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Image and Performance Enhancing Drugs 2016 National Survey Results Survey co-ordinated by


Abstract and Figures

The National IPEDinfo Survey is a study exploring image and performance drug use in Wales, England and Scotland. The survey is a Public Health Wales initiative working collaboratively with the Public Health Institute at Liverpool John Moores University, NHS Scotland, Nine Zero Five and Public Health England. All partners contributed to the development and delivery of the survey. Further information about the National IPED Info Survey can be found at
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Image and Performance Enhancing Drugs
2016 National Survey Results
Report prepared by: Emma Begley, Jim McVeigh, Vivian Hope
Survey co-ordinated by: Emma Begley, Jim McVeigh, Vivian Hope, Geo Bates, Rachel Glass,
John Campbell, Claire Tanner, Joseph Kean, Gareth Morgan, Dean Acreman and Josie Smith.
November 2017
PHI, Faculty of Education, Health and Community, Liverpool John Moores University, Henry Cotton Campus, 15-21 Webster Street, Liverpool, L3 2ET
0151 231 4511 | | | ISBN: 978-1-912210-11-4 (web)
The National IPEDinfo Survey is a study exploring image and performance drug use in Wales, England
and Scotland. The survey is a Public Health Wales initiative working collaboratively with the Public
Health Institute at Liverpool John Moores University, NHS Scotland, Nine Zero Five and Public Health
England. All partners contributed to the development and delivery of the survey. Further information
about the National IPED Info Survey can be found at
Image and Performance Enhancement Drugs (IPEDs) encompasses a wide range of substances that
are taken to alter body image and/or performance [1]. Some IPEDs are predominantly injected whilst
others are taken orally, for example, injectable IPEDs include Human Growth Hormones (HGH),
peptide hormones such as melanotan II and anabolic steroids [2]. Oral IPEDs also include a range of
anabolic steroids as well as oestrogen control, post cycle and fat loss drugs. These synthetically made
substances are often illicitly manufactured and sourced [3-5], although they are legal to possess for
personal use [6]. Studies indicate that anabolic steroids are most commonly used by men and often
alongside a repertoire of different drugs [2, 7].
Traditionally participants of elite sports, body building and power lifting were the predominate
consumers of IPEDs, however over the past two decades use of IPEDs has increased and become more
widespread [8, 9]. In particular, data from the Crime Survey for England and Wales (CSEW) indicates
that the estimated number of 16-59 year olds reporting lifetime use of anabolic steroids has increased
from 194,000 in 2005/06 to 271,000 in 2015/16 [10]. The CSEW is likely to be unreliable for rare events
like anabolic steroid use and so may under-estimate the number of people using drugs; however, data
from needle and syringe programmes also indicate that use is likely to be increasing [7, 11-13].
Globally there is a growing concern about the extent of the health consequences of IPED use, including
physical and psychological harms. Many well established harms reported are superficial (e.g. acne,
balding), however they also include more severe physical (e.g. cardiovascular disease, liver function)
and psychological (e.g. mood changes, increased aggression) problems [14, 15]. Emerging evidence
indicates that IPED use may also lead to dependence [16, 17].
Furthermore, the complicated drug regimes that people who use IPEDs employ, often alongside the
use of illicit psychoactive substances or alcohol, and the adulteration of drugs used, are likely to impact
on the extent of the adverse consequences [7, 18]. For example, there is a growing body of evidence
that alcohol [19] and oral anabolic steroids [14] are linked to adverse liver conditions. Similarly
psychoactive drugs [20] and anabolic steroids [1, 14] are linked to psychological issues such as,
depression, aggression or anxiety, although the role of the specific substances and their synergistic
effects remain unclear [21, 22]. As many of the people using IPEDs inject their drugs they are also at
risk of injecting related harms, such as, injection site infections and injuries e.g. redness, swelling,
tenderness and abscesses [2]. Additionally people who inject drugs are also vulnerable to infection
with blood borne viruses, and recent research has indicated an increased risk of blood borne virus
infection among those who inject IPEDs [23].
Despite the established adverse effects of IPEDs and the risky behaviours associated with their use,
people who use IPEDs are often reluctant to seek professional medical advice or visit primary care
services [12, 15]. Data from previous IPEDinfo surveys also indicate that people who use IPEDs will
often choose to either wait for symptoms to go away or self-medicate with natural remedies or other
pharmaceutical substances [24]. Equally people who use IPEDs may not perceive themselves as a ‘drug
user’ as they are not using psychoactive drugs like heroin and so may not access specialist drug services,
such as needle and syringe programmes. Therefore there is a need for health care services to be aware
of this and provide appropriate non-judgmental services that are responsive to the specific needs of
these individuals [11].
In order to better understand these issues, Public Health Wales initiated the National IPED Info survey
in collaboration with colleagues at the Public Health Institute, Liverpool John Moores University; NHS
Scotland; Nine Zero Five and Public Health England. This document summarises key findings from the
fourth year of this survey.
Findings from the previous waves of this survey are available at:
2013 Survey (Chandler & McVeigh, 2014):
2014 survey (McVeigh, Bates & Chandler, 2015):
2015 survey (Bates & McVeigh, 2016):
Survey Methods
The methodology used for this survey is described in more detail in the reports of the previous surveys
(see links above).
Fieldworkers recruited participants via needle and syringe programmes, harm reduction outreach
and/or through gyms and sports settings across 18 areas in England, Scotland and Wales. They
obtained verbal consent from participants and assisted them with completing the questionnaire.
Additionally, survey participants could also complete the questionnaire online in their own time, an
option which was promoted within needle and syringe programmes, gyms and online forums. As in
previous years, eligible participants must have used oral and/or injectable IPEDs at some point
during their lifetime.
