Article

Post-cycle therapy for performance and image enhancing drug users: A qualitative investigation

November 2016
Performance Enhancement & Health 5(3)

DOI:10.1016/j.peh.2016.11.002

Authors:

Deakin University

Anabolic-androgenic steroids (AAS) are synthetic forms of the hormone testosterone and their non-medical use is related to increased muscle size, muscle mass, and strength. A primary concern regarding exogenous AAS use is its potential to suppress endogenous (natural) testosterone production. In response, some users seek out substances to use post-cycle to mitigate problems associated with the resumption of endogenous testosterone production. This study sought to understand issues related to post-cycle therapy (PCT) among a sample of performance and image enhancing drugs (PIED) users in Australia. Semi-structured interviews were conducted with 26 participants (n = 24 male) who reported the use of a range of performance and image enhancing drugs (PIEDs), including AAS, human chorionic gonadotropin, growth hormone, clenbuterol, tamoxifen, insulin, and peptides. Interviews were conducted in person or by telephone, recorded, and transcribed. Data were analysed following a process of thematic analysis. Three themes emerged: (1) access to PCT; (2) maintenance of gains, maintenance of health; and (3) PCT and links to mental health. Steroids were seen as easier to access than PCT; as such, participants tended to continue to use steroids rather than taper down their use, leading to health concerns. Participants wanted access to PCT for several reasons, including minimising any loss of muscle or strength gained through their PIED cycle; because they were concerned that they were no longer naturally producing hormones; or because they were concerned about their mental health, particularly when coming 'off cycle', and the need for PCT to help adjust. This study contributes to the existing literature suggesting that PCT may act as a harm reduction measure, allowing PIED users to safely reduce or cease steroid use or to address any negative effects from use, particularly those related to mental health.

Navigating Risks and Reducing Harm: A Gendered Analysis of Anabolic-Androgenic Steroid Users Within the Risk Environment Framework Original Manuscript

Article

Full-text available

May 2024
Contemp Drug Probl

Introduction: The existing body of literature on harm reduction for those who use anabolic-androgenic steroids (AASs) predominantly concentrates on men, thereby neglecting the unique challenges faced by women in this context. Using a risk environment framework, the aim of this study was to examine the gendered harm reduction practices of male and female AAS users. The study explores their awareness of the potential harms associated with AAS use, the strategies they employ to manage those risks, and the support systems they utilize for harm reduction. Methods: The study employed purposive sampling to recruit 25 individuals (16 females and nine males) who used AAS. In-depth, semi-structured interviews were conducted and transcribed; thematic analysis was employed. Results: Both male and female users were aware of the risks and side effects of AAS. They also often trusted coaches for advice regarding AAS use, and some found peer support for open discussions. Participants also indicated the importance of verifying the legitimacy and safety of AAS. Men considered these to be manageable while women aimed to avoid them, particularly the masculinizing effects. Women downplayed the persistence of side effects and fertility challenges. Harm reduction strategies involved both men and women monitoring their health through personal cues and blood tests. However, women placed a greater emphasis on various physiological measures in their health monitoring practices. Post-cycle therapy was less discussed among women. Discussion: Overall, the study provides insights into the awareness, strategies, and support systems employed by men and women who use AAS for harm reduction purposes. There is a need to adopt a comprehensive harm reduction approach that recognizes the unique needs and experiences of women who use AAS. We emphasize the need for comprehensive education, supportive healthcare providers, and responsible coaching to minimize potential risks and ensure the well-being of individuals using AAS.

Alienation and Lack of Trust Barriers to Seeking Substance Use Disorder Treatment Among Men Who Struggle to Cease Anabolic-Androgenic Steroid Use

Article

Full-text available

Jan 2020

Anabolic-androgenic steroid (AAS) use became illegal when the Norwegian Drug Act was amended in 2013, and AAS and other image-and performance-enhancing drugs were included in the politics and treatment of substance use. Few individuals with AAS-related health problems seek substance use disorder (SUD) treatment. This article aims to explore understandings of AAS dependence, barriers to treatment-seeking, and experiences of entering SUD treatment among a sample of men with AAS-related health problems struggling to cease AAS use. Seeking treatment for AAS-related health problems within SUD treatment services was described as alienating. First, because the participants experienced their struggle to quit using AAS to be different from being dependent upon psy-choactive substances. They linked their struggles to symptoms of hormonal disturbance, need for a certain body size, and/or the sense of wellbeing provided by AAS and which enable them to function socially. Second, they experienced alienation because of their healthy identities, bodies and lifestyles, as opposed to how they viewed individuals with severe SUDs and emaciated bodies. A major barrier to treatment-seeking was partici-pants' lack of trust that SUD treatment providers had the knowledge and the means to provide treatment of their AAS-related health problems and struggle to quit AAS use. Experienced barriers towards seeking SUD treatment should be taken into account when planning, organizing and implementing health services for individuals with AAS-related health problems.

Support for non-prescribed anabolic androgenic steroids users: a qualitative exploration of their needs

Article

Jan 2020

Anabolic Androgenic Steroids (AAS) are used by the general population (particularly male gym users) for their anabolic effects (increased muscle mass). Few studies have sought AAS users’ views on what information and support they need. This study focuses on ideal support wanted by people who use AAS. Interviews were conducted with 23 self-declared adult AAS users. Using thematic analysis, six themes were identified aligned to support and information wanted by AAS users: (1) specific types of information wanted: managing risks, (2) mechanisms for communication of advice, (3) specific types of support wanted: medical and emotional, (4) stigmatisation of people who use AAS, (5) paying for support services, (6) legality of AAS use. Integral to the support was that it should be considered within the context of use and identity. Support needs to be specific, targeted towards AAS users ensuring that balanced and evidenced-based advice is given. Sensitivity to AAS users’ perceptions of their drug-use and the stigma of being classified in the same sub-set as other illicit drug users is relevant to facilitating successful engagement. Furthermore, there is a need to consider the emotional issues surrounding AAS use and how to meet these needs.

Support for people who use Anabolic Androgenic Steroids: A Systematic Scoping Review into what they want and what they access

Article

Full-text available

Jul 2019
BMC PUBLIC HEALTH

Background: Since there is a paucity of research on support for people using Anabolic Androgenic Steroids (AAS), we aimed to identify and synthesise the available evidence in this field. Gaining an understanding of the support both accessed and wanted by recreational AAS users will be of use to professionals who provide services to intravenous substance users and also to those working in the fields of public health and social care, with the aim to increase engagement of those using AAS. Methods: A systematic scoping review of the literature to explore and identify the nature and scope of information and support both accessed and wanted by non-prescribed AAS users. Any support services or information designed to help people who use AAS were considered. Results: We identified 23 papers and one report for review, which indicated that AAS users access a range of sources of information on: how to inject, substance effectiveness, dosages and side effects, suggesting this is the type of information users want. AAS users sought support from a range of sources including medical professionals, needle and syringe programmes, friends, dealers, and via the internet, suggesting that, different sources were used dependent on the information or support sought. Discussion: AAS users tended to prefer peer advice and support over that of professionals, and access information online via specialist forums, reflecting the stigma that is experienced by AAS users. These tendencies can act as barriers to accessing services provided by professionals. Conclusions: Support needs to be specific and targeted towards AAS users. Sensitivity to their perceptions of their drug-use and the associated stigma of being classified in the same sub-set as other illicit drug users is relevant to facilitating successful engagement.

Factors predicting normalization of reproductive hormones after cessation of anabolic-androgenic steroids in men: a single center retrospective study

Article

Full-text available

Dec 2023

Objective Symptomatic hypogonadism discourages men from stopping anabolic-androgenic steroids (AAS). Some men illicitly take drugs temporarily stimulating endogenous testosterone following AAS cessation (post-cycle therapy; PCT) to lessen hypogonadal symptoms. We investigated whether prior PCT use was associated with the normalization of reproductive hormones following AAS cessation. Methods Retrospective analysis of 641 men attending a clinic between 2015-2022 for a single, nonfasting, random blood test <36 months following AAS cessation, with or without PCT. Normalized reproductive hormones (ie, a combination of reference range serum luteinizing hormone, follicle-stimulating hormone, and total testosterone levels) were the surrogate marker of biochemical recovery. Results Normalization of reproductive hormones was achieved in 48.2% of men. PCT use was associated with faster biochemical recovery (13.0 (IQR8.0-19.0) weeks, PCT; 26.0 (IQR10.5-52) weeks, no-PCT; P < .001). Odds of biochemical recovery during multivariable analysis were: (1) higher with PCT (OR3.80) vs no-PCT (P = .001), in men stopping AAS ≤3 months previously; (2) reduced when 2 (OR0.55), 3 (OR0.46), or 4 (OR0.25) AAS were administered vs 1 drug (P = .009); (3) lower with AAS >6 vs ≤3 months previously (OR0.34, P = .01); (4) higher with last reported AAS >3 months (OR 5.68) vs ≤3 months (P = .001). PCT use was not associated with biochemical recovery in men stopping AAS >3 months previously. Conclusion Without evidence-based withdrawal protocols, men commonly try avoiding post-AAS hypogonadism with PCT, which is illicit, ill-defined, and not recommended. Only half of men had complete biochemical testicular recovery after stopping AAS. The surprising association of self-reported PCT use with short-term biochemical recovery from AAS-induced hypogonadism warrants further investigation.

The use of post-cycle therapy is associated with reduced withdrawal symptoms from anabolic-androgenic steroid use: a survey of 470 men

Article

Full-text available

Nov 2023
SUBST ABUSE TREAT PR

Background Anabolic–androgenic steroids (AAS) mimic the effects of testosterone and may include testosterone itself; they are used for body enhancement within the general population. AAS use has been linked with increased mortality, cardiovascular disease, mental health disorders, and infertility. AAS-induced hypogonadism can persist for an uncertain time period despite cessation, during which men may report physical and neuropsychiatric symptoms. In an attempt to mitigate these symptoms and expedite testicular recovery, many men self-administer post-cycle-therapy (PCT), typically involving human chorionic gonadotrophin (hCG) and selective oestrogen receptor modulators (SERMs), which are known to potently stimulate testicular function. However, this practice has no objective evidence of effectiveness to lessen the severity or duration of hypogonadal symptoms. Methods An anonymous survey of four-hundred-and-seventy men using AAS explored the symptoms they experienced when ceasing AAS use; the effect of PCT on relieving their symptoms, and their perceived role for health service support. Results The majority of respondents were white, aged 18–30 years old, and working in skilled manual work. 51.7% (n = 243) reported no issues with AAS use, but 35.3% reported increased aggression. 65.1% (n = 306) of respondents had attempted AAS cessation and 95.1% of these experienced at least one symptom upon AAS cessation. Low mood, tiredness and reduced libido were reported in 72.9%, 58.5% and 57.0% of men stopping AAS use, respectively, with only 4.9% reporting no symptoms. PCT had been used by 56.5% of respondents with AAS cessation and mitigated cravings to restart AAS use, withdrawal symptoms and suicidal thoughts by 60%, 60% and 50%, respectively. The effect of stopping AAS on body composition and recovery of testosterone or fertility was a concern in 60.5% and 52.4%, respectively. Most respondents felt PCT should be prescribed under medical supervision in the community. Conclusions Our survey suggests that the majority of men stopping AAS use are using some form of PCT. Some self-reported symptoms of AAS-induced hypogonadism such as cravings to restart AAS use reduce by 60% and suicidal thoughts reduce by 50%. These individuals are concerned about the negative effect of AAS use and cessation. This study provides crucial information for planning future research to evaluate the effects of PCT on symptoms when men stop AAS use.

