Illicit Use and Abuse of Anabolic-Androgenic

Substance Use & Misuse

ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: http://www.tandfonline.com/loi/isum20

Illicit Use and Abuse of Anabolic-Androgenic Steroids Among Brazilian Bodybuilders Azenildo Moura Santos, Manoel Sérgio Pereira da Rocha & Marcos Freire da Silva To cite this article: Azenildo Moura Santos, Manoel Sérgio Pereira da Rocha & Marcos Freire da Silva (2011) Illicit Use and Abuse of Anabolic-Androgenic Steroids Among Brazilian Bodybuilders, Substance Use & Misuse, 46:6, 742-748, DOI: 10.3109/10826084.2010.534123 To link to this article: http://dx.doi.org/10.3109/10826084.2010.534123

Published online: 29 Nov 2010.

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Substance Use & Misuse, 46:742–748, 2011 C 2011 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2010.534123

ORIGINAL ARTICLE

Illicit Use and Abuse of Anabolic-Androgenic Steroids Among Brazilian Bodybuilders ´ Azenildo Moura Santos1 , Manoel Sergio Pereira da Rocha2 and Marcos Freire da Silva2 Instituto de Saúde Coletiva, Universidade Federal da Bahia, Alameda Benevento, Salvador, Brazil; 2 Instituto Brasileiro de Pós – graduaça˜ o e Extensão, Recife, Brazil Downloaded by [AZENILDO SANTOS] at 20:16 05 April 2016

1

Anabolic-androgenic steroids (AAS) are used to enhance performance and appearance. The aim of this research was to assess the knowledge of AAS among Brazilian bodybuilders. The sample was comprised of 123 male participants between the ages of 18 and 50 years. Questionnaires were administered to bodybuilders from gyms in the district capital and in the rural area of Pernambuco, state of northeast of Brazil, in 2008. We analyzed the use and abuse of AAS from several different perspectives among the bodybuilders. For the participants in our study, enhanced appearance justifies the misuse of AAS. The study’s limitations are noted. Keywords anabolic-androgenic steroids, drug misuse, bodybuilding, steroids misuse, body appearance

INTRODUCTION

The use of anabolic-androgenic steroids (AAS) by individuals who have begun bodybuilding and have “esthetically changed” tends to stimulate their consumption by providing a false sense of health, with users often becoming a bit invisible, therefore resulting in what might be labeled as a “silent epidemic” (Santos, 2007; Yesalis & Bahrke, 2005b). There is a need to examine the use and abuse1 of these drugs to enhance esthetics among bodybuilding practitioners, particularly because of the health issues among young people. Our goal was to identify the main themes for later intervention based on the information obtained from the users in our investigation. Although similar findings have been documented in reports from other countries, our study, for the very first time, investigated these behaviors and attitudes in a sample of

Brazilian bodybuilders before and during AAS use and misuse. METHODS

Data were collected in 2008 from 123 volunteer male bodybuilders, between the ages of 18 and 50 years, in four fitness clubs and academies of the district capital and of the countryside of Pernambuco, state of northeast of Brazil. The study was approved by the Ethics Committee (CEP) of Centro de Ciências da Saúde (CCS) of Universidade Federal de Pernambuco (UFPE)—under the registration number 157/08, Certificate of Appreciation Presentation of Ethics Commitee (CAAE)—0155.0.172.000-08, and National Ethics System in Research Involving Human Subjects (SISNEP FR) under the registration number 192297. All of the regulations were followed according to the Bioethics Rules of Research and the Regulamentary Rules of Research Involving Human Beings (Resolution no. 196, on October 10, 1996) of the National Health Council. Selection of the locations and the dates for data collection were based upon obtaining approval from the gym managers and availability of the gyms. Four gyms were selected in total; two in the capital district and two from the rural area—each with different types of members, from low to middle social class. Permission to participate was required through a consent letter written by the facility owner, and participants were informed about the research through personal contact with the researcher and presented and signed the Term of Free and Consent Letter. Permission required from the gyms by CEP to conduct the research was valid for only one day. The participants were randomly and personally invited to participate in the study by the researchers. Volunteers were conducted

