Using the Transtheoretical Model to Explain Androgenic Anabolic Steroid Use in Adolescents and Young Adults: Part One

James E. Leone, PhD, MS, ATC, CSCS*D,1 Kimberly A. Gray, MS, ATC, CSCS,2 Jennifer M. Rossi, MS, ATC,3 and Robert M. Colandreo, DPT, ATC, CSCS1 1 Department of Movement Arts, Health Promotion, and Leisure Studies at Bridgewater State College, Bridgewater, Massachusetts; 2Department of Kinesiology at Southern Illinois University Carbondale, Carbondale, Illinois; 3Roane State Community College, Harriman, Tennessee

SUMMARY
THIS ARTICLE PROVIDES THE STRENGTH AND CONDITIONING AND HEALTH PROFESSIONAL INSIGHT INTO THE POSSIBLE RATIONALE FOR USE OF ANDROGENIC ANABOLIC STEROIDS AND OTHER PERFORMANCE-ENHANCING DRUGS USING THE TRANSTHEORETICAL MODEL. THIS MODEL IS OFTEN USED TO PROMOTE HEALTH-ADDITIVE BEHAVIORS, SUCH AS EXERCISE ADHERENCE. THE MODEL CAN BE USED TO EXAMINE HOW NEGATIVE CHOICES AND BEHAVIORS ARE MADE. THE MODEL CAN BE USED BY THE STRENGTH AND CONDITIONING PROFESSIONAL AND HEALTH PROFESSIONAL TO EXPLAIN THE SOCIOCULTURAL FACTORS FOR USING ANDROGENICANABOLIC STEROIDS AND OTHER SUBSTANCES IN YOUNGER AGE CATEGORIES.

INTRODUCTION

xamining androgenicanabolic steroid (AAS) use with the use of a theoretical model has yet to be explored in scientic literature. Oftentimes, the authors of research studies track the epidemiology of AAS use by adolescents, athletes, and young adults and present limited trend data (2,5,10,20,22,23). Even fewer studies have researched AAS from qualitative perspective. One study attempted to qualitatively explore the phenomenon of AAS use in limited groups (17). Limited to no research has attempted to incorporate the behavior process of becoming an AAS user into a health behavior theory and/or model.

Because of the increasing media attention concerning professional athletes use of AAS and similar performanceenhancing substances, for example, human growth hormone (HGH) and insulin growth factors, mainstream society may feel disconnected when trying to explain AAS in adolescents

and young adults who are not professional athletes, because of the multitude of negative consequences. Essentially, coverage of AAS in society has existed in a dichotomous world, one of sports (professional sports and NCAA Division I athletics) and another in mainstream society (32). A primary issue may be the understanding there are many more people using AAS and other substances in mainstream society than in professional and collegiate sports (8,12,17,32). Coverage that focuses solely on AAS use in sport versus mainstream society for aesthetic purposes can be seen in recent reports and studies, such as the Mitchell Report. Elliot et al. (6) discussed AAS usage trends for aesthetic purposes in adolescents in addition to use in athletics. The social aspects of AAS
KEY WORDS:

epidemiology; body image; performance-enhancement drugs; public health

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.
Copyright National Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-lift.org

47

Transtheoretical Model and Steroid Use

use also were corroborated by Sutherland and Shepherd (29). The Report to the Commissioner of Baseball of an Independent Investigation into the Illegal Use of Steroids and Other Performance Enhancing Substances by Players in Major League Baseball, informally known as the Mitchell Report, is the result of former United States Senator George J. Mitchells 20-month investigation into the use of anabolic steroids and HGH in Major League Baseball (MLB) (20). The 409-page report, released on December 13, 2007, covers the history of the use of illegal performance-enhancing substances by players and the saliency of the MLB Joint Drug Prevention and Treatment Program. The report names 89 MLB players who are alleged to have used steroids or drugs (20). A need for understanding adolescent AAS use often falls in the domain of the health and tness professional (29). Sutherland and Shepherd discuss a need for health, tness, and sports professionals to take the lead in eradicating steroids for sports or training purposes while at the same time understanding the social forces that may predispose some adolescents to use (29). Similarly, advancing research in the area of evidence-based curriculum development has been a widely discussed topic (6). Concern for what is occurring in professional sports, such as MLB pertaining to AAS use, has left many professionals and parents wondering what can be done to prevent body image disorders and the use of body image drugs (6). As it stands, few evidence-based, theory-driven programs and curricula aimed at decreasing AAS and other body image drug use have been researched and developed (6). Personal trainers and strength and conditioning professionals often interact with clients in the general population who have questions concerning sports supplementation and possibly the use of illicit substances, such as AAS. Understanding what phase they