The questionnaire was drafted by the Public Health Institute at Liverpool John Moores University with
Public Health Wales and refined following feedback from research partners and other
stakeholders. The questionnaire used in this survey was modified slightly from that used
previously, to make it quicker for participants to complete. Changes included removal of the
section on most recent cycle and the inclusion of more multiple choice and rating scale (0-10)
questions. The survey was constructed using the Bristol Online Survey Tool, an online resource
made available to Universities across the UK. Ethical approval for the survey was obtained via the
Liverpool John Moores University Research Ethics Committee. The survey was open from May-
December 2016.
We would like to thank the following individuals, in no particular order for their help with the
data collection; Adam Trice, Aaron Carnahan, Charlotte McLean, Colin Campbell, Neil Jones, Con
Lafferty, Dean Acreman, Gareth Morgan, Finlay Colville, Gary Beeny, Jane Neale, Lee Little,
Mark Lewis, Naim Vali, Jack Killingray, Sid Wiffen, David Rourke, Paul Gibson, Drew Guard. And
also Laura Heeks for her graphic design.
Key Findings: Snapshot
A total of 684 participants completed the 2016 National IPEDinfo Survey questionnaire. The majority of the
participants were recruited from gyms and needle and syringe programme across England, Wales and
Scotland; only 25 (4%) were completed by participants online.
The majority of the participants were male (94%) and described themselves as being white British (80%) and
UK nationals (95%). Participants were mostly employed (78%), and were aged between 17 and 74 years (mean
age 32 years). Overall more reported ever using oral IPEDs (89%) than injecting IPEDs (85%), steroids were
the most commonly used IPEDs. The most frequently reported oral IPED was methandrostenolone also
known as Dianabol (D-Bol); testosterone enanthate (Test E), was the most frequently injected IPED. Aesthetic
reasons, such as changing their body image and for cosmetic purposes, were the most important motivation
for use of IPEDs for more than half (56%) of the participants.
Almost one-in-five of the participants who had injected (18%) reported that they had reused their own
injecting equipment, and around one in seven (15%) reported that they had shared a multi-dose drug vial. The
majority of participants were sexually active (91%) and around half of these participants reported more than
one sexual partner during the past year; condom use was infrequent.
of participants
had used oral
in total
of participants
had used injectable
had side
effects like
said aesthetic
reasons were the
most important
The most commonly reported side effect for men was testicular atrophy (58%); other commonly reported side-
effects were sleep difficulties, changes to libido, mood swings, aggression and acne. More than half of those
reporting side effects waited for symptoms to go away on their own without seeking healthcare. One-in-five
(20%) reported that they had redness, tenderness and swelling at an injection site, indicating an injection site
infection or injury. Lastly, less than a third of participants reported ever having diagnostic tests for HIV (31%),
hepatitis B (30%) or hepatitis C (29%).
Who is using IPEDs?
A total of 684 people using IPEDs in the past 12 months were recruited throughout England,
Scotland and Wales (see figure 1). The majority of participants were men (94%), who had been
born and were residing in the UK (95%, 99% respectively). The mean age of the participants was 32
years (median 30 years; ranged 17 to 74 years) and most described themselves as heterosexual
(95%). Numerous ethnicities (n=15) were reported, with the majority of participants being white
British (80%), followed by Indian/Pakistani/Bangladeshi (8%) and white other (6%). Almost three-in-
four participants reported being in full time employment and a small minority were either
unemployed or other (incl. full time education (figure 2)). A full demographic breakdown is
provided in appendix 1. One-in-six of the participants reported that they had been in a young
offenders institute or prison (n=112, 17%), less than half of whom (n=33, 29%) reported that they
had consumed IPEDs during incarceration.
Figure 1. Distribution of survey participants across England, Scotland and
Figure 2. Employment status of the participants.
What IPEDs have people used during the past 12 months?
Nine-in-ten (89%) of the participants reported using IPEDs orally and more than eight-in-ten (85%)
through injection, with almost three-quarters (73%) having used IPEDs both orally and through
injection (see appendix 2).
12% Employed
IPEDs taken orally: Participants were asked about the various oral and injectable IPEDs they had used
during the past 12 months. Oral IPEDs were categorised into three groups: oral steroids, oestrogen
control and post cycle, and fat loss/others (figure 3). Two-fifths reported using drugs in all three of
these groups, and almost one-in-five had combined oral steroids with fat loss substances. The most
common oral steroid was methandrostenolone (also known as Dianabol or D-Bol) which more than
half of the survey participants reported using. Other oral IPEDs commonly used were oestrogen
control and post-cycle drugs, with one-in-two people reporting tamoxifen citrate use (see appendix
2). Compared to the earlier IPEDinfo surveys there was a concerning increase in the proportion of
participants reporting the use of dinitrophenol (DNP), though this remained rare, its use had risen
from 1.8% in 2015 to 3.1% in 2016. DNP is used to promote weight loss, however it has severe
adverse effects including liver failure and has been associated with a number of deaths [25].
IPEDs injected: The injectable IPEDs used were also categorised into three groups: injectable steroids,
peptides and associated growth hormones, and melanotan/other. The most common injectable IPED
was testosterone enanthate (also known as Test E) reported by almost half of survey participants.
Around one-quarter of survey participants also reported using human growth hormones (HGH) and
human chorionic gonadotropin (hCG (see appendix 2)). Of those who reported injecting IPEDs,
combining steroids with peptides and associated growth hormones was reported by two-fifths (40%
(see figure 3)).
Oral IPEDs Used
Figure 3. Patterns of oral and injectable IPED use.
At what age do people start using IPEDs?
Onset of IPED use was most common between the ages of 20 and 24 years old. However, the reported
age of first IPED use ranged from 14 years to 53 years and varied slightly depending on the method of
use (appendix 3). Almost three quarters of participants reported first using oral and injecting IPEDs
(73%, 78% respectively) before the age of 30, see figure 4 and 5.