The authors wish to thank Professor Maria da Conceiça˜ o Torres and the Sport Sociology Laboratory/DEF/UFPE for the support of the research, Professor Maurice Torrenté, Mônica Nunes, and Yeimi López for French and Spanish translator, and Mr. Michael S. Bahrke, PhD, for his support and guidance during the article construction. 1 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. Address correspondence to Azenildo Moura Santos, Instituto de Saúde Coletiva, Universidade Federal da Bahia, Alameda Benevento, 177, Ap. 1303, Salvador, 41830-595 Brazil; E-mail: [email protected]

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USE AND ABUSE OF AAS AMONG BRAZILIAN BODYBUILDERS

to a reserved area in the gym to respond anonymously to a self-administered questionnaire. The questionnaire was provided to the participants, guaranteeing them anonymity of their responses, that were then placed by the participant in a box secured with a padlock. This method was provided to preserve the anonymity of the responses, with no name or identity associated with the questionnaire and with the questionnaires securely deposited. Educationally, 34.9% of our sample had not completed the high school level, while 4.8% had not completed the primary school level. This is unusual for a sample of Brazilian males because it indicates some study participants did not even meet the basic education mandated by the national government—Education Ministry—that all children must attend school. Conversely, 19.5% of our subjects had completed the college level, reflecting the broad range of education level of participants in our study. As the doses of anabolic steroids used by bodybuilders are always beyond the supraphysiologic doses, we used the term misuse to mean the taking of supraphysiological doses and the use of several anabolic steroids simultaneously (Hall, Hall, & Chapman, 2005; Pope, Kouri, & Hudson, 2000). Additionally, the use of AAS without a physician prescription is illicit and was also considered by us as misuse. RESULTS AND DISCUSSION

One hundred twenty-three males participated in the study, of whom 66.6% had never used AAS and 33.3% were currently using or had previously used, with 95.1% between the ages of 18 and 35 years and 4.8% between the ages of 36 and 50 years. Nearly 48% of the participants had practiced bodybuilding for less than 1 year, while 52% had been practicing for more than 1 year. The sample consisted of both AAS users and nonusers. However, it was not the objective of the present research to compare the two groups along selected variables. In addition, the sample was small. Our focus was on identifying the major themes for use of AAS by our sample. Participants’ Point of View

Table 1 presents information regarding what participants understand about AAS. As for their knowledge about AAS, 34.9% said it was a damaging drug. In the view of the participants, AAS are not seen as a pharmaceutical drug or medicine. However, expanding on the therapeutic function, AAS are marginalized and often used in supraphysiological doses, far above the recommended maximum limit. This is evident in the sample, where only 5.6% answered that it was a medical drug. It should be noted that 32.5% of the participants related the use of AAS to specific treatment uses to boost muscle development, while 17% also considered AAS a hormone—associating it to illicit drugs used only for muscular growth—when they said AAS was “a medicine for fast muscular growth” (Table 1). It is apparent that the primary reason for using AAS is for fast muscular growth, not for therapeutic uses.

TABLE 1. Androgenic-anabolic steroids from the participants’ point of view What is AAS? It is a damaging drug. Medicine for fast muscle growth. It is a hormone (androgenic). It has an anabolic effect (growth of muscles). It is a medicine. ∗

Participants∗ (%) 34.9 32.5 17.0 9.7 5.6

Total number of participants: N = 123.