may be in can provide the healthiest and most efcacious solution to their inquiry. One of the health education and health behavior models that can be used to address this and like issues is the transtheoretical model (TTM) proposed and developed by Prochaska (27), which will be presented in the following section. The purpose of this article is to present and discuss how the TTM can be used to explain AAS use in adolescents and young adults.
THEORETICAL FRAMEWORK: THE TRANSTHEORETICAL MODEL

Trends of AAS use are presented in the following section.

ANDROGENIC-ANABOLIC STEROID USE IN ADOLESCENTS AND YOUNG ADULTS

TTM, also known as stage theory, was originally proposed by Prochaska in 1979 as a way to provide answers concerning stages of change people may go through in adopting (or not adopting) health behaviors. The TTM uses stages of change to integrate processes and principles of change from across major theories of intervention (7). The model originated from a comparative analysis of leading theories on psychotherapy and behavior change (27). Behavior change, for the positive or negative, unfolds through a series of steps or changes (26). At its core, the TTM has 5 core constructs: precontemplation, contemplation, preparation, action, and maintenance, although some models include a sixth stage (termination). For the sake of completeness, we have chosen to use the 6-stage model because of the fact that AAS termination (cessation) is highly desirable. In addition to these constructs, the TTM also involves decisional balance, such as pros and cons, self-efcacy, and various processes of changes, for example, consciousness raising, dramatic relief, and re-evaluation of self (13,14,27). Application of the TTM has ranged from smoking cessation to weight loss; however, the TTM has not been used to explore negative health behaviors, such as AAS use or the use of other illicit drugs. Using the model in reverse (see Table 3) to explain AAS use is the primary aim of this article. An understanding of the epidemiology of AAS use in adolescents and young adult populations is important when considering using theory to explain behaviors.

Anabolic agents, such as AAS, are substances that promote tissue growth through nitrogen sparing and protein synthesis (25). The use and abuse of AAS and other performance-enhancing substances is not new to sports (31,33). What is a newer trend is the use of AAS on a broader scale in mainstream society, likely for aesthetic purposes versus just strength and size (16,22,23). The period of adolescence and early adulthood is a particularly inuential period of ones life when making choices concerning health (27,32). People who struggle with poor selfimage, coupled with the conuence of social forces, may be at risk for developing negative health practices, such as AAS use, to compensate for poor body image (32). People who are unable to achieve personal goals or handle pressures from peers, parents, coaches, and others regarding an unrealistic ideal body image may turn to AAS or other dangerous substances to satisfy their aspirations (18). In an older, but telling study (2), the authors noted that adolescent AAS users are at risk for several adverse psychobehavioral consequences, such as addiction, violence and aggression, and social conduct disorder. It has also been suggested that AAS users form a risk behavior syndrome, which encompasses the use of other harmful drugs and substances, such as cigarettes, smokeless tobacco, marijuana, alcohol, and cocaine (20). Risk-taking is not a surprise with AAS users and is exemplied by risky behavioral practices as with hypodermic needle use and abuse of addictive drugs, such as nalbuphine hydrochloride, a narcotic for pain control (16,20,30). The enigma of AAS use by adolescents and young adults continues to be popularized by current media but understudied in theory. Tracking the epidemiology of use is confounded by self-report bias, recall bias, and issues of

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.

48

VOLUME 30 | NUMBER 6 | DECEMBER 2008

social desirability, which may affect truthfulness. Most recent data suggest younger males are most susceptible to use, with an overall national trend being 36% (46,20,22,25). Causes likely stem from sport performance pressures, but also decits in self-esteem and body image (3,4,12,32). Because of the widespread and understudied explanations concerning AAS, theories and models, such as the TTM, can effectively be used to address some of the former issues.

