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Men who use anabolic steroids to build muscle and enhance athletic performance face a substantially higher risk of experiencing long-term erectile dysfunction compared to non-users. In the years after being sanctioned for steroid use, steroid users were three times more likely to require prescription medications to treat impotence. The findings were published in The Journal of Sexual Medicine.
Anabolic-androgenic steroids are synthetic variations of the male sex hormone testosterone. Doctors occasionally prescribe these drugs to treat specific medical conditions, such as delayed puberty or diseases that cause muscle loss. Outside of medical settings, athletes and bodybuilders often use these substances to increase muscle mass, reduce fat, and improve their physical performance.
While steroids are heavily associated with competitive sports, their use extends deep into the general population. Current estimates suggest that about six percent of men worldwide will use anabolic steroids at some point in their lives.
Using synthetic hormones comes with severe biological consequences. The human body relies on a delicate biological system known as the hypothalamic-pituitary-gonadal axis to regulate hormone production. This system operates on a negative feedback loop. When the brain detects that there is enough testosterone in the bloodstream, it stops sending signals to the testicles to produce more.
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When a person introduces large amounts of artificial testosterone into their system through steroid use, the brain senses the hormone overload. The brain immediately shuts down the body’s natural testosterone factories. Over time, this constant suppression causes the testicles to shrink and natural hormone production to crash.
This disruption leads to a condition called hypogonadism, which occurs when the body can no longer produce sufficient testosterone on its own. For many men who abuse steroids, hypogonadism persists for years after they stop taking the drugs. Symptoms of low testosterone include fatigue, depression, loss of muscle mass, and sexual health problems.
One of the most common sexual health issues associated with low androgen levels is erectile dysfunction. Magnus Middelboe, a clinical pharmacologist at Copenhagen University Hospital-Bispebjerg and Frederiksberg, led a research team to investigate this specific side effect. The researchers wanted to understand the long-term risk of erectile dysfunction among men who use or have used anabolic steroids.
To investigate this relationship, the research team designed a longitudinal cohort study. This type of research tracks a specific group of people over an extended period to observe how their health outcomes develop. The researchers utilized health and law enforcement records from Denmark, a country with extensive national databases that track medical treatments and prescriptions.
The researchers identified steroid users through records kept by Anti-Doping Denmark. This national organization runs a control program that tests for performance-enhancing drugs in public fitness centers across the country. The research team looked at data from between 2001 and 2018.
They included men living in Denmark who were sanctioned under the anti-doping program. The group of steroid users included both men who tested positive for the drugs through a urine test and suspected users who refused to submit to testing.
To create a point of comparison, the researchers randomly selected a group of men from the general Danish population. For every steroid user in the study, they found men of the exact same age to serve as controls. They also matched the men based on the specific date the steroid user was sanctioned.
This matching process helps ensure that the groups are as similar as possible before the observation period begins. The average age of the men at the start of the tracking period was 27.
The research team followed the participants’ medical records from the date of their sanction until the end of 2022, death, or emigration. On average, the researchers tracked the men’s health data for 10 years.
To determine which men developed erectile dysfunction, the researchers looked at data from the Danish National Prescription Register. They tracked how many men filled new prescriptions for erectile dysfunction medications, such as sildenafil or tadalafil. The team also recorded secondary measurements, including the total number of prescriptions each man filled and the cumulative dosage of the medication over the follow-up period.
The researchers used statistical models to compare the prescription rates between the steroid users and the general population controls. They adjusted their calculations to account for differences in socioeconomic status. Specifically, the models factored in the educational attainment and occupational status of the men at the start of the study.
The research team found a strong association between steroid use and the need for erectile dysfunction treatment. Based on their statistical estimates, the 15-year risk of redeeming a prescription for erectile dysfunction medication was 24 percent among the steroid users. In contrast, only eight percent of the men in the control group required similar medical treatment over the same period.
When the researchers looked at the raw data, the steroid users were 3.6 times more likely to seek their first medical treatment for erectile dysfunction compared to the general population. After adjusting the data for age, education, and employment disparities, the estimate dropped slightly. Even with those adjustments, the steroid users were still 3.2 times more likely to start taking medication for impotence.
The individuals who used steroids also required more intensive treatment for their condition once it developed. Among the men who sought medical help for erectile dysfunction, those in the steroid group filled twice as many prescriptions as the men in the control group. The median number of prescriptions filled by steroid users was six, compared to just three for the non-users.
The steroid users also redeemed a higher median cumulative dose of the medication over the course of the study. Doses among steroid users had an interquartile range of 16 to 300, compared with 12 to 136 among the men in the control group. Both the number of prescriptions and the dosage differences were highly statistically robust.
Because the study relies on observational tracking rather than a controlled experiment, the results do not definitively prove that steroids cause erectile dysfunction. The research team could only observe disparities in medical treatment between the two groups.
The researchers relied entirely on prescription records as an indirect measure of erectile dysfunction. This approach presents several opportunities for misclassification. The prescription medications tracked in the study are occasionally used to treat other health issues, such as lower urinary tract symptoms or Raynaud’s disease, a blood vessel disorder. While these conditions are rare in young men, their presence could slightly inflate the estimates.
The data only captured medications obtained through registered pharmacies. Men who sought out treatment pills through unregistered sources or the black market were not included in the records.
Additionally, erectile dysfunction is often underdiagnosed because many men are reluctant to talk to a doctor about their sexual health. This reluctance likely leads to an underestimation of the true rate of erectile dysfunction in both the steroid users and the general population.
The study design also assumes that the men caught by the anti-doping program continued their habits. The sanctions handed down by Anti-Doping Denmark might have convinced some men to stop using steroids entirely. Those individuals remained categorized as steroid users in the data, which could dilute the final statistical associations. The researchers also lacked specific information on how long the men had been using steroids or what doses they took before getting caught.
Medical professionals suspect that prolonged hypogonadism and testosterone suppression are major factors in these sexual health issues. Other biological and environmental elements could also contribute to the higher rates of erectile dysfunction seen in the study. Cardiovascular disease, psychological stress, and the use of other recreational drugs can all severely impact sexual function.
The researchers were unable to measure lifestyle habits like smoking and alcohol consumption, which are known to cause damage to the blood vessels that facilitate erections. Different patterns of health behavior between bodybuilders and the general public might explain some of the differences in treatment rates.
The study, “Anabolic-androgenic steroid use and erectile dysfunction,” was authored by Magnus Middelboe, Ida M. Heerfordt, Josefine Windfeld-Mathiasen, Kim Peder Dalhoff, Jon Trærup Andersen, and Henrik Horwitz.
