Anabolic Steroids and Violent C r i m e - - A n Epidemiological

Study at a Jail in Stockholm, Sweden

G6ran Isacsson, Mats Garle, Else-Britt Ljung, UIf ,&,sg~rd, and UIf Bergman
Violent crime has been associated with the abuse of
anabolic-androgenic steroids (AAS) in several reports.
Speculations concerning such associations have been
raised with regard to several recent crimes committed
in Sweden. To test this hypothetical relationship,
individuals in a Stockholm jail who had been arrested
for violent crimes were screened for AAS in the urine.
No AAS were detected in the urine samples of 50
prisoners who had volunteered for the study. How-

ever, 16 prisoners refused to participate. AAS abuse

was admitted by two of the participating subjects.
Although there is a great need for epidemiological
studies to objectively confirm the association of AAS
abuse and violence, it seems that such studies will be
impossible to conduct as long as they, for legal reasons, depend on voluntary participation.

NABOLIC-ANDROGENIC STEROIDS (AAS)

include synthetic analogues to the male sexual
hormone testosterone, as well as testosterone and other
endogenous androgenic hormones. Endogenous testosterone influences the male fetus in the development of
male characteristics, including brain anatomy. 1Experimental studies in animals suggest that psychological
traits such as aggression and sexual drive are testosterone-mediated.l,2
AAS have been used for decades by athletes to
improve their performance. Anecdotal reports on
personality changes with a tendency toward increased impulsive-aggressive behavior have been
more common as the use of AAS in Sweden has
spread to broader groups of younger males abusing
AAS as a short-cut to attaining an athletic body
image. 34
Case reports on violent crimes committed by
abusers of AAS have been published in scientific
literature, 6 as have reports on psychotic episodes 7
and dependence. 8,9 Retrospective surveys of bodybuilders have also suggested a substantial proportion of psychiatric disorders among those abusing
AAS. 1 Above all, the reports have concerned
affective symptoms, with manic states during abuse
and depressive states during abstinence. =,11 These
preliminary results have been supported by an
experimental study of healthy volunteers. 12 Violence toward women when using AAS was reported
in a retrospective study concluding that partners of
AAS users may run the risk of serious injury from
users while they are on AAS. 13 Investigations using
psychometric tests have also been able to demonstrate increased aggression and hostility among
AAS users and among volunteers taking AAS
under experimental conditions. 14,15
Speculation as to an association between AAS
abuse and violent crime has been raised with regard

to several violent crimes committed in Sweden?

However, none of these cases have been confirmed
by objective (such as urine analysis) measurements
of AAS. 4,16 Furthermore, the causality between
AAS abuse and violence may be complex. 4,15,17
The epidemic of intravenous abuse of narcotics
in Swedish society was successfully monitored by
inspecting arrested people at the Stockholm jail for
needle stigmas as markers of such abuse. TM In this
epidemiological study, our aim was to use screening tests of AAS in urine as markers for such abuse
in perpretators of violent crimes. This approach
was also called for in a recent study in which
prisoners were interviewed regarding AAS abuse.19

Copyright 1998 by W.B. Saunders Company

METHOD
We screened 50 violent offenders for traces of AAS in their
urine. Persons arrested for the following crimes were included
as violent offenders: unlawful threat, assault and battery, manslaughter, murder, robbery, and rape. One person arrested for
kidnapping was also included in the study. Persons already
sentenced were excluded as too long a time had elapsed since
the crime had been committed. All included subjects were
arrested within 1 day of the crime, and urine samples were left
by 35 of the subjects (70%) within 2 days and within 6 days by
the remaining 15 (median for all subjects, 2 days).
The arrested individuals were asked whether they wanted to

From the Department of Clinical Neuroscience and Family

Medicine, Division of Psychiatry; Department of Medical
Laboratory Sciences and Technology, the Doping Control
Laboratory, Division of Clinical Pharmacology, Karolinska
Institute, Huddinge University Hospital, Huddinge, Sweden;
and the Stockholm Jail, Stockholm, Sweden.
Supported by a grant from the Swedish Institute for Public
Health (Folkhiilsoinstitutet).
Address reprint requests to Grran lsacsson, M.D., Ph.D.,
Chief Physician, Department of Clinical Neuroscience and
Family Medicine, Division of Psychiatry, Karo[inska Institute,
Huddinge University Hospital, S-141 86 Huddinge, Sweden.
Copyright 1998 by W.B. Saunders Company
0010-440X/98/3904-0009503.00/0

ComprehensivePsychiatry,Vol. 39, No. 4 (July/August), 1998: pp 203-205

203

204

ISACSSON fiT AL

participate anonymously. A subsample of those who volunteered

to give urine samples were also asked if they were willing to
undergo a personality interview. We used the Structured Clinical
Interview for DSM-III-R (SCID-II) and limited it to items for
histrionic, narcissistic, borderline, and antisocial personality
disorders, based on our assumption that these were of primary
interest} Whether the subjects were asked to be interviewed or
not depended on our limited interviewing capacity.
To get some idea of the composition of the nonparticipant
group, relevant notes were made by the jail psychiatrist regarding the nature of the crime, history of abuse, and body
constitution for all persons asked to participate. The 50 participants gave a urine sample the same day, and this was analyzed at
the Doping Control Laboratory (accredited by the International
Olympic Committee), Huddinge University Hospital, by means
of gas chromatography and mass spectrometry (GC-MS). The
SCID-II interview was conducted as soon as possible. Approximately 50 other individuals who fulfilled the inclusion criteria
were not asked to participate, as they had left the jail before they
could be approached. This occurred mostly during weekends.
The study was approved by the Committee of Ethics at
Huddinge University Hospital (930830:HS 90/93) and by the
National Prisons Board (930526: 1339-9305-0683).