USING THE TRANSTHEORETICAL MODEL TO EXPLAIN ANDROGENICANABOLIC STEROID USE

As previously discussed, TTM provides a theoretical framework that crosses many disciplines in medical, health, and behavioral sciences (27). Being that AAS use has been presented from all of these perspectives, the TTM can be used to propose explanations as to why adolescents and young adults may elect to begin using AAS and other performance-enhancing drugs.

The following sections present each stage of the TTM with a brief overview of its concepts, followed by the application of the TTM for explaining AAS use and behaviors (also see Table 3). Rather than viewing each stage as separate and distinct, often there is considerable overlap among all 6 stages (27). For a more detailed view of the TTM, see Table 1.
STAGES

Precontemplation. Persons in the precontemplation stage of the TTM have

Table 1
Components and constructs of the Transtheoretical Model (26)
Constructs Description of process

Stages of change Precontemplation Contemplation Preparation Action Maintenance Termination No intent to take action in next 6 months Intent to take action within next 6 months Intent to take action in next 30 days and has taken behavioral steps in this direction Changed overt behavior for less than 6 months Changed overt behavior for more than 6 months Former thoughts/impulses of problem behavior are no longer perceived Decisional balance Pros Cons Benets of changing behavior(s) Costs of changing behavior(s) Self-efcacy Condence Temptation Belief one can engage in healthy behavior in face of challenges Impulse to engage in unhealthy behavior in face of challenges The processes of change Consciousness raising Dramatic relief Re-evaluation of self Environmental re-evaluation Self-liberation Helping relationships Counter-conditioning Reinforcement management Stimulus control Social liberation Finding/learning new facts, ideas, and tips that support healthy behavior change Experiencing negative emotions that go along with unhealthy behavioral risks Realization that behavior change is important to ones identity Realization of negative/positive impact of unhealthy/healthy behavior on ones social & physical environment Making a rm commitment to change Seeking and using social support for healthy behavior change Substituting healthier alternative behaviors for unhealthy ones Increasing/decreasing rewards for positive/negative behaviors Removing reminders/cues to engage in unhealthy behaviors and adding positive ones Realization of social norms supporting the healthy behavior change

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.
Strength and Conditioning Journal | www.nsca-lift.org

49

Transtheoretical Model and Steroid Use

no intent to take action in the upcoming 6-month period. Failure to take action may be the result of a variety of factors, but most notably a lack of overall awareness of an issue or a low perception of risk or threat for a particular behavior (27). Users of AAS are often described as being part of a particular culture, a social construct characterized by daily behaviors centered around strength training, strict dieting (high protein and low fat), and immersion in discussions pertaining to tness, magazines, and means to obtain performance-enhancing drugs (14). This culture often is preceded by changes within ones perception of ones body, most notably his or her body image (28,32). Many people, particularly adolescents and young adults, become aware of their changing body and their image of it between the ages of 1325 years, with great variability between ages (32). Adolescents and young adults who begin using AAS often do so after an initial exposure to the AAS culture or if there is a breach in their selfesteem, which may call their body image into question (3). As people developmentally advance into adolescence and young adulthood, the homogeneity of body types greatly varies and differentiates. This differentiation process may lead one to become dissatised with his/her body type and take measures to change it (32). The use of body image drugs, such as AAS, HGH, and ephedra derivatives, often tempt people to use with hopes of changing their body for the better (12). A goal for AAS educational strategies is to keep adolescents and young adults in this stage. To borrow from the health belief model, which assesses a persons intent to act, establishing or clarifying reasons of why not to use AAS, that is, having more barriers than benets, and encountering more risks than rewards, are critical in preventing AAS use (27). Contemplation. The contemplation stage involves planning on initiating

