text:
13.2.2017
 DA
 Den Europæiske Unions Tidende
 C 46/28
 Sag anlagt den 28. december 2016 — Winkler mod Kommissionen
 (Sag T-916/16)
 (2017/C 046/33)
 Processprog: tysk
 Parter
 Sagsøger: Bernd Winkler (Grange, Irland) (ved advokat A. Kässens)
 Sagsøgt: Europa-Kommissionen
 Sagsøgerens påstande
 —
 Kommissionens afgørelse af 30. september 2016 vedrørende sagsøgerens klage annulleres og Kommissionen tilpligtes at træffe afgørelse vedrørende beregningen af kapitalværdien på tidspunktet for registreringen af sagsøgerens ansøgning den 14. september 2011.
 —
 Subsidiært tilpligtes Kommissionen at betale en erstatning på 19 920,39 EUR, der skal indbetales på sagsøgerens pensionskonto.
 Søgsmålsgrunde og væsentligste argumenter
 Til støtte for søgsmålet har sagsøgeren anført tre anbringender.
 1.
 Første anbringende vedrørende tilsidesættelse af princippet om, at et søgsmål skal anlægges inden for en rimelig frist og af principperne om retssikkerhed og om en retfærdig rettergang samt tilsidesættelse af forpligtelserne vedrørende information og høring.
 Sagsøgeren har gjort gældende, at Kommissionen ved den langsomme behandling af hans ansøgning har tilsidesat samtlige grundlæggende principper i forbindelse med en behørig gennemførelse af en administrativ procedure. Sagsøgeren blev heller ikke hørt inden vedtagelsen af den bebyrdende retsakt.
 2.
 Andet anbringende vedrørende tilsidesættelse af principperne om ligebehandling, om forbud mod forskelsbehandling og om proportionalitet.
 Inden for rammerne af det andet anbringende har sagsøgeren gjort gældende, at sammenlignelige ansøgninger fra andre kolleger, der ikke er ældre en ham, blev handlet meget hurtigere, selv om der ikke foreligger objektive forhold, der kan begrunde denne forskelsbehandling.
 3.
 Tredje anbringende vedrørende tilsidesættelse af beskyttelsen af den berettigede forventning.
 Sagsøgeren har endelig anfægtet fratrækningen af renter fra den beregnede kapitalværdi for perioden mellem indgivelsen af hans ansøgning og den endelige overførsel af kapitalbeløbet, hvilket sagsøgeren ikke blev gjort opmærksom på forudgående.


type: other

text:
6. Järelevalve lapsi puudutavates menetlustes tehtud otsuste üle ja nende otsuste täitmisele pööramine
 7. Juurdepääs õiguskaitsevahenditele
 8. Lapsendamise, sealhulgas rahvusvahelise lapsendamise kord
 Tsiviilseadustiku üldosa seaduse kohaselt on kõikidel isikutel õigusvõime. Alla 18aastastel isikutel on piiratud teovõime. Kohus võib vähemalt 15aastase lapse piiratud teovõimet laiendada, kui see on lapse huvides ja lapse arengutase seda võimaldab. Eestis on iseseisvalt kohtusse pöördumise vanuse alampiir 15 aastat.
 Kohtusüsteemide kohta saab teavet asjakohaselt e-õiguskeskkonna teabelehelt.
 Kriminaalvastutuse east (14 aastat) nooremate kuriteo toime pannud lastega tegelevad alaealiste komisjonid. Nende komisjonide otsuste peale esitatud vaided vaatab läbi maavanem ja tema otsuste peale esitatud kaebused halduskohus halduskohtumenetluses. Kui asi on olnud kohtu menetluses vähemalt üheksa kuud ja kohus ei ole mõjuva põhjuseta teinud vajalikku menetlustoimingut, on võimalik taotleda sobiva abinõu tarvitusele võtmist. Kui asja arutamine lükatakse poolte nõusolekuta edasi kauemaks kui kolm kuud, võivad pooled selle otsuse edasi kaevata. Kehtestatud on erinormid ajutise õiguskaitse meetmete kohta, mida kohus saab lapse kaitseks ja hagi tagamiseks määrata, ning seadusega on ette nähtud erand erivajadustega laste ülekuulamisest.
 Lastekaitset korraldavad Vabariigi Valitsus, lastekaitse nõukogu, sotsiaalministeerium, sotsiaalkindlustusamet, maavanemad ja kohalikud omavalitsused, kelle ülesanded on sätestatud lastekaitseseaduses.
 Kohtunike koolitust korraldab koolitusnõukogu, mis tegutseb Eesti kohtute seaduse kohaselt Riigikohtu haldusalas. Eesti Advokatuur on Euroopa Advokatuuri liige ja vahetab teiste liikmesriikidega selle kaudu koolitusteavet.
 Lapse huvidele on viidatud paljudes õigusaktides. Lastekaitseseaduses (§ 21) on sätestatud kohustus lähtuda lapse parimatest huvidest kui esmatähtsast kaalutlusest.
 Kuna lastel ei ole menetlusteovõimet, ei teavita kohus neid kohtuotsusest ja selle täitmisele pööramisest isiklikult. Kui kohtuotsus muutub täidetavaks, saab lapse seaduslik esindaja esitada kohtutäiturile täitmisavalduse. Täitemenetlusega seotud teabe edastamist lapsele peetakse seadusliku esindaja kohustuseks.
 Eestis esindavad tsiviilkohtumenetluses osalevaid lapsi nende seaduslikud esindajad, kellest eeldatakse, et nad tegutsevad lapse parimates huvides. Seega võivad lapse seaduslikud esindajad põhimõtteliselt esitada kohtule lapse nimel (hagi)avaldusi ja edasikaebusi ilma lapse nõusolekuta. Seadusest saab siiski järeldada, et laps võib esitada kohtule (hagi)avalduse või edasikaebuse ka iseseisvalt. Üldiselt eeldatakse, et ta seaduslik esindaja liitub sellega kohe. Hagita perekonnaasjades on vähemalt 14aastasel lapsel, kes saab menetlusest piisavalt aru, õigus kohtulahendeid edasi kaevata oma seadusliku esindaja kaasabita.
 Lapsendada sooviv isik esitab maavalitsusele sooviavalduse. Kui maavalitsus on veendunud, et lapsendamise tingimused on täidetud, esitab lapsendada sooviv isik kohtule lapsendamisavalduse. Lapsendamisavaldus esitatakse lapsendatava elukoha järgsele kohtule. Kui lapsendaja või lapse elukoht ei ole Eestis, ei otsusta kohus lapsendamist ilma Eesti Vabariigi Sotsiaalministeeriumis moodustatud rahvusvahelise lapsendamise komisjoni nõusolekuta. Vähemalt 10aastast last võib lapsendada üksnes tema enda nõusolekul.
 Lapsesõbralik õigusemõistmine Eestis (469 Kb)


type: caselaw

jurisdiction: EU

text:
 23.7.2005
 SV
 Europeiska unionens officiella tidning
 C 182/30
 Begäran om förhandsavgörande enligt beslut av Tribunal des affaires de sécurité sociale de Longwy av den 14 april 2005 i målet mellan Fabien Nemec och Caisse Régionale d'Assurance Maladie du Nord-Est
 (Mål C-205/05)
 (2005/C 182/52)
 Rättegångsspråk: franska
 Tribunal des affaires de sécurité sociale de Longwy, Frankrike, begär genom beslut av den 14 april 2005, som inkom till domstolens kansli den 11 maj 2005, att Europeiska gemenskapernas domstol skall meddela ett förhandsavgörande i målet mellan Fabien Nemec och Caisse Régionale d'Assurance Maladie du Nord-Est beträffande följande fråga:
 Har C.R.A.M till nackdel för Fabien Nemec fattat ett beslut som innebär en inskränkning av den i artikel 39 i EG-fördraget stadgade fria rörligheten, ett åsidosättande av förordning EG nr 883/2004 (1) eller ett åsidosättande av artikel 15 i förordning EG nr 574/72 (2), genom att vid beräkningen av det stöd för arbetare som arbetar med asbest, som med stöd av artikel 41 i lag nr 98-1194 av den 23 december 1998 tillerkänts Fabien Nemec, på grund av bestämmelserna i artikel 2 i tillämpningsförordningen för lag nr 99-247 av den 29 mars 1999 samt cirkulär 2SS/4B/99 nr 332 av den 9 juni 1999 inte beakta de löner som Fabien Nemec uppburit i Belgien, på den grunden att dessa löner inte gett upphov till inbetalningar av sociala avgifter i enlighet med artikel L 242-1 i den franska code de la sécurité sociale?
 (1) Europaparlamentets och rådets förordning (EG) nr 883/2004 av den 29 april 2004 om samordning av de sociala trygghetssystemen (EGT L 166, s. 1)
 (2) Rådets förordning (EEG) nr 574/72 av den 21 mars 1972 om tillämpningen av förordning (EEG) nr 1408/71 om tillämpningen av systemen för social trygghet när anställda eller deras familjer flyttar inom gemenskapen (EGT L 74, s. 1; svensk specialutgåva, område 5, volym 1, s. 106)


type: wikipedia

text:
Il-Fajl tal-Awtorità Internazzjonali Virtwali magħruf ukoll bħala Virtual International Authority File (VIAF) huwa fajl tal-awtorità internazzjonali. Huwa proġett konġunt ta' bosta libreriji nazzjonali li huwa mħaddem mill-Online Computer Library Centre (OCLC).
 Storja
 Diskussjonijiet dwar il-bżonn ta' awtorità internazzjonali komuni bdew lejn tmiem is-seklu 19. Wara sensiela ta' tentattivi falluti biex joħorġu b'fajl uniku ta' awtorità komuni, kien hemm qbil biex jintrabtu l-awtoritajiet nazzjonali eżistenti. Dan għaliex b'hekk il-benefiċċji kollha ta' fajl komuni jinżammu mingħajr il-bżonn ta' investiment kbir f'dak li huma ħin u spejjeż.
 Il-kunċett VIAF ġie introdott fil-Kungress Dinji tal-Libreriji u l-Informazzjoni fl-2003, li kien ospitat mill-Federazzjoni Internazzjonali tal-Assoċjazzjonijiet tal-Libreriji (IFLA). Il-proġett inbeda mill-Library of Congress tal-Istati Uniti (LC), il-Librerija Nazzjonali Ġermaniża (DNB) u l-OCLC fis-6 ta’ Awwissu 2003. Il-Bibliothèque nationale de France (BnF) ingħaqdet mal-proġett fil-5 ta' Ottubru 2007.
 Il-proġett għamel tranżizzjoni għal servizz tal-OCLC fl-4 ta' April 2012.
