Managing risks and harms associated with the use of anabolic steroids

Background: People using AAS may adopt a range of strategies to prevent and treat adverse health conditions potentially associated with the use of these substances (AAS-HC). These strategies include seeking support from physicians, using the needle and syringe exchange programme (NSP) and seeking support from informal sources such as coaches and online forums. The process of identifying risks and harms, adopting and modifying health-related strategies is similar to the methods of risk-management employed in other fields of human activity. This approach recognises the importance of the informal body of knowledge produced by decades of AAS-related folk-pharmacology and seeks to understand harm-reduction from the users’ perspective.Objectives: The primary objective of this thesis is to investigate the strategies adopted by people using AAS to prevent and treat AAS-HC. Secondary objectives include to explore the factors associated with the adoption of health strategies and the occurrence of AAS-HC, as well as the barriers and facilitators experienced by AAS users when accessing health services and other sources of support.Methods: To achieve the objectives above, three work packages (WP) were produced as part of a mixed-methods research design. WP1 is a systematic review and meta-analysis of the prevalence of AAS users seeking support from physicians. WP2 is a cross-sectional online survey that identified AAS-HC, risk factors and health-related strategies adopted by AAS users in the UK. WP3 is a qualitative study based on in-depth interviews to discuss the experiences of AAS users and their risk-management strategies (RMS).Results: The estimated overall prevalence of AAS users seeking support from physicians is 37.1%. Higher prevalence rates were observed in studies from Australia (67.3%) and amongst clients of the NSP (54.1%), whilst the lowest was observed among adolescents (17.3%). The health conditions most commonly reported by the 883 participants of the online survey were insomnia (33.3%) and anxiety (32.2%). Most participants adopted preventive strategies such as having blood tests in the last 12 months (86.2%) and seeking a GP to treat AAS-HC (55.0%). Those who sought a GP for AAS-related information were 76% less likely to report an AAS-HC in the last 12 months. The interviews described AAS users’ RMS as a continuous process of awareness and behavioural changes. Participants described an extensive use of private health services and other sources of support to bypass the barriers experienced by AAS users engaging with the public health system.Conclusion: A large number of AAS users refrain from seeking support from physicians. Health professionals should be trained to recognise and manage the most common AAS-HC and help users improve their RMS. Further studies should investigate the efficacy of AAS-related RMS and the subpopulations of AAS users more likely to experience AAS-HC and less likely to engage with health services.<br/

The Formation and Development of Illicit Performance and Image Enhancing Drug Markets: Exploring Supply and Demand, and Control Policies in Belgium and the Netherlands

This research explores the understudied phenomenon of performance and image enhancing drug (PIED) markets by examining the structure and formation of the market for PIEDs in the Netherlands and Belgium. Furthermore, this study aims to understand and analyse the actors that operate in the PIED dealing environment. In particular bodybuilding is adopted as a case study. Finally, this thesis examines how the PIED control system and its application influence these respective markets. Chapter one introduces the global PIED problem, the policy options currently available to deal with it, and its connection to anti-doping and sport. Chapter two begins by reviewing the literature on PIED use and its supply, and reflects on the anti-doping and PIED policies that seek to regulate this market. In chapter three the theoretical contours of this dissertation are developed. Chapter four describes the research methods which form the empirical bases of the findings chapters. Chapter five focuses on the general characteristics of PIED suppliers, and the ways in which the actions of PIED dealers are influenced by the market cultures in which they operate. Chapter six examines the importance of socio-cultural factors in the formation and development of PIED dealing networks within bodybuilding subcultures. Chapter seven analyses and describes the characteristics of the Belgian and Dutch PIED markets, and unravels the complex relationship between the two. Chapter eight explores the illegal production of steroids in the Netherlands and the flourishing Internet trade in Belgium. Chapter nine assesses the harms related to the production and distribution of PIEDs, and accounts for the effects that Belgian and Dutch PIED policies may have on this illicit market. Finally, in chapter ten, the main findings of this dissertation are summarized, future research endeavours are considered and policy implications are drawn from the analysis. This thesis illustrates that social systems of rules and values, and in particular the embeddedness of culture, are important factors in our efforts to comprehend illicit PIED markets. Specifically, ‘the beliefs, norms, ‘tools’, rules and behaviours appropriate to a cultural setting are key factors for understanding the structure of PIED markets and greater attention must be given to the role played by socio-cultural factors in influencing the market behaviour of criminal groups and individuals. Nevertheless, this thesis also demonstrates that it is imperative to examine the production, distribution and use of PIEDs, as embedded within a diverse combination of social, economic and cultural processes. Indeed, the structure and formation of illicit PIED markets are shaped by a variety of factors including the types of PIEDs dealt within them, the characteristics of the users, the social structures which sustain them, the cultural and economic context in which the markets exist, and market forces (e.g. technical innovations, drug policies)