change within the upcoming 6 months. People may be very aware of the benets but also acutely aware of the costs. Balancing the costs versus the benets can produce a lengthy contemplation stage (27). Many adolescents participate in athletics, which may expose them to heightened pressures to be bigger, stronger, and faster (10). Others may view AAS as a means to produce a pleasing aesthetic appearance (18). The phenomenon of the sheep mentality, may prevail during these ages, particularly if role models, and members of the peer group, are found to be using banned substances (10). Moreover, exposure to social pressures may provoke internal conict for an adolescent or young adult contemplating the use of AAS. When media, among other social pressures, reaches a critical level in terms of decision making, an external motivation may develop, which can lead to preparation for obtaining and using AAS (9). Preparation. In the preparation stage, people have the intent to take action on an issue in the immediate future (approximately 1 month). Some actions have lead up to this point, such as self-education and involvement with other people who are already involved in the process; that is other AAS users (27). Accordingly, people who have been considering the use of AAS and other substances have gathered information on the logistics ranging from nding credible substances and dealers to nancing the whole process (27). In many gymnasiums, the possibility of nding a person who has access to AAS is generally not problematic (32). Many AAS users will come up with the nancial resources to afford this behavior through working more hours at the expense of social obligations (school, personal relationships, etc.), selling personal items, or simply becoming dealers themselves (2,8). In some instances, reports have focused on men who become sex workers to pay for their habit, but who do not

identify as being homosexual (8,11,15,16). Essentially, the preparation stage ranges from guring out the nancial costs associated with AAS to nding out how to best dose and administer the AAS product. There may also continue to be an inner dialogue evaluating the associated physical risks and side effects, but the likelihood of using will continue (2). Action. The action stage is encompassed by overt modications in ones behavior and/or lifestyle within the past 6 months (27). For purposes of this article, action means the person has begun using AAS or other substances. For use of AAS to begin, the person must have resolved the inner conict discussed in the contemplation and preparation stage of this model. In the action stage, the person is intent on nding supplies, such as hypodermic needles and pills, as well as supportive treatments for side effects encountered with AAS. Side effects have been reported to range from severe body acne and breast tissue development to psychological effects, such as aggression and potentially violent behavior as with roid rage (16,32,33). Supportive treatments may include products to minimize the side effects of AAS (see Table 2), including a common cancer drug called tamoxifen, which is used to halt tissue growth in the breast (12). Users of AAS may use tamoxifen to minimize or hide the resulting gynecomastia (excessive breast tissue) that accompany mid- to longer term use (12,16). Other drugs, such as nalbuphine hydrochloride, may be used to combat the severe pain encountered with muscle tears from overtraining of muscle and tendon tissue (30). Finally, the threat of infection from injectable AAS is an ever-present possibility (8,11,12). It is not uncommon for AAS users to share needles in their subculture or to use needles more than once on themselves. These latter facts pose several public health and individual risks, from septic infection of the individual to transmission of HIV/AIDS viruses to others who share needles (11,16).

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.

50

VOLUME 30 | NUMBER 6 | DECEMBER 2008

Table 2
Adverse side effects associated with androgenic-anabolic steroid use in males and females (16,19,32)
Side effect Males Females Both

Facial and systemic acne* Peliosis hepatis (blood tumors in the liver) Yes Possibly

Yes Condition is dose dependent, with males usually taking higher doses Yes Yes Yes Yes Yes Females often experience a reduction in breast tissue* Yes Yes Yes Yes Yes Yes Yes Yes Possible, but more pronounced in males* With associated sterility

Mesenchymal kidney tumors Pronounced left ventricular hypertrophy Testicular atrophy* Enlarged clitoris* Breast tissue growth (gynecomastia) High levels of low-density lipoprotein cholesterol* Hypertension* Aggression Impotence* Jaundice* Excessive hair growth (facial and body)* Male patterned baldness Stunted growth
*Denotes possibility of a reversible side effect.

Maintenance. On the basis of the latter examples of potential risks of using AAS, users often will maintain usage for a variety of intrinsic and extrinsic reward systems. The inherent nature of the maintenance stage is based on the premise that people are less likely to be tempted to stop using a substance or enacting a behavior because of increasing condence (27). User condence is problematic in that the user will likely see and feel the results of AAS use. Androgenicanabolic steroids do in fact cause muscle hypertrophy, an increase in lean mass, and notable strength increases (1,8,10,11, 15,16,24,25,31). These intrinsic factors remind the user that their choice of AAS use behavior is working. The user sees his/her results each day in the mirror or in the increasing size of

weight stacks they lift at their local workout facility. Users also may maintain their behaviors and use of AAS based on social or external reinforcement they receive (27). People, such as personal/athletic trainers, friends, coaches, parents, or any other inuential people in the adolescences or young adults life may inadvertently compliment the results of the persons negative behavioral choices in using AAS or other potentially harmful substances. These unhealthful, but often unintended, social reinforcements from others may lead to continued AAS use. The adolescent or young adult does not want to revert back to a previous stage, which may be viewed as less physically competent or weaker (1). Therefore, without proper education on the adverse effects (see Table 2) of