 L-għan huwa li l-fajls tal-awtorità nazzjonali (bħall-Fajl tal-Awtorità tal-Ismijiet Ġermaniż) jintrabtu ma’ fajl tal-awtorità virtwali wieħed. F'dan il-fajl, rekords identiċi mis-settijiet ta' data differenti huma marbuta flimkien. Rekord VIAF jirċievi numru ta’ data standard, fih ir-rekords primarji "ara" u "ara wkoll" mir-rekords oriġinali, u jirreferi għar-rekords tal-awtorità oriġinali. Id-data ssir disponibbli onlajn u hija disponibbli għar-riċerka u l-iskambju u l-kondiviżjoni tad-data. L-aġġornament reċiproku juża l-Open Archives Initiative Protocol for Metadata Harvesting (OAI-PMH).
 In-numri tal-fajls qed jiżdiedu ukoll ma' artikli bijografiċi tal-Wikipedija u huma inkorporati fil-Wikidata.
 Christine L. Borgman torbot il-VIAF mal-International Standard Name Identifier (ISBN) u l-ORCID, u tiddeskrivi dawn t-tliet sistemi bħala "loosely coordinated efforts to standardize name forms". Borgman tikkaratterzza dawn it-tliet sistemi bħala tentattiv biex tissolva l-problema ta' diżambigwità fl-isem tal-awtur, li kibret sew hekk kif żdied l-ammont ta' data. Hija tenfasizza l-fatt li kuntrarjament għaż-żewġ sistemi l-oħra li huma mmexxija minn individwi, il-VIAF hija mmexxija mil-libreriji.
 Ġabriet tal-VIAF
 L-algoritmu tal-ġbir tal-VIAF jitħaddem darba fix-xahar. Hekk kif aktar data tiddaħħal minn libreriji li jipparteċipaw f'din is-sistema, ġabriet ta' aktar dettalji tal-awtorità jafu jingħaqdu jew jinqasmu, b'konsegwenza li l-identifikatur tal-VIAF ta' ċerti entrati partikolari jista' jvarja xi ftit.
 Referenzi
 Ħoloq esterni
 Sit web uffiċjali
 VIAF tal-OCLC
 Pubblikazzjoni
 Kotba
 Identifikaturi


jurisdiction: US

text: b'"\'-\n\n\n\n\n 0eparment of Health and Human Services\n\n OFFICE OF\n\n INSPECTOR GENERAL\n\n\n\n\n\n ADOLESCENT STE. ROID USE\n\n\n\n\n f.tlVICES\'\n\n\n\n Richard P. Kusserow\n\n\n Jr\n INSPECTOR GENERAL\n\n 1-\n FEBRUARY 1991\n lt"d3a\n\x0cDeparment of Health and Human Services\n\n OFFCE OF\n\n INSPECTOR GENERAL\n\n\n\n\n\n ADOLESCENT STEROID USE\n\n\n\n\n\n f.tlV\'(,t$.\n\n\n Richard P. Kusserow\n INSPECTOR GENERA\n OEI- 06-90- 01080\n "dia\n\x0c EXECUTIVE SUMMARY\n\n PURPOSE\n\n To describe the non-medcal. use of steroids by adolescents and to suggest appropriate education\n or intervention strategies as well as aras neeg furter research.\n\n\n BACKGROUND\n\n. Anabolic-androgenic steroids (" steroids ) are synthetic derivatives of the natial male hOrmone\n testOsterone. Most who use steroids for non-medcal reasons want to maimize the anabolic\n (growth) propertes in order to improve their muscularty, strngth, appearce, and/or capacity\n to trai. Steroids do not produce an immedate euphoria at the tie of use. Steroids are\n administered either oraly or by injection. Many users tae more than one steroid at a tie\n (stacking) for several months (cycles) and usually in dosages that gratly excee the therapeutic\n amounts.\n\n Steroid possession and distrbution for non-medcal puroses are ilegal under Federa law.\n Since the 1950\' s world class and professional athetes have used steroids to enhance their\nperformce, but more recently evidence has shown high school, and even junior high school\nstudents also use steroids. At the same time researchers ar discovering the potential for serious\nhealth risks associated with steroid use.\n\nThis i spection focuses on non-medical steroid use by adolescents accordng to the National\nInstitute on Drug Abuse (NA), professional literatu, 30 key inormants knowledgeable in\nsteroid issues, and 72 curnt or former steroid users. Findigs from our companon study on\nadolescent steroid users ar avaiable in a separte repon entitled "Adolescents and Steroids: A\nUser Perspective, " OEI 06- 90- 01081.\n\n\nFINDINGS\n\nOver One-Quarter Million Adolescents, Primtriy Mals, Use Or Have Used Steroids, And\nTheir Numbers Are Growing.\n\nThe NIDA reponed 3 percent of the Class of 1989 (4. 7% maes and 1.3% females) had used\nsteroids in their lifetie. Other smaler studies show higher rates for males. Our key informants\nagree that 5 to 11 percent is an accurate range of male use, but they also say the usage rates are\nmcreasmg.\n\x0cAdolescent Steroid Use Starts Early And Often Follows A Prolonged, Intense Pattern.\n\n The data also show that over hal the adolescents who use steroids have tred them for the fIrst\n time by age 16. The majority of our sample ar " heavy " users who incrased steroid dosages,\n variety, and cycle length over time.\n\nAdolescent Steroid Use Is Motivated By Socially Acceptable Values And Life-Stage Concerns\nWith Appearance And Peer Approval.\n\nKey informants say steroid users, in general, ar highly motivated people who tr intensely to\nimprove themselves or to achieve a positive goal and who believe they are health conscious.\nAdolescents, typically very concerned about their appearance and peer approval, use steroids\nprimary to improve athletic performance and appearance. Key informants and users believe\nthat steroids work to produce the physical effects adolescents desire. Furermore, adults and\nfamous role models inditly reinforce adolescent steroid use; non-using peers don t discourage\nuse.\n\n\nAdolescents Are At Special Risk For Some Adverse Result Of Steroid Use.\n\nKey informants believe adolescent users are more susceptible to the health risks of stuted\ngrowth and adverse psychological effects including dependence. Data also suggest steroid use\nencourages adolescents to tr other drgs for enhancing performance and counterig the side\neffects of steroid use.\n\n\n\n\nAlthough Much Remains Unknown, Experts Link Steroid Use To Serious Psychological And\nPhysical Health Risks. \n\nProlonged use of steroids concerns our key informants because of what they do and do not know\nabout their effects. Most prect that, if an adolescent uses steroids for one six-week cycle. he\nwil go on to heavy use that could possibly last for year. Intact, may of our users self-repon\naddictive thinng or behavior. The key informants li many adverse physical and\npsychological effects to steroid use.\n\nExperts Recommend Educaton Of Adolescents And Adults As The Best Solution To The\nSteroid Use Problem.\n\nExpens do not believe adolescents ar well awar of the potenti risks of steroid use nor is\nawareness a deterrent to use. Our key infonnants say, neverteless. education is the most\neffective means of deterrg use. Honest. early. repeated and clear messages concerng steroid\nuse to adolescents and responsible adults wil improve steroid education progrs.\n\n\n\n\n . ii\n\x0cTesting And Controlled Substance Status Are Potential Deterrents To Non-Medical Steroid\nUse.\n\nMany key informants suppon drg testing as a deterrnt to adolescent steroid use, but the cost is\na serious drwback. Some object to testing for legal or philosophical reasons. Limiting the\nblack market supply could help contrl steroid use. Makng steroids a controlled substace is\nseen as beneficial, but perhaps not the only enforcement effon needed.\n\n\nRECOMMENDATIONS\n\nDevelop A National Steroid Education Strategy.\n\nThe Deparent should develop a national education strategy to increase adult and adolescent\nawareness of the problem and to provide educational guidelines for local progrs. An effective\nprogr involves more than merely presentig informtion about the effects of steroids. The\nmessage for adolescents must come early and be reinforced in an honest. consistent way from\ntheir peers and responsible adults.\n\nConduct Further Medical And Scientific Research.\n\nThe Deparent, through the Public Health Service. should tae the Federal lead in expandig\nour understading of the motivap.ons for and health risks of non-medcal steroid use as a basis\nfor informed policy decisions.\n\n\nCOMMENTS\n\nWe reeived Deparnta comments on the dr repon frm the Offce of the Assistat\nSecretar for Planning and Evaluation (ASPE) and the Public Heath Servce (PHS). Both the\nASPE and the PHS generally agrd with the repon.\n\x0c ........................\n ................ ...... .......... ........\n .... ..........\n ................ ............................\n ..............\n ........ ..............\n .... .......... ................\n ....................\n .......... ............\n ...... ................................\n .................... .......................... ..............\n ......\n ...... ........ ......................\n ..........\n ..........\n ....\n ...... ............\n ......\n ........ ....\n ..........\n ....\n ........ ....\n .........\n ..........\n ...... ..........\n ........\n ..........\n .... ....\n ............ ....\n .......\n\n\n\n\n TABLE OF CONTENTS\n\n EXECUTIVE SUMMARY\n\n\n INTR 0 D U CTI 0 N ..............................................................................................................\n\n\n Purpose........................................................................................................................\n\n\n Back gronD d.......... ...... .................... \n\n\n Met hod 0 logy............ .................... .... \n .................................. .... ......00.. \n\n\n\n\n\nFIND IN G S\n\n Over One-Quarter Millon Adolescents, Primarily Males, Use Or Have\n Used Steroids, And Their Numbers Are Growing........................................\n\n\n Adolescent Steroid Use Starts Early And Often Follows A Prolonged,\n In tense Pa ttern ........ ...... \n\n\n Adolescent Steroid Use Is Motivated By Socially Acceptable Values And\n Life- Stage Concerns With Appearance And Peer Approval .............................\n\n Adolescents Are At Special Risk For Some Adverse Results Of Steroid Use......\n\n Although Much Remains Unknown, Expert Link Steroid Use To Serious\n Psychological And. hysica1 Health Risks ................................................................\n\n Experts Recommend Education Of Adolescents And Adults As The\n\n Best Solution To The Steroid Use Problem .............................................................\n\n\n Testing And Cuntrolled Substance Status Are Potential Deterrents To\n\n Non - M edi cal Steroi d Use.... ........ ........ ................................ ...... .........Ot!... \n\n\nREC 0 MMEND A TI 0 NS .................................................................................................\n\n\n Develop A National Steroid Education Strategy..........................................\n\n\n Conduct Further Medical And Scientifc Research .....................................\n\n\nCO MME NTS ............ ............ .......... .... ...... .......... ........ \n\n\nEND NOTE S.. ....\n\nBIB L lOG RAPH Y .... .......... ............ ........ .......... .......... .... .......... \n\n\x0c ..............................................................................\n\n\n\n\nAPPENDIX A: Key Informant Interviews ............................................................... . 1\n\n\n\nAPPENDIX B: Steroid User Interviews.................................................................... - 1\n\n\n\nAPPENDIX C: Steroid Incidence of Fir t:Use ................................................ C -\n\n\nAPPENDIX D: Estimate of Student Steroid Use by Grade............................ D -\n\n\nAPPENDIX E: Departmental Comments. ................................................................ . 1\n\n\n\nAPPENDIX F: Public Comments F - 1\n\n\x0c INTRODUCTION\n\nPURPOSE\n\nTo describe the non-medical use of steroids by adolescents and to suggest appropriate education\nor intervention strategies as well as areas neeg furter research.