Harmful Effects of AAS

The obtained results demonstrate that the participants are aware of the dangers due to the use and inappropriate use of AAS and of their harmful effects; 38.2% relate its use to various health problems. None of the participants mentioned that they are not harmful. All (100%) participants agreed that AAS are harmful. However, interestingly, when we compared this finding with participants’ knowledge about the harmful effects of AAS, only 34.9% said it was a damaging drug. This anomaly is one of the study limitations. Even with the guarantee of anonymity and confidentiality, we suspect some participants were hesitant to admit use of steroids as well as to being unaware of the serious harmful effects of AAS. Despite relating the harmful effects to use without a medical prescription, described by 21.9%, the desire “to grow big,” to gain muscle mass, and to overcome the risks was listed by 13% of participants, who also mentioned death related to the use of AAS. It seems the harmful effects are justified for the gain of muscle mass and the user of AAS truly doesn’t understand the damage of abusing AAS (Table 2). Adverse Effects of AAS Described

Although 80.4% of the participants recognize the adverse effects of AAS, conversely, 19.5% fail to recognize the adverse effects. Societal influence is an important factor for the perception of harmful effects. Researchers report how the general public, especially men, are exposed daily to an idealized male body image that is far more muscular than the average man (Pope, Olivardia, Gruber, & Borowiecki, 1999; Pope, Phillips, & Olivardia, 2000). Additional findings, reported by Ricciardelli and McCabe (2004), show the impact of sociocultural messages appears to be moderated by low self-esteem and negative affect for adolescent TABLE 2. Participants’ understanding of the harmful effects of anabolic-androgenic steroids Do you believe that AAS are harmful? They cause various health problems. When they are used without prescription. When they are used in excess. They may kill. They cause dependence. They are not harmful. ∗


Participants∗ (%) 38.2 21.9 20.3 13.0 6.5 0.0

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TABLE 3. Adverse effects of AAS described by the participants What adverse effects do you know due to the abuse of AAS?

Participants∗ (%)

Impotence Increased aggression and irritability Loss of sexual interest Liver and/or kidney cancer Excessive acne Hair loss Male effects in women Insomnia Cardiovascular changes/effects Gynecomastia—breast enlargement in males Hair growth Hypertension Sterility Increased LDL cholesterol Rupture of ligaments Diminished growth in teenagers

10.7 8.9 8.1 7.9 7.4 7.2 7.0 6.0 5.9 5.8 4.8 4.4 4.4 3.5 2.3 1.8

Note: LDL, low-density lipoprotein. ∗ Total number of participants: N = 123.

boys. Among the adverse effects mentioned, the sexual aspects should be highlighted, where 10.7% mentioned impotence and 8.1% noticed a loss in sexual interest. This is reinforced by Pope and Katz (1994) and Bahrke (2005), where psychiatric disorders associated with the use of AAS are described (Table 3). In addition, other studies report that AAS are associated with deleterious physical and psychological outcomes (Bahrke & Yesalis, 2002; Yesalis & Bahrke, 2005a). Conversely, some who use AAS are aware of the adverse effects but ignore the consequences of harm caused by the misuse of these substances. Information About AAS

The participants were asked where they learned about AAS, and the highest response was from “other members in the fitness clubs” (35.0%), suggesting camaraderie among the participants, creating friendships that strongly influence the use of these drugs. Silber and Souza (1998) describe teenagers—who try drugs such as tobacco and alcohol—show similar reasons: pressure from colleagues, increased stress, troubles, youthful rebellion, increased anxiety and depression, and low self-esteem. In our study, the most information about AAS was obtained from the media: TV, magazines, and newspapers. Over 12% of study participants obtained their information about AAS use from their fitness center instructors, who should be responsible for the health and the welfare of their students (see Table 4). Administration of AAS

Administration of AAS by friends was described by 31.7% of the participants (administration refers to injection of the substances) and by members from the fitness centers in 4.8% of cases—similar to results found by Korkia and Stimson (1997). This was possibly due to friendships developed by study participants in the environment

TABLE 4. Sources of information for AAS From whom did you learn about AAS? Members from the fitness club TV Instructors Magazines Health professionals Others Newspapers ∗