Mean age
of first
oral use of
25 years
Mean age
of first
injecting use
of IPEDs:
26 years
49% 44%
Gluteus Thigh Deltoid Triceps Other
Intramuscular injection sites
Figure 4. Age of first use of oral IPEDs.
Figure 5. Age of first of injecting IPEDs.
How are IPEDs used?
Patterns of use: The use of IPEDs is typically cyclic, with several substances used in sequence and/or
in combination during different periods of the cycle. The reported number of cycles and the length
of breaks in-between use varied widely. When asked about typical on and off cycles over the past
12 months, the average reported cycle length was 11 weeks for those using orally or 16 weeks for
those injecting. However, almost two-fifths of people frequently reported longer cycle periods, see
appendix 3 (most common cycle length was 12 weeks; oral and injecting cycles ranged from 0-104
and 0-161 weeks, respectively). People most commonly reported taking 12 week breaks between
periods of IPED use during the past year, with one-in-seven reporting this; the average (mean) length
of break between cycles was 20 weeks.
How injected: Most of those injecting IPEDs reported injecting intramuscularly at least twice a week
and the body site they most commonly injected into was the gluteus (79% (figure 6)). A third of
participants reported injecting subcutaneously (that is under the skin). The most commonly used body
site reported for subcutaneous injection was the abdomen (appendix 4).
Other category includes sites such as: the abdomen, biceps, pectoral, latissimus dorsi and the calf.
Figure 6. Intramuscular injection sites reported.
Where do they source their IPEDs?
Participants were most likely to obtain
IPEDs from their friends (54%) and they
considered the substances that they had
obtained to be genuine most of the time
(74% (appendix 8)).
What other substances do
they use?
People who use IPEDs also report use of a
wide range of other substances including
alcohol and illicit psychoactive
substances such as cannabis, cocaine and
amphetamines [12, 26].
Use of alcohol: Three-quarters of
participants reported consuming
alcohol monthly or more
frequently. Of the men who reported
drinking alcohol in the past 12 months,
42% consumed more than 10 units on a
typical day drinking (appendix 6, and
figure 7).
Use of other drugs and substances: Almost half (47%) of all participants reported using one or
more psychoactive drug during the past year. Cannabis was the most commonly reported
psychoactive drug used in both the past month (21%) and the past 12 months (33% (figure 8)); of
those who reported using psychoactive drugs around one-in-twenty had ever injected a psychoactive
drug (5.6% (appendix 6)).
Participants commonly reported use of over the counter or prescribed painkillers; over two fifths
(46%) of those reporting use of other substances had used either prescribed or over the counter pain
relief in the past 12 months, with one-in-ten using both over the counter and prescribed pain relief in
the past month (appendix 6).
Figure 8. Other drug and substance use past
12 months.
Figure 7. Units of alcohol consumed on a
typical drinking day past 12 months among
those reporting alcohol use.
What are the motivations for use?
Motivations for using IPEDs varied. Just over half (56%) of survey participants reported aesthetic
reasons (changing their body image or for cosmetic purposes) as a very important motivation for their
use of IPEDs. This was followed closely by non-competitive bodybuilding (45% (see figure 9)). Other
motivations for IPED use, such as: hormone replacement therapy, retaining youthfulness or to aid
injury pain/anxiety/increase confidence were generally reported as being less important (appendix 8).
Figure 9. Motivations for IPED use.
What are the adverse side effects?
There are a range of physiological and psychological harms and risks associated with the use of IPEDs.
Research has linked anabolic steroids with increased risk of acne, accelerated balding, gynaecomastia,
sexual dysfunction, mood changes as well as chronic conditions such as cardiac, metabolic, neurologic
and musculoskeletal disorders [14]. Survey participants described experiencing a range of adverse side
effects which they attributed to their IPED use. These varied differently by gender; more than half of
male participants reported testicular atrophy and almost half of female participants reported nausea.
In addition to the different effects sex hormones have in men and women, the side effects are
probably related to the differences in the IPEDs used by men and women, notably melanotan use
which was more often reported by women [27] (see figure 10 and appendix 5 for full breakdown).
One-in-five (20%) reported that they had redness, tenderness and swelling at an injection site,
indicating an injection site infection or injury. However, only 2% reported that they had an abscess,
sore or open wound at injection site (appendix 5).
Injectable IPEDs
used by men
Figure 10. IPED use and reported adverse effects by gender
Oral IPEDs
used by men
Testicular Atrophy
Sex drive
Sleep difficulties
Mood swings
Injection site pain
Raised Blood Pressure
Hair loss
Unwanted hair
Deep voice
Adverse effects
reported by men
Injectable IPEDs
used by women
Oral IPEDs
used by women
Sleep difficulties
Mood swings
Sex drive
Unwanted hair
Deep voice
Injection site pain
Raised Blood Pressure
Adverse effects
reported by women
*Ephedrin, Caffeine and Aspirin (ECA)
0% 20% 40% 60% 80% 100%
Needle and syringe programme
IPED supplier
Someone else collects from a
needle and syring programe
Survey participants could report more than one source.
Men: number of
female sexual partners
0 partners 5%
1 partner 48%
2-4 partners 29%
5-9 partners 11%
10+ partners 8%
Women: number of
male sexual partners
0 partners 14%
1 partner 50%
2-4 partners 36%
5-9 partners 0%
10+ partners 0%
Figure 11. Reported sources of injecting equipment.
What are the injecting risks?
The survey data indicate that risky injecting practicesthose that could put them at risk of infection -
occurred among the participants; almost one-in-five (18%) of the participants who had injected
reported reusing their own injecting equipment, and around one-in-seven (15%) had shared a multi-
dose vial. More than half reported washing their hands and cleaning their injection sites before
injecting, (appendix 4). Participants most commonly obtained new injecting equipment via needle and
syringe programmes, either by collecting it themselves or someone else collected for them (figure 11
and appendix 5).
