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Body Image 12 (2015) 6–13

Contents lists available at ScienceDirect

Body Image

journa l h om epa ge: www.elsev ier .com/ locate /bodyimage

ggression and body image concerns among anabolic androgenicteroid users, contemplators, and controls in Norway

da Heimly Jenssena,∗, Kim Berg Johannessenb

Østfold Hospital, Addiction Services, Department of Diagnosis and Treatment, Moss, NorwayCenter on Autobiographical Memory Research, Department of Psychology and Behavioral Sciences, Aarhus University, Denmark

r t i c l e i n f o

rticle history:eceived 5 January 2014eceived in revised form 14 July 2014ccepted 18 August 2014

eywords:nabolic androgenic steroids

a b s t r a c t

Purpose: AAS users and contemplators were investigated for differences in aggression and body imageconcern. Prevalence rates were sought as a secondary aim. Method: 396 male adolescents at Norwe-gian high schools completed a questionnaire battery during school hours. Results: Prevalence of AAS useshowed 4.0%; AAS contemplation showed 5.1%. No significant differences between the AAS users andcontemplators were found on levels of aggression and body image concern. AAS users and contemplatorsreported significantly higher levels of aggression and body image concern compared nonusing controls.

ASggressionody imagedolescents

Conclusions: AAS contemplators enhance understanding of AAS use by representing psychosocial factorscontributing to increased aggression, and AAS use or risk thereof indicative of an aggressive personalityprofile. Body image concerns for AAS users and contemplators may indicate that AAS use does not dimin-ish body image concern, and that body image concern is a risk factor for AAS use. This is supportive ofprevious research.

© 2014 Elsevier Ltd. All rights reserved.

Introduction

An anabolic androgenic steroid (AAS) is an umbrella term foreveral synthetic derivatives and structural modifications of testos-erone, varying in chemical composition and anabolic to androgenicatio (Kuhn, 2002). It is the anabolic effect that is attractive forAS users as it increases lean muscle mass and reduces body

at (Wood, 2004). Physical side effects of AAS use include coro-ary heart decease, testicular atrophy, sterility, and gynecomastiaBahrke, Yesalis, & Brower, 1998; Torres-Calleja, González-Unzaga,eCelis-Carrillo, Calzada-Sánchez, & Pedrón, 2001). Psychological

ide effects are linked to increased irritability and aggression (Perryt al., 2003; Pope, Kouri, & Hudson, 2000), increased risk of affectiveisorders, psychotic disorders, suicidality (Bahrke et al., 1998), andody dissatisfaction (Olivardia, Pope, Borowiecki, & Cohane, 2004).n addition, a number of side effects have been associated with theiscontinuation of AAS use, such as reduced muscle size, depres-ion, and male hypogonadism (Tan & Scally, 2009; Wood, 2004).

he typical pattern of AAS use follows a method termed ‘cycling’.his involves using steroids in intervals, where the cycle graduallyncreases in dose of AAS, then tapers the dose towards the end of the

∗ Corresponding author at: Østfold Hospital, Addiction Services, Department ofiagnosis and Treatment, Peer Gyntsvei 78, 1535 Moss, Norway. Tel.: +47 95487479.

E-mail addresses: idnjen@so-hf.no, idajenssen@hotmail.com (I.H. Jenssen).

ttp://dx.doi.org/10.1016/j.bodyim.2014.08.009740-1445/© 2014 Elsevier Ltd. All rights reserved.

cycle (Brower, 2002). Most users also ‘stack’ AAS, a method involv-ing the combination of several oral and injectable AAS to augmentbeneficial effects and reduce adverse effects (Wood, 2004). The AAScocktail typically follows a pattern named ‘pyramiding’, where thevarious AASs increase and decrease on a weekly basis (Wood, 2004).This pattern of polypharmacy has been reported in up to 90% of AASusers (Evans, 1997). Some of the concomitant drugs may result inmedical emergencies on their own, possibly being more dangerousthan the AAS by itself (Evans, 2004). The amount of AAS concen-tration circulating in the body during a cycle, have been reportedto reach a hundred times the physiological range of a typical adultmale (Evans, 2004), with doses reaching up to a hundred timesmore than for medical prescriptions (Brower, 2002). The exact con-centration of AAS in the body is difficult to establish, however, dueto use of veterinary preparations and false content labels in themanufacturing of AAS for recreational use (O’Sullivan, Kennedy, &Casey, 2000). Overall, there are individuals that either unknowinglyor consciously defies potentially lethal side effects when initiat-ing and continuing AAS use. As such, investigating the underlyingreasons for AAS use is of utter importance.