Participants∗ (%) 35.0 19.3 12.2 11.4 10.5 7.0 4.3


of the fitness clubs. Moreover, administration of AAS by pharmacists was reported by 29.2% of the participants (pharmacist refers to a degreed professional responsible for the drugstore). AAS users use the drugstores to purchase AAS without a prescription and as a site to administer AAS purchased in other places. Not unexpectedly, 2.4% of the gym instructors also administrated AAS. Administration by pharmacists and by gym instructors represents both a public health concern and an ethical issue (Table 5). Site for Administration of AAS

It is possible to see the strong relationship between who administered the AAS and where the AAS were administered, relating administration by study participant—at home (53.6%) and by a pharmacist in the drugstore (36.5%). Some participants have AAS administered to them in the fitness center (7.3%). These data are contrary to Brazilian law, because the use of AAS without a prescription and principally administered in the fitness center is strictly prohibited and illegal. In Brazil, the use of AAS, stimulants, and narcotics are considered doping in sport according to the Health Ministry and Sport Ministry (Resolution no. 2, on May 5, 2004; Brasil, 2004; Table 6). Purchase Location of AAS

Where AAS are purchased reveals a very dangerous situation. Drugstores should be seen as health stores, but rather, they often sell the drugs without a prescription, as mentioned by 42.5% of study participants. This demonstrates the neglect of some drugstores for public health and the desire for profit at any cost, all associated with the absence and omission of the pharmacist. Another critical and important fact is that more than 44% of the TABLE 5. The use of AAS Who administered the AAS? Friends Pharmacist Others Nurse Members Instructors ∗


Participants∗ (%) 31.7 29.2 19.5 12.1 4.8 2.4

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TABLE 6. Environment used for the application of AAS Where the AAS were administered? At home Drugstore Fitness club Hospital


∗

TABLE 8. AAS most often used by participants

Participants∗ (%) 53.6 36.5 7.3 2.4

Which of the following AAS did you use? Commercial name Durateston


participants purchased AAS in the fitness center, where as 11.1% of study participants purchased AAS from “a salesman” in the fitness club, and 9.2% purchased AAS from a fitness center instructor (Table 7). We suspect this situation will only worsen, and it emphasizes the results found in the present study, a burgeoning Brazilian AAS “black market.” Despite the efforts of the National Agency for Sanitary Surveillance (ANVISA), aiming to control and track the sales of controlled medicine with the launch of the National System of Management of Controlled Products—SNGPC, the sales of such substances without medical prescription are still significant. Only 5.5% of the AAS were purchased via the Internet, possibly because imported drugs are more difficult to purchase. Whitehead and Chillag (1992) have found similar results with the purchase of AAS.

Deca durabolin Hemogenin ADE Parabolan Others Equipoise Primobolan Winstrol ∗

Participants∗

Active principle

(%)

Testosterone Propionate, Testosterone Fenilpropionate, Testosterone Isocaprionate, Testosterone Caproate Nandrolone Decanoate Oximetolone Vitamins A, D, E Trembolone

26.7

Bolderone Undeclynate Metenolone Estanozolol

19.0 13.7 9.1 9.1 8.4 7.6 3.8 2.2


assumed participants used more than one type of AAS or more than one product. Most researchers report polypharmacy or “stacking,” the use of multiple AAS, and other miscellaneous substances by bodybuilders (Table 8). Reasons for Using AAS

Most Frequently Used AAS

Durateston (26.7%), Deca-durabolin (19.0%), and Hemogenin (13.7%) are the most frequent AAS or “bombs” used by the participants. Both oral and injectable steroid preparations are used. Among other AAS mentioned by 8.4% of the participants are anabol, anavar, dianabol, anadrol, nebido (testosterone undecanoate), parabolan, deposteron, ganekil (testosterone fenilpropionate), masteron, and clenbuterol (a beta-2 agonist). Winstrol, primobolan, parabolan, anavar, anabol, anadrol, masteron, and ganekil are imported drugs in Brazil, only purchased via the Internet or in illegal markets. Important to also spotlight in our report is the use of veterinary substances by the participants, among them ADE (an Emulsifiable Injection indicated as a source of vitamins A, D, and E for cattle, horses, pigs, goats, and rabbits; 9.1%) and equipoise (7.6%). Veterinary substances are responsible for many of the deaths that have occurred in Brazil. Participants in our study did not specify singular or multiple drug use in our questionnaire; however, we TABLE 7. Where AAS are purchased Where do you get or buy the AAS? Drugstore—without medical prescription Members of gyms “Salesman” in the fitness clubs Instructor Others Via the Internet ∗