\n\n\nBACKGROUND\n\nAnabolic-androgenic steroids (" steroids" ) ar synthetic derivatives of the natual hormone\n male\ntestosterone. The androgenic effects of testosterone ar incrased aggressiveness, the growth of\nthe male reproductive tract during adolescence, and the development of seconda male\ncharacteristics such as increased body/facial hai. The anabolic effects ar the retention of\ndietar protein and increased muscle mass. An effect durng pubert is the s ulation of long\n l closure.\nbone growth with subsequent epiphyseal Although separting the androgenic and\nanabolic effects is diffcult , most who use steroids for non-medcal reasons waIt to maximze the\nanabolic propertes to improve their strngt, appearce, and/or capacity to tr.Unlie\n recrational" drgs, such as cocaine, steroids do not produce an imedate euphoria at the time\nof use.\n\n\n\nUse in combinations and cycles\n\nSteroids ar admnistere either orally or by injection. A common practice f no!)-medical use is\nto " stack" steroids, i.e., to combine severa steroids, usually at least one ora and one injectable,\nin an effon to saturate receptors that can stimulate growt. Dosages often gratly excee the\nusual therapeutic amounts and may include products intended for veteri use;" Some users\n cycle " the drgs by takng them for 4 to 18 weeks, then discontinuig them for several months;\nothers tae steroids continuously.\n\nIllegal activi increases\n\n\n for non-medcal purses is ilegal under Fedral law. The\nSteroid possession and distrbution\nFood and Drg Admnistrtion (FA) has approved steroids as drgs which may be prescrbed\nonly by a licensed physician for specifc puroses. Steroids have lite approved uses, such as\nthe treatment of cenain anemias, breast cancer, male hypogonadsm , and delayed adolescence in\nboys. Congress passed the Anti-Drug Abuse Act of 1988 which includes several provisions to\ncontrol the distrbution of steroids for non-medical purposes. For a limited time in 1989 the\nOffice of Inspector General (OIG) was delegated the authority to conduct investigations of\nilegal distrbution of steroids. In November 1990 steroids were added to Schedule II of the\nFedera Controlled Substaces Act, makng steroid distrbution and possession without a\nprescription ilegal. 2\n\n\n\n\n nal!e 1\n\n\x0cThe non-medcal use of steroids is not a new issue, but the user population seems to be\nexpanding. Beginning in the early 1950\' s steroid use appear confIned to world class and\nprofessional athletes, but more recently, steroid use has incrased signifIcantly among amateurs.\nIn December 1986, for example, 26 college football players, from at least 7 universities, were\nbard from post-season bowl games after testing positive for steroids. Evidence has shown that\nhigh school , and even junior high school , students also use steroids.\n\nSerious health risks suggested\n\nAt the same time, researchers ar discovering the potential for serious health risks of steroid use.\nNo systematic studies of the health risks to athletes or body builders, who use steroids at higher\nthan therapeutic doses, have been conducted. Health risk data do exist, however, from medical\ncase studies and from a limited number of case repons on athletes. Suggested side effects range\nfrom acne or fluid retention to mood swings, tempora sterility, cardiovascular disease, and\nliver disease. Some risks may be even grater for adolescent users because of their\ndevelopmenta stage. Since some steroids ar injected, researhers suggest an incidental health\neffect of steroid use may be contrcting AIDS though the shared use of contanate needles.\n\n\nMETHODOLOGY\n\nThis inspection focuses on non-medcal steroid use by adolescents accordig to four major\nsources: the National Institute on Drg Abuse (NA), professional and origial research\nliterature, interviews of 30 key informants knowledgeable in steroid issues, and interviews of 72\ncurrent or former steroid users. Since sci ntifIc inquir in the study area has been limted,\nfIndings ar based on the compilation of the best available research information frm NIDA and\nother professional sources and of anecdotal data we gathere from key informants and users.\n\nEach year NIA sponsors a national high school senior surey (1). In 1989, for the fit tie,\nthe surey included questions concerng non-medcal steroid use. We examed the preliar\ndata on national steroid use as reported by the high school clas of 1989. We also completed a\ncontent analysis of the reent literatue (se Bibliogrphy). This analysis examned\nincidence/prevalence of steroid use, motivations for adolescent use, use patterns and trends,\nhealth risks associate with steroids, and education/intervention strategies.\n\nWe collected data from 30 well-known key informants by using in- depth, strctured interviews.\nWe selecte these respondents based on their promience in professional or research literature\n(16 had wrttn material we used for our content analysis), their professional afliations, or\nrecommendations by other key informants. Their aras of expertse ar medcine, education\nsubstace abuse , drg testing, spons, and/or coaching (see Appendi A for a complete listing).\nThey have been involved with the steroid issue in some way for 8 years, on average.\nTwenty-seven have personal contact with current or former steroid users in varous age groups\nand levels of athletic competition.\n\nWe also collected detaied data on use patterns and motivations from 72 steroid users (55 current\nand 17 former). We contrcted with three key informants to complete confidential, in- depth\n\n\n e2\n\x0cinterviews using our instrment (see Appendix A). The curent or former users, selecte\njudgmentaly by the interviewers, met three crteria: 1) age 25 or younger at the time of the\ninterview, 2) initiated steroid use in high school or younger, and 3) completed at least one steroid\ncycle of 6 weeks or longer (see Appendix B). Detaled fIndings from these interviews are\npresented in a separte repon entitled " Adolescents and Steroids: A User Perspective, " OEI\n06-90- 01081.\n\n\n\n\n na!!e 3\n\n\x0c FINDINGS\n\nOver One-Quarter Milion Adolescents, Primarily Males, Use Or Have Used Steroids, And\nTheir Numbers Are Growing.\n\n Mounting evidence indicates signifcant numbers of adolescents use steroids.\n\nThe NIDA survey, the only national data base in this study area, reported 3 percent of the Class\nof 1989 had used steroids in their lifetime. Three earlier studies of high school students, not\nnationaly representative, showed similar rates ranging from 3 percent to 5. 7 percent (see Table 1\non page 4). In 1988, Willam E. Buckley et al. reponed 6. 6 percent of male high school seniors\nuse or had used steroids in their lifetime (2).\n\nUsing the NIDA lifetime incidence of 3 percent, we can estiate that 83,430 students from the\nClass of 1989 used steroids at some time.\n 3 Furer, we calculate approximately 262 000\nstudents in grades 7 to 12 in 1989 used or had used steroids. Buckley et al., at a 6. 6 percent\nincidence for males, estimated 2?0, 000 to 500, 000 male adolescents in secondar schools\nprobably use or have used steroids.\n\nSome key infonnants suggest, however, these rates may be unden-eponed. The NIDA data, for\nexample, do not include information from school drop-outs. Dr. Charles Yesalis, a steroid\nresearcher, said that the secrecy involved in steroid use is so great that it must be a\nmethodological consideration when designing steroid studies (3).\n\n Usage rates are much higher for adolescent mals thanfemaIes.\n\nThe NIDAdata show, as do\nother studies, that adolescent TABLE 1\nmales use steroids at a Summary of Steroid Usage Data\nhigher rate than adolescent\nfemales. The rage is 4. STUDY GRADE TOTAL MALE FEMALE\npercent to 11. 1 percent for\nmales and only 0. 5 percent NIA - 1990 1.3\nto 2. 5 percent for females\n Buckley et aI. - 1988\n(see Table 1). Two- thirds of\n Johnson et aI. - 1989 11.\nthe key informants agree 5\npercent to 11 percent of high WindsorlDumitr - 1989 9 - 12 1.4\n\nschool males have used Temey/McLan - 1990 9 - 12 4.4\nsteroids. No one thought * Percent of adolescents who use or have used steroids\nthis range was " very high"\nOther studies show that\nmale users are usually\nathletes with 65 to 84 percent parcipating in spons (4). Ninety-six percent of our users were in\na competitive spon or weight-trining program at the tie they began steroid use.\n\n\n page 4\n\x0c" , \n\n\n\n\n\n Adolescent steroid use is growing according to key informants and users.\n\n Overall , both key informts (67%) and users (93%) believe steroid use is increasing among\n senior high school students. Supportng evidence com s from Portand, Oregon where\n researhers evaluated high school varsity football players over the thee academic years of 1987\n to 1989. In that brief time, the percentage of self-reponed steroid use more than trpled, rising\n from 1.1 percent to 3. 8 percent (5). Key informants (60%) and users (57%) also believe use is\n rising among junior high school students although both groups ar less sure of the use trend for\n younger students. Inclusion of steroid use questions in subsequent annual NIDA high school\n senior surveys wil yield trend data for both junior and senior high school students.\n\n\n Adolescent Steroid Use Starts Early And Often Follows A Prolonged, Intense Pattern.\n\n First use occurs by age 16 for over half the adlescents who try steroids.\n\n Many adolescents, who use steroids, have tred them for the fIrst tie by age 16. Fifty- the\n percent of our user sample repon they had staed at age 16 or younger; 85 percent had staed by"\n age 17. NIA reponed that 56 percent of the male users fit tred steroids by 10th gmde (age\n 15 to 16) or younger (see Appendi C). Another 22 percent had staed use by 11th grde (age\n 16 to 17) for a cumulative rate of 78 percent. The female incidence of fIst use follows the same\n pattern. The Buckley et al. data for males trcks our user data and NIA\' s and shows 71.3\n percent stared by age 16.\n\n\n\n Adolescents appear at riskfor heavy, prolonged use.\n\n Twenty-six key informants (87%) predct that an adolescent user who completes one 6-week\n steroid cycle is likely to go on to use for 5 cycles or more. Five cycles is a signifcant number\n because for some researchers it marks the beging of "heavy " steroid use (6). Furer, once\n users crss the 5-cycle mark, many key informants believe they wil contiue use for years \xc2\xad\n afterwards.\n\n Most users in our sample ar " heavy " users accordig to ths researh definition. Six.ty.;five\n 5 Their\n percent of users repon they have taen steroids for fIve cycles or more in their lifetie.\n lifetime average is eight cycles. The average length of their last completed cycle is 11 weeks.\n Curnt users sta tag steroids 3 years ago on average; 35 percent have used steroids for 4\n years or longer. Eighty-six percent have no definite plans to stop using.\n\n Many users increase steroid dosages, variety and cycle length over time.\n\n Most of our users also say they progressively intensifed their steroid use. Over time they used\n larger dosages (89%), increased the number of different steroids per cycle (72%), lengthened\n their cycles of use (64%) and shonened the time between cycles (65%). Other signs of their\n intense steroid use ar: 1) steroid doses gratly exceed the norm therapeutic levels, 2) 99\n\n\n\n n31!e 5\n\x0c ... .,\n\n\n\n\n percent of the users inject steroids, and 3) users combine an average of 5 different steroids in one\n\n cycle.