AAS in this population, or if the person experiences a traumatic side effect themselves, use will likely continue (6). Termination. According to Prochaskas original model of the TTM, people may progress to a termination stage where they do not give any thought to their new behavior because it has become second nature based on temporal events (27). The use of AAS and other substances, compared with positive health behaviors, often does not reach a termination stage. Drug use produces dependence and addictive type of qualities that stay with the individual throughout his/her life, thus terminating the thoughts of the dangers of use (11). As with other types of drug and alcohol treatment approaches, many AAS users encounter similar dependence issues, such as withdrawal and

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.
Strength and Conditioning Journal | www.nsca-lift.org

51

Transtheoretical Model and Steroid Use

Table 3
The Transtheoretical Model constructs with negative behaviors associated with AAS use
Constructs Description of process

Stages of change Precontemplation AAS behavior Contemplation AAS behavior Preparation AAS behavior Action AAS behavior Maintenance AAS behavior Termination AAS behavior No intent to take action in next 6 months None or unaware of issue Intent to take action within next 6 months Thinking about possible AAS use; may have low self-esteem or body image issues Intent to take action in next 30 days and has taken behavioral steps in this direction Talking to sources in the know, self-educating, researching supplies and costs Changed overt behavior for less than 6 months Gathered supplies, secured a dealer, begins use of AAS with rst benets noted Changed overt behavior for more than 6 months Sees efcacy of AAS, dismisses side-effects, compliments reinforce negative behaviors Former thoughts/impulses of problem behavior are no longer perceived Continues to use as the result of internal reward (self-condence, strength) based on external cues (i.e., compliments); questionable dependency issues Decisional balance Pros AAS behavior Cons AAS behavior Benets of changing behavior(s) Views AAS as boost to strength, power, aesthetic, self-condence, and self-esteem Costs of changing behavior(s) Considers possible side-effects, nancial burden of use, possible legal implications Self-efcacy Condence AAS behavior Temptation AAS behavior Belief one can engage in healthy behavior in face of challenges Notable physical changes in muscle, lean mass, and strength reinforce condence Impulse to engage in unhealthy behavior in face of challenges May occur at contemplation stage, values, morals and self-judgments are made The processes of change Consciousness raising AAS behavior Dramatic relief AAS behavior Self re-evaluation AAS behavior Environmental re-evaluation AAS behavior Self-liberation Finding/learning new facts, ideas, and tips that support healthy behavior change Potential users will self-educate and contact inside sources and media Experiencing negative emotions that go along with unhealthy behavioral risks Users may experience sense of guilt or shame from using, but continue to use Realization that behavior change is important to ones identity Belief that muscle strength and size as well as aesthetics dene the person Realization of negative/positive impact of unhealthy/healthy behavior on ones social and physical environment May experience social difculties, avoid relationships, possible aggression and violent behavior toward others Making a rm commitment to change

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.

52

VOLUME 30 | NUMBER 6 | DECEMBER 2008

Table 3 continued
Constructs AAS behavior Helping relationships AAS behavior Counter-conditioning AAS behavior Reinforcement management AAS Behavior Stimulus control AAS behavior Social liberation AAS behavior
AAS = androgenic-anabolic steroid.

Description of process Belief that investment in AAS outweighs other life values Seeking and using social support for healthy behavior change AAS users will turn to fellow users for a supportive environment and culture Substituting healthier alternative behaviors for unhealthy ones May view ritualistic weight training and dietary modications as healthy versus obsessive Increasing/decreasing rewards for positive/negative behaviors As AAS continues, praise and positive comments reinforce negative behaviors Removing reminders/cues to engage in unhealthy behaviors and adding positive ones Educational strategies or interventions become futile because the user sees and feels the efcacy of AAS use Realization of social norms supporting the healthy behavior change AAS users will turn to support/reinforcement of negative behaviors from their gym peers and weight training culture to support their social norms

mood disturbances. Withdrawal from AAS, however, remains a controversial theory (24,33). The lure of drug use will always remain; how it is managed through self-control and treatment becomes the main goal of intervention and treatment strategies.
PRACTICAL APPLICATIONS

conditioning professionals and also among the clients they work with each day. Effective communication will hopefully parlay into further discussions and interventions curtailing the use of performance-enhancing substances, such as AAS.
SUMMARY

James E. Leone is an Assistant Professor of Health Education in the Department of Movement Arts, Health Promotion, and Leisure Studies at Bridgewater State College.