Primary reasons for using AAS included the following: to elevate physical development, to enhance esthetics and for personal satisfaction, to obtain a massive well-defined body, to be admired for physical qualities, dissatisfaction with physical appearance, and low self-esteem. Whitehead and Chillag (1992) found the predominant reason for using AAS was to improve appearance. Two important findings to be emphasized in evaluating our results include none (0%) of the participants mentioned the use of AAS for treatment of legitimate health problems and 4.0% reported using AAS with a medical prescription, confirming that AAS are used primarily to enhance muscular mass and appearance rather than for treatment of a specific medical condition (Table 9). Study Limitations

First, this study was conducted in only four gyms. Consequently, this small number may not be representative of the many different gyms in both the urban and rural areas of Brazil. While many of these gyms are registered, TABLE 9. Reasons leading to the use of AAS

Participants∗ (%) 42.5 24.0 11.1 9.2 7.4 5.5

What reason(s) made you use AAS? Elevates physical development Esthetics/appearance Health concerns Medical prescription Higher social acceptance It brings benefits ∗


Participants∗ (%) 40.8 26.5 24.4 4.0 2.0 2.0


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others may be considered unregistered, clandestine gyms. Second, education level of the participants could be a limitation. Perhaps not all subjects—because of the low education level, did not fully understand the questions, and/or perhaps the questions asked were unclear. Even with a pretest of the questionnaire, some questions may have been confusing. The validity of self-reported data is sometimes questioned. Third, the number of available study participants may have varied with the time researchers spent in the gyms and the amount of time researchers were allowed in the gyms. Fourth, selection of the locations and the dates for data collection were intentionally scheduled based on permission and access to the gyms in the capital and rural areas. Some gym managers refused to participate in an AAS research project with their members.

ing exalts the “perfect” body, and Brazil has the principal, large urban centers close to the beaches with warm, sunny tropical weather, where summer is a time to “look good,” something often highlighted by domestic and foreign media, the local population, and tourists. The acquisition of AAS in drugstores without medical prescriptions is worrisome and a public health problem. However, it is also important to underline the need for education and publicity campaigns that address the problems related to the use and misuse of AAS. There should be education programs among the bodybuilding practitioner populations in fitness clubs, social clubs, and schools. The social, cultural, and anthropologic aspects should be considered when the young population is exposed to an environment that pursues the muscular ideal.

SUMMARY

CONCLUSIONS

Most of the study participants knew about the adverse health effects resulting from the use of these drugs—mainly the effects related to sexual disorders such as impotence, loss of libido, and the masculinizing effects in women. Increased aggression and irritability were also two of the most frequently mentioned adverse health effects. Clear and explicit is the misuse of AAS as medical drugs for therapeutic and clinical use, emphasizing the notion that use of these drugs is primarily for muscular growth and reducing the perception of these as therapeutic drugs among the majority. It was also observed that bodybuilding practitioners are aware of the health problems related to the misuse of these drugs, even though they continue to use them because their desire to develop muscular mass outweighs the risks. Some believe harm occurs only when used excessively, but it is important to emphasize that it doesn’t matter how much is used because various factors contribute to the harmful reactions, including age, gender, and current health status of the user, and these need to be taken into consideration. Among the most frequently used substances are ADE and equipoise—two substances used in animal science and medicine. It is also important to highlight that use of Durateston, Deca-durabolin, and Hemogenin is more prevalent in the countryside because of pharmacy access and may be purchased in most drugstores that distribute controlled products. Evans (2004), in an overview of AAS, reported that up to 90% of AAS users practice polypharmacy, taking a mix of muscle-shaping drugs, in addition to stacking different brands of steroids. Sk˚arberg, Nyberg, and Engström (2008) showed the importance of understanding how AAS use can develop either with or without the concomitant use of other “drugs of abuse” and that the use of AAS can progress to the use of other drugs. The attitude among Brazilian bodybuilders is a focus on appearance, principally in the urban areas, as we see greater social, economic, and education development in the urban areas as compared with the rural areas—particularly comparing the northeast (the region of research) to the southeast (the more densely populated area of the country) of Brazil. The culture of bodybuild-