Several studies have shown that steroid use is often initiatedduring adolescence (Faigenbaum, Zaichkowsky, Gardner, & Micheli,

1998; Yesalis, Kennedy, Kopstein, & Bahrke, 1993). Prevalence ratesof AAS use in American male high-school students is approximately3.3% (Centers for Disease Control, 2010) whereas Scandinavianprevalence rates lie between 1.2% and 2.9% (Barland & Tangen,

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I.H. Jenssen, K.B. Johanness

009; Wichstrøm & Pedersen, 2001). Kanayama, Pope, and Hudson2001) point to the importance of examining prevalence of AASse internationally. As female AAS use is relatively rare in the gen-ral population (Kanayama, Boynes, Hudson, Field, & Pope, 2007),he current study will investigate the prevalence rate of adoles-ent male students in Norway. Due to the recent aetiology of thisesearch field, relatively few studies have examined the statusf at-risk male adolescents for AAS use (Cafri et al., 2005; Pope,anayama, & Hudson, 2012). Thus, the current study will also

nvestigate the prevalence rate of adolescents contemplating AASse.

AAS have traditionally been associated with the field of profes-ional sports, where it has been used with the intent to enhancethletes’ performance levels (Wichstrøm & Pedersen, 2001). In theast decades, however, AAS use has emigrated from the field ofrganised sports to become an increasing public health problemKanayama, Hudson, & Pope, 2008). Indeed, Brower (1989) iden-ifies three types of AAS users; the athlete, the aesthete, and theghting elite. While the athletes use AAS to enhance sports per-

ormances, the aesthetes use AAS to enhance physical appearance,nd the fighting elite is argued to use AAS to enhance fightingotential (Brower, 1989). In this study, these three types of AASsers will provide a useful framework for the investigation of AASse.

Many studies have focused on the athlete type AAS user (Burnett Kleimann, 1994), and according to Miller, Barnes, Sabo, Melnick,nd Farrel (2002), wrongfully so. They argue that with the spreadf AAS beyond the field of organised sports, a continuation of aesearch field favouring this perspective will limit other perspec-ives. The current study will therefore focus on Brower’s (1989)esthete type and fighting elite type AAS user.

Some research argues that AAS use is primarily predictedy problem behaviour (Wichstrøm & Pedersen, 2001). Miller,offmann, Sabo, Melnick, and Farrel (2010) found that substancebuse, fighting and risky sexual behaviour were better predictorsf AAS use compared to athletic involvement. Other studies haveound a link between aggression and AAS use. For instance, labo-atory studies have found increased aggressive responses for ratsWood et al., 2013) and males (Pope et al., 2000) after testos-erone supplementation. Research has also showed that adolescentAS contemplators tend to be more aggressive than nonusers

Elliot & Goldberg, 1996). The current study will therefore examineggression levels for AAS using and AAS contemplating adolescentsompared to a healthy nonusing group of adolescents. This shalle investigated in the light of the Risk Behaviour Syndrome (RBS;essor & Jessor, 1977). Middleman, Faulkner, Woods, Emans, anduRant (1995) portray this syndrome as a clustering of adoles-ent intraindividual covariation of risk and problem behaviours.roblem behaviours are behaviours condemned by society (Jessor

Jessor, 1977), and seeing that AAS use is illegal in many countries,ne may argue that AAS use has common factors with other illegalrugs.

Research investigating body image concerns has found thatody dissatisfaction poses as a risk factor for adolescent AAS useBlouin & Goldfield, 1995; Pope et al., 2012). Evans (1997) foundhat two thirds of recreational body builders used AAS to enhanceheir physical appearance rather than enhancing sports perform-nces. Further, Brower, Blow, Young, and Hill (1991) found thatependent AAS use was best predicted by dose of administeredAS and dissatisfaction with body size. This was also shown innother study, where long-term users showed significantly higherevels of body dissatisfaction, to the point of reaching clinical lev-

ls of muscle dysmorphia (Cafri et al., 2005). Other studies haveound a link between AAS use and body image concern in ado-escent samples (Blouin & Goldfield, 1995; Komoroski & Rickert,992). Smolak, Murnen, and Thompson (2005) found that middle

dy Image 12 (2015) 6–13 7

and high school boys who reported muscle or unspecified bodydissatisfaction were more likely to initiate use of AAS and other foodsupplements. Further, the percentage of adolescent boys worryingabout body image has been found to reach the same level as bod-ily dissatisfied adolescent girls (Ricciardelli & McCabe, 2007). In asociety where pressure from media and peers to obtain a mesomor-phic body shape play a contributory part to body dissatisfaction anddrive for muscularity (Daniel & Bridges, 2010; Hardit & Hannum,2012), it is likely that investigating male body image as it relatesto AAS users and potential users is highly relevant. As such, thecurrent study finds it important to investigate AAS using and AAScontemplating adolescents on the measure of body image concern.This will be examined through Brower’s (2002) two-stage model ofAAS dependence.