Understanding harm reduction perspectives of performance and image enhancing drug consumers and health care providers

Article

May 2022

Research has documented the harms associated with performance and image enhancing drug (PIED) use and lack of disclosure of use to healthcare providers (HCPs). Given that the relationship between HCPs and PIED consumers plays an important role in harm reduction, research is required to understand the barriers and facilitators for consumers to engage in help-seeking. This qualitative study explored the attitudes around current harm reduction frameworks for PIED consumers in Australia. Interviews were conducted with identified key stakeholders, who included a variety of PIED consumers as well as HCPs who come into frequent contact with PIED consumers. All participants were asked questions regarding the key barriers and facilitators for PIED consumers to help-seek, and how to best increase engagement among PIED consumers with HCPs. HCPs in Australia are calling for education around PIEDs, which is reflected as a ‘therapeutic barrier’ by consumers. This barrier represents an ongoing need to upskill HCPs in working with PIED consumers. Our data also showed a ‘safe space’ dynamic among peer-consumers in this space. Optimising harm reduction frameworks requires more synergy between peers and needle and syringe programs (NSPs), which remain safe and trusted environments for PIED consumers. We recommend harm reduction frameworks be strengthened through an increase in, and leveraging of, peer-led education programs.

Semaglutide, Testosterone and Sildenafil advertising on social media: The Normalisation of lifestyle enhancement drugs

Article

Full-text available

Sep 2024

Recently, there has been a sharp increase in advertising for the 'prescription-only' medicines semaglutide and testosterone on social media platforms in the UK, along with the 'pharmacy medicine' sexual enhancer Sildenafil. These promoted adverts appear to come from both legitimate clinics in the case of testosterone replacement therapy (TRT) and Sildenafil, and illicitly operating suppliers with the attempted appearance of legitimacy in the case of semaglutide. This commentary explores the extent to which the prevalent advertising of these lifestyle medicines on social media is normalising their use, and the potential harms associated with each. For testosterone / TRT, we consider the over-medicalisation of men's general wellbeing concerns and potential harms relating to dependency if use is promoted and encouraged beyond medical need, paralleling prior observations for the sexual enhancer sildenafil. This is followed by an exploration of harms relating to black market semaglutide supply on social media to individuals who are often unaware they are not accessing legitimate pharmaceutical product, including the dangers of product contamination and substitution, as well as uninformed use linked to a lack of information on safe dosages provided by suppliers. Following these discussions, this commentary examines the potential harm reduction impacts that direct to consumer (DTC) supply of prescription medicines could have, and considers how policy could encourage these beneficial effects without further nor-malising or encouraging drug use in otherwise healthy individuals. However, we also note the importance of tackling prevailing cultural pressures towards lifestyle drug use and the need to address these through education and similar policies.

Navigating non-medical androgen use: Towards a harm reduction paradigm

Article

Full-text available

Aug 2024

Non-medical androgen use is on the rise, with short-term side effects being well-documented whereas long-term consequences remain less understood but are likely to entail cardiovascular illness and permanent endocrine disruptions. Current educational initiatives are falling short in curbing this significant increase, signaling the need for a different approach. In this context, harm reduction emerges as a promising secondary prevention strategy. The key principles of the harm reduction approach outlined in this article emphasize educating individuals about side effects, limiting androgen use, and monitoring health closely. Successful implementation of this strategy hinges upon healthcare providers possessing expertise in the field, fostering non-judgmental interpersonal relationships, and securing cooperation of the athlete. The efficacy of this strategy will be rigorously evaluated in the HARNAS trial, comparing its outcomes with those of a historical control group. The findings from this trial are anticipated to be published in the coming years, shedding light on the effectiveness of this pioneering approach.

Androgen abuse: Risks and adverse effects in men

Article

Full-text available

Jul 2024
ANN NY ACAD SCI

Androgens, formerly known as anabolic‐androgenic steroids, mimic the effects of testosterone and are being increasingly abused for nonmedical purposes such as body and performance enhancement. Androgen abuse is associated with increased mortality, and multisystem adverse effects have been reported, including cardiovascular toxicity, infertility, hypogonadism, hepatotoxicity, and mental health disorders. Men may present with the negative health consequences of androgen abuse even despite cessation for a number of years. There is frequently a reluctance to disclose androgen abuse, and substances are often sourced from the black market, which is not regulated and where the products sold may be counterfeit. All men should be encouraged to stop androgen abuse. Managing associated adverse effects will be organ‐specific and is complex due to physical and neuropsychiatric symptoms, substance dependence, and high rates of relapse. Given the broad reach and prolonged adverse effects of androgen abuse, clinicians across medical specialties should have an awareness of androgen abuse, its increasing prevalence, and the harms it poses to men and their families. This narrative review aims to summarize the adverse effects and risks associated with androgen abuse.

The health effects of non-prescribed anabolic-androgenic steroid use: Findings from The Performance and image- enhancing drugs UseRS' Health (PUSH) audit

Article

Full-text available

Jul 2024
DRUG ALCOHOL REV

Introduction To ascertain the adverse health outcomes experienced by those using prescribed testosterone and non-prescribed anabolic–androgenic steroids presenting to general practitioner (GP) clinics. Methods Retrospective clinical audit from nine GP clinics in major metropolitan areas across three Australian states. Data included demographic and individual characteristics (age, sexuality, body mass index, smoking status and HIV status); performance and image-enhancing drug use (type, reasons for use, patient-reported adverse effects); and blood biochemistry measurements (lipid profiles, liver function tests and red blood cell tests). Adverse health outcomes included evidence of polycythaemia, hypertension, liver abnormalities and hypercholesterolemia. Results Three hundred men were identified as either using prescribed testosterone (66%; n = 197) or non-prescribed anabolic–androgenic steroids (AAS) (34%; n = 103). Individuals in the prescribed group were more likely to be older (p < 0.001), gay or bisexual (p < 0.001) and living with diagnosed HIV (p < 0.001) compared to individuals in the non-prescribed group. Abnormal liver function, polycythemia and gynecomastia were the top three adverse events experienced. When adjusting for age, sexuality, HIV status and smoking status, those who used non-prescribed AAS were more likely to experience any adverse event (aPR = 1.28; 95% CI 1.01–1.60; p = 0.038), hypertension (aPR = 1.86; 95% CI 1.19–2.91; p = 0.006) and liver abnormalities (aPR = 1.51; 95% CI 1.04–2.20; p = 0.030) compared to those using prescribed testosterone. Discussion and Conclusion For GPs who have clients who may be using, or who they suspect of using, AAS, these findings highlight the importance of not only exploring a patient's history of the adverse effects they have experienced, but that measuring for these other conditions may provide a more accurate clinical picture.

Off-label use of Clomiphene citrate to Treat Anabolic androgenic Steroid induced Hypogonadism upon cessation among men (CloTASH) - a pilot study protocol

Article

Jun 2024

Background Non-prescribed anabolic androgenic steroid (AAS) use is associated with AAS-induced hypogonadism (ASIH), and metabolic, cardiovascular, and mental health risks. Symptoms of ASIH (fatigue, depression, anxiety, sexual dysfunction) are hard to endure following cessation, but there is no consensus on whether endocrine treatment should be used to treat ASIH. This proof-of-concept study aims to explore safety of off-label clomiphene citrate therapy, whether the treatment will reduce the symptoms of androgen deficiency, and to study changes in health risks after cessation. Methods In this open-labeled non-randomized off-label hormone intervention pilot study, we shall include males with AAS dependence intending to cease use. The 16-week intervention included clomiphene citrate, transdermal testosterone gel for the first four weeks and optional human chorionic gonadotropin (hCG) from week 4 if low treatment response. Measures of physical and mental health will be examined from ongoing AAS use, during the intervention, and at 6- and 12 months post cessation. Change in self-reported symptoms of hypogonadism and other withdrawal symptoms will be compared with data from a group of men who ended AAS use temporarily without the medical intervention. The study may provide valuable clinical insights and may be used to inform the design of future intervention studies.

Clomiphene citrate and optional human chorionic gonadotropin for treating male hypogonadism arising from long-term anabolic-androgenic steroid use-A pilot study

Article

Full-text available

May 2024

Introduction: Long-term anabolic-androgenic steroid (AAS) use poses several health risks, including secondary hypogonadism. There is a knowledge gap on treatment targeting the hypothalamic-pituitary-gonadal (HPG) axis among men with anabolic steroid-induced hypogonadism (ASIH). This study aims to gain insights into the potential utility of endocrine therapy to restore endogenous testosterone levels and alleviate ASIH symptoms in AAS dependent men. Methods: In this proof-of-concept, single-site, open longitudinal pilot study, AAS dependent men with continuous AAS use and a desire to permanently discontinue use, were given endocrine therapy. The treatment included 25 mg clomiphene citrate (CC) every second day for 16 weeks, transdermal testosterone daily during the first four weeks, and if indicated, human chorionic gonadotropin (hCG) injections for a maximum of eight weeks. Physical exams including blood collection and online questionnaires were completed every four and two weeks, respectively. Results: Ten participants, with median age 32 years (interquartile range 30-45), with mean ± standard deviation AAS use of 11 ± 4 years, completed the CC intervention. Seven participants received hCG as part of their treatment protocol. Mild adverse events included headaches, dizziness, and mood swings, and no serious adverse events occurred. During the intervention, there was a decrease in levels of hematocrit, hemoglobin and ALT (alanine aminotransferase), as well as an increase in serum FSH (follicle stimulating hormone), LH (luteinizing hormone) and SHBG (sex hormone binding globulin). Five of ten participants reached a total testosterone level within normal range (9-30 nmol/l). The HPG axis response varied greatly among participants, and was not aligned with the severity of ASIH related withdrawal symptoms. Conclusions: The findings from this proof-of-concept study may guide future randomized controlled trials aiming to investigate potential endocrine therapeutic approaches to ASIH.

'The general concept is a safer use approach': how image and performance enhancing drug coaches negotiate safety through community care

Article

May 2024
DRUG-EDUC PREV POLIC

Background: Drug coaches are a novel extension of traditional personal trainers who play a significant role providing support and shaping drug-related behaviours for people who use image and performance enhancing drugs (IPEDs). They constitute a critical domain for everyday risk management, where substance use, and its associated harms are influenced by social exchange. This study investigated how IPED coaches negotiate safety within the community through the provision of their services and the partnerships they form with clients. Method: Ten IPED coaches, selected through purposive sampling, engaged in semi-structured interviews (32-57 minutes in length) exploring the way in which they operate in their field of practice. Iterative inductive analysis was applied to the transcripts, enhanced by discussions among researchers and an independent coder. Results: The findings are organised under three categories, revealing the nuanced strategies and identities of IPED coaches, emphasising harm reduction and optimising 'gains' in IPED use. These coaches play a significant role in harm reduction, wielding their 'chemical capital' and lived experience to integrate nuanced harm reduction strategies into their partnerships with clients. Conclusion: Embodying a model of peer-driven knowledge exchange and emphasising open and inclusive discourse IPED coaches offer a vehicle toward integrated harm reduction strategies.

