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Research Letter
Impact of Policy on Children
May 18, 2020

Association Between Legal Performance-Enhancing Substances and Use of Anabolic-Androgenic Steroids in Young Adults

Author Affiliations
  • 1Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
  • 2School of Social Work, Simmons University, Boston, Massachusetts
  • 3Department of Psychiatry, University of California, San Francisco
  • 4Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
  • 5Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
  • 6Department of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles
JAMA Pediatr. 2020;174(10):992-993. doi:10.1001/jamapediatrics.2020.0883

Anabolic-androgenic steroids are schedule III drugs that are often used without a prescription to increase muscle mass and tone for appearance or performance enhancement.1,2 Use of anabolic-androgenic steroids is associated with negative physiological (eg, cardiovascular, neuroendocrine, musculoskeletal, and renal) health outcomes.1 Anabolic-androgenic steroids are also associated with mood and substance-use disorders, aggression, and violence.1 The use of anabolic-androgenic steroids is frequently observed among adolescents in the United States and is more prevalent among adolescent boys (3.3% of boys reporting use) compared with adolescent girls (2.4% of girls reporting use) nationwide.3 Although the use of anabolic-androgenic steroids is cross-sectionally associated with legal performance-enhancing substances, including creatine monohydrate,1,2 there is a paucity of longitudinal data determining predictors of anabolic-androgenic steroid use. Here, we examine the longitudinal association between legal performance-enhancing substances and subsequent use of anabolic-androgenic steroids in a population-based cohort of young adults. We hypothesized that legal performance-enhancing substance use in young adulthood would be associated with subsequent anabolic-androgenic steroid use at 7-year follow-up.


We analyzed prospective cohort data from 12 695 participants in the National Longitudinal Study of Adolescent to Adult Health, which began in 1994 and has surveyed over 20 000 adolescents in grades 7 to 12 across the United States. Subsequent waves, of which there are presently 5, have tracked participants to their early 40s. The study is still ongoing.

The University of North Carolina institutional review board approved the National Longitudinal Study of Adolescent to Adult Health, and written informed consent was obtained from all participants. As a secondary analysis of de-identified information, the present analysis was not considered to be human subject research and did not require separate institutional review board approval. This nationally representative sample included data available at both wave III (2001-2002; participants aged 18-26 years; n = 14 322) and wave IV (2008; participants aged 24-32 years; n = 14 800) of the study. At wave III, participants were asked if they had used “legal performance-enhancing substances for athletes (such as creatine monohydrate or androstenedione)” in the past year. At waves III and IV, participants were asked if they had ever used anabolic-androgenic steroids. Logistic regression analysis was conducted using Stata, version 15.0 (StataCorp Inc) with legal performance-enhancing substances (exposure, wave III) and anabolic-androgenic steroid use (outcome, wave IV). Data were adjusted for use of anabolic-androgenic steroids (wave III), age, race/ethnicity, household income, and body mass index using sample weighting to yield nationally representative estimates. Because this analysis incorporates national sample weighting from the study, all percentages are weighted. Data were missing from 229 participants (1.5%) for legal performance-enhancing substances and from 78 participants (0.5%) for anabolic-androgenic steroids. Significance (2-tailed test) was set at α = .05.


The overall cohort of 12 695 young adults included 50.8% males with a mean (SE) age of 21.8 (0.1) years. At wave III, 16.1% of young men and 1.2% of young women reported using legal performance-enhancing substances in the previous year. At the 7-year follow-up (wave IV), 4.2% of men and 0.8% of women reported anabolic-androgenic steroid use within the past year. Among young men, 12.5% of those who used legal performance-enhancing substances vs 2.7% of those who did not use performance-enhancing substances reported anabolic-androgenic steroid use at the 7-year follow-up (Figure) (P < .001). Among young men, use of legal performance-enhancing substances at wave III was associated with higher odds of anabolic-androgenic steroid use at wave IV (adjusted odds ratio, 3.18; 95% CI, 1.90-5.32; P < .001) compared with nonuse of legal performance-enhancing substances when adjusting for age, race/ethnicity, income, body mass index, and wave III anabolic-androgenic steroid use. There was no statistically significant association between legal performance-enhancing substance use at wave III and anabolic-androgenic steroid use at wave IV among young women (adjusted odds ratio, 0.18; 95% CI, 0.02-1.78; P = .14).

Figure.  Prevalence of Anabolic-Androgenic Steroid Use at 7-Year Follow-Up Among Young Men Aged 24 to 32 Years Who Did vs Did Not Report Use of Legal Performance-Enhancing Substances at Ages 18 to 26 Years
Prevalence of Anabolic-Androgenic Steroid Use at 7-Year Follow-Up Among Young Men Aged 24 to 32 Years Who Did vs Did Not Report Use of Legal Performance-Enhancing Substances at Ages 18 to 26 Years

Error bars indicate 95% CIs.


