Eriksen, Michael

Kondo, Albert T.

English

Georgia State University

Georgia State University
ScholarWorks @ Georgia State University
Public Health Faculty Publications School of Public Health
1989
Anabolic steroid use among male high school
seniors [letter]
Michael Eriksen
Georgia State University, meriksen@gsu.edu
Albert T. Kondo
Follow this and additional works at: https://scholarworks.gsu.edu/iph_facpub
Part of the Public Health Commons
This Letter to the Editor is brought to you for free and open access by the School of Public Health at ScholarWorks @ Georgia State University. It has
been accepted for inclusion in Public Health Faculty Publications by an authorized administrator of ScholarWorks @ Georgia State University. For
more information, please contact scholarworks@gsu.edu.
Recommended Citation
Eriksen, M.P. and Kondo, A.T. (1989). Anabolic steroid use among male high school seniors [letter]. Journal of the American Medical
Association, 261(18): 2639-2640. (invited) doi:10.1001/jama.1989.03420180063030.
federal control. Phys Sports Med. 1988;16:189-192.
4. Pope HG, Katz DL. Affective and psychotic symptoms
associated with anabolic steroid use. Am J Psychiatry.
1988;145:487-490.
5. Calabrese LH. Acquired immune deficiency syndrome(AIDS) and sports. Phys Sports Med. In press.
To the Editor. \p=m-\Documentingthe prev-
alence of substance abuse is the first
step in developing effective prevention
strategies. In this regard, the article by
Buckley et al1 made a positive contribu-
tion to the control and prevention of ste-
roid use among male high school se-
niors. This article received considerable
publicity for its findings, largely from
the authors' suggestion that extrapola-
tion of its survey results indicated that
250 000 to 500 000 male adolescents in
this country are presently using anabo-
lic steroids. Of course, both the broad-
cast and print media chose to emphasize
the higher estimate. In reviewing this
article, we feel that the ability to gener-
alize their results and the corresponding
national prevalence estimates must be
questioned because of the manner in
which the sample was selected.
The sample of high schools selected
for study was restricted to those that
employ a certified athletic trainer. Fur-
ther, it was noted by the authors that
only 10% of high schools employ such a
professional and, because of this, the
sample was not random. They rational¬
ized their selection by indicating that
the high schools chosen "do share the
characteristics of a large number of
schools in the United States"; however,
they neglected to acknowledge the na¬
ture of these characteristics. It can be
reasonably hypothesized that schools
that employ these specialists are differ¬
ent in ways that may influence the
study's findings. For example, these
schools may place a higher priority on
athletic performance and achievement,
which could contribute to increased use
of anabolic steroids. On the other hand,
certified athletic trainers may be more
effective in providing education and ac¬
tually prevent the use of anabolic
steroids.
In our opinion, the researchers' meth¬
od of selecting their sampling frame in¬
troduced the possibility of severe bias
and a consequent limitation ofgenerali-
zability. We feel that the bias yielded
results that when extrapolated to all
high schools in the United States overes¬
timated the use of anabolic steroids
among male high school seniors and un¬
duly influenced the allocation of limited
school prevention resources.
Michael P Eriksen, ScD
Albert T. Kondo, PhD
University ofTexas
M. D. Anderson Cancer Center
Houston
1. Buckley WE, Yesalis CE III, Friedl KE, Anderson WA,Streit AL, Wright JE. Estimated prevalence of anabolic
steroid use among male high school seniors. JAMA.
1988;260:3441-3445.
To the Editor. \p=m-\Wewere interested in
the study by Buckley et al1 concerning
the prevalence of anabolic steroid use
among male high school seniors.
We believe that, because question-
naires were administered by students'
homeroom teachers, underreporting
may have been present. Although the
authors contend this is a normal testing
environment, it is not an environment
conducive to confidentiality regarding
possible unethical or illegal activity.
Secondly, we wonder if supplements
sold in health food stores and through
magazines as having anabolic properties
were differentiated from true anabolic
steroids.
Why were high school seniors, identi-
fied as the "user group," were greater
than 19 years old, as these college-age