What are the sexual risks?
The majority of survey participants were sexually active (91%) and around half of sexually active
participants reported having more than one sexual partner within the past year (see figure 12 and
appendix 7 for more details). Amongst those sexually active, condom use was infrequent, indicating
many are at risk of sexually transmitted infections. The number of people who reported same sex
partners was small; 9% of males reported having a same sex partner in the past year (see appendix 7).
Figure 12. Number of sexual partners during past 12 months.
Participants could report more than one response
Waited for them to go away on their own (55%)
Treated them myself (34%)
Treated by my GP (4%)
Treated by another health service (4%)
Other (4%)
Hepatitis B Hepatitis C HIV Hepatitis B
Ever had diagnostic test Ever been
What were the responses to harms and what health services were used?
Globally there is growing concern about the health consequences of IPED use, including infections
such as HIV and hepatitis B and C and the side-effects of use [23]. It is important to understand the
ways in which people who use IPEDs respond to the risks and harms that can arise from the use of
these drugs in order to ensure health services can provide appropriate help. Our survey data
indicated that more than half of those reporting side effects waited for symptoms of these to go
away on their own, without seeking medical help/advice (figure 13).
The majority of people reported that they had used health services, such as, walk-in clinics, General
Practitioners, Accident and Emergency departments or sexual health clinics, (65%) in the past 12
months (appendix 5). However, this also indicates that over one third of those using IPEDs had no
contact with health services during the previous year. This is a particular concern due to the reported
adverse effects and common route of administration associated with IPED use (i.e. injection).
Due to the risk of contracting blood borne viruses associated with injecting drug use, survey
participants were asked about hepatitis B vaccination and testing for blood borne viral infections
such as HIV. Data indicated that the majority of participants had not been vaccinated against
hepatitis B, and that testing for blood borne viral infections was uncommon (figure 14). However,
of those reporting a diagnostic test for a blood borne virus and providing information on year of
their last test, 2016 was the most frequently reported year of test (appendix 5).
Figure 14. Ever been tested for blood borne viruses or vaccinated against Hepatitis B.
Figure 13. Participant responses to side effects from their IPED use.
The data presented here corroborate findings from the previous surveys of people using IPEDs [24, 28,
29]. They highlight that the average person using IPEDs in the UK is likely to be a white British male, in
their 30s; most of whom use a mixture of injectable and oral anabolic steroids and typically inject their
IPEDs intramuscularly. New data from this survey indicate that motivations for use are often complex,
but were most often related to aesthetic purposes, though athletic performance and non-
competitive bodybuilding were also common motivations, these findings are consistent with the
wider evidence on motivations [21, 30].
Most had started using IPEDs before the age of 30, however, some had initiated use whilst in
adolescence and it is a particular concern that some reported having done so at the ages 14 and 15
years. Initiating use at such a young age is a public health concern, as those who start using IPEDs
at younger ages may be at risk of negative impacts on their development and maturation [6].
It is reassuring to find that the average age for starting to inject IPEDs and the average age for first
use of needle and syringe programmes were both 26 years. This indicates most people are probably
directly accessing clean sterile equipment when they start injecting. This also offers an opportunity
for healthcare professionals to provide harm reduction advice early on. Although there has been a
marked increase in the number of people using IPEDs accessing NSPs [7] some of these also collect
equipment for others, who may not be directly accessing services [31]. There needs to be a
continued effort to engage people who are using IPEDs with services, such as needle and syringe
programmes and primary health care.
The data from this survey confirm that IPED use is complex and varied, including complex
regimes/cycles of use and poly-drug use repertories. People using IPEDs also report the use of a broad
range of other illicit drugs, most commonly cannabis, cocaine and ecstasy alongside their use of IPEDs.
Many survey respondents also reported using prescription and/or over the counter pain relief
medication. This complexity makes informing policy and practice challenging. Further research is
needed to investigate and understand the combinations of drugs used and drug use practices among
people using IPEDs in order to establish effective health responses.
The uptake of testing for blood borne viruses and hepatitis B vaccination remains low amongst people
using IPEDs, the reason for this is currently unclear. Effective and targeted qualitative research is
therefore required in order to explore these factors further. Harms associated with the use of IPEDs
extend beyond the transmission of infections through injection [32]. For example, people using IPEDs
commonly report low levels of condom use and can be highly sexually active so are at increased risk
of sexually transmitted infections [2, 12]. In order to combat this, targeted interventions to address
the sexual health needs of this population will also be required.
Whats next?
The National IPEDinfo survey has provided an important insight into a population using IPEDs.
However, we lack detailed information on the size and nature of this population, and so it is unlikely
that this survey will have adequately captured all types of use and groups of people using IPEDs.
Therefore further research is needed to investigate particular sub-group populations (e.g. young
people) that may be most difficult to reach through surveys such as this one. Additionally conducting
more qualitative research with people using IPEDs will help us better understand behaviours and
develop responses to: patterns of drug use, the transition between use of different substances, and
issues with health service engagement. Understanding these behaviours will better equip us to
deliver effective and appropriate health responses for those using IPEDs.