“Bigger, stronger, sicker”, Integrative Psychological Assessment for Muscle Dysmorphia: Case Studies of Two Young Women Bodybuilders

Article

Mar 2024

Over the past three decades, the development of knowledge about muscle dysmorphia has enabled the scientific community to gain a better understanding of its etiopathogenesis and mechanism. However, few cases have been described, due to the absence of screening protocols and treatment guidelines. The aim of the current study was to evaluate muscle dysmorphia symptomatology, through an integrative psychological assessment, in two young female bodybuilders. In the first case study, we will focus on Mrs. I., who practices recreational bodybuilding, suffers from muscle dysmorphia with a form of eating disorder, and uses illegal APEDs. For the second case study, we will focus on Mrs L., who suffers from muscle dysmorphia, but with a predominant form of body dysmorphic disorder. The two case studies provided nuance of muscle dysmorphia symptomatology, leading a better understanding with its comorbidities, particularly in relation to eating disorders, body dysmorphic disorders and pathological exercise. Our study highlights the importance of an integrative psychological assessment in muscle dysmorphia and shows the interest of using pluri-modal approach in its diagnostic, whether for the field of psychopathology or sports psychology.

Big business: The private sector market for image and performance enhancing drug harm reduction in the UK

Article

Full-text available

Nov 2023
INT J DRUG POLICY

This article draws on three mutually independent ethnographic studies to explore the private sector market for image and performance enhancing drug (IPED) harm reduction in the UK, specifically examining (1) steroid accessory supplements; (2) blood testing services; and (3) bloodletting services. After contextualising the work with a discussion of IPED use and harm reduction and the substantial growth of the global health and fitness industry, each private sector provision is critically interrogated with the following questions in mind: what is the role and utility of these services compared to public sector provision? Why has the private sector begun to deliver IPED harm reduction products and services in the UK? And how does this provision relate to the health and fitness industry more broadly? The paper concludes with some reflections about the future direction of IPED harm reduction, the importance of community-led services, and the need to think innovatively if we are to best protect users' health and wellbeing.

Challenges recruiting men with a desire to cease anabolic-androgenic steroid use to a pilot involving hormone therapy intervention

Article

Full-text available

Aug 2023

Health service engagement, side effects and concerns among men with anabolic-androgenic steroid use: a cross-sectional Norwegian study

Article

Full-text available

Apr 2023
SUBST ABUSE TREAT PR

Background Recreational use of anabolic-androgenic steroids (AAS) is a public health concern world-wide associated with a range of physical and psychological side effects. Still, people who use AAS tend to be reluctant to seek treatment. This study aims to explore use characteristics, treatment-seeking behaviour, side effects and associated health concerns among men with AAS use. Methods The study includes cross-sectional self-report data from 90 men with a current or previous use of AAS exceeding 12 months, where 41 (45.6%) had sought treatment at least once during their lifetime, and 49 (54.4%) had not. Health service engagement was examined with descriptive statistics on reasons for contacting health services, transparency about AAS use, satisfaction with health services and reasons for not seeking treatment. Furthermore, experienced side effects and health concerns were compared between the treatment seeking and the non-treatment seeking group, using two-sample t-tests and Chi² or Fisher exact tests for numerical and categorical variables, respectively. Results All 90 AAS-using men reported side effects from AAS use. Treatment seekers were significantly younger, experienced more side effects including gynecomastia, excessive sweating, fatigue, depression and anxiety, and expressed more concern for testosterone deficiency. Preventive health check-up was the most common reason for seeking treatment (n = 22, 53.7%), and 38 men (93%) were transparent about AAS use during consultations with health professionals. The main reported reasons for not seeking healthcare services were that the experienced side effects were not considered to be of treatment demanding nature (n = 39, 79.6%) and the belief that healthcare providers had scarce knowledge about AAS use and its health impacts (n = 12, 24.5%). Conclusions Reluctance to seek treatment among people who use AAS, despite having associated side effects and health concerns, may contribute to continued health risks. It is important to fill the knowledge gap on how to reach and treat this new patient group, and policy makers and treatment providers need to be educated on how to meet their treatment needs.

Exploring the experiences of general practitioners working with patients who use performance and image enhancing drugs

Article

Feb 2023

The Use of Anabolic Androgenic Steroids as a Public Health Issue

Chapter

Dec 2022

Chapter 04. The Use of Anabolic Androgenic Steroids as a Public Health Issue; Jim McVeigh, Geoff Bates, and Gemma Anne Yarwood Chapter

Chapter

Dec 2022

In recent years there have been increasing calls for the use of anabolic steroids and associated drugs to be recognised as a public health issue. Once the domain of the competitive athlete and professional bodybuilder, recent decades have seen the diffusion of AAS from the hardcore gyms of the 1980s and 1990s to the mainstream exercise and fitness environments of the 21st century. Alongside the apparent increases in the use of these drugs, there is a growing evidence base in relation to harms - physical, psychological and (to some extent) social. But is this form of drug use a public health issue? What criteria should we use to make this judgement? What is the available evidence and has our understanding of the issue improved? By drawing on the authors’ research in the United Kingdom (UK) and the wider international literature this chapter will explore these issues and attempt to answer the fundamental question - is the use of anabolic steroids a public health issue?

‘Sustaining masculinity’: a scoping review of anabolic androgenic steroid use by older males

Article

Full-text available

Nov 2022

In the past, research, policy and media have reported the use of anabolic androgenic steroids (AAS) primarily among younger males. However, recent studies have indicated the presence of an older cohort of men who use AAS in comparison to previous years. We carried out a scoping review of the extant literature to map and describe what is known about the use of AAS by older men (>40 years). A systematic search collected and analysed empirical research and grey literature relevant to the research question. Following application of inclusion and exclusion criteria, 44 studies were included which were subsequently charted and thematically analysed. The records included originated from the UK, USA, Canada, Australia, Slovenia, Norway, Spain, Turkey, Switzerland, Japan, and five global studies and were published between 1996 and 2021. Age ranged overall from 14 to 78 years old, however our review only discussed findings pertaining to those older than 40. Three main themes with subthemes were generated as follows: 1) Characteristics of AAS Use; Self-reported Adverse Effects from AAS Use; and Harms Diagnosed by Medical Professional. The review highlights the significant risks to hypothalamic-pituitary testicular function, cardiovascular health, and other organ systems as a result of the ageing man who is motivated to sustain masculine characteristics such as muscularity, youthfulness, sexual function, and perceived desirability and attractiveness. Future research is required to further understand the motivations of older men who use AAS. Furthermore, there is a need for age-specific research and recommendations to inform future policy and practice pertaining so that age-appropriate healthcare and policy decisions can be made in the future.

Mixed-methods research on androgen abuse - a review

Article

Aug 2022
Curr Opin Endocrinol Diabetes Obes

Purpose of review: This paper reviews the mixed-methods studies from the last 2 years (2021-2022) into androgen use to highlight the most relevant developments within the field (see video, http://links.lww.com/COE/A35). Recent findings: The literature review found seven papers from 2021 to 2022. These seven cover a range of important considerations, including interventions to reduce androgen use, educational tools to increase professionals' knowledge, explorations on the comorbidity of use with other substances, motivations for use, potential risks factors for androgens' initiation, or risks of using androgens. Key findings include a greater understanding of motivations for use, particularly in females and older males; identification of potential risks for starting use/using androgens; benefits of including practical strength exercises in preventive intervention programmes and the efficacy of e-learning tools to increase professionals' knowledge of androgens use, as well as an increase in their confidence to support androgen users. Summary: The key implications for clinical practice are that we still need to support healthcare professionals to overcome the barriers for increasing their skills and knowledge around androgen use. A recognition that people who have become dependent on androgen use are potentially at risk of considerable harm, with further research needed into sub-groups of androgen users.

Prevalence of anabolic steroid users seeking support from physicians: a systematic review and meta-analysis

Article

Full-text available

Jul 2022

Objectives To estimate the overall prevalence of androgenic-anabolic steroids (AAS) users seeking support from physicians. Secondary objectives are to compare this prevalence in different locations and among subpopulations of AAS users, and to discuss some of the factors that could have influenced the engagement of AAS users with physicians. Design Systematic review and meta-analysis. Data sources MEDLINE, PsycINFO, Web of Science and SciELO were searched in January 2022. Eligibility criteria Quantitative and qualitative studies reporting the number of AAS users who sought support from physicians, with no restrictions of language or time of publication. Data extraction and synthesis Two independent reviewers extracted data and assessed the quality of studies, including publication bias. A random-effects meta-analysis was performed to estimate the overall prevalence of AAS users seeking support from physicians, followed by pooled prevalence rates by studies’ location and the subpopulation of AAS users. Results We identified 36 studies published between 1988 and 2021, involving 10 101 AAS users. The estimated overall prevalence of AAS users seeking support from physicians is 37.12% (95% CI 29.71% to 44.52%). Higher prevalence rates were observed in studies from Australia (67.27%; 95% CI 42.29% to 87.25%) and among clients of the needle and syringe exchange programme (54.13%; 95% CI 36.41% to 71.84%). The lowest prevalence was observed among adolescent AAS users (17.27%; 95% CI 4.80% to 29.74%). Conclusion Our findings suggest that about one-third of AAS users seek support from physicians, with remarkable differences between locations and subpopulations of AAS users. Further studies should investigate the factors influencing the engagement of AAS users with physicians. PROSPERO registration number CRD42020177919.

Endocrine treatment of anabolic-androgenic steroid induced hypogonadism in males: A pilot study

Article

May 2022

Knowledge and experience of using performance and image enhancing drugs among attendees of a Needle and Syringe Program in Australia: A qualitative study

Article

Mar 2022

Background The availability and utilisation of performance and image enhancing drugs (PIEDs) have been increasing in the last decade. This study aimed to understand the knowledge and experience of PIED use amongst attendees of a Needle and Syringe Program (NSP) in Australia. It also investigated their experience of seeking medical advice and accessing the NSP service. Methods Semi-structured interviews were conducted with 19 participants between September 2016 and April 2017. Audio recordings of the interviews were transcribed verbatim and content analysis was conducted. Results All 19 participants were male, with 10 participants aged 18–25 and 15 working. Participants showed sound knowledge of injecting practices and side effects; however, their understanding about blood-borne virus transmission risks was limited. Most of them reported experiencing injection-related injuries and considered this as common. They would seek general medical advice; however, they would not disclose their PIED use if not required as their past experience indicated that general practitioners lacked knowledge and support. Participants expressed concerns before their first visit to the NSP service, but thought staff were open minded, non-judgemental and helpful after the visit. They also highlighted the difficulty in accessing the service for injection equipment during business hours and provided suggestions on service improvement including extending the opening hours, using vending machines and providing a peer support program. Conclusions The findings suggest there is a need to educate PIED users about blood-borne virus transmission risks, improve general practitioners’ understanding about PIED use, and investigate the feasibility of extending the NSP service hours and for the service to provide a peer support program to clients who use PIEDs.