Glocal fitness doping: Policy, practice and prevention in the United States and Sweden

Situated within a framework of a globalized gym and fitness culture, this paper aims to investigate and compare how fitness doping can be understood in relation to, and how it is affected by, different national and local contexts. Representing different forms of welfare state regimes, the comparative analysis focuses on policy, practice, and prevention in the United States and Sweden. The findings indicate, among other things, how national level policy and implementation reflect local priorities, understandings, and values. Sweden’s choices form a pattern reflecting the priority of protecting the collective good over individual pursuits. Conversely, that the U.S. does not police outside formally governed competitions in sports or in criminal contexts. Further, U.S. bodybuilders do not feel targeted for their appearance in the same ways, illustrating the priority of individual choice. Further, the paper discusses how each country implements anti-doping in ways consistent with global policies, but are also informed by various local understandings and values. This interplay between the supranational structures and locally diverse implementation is not only complex, but can seem contradictory as each locality partly remains within a global system of anti-doping in sport, and partly operates outside this context. We suggest glocal fitness doping needs to be understood as a process through which global ideals, organisations, and more contribute to influencing local and national prevention policies and cultures, and vice versa

Public health impact and implications of the use of anabolic androgenic steroids (AAS) and associated drugs amongst the male general population.

Anabolic androgenic steroids (AAS) and associated drug use is now recognised as a significant concern and an emerging public health issue. Once restricted to the elite sporting arena, recent decades have seen AAS diffuse through bodybuilding and gym culture to an increasingly image conscious general population. This portfolio of research contributes to our understanding of this phenomenon in relation to our understanding of the extent and characteristics of AAS use, emerging harms and the policy response to the issue, as summarised below. While specific prevalence is unknown, data from needle and syringe programmes (NSPs) indicate growing numbers of people who inject AAS and associated drugs. Often portrayed in the media as a homogenous group of young male, working class men, a growing body of research indicates a much more diverse population in relation to demographic characteristics and motivations for use. Further research indicates that this is by no means confined to the United Kingdom (UK) but is a global public health issue although barely recognised in some countries such as the Republic of Ireland. Changes in the specific drugs of use and the regimes employed have been identified, with a growing pharmacopeia of easily accessible and affordable peptide hormones being used as a direct result of the rise of the Internet, coupled with developments in manufacturing and transportation. Opinion, anecdote and targeted marketing on the Internet fill the void of a lack of empirical evidence in the field of AAS, image and performance enhancing drugs (IPEDs) influencing a trend towards higher dosages, multiple drugs and prolonged use. Drug use is not confined to IPEDs, with psychoactive drug use identified in populations in UK and Internationally. Our understanding of the chronic health harms associated with AAS has increased over the last 25 years, in particular cardiovascular damage, psychological harms and the potential for dependence. However, this research has made a significant contribution to the recognition and understanding of the harms associated with the administration of these drugs through injection and the impact of adulterated products as a result of the illicit market. The extent of localised infection and soft tissue injury is a cause for concern, an issue previously neglected. Of further concern is the prevalence of blood borne virus (BBV) infection within the population of AAS users. In the first studies of their kind, HIV amongst AAS injectors has been shown to be at a similar level as that in psychoactive drug injectors in the UK. Hepatitis B and hepatitis C levels were identified as being higher than in the general population, and of key concern is the low levels of awareness of hepatitis C positive status amongst AAS injectors. The UK has operated a comprehensive NSP system since the 1980s, which has seen increasing numbers of AAS injectors however, there remains barriers to engagement with this population of people who inject drugs. Data from interviews and surveys submitted here identify a level of mistrust and lack of confidence among AAS users when it comes to engaging with health professionals. The following thesis, submitted in partial fulfilment of the requirements of Liverpool John Moores University for the degree of Doctor of Philosophy spans over twenty years of academic work within the specific field of AAS use. The research provides the groundwork for the development of meaningful and successful policies and interventions to reduce harm and promote health based on the need of this population. The submission includes a brief critical reflection on the undertaken research and the engagement with the research population, drawing on my experiences, positionality and evolution of knowledge and understanding. This further informs the concluding remarks and suggestions for future research