Appendix 1. Demographics
Recruitment site where
participants took part
Completed surveys
South East Wales
North Wales
West Wales
North East
Devon & South West
*25 online submissions
Sex of participants
Completed surveys
(N=684 respondents)
643 (94%)
41 (6%)
Age, years of
(N=684 respondents)
Up to 19
30 (4%)
118 (17%)
167 (24%)
127 (19%)
108 (16%)
40 and over
134 (20%)
Mean (median) age
32 (30)
(N=682 respondents)
531 (78%)
Full time education/Other
68 (10%)
83 (12%)
(N=684 respondents
White British
548 (80%)
White (Irish, Eastern European, Other)
42 (6%)
Mixed other (white & black Caribbean/African, white
Asian, other mix)
21 (3%)
Indian, Pakistani, Bangladeshi
53 (8%)
Black Caribbean/British, Arab, Other
20 (3%)
Self-reported sexuality
Heterosexual or straight
646 (95%)
Gay or Lesbian
20 (3%)
11 (2%)
Prefer not to say
4 (0.6%)
Imprisonment and IPED use
Frequency (%)
Have you ever been
incarcerated (N=662)
112 (17%)
Have you ever taken IPEDs in
prison (oral or injectable;
33 (29.4%)
Appendix 2. Reported IPED use
Ever used IPEDs
Oral (N=682)
605 (89%)
Injectable (N=683)
580 (85%)
Both oral and injectable (N=684)
501 (73%)
Appendix 3. Age of onset and cycle routines
Age of onset first
use IPEDs
Injection N=537
Oral N=590
Up to 19
70 (13%)
113 (19%)
182 (34%)
202 (34%)
142 (26%)
144 (24%)
73 (14%)
78 (13%)
44 (8%)
33 (6%)
40 and over
26 (5%)
20 (3%)
Mean (median) age
26 (25)
25 (24)
Last 12 month Oral IPED use
Total use past year
N=587 (%)
Anabolic Steroids (N=507, 86%)
(Dianabol; D-Bol)
329 (56%)
Mesterolone (Proviron; Pro-V)
75 (13%)
Oxandrolone (Anavar)
274 (47%)
Oxymetholone (Anapolan 50;
214 (36%)
Stanozolol (Winstrol; Winnie)
172 (29%)
Estrogen control and post-cycle drugs (N= 347, 59%)
138 (24%)
Tamoxifen citrate (Nolvadex)
301 (51%)
Clomiphene citrate (Clomid)
200 (34%)
53 (9%)
Fat loss & others drugs (N=419, 71%)
199 (34%)
43 (7%)
Dinitrophenol (DNP)
21 (4%)
Ephedrin, Caffeine and Aspirin
177 (30%)
Prohormones/ designer
84 (14%)
Levothyroxine (T4)
38 (6%)
Liothyronine (T3)
72 (12%)
123 (21%)
Pre-workout (stimulant type)
227 (39%)
Viagra/ Cialis
141 (24%)
Last 12 month injectable IPED use
Past year N=563
Injectable Steroids (N=542, 96%)
Testosterone Propionate (Test P)
237 (42%)
Testosterone Cypionate (Test Cyp)
190 (34%)
Testosterone Enanthate (Test E)
310 (55%)
Testosterone Suspension (Sus 250)
131 (23%)
223 (40%)
Trenbolone Acetate (Tren Ace)
186 (33%)
Trenbolone Enanthate (Tren E)
165 (29%)
Stanozolol (Winstrol; Winnie)
98 (17%)
Boldenone (Equipoise; EQ)
105 (19%)
Masteron (Drostanolone; Mast)
117 (21%)
Methenolone (Primpobolan; Primo)
75 (13%)
Nandrolone (Deca-Durabolin; Deca)
298 (53%)
Blend of steroids in one vial (e.g.
Fast Rip, Tri-Tren)
188 (33%)
Peptides & associated growth hormones (N= 298, 53%)
55 (10%)
Human growth hormone
169 (30%)
39 (7%)
55 (10%)
CJC 1295
18 (3%)
MGF (Mechano Growth Factor)
7 (1%)
HCG (Human Chorionic
189 (34%)
Other listed IPEDs (N=92, 16%)
89 (16%)
5 (0.8%)
Duration of IPED cycle
Length of oral cycle*
Length of injectable cycle*
Length of break in use*
No. of cycles
*reported in weeks
Appendix 4. Injection practices and equipment
Frequency of injecting IPEDs
by method
N=553 (%)
N=194 (%)
More than once per day
4 (0.7%)
30 (15%)
17 (3%)
83 (43%)
Every other day
167 (30%)
35 (18%)
Twice per week
263 (48%)
14 (7%)
Once per week
96 (17%)
8 (4%)
Less than once per week
6 (1%)
24 (12%)
Injection site
457 (83%)
12 (6%)
284 (51%)
8 (4%)
253 (46%)
6 (3%)
9 (2%)
163 (84%)
50 (9%)
1 (0.5%)
39 (7%)
1 (0.5%)
28 (5%)
Latissimus dorsi
20 (4%)
10 (2%)
3 (2%)
Before injecting have you
Always washed your hands (N=577)
395 (68%)
Always cleaned the injection site (N=580)
432 (74%)
Before injecting have you
Ever reused injecting equipment used
by someone else?