Investigating the impact of COVID-19 on performance and image enhancing drug use

Article

Full-text available

Dec 2021

Background Emerging research has suggested that the COVID-19 pandemic has had some impact on substance use patterns. The aim of the study was to conduct a rapid survey to assess the impact of COVID-19 on performance and image enhancing drug (PIED) use and training, and any subsequent negative physical or mental health outcomes. Methods During 2020, a convenience sample of 60 PIED consumers (mean age = 26.69; 68.3% located outside Australia) completed a quantitative anonymous online survey exploring how the coronavirus pandemic impacted patterns of PIED use and associated exercise habits. The survey was administered via the Qualtrics platform and distributed online through PIED forums as well as through the investigators’ networks. Participants were asked about their PIED use and exercise habits prior to and during restricted movement ‘lockdowns’. Results During pre-COVID, the majority of the sample opted to ‘blast-cruise’ (an initial high dose, followed by a lower maintenance dose; 71.7%, n = 43). During lockdown, 45% (n = 27) reported a change in PIED use as a result of the restrictions. In light of health concerns during COVID-19, a majority of men (60%, n = 36) did not take any extra precautions relating to their PIED use. A subgroup of men ceased using PIEDs completely (16.7%, n = 10) with the majority (80%, n = 8) of that subgroup following post-cycle therapy (PCT) of some kind. Only a small proportion of the sample reported negative mental health issues as a result of PCT access issues. Conclusions This study contributes to the emerging literature of the impact of the COVID-19 pandemic on substance use, specifically PIED use among men. The results suggest that the pandemic did influence the choice of PIEDs that participants consumed, although there was little disruption to patterns of exercise, an important aspect of PIED use. Of the men who did cease use completely, the majority reported little issue with PCT access; those who reported difficulty accessing PCT compounds indicated experience some mental health concerns related to ceasing their PIED use. Clinicians and those who come into contact with this group should be alert for any negative physical or mental health concerns resulting from disrupted or ceased PIED use.

Looking Beyond the Provision of Injecting Equipment to People Who Use Anabolic Androgenic Steroids: Harm Reduction and Behavior Change Goals for UK Policy

Article

Full-text available

Mar 2021

Understanding of the choices and motivations of people who use anabolic androgenic steroids (AAS) for muscular enhancement has increased greatly in the past thirty years, along with understanding of a wide range of health harms associated with this form of drug use in the community. During this period the predominant public health intervention for this population in the UK has consistently remained the provision of injecting equipment to prevent blood borne virus (BBV) transmission. The study explored the health professionals’ and other stakeholders’ perceptions on: whether the current UK public health response is sufficient to address the needs of people who use AAS, and if not, what other needs they might have. This included an exploration of whether there were gaps in harm reduction strategies or other behavioral outcomes and interventions that were needed. Interviews with 27 stakeholders who provide support to people who use AAS in a variety of roles established consensus on the need for a range of interventions to reduce harm and risk in those that choose to use AAS, to prevent initiation, to motivate and support cessation, and to prevent relapse. Study findings indicate that while providing sterile injecting equipment remains essential, it should be considered a bare minimum. The challenge is to develop and deliver a range of harm reduction interventions that look beyond BBV prevention to provide appropriate support to who choose to use AAS at all points in their cycles of use and ultimately for those choosing the temporary or permanent cessation of use.

Libido as a motivator for starting and restarting non-prescribed anabolic androgenic steroid use among men: a mixed-methods study

Article

Feb 2021

Anabolic Androgenic Steroids (AAS) are commonly used for their anabolic effects and the potentially detrimental consequences are well documented. Most studies focus on the motivations of increased muscle development and report increased libido as a secondary motivation. This paper aims to explore users’ reports of libido as a motivator for starting and restarting AAS use. This mixed-methods study comprised questionnaires with 133 adult male AAS users (with 38% selecting increased libido as motivation for using), and 23 semi-structured interviews with a sub-sample. Thematic analysis identified four interlinked themes: increased libido as a motivation for starting/re-starting AAS; increased libido/sexual performance as a beneficial effect; mixed experiences with physicians regarding libido changes and hypogonadism and reduced sexual functioning and fertility after AAS cessation. Increased libido was identified as a benefit by 90% but motivations for use changed over time. Reasons for AAS use included mitigating the effects of aging particularly linked to the concept of virility. AAS as self-medication for low testosterone needs further investigation as does the idea of hegemonic masculinity as a reinforcing driver for AAS use. This study highlights the need to consider how AAS users’ views of medical support impact self-medication choices.

Underwood. 2020. Testing the boundaries Self-medicated testosterone replacement and why it is practised

Article

Dec 2020
INT J DRUG POLICY

Background: Testosterone is used therapeutically in medical settings. Non-prescribed testosterone use is typically illegal, described as ‘enhancement’ or ‘doping’, and considered a problem. However, research has found that some non-prescribed testosterone use may be therapeutic (i.e. self-medication). Little is known about testosterone self- medication. It has been noted among individuals who use image and performance enhancing drugs (IPEDs), but never systematically explored. Approach: This paper describes the findings of a 4-year ethnographic study in online forums and social media groups frequented by people who use IPEDs. It focusses on 31 men who used enhancement doses of testosterone, but who described some of their testosterone use as ‘testosterone replacement therapy’ (TRT). In particular, it focuses on the 26 (84%) of these individuals who self-medicated TRT. Data was analysed thematically (using NVivo) in order to answer the question: ‘how and why is testosterone self-medicated?’. Using Bacchi’s (2016) prob- lematization approach to policy analysis, this paper also asks, ‘what happens to the ‘problem’ of non-prescribed testosterone use if such use is therapeutic?’. Findings: Self-medicated TRT was found to be very similar to TRT as practised in medical contexts. Self- medication was often practised because of an inability to access testosterone through health practitioners (who were either reluctant or unable to prescribe). However, some individuals were found to prefer self-medication because of price, ease of access, reliability of supply, and because health practitioners were perceived as lacking expertise regarding testosterone use. Conclusion: By documenting the therapeutic use of testosterone outside of medical settings, this paper calls into question previous conceptualisations of all illicit testosterone use as ‘abuse’, and the utility of the re- pair/enhancement dichotomy as a foundation for discussions of drug use. It suggests that in some cases the problem may not be non-prescribed testosterone use per se , but policies that prevent access to medical treatment.

Male Figural Rating Scales: A Critical Review of the Literature

Article

Full-text available

Apr 2020
BEHAV CHANGE

Figural rating scales are tools used to measure male body dissatisfaction. The present review aimed to examine the design and psychometric properties of male figural rating scales and make recommendations based on findings. Relevant databases were systematically searched for studies that had developed and validated male figural rating scales. Twenty studies were included in this review. Figural rating scales differed in terms of the number of images represented and type of stimuli used (hand-drawn silhouettes, hand-drawn figures, computer-rendered figures, and photograph figures). Reliability and validity evidence varied greatly in strength across all scales. Four of the 20 scales included a correlational analysis between figural rating scale scores and eating disorder symptoms. Results showed the moderate to high positive correlations between eating disorder symptoms and figural rating scale perceived and index scores, suggesting that figural rating scales are sensitive to detecting eating disorder symptoms. Ideally, male figural rating scales should show strong validity and reliability, include variations in both body fat and muscularity, utilise realistic body stimuli, and be interval scales. No existing male figural rating scale meets these criteria. However, this review identifies five figural rating scales that meet the majority of the recommended criteria.

The modes of administration of anabolic-androgenic steroid users (AAS): are non-injecting people who use steroids overlooked?

Article

May 2019

Introduction: There is increasing public health concern about the use of anabolic-androgenic steroids (AAS). Understanding of drug use patterns and practices is important if we are to develop appropriate risk-reduction interventions. Yet, much remains unclear about the modes of administration adopted by AAS users. Methods: We used data from a sub-sample of participants from the Global Drug Survey 2015; males who reported using injectable or oral AAS in their lifetime (n = 1008). Results: Amongst our sample, approximately one third (35.62%) reported using only injectable AAS during their lifetime while 35.84% reported using only oral, with less than one third (28.54%) using both. Conclusion: These findings suggest there may be a sub-population of individuals who only use AAS orally. Needle and syringe programmes (NSPs) are currently the primary point of health service engagement; forming the main healthcare environment for medical and harm reduction advice on steroids. Yet, NSP-based resources are unlikely to reach or be appropriate to those who do not inject AAS. While there is a general need for health services to be more accessible when it comes to AAS use, non-injectors are an overlooked group that require attention.

Sizing it up: A Systematic Review of the Nosology of Muscle Dysmorphia

Article

Sep 2018

An evidence-based socioecological framework to understand men’s use of anabolic androgenic steroids and inform interventions in this area

Article

Jul 2018

Research into men’s use of anabolic androgenic steroids (AAS) over the past three decades has identified many factors that contribute to decision-making in this area. However, there are limited theoretical frameworks to synthesise this research and guide practice, such as interventions to prevent use or reduce health risks. To address this gap, a socioecological framework is presented based upon the international literature examining AAS use. Socioecological models recognise that individuals and behaviours exist within complex physical and social systems and are useful tools for guiding interventions to ensure consideration is given to multiple influential factors. This framework proposes that use of AAS is the result of the interaction of a range of factors at the individual, social network, institutional, community, and societal levels that are likely to change over time and with experience. Viewed through this framework, it becomes clear that AAS use can be a complex behaviour with many influential environments and relationships impacting on a diverse population in different ways and at different times. The implications of findings for engaging with people who use AAS and delivering interventions are discussed, such as the identification of important transition times and influencing norms within social groups and communities.

Development and Validation of the New Somatomorphic Matrix-Male: A Figural Rating Scale for Measuring Male Actual-Ideal Body Discrepancy

Article

Full-text available

Jul 2018

This study aimed to develop and examine the validity evidence of the New Somatomorphic Matrix–Male (NSM-M) as a measure of actual–ideal body discrepancy. The NSM-M is a visual matrix of 34 male bodies that vary along two dimensions: body fat percentage (range = 4 – 40%) and muscularity (fat-free mass index; range = 16.5–30 kg/m2; 36.4–66.1 lbs/m2). In Study 1, participants were 2,733 sexual minority males recruited via a geosocial networking smartphone application. Participants selected their “actual” and “ideal” bodies on the NSM-M and additionally completed questionnaires measuring body dissatisfaction, eating disorder symptoms, quality of life, and anabolic steroid use. In Study 2, participants were 33 males from a community sample. They completed the NSM-M across two sessions, 7–14 days apart. NSM-M scores demonstrated concurrent and convergent validity as a measure of male body dissatisfaction. In addition, NSM-M scores discriminated between steroid users and nonusers, and between body mass index categories. The NSM-M also demonstrated sound test–retest reliability across a 7- to 14-day period. In sum, the NSM-M is validated figural measure of male actual–ideal body discrepancy with notable strengths, including fast administration time and enhanced ecological validity.