The balancing act : how risk is experienced, navigated and perceived by users of performance enhancing drugs

The current literature concerning performance-enhancing drug (PED) use is often highly medicalised. Limited research exists which delves into the lived experience within the context of PED use, particularly in a risk-oriented context. This thesis uses qualitative methods to explore the experience, perception and navigation of risks associated with PED use in greater detail. The three empirical studies in this thesis are connected via PED use, which is self-identified as functional, but perceived as deviant by society. Study 1 uses Interpretative Phenomenological Analysis to highlight the experiences and challenges of AAS use from the perspective of four women, drawing out the impact on their identity. Study 2 is a thematic analysis study of experiences and perceptions of twelve 2,4-dinitrophenol (2,4-DNP) users. This study evidenced strong control over every aspect of using a controversial and polarising compound. The thematic analysis of study 3 highlighted key influential factors that impact the physician-patient interaction and expands on the notion of risk for non-PED using individuals. The results collectively show how the perception and navigation of risks in a PED-use context shape the experiences of risk. These results are explored within a Risk Society Model (RSM). Risk perception is framed through a social-constructionist lens to reflect the highly individualistic nature of risk assessment impacted by sociocultural influences. Risk navigation in PED-use is complex and multifold, heavily dependent on the nature of the risk and the resources available to participants at the time. These studies highlight the importance of understanding lived experiences of risk and hazard management. These results offer a different perspective to those within the current literature and aim to contribute experiential knowledge and understanding upon which coproductive harm reduction interventions can be built

Generating evidence on the use of Image and performance enhancing drugs in the UK: Results from a scoping review and expert consultation by the Anabolic Steroid UK network.

Background The use of anabolic androgenic steroids (AAS) and associated image and performance enhancing drugs (IPEDs) is now a global phenomenon. There is a need to develop evidence to support the development of interventions to prevent the commencement of use, to minimise the potential harms or to support those in their cessation of use. While the United Kingdom (UK) is no exception to this issue, its public health and legislative response to the phenomenon differs to other countries and requires the examination of research specific to the UK. Therefore, a scoping review has been conducted to examine the recent relevant literature to help inform the development and evaluation of effective interventions to reduce the harmful use of IPEDs. Methods A comprehensive search strategy was developed for multiple bibliographic databases, supported by and iterative citation searching process and complimented by expert input from the Anabolic Steroid UK Network. Research conducted by or UK academics or within the UK were eligible, if published in the previous five years. Results 3 In total 87 eligible outputs were identified, including 26 review articles, 25 qualitative papers and 24 quantitative papers. together with small numbers of clinical studies/case reports (6) and commentaries/correspondence (6). The most common topics of research were public health, treatment and harm reduction (41), followed by studies focusing on epidemiology, sub-groups of people using IPEDs and motivations for use (34). The studies illustrated the diverse populations of people who use a range of enhancement drugs including concomitant psychoactive drug use. A number of papers focused on blood borne viruses and associated issues, while others reported on the uptake of needle and syringe programmes. No effectiveness evaluations related to any aspect of treatment, harm reduction or other intervention were published during study period. Conclusion There is a need for the development of effectiveness evaluations of current interventions and any future service provision for people using image and performance enhancing drugs. While there have been no studies of this nature to date, this review illustrates the rich data that has been gathered through diverse methodologies, that will assist in the development of future effectiveness evaluations