Use of legal performance-enhancing substances among young adult men (aged 18-26 years) was significantly prospectively associated with anabolic-androgenic steroid use at 7-year follow-up (aged 24-32 years). To our knowledge, this is the first longitudinal investigation of this association among a nationally representative sample. Results suggest that legal performance-enhancing substance use may serve as a gateway to anabolic-androgenic steroid use. This has significant implications for regulation of legal performance-enhancing substances, which are relatively common among the adolescent and young adult population,1,2 accessible over the counter, and unregulated by the US Food and Drug Administration.4 The notion that use of legal performance-enhancing substances may lead to a 3-fold increased risk for future use of illicit anabolic-androgenic steroids provides support for increasing state and federal regulation of these products. Limitations to this study include self-reported data, lifetime (as opposed to 12-month) assessment of anabolic-androgenic steroids use, inability to distinguish between prescription or nonprescription anabolic-androgenic steroid use, and inability to analyze associations between specific substances (ie, creatine monohydrate or androstenedione) and anabolic-androgenic steroid use.


The current study suggests that use of performance-enhancing substances among young men may increase vulnerability for anabolic-androgenic steroid use in young adulthood. Health care professionals should monitor and screen for anabolic-androgenic steroid use among adult men who have previously used legal performance-enhancing substances and refer patients to mental health and substance abuse treatment when appropriate.

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Article Information

Accepted for Publication: January 16, 2020.

Corresponding Author: Jason M. Nagata, MD, MSc, 550 16th St, 4th Floor, PO Box 0110, San Francisco, California 94158 (jasonmnagata@gmail.com).

Published Online: May 18, 2020. doi:10.1001/jamapediatrics.2020.0883

Author Contributions: Dr Nagata had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nagata, Ganson, Murray.

Acquisition, analysis, or interpretation of data: Nagata, Ganson, Gorrell, Mitchison.

Drafting of the manuscript: Nagata, Ganson, Gorrell, Murray.

Critical revision of the manuscript for important intellectual content: Nagata, Ganson, Gorrell, Mitchison.

Statistical analysis: Nagata, Ganson.

Supervision: Nagata, Murray.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grant K12HD00085033 from the Pediatric Scientist Development Program and was funded by the American Academy of Pediatrics and the American Pediatric Society (Dr Nagata), grant CDA34760281 from the American Heart Association Career Development Award (Dr Nagata), and grant K23 MH115184 from the National Institutes of Health (Dr Murray).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Ronald R. Rindfuss, PhD, and Barbara Entwisle, PhD, provided assistance in the original design. They were not compensated for their contributions.

Additional Information: This research uses data from the National Longitudinal Study of Adolescent to Adult Health, a program project directed by Kathleen Mullan Harris, PhD, and designed by J. Richard Udry, PhD, Peter S. Bearman, PhD, and Kathleen Mullan Harris, PhD, at the University of North Carolina, Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. No direct support was received from grant P01-HD31921 for this analysis. Information on how to obtain the National Longitudinal Study of Adolescent to Adult Health data files is available online (http://www.cpc.unc.edu/addhealth).

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LaBotz  M, Griesemer  BA; Council on Sports Medicine and Fitness.  Use of performance-enhancing substances.   Pediatrics. 2016;138(1):e20161300. doi:10.1542/peds.2016-1300 PubMedGoogle Scholar
Kann  L, McManus  T, Harris  WA,  et al.  Youth risk behavior surveillance—United States, 2017.   MMWR Surveill Summ. 2018;67(8):1-114. doi:10.15585/mmwr.ss6708a1 PubMedGoogle ScholarCrossref
Ganson  KT, Murray  SB, Nagata  JM.  A call for public policy and research to reduce use of appearance and performance enhancing drugs and substances among adolescents.   Lancet Child Adolesc Health. 2020;4(1):13-14. doi:10.1016/S2352-4642(19)30345-1PubMedGoogle ScholarCrossref
1 Comment for this article
Post Hoc Fallacy
Lester Prince, MD, PhD | Retired
The authors conclude that because people who use legal performance-enhancing substances such as creatine monohydrate are more likely to later use illegal performance-enhancing substances, such as anabolic-androgenic steroids, then it follows that the legal substances act as "gateway drugs" for the illegal substances, and thus need to be more strictly regulated. But we should ask who is using these substances, and why. Is it not much more likely that a young adult who is actively participating in athletic activities would be apt to use a legal product such as creatine monohydrate than a sedentary person; that after the passage of seven years the former athletes would still be more apt to be engaged in athletics than their formerly sedentary counterparts; and that long-term athletes would be more apt to use both legal and illegal performance-enhancing substances than those with a consistently sedentary lifestyle? It is important to remember that association does not equate with causation.