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Using theTranstheoretical Model toExplain AndrogenicAnabolic Steroid Use inAdolescents and YoungAdults: Part OneJames 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, CSCS 11 Department of Movement Arts, Health Promotion, and Leisure Studies at Bridgewater State College, Bridgewater,Massachusetts; 2 Department of Kinesiology at Southern Illinois University Carbondale, Carbondale, Illinois; 3 RoaneState Community College, Harriman, Tennessee

S U M M A R YTHIS ARTICLE PROVIDES THESTRENGTH AND CONDITIONINGAND HEALTH PROFESSIONAL IN-SIGHT INTO THE POSSIBLE RATIO-NALE FOR USE OF ANDROGENICANABOLIC STEROIDS AND OTHERPERFORMANCE-ENHANCINGDRUGS USING THE TRANS-THEORETICAL MODEL. THISMODEL IS OFTEN USED TOPROMOTE HEALTH-ADDITIVE

BEHAVIORS, SUCH AS EXERCISEADHERENCE. THE MODEL CAN BEUSED TO EXAMINE HOW NEGATIVECHOICES AND BEHAVIORS AREMADE. THE MODEL CAN BE USEDBY THE STRENGTH AND CONDI-TIONING PROFESSIONAL ANDHEALTH PROFESSIONAL TOEXPLAIN THE SOCIOCULTURALFACTORS FOR USINGANDROGENICANABOLIC STE-ROIDS AND OTHER SUBSTANCES

IN YOUNGER AGE CATEGORIES.

INTRODUCTION

Examining androgenicanabolicsteroid (AAS) use with the useof a theoretical model has yet to

be explored in scientic literature.Oftentimes, the authors of researchstudies track the epidemiology of AASuse by adolescents, athletes, and young adults and present limited trend data (2,5,10,20,22,23). Even fewer studieshave researched AAS from qualitativeperspective. One study attempted toqualitatively explore the phenomenon

of AAS use in limited groups (17).Limited to no research has attemptedto incorporate the behavior process of becoming an AAS user into a healthbehavior theory and/or model.

Because of the increasing media atten-tion concerning professional athletesuse of AAS and similar performance-enhancing substances, for example,human growth hormone (HGH) andinsulin growth factors, mainstreamsociety may feel disconnected when

trying to explain AAS in adolescents

and young adults who are not pro-fessional athletes, because of the mul-titude of negative consequences.Essentially, coverage of AAS in societyhas existed in a dichotomous world,one of sports (professional sports andNCAA Division I athletics) and an-other in mainstream society (32). Aprimary issue may be the understand-ing there are many more people using AAS and other substances in main-stream society than in professional andcollegiate sports (8,12,17,32). Coverage

that focuses solely on AAS use in sportversus mainstream society for aestheticpurposes can be seen in recent reportsand studies, such as the MitchellReport. Elliot et al. (6) discussed AASusage trends for aesthetic purposes inadolescents in addition to use inathletics. The social aspects of AAS

K E Y W O R D S :

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

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social desirability, which may affecttruthfulness. Most recent data suggestyounger males are most susceptible touse, with an overall national trend

being 36% (46,20,22,25). Causes likelystem from sport performance pressures,but also decits in self-esteem and bodyimage (3,4,12,32). Because of the wide-spread and understudied explanationsconcerning AAS, theories and models,such as the TTM, can effectively beused to address some of the formerissues.

USING THE TRANSTHEORETICALMODEL TO EXPLAINANDROGENICANABOLICSTEROID USEAs previously discussed, TTM pro-vides a theoretical framework thatcrosses many disciplines in medical,health, and behavioral sciences (27).Being that AAS use has been presentedfrom all of these perspectives, the TTMcan be used to propose explanations asto why adolescents and young adultsmay elect to begin using AAS andother performance-enhancing drugs.

The following sections present eachstage of the TTM with a brief overviewof its concepts, followed by the appli-cation of the TTM for explaining AAS

use and behaviors (also see Table 3).Rather than viewing each stage asseparate and distinct, often there isconsiderable overlap among all 6 stages(27). For a more detailed view of theTTM, see Table 1.