individuals are usually not still in high
school?
Lastly, we agree that educational in-
terventions should begin as early in life
as possible, but have concerns about the
efficacy of such programs. With regard
to other preventive measures, such as
seat belt use, educational campaigns do
not appear effective when compared
with compulsory legislation with associ-
ated penalties.2
Our research findings regarding
educational interventions among high
school athletes indicated that these pro¬
grams did not alter attitudes regarding
anabolic steroid use.3
Linn Goldberg, MD
Diane L. Elliot, MD
Eric Bosworth
The Oregon Health
Sciences University
Portland
1. Buckley WE, Yesalis III CE, Friedl KE, Anderson WA,
Streit AL, Wright JE. Estimated prevalence of anabolic
steroid use among male high school seniors. JAMA.
1988;260:3441-3445.
2. Orsay EM, Turnbull TL, Dunne M, BarrettJA, Langen-berg P, Orsay CP. Prospective study of the effect of safety
belts on morbidity and health care costs in motor-vehicle
accidents. JAMA. 1988;260:3598-3603.
3. Bosworth E, Bents R, Trevisan L, Goldberg L. Anabolic
steroids and high school athletes. Med Sci Sports Exerc.
1988;20:3.
In Reply. \p=m-\Amselet al make several
observations that further focus the pub-
lic health implications of the nonmedical
use of anabolic steroids. While the ex-
tent of needle sharing among anabolic
steroid users is unknown, we agree that
this behavior could increase the rate of
human immunodeficiency virus infec-
tion. In fact, we mention this concern in
an article that will appear in the Journal
ofDrug Education.1
Drs Eriksen and Kondo criticize the
generalizability of our findings to the
entire population of adolescent males.
In our study, we made every attempt to
consider the characteristics of the sam-
pling process as it relates to its repre-
sentativeness as well as to the issues of
overreporting and underreporting. We
acknowledged in our article that the
presence ofa certified athletic trainer as
a requisite for a high school to be in the
study population introduces a potential
bias. However, we contend that this
does not represent a severe bias and, on
balance, any bias introduced is more
likely to be on the side of underreport¬
ing. For example, in the states where
the use ofanabolic steroids is considered
high based on anecdotal evidence, we
experienced lower participation rates.
Also, the premise that schools with ath¬
letic trainers may place a higher priority
on athletic performance and achieve¬
ment is, in our opinion, based on a mis¬
understanding of the role of the athletic
trainer in the school athletic environ¬
ment. Several school administrators
mentioned that the presence of the ath¬
letic trainer was an indication of their
interest in the welfare of the student
athlete rather than in a successful ath¬
letic record. Finally, the rate ofanabolic
steroid use established by our study was
reasonably comparable to several state¬
wide studies (as referenced in our arti¬
cle) in which the large majority of
schools surveyed probably did not have a
certified athletic trainer.
Goldberg et al interpreted the nature
of our methodology as resulting in an
underreporting of anabolic steroid use
rather than the overreporting sug¬
gested in the letter discussed previous¬
ly. However, several participating ath¬letic trainers commented that the
homeroom testing environment was
routinely used for grade- or school-wide
testing procedures, including surveys
designed to determine alcohol and rec¬
reational drug experience. Only one
school indicated that the method of ad¬
ministration of the survey was the rea¬
son for their refusal to participate in the
study; they did not have a homeroom
period.
The suggestion for caution regarding
generalizability ofour findings is appro¬
priate. We view our work as prelimi¬
nary; this research was the first national
study in this area. Our feeling is, howev¬
er, that our estimates of prevalence of
anabolic steroid use represented a lower
limit. Clearly, more research is indi¬
cated not only on the level of use, but
also on interventional strategies and the
identification of the long-term health
effects.
William E. Buckley, PhD
Charles E. Yesalis III, ScD
Pennsylvania State University
University Park
1. Yesalis CE, Streit AL, Vicary JR,et al. Anabolic steroid
use: indications of habituation among adolescents. J Drug
Educ. In press.
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Anabolic steroid use among male high school seniors [letter]