Brower’s model (2002) attempts to account for the particulari-ties of AAS use as it differs and relates to other drug dependencies.He argues that AAS dependence does not conform to the typical pat-tern of drug addiction where drug use is maintained and increasedfor their euphoric effects. AAS are, rather, cumulative action sub-stances giving a delayed effect of muscle gain (Kanayama, Brower,Wood, Hudson, & Pope, 2009). It develops from a sociocultural con-text where individuals, with various agendas, seek a larger musclemass and a mesomorphic body type (Mishkind, Rodin, Silberstein,& Striegel-Moore, 1986). This constitutes the first stage of Brower’s(2002) model, and is also known as ‘the body image mechanism’of AAS dependence (Kanayama, Brower, Wood, Hudson, & Pope,2010). At this stage, individuals exercise more frequently and withhigh intensity, often following a strict diet to obtain the desiredmuscle gain. It is this very goal-directedness of the weight trainingthat is the most discernible difference from other drug addictions,and Brower (2002) argues that the reinforcing elements of AAS useare the anabolic effects. In stage two of Brower’s (2002) model,AAS users have self-administered AAS at supraphysiologic dosesfor a substantial amount of time, thus enabling the activation ofthe brain’s reward system. As such, AAS dependence at stage twoconforms more to classical drug dependence conforming to thepositively reinforcing hedonic effects. This hedonic route to AASdependence is argued to be a subset of the body image mecha-nism, as there are no reported cases of AAS dependence withoutstage one’s goal-oriented weight training and its body buildingeffects (Brower, 2002). The focus of the present study is that ofBrower’s (2002) stage one of model of AAS dependence, as it isargued to be the most relevant for a nonclinical group of adoles-cents.

In summary, this study will investigate self-reported levels ofaggression and body image concern relating to AAS use and con-templation in a sample of adolescent male students. The currentstudy also seeks to investigate prevalence rates for AAS use andcontemplation in a sample of adolescent male students in Norway.

Method

Participants

The present study consists of 414 male adolescents from sixupper secondary schools in the region of Oslo, Norway. Eigh-teen (4.3%) respondents were excluded from the analyses due toincompletion of the questionnaire battery. The remaining 396 par-ticipants had a mean age of 16.8 years (SD = 1.02), ranging from16 to 21 years. The schools were selected on basis of geographical

nomic status. The first author approached the school managementthrough telephone and letter, and the school management gaveconsent to initiate study. Six out of eight approached schools gaveconsent to partake in the study, giving a response rate of 75%.

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rocedure and Materials

No ethical review was needed for the present study. Throughersonal communication with the Norwegian Data InspectorateNorsk samfunnsvitenskapelig datatjeneste AS) it was establishedhat the study did not need to be submitted for an ethical review, asespondents were above the age of 16 and the data collection wasnonymous. The same applied for parental response.

Participants filled out the questionnaires during school hoursn groups of approximately 15–20 students, with the first authornd a teacher present. Before the questionnaire battery was handedut, the students were briefed about the nature of the study, andhat participation was completely voluntary and confidential. Nonef the students refused participation. They were asked to fill inhe questionnaire battery in silence to avoid influence from oth-rs. All measures in the questionnaire battery were presented in atructured response format.

In the present study we wanted to collect information fromach participant about level of aggression, body image concern, andresent use of AAS or the contemplation thereof. First, the partic-

pants received information concerning the definition of AAS, aso rule out reports of use of anabolic steroids as prescribed due to

edical conditions. For the sake of convenience, the test batterysed the terminology “anabolic steroids”, and not AAS. Second, thearticipants filled out the Aggression Questionnaire (AQ; Buss &erry, 1992). The AQ measures aggression as it manifests throughts four subscales of physical and verbal aggression, anger, and hos-ility. It is a 29-item questionnaire providing information abouthe instrumental, affective and cognitive components of aggres-ion as it presents in an individual’s personality. The questionnaires found to have strong reliability and validity (Buss & Perry, 1992),

hich is further supported with the current study’s high internalalidity (Cronbach ̨ = .91). No changes were made to the ques-ionnaire with regards to the age of the current study’s sample.revious research has shown temporal stability in results for ado-escents the same age as the current study investigated (Fossati,

affei, Acquarini, & Di Ceglie, 2003).Third, two measures concerning body image were included. The

ale Body Dissatisfaction Scale (MBDS; Ochner, Gray, & Brickner,009) comprises 25 items on a 5-point Likert scale. Additionally,

able 1escriptive features of upper secondary male students (N = 396).