Following analysis of the data, our results indicate that of the participants in the study, 33.3% of male bodybuilding practitioners use and misuse AAS. It is also evident that use is related to the facility (drugstore, fitness center, social clubs) and to access of these substances in the fitness clubs of the capital city, where 46% of the participants are currently using or have already used AAS, as opposed to 24.6% in the countryside. However, city size has not been an important factor in other studies (Bahrke, Yesalis, Kopstein, & Stephens, 2000; Nilson, Baigi, Marklun, & Fridlund, 2001; Whitehead & Chillag, 1992). For the participants in our study, appearance justifies the misuse of AAS. From a public health point of view, the problem with AAS is the potential detrimental impact on the individual and the community. We postulate that these behaviors and attitudes are global. Declaration of interest

The authors, Azenildo Moura Santos, Manoel Sérgio Pereira da Rocha and Marcos Freire da Silva, report no conflicts of interest. The authors alone are responsible for the content and writing of the article. ´ RESUM E´ Utilisation illicite et abus de stéroides anabolisants androgènes par des culturistes brésiliens

Les stéroides anabolisants androgènes (SAA) sont utilisés pour augmenter la performance et améliorer l’apparence. Le but de cette recherche est d’évaluer la connaissance des SAA qu’ont des culturistes brésiliens. L’échantillon comprenait 123 participants masculins, aˆ gés entre 18 et 50 ans. Des questionnaires ont e´ té soumis a` des culturistes de clubs situés dans la capitale et dans la zone rurale de Pernambuco, e´ tat du Nord-Est du Brésil, en 2008. Nous avons analysé l’utilisation et l’abus des SAA chez les culturistes suivant plusieurs perspectives différentes. Pour les participants a` notre e´ tude, l’amélioration de l’apparence justifie l’abus des SAA.


Mots-clés: Stéroides anabolisants androgènes; Abus de drogues; Culturisme; Mauvais usage des stéroides; Apparence corporelle.

Marcos Freire da Silva received his bachelors’ degree in pharmacology and is Clinical Pharmacology Specialist. His primary interests include performance-enhancing substances, doping in sport and exercise, anabolic-androgenic steroids in public health, drugs in sports, and drugs and adolescents

RESUMEN


Uso il´ıcito y abuso de Esteroides ´ Anabolico-Androg´ enicos entre f´ısico-culturistas brasileros