Psychology of Men & Masculinity Development and Validation of the New Somatomorphic Matrix-Male: A Figural Rating Scale for Measuring Male Actual-Ideal Body Discrepancy

Article

Full-text available

Jul 2018

This study aimed to develop and examine the validity evidence of the New Somatomorphic Matrix–Male (NSM-M) as a measure of actual–ideal body discrepancy. The NSM-M is a visual matrix of 34 male bodies that vary along two dimensions: body fat percentage (range = 4–40%) and muscularity (fat-free mass index; range = 16.5–30 kg/m2; 36.4–66.1 lbs/m2). In Study 1, participants were 2,733 sexual minority males recruited via a geosocial networking smartphone application. Participants selected their “actual” and “ideal” bodies on the NSM-M and additionally completed questionnaires measuring body dissatisfaction, eating disorder symptoms, quality of life, and anabolic steroid use. In Study 2, participants were 33 males from a community sample. They completed the NSM-M across two sessions, 7–14 days apart. NSM-M scores demonstrated concurrent and convergent validity as a measure of male body dissatisfaction. In addition, NSM-M scores discriminated between steroid users and nonusers, and between body mass index categories. The NSM-M also demonstrated sound test–retest reliability across a 7- to 14-day period. In sum, the NSM-M is validated figural measure of male actual–ideal body discrepancy with notable strengths, including fast administration time and enhanced ecological validity.

The Contribution of Social Media to Body Dissatisfaction, Eating Disorder Symptoms, and Anabolic Steroid Use Among Sexual Minority Men

Article

Jan 2018

Social media has been associated with body dissatisfaction and eating disorder symptoms among young women and adolescent girls. However, despite notable evidence of susceptibility to body image pressures, it remains unknown whether these associations generalize to sexual minority men. A nationwide sample of 2,733 sexual minority men completed an online survey advertised to Australian and New Zealand users of a popular dating app. Participants answered questions about how frequently they used 11 different social media platforms in addition to questions about their dating app use, body image, eating disorder symptoms, and anabolic steroids. Facebook, Youtube, Instagram, and Snapchat were the most frequently used social media platforms. A pattern of small-sized and positive associations emerged between social media use and body dissatisfaction, eating disorder symptoms, and thoughts about using anabolic steroids. Facebook, Instagram, and Snapchat evidenced the strongest associations. The associations of social media use with both muscularity dissatisfaction and eating disorder symptoms were stronger for image-centric social media platforms (e.g., Instagram) than nonimage-centric platforms (e.g., Wordpress); no differences were observed for body fat dissatisfaction, height dissatisfaction , or thoughts about using anabolic steroids. Previously documented associations of social media use with body dissatisfaction and related variables among women and girls appear to generalize to sexual minority men. Social media platforms that more centrally involve imagery may be of greater concern than nonimage-centric platforms. Additional research with sexual minority men is needed to elucidate the distinctions between adaptive and maladaptive social media use in the context of body dissatisfaction, eating disorders, and anabolic steroid use.

“Raw juicing” – an online study of the home manufacture of anabolic androgenic steroids (AAS) for injection in contemporary performance and image enhancement (PIED) culture

Article

Dec 2017

Background New evidence with regard to an under documented practice – the home manufacture of anabolic androgenic steroids (AAS) for injection, known as ‘homebrewing’ – in contemporary injecting performance and image enhancing drug (PIED) culture is the subject of this paper. Methods Data was collected from five publicly accessible internet discussion forums and coded using NVivo software. For the purposes of this study, threads in relation to homebrewing (n = 14) were extracted from the final set of records for ethnographic content analysis. Results Motivation to perform homebrewing was largely grounded in the circumnavigation of unreliable online sourcing routes for AAS products, financial losses and potential harms associated with contaminated and counterfeit injectables. Instructions on how to perform homebrewing were found within discussion threads. Identified areas of concern included potential for sterility and dosing issues, injecting harms, isolation from health services. Conclusion This study provides a snapshot of online communal activity around practice of homebrewing AAS amongst individuals who inject AAS. Further research in this area is warranted, and will be of benefit to healthcare workers, treatment providers and policy makers particularly as this relates to evidence informed and targeted harm reduction policies and effective public health interventions.

From ‘bro, do you even lift?’ to ‘bro, do you even science?’: How the relationship between science and broscience can inform the development of allied image and performance enhancing drug harm reduction

Article

Aug 2024

Mair Underwood

Social media influencers, YouTube & performance and image enhancing drugs: A narrative-typology

Article

Oct 2023

Background The health and fitness industry has witnessed a rise of influencers on social media promoting a myriad of brands and products, including some promoting anabolic steroids and other performance and image enhancing drugs (PIEDs). It is currently unclear, however, what type of information and advice social media influencers distribute. Aim This study aims to examine the narratives of social media influencers who discuss PIEDs. Method The study identified 20 influencers specialized in PIEDs and then made a content analysis of the videos they posted on YouTube. Findings While we find several similarities in influencers’ narratives, we also categorize them in three distinct categories: (1) narratives primarily relying on scientific literature and discussing ‘usual’ bodybuilders’ products and doses; (2) narratives primarily relying on the influencers’ personal experience and discussing ‘usual’ bodybuilders products and doses; and (3) narratives primarily relying on the influencers’ personal experience and discussing experimental products and ‘unusual’ doses. Recommendations The narrative-typology should be used as a means of identifying high-risk videos on social media platforms like YouTube. Policy-makers should do more to challenge high-risk and potentially harmful discussions. Conversely, reliable discussions ought to be made more visible to ensure they are not overshadowed by flashier and riskier narratives.

A review of recent evidence on androgen abuse from interviews with users

Article

Aug 2023
Curr Opin Endocrinol Diabetes Obes

Purpose of review: Androgens (also known as anabolic-androgenic steroids; AAS) are increasingly being abused worldwide to enhance body physique or athletic performance. Qualitative studies including interviews provide a wider understanding of androgen abuse and focus specific support needs to this group. This narrative review summarizes recent studies (2021-2023) using interviews with individuals abusing androgens. Recent findings: Motivations for androgen abuse in men include desires to achieve certain physicality, enhance self-confidence and improve libido. The risks of androgen abuse are justified to achieve these outcomes and men may use other illicit substances as postcycle-therapy to lessen the risks. Some adverse effects may be more pronounced with certain substances. The therapeutic relationship with healthcare professionals is often described negatively by androgen abusers due to stigma and a perceived lack of knowledge. Both healthcare professionals and androgen abusers agree that development of guidelines are needed. Androgen abuse in women is rare however body dissatisfaction and desires for improve appearance and strength are motivators. Summary: Recent qualitative studies have helped further our understanding of men and women who abuse androgens, however the small number of recently published studies confirms there is still a paucity of evidence in the literature. Further research is needed to develop specific harm minimization strategies in those abusing androgens.

Anabolics coaching: A necessary evil?

Article

Aug 2022

Mair Underwood

“For research use only”: A comprehensive analysis of SARMs and related IPEDs purchased on local Australian websites between 2017 and 2018

Article

Oct 2021

Introduction: The range of image and performance enhancing drugs (IPEDs) available is expanding beyond anabolic-androgenic steroids to alternatives such as selective androgen receptor modulators (SARMs). Many have yet to complete clinical trials, so their toxicity and drug-drug interactions are unknown. Yet, they are easily accessible online and are marketed for synergistic use in cycles. This poly-drug use has implications in anti-doping and public health. Comprehensive studies on these products are lacking, particularly research focused on the Australian market, leading to a deficiency in understanding of the nature and use of these alternative IPEDs. Method: Australian online retailers were surveyed, and 107 oral liquid products purporting to contain IPEDs were purchased between 2017 and 2018. A further 4 were obtained from a drug seizure. The product websites, packaging, contamination, and main active pharmaceutical ingredients were used to assess the product quality, to gain a holistic understanding of the products. A month-long stability test was conducted to identify other potential risks associated with the use of these products in Australia. Results: Most online retailer websites were still live in 2019, notwithstanding changes in the Poisons Standard regarding popular IPEDs. Just over half the products were still available on the same website. Most homepages featured fitspo imagery, notably including women. Product-specific pages often featured a “for research use only” warning and presented usage details informally. The packaging also featured the “for research use only” warning, while lacking many requirements of true therapeutic goods. Qualitative chemical analysis revealed that while 94 of the 111 products correctly identified the main active pharmaceutical ingredient on the label, 90 were contaminated with other IPEDs. Validated quantitative chemical methods assessed dosage strength and homogeneity to reveal that only 34 of the 111 were considered of good quality. Uniting the chemical analysis data revealed that the only high quality IPED was one of the seized products. Additionally, the stability test revealed that these IPEDs are generally stable across the different conditions tested, approximating Australian weather extremes. Conclusion: This research has strengthened concerns over the quality of IPED products sold on the Australian market and indicates there is no relationship between IPED product presentation and its chemical quality. The high proportion of contaminated IPED products may lead to poly-drug positives in doping control and possible adverse health effects due to drug-drug interactions. Education on IPEDs must expand to include these other classes to protect the community.

Supply and Enhance: Tracing the Doping Supply Chain in the 1980s

Thesis

Full-text available

Aug 2020

Daniel Lukas Rosenke

Like Michael Jackson’s iconic album Thriller, the HIV/AIDS pandemic, and the fall of the Berlin Wall, performance-enhancing drugs are part of the zeitgeist of the 1980s, a decade of turbulence in the sporting world and one of enlightenment for fans and journalists worldwide. Sport’s dirty little secret was first revealed at the 1983 Pan-American Games, where a throng of positive tests and the mass exodus of (ostensibly) guilty American athletes brought doping to mainstream audiences, and alerted policy makers to a societal ill that could no longer be ignored. Popular anabolic drugs like Dianabol and Testosterone Depot had been in wide use for decades, and in the absence of rigorous controls – both anti-doping and statutory – spread like wildfire in elite sport, bodybuilding, and gym culture. By the mid-1980s gaining access to them was all but a formality, as simple as paying a visit to one’s family physician, the resident dealer at Gold’s Gym, or the local discus champion peddling Mexican steroids to make ends meet. While chemical enhancement in this era is well-represented in the extant literature, relatively little has been said about how these drugs fell in the hands of users. Each of the three articles in this volume survey a different supply source for performance-enhancing drugs in the 1980s. In the first study, I profile the enigmatic doping physician Robert Kerr, an open advocate for the safe x use of anabolic steroids under medical supervision. After prescribing the drugs for more than seventeen years, Kerr embraced the role of anti-doping advocate, appearing as an expert witness in several government-led hearings in the late 1980s. In the second study, I investigate a drug-smuggling incident at Montreal’s Mirabel Airport. On 31 October 1983, four of Canada’s premier weightlifters were arrested after border agents discovered a cache of anabolic steroids in each of their bags. The men had purchased them from Soviet lifters for resale on home soil. The third essay chronicles the rise and fall of America’s largest steroid distribution ring, and as a parallel narrative, an anti-steroid counteroffensive headed by the FBI. Combined, these studies provide historical context for the proliferation of doping agents in North America, and the efforts of sports federations and politicians to remedy the problem.

Fragile Femininity, Embodiment, and Self-Managing Harm: An Interpretative Phenomenological Study Exploring the Lived Experience of Females who use Anabolic-Androgenic Steroids.

Article

Full-text available

Jun 2021

Little research exists on the lived experiences of female anabolic-androgenic steroid (AAS) use from a harm reduction perspective. This study aims to address this gap and explore the experiences, perceptions, and perspectives of AAS-using females through their journeys of starting, using, and coming off AAS to facilitate appropriate public health policies. Four females, recruited using opportunistic purposive sampling, participated in semi-structured interviews. Using Interpretative Phenomenological Analysis (IPA), four superordinate themes clarify the experiences and narratives detailed by the participants: preparation and anxiety (before using AAS); deviation from feminine identity (during AAS use); turbulence of cessation (end of AAS use); and rediscovering femininity (post-AAS cessation reflections). The results show how harm arising from AAS use is characterised by the development of virilising effects and the complex framing of their feminine identity, providing a clearer image of how harm is defined and managed by this population. While participants anticipated adverse side effects, this did not prevent negative emotions arising from their development. Our results also suggest that gender identity in this unique population is inseparable but not irreconcilable with the changing body. Illuminating this specific facet of AAS use can help inform holistic, meaningful, and more inclusive harm reduction measures by adding experiential information from this unique but understudied and hard-to-reach group.