STAGES

Precontemplation. Persons in the pre-contemplation stage of the TTM have

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

Constructs Description of process

Stages of change

Precontemplation No intent to take action in next 6 months

Contemplation Intent to take action within next 6 months

Preparation Intent to take action in next 30 days and has taken behavioral steps in this direction

Action Changed overt behavior for less than 6 months

Maintenance Changed overt behavior for more than 6 months

Termination Former thoughts/impulses of problem behavior are no longer perceived

Decisional balancePros Benets of changing behavior(s)

Cons Costs of changing behavior(s)

Self-efcacy

Condence Belief one can engage in healthy behavior in face of challenges

Temptation Impulse to engage in unhealthy behavior in face of challenges

The processes of change

Consciousness raising Finding/learning new facts, ideas, and tips that support healthy behavior change

Dramatic relief Experiencing negative emotions that go along with unhealthy behavioral risks

Re-evaluation of self Realization that behavior change is important to ones identity

Environmental re-evaluation Realization of negative/positive impact of unhealthy/healthy behavior onones social & physical environment

Self-liberation Making a rm commitment to change

Helping relationships Seeking and using social support for healthy behavior change

Counter-conditioning Substituting healthier alternative behaviors for unhealthy ones

Reinforcement management Increasing/decreasing rewards for positive/negative behaviors

Stimulus control Removing reminders/cues to engage in unhealthy behaviors and adding positive ones

Social liberation Realization of social norms supporting the healthy behavior change

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no intent to take action in the upcom-ing 6-month period. Failure to takeaction may be the result of a variety of factors, but most notably a lack of

overall awareness of an issue or a lowperception of risk or threat for a particular behavior (27). Users of AAS are often described as being partof a particular culture, a social con-struct characterized by daily behaviorscentered around strength training,strict dieting (high protein and lowfat), and immersion in discussionspertaining to tness, magazines, andmeans to obtain performance-enhanc-ing drugs (14). This culture often ispreceded by changes within ones

perception of ones body, most notablyhis or her body image (28,32). Manypeople, particularly adolescents andyoung adults, become aware of theirchanging body and their image of itbetween the ages of 1325 years, withgreat variability between ages (32).Adolescents and young adults whobegin using AAS often do so afteran initial exposure to the AAS cultureor if there is a breach in their self-esteem, which may call their bodyimage into question (3). As peopledevelopmentally advance into adoles-cence and young adulthood, thehomogeneity of body types greatlyvaries and differentiates. This differen-tiation process may lead one tobecome dissatised with his/her bodytype and take measures to change it(32). The use of body image drugs,such as AAS, HGH, and ephedra derivatives, often tempt people touse with hopes of changing theirbody for the better (12). A goal for

AAS educational strategies is to keepadolescents and young adults in thisstage. To borrow from the healthbelief model, which assesses a personsintent to act, establishing or clarifying reasons of why not to use AAS, thatis, having more barriers than benets,and encountering more risks thanrewards, 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 thebenets but also acutely aware of thecosts. Balancing the costs versus the

benets can produce a lengthy con-templation stage (27).Many adolescents participate in ath-letics, which may expose them toheightened pressures to be bigger,stronger, and faster (10). Others mayview AAS as a means to producea pleasing aesthetic appearance (18).The phenomenon of the sheep men-tality, may prevail during these ages,particularly if role models, and mem-bers of the peer group, are found to beusing banned substances (10). More-over, exposure to social pressures mayprovoke internal conict for an ado-lescent or young adult contemplating the use of AAS. When media, among other social pressures, reaches a criticallevel in terms of decision making, anexternal motivation may develop,which can lead to preparation forobtaining 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 ac-tions have lead up to this point, such asself-education and involvement withother people who are already involvedin the process; that is other AASusers (27).

Accordingly, people who have beenconsidering the use of AAS and othersubstances have gathered informationon the logistics ranging from nding credible substances and dealers tonancing the whole process (27). Inmany gymnasiums, the possibility of nding a person who has access toAAS is generally not problematic (32).Many AAS users will come up with thenancial resources to afford this be-havior through working more hours atthe expense of social obligations(school, personal relationships, etc.),selling personal items, or simply be-coming dealers themselves (2,8). Insome instances, reports have focusedon men who become sex workers to

pay for their habit, but who do not

identify as being homosexual(8,11,15,16). Essentially, the prepara-tion stage ranges from guring out thenancial costs associated with AAS to

nding out how to best dose andadminister the AAS product. Theremay also continue to be an innerdialogue evaluating the associatedphysical risks and side effects, but thelikelihood of using will continue (2).

Action. The action stage is encom-passed by overt modications in onesbehavior and/or lifestyle within thepast 6 months (27). For purposes of thisarticle, action means the person hasbegun using AAS or other substances.