\n\n\n\n Adolescent Steroid Use Is Motivated By Socially Acceptable Values And Life- Stage\n Concerns With Appearance And Peer Approval. \n\n\n Key informants perceive that steroid use, in genera, is uniquely motivate by values society\n normally considers " goo" . They think adolescents may be more vulnerable to steroid use\n because of these societa values and their own strong concerns about appearce and peer\n approval. Although the percentage of adolescents who use or have used steroids is low\n compard to some other drgs,\n 6 nearly two- thirds of the key informts still ra\n non-megical\n steroid use as a major (27%) or moderate (37%) problem precisely because these values and\n\n concerns lead adolescents to steroid use.\n\n\n Steroid users have more positive motivatons than other drug users.\n\n Twenty-tWo of 29 key informants charcterize steroid use as a unique substace abuse problem.\n- . They describe steroid users, in general, as highly motivated people who are trg to improve\n themselves or to achieve a positive goal. They want to be better athetes, even champions; they\n want to look bettr. Steroid users believe that they tae car of their bodes and that they are\n health conscious.\n\n Unlike other drg users, who frequently have negative or no goals, steroid users do not seek to\n escape reality or to attn instat gratifIcation. In fact, steroids do not produce an immedate\n\n euphortadt the time of use. Athletes and appearance conscious individuals know they must trRc.\n\n intensely to reach their goals, and they ar wiling to mae that effon. They see steroids as a\n\n way to" i1ppioach their goal faster or to attn an even higher level of performance. If there isa\n \'"C\n\n\n negative motivation underlying steroid u se, it is " an over-reliance on physical attbutes for\n\n obtaining a sense of self-wort. " (7)\n\n\n\n Adolescent concerns with appearance and peer approval motivate their steroid use.\n\n For adolescent males, muscularty and strngt are tWo key ingrents of their perceived\n\n success and favorable self-esteem. Appearance is also an importt factor. The users, key\n\n informants and literature all say the desire to do well in sport, or its varations of increasing\n\n strengt, size and spee, lead adolescents to steroid use. Al the key inormants and nearly\n\n two- thirds of the users also repon improving appearce as a reason for stang steroid use.\n\n Matching perceived use by competitors was also mentioned often by both groups. However,\n\n while all the key informants say moneta rewars, such as scholarhips, ar a motivation to use\n\n steroids, only 24 percent of the users repon this reason. More compellng to them is the desire to\n\n be happier or like themselves better (53%).\n\n\n Peer group involvement is very imponant during adolescence. In fact, peers are listed the most\n\n frequently by our key informants as the key influence on adolescents to use steroids. The users\n\n\n\n\n page 6\n\x0cstrongly agr saying they were influenced to begin steroid use priary by frends or athletes at\nthe gym where they work out (53%) and by school frends (40%). In most cases, the frend was\na user who had achieved the results that our respondent desired. Furter, non-parcipating peers\ndon t discourage use. Seventy- three percent of our users agr with the statement, " My friends,\nwho don t use steroids, don t car if I use.\n\n Steroids work, producing physical and other effects that adolescents desire.\n\nAlmost all of our key informants believe that steroids do produce the effects adolescents\nperceive as benefIcial. In combination with a proper regimen of traiing and nutrtion, they say\nsteroids are effective for incrasing muscle mass (97%), strength (97%) and traiing capacity\n(93%). Most also believe steroids and a proper regimen increase spee (67%) and enhance\nsexual capacity or enjoyment, at least initially (57%). They agree steroids do not increase\ncardiovascular endurance (60%) or prevent injuries (80%). In addition, the American College of\nSpons Medicine, which does not advocate steroid use, offcialy concedes that concurent use of\nsteroids with proper training and diet may enhance performce.\n\nCurrnt and former users strongly agr that steroids work. Sixty- four users (89%) report they\ngot the results they hoped for when they staed using and noxe they "realy improved\nphysically. " They cite large, measurble gains in weight, muscle mas and definition, strengt\nand athletic accomplishments. Among users who achieved the desir results, 97 percent agre\nthat the physical effects encouraged them to continue using steroids. Improved appearance and\nincreased sexual drve, prowess or pleasure are examples of unexpecte benefits mentioned by\n43 percent of users. Although former users are less enthusiastic, most curent users believe the\nemotional and social benefits of physical improvement are gettng along better with others,\ngreater satisfaction with life and being liked better by their pe. rs;- ,\n\n Adults andfamous role models also reinforce ster i4 U$e;\n\n\n\nKey informants also believe responsible adults, in addition to peers, inuence steroid use. They\nlist parents, coaches/trers, successful athletes or entertptpersonalties that act as role\nmodels, and society in genera as sources of influence or pres ure for an adolescent. They say\nthat, whether intentional or not, parnts and coaches place grat pressur on young people to\ncompete and wi, while sendig a mixed message of what are acceptable ways to accomplish\nthat goal. At other times the message is clear that using steroids to enhance performance is\nacceptable when our society prases winning, accords athletes special tratment, and overlooks\ntheir transgressions.\n\nThe users \' responses indicate that adults indictly encourage adolescent steroid use by sending\nmixed messages. Fifty-fIve percent agre with the statement "My parnts probably know I use\n(or used) steroids, " although 93 percent also agree that "My parnts believe gettng good grades\nis more imponant than winning at sport. " Only 59 percent say goo grdes are more imponant\nthan winning at their schools. Of the 41 users who have coaches, 61 percent disagree with the\n\nstatement, " My coaches really believe that steroid use is a bad idea. " However, our users seldom\nassociate adults they know personally with motivation to begin steroid use: non-school\n\n\n\n page 7\n\x0ccoach/trner (15%), school coach/trainer (6%), personal doctor (6%). No one repons parents as\na motivation.\n\nFamous role models also influence adolescents. The users believe that may high- level athletes\nhave used steroids, and 42 percent say this influenced them to sta using. Fifty-seven percent\npointed to " muscle magaznes " and seven percent to entenanment personalties as source\ninfluence.\n\nA researcher/physician aptly summazes the interplay of societa influences and values on a\npotential adolescent steroid user. \n\n\n Young males with a tendency towards high risk behaviors, for whom\n physical attributes have a high personal value, ma be at most riskfor\n initial use. Social influences from peers, coaches, trainers and family\n as well as prevailng cultural values to compete, to win, to look\n good, and to be big and powerfl probably also contribute to initial\n use. (7)\n\n\nAdolescents Are At Special Risk For Some Adverse Results Of Steroid Use.\n\n Key informants believe adlescent users are more susceptible to some health effects.\n\nTwenty-seven of 30 key informants believe that adolescents who tae steroids, as opposed to\nadults, ar at special risk for adverse results. Twenty say they are most worred about stunted\ngrowth and adverse psychological effects including dependence. dolescent steroid use may\nhinder long bone growth and the subsequent epiphyseal closure at pubeny. Furer, the\ndeveloping adolescent may be especially vulnerable to the psychological effects of steroids, such\nas the possible drg- induced moo changes (8). Our key inormts ar also concerned\ngeneraly about the potential for serious health risks of steroid use which we discuss in detal\nbeginning on page 9.\n\n Steroid use encourages adolescents to tr other drugs.\n\n\nThe key informants and literatu suggest steroid use leads adolescent users to other drugs.\nTwenty- thee of 30 key informants believe that other drgs taken to enhance performce\n(human growth hormone, amphetanes, eryopoietin) also have the same abuse potential as\nsteroids, assuming cost and availabilty are not prohibitive. Nearly hal of our key informants\nthink it is liely that adolescents can also obtain marjuana and cocaie from their steroid source.\nIn addition, handbooks available to adolescents suggest ways to counter the side effects of\nsteroid use with other drgs often available on the black market, e. g., estrogen inhibitors for\ngynecomastia, diuretics for fluid retention , human chorionic gonadotropin (HCG) to stimulate\nnatura testosterone production (8).\n\n\n\n\n page 8\n\x0c , "\n\n\n\n\n\nOur userdata suppon the key informants and the literature. Fort-four percent of the users\nconsult a user s handbook for steroid information, apparntly the same handbook that discusses\ncountering the side effects of steroids. Afterstag steroids, 49 percent of the users staed\nother drgs for peIformance enhancement or for counterig the side effects of steroid use.\nExpressed as a percentage of all sampled users, they added estrogen inhibitors (31 %), HCG\n(22%), diuretics (17%), " uppers " including amphetanes (17%), pain-killers (15%) and\nrecreational drgs other than alcohol (11 %).\n\nBefore stang steroids, nearly two-thirds of the users repon drg use, but of a diferent type.\nThey used alcohol (65%), marjuana (26%) and nicotie (14%). A few mention " uppers " (4. 2%)\nand pain- killers (1.4%). None repon use of diuretics, estrogen inhibitors or HCG.\n\n\nAlthough Much Remains Unknown, Experts Link Steroid Use To Serious Psychological\nAnd Physical Health Risks.\n\n Key informants emphasize they do not understand enough about the effects of steroid\n use.\n\nSixty- fIve percent of our key informts feel that expen understadig of the shon-term effects\nof steroid use is " goo" or " very good." On the other hand, 96 percent say expen understading\nof the long-term effects of steroid use is " fai" to " very poor. " Many strongly favor fuer\nsystematic medcal research of steroid effects as an underping for well-conceived educational\nprogrs and futue legislation to control steroid distrbution and use. A common sentiment of\nresearchers and physicians is It would be a waste of money to put more effon into seeing if\nsteroids work. We need other knowledge (about shon- and long-term) effects urgently. " (3)\n\nWe asked our physician/rescariTer group whether, in their professional opinon, short-term\nsteroid use (less than one year) or long-term use is lied either strngly, weaky or not at all to a\nwide varety of adverse heath effects. Many perceive lis but carfuly qualify their answers\noveral or by each health effect being rated A summa statement from other researh that well\ndescribes their qualifcations also is,\n\n The preserzce and magnitude of anaolic or androgenic effects and\n complications of steroid use depend on the specifc drugs taken, the size\n and frequency of doses, the duration of use, the route of administration,\n and the age and health of the user. Individual responses to diferent\n steroids vary. Acute, life threatening side effects are exceedingly rare.