RESULTS

To obtain 50 volunteers to provide a urine

sample to test for AAS, it was necessary to
approach 66 individuals fulfilling the inclusion
criteria. This took place between October 1, 1993
and March 14, 1994. The nonparticipation rate was
24%. The median age was 27 years (range, 16 to
52). In terms of crimes for which they had been
arrested, the group consisted of two unlawful
threats, 20 assault and batteries, two murders and
one attempted murder, 20 robberies, four rapes, and
one kidnapping. AAS was not detected in any of the
50 urine samples.
One subject reported abuse of AAS in a cyclic
"on-off pattern." At the time of the alleged crime,
he was in an "off" phase. Another subject admitted,
during a subsequent stay at the jail, he actually had
used AAS on the previous (index) visit. He was
surprised about the negative urine test as he was
convinced that his urine sample would have contained AAS. Three subjects had a body constitution
("body-builders") that gave an impression of AAS
abuse, although they denied such abuse and there
were no other circumstances that supported the
suspicions. Abuse of other substances was reported
by 18 (36%) of the subjects included in the study.
Of the 12 interviewed subjects, 10 fulfilled the
criteria for at least one, usually three, personality
disorders (PD) according to DSM-III-R. Thus, the
criteria for Histrionic PD were met by four subjects, Antisocial PD by six, Narcissistic PD by four,

Borderline PD by seven, and PD-Not Otherwise

Specified by two subjects. Only two of these 12 had
given an overt impression of having a PD. The
subject who admitted AAS abuse fulfilled the
criteria for all four PDs.
Among the 16 who refused to participate, the
mean age was 31 years. The crimes were unlawful
threat (n = 2), assault and battery (n = 7), murder
(n = 2), robbery (n = 2), and rape (n = 3). Three
gave a clinical impression of having an antisocial
PD, and two appeared to be "paranoid." Two were
suspected of being abusers of AAS, and four were
probably abusers of other substances.

DISCUSSION

This study with a large, probably systematic,

nonparticipation rate does not allow any conclusions to be drawn regarding the relation between
abuse of AAS and violent crime. However, it
clearly demonstrates the difficulties in establishing
such a relationship and gives some hints for further
research.
One subject admitted abusing AAS, and others
gave an impression of such abuse. Subsequently
imprisoned after the study, one of the included
subjects admitted he had denied a current AAS
abuse when interviewed. Some AAS are cleared
from the body fluids rapidly and may, thus, be
absent in the urine analysis if some days have
elapsed since the last intake. On the other hand,
some AAS, such as nandrolone decanoate given
intramuscularly, may be detected 4 to 12 months
after the injection. Furthermore, several varieties of
fake ALAS are known to be available containing
only sesame oil for injection or caffeine in tablet
form. The frequently occurring cyclic "on-off"
pattern of intake may also give rise to methodological problems. The result of the personality interviews is in line with that expected for a jail
population. The subject who admitted AAS abuse
at the interview fulfilled the criteria for all personality disorders for which he was tested. He was
aggressive also while in jail and had been incarcerated for trying to shoot someone. In agreement with
the findings of violence towards women previously
reported, 13 this subject spontaneously admitted that
he had beaten his girlfriend. Provided there is a
relation between AAS abuse and this type of
aggressive behavior, 21 at least one question remains---does AAS abuse induce such behavior, or

ANABOLIC STEROIDS AND VIOLENT CRIME

205

is it an underlying personality disorder that increases the risk for AAS abuse as well as for violent
outbursts? a5,17 Presumably, there is a multifactorial
causality behind violent crimes. There is, however,
increasing evidence from experimental studies that
AAS might be one such factor in susceptible
individuals.12,14
Our result is consistent with an American investigation in which 133 prisoners were interviewed,
and two cases of apparent AAS induced crimes
were found. 19 Both studies suggest that AAS is a
factor in criminal behavior, although infrequently.
In the American interview study, the dropout rate
was approximately 50%. It was concluded that
perhaps only a study using urine testing for steroids
in sequential offenders, especially violent offenders, could offer a greater degree of objectivity in
response to this question. The present study, with
the design proposed and with a 24% dropout rate,
was not able to find any AAS in the urine tests,
although we found circumstantial evidence indicating that a few violent offenders did abuse AAS.

In conclusion, there is reason to suspect that

abuse of AAS does increase the risk of violent
outbursts among susceptible individuals. 2,12,19 A
Swedish Governmental Commission "Doping in a
Public Health Perspective" proposed in 1996 that
AAS should be legally placed in the same category
as opiates, etc. 4 In the United States, AAS are
controlled substances in accordance with Schedule
III, or in some states Schedule II (i.e., the same as
for opiates). 22 We believe that screening violent
offenders for AAS (and other substances) is a
possible way of obtaining knowledge about an
emerging problem of great social concern. Our
survey demonstrates that to obtain valid results, the
subjects must be tested regardless of consent. This
requires a revision of current Swedish law. We
agree with the conclusion of Pope et al. that AAS
use "represents an uncommon but occasionally
important contributor to criminal activity. Therefore, it would seem useful to seek a history of
steroid use in men being evaluated in connection
with criminal prosecutions or convictions." 19

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