For use of AAS to begin, the personmust have resolved the inner conictdiscussed in the contemplation andpreparation stage of this model. In theaction stage, the person is intent onnding supplies, such as hypodermicneedles and pills, as well as supportivetreatments for side effects encounteredwith AAS. Side effects have beenreported to range from severe bodyacne and breast tissue development topsychological effects, such as aggres-sion and potentially violent behavior aswith roid rage (16,32,33). Supportivetreatments may include products tominimize the side effects of AAS (seeTable 2), including a common cancerdrug called tamoxifen, which is used tohalt tissue growth in the breast (12).Users of AAS may use tamoxifen tominimize or hide the resulting gyneco-mastia (excessive breast tissue) thataccompany mid- to longer term use(12,16). Other drugs, such as nalbu-phine hydrochloride, may be used tocombat the severe pain encounteredwith muscle tears from overtraining of muscle and tendon tissue (30). Finally,the threat of infection from injectableAAS is an ever-present possibility(8,11,12). It is not uncommon forAAS users to share needles in theirsubculture or to use needles more thanonce on themselves. These latter factspose several public health and individ-ual risks, from septic infection of theindividual to transmission of HI-V/AIDS viruses to others who share

needles (11,16).

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Maintenance. On the basis of the latterexamples of potential risks of using AAS, users often will maintain usagefor a variety of intrinsic and extrinsicreward systems. The inherent nature of the maintenance stage is based on thepremise that people are less likely to betempted to stop using a substance orenacting a behavior because of in-

creasing condence (27). User con-dence is problematic in that the userwill likely see and feel the results of AAS use. Androgenicanabolic ste-roids do in fact cause muscle hyper-trophy, an increase in lean mass, andnotable strength increases (1,8,10,11,15,16,24,25,31). These intrinsic factorsremind the user that their choice of AAS use behavior is working. The usersees his/her results each day in the

mirror or in the increasing size of

weight stacks they lift at their localworkout facility.

Users also may maintain their behav-iors and use of AAS based on social orexternal reinforcement they receive(27). People, such as personal/athletictrainers, friends, coaches, parents, orany other inuential people in theadolescences or young adults lifemay inadvertently compliment theresults of the persons negative behav-ioral choices in using AAS or otherpotentially harmful substances. Theseunhealthful, but often unintended,social reinforcements from othersmay lead to continued AAS use. Theadolescent or young adult doesnot want to revert back to a previousstage, which may be viewed as lessphysically competent or weaker (1).Therefore, without proper education

on the adverse effects (see Table 2) of

AAS in this population, or if theperson experiences a traumatic sideeffect themselves, use will likelycontinue (6).

Termination. According to Prochaskasoriginal model of the TTM, people mayprogress to a termination stage wherethey do not give any thought to theirnew behavior because it has becomesecond nature based on temporal events(27). The use of AAS and othersubstances, compared with positivehealth behaviors, often does not reacha termination stage. Drug use producesdependence and addictive type of qualities that stay with the individualthroughout his/her life, thus terminat-ing the thoughts of the dangers of use(11). As with other types of drug andalcohol treatment approaches, manyAAS users encounter similar depen-

dence issues, such as withdrawal and

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

Side effect Males Females Both

Facial and systemic acne* YesPeliosis hepatis (blood tumors in the liver) Yes Possibly Condition is dose dependent,

with males usually takinghigher doses

Mesenchymal kidney tumors Yes

Pronounced left ventricular hypertrophy Yes

Testicular atrophy* Yes With associated sterility

Enlarged clitoris* Yes

Breast tissue growth (gynecomastia) Yes Females often experiencea reduction in breast tissue*

High levels of low-density lipoprotein cholesterol* Yes

Hypertension* Yes

Aggression Yes Possible, but morepronounced in males*

Impotence* Yes

Jaundice* Yes

Excessive hair growth (facial and body)* Yes

Male patterned baldness Yes

Stunted growth Yes

*Denotes possibility of a reversible side effect.




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Table 3The Transtheoretical Model constructs with negative behaviors associated with AAS use


Stages of changePrecontemplation No intent to take action in next 6 months

AAS behavior None or unaware of issue

Contemplation Intent to take action within next 6 months

AAS behavior Thinking about possible AAS use; may have low self-esteem or body image issues

Preparation Intent to take action in next 30 days and has taken behavioral steps in this direction

AAS behavior Talking to sources in the know, self-educating, researching supplies and costs

Action Changed overt behavior for less than 6 months

AAS behavior Gathered supplies, secured a dealer, begins use of AAS with rst benets noted

Maintenance Changed overt behavior for more than 6 months

AAS behavior Sees efcacy of AAS, dismisses side-effects, compliments reinforce negative behaviors

Termination Former thoughts/impulses of problem behavior are no longer perceived

AAS behavior 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 Benets of changing behavior(s)

AAS behavior Views AAS as boost to strength, power, aesthetic, self-condence, and self-esteem

