association between AAS and antisocial behavior, producing an overly conservative estimate of this association. Allowing for this consideration, and placing the 2 studies side-by-side, one could state that Lundholm et al. suggest that the relationship of AAS use to antisocial behavior is at least partially explained by pathways involving other illicit drug use. However, our study suggests that the relationship of AAS use to antisocial behavior cannot be entirely explained by other illicit drug use among AAS users, since these users were substantially more antisocial, even than other nonAAS-using illicit drug users. Thus, the 2 findings somewhat complement each other, and bring us a bit closer to understanding the complex relationship among these variables. Our findings have potential implications for drug prevention work. Young males who display serious conduct problems in school may be at greater risk for using AAS compared with their more socially adjusted peers. Indeed a recent study of 233 male weightlifters found that adolescent conduct disorder was a strong predictor of AAS use [26]. Conversely, AAS doping might plausibly increase the likelihood that some adolescents will become more anti-social and engage in criminal acts. Identifying these individuals at an early stage and offering appropriate support could reduce their risk of such behavior. Strengths of this study are the large sample size, high response percentage, and comprehensive survey questions, which allowed a range of anti-social behaviors to be assessed over time. Also, the survey was conducted on multiple occasions at 2-year intervals, allowing us to judge whether there were any secular trends in the prevalence of substance abuse or antisocial behaviors. We found that these prevalence measures generally remained relatively stable from 2002 through 2012. Nevertheless, we performed our analyses using data from 3 separate Hallgren/Pope Jr/Kanayama/Hudson/ Lundin/Källmén

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Table 1. Percentage of respondents reporting various antisocial

Color version available online

2012 Poly-Substance 2008 use 2004

2012 Bullying

2008 2004

2012 Criminality

2008 2004

Contacts with social services

Conduct problems

Poor school adjustment

2012 2004

2012 2008

2012

2012 Truancy

2008 2004

Fig. 1. Risk ratios and 95% confidence in-

2012 Cheating at school

2008 2004 0.25 0.5

0.7

1

2

3

4

5

7

10

20

30

40

Risk ratio (95% confidence interval)

survey years to assess the stability of the findings, and were able to show that the results remained very similar across time. Finally, we were able to take advantage of the fact that the survey specifically mentioned ‘doping’ and ‘anabolic steroids’, which helped to minimize possible confusion with corticosteroid products or nutritional supplements – a potential problem with anonymous sur-

veys asking about ‘steroids’ [21, 27]. As a further measure to minimize the problem of possible false-positive responses, we restricted our analyses to year 11 students, since inspection showed their responses to be more reliable, as outlined above. The study also has certain limitations. First, some participants may have misrepresented their actual use of

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tervals for AAS users (red) and for nonAAS illicit drug users (blue) as compared to the reference group of drug non-users (colors refer to the online version only). Note that for the variable ‘polysubstance use’, the risk ratio is shown only for AAS users vs. the non-AAS illicit drug users as a reference group, since the drug non-users by definition displayed no polysubstance use.

illicit substances, or provided false-positive or false-negative responses because they misinterpreted certain questions. Second, our analyses in each of the 3 study years were cross-sectional. Although the survey was performed every second year from 2002 onwards, we could not take advantage of this fact to perform longitudinal analyses because the year 11 students surveyed at each time point were entirely discrete groups of individuals, rather than the same individuals followed repeatedly in successive survey waves. A limitation of our cross-sectional design,

as with other cross-sectional studies cited earlier, is that our findings cannot establish specific causal relationships among the variables assessed. Third, we possessed only limited information about other environmental or familial factors that might be associated with AAS use or antisocial behaviors in this population. Where possible, future research should employ evaluations that include specific questions about the type of doping products used. Prospective designs can better characterize the relationship of AAS use and anti-social behaviors.

References

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Anti-Social Behaviors Associated with Anabolic-Androgenic Steroid Use among Male Adolescents.

Anabolic-androgenic steroids (AAS) have been linked to a range of problematic behaviors, but AAS use is still sometimes portrayed as more benign than ...
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