Russian roulette with unlicensed fat-burner drug 2,4-dinitrophenol (DNP) : evidence from a multidisciplinary study of the internet, bodybuilding supplements and DNP users

BACKGROUND: 2,4-Dinitrophenol (DNP) poses serious health-risks to humans. The aims of this three-stage multidisciplinary project were, for the first time, to assess the risks to the general public from fraudulent sale of or adulteration/contamination with DNP; and to investigate motives, reasons and risk-management among DNP-user bodybuilders and avid exercisers. METHODS: Using multiple search-engines and guidance for Internet research, online retailers and bodybuilding forums/blogs were systematically explored for availability of DNP, advice offered on DNP use and user profiles. Ninety-eight pre-workout and weight-loss supplements were purchased and analysed for DNP using liquid-chromatography-mass-spectrometry. Psychosocial variables were captured in an international sample of 35 DNP users (26.06 ± 6.10 years, 94.3 % male) with an anonymous, semi-qualitative self-reported survey. RESULTS: Although an industrial chemical, evidence from the Internet showed that DNP is sold 'as is', in capsules or tablets to suit human consumption, and is used 'uncut'. Analytical results confirmed that DNP is not on the supplement market disguised under fictitious supplement names, but infrequently was present as contaminant in some supplements (14/98) at low concentration (<100mcg/kg). Users make conscious and 'informed' decisions about DNP; are well-prepared for the side-effects and show nonchalant attitude toward self-experimentation with DNP. Steps are often taken to ensure that DNP is genuine. Personal experience with performance- and appearance enhancing substances appears to be a gateway to DNP. Advice on DNP and experiences are shared online. The significant discrepancy between the normative perception and the actual visibility suggests that DNP use is-contrary to the Internet accounts-a highly concealed and lonesome activity in real life. Positive experiences with the expected weight-loss prevail over the negative experiences from side effects (all but two users considered using DNP again) and help with using DNP safely is considered preferable over scare-tactics. CONCLUSION: Legislation banning DNP sale for human consumption protects the general public but DNP is sold 'as is' and used 'uncut' by determined users who are not dissuaded from experimenting with DNP based on health threats. Further research with stakeholders' active participation is imperative for targeted, proactive public health policies and harm-reduction measures for DNP, and other illicit supplements

“Blood Letting” – Self-phlebotomy in injecting anabolic-androgenic steroids within Performance and Image Enhancing Drug (PIED) culture

Background New evidence with regard to a previously undocumented practice – self phlebotomy, known as ‘bloodletting’ – incontemporary injecting performance and image enhancing drug (PIED) culture is the subject of this paper. While self phlebotomy has been evidenced in psychiatric patients previously, it was performed here in people who inject AAS as a self directed health care procedure. Methods Data was collected from five publicly accessible internet discussion forums and coded using NVivo software. For the purposes of this study, posts in relation to bloodletting were extracted from the final set of records for analysis Results Motivation to perform bloodletting or to ‘self – bleed’ was largely grounded in experiencing symptoms of high blood pressure or a high red blood cell count (RBC).Instructions on how to perform bloodletting were found within discussion threads. Conclusion This study is intended to provide the first snapshot of online communal activity around practice of self-phlebotomy or bloodletting amongst people 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

Perceptions and Embodiments of Masculinities Amongst Men Who Use(d) Image and Performance Enhancing Drugs: a Mixed-Methods Approach During COVID-19 and Beyond