ScholarWorks @ Georgia State University

Georgia State UniversityScholarWorks @ Georgia State UniversityPublic Health Faculty Publications School of Public Health1989Anabolic steroid use among male high schoolseniors [letter]Michael EriksenGeorgia State University, meriksen@gsu.eduAlbert T. KondoFollow this and additional works at: https://scholarworks.gsu.edu/iph_facpubPart of the Public Health CommonsThis Letter to the Editor is brought to you for free and open access by the School of Public Health at ScholarWorks @ Georgia State University. It hasbeen accepted for inclusion in Public Health Faculty Publications by an authorized administrator of ScholarWorks @ Georgia State University. Formore information, please contact scholarworks@gsu.edu.Recommended CitationEriksen, M.P. and Kondo, A.T. (1989). Anabolic steroid use among male high school seniors [letter]. Journal of the American MedicalAssociation, 261(18): 2639-2640. (invited) doi:10.1001/jama.1989.03420180063030.federal control. Phys Sports Med. 1988;16:189-192.4. Pope HG, Katz DL. Affective and psychotic symptomsassociated with anabolic steroid use. Am J Psychiatry.1988;145:487-490.5. Calabrese LH. Acquired immune deficiency syndrome(AIDS) and sports. Phys Sports Med. In press.To the Editor. \p=m-\Documentingthe prev-alence of substance abuse is the firststep in developing effective preventionstrategies. In this regard, the article byBuckley et al1 made a positive contribu-tion to the control and prevention of ste-roid use among male high school se-niors. This article received considerablepublicity for its findings, largely fromthe authors' suggestion that extrapola-tion of its survey results indicated that250 000 to 500 000 male adolescents inthis country are presently using anabo-lic steroids. Of course, both the broad-cast and print media chose to emphasizethe higher estimate. In reviewing thisarticle, we feel that the ability to gener-alize their results and the correspondingnational prevalence estimates must bequestioned because of the manner inwhich the sample was selected.The sample of high schools selectedfor study was restricted to those thatemploy a certified athletic trainer. Fur-ther, it was noted by the authors thatonly 10% of high schools employ such aprofessional and, because of this, thesample was not random. They rational¬ized their selection by indicating thatthe high schools chosen "do share thecharacteristics of a large number ofschools in the United States"; however,they neglected to acknowledge the na¬ture of these characteristics. It can bereasonably hypothesized that schoolsthat employ these specialists are differ¬ent in ways that may influence thestudy's findings. For example, theseschools may place a higher priority onathletic performance and achievement,which could contribute to increased useof anabolic steroids. On the other hand,certified athletic trainers may be moreeffective in providing education and ac¬tually prevent the use of anabolicsteroids.In our opinion, the researchers' meth¬od of selecting their sampling frame in¬troduced the possibility of severe biasand a consequent limitation ofgenerali-zability. We feel that the bias yieldedresults that when extrapolated to allhigh schools in the United States overes¬timated the use of anabolic steroidsamong male high school seniors and un¬duly influenced the allocation of limitedschool prevention resources.Michael P Eriksen, ScDAlbert T. Kondo, PhDUniversity ofTexasM. D. Anderson Cancer CenterHouston1. Buckley WE, Yesalis CE III, Friedl KE, Anderson WA,Streit AL, Wright JE. Estimated prevalence of anabolicsteroid use among male high school seniors. JAMA.1988;260:3441-3445.To the Editor. \p=m-\Wewere interested inthe study by Buckley et al1 concerningthe prevalence of anabolic steroid useamong male high school seniors.We believe that, because question-naires were administered by students'homeroom teachers, underreportingmay have been present. Although theauthors contend this is a normal testingenvironment, it is not an environmentconducive to confidentiality regardingpossible unethical or illegal activity.Secondly, we wonder if supplementssold in health food stores and throughmagazines as having anabolic propertieswere differentiated from true anabolicsteroids.Why were high school seniors, identi-fied as the "user group," were greaterthan 19 years old, as these college-ageindividuals are