Variable Steroid users (n = 16)

n %

EthnicityNorwegian 6 37.5

Eastern European 4 25.0

Western European – –

African 2 12.5

Asian – –

Middle Eastern 2 –

North American – 12.5

South American – –

Mixed ethnicity – –

Not disclosed 2 12.5

Clinical diagnosisADHD 1 6.3

Depression 2 12.6

Psychosis – –

Dyslexia – –

Other 1 6.2

None 12 75.0

Not disclosed – –

Drugs before steroid useYes 6 37.5No 1 6.2Not disclosed 9 56.3

ote. n = amount of times the variables were reported, and as such not necessarily repres

dy Image 12 (2015) 6–13

respondents score the importance of each item’s content on a scalefrom 1 to 10. The importance ratings are divided by 10, and multi-plied with the Likert scale items giving a score between 2.5 and 125.The higher the score, the more body dissatisfaction. This scale isintended to target male body dissatisfaction in particular. The scalehas been found to have an adequate level of reliability (Ochner et al.,2009), further supported in this study where Cronbach ̨ = .89.

The Body Change Inventory (BCI; Ricciardelli & McCabe, 2002)was included to measure cognitive and behavioural factors of bodyimage. The scale is specifically designed for adolescents. The scaleconsists of three subscales with: strategies to decrease body size,strategies to increase body size, and strategies to increase musclesize. All three subscales comprise strategies pertaining to food andexercise and there are six items per subscale rated on a 5-point Lik-ert scale. The questionnaire measures body image investment, andas such pays particular attention to the centrality of an individual’sappearance to his sense of self (Smolak, 2004). Upon scale construc-tion an internal reliability for the three factors or subscales was veryhigh (Cronbach ̨ > .90) (Ricciardelli & McCabe, 2002). This is fur-ther supported in the current study with Cronbach ̨ = .91, .92, and.90 for the subscales body strategies to decrease weight, increaseweight, and increase muscle respectively.

Finally, participants disclosed information pertaining to AAS useand AAS contemplation. Information concerning contemplation ofAAS use was obtained through including an item in the question-naire asking participants to disclose on whether they currentlywere contemplating AAS use, and the reason thereof.

Missing responses in the dataset were replaced using the expec-tation maximisation algorithm in SPSS when less than 20% of aquestionnaire’s items were randomly missing.

Results

Prevalence

Out of the 396 participants that were recruited (Table 1), sixteen

respondents reported having used AAS, giving a prevalence rate of4.0%. Twenty of the nonusers reported that they contemplated ini-tiating AAS use, giving a prevalence of 5.1%. The remaining 360(90.9%) participants reported not ever using or contemplating the

Steroid contemplators (n = 20) Control group (n = 360)

n % n %

10 50.0 246 68.32 10.0 12 3.31 5.0 11 3.11 5.0 21 5.82 10.0 19 5.32 10.0 14 3.9– – 5 1.41 5.0 – –– – 13 3.61 5.0 19 5.3

2 10.0 14 3.9– – 5 1.4– – 1 0.3– – 6 1.7– – 5 1.4

18 90.0 330 91.7– – 7 1.9

entative of one individual.

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Table 2Descriptive socio-cultural features of AAS users.

Descriptives n %

Parental statusMarried 7 43.7Divorced 7 43.7Not disclosed 2 12.5

Father’s highest educational levelSecondary school 2 12.5Vocational education 7 43.7College 2 12.5University 4 25Not disclosed 1 6.2

Mother’s highest educational levelSecondary school 3 18.7Vocational education 7 43.7College 1 6.2University 3 18.7Not disclosed 2 12.5

School specialisationSports 5 31.1Electronics 6 37.5General studies 2 12.5

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Industrialisation 2 12.5Food and restaurant services 1 6.2

se of AAS. The groups did not differ with regard to age (p = .8).ne AAS user (6.2%) reported having an ADHD diagnosis, and two

eported having clinical depression (12.5%). Six of the AAS userseported drug use before initiation of AAS (37.5%), where threearticipants reported use of cannabis (30%), three reported use oflcohol (30%), two reported use of cigarettes (20%) and one par-icipant reported use of amphetamine (10%). All six also reported100%) use of muscle building supplements. Table 2 provides morenformation regarding socio-cultural descriptive features of theAS users.

omparing Study Measures to Student Group

A series of one-way ANOVAs were conducted to investigate theifferences in self- reported levels of aggression and body imageoncern between the male adolescent AAS users, AAS contempla-ors, and the nonusing control group (Table 3).