Liver injury associated with the use of selective androgen receptor modulators and post-cycle therapy: Two case reports and literature review

Article

Full-text available

Jun 2021

Background: Muscle growth promoters are being developed for the treatment of disease-induced loss of muscle mass. Ligandrol and ostarine are selective androgen receptor modulators (SARMs) with a non-steroidal structure and a presumably more favorable side effect profile. In recent years, these substances with or without "post-cycle therapy" (PCT) are often misused by amateur athletes aiming to promote muscle growth. At the same time, reports on their toxic effects on organ systems are emerging. Case summary: We report two cases of liver injury in young men who used ligandrol and/or ostarine for a few weeks followed by the use of substances for PCT. Acute liver injury occurred in both cases after stopping SARMs while on PCT. The clinical picture was dominated by jaundice and fatigue. The biochemical pattern showed a mixed type of injury with normal alkaline phosphatase and high concentrations of bilirubin and serum bile acids. Histological evidence showed predominantly cholestatic injury with canalicular bile plugs, ductopenia, and mild hepatocellular damage without significant fibrosis. The patients recovered from the condition after 3 mo. The off target effects of SARMs were likely idiosyncratic, but our report highlights the yet unrecognized effects of other toxic substances used for PCT, supra-therapeutic doses, and the complete absence of monitoring for adverse effects. Conclusion: Among muscle-building amateur athletes, SARMs (ligandrol or ostarine) and/or substances in PCT may cause cholestatic liver injury with prolonged recovery.

Performance- and image-enhancing drug use in the community: use prevalence, user demographics and the potential role of wastewater-based epidemiology

Article

Jun 2021
J HAZARD MATER

Performance- and image-enhancing drugs (PIEDs) misuse is a significant public health issue. Currently, seizure data, surveys, anti-doping testing, and needle service provider data are used to estimate PIED use in populations. These methods are time consuming, single point-in-time measurements that often consist of small sample sizes and do not truly capture PIED prevalence. Wastewater-based epidemiology (WBE) has been used globally to assess and monitor licit and illicit drug consumption within the general community. This method can objectively cover large populations as well as specific subpopulations (gyms, music festivals, prisons), and has potential as a complementary monitoring method for PIED use. Information obtained through WBE could be used to aid public health authorities in developing targeted prevention and education programmes. Research on PIED analysis in wastewater is limited and presents a significant gap in the literature. The focus is on anabolic steroids, and one steroid alternative currently growing in popularity; selective androgenic receptor modulators. This encompasses medical uses, addiction, prevalence, user typology and associated public health implications. An overview of wastewater-based epidemiology is described including its benefits, limitations and potential as a monitoring method for PIED use. A summary of previous work in this field is presented. Finally, we summarise gaps in the literature, future perspectives and recommendations for monitoring PIEDs in wastewater.

Appearance- and Performance-Enhancing Substances Including Anabolic-Androgenic Steroids Among Boys and Men

Chapter

Apr 2021

Body dissatisfaction, particularly with a focus on muscularity, continues to be a pervasive issue among boys and men. It may then come as no surprise that some look to use special drugs and substances to facilitate their pursuit of an increasingly muscular physique. This chapter highlights a myriad of both legal and illegal appearance- and performance-enhancing substances (APESs) which could be sought for such functions, with a particular focus on a class of illicit APES that has received arguably the greatest empirical and clinical attention – anabolic-androgenic steroids (AASs). While AASs may be sought out to boost lean muscularity at a rate virtually impossible through conventional diet or exercise alone, our chapter first presents medical research to underscore the physical and psychological health complications connected with its use. Second, we illustrate the close relationship between problematic male body image and the motivation to use AASs, highlighting in particular its association with muscle dysmorphia, a serious psychiatric condition hallmarked by the pathological extreme pursuit of muscularity. The chapter closes by synthesizing available literature to provide an overview of important (but preliminary) considerations, guidance, and recommendations that may help support clinicians in dealing with the complexities of AAS use.

Body Image Disorders in Men

Chapter

Mar 2021

Although research shows that there is a silent crisis in men's mental health, there remains surprisingly little literature on the subject. This important textbook provides up-to-date, practical and evidence-based information on how mental health issues affect men and the way treatments should be offered to them. Key opinion leaders from across the globe have been brought together to offer much-needed understanding about the socio-politico-economic context of men's lives today as well as ethnic and cultural effects and genetic, epigenetic and gene-environment interaction. Clinically focused chapters cover topics such as suicide and self-harm, violence, sociopathy and substance misuse in men; depression, anxiety and related disorders; and psychotic and cognitive disorders. The book uses a lifespan approach to assessment and treatment, accounting for age and developmental phase. An invaluable source of information for clinical specialists and trainees in psychiatry, psychology, and mental health nursing as well as social workers, and occupational therapists.

‘Shades of Grey’: The Ethics of Social Work Practice in Relation to Un-prescribed Anabolic Androgenic Steroid Use

Article

Dec 2018

Orlanda Harvey

This paper reflects on some of the ethical dilemmas that social workers face when assessing risk in relation to those using substances. It explores how legislation and societal factors can impact not just on people’s choices and decisions but also on their ‘vulnerability’ and access to services. Vulnerability, a contested term, is linked, in this paper, to assessment of risk. There are ethical issues that arise when assessing risk with people who use Anabolic Androgenic Steroids (AAS) from both service user and professional perspectives. These ethical issues concern a person’s right to choose and make potentially harmful decisions. The paper argues that using substances such as AAS in and of itself does not suffice to make a person vulnerable but this does not mean that people using AAS are not in need of support. It suggests that there may be some groups of people who are more at risk to starting AAS use and that social workers should be aware of these. It also recommends the need for further qualitative research to understand the reasons for starting use and support to help people stop using AAS.

Research Methods for Clinical and Health Psychology

Article

Full-text available

Jan 2003

The Anabolic 500 Survey: Characteristics of Male Users versus Nonusers of Anabolic-Androgenic Steroids for Strength Training

Article

Full-text available

Aug 2011
PHARMACOTHERAPY

To contrast the characteristics of two groups of men who participated in strength-training exercise-those who reported anabolicandrogenic steroid (AAS) use versus those who reported no AAS use. Analysis of data from the Anabolic 500, a cross-sectional survey. Five hundred six male self-reported AAS users (mean age 29.3 yrs) and 771 male self-reported nonusers of AAS (mean age 25.2 yrs) who completed an online survey between February 19 and June 30, 2009. Respondents were recruited from Internet discussion boards of 38 fitness, bodybuilding, weightlifting, and steroid Web sites. The respondents provided online informed consent and completed the Anabolic 500, a 99-item Web-based survey. Data were collected on demographics, use of AAS and other performance-enhancing agents, alcohol and illicit drug use, substance dependence disorder, other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses, and history of sexual and/or physical abuse. Most (70.4%) of the AAS users were recreational exercisers who reported using an average of 11.1 performance-enhancing agents in their routine. Compared with nonusers, the AAS users were more likely to meet criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001), report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010), use cocaine within the past 12 months (11.3% vs 4.7%, p<0.001), and report a history of sexual abuse (6.1% vs 2.7%, p=0.005). Most of the AAS users in this study were recreational exercisers who practiced polypharmacy. The AAS users were more likely than nonusers to meet criteria for substance dependence disorder, report a diagnosis of an anxiety disorder, report recent cocaine use, and have a history of sexual abuse. The information uncovered in this study may help clinicians and researchers develop appropriate intervention strategies for AAS abuse.

Treatment of Anabolic-Androgenic Steroid Dependence: Emerging Evidence and Its Implications

Article

Full-text available

Feb 2010

Currently, few users of anabolic-androgenic steroids (AAS) seek substance abuse treatment. But this picture may soon change substantially, because illicit AAS use did not become widespread until the 1980s, and consequently the older members of this AAS-using population - those who initiated AAS as youths in the 1980s - are only now reaching middle age. Members of this group, especially those who have developed AAS dependence, may therefore be entering the age of risk for cardiac and psychoneuroendocrine complications sufficient to motivate them for substance abuse treatment. We suggest that this treatment should address at least three etiologic mechanisms by which AAS dependence might develop. First, individuals with body image disorders such as "muscle dysmorphia" may become dependent on AAS for their anabolic effects; these body image disorders may respond to psychological therapies or pharmacological treatments. Second, AAS suppress the male hypothalamic-pituitary-gonadal axis via their androgenic effects, potentially causing hypogonadism during AAS withdrawal. Men experiencing prolonged dysphoric effects or frank major depression from hypogonadism may desire to resume AAS, thus contributing to AAS dependence. AAS-induced hypogonadism may require treatment with human chorionic gonadotropin or clomiphene to reactivate neuroendocrine function, and may necessitate antidepressant treatments in cases of depression inadequately responsive to endocrine therapies alone. Third, human and animal evidence indicates that AAS also possess hedonic effects, which likely promote dependence via mechanisms shared with classical addictive drugs, especially opioids. Indeed, the opioid antagonist naltrexone blocks AAS dependence in animals. By inference, pharmacological and psychosocial treatments for human opioid dependence might also benefit AAS-dependent individuals.

Bigorexia: Bodybuilding and Muscle Dysmorphia

Article

Full-text available

May 2009
EUR EAT DISORD REV

Philip E Mosley

Muscle dysmorphia is an emerging condition that primarily affects male bodybuilders. Such individuals obsess about being inadequately muscular. Compulsions include spending hours in the gym, squandering excessive amounts of money on ineffectual sports supplements, abnormal eating patterns or even substance abuse. In this essay, I illustrate the features of muscle dysmorphia by employing the first-person account of a male bodybuilder afflicted by this condition. I briefly outline the history of bodybuilding and examine whether the growth of this sport is linked to a growing concern with body image amongst males. I suggest that muscle dysmorphia may be a new expression of a common pathology shared with the eating disorders.

The Effects of Supraphysiologic Doses of Testosterone on Muscle Size and Strength in Normal Men

Article

Full-text available

Aug 1996

Athletes often take androgenic steroids in an attempt to increase their strength. The efficacy of these substances for this purpose is unsubstantiated, however. We randomly assigned 43 normal men to one of four groups: placebo with no exercise; testosterone with no exercise; placebo plus exercise; and testosterone plus exercise. The men received injections of 600 mg of testosterone enanthate or placebo weekly for 10 weeks. The men in the exercise groups performed standardized weight-lifting exercises three times weekly. Before and after the treatment period, fat-free mass was determined by underwater weighing, muscle size was measured by magnetic resonance imaging, and the strength of the arms and legs was assessed by bench-press and squatting exercises, respectively. Among the men in the no-exercise groups, those given testosterone had greater increases than those given placebo in muscle size in their arms (mean [+/-SE] change in triceps area, 424 +/- 104 vs. -81 +/- 109 square millimeters; P < 0.05) and legs (change in quadriceps area, 607 +/- 123 vs. -131 +/- 111 square millimeters; P < 0.05) and greater increases in strength in the bench-press (9 +/- 4 vs. -1 +/- 1 kg, P < 0.05) and squatting exercises (16 +/- 4 vs. 3 +/- 1 kg, P < 0.05). The men assigned to testosterone and exercise had greater increases in fat-free mass (6.1 +/- 0.6 kg) and muscle size (triceps area, 501 +/- 104 square millimeters; quadriceps area, 1174 +/- 91 square millimeters) than those assigned to either no-exercise group, and greater increases in muscle strength (bench-press strength, 22 +/- 2 kg; squatting-exercise capacity, 38 +/- 4 kg) than either no-exercise group. Neither mood nor behavior was altered in any group. Supraphysiologic doses of testosterone, especially when combined with strength training, increase fat-free mass and muscle size and strength in normal men.