\n Long-term deleterious effects are unknown. (8)\n\n The risk of steroid addiction is of partcular concern for adolescent users.\n\nAddiction to a substance can be a psychological and/or phy ical dependence. Many key\ninformants believe adolescents who use steroids ar at a special risk for adverse psychological\neffects. In fact, the physician/researcher group, when rankig the health risks of steroid use\n\n\n\n page 9\n\x0crepon, in their judgment, a strong link, for shon-term and long-term use, between steroid use and\npsychological dependence. To date, researh has not shown a link between steroid use and\nphysical dependence, but may key informants frm the physician/researcher group believe\nphysical dependence is a potential effect. Although not yet conclusive by the stadads of\nscientifIc research, in our opinion, suffcient evidence does exist in literatur to rase the serious\npossibilty that steroids ar addictive.\n\nBuckley et al. describe the intensity and pattrn of steroid use by 226 adolescent males (2).\nThiry-eight percent fIst used steroids at age 15 or younger; another 33 percent had staed by\nage 16. Fony percent of the users reponed 5 cycles or more of use. Fort-four percent took\nmore than one steroid at a time; 38 percent used both ora and injectable forms of steroids. They\ncommented, "When one considers (this data), it is clear that the potential for the development of\nlong-term use patterns is real.\n\nTo develop the dependence issue, Dr. Charles Yesalis, a principal investigator of the Buckley et\nal. research team, funher analyze the surey data (6). One- quaner of the 226 self-reponed\nusers, when faced with health risk scenaros related to steroid use, state their intentions to\ncontinue use regardless of die health consequences such as permanent sterity, hean attcks or\nliver disease. He al so noted their use of injectable steroids indicated " an increased level of\ncommitment. " Sixty- thre percent of the early initiators reponed 5 cycles or more and were\nmore likely to exhibit symptoms consistent with habituation: unwilngness to stop use,\nperceptions of benefIts of use, rationaliztion of use and overlooking of health risks.\n\nPsychiatrst Kik Brower has also studied the issue of steroid addction. He believes that the\nadolescent users in the Yesals analysis above show evidence of addctive\n possibly\n thg\n dependent (7).\n and that up to\n In another\n25 percent of adolescent steroid users - at a given tie ar\nwork Brower et al. interviewed 45 weightlfters who admtted steroid use for a mean of 26\nmonths (including time between cy,; es) and with a mean of 2. 8 dierent steroids at one tie,\nexceeding therapeutic doses (9). A self- adnistere questionnai elicite informtion\nstandard symptoms of dependence.\n 8 At least one dependent symptom was reponed by 93\npercent Thee or more symptoms, consistent with a diagnosis of chemical dependency, were\nreponed by 58 percent.\n\n Many steroid\' users in our sample exhibit adctive thinking or behavior.\n\nBy applyig the addiction crteria from the literature to our self-reponed user data, we find\nevidence of addictive thinking and behavior. As we have seen, their use patterns are long and\nintense, i.e., 65 percent have used for 5 cycles or more, 86 percent tae 3 or more steroids at a\ntime, 91 percent use both ora and injectable steroids. Funermore, quittng steroid use does not\nappear likely for many current users: most have no definite plans to stop using steroids (86%),\nmany would not stop even if others do (78%), and they wouldn\' t stop use even if they were\nconvinced steroids are really bad for their health (38%). One- quaner of curnt users tred to\nquit but couldn\' t (9%), quit use completely for a while but stard again (22%) or did both.\nFunher, nearly all say starng steroid use was a goo decision (93%) which they would repeat if\nthey had to decide again (87%).\n page 10\n\n\x0c The users also seem to over- look or rationalize the effects of steroid use. Fifty-three percent say\n they got along better with others while using steroids, but the same users also say they had more\n arguments or physical fIghts. Twenty- fIve percent sold steroids to pay for their own. Eighty-two\n percent of CUITent users (but only one former user) disagre with medical expens and\n professional athletes who have said steroid use can cause serious health problems. At the same\n time, many former and CUITent users repon physical changes in themselves that they attbute\n directly to their steroid use: bloated appearance (75%), shrinkng testicles (61 %), breast\n development in males (42%), breast reduction in females (50%), bone/joint pain (28%),\n diffculty sleeping (22%), frequent urge to urinate (17%) and nosebleeds (10%). Finaly, 87\n percent of CUITent users agree the bad effects wil go away as soon as use is stopped, but only 41\n percent of former users agree the effects go away.\n\n Experts also link steroid use to other serious psychological effects.\n\n Other possible adverse psychological effects of steroid use include increased irrtability, violent\n behavior, depression , mania, psychosis, and suicide (or attempted suicide). All of these are to\n some degree linked to steroid use in the opinion of our physician/researcher group. They believe\n there are strong links, for shon-term and long-term use, to increased irtability and violent\n behavior. Depression is strongly connected by them to long-term use. Psychotic \n dlor manic\n symptoms and suicide are linked, with no consensus in degree, to both shon and long-term use.\n\n Similar to addiction , evidence does exist in literatue to suppon a real possibilty that steroids\n cause other psychological effects. Drs. Harson Pope and David Katz questioned 41\n bodybuilders and football players who had used steroids (10). Having no histories of past\n psychiatrc diffIculties, five subjects met the criteria for psychotic episodes and 5 for manic\n, episodes during periods of steroid use. No subject descrbed comparble behavior-when they\n were not using steroids. Dr. Mark Humben found a relationship between steroid use and mood\n states (11). Mood scores of athlete users changed signifIcantly after 4 weeks of st Joid,use and\n. approached pretest measurs 4 weeks after discontiuing use. Whle using steroid , athetes\n reponed to Humben a decrease in vigor and increases in hostility, anxiety, confusion , depression,\n and fatigue.\n\n Users repon indications of adverse psychological effects. Fifty-one percent k?d;J.ilOre arguments\n or physical fIghts while using steroids. Twenty- fIve percent repon doing serious damge to\n propeny or a person either in anger or " for fun . Someties they were very sad (28 %); 3 users\n even seriously considered suicide. Finally, 6 of the 17 former users say one of the main reasons\n they stopped was they experienced undesirable behavioral or emotional effects.\n\n Key informants link several negative physical health effects to steroid use.\n\nWe asked our physicians/researchers about links between steroid use and physical health\nproblems just as we asked about psychological health problems. With the same qualifIcations\ndescribed on page 9, they do believe adverse physical health effects stem from steroid use. For\nboth long-term and shon-term use they consistently see strong linkages between steroids and\nacne, fluid retention , gynecomastia (breast development in males), masculinization in females,\n\n\n\n page 11\n\n\x0c reversible sterility (males), incrased LDL (bad cholesterol), decreased HDL (goo cholesterol),\n and high bloo pressure. They also perceive strong links between long-term use and baldness,\n increased chance of injury to muscles, tendons and ligaments, and liver problems. They see no\n link between shon -term stero d use and permanent sterility in males.\n\n For other physical health effects, expen opinion is somewhat less cenan. ough there is no\n consensus as to the degr of linkage, they do perceive links between shon- and long-term\n steroid usage and sexual problems/impotence, stunted growth and prostate problems. The same\n is true for their opinion of shon-term use and incrased chance of injur to muscles, tendons and\n ligaments and Ilver problems. For long-term use, they see links, without a consensus on degree,\n to cardiovascular disease, kidney problems and cancer. No consensus emerged for long-term\n steroid use and possible links to permanent male sterility, or for any linage between roid use\n and accelerated aging of the skin or immune system problems. \'\n\n Despite the dear of research on the effects of steroids, a fInal thought offered by a key\n informant is noteworty:\n\n These drugs are too powerfl not to have some daging effects\n associated with long-term use, and it is imprudent to assume that\n athletes are immune to the deleterious effects that are seen in\n animals. (3)\n\n\n Experts Recommend Education Of Adolescents And Adults As The Best Solution To The\n Steroid Use Problem.\n\n Key infonnants do not believe adolescents are well aware of the risks of steroid use.\n\n\' Adolescents ar not perceivedas knowledgeable about the potential dagers of steroids:\n Two- thirds of our key inormts believe junior high school students ar " somewhat unaware\n (33%) or " very unaware" (33%) of the potential risks of steroid use. They rate senior high\n school students \' knowledge better with 27 of 30 key informantssayig the older students are\n somewhat aware " (47%) to " somewhat unawar" (43%). Terney and McLai refox;d nearly\n 55 percent of the high school students they surveyed were not awar of the medical risks\n associated with steroid use (12). Johnson et al. found 22 percent of male, high-school users did\n not know of any complications associated with steroid use (13).\n\n Our users, with an average age of 20, know more about the medcal risks of steroid use than the\n above subjects. All could name at least the serious health problems medcal expert and\n professional athletes say may be caused by steroids. Two-thirds could name more than thee\n health problems.\n\n\n\n\n page 12\n\n\x0c Knowledge of potential health risks alone is not a deten\'ent to steroid use.\n\nA frustrting aspect of adolescents \' knowledge of steroids is that, even when they ar aware of\npotential health risks, that awarness does not deter steroid use. Eighteen of 30 key informants\nrate knowledge of risks as ineffective in stering adolescents away from the drgs. The primar\nreason given is the general tendency for incrased risk- tag by adolescents the " it can\nhappen to me" syndrome. Other impottt reasons offere by our key informants ar adolescent\nperceptions that the rewar of steroid use outweigh the risks and that the medcal community\nwas wrong previously in saying steroids don t work.\n\nThe medical community s loss of credibilty is impottt when discussing adolescent steroid use\nand possible strategies for deterrng use. Pror to 1984 , expert repeatedy denied, based on\nmixed results from earlier steroid studies, that steroids enhanced performance. In 1984,\nhowever, the American College of Spons Medcine revised its position on steroids to say that\nconcurrent use of steroids with proper trning and diet may enhance performance. Also in 1984\nHaupt and Rovere reviewed the steroid literatu and concluded that :msistent improvements in .