The AQ and all its subscales yielded significant findings. Postoc analyses using Tukey’s HSD showed that both AAS users andAS contemplators reported significantly higher levels of overallggression as well as higher levels of anger compared to the

able 3tudy measure scores for the three groups of AAS users (n = 16), AAS contemplators (n = 2

Study variables Study groups

UsersM (SD)

CoM

Aggression QuestionnaireTotal score 84.43 (23.47) 83Anger Subscale 21.79 (7.23) 19Physical Aggression Subscale 27.43 (8.93) 25Hostility Subscale 20.64 (7.92) 22Verbal Aggression Subscale 14.57 (4.03) 14

Body Image QuestionnairesMBDS total score 39.79 (8.52) 58BCI increase muscle size with exercise 8.06 (3.04) 8BCI increase muscle size with food 7.50 (3.20) 7BCI increase weight with exercise 7.69 (3.00) 7BCI increase weight with food 6.56 (3.01) 7BCI decrease weight with exercise 5.69 (2.52) 5BCI decrease weight with food 5.31 (2.41) 5

otes: df(2, 305–380).* p ≤ .05.

** p ≤ .005.

dy Image 12 (2015) 6–13 9

control group (p < .05). Tukey’s HSD post hoc tests also showedthat AAS users reported significantly higher levels of physicalaggression than the controls (p < .05). Individuals considering AASuse also reported significantly higher levels of hostility and verbalaggression compared to the controls (p < .05), shown by a Tamhanepost hoc test. Interestingly, none of the subscales of the AggressionQuestionnaire yielded any significant differences between the AASusers and the AAS contemplators.

Further, a significant difference was found on the MBDS, mea-suring body image concern. Tamhane post hoc tests found that bothAAS users and contemplators reported a higher level of body dis-satisfaction compared to the control group (p < .05). Post hoc testsdid not yield the difference between the AAS users and the AAScontemplators significant.

Several significant differences were found for the BCI. Firstly,a Tukey’s HSD post hoc test showed that AAS users reported sig-nificantly more investment in food-related body change strategiesto increase muscle size compared to the control group (p < .05).Tukey’s HSD post hoc tests also found that participants contemplat-ing AAS use reported significantly more investment in both food-and exercise-related body change strategies to increase muscle sizecompared to the controls (p < .05). Secondly, a Tukey’s HSD posthoc test showed that adolescents considering AAS use were alsomore invested in food- and exercise-related strategies to increaseweight compared to the control group (p < .05). No differences werefound between the AAS users and contemplators on either food- orexercise-related body change strategies on any of the three sub-scales.

Discussion

A large sample of adolescent males was assessed on the indicesof aggression and body image to investigate prevalence and dif-ferences in terms of AAS use and contemplation in Norway. Thisstudy found a 4.0% prevalence of adolescent male AAS users anda prevalence rate of 5.1% of AAS contemplating adolescent males.This seems to resonate well with other study findings exploring AASusing adolescents from Western societies (Amtmann, 2004). Sev-eral researchers argue, however, that underreporting of AAS use is

common in prevalence studies (Kanayama et al., 2001). Indeed, theresearcher in the current study received post hoc feedback fromschool health personnel concerning previously known AAS usingstudents informing that they did not report AAS use in the survey.

0), and controls (n = 360) as they relate to aggression, and body image.

F �2

ntemplators(SD)

ControlsM (SD)

.29 (20.56) 68.26 (18.40) 9.58** .06

.82 (5.92) 15.56 (5.50) 12.27** .07

.88 (6.75) 21.72 (7.15) 6.49** .04

.65 (7.07) 18.20 (6.01) 5.03* .03

.94 (3.96) 12.80 (3.62) 4.14* .03

.31 (28.38) 33.02 (15.31) 10.43** .09

.40 (3.28) 6.64 (2.60) 6.05* .03

.75 (3.13) 5.64 (2.48) 10.96** .05

.68 (3.67) 6.00 (2.70) 4.27* .02

.16 (4.05) 5.33 (2.52) 5.80** .03

.84 (3.10) 4.62 (2.30) 3.80* .02

.53 (2.34) 4.45 (2.10) 3.44* .02

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s such, underreporting may also have been likely in the currenttudy.