It has become increasingly important to address performance-enhancing substance use as with androgenic anabolic steroids in the strength and conditioning profession. Not only is this a contemporary issue relevant to athletes and those who are physically active but also for populations who use these drugs for enhancing appearance with hopes of achieving an aesthetic sociocultural ideal. Identifying behaviors, such as secrecy, ritualistic exercise patterns, change in affect, and issues with money, among other behaviors indicative of AAS use should be noted by the strength and conditioning professional. Understanding how to use health theory and health behavior models (see Table 3), such as TTM, to explain AAS use may help improve communication among strength and

Much of the discussion surrounding AAS use and other performance-enhancing substances stems from examples in professional sports, such as the National Football League and MLB. Only a fraction of this discussion in the popular media has addressed this issue from a public health perspective. Clearly, more people use AAS and like substances for aesthetic purposes versus sport performance (12). Being that strength and conditioning professionals are on the front lines of this issue and are often called upon to be resource persons, a clear understanding of the psychobehavioral processes people experience related to AAS use is needed. Part two of this theoretical and conceptual model will present effective theory-based strategies to help identify and curtail the use of performance-enhancing drugs, such as AAS.

Kimberly A. Gray is an instructor and serves as the Clinical Education Coordinator for the Athletic Training Education Program in the Department of Kinesiology at Southern Illinois University Carbondale.

Jennifer M. Rossi is an adjunct faculty member at Roane State Community College and does clinical outreach work for Star Physical Therapy, Inc. in Lenoir City, Tennessee.

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.
Strength and Conditioning Journal | www.nsca-lift.org

53

Transtheoretical Model and Steroid Use

Robert M. Colandreo is an Assistant Professor and Director of Clinical Education for the Athletic Training Education Program at Bridgewater State College in the Department of Movement Arts, Health Promotion, and Leisure Studies.
REFERENCES
1. Berning JM, Adams KJ, and Stamford BA. Anabolic steroid usage in athletics: Facts, ction, and public relations. J Strength Cond Res 18: 908917, 2004. 2. Burnett KF and Kleiman ME. Psychological characteristics of adolescent steroid users. Adolescence 29: 8190, 1994. 3. Cohane G and Pope HG. Body image in boys: A review of the literature. Int J Eat Disord 29: 373379, 2001. 4. Drewnowski A, Kurth CL, and Krahn DD. Effects of body image on dieting, exercise, and anabolic steroid use in adolescent males. Int J Eat Disord 17: 381386, 1995. 5. Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris WA, Lowry R, Mcmanus T, Chyen D, Shanklin S, Lim C, Grunbaum J, and Wechsler H. Youth risk behavior surveillance: United States 2005. Surveillance Summaries 55: SS5, 2005. 6. Elliot DL, Moe EL, Goldberg L, Defrancesco CA, Durham MB, and Hix-Small H. Denition and outcome of a curriculum to prevent disordered eating and body-shaping drug use. J School Health 76: 6773, 2006. 7. Ficke DL and Farris KB. Use of the transtheoretical model in the medication use process. Ann Pharmacother 39: 13251330, 2005. 8. Halkitis PN, Moeller RW, and Deraleau LB. Steroid use in gay, bisexual, and nonidentied men-who-have-sex-with-men: Relations to masculinity, physical, and mental health. Psych Men Masc 9: 106 115, 2008. 9. Hargreaves D and Tiggemann M. The effect of television commercials on mood and body dissatisfaction: The role of selfschema activation. J Soc Clin Psych 21: 287308, 2002.