Testosterone dose-response relationships in healthy young men

Article

Full-text available

Jan 2002

Testosterone increases muscle mass and strength and regulates other physiological processes, but we do not know whether testosterone effects are dose dependent and whether dose requirements for maintaining various androgen-dependent processes are similar. To determine the effects of graded doses of testosterone on body composition, muscle size, strength, power, sexual and cognitive functions, prostate-specific antigen (PSA), plasma lipids, hemoglobin, and insulin-like growth factor I (IGF-I) levels, 61 eugonadal men, 18-35 yr, were randomized to one of five groups to receive monthly injections of a long-acting gonadotropin-releasing hormone (GnRH) agonist, to suppress endogenous testosterone secretion, and weekly injections of 25, 50, 125, 300, or 600 mg of testosterone enanthate for 20 wk. Energy and protein intakes were standardized. The administration of the GnRH agonist plus graded doses of testosterone resulted in mean nadir testosterone concentrations of 253, 306, 542, 1,345, and 2,370 ng/dl at the 25-, 50-, 125-, 300-, and 600-mg doses, respectively. Fat-free mass increased dose dependently in men receiving 125, 300, or 600 mg of testosterone weekly (change +3.4, 5.2, and 7.9 kg, respectively). The changes in fat-free mass were highly dependent on testosterone dose (P = 0.0001) and correlated with log testosterone concentrations (r = 0.73, P = 0.0001). Changes in leg press strength, leg power, thigh and quadriceps muscle volumes, hemoglobin, and IGF-I were positively correlated with testosterone concentrations, whereas changes in fat mass and plasma high-density lipoprotein (HDL) cholesterol were negatively correlated. Sexual function, visual-spatial cognition and mood, and PSA levels did not change significantly at any dose. We conclude that changes in circulating testosterone concentrations, induced by GnRH agonist and testosterone administration, are associated with testosterone dose- and concentration-dependent changes in fat-free mass, muscle size, strength and power, fat mass, hemoglobin, HDL cholesterol, and IGF-I levels, in conformity with a single linear dose-response relationship. However, different androgen-dependent processes have different testosterone dose-response relationships.

A league of their own: Demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States

Article

Full-text available

Feb 2007
Sports Nutr Rev J

Rule violations among elite-level sports competitors and tragedies among adolescents have largely defined the issue of non-medical anabolic-androgenic steroid (NMAAS) use for the public and policy makers. However, the predominant and oft-ignored segment of the NMAAS community exists in the general population that is neither participating in competitive sports nor adolescent. A clearer profile of NMAAS users within the general population is an initial step in developing a full understanding of NMAAS use and devising appropriate policy and interventions. This survey sought to provide a more comprehensive profile of NMAAS users by accessing a large sample of user respondents from around the United States. U.S.-based male NMAAS users (n = 1955) were recruited from various Internet websites dedicated to resistance training activities and use of ergogenic substances, mass emails, and print media to participate in a 291-item web-based survey. The Internet was utilized to provide a large and geographically diverse sample with the greatest degree of anonymity to facilitate participation. The majority of respondents did not initiate AAS use during adolescence and their NMAAS use was not motivated by athletics. The typical user was a Caucasian, highly-educated, gainfully employed professional approximately 30 years of age, who was earning an above-average income, was not active in organized sports, and whose use was motivated by increases in skeletal muscle mass, strength, and physical attractiveness. These findings question commonly held views of the typical NMAAS user and the associated underlying motivations. The focus on "cheating" athletes and at risk youth has led to ineffective policy as it relates to the predominant group of NMAAS users. Effective policy, prevention or intervention should address the target population(s) and their reasons for use while utilizing their desire for responsible use and education.

Muscle Dysmorphia: Clinical Presentation and Treatment Strategies

Article

Aug 2017

Muscle dysmorphia is a recently identified, complex, and largely unknown psychiatric disorder. Individuals with muscle dysmorphia typically report preoccupation with thoughts of attaining greater muscularity; conceal their bodies in public; have poor levels of insight into their preoccupation; report extreme functional impairment due to their preoccupation; have elevated rates of comorbid eating, mood, anxiety, and body dysmorphic disorders; use steroids; exercise compulsively; are strong adherents to traditional male gender roles; and report an elevated history of suicide attempts. Treatments for eating disorders and body dysmorphic disorder may be effective for muscle dysmorphia, and case report evidence has shown family-based therapy to be effective for adolescent muscle dysmorphia. Additional treatment strategies include dismantling ego-syntonic beliefs and toxic beliefs surrounding masculinity. Comorbid steroid use and/or dependence complicates treatment and may require incorporating an endocrinologist into the treatment team.

Research methods in health psychology

Chapter

Nov 2004

Anabolic steroids: Lots of muscle in the short-term, potentially devastating health consequences in the long-term

Article

Jul 2016
DRUG ALCOHOL REV

Anabolic steroid use and body image psychopathology in men: Delineating between appearance- versus performance-driven motivations

Article

Jun 2016

Objective: Anabolic androgenic steroid (AAS) use has been robustly associated with negative body image, and eating- and muscularity-oriented psychopathology. However, with AAS being increasingly utilized for both appearance and athletic performance-related purposes, we investigated whether comorbid body image psychopathology varies as a function of motivation for usage. Method: Self-reported motivation for current and initial AAS use was recorded amongst 122 AAS using males, alongside measures of current disordered eating and muscle dysmorphia psychopathology. Results: Those reporting AAS for appearance purposes reported greater overall eating disorder psychopathology, F(2, 118)=7.45, p=0.001, ηp(2)=0.11, and muscle dysmorphia psychopathology, F(2, 118)=7.22, p<0.001, ηp(2)=0.11, than those using AAS primarily for performance purposes. Additionally, greater dietary restraint, F(2, 116)=3.61, p=0.030, ηp(2)=0.06, functional impairment, F(2, 118)=3.26, p=0.042, ηp(2)=0.05, and drive for size, F(2, 118)=10.76, p<0.001, ηp(2)=0.15, was demonstrated in those using ASS for appearance purposes. Discussion: Motivation for AAS use may be important in accounting for differential profiles of body image psychopathology amongst users. Men whose AAS use is driven primarily by appearance-related concerns may be a particularly dysfunctional subgroup.

Do performance and image enhancing drug users in regional Queensland experience difficulty accessing health services?

Article

Dec 2015
DRUG ALCOHOL REV

Introduction and aim: To understand health service access and needs of people who use performance and image enhancing drugs (PIED) in regional Queensland. Design and methods: Semi-structured interviews were conducted with 21 people (n = 19 men) who reported the use of a range of PIEDs, including anabolic-androgenic steroids, human chorionic gonadotropin, growth hormone, clenbuterol, tamoxifen, insulin and peptides. Results: Participants reported accessing a range of services, including needle and syringe programs and pharmacies, for sterile injecting equipment. While PIEDs users attributed some stigma to needle and syringe programs, they were seen as an important service for injecting equipment. Participants reported receiving either positive care from health-care providers, such as general practitioners (GP), or having negative experiences due to the stigma attached with PIED use. Few participants reported disclosing their PIED use to their GP not only because of the concerns that their GP would no longer see them but also because they felt their GP was not knowledgeable about these substances. Discussion and conclusion: Participants in the study reported no difficulty in accessing health services based on living in a regional area, with their concern focused more upon how they were viewed and treated by service staff. [Dunn M, Henshaw R, Mckay F. H. Do performance and image enhancing drug users in regional Queensland experience difficulty accessing health services? Drug Alcohol Rev 2015;00:000-000].

Anabolic-androgenic steroid abuse

Article

Jan 2000

Go big or go home: A thematic content analysis of pro-muscularity websites

Article

Nov 2015

Existing content analyses of pro-eating disorder web content have focused on thinness-oriented eating disorder pathology. With the increasing prevalence of muscularity-oriented body image concerns, we conducted a systematic content analysis of 421 active pro-muscularity websites including static content websites, blogs, and online forums. Emergent coding methods were utilized (Cohen's kappa range=.78-.88), and eight distinct thematic categories were identified: rigid dietary practices (26.2%), rigid exercise rules (18.4%), the broader benefits of muscularity (16.1%), the encouragement of the drive for size (15.9%), the labeling of non-ideal body (11.4%), marginalizing other areas of life (6.1%), muscle enhancing substances (3.3%), and minimizing medical risk (2.6%). Pro-muscularity websites provide explicit material surrounding potentially non-healthful muscularity-oriented eating and exercise practices. Clinician awareness of the potentially non-healthful behaviors involved in the pursuit of muscularity may enhance the detection and treatment of male eating disorders, in particular.

Body conceptions and virtual ethnopharmacology in an online bodybuilding community

Article

Aug 2012

This study aimed to establish the common body conceptions of a serious online bodybuilding community and determine the role of the online forum in ‘virtual ethnopharmacology’: the word of ‘mouse’ sharing of drug protocols. Data were obtained from an online discussion forum dedicated to muscular development, and evaluated using a narrative-based analytical method. Forum postings were collected over a period of 36 months, transposed to software, and thematically coded. The results expose extreme, and sometimes contradictory, body-image constructs held by a devoted muscle-building community obsessed with muscular hypertrophy. Preoccupations with associated accoutrements were also identified, including nutrition and supplements, training regimes and anabolic androgenic substances. This study provides insight into the extreme body conceptions of bodybuilders normally restricted to gym insiders. It also reveals the significance of online platforms in the distribution of pharmacological knowledge and practice.

Qualitative Field Study for Users of Performance and Image Enhancing Drugs

Article

Development and Validation of the Appearance and Performance Enhancing Drug Use Schedule

Article

May 2011

Appearance-and-performance enhancing drug (APED) use is a form of drug use that includes use of a wide range of substances such as anabolic-androgenic steroids (AASs) and associated behaviors including intense exercise and dietary control. To date, there are no reliable or valid measures of the core features of APED use. The present study describes the development and psychometric evaluation of the Appearance and Performance Enhancing Drug Use Schedule (APEDUS) which is a semi-structured interview designed to assess the spectrum of drug use and related features of APED use. Eighty-five current APED using men and women (having used an illicit APED in the past year and planning to use an illicit APED in the future) completed the APEDUS and measures of convergent and divergent validity. Inter-rater agreement, scale reliability, one-week test-retest reliability, convergent and divergent validity, and construct validity were evaluated for each of the APEDUS scales. The APEDUS is a modular interview with 10 sections designed to assess the core drug and non-drug phenomena associated with APED use. All scales and individual items demonstrated high inter-rater agreement and reliability. Individual scales significantly correlated with convergent measures (DSM-IV diagnoses, aggression, impulsivity, eating disorder pathology) and were uncorrelated with a measure of social desirability. APEDUS subscale scores were also accurate measures of AAS dependence. The APEDUS is a reliable and valid measure of APED phenomena and an accurate measure of the core pathology associated with APED use. Issues with assessing APED use are considered and future research is considered.