The present study found that AAS users reported significantlyncreased levels of aggression compared to the nonusing controlroup, supporting previous research. For instance, Wood (2004)howed that in animal laboratory studies, AAS use modified aggres-ive behaviours for both rats and hamsters. Wood et al. (2013)lso found increased levels of aggression in adolescent rats treatedith testosterone. Further, Pope et al. (2000) found heightened

ggression levels in a laboratory study conducted on nonusingdults administering supraphysiological doses of testosterone.hese results suggest causality in terms of increased aggressionnder AAS use, both in animals and for humans.

The current study also found significant differences betweendolescents considering AAS use and the control group. Interest-ngly, adolescents considering AAS use were also found to reportignificantly higher levels of aggression compared to the controlroup. No significant difference was found between the AAS usersnd the AAS contemplators on levels of aggression. This may indi-ate that heightened levels of aggression for AAS users is not solelyue to the chemical compound of the synthetic testosterone itself,ut may imply that aggression also is manifested through psycho-

ogical or sociological factors. Indeed, Lumia and McGinnis’ (2010)eview on animal studies as they relate to AAS use and aggression,ound several studies showing that the expression of aggressions modulated by both experienced external social events and anndividually perceived provocation. The authors found that thehemical makeup of the various AAS contributed to levels of aggres-ion. Yet, others argue that AAS use lowers the threshold to aggressnd not aggression per se (Lumia & McGinnis, 2010). Further, Woodt al. (2013) found that despite increased levels of testosteroneiving increased levels of aggression in rats, it did not increaseggressive motivation or impulsivity. However, as the results areerived from animal studies the applicability to humans is unclear.

The relation between personality and aggression is ambiguous.rower (2002) points to the possibility of the confounding effectf personality for individuals choosing to initiate AAS use, whichay cause flawed conclusions in terms of attributing psychologi-

al effects to AAS use and not the user of AAS. Similarly, Su et al.1993) argue that AAS users may be aggressive, as part of a par-icular personality profile, even before AAS initiation. The currentnding of AAS contemplators reporting higher levels of aggressionompared to the control group and not differing in overall level ofggression compared to the AAS users may be suggestive of this.

Indeed, research has found that problem behaviour as well asisky behaviour is both highly associated and most predictive of AASse (McCabe, Brower, West, Nelson, & Wechsler, 2007; Miller et al.,010; Pope et al., 2012). For instance, both Wichstrøm and Pedersen2001) and Miller et al. (2010) found that problem behaviour was

ore predictive of AAS use than a wish to become more attractive oro enhance athletic performances. Also, research has found conductisorder a strong, independent risk factor for later AAS use (Popet al., 2012). Furthermore, Hildebrandt, Harty, and Langenbucher2012) found that use of muscle building supplement was a riskactor for AAS use. A similar finding was shown in the current study.ll six AAS using participants reporting previous drug use beforeAS initiation disclosed the use of muscle building supplement.

Overall, the heightened levels of aggression for AAS usersound in this study account for Jessor and Jessor’s (1977) RBS.urthermore, the heightened levels of aggression found for AASontemplators do not undermine the relevance of the riskehaviour syndrome. Indeed, as part of the Problem Behaviour The-

ry (1977), this syndrome also accounts for psychosocial influencesn risk behaviour.

No significant difference was found between AAS users and AASontemplators in overall level of aggression. The results of the AQ

dy Image 12 (2015) 6–13

subscales do, however, give insight into the differing pattern ofexpressed aggression between AAS users and AAS contemplatorswhen compared to the nonusing control group. Whilst the formerdiffer significantly from the controls on heightened levels of angerand physical aggression, the contemplators differ from the controlgroup in terms of increased levels of anger, hostility, and verbalaggression. According to Buss and Perry (1992), hostility repre-sents the cognitive element of aggressive behaviour. Indeed, Elliotand Goldberg (1996) found adolescents considering AAS use to bemore hostile than a nonusing control group, supporting the cur-rent finding. Overall, it seems that both the AAS users and the AAScontemplators are more aggressively aroused than the controls.Thus, whilst both the AAS users and contemplators were affectiveand instrumental in their aggression, the contemplators were alsocognitively aroused. An elaboration on the differing expressionsof aggression between the two groups is an interesting topic forfurther research.