10. Hoffman JR, Faigenbaum AD, Ratamess NA, Ross R, Kang J, and Tenebaum G. Nutritional supplementation and anabolic steroid use in adolescents. Med Sci Sport Exerc 40: 1524, 2008. 11. Kanayama G, Cohane GH, Weiss RD, and Pope HG. Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: An underrecognized problem? J Clin Psychiatry 64: 156160, 2003. 12. Kanayama G, Pope HG, and Hudson JI. Body image drugs: A growing psychosomatic problem. Psychother Psychosom 70: 6165, 2001. 13. Kieuk D. Success strategiesPart 1. Strength Cond J 25: 2122, 2003. 14. Kieuk D. Success strategiesPart 2. Strength Cond J 25: 1213, 2003. 15. Klein AM. Little Big Men: Bodybuilding Subculture and Gender Construction. New York: State University of New York Press, 1993. pp. 731. 16. Lenehan P. Anabolic Steroids and Other Performance Enhancing Drugs. London: Taylor and Francis, 2003. pp. 5382, 117134. 17. Leone JE and Fetro JV. Perceptions and attitudes toward androgenicanabolic steroid usage in among two age categories: A qualitative inquiry. J Strength Cond Res 21: 532537, 2007. 18. Leone JE, Sedory EJ, and Gray KA. Recognition and treatment of muscle dysmorphia and related body image disorders. J Athl Train 40: 352359, 2005. 19. Maravelias C, Dona A, Stefanidou M, and Spiliopoulou C. Adverse effects of anabolic steroids in athletes: A constant threat. Toxicol Lett 158: 167175, 2005. 20. Middleman AB, Faulkner AH, Woods ER, Emans SJ, and Durant RH. High-risk behaviors among high school students in Massachusetts who use anabolic steroids. Pediatrics 96: 268272, 1995. 21. Mitchell GJ. Use of performance-enhancing drugs in Major League Baseball (MLB). Ofce of the Commissioner of Baseball. December 13, 2007. Available at: http:// mlb.mlb.com/mlb/news/mitchell/index.jsp. Accessed: February 2, 2008. 22. Nilsson S, Baigi A, Marklund B, and Fridlund B. Trends in the misuse of androgenic anabolic steroids among boys

1617 years old in a primary healthcare area in Sweden. Scand J Prim Health Care 19: 181182, 2001. 23. Nilsson S, Spak F, Marklund B, Baigi A, and Allebeck P. Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden. Substance Use Misuse 39: 11831197, 2004. 24. Pope HG and Katz DL. Psychiatric effects of anabolic steroids. Psych Ann 22: 2429, 1992. 25. Powers M. Performance-enhancing drugs. In: Principles of Pharmacology for Athletic Trainers. J. Houglum, G. Harrelson, and D. Leaver-Dunn, eds. Thorofare, NJ: Slack, 2005. pp. 327332. 26. Prochaska JO and Diclemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Counsel Clin Psych 51: 390395, 1983. 27. Prochaska JO, Redding CA, and Evers KE. The transtheoretical model and stages of change. In: Health Behavior and Health Education: Theory Research, and Practice. K. Glanz, B.K. Rimer, and F. Marcus-Lewis, eds. San Francisco, CA: Jossey-Bass, 2002. pp. 99120. 28. Sondhaus EL, Kurtz RM, and Strube MJ. Body attitude, gender and self-concept: A 30-year perspective. J Psychol 135: 413429, 2001. 29. Sutherland I and Shepherd JP. Social dimensions of adolescent substance abuse. Addiction 96: 445458, 2001. 30. Wines JD, Gruber AJ, Pope HG, and Lukas SE. Nalbuphine hydrochloride dependence in anabolic steroid users. Am J Addict 8: 161164, 1999. 31. Wright JE and Cowart VS. Anabolic Steroids. Carmel, IN: Benchmark Press Inc., 1990. pp. 4571. 32. Wroblewska AM. Androgenic-anabolic steroids and body dysmorphia in young men. J Psychosom Res 42: 225234, 1997. 33. Yesalis CE, Vicary JR, and Buckley WE. Anabolic steroid use among adolescents: A study of indications of psychological dependence. In: Anabolic Steroids in Sport and Exercise. C.E. Yesalis, ed. Champaign, IL: Human Kinetics, 1993. pp. 216229.

Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.

54

VOLUME 30 | NUMBER 6 | DECEMBER 2008