The use of IPEDs (Image and Performance Enhancing Drugs) has become a growing area of concern for public health, particularly over the last decade (Santos and Coomber, 2017). The vast majority of the population consuming these substances are men, who are utilising them in the attempt to boost their physical appearance and/or performance (Sagoe et al., 2014). Historically, it was widely understood that men who use IPEDs do so predominantly for athletic pursuits, in order to improve sporting performance or for bodybuilding (Hope et al., 2021). However, recent years has seen a diffusion of these substances in society, with more non-sporting populations consuming them (Bates and Backhouse, 2019), often in the pursuit of achieving body image goals (Harris, Dunn and Alywn, 2016), and/or increasing muscularity (Bates et al., 2021). In this growing cohort, the role of masculinity plays an important role of influencing this consumption, with neoliberal masculine contemporary body image ideals reflecting an increasingly sexualised and fetishized version of the male form (Wykes and Gunter, 2004; Hakim, 2019). However, there have been limited studies exploring the role of idealised and contemporary masculinities in the uptake and continued use of these substances, as well as the cultures that surround them. This study presents one of the very first qualitative explorations of the perceptions of masculinities among men who use IPEDs. This research took place between 2019-2022, during the COVID-19 pandemic, and as such has also grounded its findings within the time context of the pandemic, and further seeks to observe how men’s use of IPEDs and other fitness behaviours were affected during this time. This thesis is therefore conducted in order to provide context and insight into the population of men who use IPEDs, and, ultimately, hopes to encourage drug policy and its makers to consider these thematic connections, and to reflect these in its development and implementation. The contribution made by this research work consists of two main studies, exploring six research objectives. The first aims to explore the objectives specifically relating to their presentation across online platforms. It consists of a netnographic investigation carried out across four major bodybuilding forums and focuses on the following areas of analysis: (1) Masculinities, (2) Motivations for use (of IPEDs), (3) Body goals (e.g., losing mass), (4) Attitudes towards women and/or sexuality, and (5) General attitudes towards IPED use. From this, five major thematic subthemes emerged and were analysed in a subsequent application to theory: (1) Workout routines, (2) IPED use in lockdown, (3) The body and body image, (4) Mental health, IPED use and COVID-19, and (5) Masculinities, sex, and sexuality. Additional data was collected during a follow up study, which provides further insight into the research aims and objectives, as well as further context to the themes observed during the netnographic study, by utilising first-person accounts from men who use IPEDs. This research consists of a cross-sectional survey comprising of 11 independent questions, providing mixed data types, including written word, original images, and Likert scales. The invites to participate in this study were disseminated across the platforms observed during the netnographic research component, as well as additional online forums and social media. 15 men participated in the survey during May 2021, and their responses were subject to deductive thematic analysis, which highlighted four prominent themes which were subsequently analysed: (1) IPED use, exploring uptake, side-effects, and the impact of COVID-19. (2) Body image amongst men who use(d) IPEDs, which explores body image goals and the impact of culture on body ideals. (3) Idealised masculinities amongst men who use IPEDs, which explores the connections of these idealisations to body image, themes of dominance and toxicity, heteronormativity, sexual performance, and capitalism. (4) Social media, IPEDs, masculinities and mental health, which explores the pressures on body image presented by social media, and its role in mental health amongst men who use IPEDs. The original contribution to knowledge focuses on the intersection of methodology types applied to this topic area, as well as the in-depth analysis of masculine gender identities and their contemporary influences. The main conclusions presented by this thesis, by research objectives, are (1) findings supported broader literature on key motivations for uptake of IPEDs amongst men, with predominant rationales being: muscle gain, body image, and strength. (2) An emphasis on traditional masculine identities was observed within the collected data, including language related to heteronormativity and sexism. Clear links were also made between men who consume IPEDs utilising muscularity as a tool to present and articulate visual expressions of masculinities. (3) A relationship between social and traditional medias and contemporary idealised forms of masculinities was observed and was further highlighted as a key influence on body image goals amongst men who use IPEDs. (4) An influential relationship was observed between capitalism, subcultural ideals, and the uptake of IPEDs, specifically in relation to societal body image norms. (5) COVID-19 was shown to significantly impact on both fitness behaviours and the consumption of IPEDs, including the rationales for uptake and continued consumption. Online platforms also presented as key areas for support and education for men who use IPEDs, with heightened importance in the COVID-19 pandemic. (6) COVID-19 did not exacerbate existing views relating to traditional masculinities, heteronormativity, and sexism, but did provide new language to be used within these contexts. Overall, a strong relationship between body image, idealised masculinities and online spaces emerged throughout this research. These factors were observed both in relation to influences of uptake of IPEDs, as well as acting as important avenues for the effective dissemination of support and education to men who consume IPEDs. Future studies should continue to explore the nuances of these relationships and the effective utilisation of online spaces for encouraging safe consumption