It was found that male AAS users reported significantly higherlevels of body dissatisfaction compared to the nonusing controlgroup on the MBDS. This is supportive of existing research. Forinstance, Blouin and Goldfield (1995) found that AAS using bodybuilders reported significantly higher on drive for bulk comparedto nonusing athletes. Further, the most frequent reason for AAS usereported by the bodybuilders was to enhance their looks, makingthe researchers conclude that bodybuilding and AAS use is stronglyassociated with the previously introduced body image of the meso-morph. The current study furthers this result by expanding theAAS type user reporting increased levels of body dissatisfactionbeyond that of the bodybuilder. Olivardia et al. (2004) also showedan association between AAS use and low body satisfaction. Theyfound an association between body dissatisfied American collegemen and use of performance-enhancing substances. The currentstudy extends previous research by finding a significant differ-ence between body dissatisfaction and use of the more specificperformance-enhancing substance of AAS.

Similarly, the current study showed that male adolescentsconsidering AAS use also reported significantly higher levels ofbody dissatisfaction compared to the control group on the MBDS.Similar results have previously been found. For instance, Brower,Blow, and Hill (1994) found that nonusers contemplating AAS usereported greater body dissatisfaction compared to nonusers notconsidering AAS use. Brower et al. (1994) also found that high-risk nonusers reported more body dissatisfaction than low-risknonusers. Further, Pope et al. (2012) found that body image con-cern in adolescence was an independent risk factor for later AASuse in weightlifters. The researchers’ measures were assessed ret-rospectively from adult males, and by investigating an adolescentsample, the current study further built on Pope et al.’s (2012) find-ings. Overall, it seems that body image concerns play a contributoryrole with regards to increasing the risk of AAS use.

No significant differences were found between the AAS usersand contemplators in relation to the MBDS. This result may haveseveral implications. As both the AAS using adolescents and theAAS contemplating adolescents showed more body dissatisfactioncompared to the control group, this result points to the impor-tance of focusing on body image concerns in prevention efforts.The mere fact that the participants contemplated AAS use portraystheir concerns regarding body image.

It has previously been mentioned that drive for muscularityhas been associated with a risk of AAS use (Blouin & Goldfield,1995). Tylka (2011) found that muscle dissatisfaction predictedbehaviours aimed at enhancing muscularity. The current study

further enhances the understanding of Tylka’s (2011) result byproviding insight into the manifestation of muscularity enhanc-ing behaviours endeavoured by individuals reporting high bodyimage concern. The BCI showed that AAS users reported more body

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mage investment relating to food-related body change strategieso increase muscles compared to the controls. This result is noturprising, as the sheer fact that these individuals use AAS pro-ides evidence of this investment. Nevertheless, it is importanto explore what seems like obvious relations. The findings alsohowed that AAS contemplators reported significantly more invest-ent in both food- and exercise-related body change strategies

o increase muscle size than controls. This result is supportive oflouin and Goldfield’s (1995) findings that drive for muscularity isonnected to risk of AAS use.

Furthermore, this study found that adolescents considering AASse were more invested in food- and exercise-related strategieso increase weight compared to the control group. It is interest-ng that these results are not mirrored by the AAS using group,

here no significant findings were found for investment in food-r exercise-related strategies to increase weight. This may indicatehat in terms of body image investment, the AAS contemplating

ales’ investment is more diverse than the AAS users’ investmentoncerning body change strategies. It may also indicate, as pre-iously described, that there is a difference in perception of thedeal body between adolescents contemplating AAS use and ado-escent AAS users. To further this argument, previous research hashown that contemplating at-risk adolescents reported higher lev-ls of body image concern compared to AAS users (Brower et al.,994). Such a finding would indicate that AAS use might actually

ncrease body satisfaction. Indeed, this was the conclusion reachedy Brower et al. (1994). In this perspective, one may argue thathere could be a difference between the AAS users and the AASontemplators that the MBDS was unable to manifest, but may bendicated by the BCI’s investment in body image. However, in theresent study we do not find significant differences between thewo groups with regard to body dissatisfaction as measured by the

BDS.Finally, the subscale of the BCI exploring food and exercise-

elated body change strategies to decrease weight found that AASontemplators reported increased investment to both strategiesompared to the control group. No differences were found betweenhe AAS users and the controls, or between the AAS users and con-emplators. Thus, it seems to be that male adolescents consideringAS use do so both in terms of reducing body size, as well as increas-

ng muscle mass. Indeed, several researchers have pointed to theact that body satisfaction follows a dual pathway for men; thoseith a drive for thinness and a lean body, and those with a drive

or muscularity, and as such, a larger body (McCabe & Ricciardelli,001; Tylka, 2011).