N= 574 respondents
11 (2%)
Before injecting have you
Ever reused your own injecting
N= 575 respondents
102 (18%)
Before injecting have you
Ever shared a multi-dose vial
N= 576 respondents
84 (15%)
Proportion of those collecting
equipment for other people
Frequency N=538
1 person
69 (13%)
2-9 people
51 (9%)
10+ people
8 (1.5%)
Those who haven’t collected
equipment for others
410 (76%)
Self-reported source for
obtaining injecting equipment
Needle and syringe programme
446 (77%)
The Internet
86 (15%)
IPED supplier
97 (17%)
A friend
109 (19%)
Someone else collects equipment
from an NSP for me
57 (9.8%)
Appendix 5. Adverse effects/risks and responses to risk
Self-reported adverse effects and problems
Self-report past year N=628
Males n=592 (%)
Females n=36 (%)
Pain at injection site
207 (35%)
3 (8.3%)
Mood swings
233 (39%)
13 (36%)
Testicular atrophy
345 (58%)
Increased aggression/irritability
233 (39%)
3 (8.3%)
Raised blood pressure
175 (30%)
2 (5.5%)
Redness, tenderness and swelling at injection site
118 (20%)
6 (17%)
147 (25%)
1 (2.7%)
Unwanted facial or body hair
81 (14%)
6 (17%)
Hair loss (male pattern baldness)
90 (15%)
63 (11%)
20 (56%)
Deepening of voice
43 (7.2%)
5 (14%)
221 (37%)
7 (19%)
Abscess, sore or open wound at injection site
12 (2.0%)
Depression/low mood
182 (31%)
6 (17%)
Sleep difficulties/disturbed sleep
243 (41%)
19 (53%)
Change in sex drive
316 (53%)
9 (25%)
Responses to side effects or problems
experienced with IPED use
N= 614 (%)
Waited for side effects to go away on their own
440 (72%)
Treated side effects myself
270 (44%)
Sought treatment from a General practitioner
34 (5.5%)
Sought treatment from another health service
28 (4.5%)
28 (4.5%)
History of testing for Blood Borne Viruses
Ever had a dose of the hepatitis B vaccine (n=676)
165 (24%)
Ever been tested for hepatitis B (n=673)
201 (30%)
Ever been tested for hepatitis C (n=672)
197 (29%)
Ever been tested for HIV (n=672)
211 (31%)
Reported year last test for
Hepatitis B (n=188)
6 (3.1%)
37 (20%)
145 (77%)
56 (30%)
Hepatitis C (n=172)
5 (2.9%)
38 (22%)
129 (75%)
49 (28.4%)
HIV (n=187)
5 (2.6)
38 (20%)
144 (77%)
56 (30%)
Health services accessed for any reason during past 12
N=652 (%)
NHS walk-in clinic
72 (11%)
General practitioner or family doctor
300 (46%)
Accident and Emergency
70 (10.7%)
Genitourinary, sexual transmitted disease or sexual health clinic
72 (11%)
None of these services
227 (35%)
Any other clinical health tests
in the past 12 months
N=651 (%)
Liver function Test
115 (18%)
Blood Pressure
186 (28.5%)
Testosterone Levels
84 (13%)
Electro-cardiograph (ECG)
35 (5.3%)
Cholesterol test
96 (14.7%)
None of these tests
425 (65%)
Appendix 6. Other reported substance use
Last Month N=662 (%)
Last Year N=662 (%)
Prescribed painkillers only
5 (0.7%)
10 (1.5%)
Over the counter painkillers only
35 (5.3%)
71 (11%)
Both over the counter and
prescribed painkillers reported
66 (10%)
108 (16%)
Other substance use N=662
Past month
Past year
142 (21%)
216 (33%)
84 (13%)
166 (25%)
34 (5.1%)
94 (14%)
4 (0.6%)
12 (1.8%)
12 (1.8%)
45 (6.8%)
11 (1.6%)
19 (2.9%)
Synthetic Cannabinoids
9 (0.9%)
25 (3.8%)
6 (0.9%)
24 (3.6%)
7 (1%)
31 (4.7%)
3 (0.4%)
9 (1.4%)
3 (0.4%)
8 (1.2%)
Prescribed painkiller
87 (13%)
168 (25%)
Painkiller medication
purchased over the counter
170 (26%)
278 (42%)
4 (0.6%)
7 (1.4%)
Injecting drug use
Ever N=672 (%)
Ever injected a psychoactive drug
38 (5.6%)
Frequency of alcohol consumption
Frequency N= 681 (%)
Monthly or less
230 (34%)
2-4 times a month
179 (26%)
2-3 times per week
74 (11%)
4+ times per week
22 (3%)
176 (26%)
Number of units on a
typical day drinking
Frequency N = 516
1 or 2
61 (12%)
3 or 4
80 (15%)
5 or 6
90 (17%)
7 to 9
70 (14%)
10 or more
215 (42%)
Appendix 7. Sex and sexual health
Have you been sexually active
past 12 months
N=671 (%)
609 (91%)
62 (9%)
Males reporting on No. of
sexual partners past year
Female Partners
(N=596 respondents)
Male Partners
(N=341 respondents)
27 (4.5%)
310 (91%)
286 (48%)
11 (3.2%)
175 (29%)
11 (3.2%)
63 (10.5)
4 (1.1%)
10 or more
45 (7.5%)
5 (1.4%)
Females reporting on No. of
sexual partners past year
Female Partners
(N=26 respondents)
Male Partners
(N=36 respondents)
19 (73%)
5 (14%)
5 (19%)
18 (50%)
2 (7.6%)
13 (36%)
Condom use
Amongst all
sexually active
Amongst those
with 2+ partners
77 (13%)
43 (14.6%)
75 (12%)
67 (22.7%)
About half the time
50 (8%)
46 (15.6%)
49 (8%)
38 (13%)
367 (60%)
100 (34%)
Appendix 8. Other aspects of IPED use
Where do you get your
IPEDs from
Frequency N=677
363 (54%)
79 (12%)
Prescribed by doctor
6 (0.8%)
249 (37%)
Underground lab
72 (11%)
Bought abroad
56 (8.2%)
Home made
2 (0.2%)
156 (23.4%)
Not obtained any
2 (0.2%)
Score of 10
Score of 1
Develop sporting/athletic performance (non-
bodybuilding) N=557
151 (27%)
176 (33%)
Support occupational performance N=529
53 (10%)
332 (63%)
Bodybuilding (competitive) N=591
120 (22%)
336 (62%)
Bodybuilding (non-competitive) N=591
268 (45%)
132 (22%)
Increase sex drive N=534
45 (8.4%)
295 (55%)
Develop body image/cosmetic purposes N= 557
338 (56%)
50 (8.2%)
Hormone Replacement Therapy N=512
40 (7.8%)
407 (79%)
Retain/regain youthful appearance N=520
34 (6.5%)
333 (64%)
Other Strength, injury pain, cope with
depression/anxiety, confidence, and increase energy.