Cons Costs of changing behavior(s)

AAS behavior Considers possible side-effects, nancial burden of use, possible legal implications

Self-efcacy

Condence Belief one can engage in healthy behavior in face of challenges

AAS behavior Notable physical changes in muscle, lean mass, and strength reinforce condence

Temptation Impulse to engage in unhealthy behavior in face of challenges

AAS behavior May occur at contemplation stage, values, morals and self-judgments are made

The processes of change

Consciousness raising Finding/learning new facts, ideas, and tips that support healthy behavior change

AAS behavior Potential users will self-educate and contact inside sources and mediaDramatic relief Experiencing negative emotions that go along with unhealthy behavioral risks

AAS behavior Users may experience sense of guilt or shame from using, but continue to use

Self re-evaluation Realization that behavior change is important to ones identity

AAS behavior Belief that muscle strength and size as well as aesthetics dene the person

Environmental re-evaluation Realization of negative/positive impact of unhealthy/healthy behavioron ones social and physical environment

AAS behavior May experience social difculties, avoid relationships, possible aggressionand violent behavior toward others

Self-liberation Making a rm commitment to change





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mood disturbances. Withdrawal fromAAS, however, remains a controversialtheory (24,33). The lure of drug use willalways remain; how it is managedthrough self-control and treatment

becomes the main goal of interventionand treatment strategies.

PRACTICAL APPLICATIONSIt has become increasingly importantto address performance-enhancing substance use as with androgenicanabolic steroids in the strength andconditioning profession. Not only isthis a contemporary issue relevant toathletes and those who are physicallyactive but also for populations whouse these drugs for enhancing appear-ance with hopes of achieving anaesthetic sociocultural ideal. Identify-ing behaviors, such as secrecy, ritual-istic exercise patterns, change in affect,and issues with money, among other behaviors indicative of AASuse should be noted by the strengthand conditioning professional. Under-standing how to use health theoryand health behavior models (seeTable 3), such as TTM, to explainAAS use may help improve commu-

nication among strength and

conditioning professionals and alsoamong the clients they work with eachday. Effective communication willhopefully parlay into further discus-sions and interventions curtailing the

use of performance-enhancing sub-stances, such as AAS.

SUMMARYMuch of the discussion surrounding AAS use and other performance-en-hancing substances stems from exam-ples in professional sports, such as theNational Football League and MLB.Only a fraction of this discussion in thepopular media has addressed this issuefrom a public health perspective.Clearly, more people use AAS and likesubstances for aesthetic purposes ver-sus sport performance (12). Being thatstrength and conditioning professio-nals are on the front lines of this issueand are often called upon to beresource persons, a clear understanding of the psychobehavioral processespeople experience related to AAS useis needed. Part two of this theoreticaland conceptual model will presenteffective theory-based strategies to helpidentify and curtail the use of perfor-

mance-enhancing drugs, such as AAS.

James E. Leoneis an Assistant Pro-

fessor of HealthEducation in the Department of

Movement Arts,Health Promotion,and Leisure Studies

at Bridgewater State College.

Kimberly A. Gray is an instructor and serves as the Clinical Education Coordina- tor for the Athletic Training Education Program in the De-

partment of Kinesiology at SouthernIllinois University Carbondale.

Jennifer M. Rossiis an adjunct faculty member at Roane State Community College and does clin-

ical outreach work for Star Physical

Therapy, Inc. in Lenoir City, Tennessee.

Table 3 continued


AAS behavior Belief that investment in AAS outweighs other life values

Helping relationships Seeking and using social support for healthy behavior change

AAS behavior AAS users will turn to fellow users for a supportive environment and culture

Counter-conditioning Substituting healthier alternative behaviors for unhealthy ones

AAS behavior May view ritualistic weight training and dietary modications as healthy versus obsessive

Reinforcement management Increasing/decreasing rewards for positive/negative behaviors

AAS Behavior As AAS continues, praise and positive comments reinforce negative behaviors

Stimulus control Removing reminders/cues to engage in unhealthy behaviors and adding positive ones

AAS behavior Educational strategies or interventions become futile because the user seesand feels the efcacy of AAS use

Social liberation Realization of social norms supporting the healthy behavior change

AAS behavior AAS users will turn to support/reinforcement of negative behaviors from theirgym peers and weight training culture to support their social norms

AAS = androgenic-anabolic steroid.




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Robert M.Colandreo is an Assistant Professor and Director of Clinical Education

for the Athletic Training Educa-

tion Program at Bridgewater State College in the Department of Movement Arts,Health Promotion, and Leisure Studies.

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