In summary, the current study provides evidence of increasedody image concern for AAS using adolescent males compared toontrols. AAS users reported being significantly lower in body satis-action, as well as being significantly more invested in body changetrategies pertaining to muscle size increase. As such, support ofrower’s (2002) stage one of AAS dependence exists as well asrower’s (1989) AAS type users of the aesthete and the athlete.

nterestingly, similar significant findings were shown for the AASontemplating group. Thus, it may seem that body dissatisfaction is

risk factor for AAS initiation. Further, this study suggests that bodyatisfaction does not increase with AAS use. These results point tohe need for exploration of alternative routes to increased bodyatisfaction for adolescent males other than initiation of AAS use.

Indeed, an argument can be made that the two models underhich the two indices of aggression and body image concern have

een investigated relating to AAS use and contemplation do notave to exclude each other, but act as two different psychosocial

outes to AAS use. As such, in the current study, the two mostresent AAS type users as introduced by Brower (1989) are the aes-hetes and the fighting elite. This is supportive of Pope et al.’s (2012)here conduct disorder and adolescent body image concern were

dy Image 12 (2015) 6–13 11

found to be independent risk factors for subsequent use of AAS. Assuch, one can argue the need for different perspectives in termsof intervention. Arguably, AAS using individuals will be subjectedto physical and/or psychological side effects, which may initiatecontact with the public health care system. One may also comeinto contact with AAS users in public health care systems whereconcomitant drug use is of clinical levels, or as a consequence ofproblem behaviours. Another route still, is preventative interven-tions in a school setting with regards to risky behaviours and bodyimage concern in adolescence.

Limitations and Future Research

First, the possibility of selection bias is present as only a smallnumber of upper secondary schools were approached over a rel-atively small geographical area. Second, and yet more important;AAS users in this study might have been under-sampled. Severalresearchers have pointed to the risk of underreporting AAS use dueto its illegal status (Brower et al., 1994; Wichstrøm & Pedersen,2001).

A third limitation is that there might have been other factorssuch as social influences contributing to AAS use not explored in thisstudy. For instance, Tylka (2011) state that peer influences are par-ticularly present during adolescence, and indeed these might haveinfluenced the respondents in the current study. Future studiesshould explore measures investigating social influences of parents,peers and the media (known as the tripartite influence model) as itrelates to AAS use.

Finally, the study suffered from small samples of individualsreporting AAS use and AAS contemplation. This caused the samplesizes in these two groups to differ largely from the comparison con-trol group, likely affecting the results and increasing the probabilityof a type II error. However, due to relatively similar standard devi-ations between the three groups on the different measures reducesthis potential threat to the present results. By increasing the num-ber of respondents in the AAS using and AAS contemplating groups,one may infer the results with more confidence. Another alternativecould have been to randomly choose respondents from the controlgroup to ensure similar sample sizes across the three groups as per-formed in Brower et al.’s (1994) study on high- and low-risk AASusers.

Conclusions

In the present study, the prevalence of adolescent AAS useamong Norwegian male adolescents was found to be comparableto other current and relevant studies. Interestingly, no significantdifferences were found between AAS users and AAS contemplatingadolescent males in relation to aggression and body image con-cern. This points towards psychosocial aspects of aggressive acts,rather than AAS enabling indiscriminate and unprovoked roid ragedue to its very chemical compound. The increased levels of aggres-sion found for both these groups compared to a nonusing controlgroup is supportive of Jessor and Jessor’s (1977) RBS, and maybe indicative of an aggressive personality profile. Further, no dif-ferences between AAS users and contemplators concerning bodyimage were found. This finding suggests that body dissatisfactiondoes not decrease with AAS use. The finding is also indicative ofbody image concern being a risk factor for subsequent AAS use. AASusers reporting lower levels of body satisfaction and higher invest-ment in body change strategies to increase muscle sizes providessupport to the existence of Brower’s (2002) body image mechanism

of AAS dependence. The findings pertaining to AAS contemplatorsas high in aggression and body image concern is supportive of previ-ous research (Pope et al., 2012). The current study’s findings implythe presence of two routes to AAS use; namely that in the spirit

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2 I.H. Jenssen, K.B. Johanness

f the aesthete’s body image concern, and that in the spirit of theghting elite’s problem behaviour. It follows that efforts in adoles-ent prevention and intervention programmes for AAS users andt-risk users could benefit from a tailored perspective with respecto body image or problem behaviours.

Future large scale and longitudinal studies on differences andimilarities between AAS users and contemplators are needed forurther understanding of the relationship between aggression andody image in male adolescents.

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