12 (13%)
74 (79%)
Frequency of using IPEDs
thought to be fake
1 (0.1%)
13 (2%)
159 (24%)
490 (74%)
... The meteoric rise of the health and fitness industry has brought with it a shadow in the form of image and performance enhancing drugs that, despite the ever-broadening anti-doping movement (Mulrooney et al., 2019), remain indelibly connected to hardcore gym work. IPEDs, within this article, can be defined as 'substances that enhance muscle growth and reduce body fat' (Underwood, 2017: 78), encompassing drugs like anabolic androgenic steroids (AAS), human growth hormone (hGH) and fat burners like ephedrine (Hope et al., 2013;Sagoe et al., 2014;Begley et al., 2017). By far the most popular IPEDs are AAS, a class of drugs that include the male hormone testosterone, or a synthetic derivative of it, that can be administered either orally or as an intramuscular injection (Begley et al., 2017). ...
... IPEDs, within this article, can be defined as 'substances that enhance muscle growth and reduce body fat' (Underwood, 2017: 78), encompassing drugs like anabolic androgenic steroids (AAS), human growth hormone (hGH) and fat burners like ephedrine (Hope et al., 2013;Sagoe et al., 2014;Begley et al., 2017). By far the most popular IPEDs are AAS, a class of drugs that include the male hormone testosterone, or a synthetic derivative of it, that can be administered either orally or as an intramuscular injection (Begley et al., 2017). AAS are commonly used as part of a 'cycle', whereby a course is taken in a set period (typically eight to twelve weeks) before the user is 'off-cycle', where they assume a period of abstinence (Evans-Brown et al, 2012) and post-cycle therapy (PCT). ...
... Across the literature, a consensus has emerged that, prior to the pandemic, the consumption of IPEDs was increasing rapidly both nationally and internationally (McVeigh and Begley, 2017;Mullen et al., 2020), particularly in younger generations and those outside of the hardcore fitness community (Hall and Antonopoulos, 2016). However, the academy is yet to examine the impacts of the pandemic on these previously burgeoning figures of use (for an exception, see Zoob Carter et al., 2021). ...
2020 has proven to be an unprecedented year for all of us, as the ‘new normal’ of lockdown, the challenges of home schooling and the realities of living through a global pandemic have raised fundamental questions about the structure of our society and made us evaluate how we live. But how has the COVID-19 pandemic, and the subsequent restrictions upon public life, affected those of the population whose lives are contoured around the gym and bodywork? Utilising data precured through semi-structured interviews with image and performance enhancing drug-using bodybuilders as part of the author’s PhD research, this article sets out to provide a glimpse into the realities of life in the hardcore fitness community in 2020. First, the impact of lockdown on the men’s training will be explored, and their flouting of the restrictions will be described. Following this, the sample’s IPED consumption during this period will be examined, noting an overall reduction in use and a homogenisation of their favoured substances. Finally, the impacts of the COVID-19 pandemic on the IPED market itself will be explored, wherein the sample’s accounts of panic-buying, supply chain issues and declining demand will be presented. Ultimately, whilst not entirely generalisable given the modest sample size, it is hoped that this article will serve to paint a picture of life under lockdown for the most committed gym users in the population, and follow the community’s challenges during the ‘longest year’.
... Subsequent work supported this finding, indicating the enduring presence of HIV amongst people who inject AAS and associated IPEDs (Hope et al., 2016). Furthermore, research has also identified elevated levels of hepatitis C within this population (Hope et al., 2013(Hope et al., , 2016Hope & Iversen, 2019), often remaining undiagnosed (Hope et al., 2017(Hope et al., , 2020. However, while the presence of BBV amongst populations who use AAS is unclear, the route of transmission remains unclear, with sharing of injecting equipment during previous psychoactive drug injecting behaviour or sexual transmission likely routes of at least some infections (Hope et al., 2013;Hope & Iversen, 2019). ...
... While data related to blood-borne viruses amongst this population are largely restricted to the United Kingdom (Hope & Iversen, 2019;Hope et al., 2013;Hope et al., 2016;Hope et al., 2017;Hope et al., 2020), this is also a cause for concern. The additional indirect harms caused by adulterated and contaminated products from the illicit market ) merely compound the issue. ...
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?
... Increasingly, scholars have recognized that there is substantial variability in terms of motives and experiences among IPED users and in the transformative nature of the drugs (Begley et al. 2017;Underwood 2017). As suggested by Kyle Mulrooney and colleagues, there is a need to debate IPED use not only within the narrative of harm, but also in terms of pleasure and recreation, as "pleasure is an essential part of a coherent and reasoned response to steroid consumption" (2019: 101). ...
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Through hegemonic ideas about muscles and extraordinary performances, image- and performance-enhancing drugs (IPEDs) and their use have been traditionally connected to hypersexualized masculinities. This link has resulted in spectacular ideas and fantasies about what IPEDs can do to/with men regarding their bodies and sexual performance. However, these ideas do not always manifest or correspond with daily life. Using a qualitative and case-study-based approach, this article investigates the relationship between doped and spectacular masculinities as they are presented and constructed in and through an online doping community, and users’ experiences of side effects of the doped body and its social consequences. Analytically, the article draws on Guy Debord’s work on the relationship between the spectacle and the real , and the ongoing theoretical debate on different reconfigurations and redefinitions of doped masculinities. It argues that anticipations of and effects from IPEDs can bring alternative ways of enacting doping masculinity and sexuality in the context of online communication while also blurring the lines between fantasy and lived experience.
... Eine weitere wichtige Gruppe stellen die 40-jährigen IPED-Anwendenden dar, da sie IPED oft aus «Anti-Aging»-Gründen verwenden. Diese Gruppe wird in Zukunft zunehmen[16]. Eine besondere weitere Risikogruppe für die Verwendung von IPED sind Personen mit einer Muskeldysmorphie (MD): eine psychische Störung, bei dem das Individuum befürchtet, nicht muskulös genug zu sein[3]. IPED-Konsum im Rahmen einer MD ist mit einer stärker ausgeprägten Psychopathologie vergesellschaftet. ...
