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

Gaps in Federal Laws That Weaken Consumer Protection and law Enforcement

AASs were once readily available as prescription drugs with minimal federal enforcement until reports began to emerge in the media in the 1980s, describing a rising epidemic of use among competitive athletes and high school students who used these drugs to manipulate their appearance. In response, the US Congress passed the Anabolic Steroid Control Act of 1990,[32] which classified AASs as Schedule III controlled substances, thereby criminalizing possession without a prescription (Figure 1). The gaps in this law still allowed for the possession of unlisted steroidal compounds and "prohormones," precursors that are metabolized by enzymes in the body into an active androgenic compound. These prohormones and other substances also became classified as Schedule III substances in 2004 via the successor to the 1990 law, the Anabolic Steroid Control Act of 2004.[33] The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 made it illegal to purchase controlled substances online without a prescription.[34] Eventually, the Designer Steroid Control Act of 2014 closed additional loopholes in the former Steroid Control Acts and gave full jurisdiction of the regulation of these compounds to the Justice Department.[35] Despite these laws, the abuse of AASs and SARMs by nonathlete weightlifters has continued to grow; the increasing demand for these substances is being filled by a burgeoning underground marketplace that exists outside the bounds of the consumer protection laws and the normal regulatory oversight that governs the sales of pharmaceuticals and other consumer products. Regrettably, these same laws have made it increasingly difficult for physicians to prescribe testosterone and other compounds even for approved indications. Similar laws have been passed in other countries with parallel outcomes. For example, Queensland, sometimes called the "steroid capital" of Australia, reclassified AASs as Schedule 1 drugs in 2014, increasing penalties for possession and distribution. Despite this tough legislation, the Australian Crime Commission reported an increase in steroid seizures due to increased domestic production and easy Internet access.[36]

Figure 1.

Timeline of laws passed by the United States Congress regulating the use and distribution of AASs. Many other countries have their own laws for AAS prescriptions, sales, and distribution, which are not shown in this figure.

Three recent developments have further challenged detection and regulatory oversight by the US Food and Drug Administration and the US Drug Enforcement Agency. First, recent years have seen the synthesis and distribution of novel AASs, such as tetrahydrogestrinone and madol, that had no medicinal applications, and which were produced solely for illicit use. Because these novel molecules had not been known or tested previously, their detection remained elusive for several years. Second, various novel compounds have appeared that represent precursor molecules with no androgenic or anabolic activity of their own, but which are converted in the body into active androgenic compounds. Third, during the past decade, the use of other appearance- and performance-enhancing drugs such as nonsteroidal SARMs has been growing among athletes, recreational bodybuilders, and members of US armed forces.[12–15]