Use, Misuse, and Addiction to Anabolic Steroids
Testosterone isn’t just for males, body builders, or athletes anymore.
Updated September 16, 2025 | Reviewed by Michelle Quirk
Synthetic testosterone , also known as anabolic‑androgenic steroids (AAS), is a controlled drug prescribed for delayed puberty in boys, testosterone (T) deficiency in adults, breast cancer, gender dysphoria , and other disorders. They are Schedule III drugs. According to the Drug Enforcement Administration (DEA), anabolic steroids are also drugs of abuse. About 3–4 percent of men in the United States report lifetime AAS use, compared with 0.5–1 percent of women. The prescription testosterone market in the United States is substantial and growing, with more than 5 million prescriptions written annually and an estimated $1 billion in sales.
More striking still is the booming self- medication with testosterone supplements. Testosterone “boosters”—often herbal or vitamin‑based products—represent a $3.7 billion global market projected to nearly double by 2030. This means there are 3 million users in the United States, and epidemiologic studies suggest up to 30 percent of long-term AAS users may develop addiction , some with co-occurring body image disorders. Research in clinical trials and experiences in Olympic and professional athletes have shown that elevated T increases lean muscle mass, strength, and power. The evidence is so compelling that the Olympics and professional sports enforce bans on testosterone use because of the unfair advantage these AAS create. These bans to maintain fair competition are also part of AAS's allure among athletes, weekend warriors, and others.
The stereotypical user is a middle-class male in his 20s–40s, engaged in competitive sports, intense exercise, or recreational bodybuilding. Though technically off‑label, more men and women have been self-medicating with T. “Low T” prescribers of vitamins and T enhancers market testosterone to middle‑aged men concerned about aging and overall well-being. Increased energy, interest in fitness, sports performance, and desire to reverse fatigue, low libido, or mood changes motivate testosterone seeking. Women have been using it more, too, for T-related athletic performance enhancement, lean bodies, energy, confidence , and libido. T has been prescribed for hypoactive sexual desire disorder (HSDD) in postmenopausal women, supported by global consensus guidelines, although no Food and Drug Administration (FDA)‑approved female formulation exists.
Supplemental testosterone increases muscle mass, boosts red blood cell production, and reinforces competitive drive. Pre‑competition testosterone surges correlate with improved outcomes, and victories can further elevate testosterone, creating feedback loops of motivation . Some use more than one type of anabolic steroid sequentially, also known as “stacking.” These drugs are available in capsules, tablets, sublingual tablets, gels, transdermal patches, creams, and injectable drugs. They are purchased (illegally) from individuals or over the Internet or Darknet. Use of prescribed and nonprescribed anabolic steroids is growing rapidly .
Long-Term Effects on Men and Women
Body image pressures include the pursuit of muscularity, leanness, or “toned” physique, sometimes linked to muscle dysmorphia. Some case reports tie AAS link with past histories of trauma or low self-esteem , with steroids perceived as empowering or protective.
Women are also less likely to reveal their use of AAS. When women abuse anabolic steroids, it may cause irreversible voice deepening and increased body/facial hair and acne, as well as clitoromegaly and irregular menstruation. When men abuse these drugs, they may experience shrinking testicles, enlarged male breast tissue (gynecomastia), sterility, and elevated risks for prostate cancer. For men and women, the drugs may elevate blood cholesterol levels and increase risks for heart attacks and strokes. Psychiatric effects may occur, such as extreme anger known as “roid rage.” If an addicted person stops taking the drugs, withdrawal syndromes can be severe with mood swings and, especially, suicidal depression .
Historical and Medical Background
The discovery of testosterone in the 1930s was followed by its use in hypogonadal men, ushering in the era of anabolic‑androgenic steroids. Clinically, testosterone replacement therapy (TRT) is FDA‑approved only for men with documented hypogonadism due to identifiable medical causes.
In both 2015 and 2025, the FDA clarified that testosterone is not approved for age‑related T decline or male menopause complaints alone. Male “andropause” remains disputed. For many men, medicine’s dismissal of their concerns as “just aging” fuels distrust and drives them to use supplements and telehealth clinics. Men are “voting with their feet,” seeking solutions outside traditional healthcare. Off‑label use for both men and women is common.
The Endocrine Society and American Urological Association recommend caution, requiring male patients to experience symptoms of low testosterone and repeated low blood levels of testosterone. Multiple randomized controlled trials have found that transdermal testosterone improved the frequency of satisfying sexual events, sexual desire and arousal, orgasm frequency, self-image , and pleasure in both surgically and naturally menopausal women.
Anabolic steroids increase dopamine release in the brain’s nucleus accumbens, akin to how cocaine or amphetamines work, though subtler. Users often escalate from modest “cycles” to complex multi‑drug stacks. Chronic exposure produces tolerance and withdrawal states marked by depression, irritability/anger, and fatigue.
First use often occurs in the late teens or early 20s. Peak dependence is in the 20s–40s. About 90 percent of dependent users are men. Studies suggest MSM (men who have sex with men) are 3–5 times more likely than heterosexual men to use AAS, which may be linked to muscular body ideals.
Since the 1980s, Harvard’s Harrison Pope has documented chronic AAS users and addiction. Users continued AAS despite adverse physical, psychological, and social consequences, and described intense preoccupation with obtaining and using these drugs. Tolerance, dependence, craving, and continued use occur, and men persist in using despite real consequences like acne, gynecomastia, infertility , hypertension, or legal/social consequences. Work, relationships, and finances suffer due to preoccupation with steroids or associated training regimens. Risky use is reflected in needle-sharing and black-market purchases. Most AAS-dependent people are not elite athletes but may be weekend or wannabe athletes seeking an edge, fitness enthusiasts, or recreational weightlifters who seek increased muscle mass and reduced fat for aesthetic reasons, often tied to muscle dysmorphia (“reverse anorexia,” the belief that one’s body is too small or inadequately muscular). Users have a higher prevalence of body image disturbance, perfectionism , and sometimes prior psychiatric vulnerabilities (depression, trauma, anxiety , substance use disorders). Recent data suggest higher rates of use among MSM communities, partly due to cultural emphasis on muscularity and body image.
The DSM-5 doesn’t list AAS addiction as a distinct entity but allows its diagnosis under “Other Substance Use Disorders.” The criteria mirror those of other substance disorders: tolerance, withdrawal symptoms like depression, hypogonadism on discontinuation, loss of control, unsuccessful efforts to cut down, spending excessive time obtaining/using, craving, continued use despite problems, and social/occupational impairment. Pope and Kanayama have shown that many chronic users meet three or more of these criteria, qualifying for a substance use disorder diagnosis.
Women represent a small minority of AAS users, and the global lifetime prevalence is approximately 0.5–1 percent among women, versus about 3–4 percent in men. Women with classical anorexia or bulimia rarely use testosterone, but in those whose body-image pathology shifts toward muscularity or “fitness culture,” AAS use emerges as a risk. Muscle dysmorphia (“reverse anorexia”) is recognized as a subtype of body dysmorphic disorder (BDD), with a well-documented association with AAS use in men and women.
What appears to be driving the use of AAS by men is the perception of andropause or low testosterone, reflected by low energy, poor motivation, decreased muscle mass, increased visceral fat, reduced libido, erectile dysfunction, depression, and low confidence .
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Mark S. Gold, M.D., is a pioneering researcher, professor, and chairman of psychiatry at Yale, the University of Florida, and Washington University in St Louis.
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