Full-text available
Zur Verbesserung von Aussehen oder Leistung wird im Fitness-Bereich neben Supplementen auch auf Medikamente zurückgegriffen. Diese Anwender von «Image and performance enhancing drugs» sind nicht leicht zu identifizieren. Aufgrund von fehlendem Bewusstsein für die Thematik sind sie bei ihrer Suche nach medizinischem Rat von Stigmatisierung betroffen.
... A challenge in providing harm reduction to this population is that interventions must be developed for the diverse androgen using community [12]. Although much of the focus is on those using androgens for muscular enhancement, there is growing recognition of those using in an attempt to retain their youthfulness [13] or as self-management of low testosterone [14 & ] and there is great variation in characteristics of this population and their practices. For example, research focusing on harm reduction is commonly focused on androgen injectors, but analysis of data from the Global Drug Survey highlighted the sizable proportion of the population that only consume androgens orally [15 & ]. ...
Purpose of review: As evidence continues to emerge of the harms associated with nonmedical androgen use, this review explores the implications from recent studies for designing strategies to reduce harm and support good health amongst androgen users. Recent findings: Studies have predominantly come from researchers in the UK and Australia. Major themes include questioning the scope and content of harm reduction strategies and identifying approaches to improve engagement between the androgen using community and healthcare providers. Findings suggest that a broader range of interventions and forms of advice are needed than are commonly provided. This must be supported by efforts to increase opportunities to deliver harm reduction through new engagement approaches, better relationships with health professionals and more guidance on identifying and managing associated adverse health impacts. Summary: A fully developed harm reduction-based response to nonmedical androgen use will be one that not only seeks to reduce risk of bloodborne virus transmission and injecting-related harms, but that considers the range of needs amongst the diverse community of androgen users and respects their decisions and rights. Co-producing interventions with members of this community will help develop effective and engaging approaches. Rigorous studies are needed to evaluate new harm reduction interventions as well as those already delivered.
... However, due to the dominance of the narrative of harm, other perspectives have been backgrounded (Christiansen et al. 2017;Zahnow et al. 2017). Today, there is an increasing body of research suggesting that there is substantial variability among steroid-using populations in terms of the motives behind their use and how individuals understand their own motives and the effects and transformative nature of the drugs (Begley et al. 2017;Christiansen et al. 2017;Underwood 2017). Kyle Mulrooney and colleagues talk about the need for discussing the issue of drug use, not only from a harm-narrative perspective, but also in terms of recreation and pleasure: ...
This article aims to explore the connections between bodybuilding, (hyper)masculinity, sexuality, and the construction of subcultural and sexual spaces among Swedish male fitness dopers. Analytically, the article employs the perspectives of hardcore masculinities—and the potential harms to relationships and health involved in the use of doping—as well as more legitimate and hegemonic masculinity configurations. The results show that there is a delicate balance between masculinity-connoted sexual and other bodily urges and desires, on the one hand, and the loss of control, on the other. Living in a pornographic imaginary can also result in a loss of reasonable contact with the world outside the subculture of bodybuilding. Upholding this lifestyle thus involves an ambivalent construction of masculinity found at the intersection between marginality and hegemony, which sometimes leads to loneliness and a lack of intimate relationships.
Using the concept of the drug apartheid, this chapter explores how, within an epoch of neoliberal consumer capitalism, a hierarchy of substance use exists; with the righteous consumption of licit drugs inferring cultural competence and effective citizenship whilst inappropriate drug use infers cultural obsolescence, the failure of users to abide by neoliberal notions of responsible consumption and play a productive role in society. In doing so, we argue that it is only through a consideration of the position and outcomes of all drug consumption within the ever-evolving context of consumerism, that we can fully locate the historical and contemporary existence, application and consequences of stigmatisation and illustrate the purposeful role this serves in ensuring the smooth order of the socio-economic status quo.KeywordsDrug useDrug policyConsumerismStigmaNeoliberalism
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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.
Boys and men with eating disorders remain a population that is under-recognized and underserved within both research and clinical contexts. It has been well documented that boys and men with eating disorders often exhibit distinct clinical presentations with regard to core cognitive (e.g., body image) and behavioral (e.g., pathological exercise) symptoms. Such differences, along with the greater likelihood of muscularity-oriented disordered eating among boys and men, emphasize the importance of understanding and recognizing unique factors of clinical relevance within this population. This book reviews the most up-to-date research findings on eating disorders among boys and men, with an emphasis on clinically salient information across multiple domains. Five sections are included, with the first focused on a historical overview and the unique nature and prevalence of specific forms of eating disorder symptoms and body image concerns in boys and men. The second section details population-specific considerations for the diagnosis and assessment of eating disorders, body image concerns, and muscle dysmorphia in boys and men. The third section identifies unique concerns regarding medical complications and care in this population, including medical complications of appearance and performance-enhancing substances. The fourth section reviews current findings and considerations for eating disorder prevention and intervention for boys and men. The fifth section of the book focuses on specific populations (e.g., sexual minorities, gender minorities) and addresses sociocultural factors of particular relevance for eating disorders in boys and men (e.g., racial and ethnic considerations, cross-cultural considerations). The book then concludes with a concise overview of key takeaways and a focused summary of current evidence gaps and unanswered questions, as well as directions for future research. Written by experts in the field, Eating Disorders in Boys and Men is a comprehensive guide to an under-reported topic. It is an excellent resource for primary care physicians, adolescent medicine physicians, pediatricians, psychologists, clinical social workers, and any other professional conducting research with or providing clinical care for boys and men with eating disorders. It is also an excellent resource for students, residents, fellows, and trainees across various disciplines.
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.
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