The SAGE handbook of Qualitative Research

Article

Jan 1994

Qualitative Data Analysis: An Expanded Source Book

Article

Dec 1994

Incl. bibl., index

Body Image Disturbance in 1000 Male Appearance and Performance Enhancing Drug Users

Article

Oct 2010

Body image disturbance (BID) among men has only recently become a phenomenon of clinical significance with noted heterogeneity in the behavioral consequences of these disturbances. The degree of heterogeneity among appearance and performance enhancing drug (APED) users is unknown and an empirically derived framework for studying BID is necessary. APED users (N=1000) were recruited via the Internet and they completed a comprehensive online assessment APED use patterns, motivations, consequences, and BID. Data were evaluated using latent trait, latent class, and factor mixture models. Model results were validated using a range of covariates including cycle characteristics, age, APED history, and APED risk. A 1-Factor, 4-Class model provided the best fit to the data with Class 1 scoring the highest on all measures of BID and Class 4 the lowest on all measures. Class 2 differed in their preference for being lean over muscular and Class 3 preferred adding mass and size. Each class was associated with unique risks, APED history, and training identity. Not all APED users suffer from significant BID and there are unique profiles for those with elevated BID. Future research on male BID should account for this structure in order to better define relevant diagnostic categories and evaluate the clinical significance of BID.

Neuroendocrine Physiology of the Normal Male Gonadal Axis

Article

Apr 1993
ENDOCRIN METAB CLIN

The normal male reproductive axis requires coordinate control of hypothalamo-pituitary testicular components. Such coordinate control is accomplished by specific feedback regulation. Here, we have reviewed the physiology of neuroendocrine feedback controls operating within the healthy male reproductive axis.

Muscle Dysmorphia in Male Weightlifters: A Case-Control Study

Article

Sep 2000

Muscle dysmorphia is a form of body dysmorphic disorder in which individuals develop a pathological preoccupation with their muscularity. The authors interviewed 24 men with muscle dysmorphia and 30 normal comparison weightlifters, recruited from gymnasiums in the Boston area, using a battery of demographic, psychiatric, and physical measures. The men with muscle dysmorphia differed significantly from the normal comparison weightlifters on numerous measures, including body dissatisfaction, eating attitudes, prevalence of anabolic steroid use, and lifetime prevalence of DSM-IV mood, anxiety, and eating disorders. The men with muscle dysmorphia frequently described shame, embarrassment, and impairment of social and occupational functioning in association with their condition. By contrast, normal weightlifters displayed little pathology. Indeed, in an a posteriori analysis, the normal weightlifters proved closely comparable to a group of male college students recruited as a normal comparison group in an earlier study. Muscle dysmorphia appears to be a valid diagnostic entity, possibly related to a larger group of disorders, and is associated with striking and stereotypical features. Men with muscle dysmorphia differ sharply from normal weightlifters, most of whom display little psychopathology. Further research is necessary to characterize the nosology and potential treatment of this syndrome.

Anabolic steroid users' attitude towards physicians

Article

Oct 2004

To assess anabolic-androgenic steroid (AAS) users' trust in the knowledge and advice of physicians. Interviews of AAS users and non-users. Research offices. Eighty weight-lifters (43 AAS users, 37 non-users) recruited by advertisement in Massachusetts and Florida, USA. Personal interviews and questionnaire responses, including subjects' ratings of physicians' knowledge regarding various health- and drug-related topics. AAS users also rated their level of trust in various sources of information about AAS. Both groups of subjects gave physicians high ratings on knowledge about general health, cigarette smoking, alcohol, and conventional illicit drugs, but gave physicians markedly and significantly lower ratings on knowledge about AAS. When rating sources of information on AAS, users scored physicians as no more reliable than their friends, Internet sites, or the person(s) who sold them the steroids. Forty percent of users trusted information on AAS from their drug dealers at least as much as information from any physician that they had seen, and 56% had never revealed their AAS use to any physician. AAS users show little trust in physicians' knowledge about AAS, and often do not disclose their AAS use to physicians. These attitudes compromise physicians' ability to educate or treat AAS users. Physicians can respond to these problems by learning more about AAS and by maintaining a high index of suspicion when evaluating athletic male patients.

Acute and chronic cognitive disorders caused by cannabis use

Article

Feb 2005

Cannabis is currently the most commonly used illegal psychoactive substance amongst young people aged between 15 and 24, and it seems that 5% of this age group is addicted to it. Many research teams focused particularly on the cognitive disorders caused by cannabis use. Amongst the cognitive functions considered, memory-related, attention-related, psychomotor and motivation-related functions were proved deteriorated by acute and chronic cannabis use; a very important point, especially among teenagers, as possible alteration at the social and academic level could be the outcome. However studies on long-term and persistent cognitive effects haven't provided convergent conclusions. Methodological differences could partly affect these observations. Therefore it seems necessary to develop studies with larger samples.

Toxicological findings and manner of death in autopsied users of anabolic androgenic steroids

Article

Mar 2006
DRUG ALCOHOL DEPEN

With the aim to characterize patterns in toxicological profile and manner of death in deceased users of anabolic androgenic steroids (AAS), a retrospective autopsy protocol study of 52 deceased users of AAS was undertaken. The AAS users were compared to 68 deceased users of amphetamine and/or heroin who were consecutively tested and found to be negative for AAS. Use of AAS was in the majority of cases (79%) associated with concomitant use of psychotropic substances. AAS-related deaths differed in several respects from deaths among users of heroin or amphetamine, most strikingly with regard to: (a) the median age at death, which was significantly lower for AAS users (24.5 years) than for users of heroin and/or amphetamine (34 and 40 years, respectively); (b) the manner of death, with AAS users dying significantly more often from homicide or suicide than users of other drugs; and (c) the body mass index (BMI), with AAS users exhibiting significantly higher BMI than users of other drugs. These results support the earlier reported association between use of AAS and use of other psychoactive substances. In addition, the data suggest that AAS users are more likely to become involved in incidents leading to violent death and have a higher risk of dying at a younger age than users of other drugs.

Clinical features of muscle dysmorphia among males with body dysmorphic disorder

Article

Jan 2006

Muscle dysmorphia - a pathological preoccupation with muscularity - appears to be a form of body dysmorphic disorder (BDD) with a focus on muscularity. However, little is known about muscle dysmorphia in men with BDD, and no study has compared men with BDD who do and do not report muscle dysmorphia. To explore this issue, we reviewed the histories of 63 men with BDD; we compared those rated as having a history of muscle dysmorphia with those who had BDD but not muscle dysmorphia in several domains. The 14 men with muscle dysmorphia resembled the 49 comparison men in demographic features, BDD severity, delusionality, and number of non-muscle-related body parts of concern. However, those with muscle dysmorphia were more likely to have attempted suicide, had poorer quality of life, and had a higher frequency of any substance use disorder and anabolic steroid abuse. Thus, muscle dysmorphia was associated with greater psychopathology.

Long-term psychiatric and medical consequences of anabolic-androgenic steroid use: A looming public health concern?

Article

Aug 2008
DRUG ALCOHOL DEPEN

The problem of anabolic-androgenic steroid (AAS) abuse has recently generated widespread public and media attention. Most AAS abusers, however, are not elite athletes like those portrayed in the media, and many are not competitive athletes at all. This larger but less visible population of ordinary AAS users began to emerge in about 1980. The senior members of this population are now entering middle age; they represent the leading wave of a new type of aging former substance abusers, with specific medical and psychiatric risks. We reviewed the evolving literature on long-term psychiatric and medical consequences of AAS abuse. Long-term use of supraphysiologic doses of AAS may cause irreversible cardiovascular toxicity, especially atherosclerotic effects and cardiomyopathy. In other organ systems, evidence of persistent toxicity is more modest, and interestingly, there is little evidence for an increased risk of prostate cancer. High concentrations of AAS, comparable to those likely sustained by many AAS abusers, produce apoptotic effects on various cell types, including neuronal cells--raising the specter of possibly irreversible neuropsychiatric toxicity. Finally, AAS abuse appears to be associated with a range of potentially prolonged psychiatric effects, including dependence syndromes, mood syndromes, and progression to other forms of substance abuse. However, the prevalence and severity of these various effects remains poorly understood. As the first large wave of former AAS users now moves into middle age, it will be important to obtain more systematic data on the long-term psychiatric and medical consequences of this form of substance abuse.

Steroids, male body image, and the intimate self

Jan 2015

D Adair

Adair, D. (2015). Steroids, male body image, and the intimate self. In J. Knijnik, & D. Adair (Eds.), Embodied Masculinities in Global Sport. Morgantown, WV: Publishing, West Virginia University.

Australian needle and syringe program survey 20 year national data report

Jan 1995

J Iversen
L Maher

Iversen, J., & Maher, L. (2015). Australian needle and syringe program survey 20 year national data report 1995-2014. Sydney: Kirby Institute, University of New South Wales.

Body image disturbance in 1000 male appearance and performance enhancing drug users

Jan 2010
J PSYCHIATR RES
841-846

T Hildebrandt
L Alfano
J W Langenbucher

Hildebrandt, T., Alfano, L., & Langenbucher, J. W. (2010). Body image disturbance in 1000 male appearance and performance enhancing drug users. Journal of Psychiatric Research, 44, 841-846.

Go big or go home: A thematic content analysis of pro-muscularity websites

Jan 2016
BODY IMAGE
17-20

S B Murray
S Griffiths
L Hazery
T Shen
T Wooldridge
J M Mond

Murray, S. B., Griffiths, S., Hazery, L., Shen, T., Wooldridge, T., & Mond, J. M. (2016). Go big or go home: A thematic content analysis of pro-muscularity websites. Body Image, 16, 17-20. http://dx.doi.org/10.1016/j.bodyim.2015.10.002

Muscle dysmorphia in male weightlifters: A case-control study

Jan 2000
AM J PSYCHIAT
1291-1296

R Olivardia
H G Pope
J Hudson

Olivardia, R., Pope, H. G., & Hudson, J. (2000). Muscle dysmorphia in male weightlifters: A case-control study. American Journal of Psychiatry, 157(8), 1291-1296. http://dx.doi.org/10.1176/appi.ajp.157.8.1291

Toxicological findings and manner of death in autopsied users of anabolic androgenic steroids

Jan 2006
DRUG ALCOHOL DEPEN
241-249

A Petersson
M Garle
P Holmgren
H Druid
P Krantz
I Thiblin

Petersson, A., Garle, M., Holmgren, P., Druid, H., Krantz, P., & Thiblin, I. (2006). Toxicological findings and manner of death in autopsied users of anabolic androgenic steroids. Drug and Alcohol Dependence, 81(3), 241-249.

Post-cycle therapy for performance and image enhancing drug users: A qualitative investigation

Abstract

No full-text available

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