\nmuscle strengt and size could result frm steroid use in athetes who followed proper training\nand dieta regiens. Many physicians and scientists, however, sti insiste any weight gained\nwhile takng steroids was maily the result of fluid r tention and that any strengt gain was\nlargely psychological.\n\nAs we mentioned earlier, 82 percent of current users diagr with medcal expens and\nprofessional athletes who say steroid use can cause serious health problems. They disagree\nbecause neither they, nor other users they know, are experiencing health problems. Many also\ncite the lack of " hard evidence " to back up warngs (56%), their suspicion the warngs are\nmerely scar tactics (38%) and previous statemepts by expert who say steroids don t work\n(27%). In shar contrast, 16 of 17 former users agr with the expert that steroid use poses\nserious risks. Actualy experiencing the negative he;vtO effects was a strong motivation for over\nhalf the former users to stop tang steroids.\n\n Nevertheless, experts say educaton is \'the most effective means of deterrng steroid use.\n\nNineteen of 28 key informants say that, ovemH, ooucation is sti the most effective means of\ndeterrng steroid use among junior and senior high school students. The adolescents themselves\nare mentioned most often by key informants as the appropriate taets of the educational effon.\nHowever, they say coaches, trners, and parents should also be included Only one former user\nrepons disapproval by a coach or parnt as a reason for stopping steroid use. Whether the adults\ndidn t object to the steroid use or the objection was not hear seems imaterial next to fact that\nadults apparently ar not playing as strong a role as they could in deterrg use. Education was\nalso suggested for other school personnel and health care professionals, including physicians.\n\nCoaches should be a specifIc taget group for education accordng to literature and key\ninformants. Coaches have special influence on a young person s life, yet sometimes they do not\nappear well informed or alen to the steroid problem. In 1988 Dr. E. James Swenson et al.\npublished a surey of 474 high school varsity coaches (14). The coaches did not generaly\n\n\n\n page 13\n\n\x0c gy \n\n\n\nconsider steroid use to be a problem, with only 11 percent to 14 percent (for different school\nyears) reportng some use among their athletes. This incidence rate is the inverse of the result\nreponed by Buckley et al. who found evidence of use at 85 percent of their sample schools.\n\nSwenson et al\' also reponed that, although about 70 percent of coaches felt informed about\nsteroids, may, in fact, had misconceptions. . For example, 45 percent felt steroids are effective in\npreventing injur. While most coaches would look for strngth increase as an early sign of\nsteroid use, less than half would look for intabilty or fluid retention. 10 Thus, most coaches\nwould be more liely to miss the early signs of steroid use. The researhers concluded the\ncoaches were most likely uninformed and unaware of the tre incidence of steroid use, but\ncommented that possibly the coaches did not want to know the extent of the problem, as " it may\ncause them to tae action that would effect their win- loss reord.\n\n Honest, early, repeated, and clear messages improve steroid educaton programs.\n\n\nIf steroid education is imponat but currnt effort ar not deterrng steroid use, then what makes\na steroid education progr more effective? Our key informants say, more than anything else,\nwe should tell adolescents honestly what we do and do not know about the effects and risks of\nsteroid use. Scare tactics and continuing to say that steroids do not work are major en-ors\nbecause of the prior loss of credbilty by the medcal community and because adolescents know\nthat steroids do work for the goals they have in mid, namely improved strngt, muscularty\nand appearce.\n\nWe also need to recognize for educational puroses that adolescent steroid users ar, in\nsociological terms, a " deviant sub-cultur. " Users are so secetive that some athetes would\nrather confess to cocaine use than to steroid use (3). , lnfpnnation about the drawbacks of use that\ncomes from outside this cultu has litte influence on its members. In fact, in the past, the\nvarous educational and preventive measurs s_eem 10 have been effective only in curling drg\nuse to a degre, if at all , and drving it furer underground-(l5). Our users say people who\nmotivated them to use steroids and provide informtion about the drgs are preomiantly their\nschool and frends. Johnson et al. suggest that, since peers provide a major soure of\ninformation concernng steroids, peer advice and educ tion, which has been used effectively in\nother settgs, may provide an effective interventiQ\'. to lit steroid use (13).\n\n\nAnother strtegy for improving the effect of steroid education is to deliver the message " early\nand often. " As we have discussed, the data show that some adolescentS sta steroids at young\nages and continue though high school. This suggests that junior high school or earlier is an\nappropriate time to begin steroid education. In addition, one educational session wil probably\nnot be a deterrnt according to Dr. Linn Goldberg et al. (16). They assesse the steroid\nknowledge and atttudes of six varsity high school football team before and after an education\nintervention. Four teams were included in the intervention and two teams were controls.\nAlthough students showed increased awareness of the adverse effects of steroid use afer the\neducation progr, no differences in atttudes toward steroid use occured as compard to the\ncontrols.\n\n\n\n\n page 14\n\n\x0c - .\n\n\n\n\nSimply supplying informtion about steroids is not enough. Dr. Mimi Johnson summzed a\n\nstudy by Gordon and McAlister which said that informational approaches to drg and alcohol\n\nuse in the school systems have failed with no apparent decrase in use (8). " It is felt that these\n\napproaches do not address the reasons teenagers use the chemicals. " Key informts and the\n\nNational Consensus Meeting of Anabolic/Andrgenic Steroids (17) agr regarding steroid\n\neducation. They suggest an education progr should:\n\n\n clearly and consistently send a message from coaches, parents, educators and\n physicians that they don t want adolescents to use steroids.\n\n help adolescents develop realistic expectations and goals for themselves and\n alternatives to steroid use, such as improved weight trning methods, n.utrtion\n or training techniques,\n\n advocate and encourage social suppon for using steroids, including a\n not\n\n de-emphasis of winning at all costs and the socialmoneta rewards attached to\n wmmng,\n\n encourage positive role modeling by elite and professional athetes,\n\n emphasize the moral and ethical aspects of steroid use, i.e., steroid use is\n cheating and destroys fai play.\n\n\n\n\n\nTesting And Controlled Substance Status Are Potential Deterrents To Non- Medical Steroid\nUse.\n\n Most key\'infor;nants would favor drug testing as a deterrent were it not for high costs.\n\nMany key informants would advocate testing as a deteITnt to adolescent steroid use, but cost is\na serious drwback. Twenty of 30 say, if cost were not a factor, they would advocate a large or\nmoderate deterrnt role for drg testig. When the 20 key inormants considere cost, 16 then\nwithdrw their suppon of steroid testig, sayig it should have a sma role or no role. Dr.\nRoben Voy, former diector of spons medicine for the United States Olympic Commttee, has\nsaid regardig testig and subsequent sanctions,\n\n Some risk has to be associated with (steroid use).... Drug education in\n and of itself wil not work. Without testing nobody\'s going to listen to\n education. The penalties don t have to be draconian, but there must be\n some penalties. (18)\n\nThe National Consensus Meeting of Anabolic/Androgenic Steroids parcipants went so far as to\nrecommend encourging the liabilty insurace industr to develop coverage for schools \' drg\ntesting progrs in order to make drg testig more readily avaiable at all levels of athletic\n\n\n\n page 15\n\n\x0ccompetition (17). They also suppon drg testing as an effective deterrent, but only in\nconjunction with a comprehensive progr of education and rehabilitation.\n\nOur key informants and other expens ar also concerned about what constitutes an effective drg\ntesting progr. They say the essentials of a testing progr ar unannounced, random test\ntimes (possibly year-round and for all team members), assurances of accurcy, rehabiltation or\ncounseling progrs for " positives " and defInite, pre- determned crteri for who wi be tested.\nMany of these essential elements ar expensive, plus, these elements and others rase legal and\nphilosophical issues. In fact, the National Collegiate Athletic Association (NCAA) was legally\nchallenged on these issues after their drg testig program went into effect in the fall of 1986.\n\nWhile expert say radom , unannounced testing is tlYe only sur way to detect drg abuse, it is\nalso one of the most controversial points. " It may be that random testing is appropriate for\nathletes at some level of competition, but not for others. " (18) Furter, the timing of drg testing\ncorresponds poorly with drg taing and a signifcant number of users don t face drg testing at\nall (3). On the issue of accuracy, access to qualfIed laboratories is a problem. The advanced\nInternational Olympic Committee (lOC) testig techniques aren t available everywhere, and\nsome believe " there s a clear dierence in testig abilties between the lac approved\nlaboratories and private, commercial laboratories. " (19)\n\nNine key informts opposed a substatial role for drg testing as a deterrnt to steroid use even\nif cost were not a factor. Besides questioning the accurcy of testig, they also object to testing\nas an invasion of privacy, and a discrmiatory practice that singles out one drg population.\nThey also believe education is more imponat than testing.\n\n Limiting the \n upp()\' could help control non-medical steroid use.\n\nData on the growth of steroid use and the possible health consequences has produce effons\nshut down the steroid supply for non-medcal use. The key inormants believe the priar\nsteroid sources for young users ar peers and drg deers, maiy in a commercia\nsetting.\n ll Users\n agr while adding pharacists (31 %) and ma order sources (28%). In\nNovember 1990 the Congrss addressed the problem of non-medcal steroid use by scheduling\nthem under the Controlled Substaces Act, makng it ilegal under Federa law to distrbute and\npossess steroids without a prescription.\n\nTwenty-one of 30 key informants and other expert see benefIt in controllng steroids. The key\ninformants believe controllng steroids holds physicians accountable for the drgs they prescribe,\nlimits the supply of steroids manufactured in this countr, and allows imposition of strcter\npenalties for use violations. Because of the record- keeping required, other expens believe\ndiversion of supplies from legitimate domestic maufacturs (theft, resale by consumers, fIling\nof fraudulent prescrptions)(4) to black markets wil be harder (20).