Los Esteroides Anabólico – Androgénicos (EAA) Se utilizan para mejorar el rendimiento y la apariencia. El objetivo de esta investigación, fue evaluar el conocimiento de los EAA entre f´ısico-culturistas brasileros. La muestra se compone de 123 participantes del sexo masculino, con edades entre los 18 y 50 años. Los cuestionarios fueron realizados a los f´ısico-culturistas de gimnasios en el Distrito Capital y en la zona rural de Pernambuco, estado del nordeste de Brasil, en 2008. Se analizó el uso y abuso de EAA desde distintas perspectivas entre los f´ısico-culturistas. Para los participantes en nuestro estudio, la apariencia mejorada justifica el abuso de EAA. Palabras Clave: Esteroides Anabólico – Androgénicos, Abuso de drogas, Fisico-culturismo, Mal uso de esteroides, Apariencia corporal. THE AUTHORS Azenildo Moura Santos received his bachelors’ degree in physical education and is Exercise Physiology Specialist at the Sport Sociology Laboratory and Psychology Laboratory of Sport, Centro de Ciências da Saúde (CCS), Departamento de Educaça˜ o F´ısica (DEF), Universidade Federal de Pernambuco (UFPE). He is concluding his PhD program at the Instituto de Saúde Coletiva—ISC, Federal University of Bahia, Brazil, and got a scholarship of research fellow of the National Council of Scientific and Technologic Development—CNPq, Ministry of Science and Technology, Brazil. His primary interests include psychophysiology phenomenon in sports, sport nutrition, performance enhancing substances, doping in sport and exercise, body image in sports and exercise, anabolic-androgenic steroids in public health, and health promotion. Manoel Sérgio Pereira da Rocha received his bachelors’ degree in pharmacology and is Clinical Pharmacology Specialist. His primary interests include performance-enhancing substances, doping in sport and exercise, anabolic-androgenic steroids in public health, drugs in sports, and drugs and adolescents.

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GLOSSARY

Anabolic-androgenic steroids: Hormones are responsible for the harmony of the vital functions of the organism. Anabolic-androgenic steroids (AAS) are synthetic forms of the primary male sex hormone, testosterone, that imitate the anabolic effects of testosterone with the aim of activating protein metabolism, retaining nitrogen, elevating ribonucleic acid (RNA) activity, and promoting an anabolic effect of growth synthesis. Body appearance: Body image—an individual’s perception of their own body. A personal evaluation of what the individual self is physically and biologically. Body image also is the mental schema of individual self and the relation against others. Drug abuse: As the doses of anabolic steroids used by bodybuilders are always beyond the supraphysiologic doses, we used the term abuse to mean the taking of supraphysiological doses and the use of several anabolic steroids simultaneously (Hall et al., 2005; Pope, Kouri, & Hudson, 2000). Additionally, the use of AAS without a physician prescription is illicit and was also considered by us as abuse. Masculinizing: Sexual disorder effects in women, with hair on unusual places for women (e.g., as little mustache), deep voice, and baldness. Silent epidemic: According to Santos (2007), the use of these drugs by individuals who have began bodybuilding and have now “esthetically changed” tends to stimulate their consumption by believing in a false sense of health, maintaining themselves as a bit invisible or silent, being therefore classified as a “silent epidemic.”

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Ricciardelli, L. A., & McCabe, M. P. (2004). A biopsychosocial model of disordered eating and the pursuit of muscularity in adolescent boys. Psychological Bulletin, 130(2), 179–205. Santos, A. M. (2007). O Mundo Anabólico: análise do uso de esteróides anabólicos nos esportes (2nd ed.). Rev. e ampl. São Paulo, Brazil: Manole. Silber, T. J., & Souza, R. P. (1998). Uso e abuso de drogas na adolescência: o que se deve saber e o que se pode fazer. Adolesc. Latinoam, 1(3), 148–161. Sk˚arberg, K., Nyberg, F., & Engström, I. (2008). The development of multiple drug use among anabolic-androgenic steroid users: Six subjective case reports. Substance Abuse Treatment, Prevention, and Policy, 3, 24. Whitehead, R., & Chillag, S. (1992). Anabolic steroid use among adolescents in a rural state. The Journal of Family Practice, 4(35), 401–405. Yesalis, C. E., & Bahrke, M. S. (2005a). Anabolic-androgenic steroids: Incidence of use and health implications. President’s Council on Physical Fitness & Sports, Research Digest, March, 5(5), 1–8. Yesalis, C. E., & Bahrke, M. S. (2005b). Societal alternatives to performance-enhancing drug and supplement use in sport. Testimony before the Subcommittee, Trade, and Consumer Protection and the Subcommittee on Health. Retrieved October 3, 2007, from http://archives.energycommerce.house.gov/ reparchives/108/Hearings/03102005hearing1452/Yesalis.pdf