usually not still in highschool?Lastly, we agree that educational in-terventions should begin as early in lifeas possible, but have concerns about theefficacy of such programs. With regardto other preventive measures, such asseat belt use, educational campaigns donot appear effective when comparedwith compulsory legislation with associ-ated penalties.2Our research findings regardingeducational interventions among highschool athletes indicated that these pro¬grams did not alter attitudes regardinganabolic steroid use.3Linn Goldberg, MDDiane L. Elliot, MDEric BosworthThe Oregon HealthSciences UniversityPortland1. Buckley WE, Yesalis III CE, Friedl KE, Anderson WA,Streit AL, Wright JE. Estimated prevalence of anabolicsteroid use among male high school seniors. JAMA.1988;260:3441-3445.2. Orsay EM, Turnbull TL, Dunne M, BarrettJA, Langen-berg P, Orsay CP. Prospective study of the effect of safetybelts on morbidity and health care costs in motor-vehicleaccidents. JAMA. 1988;260:3598-3603.3. Bosworth E, Bents R, Trevisan L, Goldberg L. Anabolicsteroids and high school athletes. Med Sci Sports Exerc.1988;20:3.In Reply. \p=m-\Amselet al make severalobservations that further focus the pub-lic health implications of the nonmedicaluse of anabolic steroids. While the ex-tent of needle sharing among anabolicsteroid users is unknown, we agree thatthis behavior could increase the rate ofhuman immunodeficiency virus infec-tion. In fact, we mention this concern inan article that will appear in the JournalofDrug Education.1Drs Eriksen and Kondo criticize thegeneralizability of our findings to theentire population of adolescent males.In our study, we made every attempt toconsider the characteristics of the sam-pling process as it relates to its repre-sentativeness as well as to the issues ofoverreporting and underreporting. Weacknowledged in our article that thepresence ofa certified athletic trainer asa requisite for a high school to be in thestudy population introduces a potentialbias. However, we contend that thisdoes not represent a severe bias and, onbalance, any bias introduced is morelikely to be on the side of underreport¬ing. For example, in the states wherethe use ofanabolic steroids is consideredhigh based on anecdotal evidence, weexperienced lower participation rates.Also, the premise that schools with ath¬letic trainers may place a higher priorityon athletic performance and achieve¬ment is, in our opinion, based on a mis¬understanding of the role of the athletictrainer in the school athletic environ¬ment. Several school administratorsmentioned that the presence of the ath¬letic trainer was an indication of theirinterest in the welfare of the studentathlete rather than in a successful ath¬letic record. Finally, the rate ofanabolicsteroid use established by our study wasreasonably comparable to several state¬wide studies (as referenced in our arti¬cle) in which the large majority ofschools surveyed probably did not have acertified athletic trainer.Goldberg et al interpreted the natureof our methodology as resulting in anunderreporting of anabolic steroid userather than the overreporting sug¬gested in the letter discussed previous¬ly. However, several participating ath¬letic trainers commented that thehomeroom testing environment wasroutinely used for grade- or school-widetesting procedures, including surveysdesigned to determine alcohol and rec¬reational drug experience. Only oneschool indicated that the method of ad¬ministration of the survey was the rea¬son for their refusal to participate in thestudy; they did not have a homeroomperiod.The suggestion for caution regardinggeneralizability ofour findings is appro¬priate. We view our work as prelimi¬nary; this research was the first nationalstudy in this area. Our feeling is, howev¬er, that our estimates of prevalence ofanabolic steroid use represented a lowerlimit. Clearly, more research is indi¬cated not only on the level of use, butalso on interventional strategies and theidentification of the long-term healtheffects.William E. Buckley, PhDCharles E. Yesalis III, ScDPennsylvania State UniversityUniversity Park1. Yesalis CE, Streit AL, Vicary JR,et al. Anabolic steroiduse: indications of habituation among adolescents. J DrugEduc. In press.Downloaded From: http://jama.jamanetwork.com/ by a Georgia State University User  on 10/13/2015

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