\n\nSome key informants and other expens doubt scheduling wil have much effect on the black\nmarket (20). For example, according to the Deparent of Justice, besides diversion from\nlegitimate manufacturers, other sources of black market steroids are clandestinely manufactured\ngoods, including counterfeits, and smuggled products (4). Other enforcement effons, however,\n\n\n page 16\n\n\x0cappear to limit these black market sources. For example, during the 6 months the OIG had\nauthority to conduct investigations of ilegal distrbution of steroids, 25 arsts and convictions\nresulted. Besides diversion of steroids from legitimate domestic manufacturers, OIG\ninvestigators identifIed criminal activities of counterfeiting brand-name steroids, smuggling\nsteroids into the United States and domestic underground. laboratories.\n\nSixty-thre percent of our users saysteroids ar becoming harder to obtan. However, the\nperceptions of our key informants concerning the steroid supply var widely. Some key\ninformants believe all steroids are harder to obtan; others say high qualty or real\n(non-counterfeit) steroids are more scarce. Of the 12 sayig steroids ar more scare, the\nmajority believe restrctive state laws and incrased enforcement ar the causes. An additional\nconcern is that a declining supply is temporar, parcularly if illcit drg dealers are including\nsteroids in their operations.\n\n\n\n\n page 17\n\n\x0c. .\n\n\n\n\n RECOMMENDATIONS\n\n Overall, our key informants, steroid users and literature review indicate that no single approach\n wil solve the problem of adolescent steroid use. Rather, a solution lies within a strategy to\n improve education for adults as well as adolescents and to conduct additional medcal and\n scientifIc research.\n\n\n Develop A National Steroid Education Strategy\n\n The Public Health Service is currently developing a national strategy for addressing the problem\n of non-medcal steroid use. We recommend that it include following elements: a national\n public awareness campaign using credble spokespeople, addition of steroid information to drg\n education currcula on al levels and issuance of guidelines for effective steroid education\n intervention at the local level. We also recommend aggressive testig by the NCAA , National\n Footbal League and other amateur and professional spons associations to promote steroid- free\n athletic competition at the college and professional levels, as this should have a signcant\n educational impact on adolescents.\n\n Key informants believe that education is the most effective means of deterrng steroid use even\n though it doesn t always work. Education involves more , however, than merely presenting\n information about the effects of steroids to adolescents. The educational tagets should include\n coaches, trainers, parents and medical professionals as well as adolescents. The educational\n message for adolescents must come early and be reinforced often in an honest, consistent way\n from their peers and responsible adults. We must find ways to overcome adolescent resistace to\n the message based on their own sense of immonaity, the high degree of secm;y involved in\n steroid use, and the previous loss of crbilty by the medcal communty. Finaly, the\n educational intervention must be talored to several audiences the responsi1?le\' adult vs. the\n adolescent, the potential user vs. the curnt user, the appearce user vs. the athetic user, the\n non- dependent user vs. the dependent user in conjunction with rehabiltation nee.\n\n\n Conduct Further Medical And Scientifc Research\n\n The Deparent, though the Public Health Service, should tae the Federal lead in conducting\n medical and scientific research on steroids. Curnt understading of the racations of\n non-medcal use of steroids is very limited. A pressing nee exists to accurtely identiy the\n potential adverse health effects of shon-term and long-term steroid use, parcularly for\n adolescents. Such research should focus on adverse physical and psychological effects,\n especially, the risk of addiction. Because of the secrey surounding steroid use, innovative and\n unconventional researh methods may be reuired. Another imponant need is to expand the\n available information on trnds in the incidence and prevalence of adolescent steroid use and\n information on the knowledge, atttudes, beliefs, use patterns and motivations of adolescents.\n Continued, or even expanded, coverage of steroids in the NIA annual surey of high school\n seniors is one means of buildig useful trend data on adolescent use.\n\n\n page 18\n\n\x0c COMMENTS\n\nWe received comments on the draft repon from two Deparent of Health and Human Services\nentities - the Office of the Assistant Secretar for Planning and Evaluation and the Public Health\nService. Our responses to their technical comments as well as the full text of their comments\nin Appendix E. Public Comments are in Appendix F.\n\n\nOffce of the Assistant Secretary for Planning and Evaluation (ASPE)\n\nThe ASPE agreed with the repon. In paricular, they think " the repon s highlighting of the fact\nthat steroid use is motivated by socially acceptable values is very benefIcial and should\ncontrbute to bringing this factor to the attention of those developing educational materials.\n\n\nPublic Health Service (PHS)\n\nThe PHS generally agred with the findings and recommendations of the report They believe\n -ecommeridations would be inappropriate since the Interagency\nhasty implementation of the \n\n\nTask Force on Anabolic Steroid Abuse, in which they ar active pancipants, has not fmalized its\nrepon and recommendations for steroid regulation/enforcement, prevention/education , and\nresearch. The PHS specifIcally notes that while we stressed the PHS role in an education\ncampaign, " it is imponant to recognize that any effon in this area wil require coordiation\nacross Depanments.\n\nWe agree with the PHS. In addition, we appreciate the opportunity they provided us to present\nour findings to the Interagency Task Force on Anaolic Steroid Abuse and to review the draft\nreports from the Task Force sub-committees on preventon/education and research. Their\nproposed activities match our recommendations. Like the PHS we believe a well-planned and\ncoordinated approach to the problem of adlescent steroid use should take into account the\nwork, now underway, of the Task Force. In addition, after we issued our draft report, Congress\npassed the Anabolic Steroids Control.Act of 1990. Besides making steroids a controlled\nsubstance, this Act amend the Public Health Service Act to include the development and support\nof " innovative demonstration program designed to identify and deter improper use or abuse of\nanabolic steroids by students, especially students in secondary schools. " The implementing\nregulations are not yet written, but obviously these demonstration programs must also be\nconsidered in the Department s steroid prevention/education and research strategy.\n\n\n\n\n page 19\n\n\x0c ENDNOTES\n\n 1. Refers to the end of a long bone (epiphysis) composed of cartilage or separated from the\n\n bone shaft by a disk of canlage; after the period of growth, bone tissue replaces the\n\n cartilage at the epiphysis to form a single bone with the shaft.\n\n\n 2. Each controlled drug is on one of fIve schedules depending on its potential for abuse and\n dependence. Schedule I drgs have the highest abuse potential and no accepted medical\n uses, e. g. heroin. Schedule ill includes, besides steroids, stimulants, depressants, and\n narcotic drgs like codeine. Penalties for the ilegal possession or distrbution of scheduled\n drugs are prison sentences and/or fInes.\n\n 83,430 = 3% of 2, 781 000 the estimated number of graduates in the Class of 1989,\n according to the U. S. Depanment of Education.\n\n 4. Computed from 1989 enrollment data from the U. S. Depanent of Education and NIDA\n\n data on incidence of fIrst steroid use by grade (see Appendices C and D).\n\n\n 5. We\n or longer.\n collected data only from those usersrwho had completed \t at least one cycle of six weeks\n\n\n 6. NIDA reponed for the Class of 1989 that the lifetime prevalence of use was 90. 7% for\n . alcohol , 43. 7% for marjuana, 19. 1 % for amphetamines, 18. 6% for inhalants, 10.3% for\n cocaine and 8. 3% for LSD.\n\n 7. For similar and/or compatible results-fiom\' ot..her work , see Goldstein (29), and Fuller and\n\n Lafountain (27).\n\n\n 8. The American Psychiatrc Association s DIagnostic and Statistical Maual of Mental\n Disorders (DSM- ll- R). Examples are withdrawal symptoms, contiued use despite\n problems from use, more drg taen than intended, large tie\n expenditure on drg-related\n activity, usual activities replacecl by drug use, unable to cut down or control use.\n\n 9. Also see Pope and Katz (31) for a smaller case study in violent crimes linked to steroid use.\n10.\t A complicating factor is steroid use may increase aggrssiveness and tolerance of stress,\n both positives for some competitive sport.\n\n11. According to Buckley et al. (2), Yesalis et al. (37), and Frankie et al. (26) the major source\n of steroids for non-medical use is the black market.\n\n\n\n\n page 20\n\x0c ,, "" , " , "\n\n\n\n\n\n BIBLIOGRAPHY\n\nA. PRIMARY\n\n\n . National Institute on Drug Abuse, Epidemiology Research Brach, Floor 11A, Parklawn\n Building, 5600 Fishers Lane, Rockvile, MD 20857 by to the Institute for Socialgrt\n Research , University of Michigan, Ann Arbor, MI.\n\n 2. Buckley, Wiliam E. et al., "Estimated Prevalence of Anabolic Steroid Use Among Male\n\n High School Seniors, The Journal pfthe American Medical Association vol. 260, n. 23,\n\n pp. 3441- 3445, December 16, 1988.\n\n 3. Cowar, Virginia, " National Institute on Drug Abuse May Join in Anabolic Steroid\n\n Research The Journal of the American Medical Association, \n vol. 261 , n. 13,\n\n pp. 1855- 1856, April 7, 1989.\n\n\n\n4. United States General Accounting Offce, "Drg Misu e: Anabolic Steroids and Human\n\n Growth Hormone, " GAO-HR- 89- 109, 1989.\n\n\n\n5. Boyea, Steven et al. Ergogenic Drg Use Among High School Athletes: A Three Year\n\n Sequential Study, " abstract of work accepted for pr sentation at the annual meeting of the\n\n American College of Spons Medicine, May 1990.\n\n\n6. Yesalis, Charles E. et al., " Anabolic Steroid Use: Indications of Habituation Among\n\n Adolescents, Journal of Drug Education, \n vol. 19(2), pp. 103- 116, 1989.\n\n\n\n7. " . Bruvver,Kik J. Rehabiltation for Anabolic- Androgenic Steroid Dependence, " based Q"!Hl:"":"\n paper presented at the National Consensus Meeting on Anabolic Androgenic Steroids, Los\n Angeles, CA , July 30- , 1989.\n\n8. Johnson, Mimi Anabolic Steroid Use in Adolescent Athetes, " scheduled for publication\n in Pediatric Clinics of North America, vol. 37, n. 5, October 1990.\n\n9. Brower, Kik J. et al., "Physical and Psychological Dependence on Anabolic-Androgenic\n\n Steroids, " Deparment of Psychiatr, University of Michigan, Ann Arbor, MI, for the\n\n Workshop Conference on Androgen Therapy: Biologic and Clinical Consequences\n\n sponsored by Penn State College of Medcine, Marco Island, FL , Januar 17- 20, 1990.\n\n\n10. Pope, Harson G. and David L. Katz Affective and Psychotic Symptoms Associated with\n Anabolic Steroid Use, American Journal of Psychi,!tr, vol. 145, n. 4 , pp. 487- 490, April\n 1988.\n\n\n\n\n page 21\n\x0c , ," " , "\t , "\n\n\n\n\n\n 11. Humben, Mark D., "Psychological Effects of Self-: Administered Anabolic Steroids on Male\n Athletes: Hostilty, Depression, Vigor, Fatigue, Anxiety and Confusion " doctoral\n dissenation , United States International University, San Diego, CA 1990.\n\n12. Terney, Rise and Lar McLain, "The Use of Anabolic Steroids in High School Students,\n Loyola University, May 1988; published in \n American Journal of Diseases of Children,\n vol. 144 , Januar 1990.\n\n13. Johnson, Mimi et aI. Anabolic Steroid Use by Male Adolescents, Pediatrics, voL 83, n.\n 6, pp. 921- 924 , June 1989.\n\n14. Swenson , E. James et aI., " Perspectiveson Anabolic Stero ds: Survey of High School\n\n Varsity Football Head Coaches, " Deparment of Family Practice, Michigan- State\n\n University, a paper of 40 pages, May 1988.\n\n\n15. Wright, James E. and Michael H. Stone\t Anabolic Drg Use by Athletes Literature\n\n Review " position paper on anabolic drg use by athletes, National Strength and\n\n Conditioning Association , 1985.\n\n\n\n16. Goldberg, Linn et al., "Effect of an Anabolic Steroid Education Program on Knowledge and\n Attitudes of High School Footbal Players, Journal of Adolesce t Health Care, \n vol. 11\n n. 2 , March 1990.\n\n17. Repon of the National Consensus Meeting of Anabolic/Androgenic Steroids, July 30\xc2\xad\n 1989, Los Angeles, CA , sponsored by the USOC, NCAA , National Federation of State\n High School Associations and the Amateur Athletic Foundation of Los Angeles.\n\n18_ war, Virginia, "Drug Testing Programs Face Snags and Legal Challenges, The\n Physician and Sportsmedicine, \n vol. 16, n. 2, pp. 165- 172 , Februar 1988.\n\n19. Cowar, Virginia, " Reflections on the Medcal Aspects of the 1988 Olympic Summer\n Games, The Physician and Sportsmedicine, \n vol. 16, n. 12 , pp. 118- 123, December 1988. \xc2\xad\n\n20. Cowar, Virginia, "Would Controlled Substace Status Affect Steroid Trafcking?" The\n Physician and Sportsmedicine, \n vol. 15, n. 5, pp. 151- 154 , May 1987.\n\n\n SUPPLEMENTAL\n\n21.. . Amsel , Zili et al. Anabolic Steroid Use Among Male High School Seniors - To the Editor,\n The Journal of the American Medical Association, \n ol. 261 , n. 18, p. 2639, May 12 , 1989.\n\n22. Costill , D. L. et aI. Anabolic Steroid Use Among Athletes: Changes in HDL- C Levels,\n The Physician and Sportsmedicine, \n vol. 12 , n. 6, pp. 113- 117 , June 1984.\n\n\n\n\n page 22\n\x0c ," , "\n\n\n\n\n\n23. Cowan, Virginia, "Physician- Competitor s Advice to Colleagues: Steroid Users Respond to\n Education , Rehabilitation The Journal of the American Medical Association, \n vol. 257,\n n. 4 , pp. 427- 428, Jan 23/30, 1987.\n\n24. Cronin , Bar, " The Steroid Menace Chicago Sun-Times special reprint, Februar 1989.\n\n25. Duda, Mar, " NCAA: Only 4 Percent of Athletes U ed Steroids, The Physician and\n Sportsmedicine, vol. 13, n. 8, p. 30, August 1985.\n\n26. Frakie, Mark et al., " Use of Androgenic Anabolic Steroids by Athletes - To the Editor\n The Journal of the American Medical Association, \n vol. 252, n. 4 , p. 482 , July 27, 1984.\n\n27. Fuller, John R. and Marc LaFountain; "Performance- Enhancing Drugs in Spon: A\n Different Form of Drug Abuse, Adolescence, vol. XXII , n. 88, pp. 969- 976, Winter 1987.\n\n\n28. Goldman, Bob, Death in the Locker Room, \n The Body Press, Tucson , AZ , 371 pages, 1984.\n\n29. Goldstein , Paul Anabolic Steroids: An Ethnogrphic Approach " Narcotic and Drug\n Research , Inc., a paper of 36 pages, submitted to NIDA )989.\n\n30. National Institute on Drug Abuse, agency contact for steroid issues: Lynda Erioff, Ph. D.,\n Room 10A- 31, 5600 Fishers Lae, Rockvile, MD, 20857.\n\n31. Pope, Harson G. and David Katz, "Homicide and Near-Homicide by Anabolic Steroid\n Users, vol. 51, n. 1 , pp. 28- 31, Januar 1990.\n Journal of Clinical Psychiatry,\n\n\n\n\n32. Pope, Harson G. et al., " Anabolic- Androgenic Steroid Use Among 1010 College Men,\n The Physician and Sportsmedicine, \n vol. 16, n. 7, pp: 75- , July 1988.\n\n33. Struss, Richard H. et al., " Anabolic Steroid Use and Perceived Effects in Ten\n Weight-Traned Women Athetes, The Journal of the American Medical Association,\n vol. 253, n. 19, pp. 2871-2873, May 17, 1985.\n\n34. Taylor, Wiliam N., " Synthetic Anabolic-AruiIogeJ.iic Steroids: A Plea for Controlled\n Substace Status, The Physician and Sportsmedicine, \n vol. 15, n. 5, pp. 140- 150, May 1987.\n\n35. Telander, R. and M. Noden The Death of an Athlete, Sports Illustrated,\n vol. 70, n. 8,\n Februar 20, 1989.\n\n36. Windsor, Roben and Daniel Dumitr, "Prvalence of Anabolic Steroid Use by Male and\n Female Adolescents, vol. 21 , n. 5,\n Medicine and Science in Sports and Exercise, \n\n\n pp. 494- 497, Februar 1989.\n\n37. Yesalis, Charles E. et al., "Incidence of the Non-Medical Use of Anabolic- Androgenic\n Steroids, " a paper submitted to NIDA , 1989.\n\n\n\n\n page 23\n\x0c - -. .\n\n\n\n\nSimon McNeely, Secretary-Treasurer\nSociety of State Directors of Health, Physical Education and Recreation\n9805 Hilridge Drive\n\nKensington , MD 20895\n\n\nRobert E. "Skip " Morris, Executive Oirector\nNational High School Athletic Coaches Association\n O. Box 941329\nMaitland, FL 32794\n\n\nDick Stickle, Executive Director\nNational Federation TARGET Program Inc.\n11724 Plaza Circle\n O. Box 20626\nKansas City, MO 64195\n\n Professional da: Affiliate of National Federation of State High\n School Associations .\n\n\n\nFrank Uryasz\n\nDirector of Spons Sciences\nNational Collegiate Athletic Association (NCAA)\n6201 College Boulevard\nOverland Park , KS 66211\n\n\nPaul Zeek\nLamar University\n O. Box 10115\nBeaumont, TX 77710\n\n Professional data: \n Acting Executive Dirctor, National Athletic Tra\xc2\xad\n ers Association\n\x0c . ,\n\n\n\n\n\n APPENDIX\nSTEROID USER INTERVIEWS\n\nSteroid users ar diffcult to identify and contact for interviews. We initialy tred to- complete\nthe interviews ourelves by instaling a toll-fre " 800" telephone number and circulatig our\nrequest for user interviews though our key informants. This prouced only five qualifed\ninterviews despite assurances of confidentiality. We then contrted with th key informants,\nNeil Carolan, Dr. James Wright and Dr. Mark Humben, to conduct in- depth interviews of steroid\nusers who met the crteria: 1) age 25 or younger at the tie of the interview, 2) initiated steroid\nuse in high school or earlier, and 3) completed at least one steroid cycle of 6 weeks or longer;\nOtherwise, the interviewers judgmentally selected the users to intervew.\n\nSeventy-tWo steroid users (55 curent + 17 former) provided informtion about themselves by\ncompleting a confIdential, strctured intervew of 39 questions. All intervewers captued the\nself-reponed user data on the instrment we designed and pre-tested, but they did not attempt to\nverify the factual accuracy of the users \' answers. All personally conducted the interviews either\nface to face or by telephone.\n\nThe CUITent and former users were 93 percent male with an average curent age of 20 and an\naverage initiation age of 16. They come from 10 states and frm vared settgs and locations\nwithin those states. Dr. Wright pointed out that he visite several counties for his 11 interviews\nin one state. Neither he, nor Dr. Humbert simply concentrate on one commercial gym which\ncaters to " hard core " bodybuilding and weightliftng trning. Mr. Carolan, a substace abuse\ntherapist interViewed users who were refe1Ts from other drg counseling progrs, curnt\nclients, and word-of-mouth contacts limited to this project. Most were parent- or self-refeITed;\nnone wele court-referrd.\n\x0c APPENDIX \n\n STEROID INCIDENCE OF FIRST USE\n National High School Senior Survey, Class of 1989\n Sponsored by the National Institute on Drug Abuse\n\nGrade Total Male Female\n\n6 or below 0.3 0.2\n\n7 to 8 0.3\n\n 0.4\n\n 1.0\n\n 1.0 0.4\n\n 1.0\n\nNever Used 97. 95.3 98.\n\n\n*For further infprmtion. contact Chief. Epidemiology Research Branch. National\nInstitute on Drug Abuse, Floor 11 A. ParklawnBuilding. 5600 Fishers Lane,\n\nRf/ckvile, MD 20857.\n\n\n\n\n C - 1\n\n\x0c\' ,\n\n\n\n\n\n APPENDIX D\n\n ESTIMATE OF STUDENT STEROID USE BY GRADE\n\n If we assume that the incidence of fIrst use for the Class.of 1989 is typical (see Appendix C),\n then we can estimate student steroid use by grade. Using enrollment data from the U.\n Deparent of Education, we calculate, that in the 1989 school year approximately 97, 000\n students tred steroids for the fIrst time and that by the end of the 1989 school year\n approximately 262 000 students in grades 7 to 12 used or had used steroids.\n\n Grade/Class % First Use # Students Cumulative Cumulative\n # Enrolled By Grade First Use School Year All Grades\n By Grade\n\n or below 354*\n 353, 837 (grade 6)\n\n to 8 - Class of\' 800 13, 154 13, 154\n 293, 000 per class\n (approximate)\n\n 9 - Class of 0.5 17, 821 30, 975 129\n 564 104\n\n 10 \t Class of\' 16, 657 . 47, 632 761\n 331 358\n\n 11 -\t Class of \' 25,293 72, 925 164 686\n 161, 609\n\n 12 -\t Class 0/\' 172 97, 097 261 783\n 021 532\n\n *Based on enrollment data for grade 6; data for incidence of first use by grades 1 through individually is nor\n available.\n\n\n\n\n D-1\n\x0c. \'! ...\n\n\n\n\n APPENDIX \n\n PUBLIC COMMENTS\n\n Charles E. Yesalis, Sc. D., Depanment of Health Policy and Admnistrtion, Pennsylvania State\n University, is a nationally recognized steroid researcher. Below ar excerpts from a letter he\n wrote us after he reviewed the draft repon.\n\n Overall the reports are well done and represent a valuable contribution\n to the literature. I do, however, have a concern with the report\'s conclu\xc2\xad\n sions on strategies to deal with this problem. Once again the central\n focus appears to be directed at the education of users or potential users\n of anabolic steroids. Much less attention is given to our social environ\xc2\xad\n ment which, in my opinion, gives strong signals to our children to use\n these drugs. Your report states that anabolic steroids are not mood al\xc2\xad\n tering at the time of administration. You fail, however, to proceed to\n what I believe is the only logical conclusion: the appetite for these\n drugs ha been created by our fiation on sport and physical appear-\n ance. Children do not have an \n innate desire to look like Mr. Universe\n nor do they by nature play games for the sole purpose of winning\n teach them this. Our youngsters look around and see numerous exam\xc2\xad\n pIes, both inside and outside of sport, of win at any cost, winner take\n wil help you win and they\n all, and bigger is better. Anabolic steroids \n\n\n wil make you bigger.\n\n Our children are influenced by the adulation offans and material re\xc2\xad\n wards which often accompany success at the Olympic, collegiate and\n professional levels of sport. Moreover, because of reports in the news\n media as well as written and verbal testimonials by athletes, adoles\xc2\xad\n cents are \n aware of the role anabolic steroids play in the success of\n many so called role-model athletes.\n\n Although the report acknowledges that anabolic steroids are capable of\n enhancing strength, size and capacity to train, the report once again\n stops short of an obvious conclusion: do not use these . drugs, all\n if you\n\n else being equal, YOU WILL NOT WIN AS OFTEN.... This conclusion\n also has signifcant implications for strategies to solve the. problem of\n steroid use among adolescents. If coaches are not wiling to say with\n sincerity to their athletes, My opposition to steroids is so great that I\n am wiling to lose every game rather than have any of you use steroids.\n this problem wil continue. Ifparents, athletic directors and principals\n are not wiling to support such a stance by coaches, this problem wil\n continue.\n\n F - 1\n\n\x0c'