Social suppliers: Exploring the cultural contours of the performance and image enhancing drug (PIED) market among bodybuilders in the Netherlands and Belgium

Across the spectrum of legality: The market activities of influencers specialized in steroids and other performance and image enhancing drugs

BACKGROUND

Like many other goods and services, performance and image enhancing drugs (PIEDs), and particularly androgenic anabolic steroids (AAS), are increasingly discussed and promoted by social media influencers. Little, however, is known about the influencers specialized in PIEDs and which drugs and services they promote and sell.

AIMS

Against this background, the study has been intended to identify prominent influencers specialized in PIEDs, examine the market activities they engage in, and assess the latter's legality.

METHODS

We first searched the clean internet to identify prominent PIED influencers. Second, we conducted a six-month-long, non-reactive digital ethnography of the social media accounts of 20 influencers and, via a content analysis, identified the market activities they engage in. Third, we assessed the latter's legality, primarily using the EU legislation as a benchmark.

FINDINGS

The selected influencers are all current or former bodybuilders, predominantly male and from the United States. Many of them have developed a considerable number of followers, in three cases exceeding one million. They engage in various market activities that span the whole spectrum of legality, from legal to illegal, with many activities having an uncertain, but often dubious, legal status.

CONCLUSIONS

Though they may promote harm reduction for some users, PIED influencers also promote the public acceptance of PIED use beyond the bodybuilding community and enhance access to PIEDs for millions of people. Multifaceted policy interventions are required, aiming at preventing influencers from becoming a major source of information on, and route of access to, PIEDs.

Investigating the methods and characteristics of the trafficking of performance and image enhancing drugs in Australia

INTRODUCTION

Using case law, the aims of this study were to document the methods for trafficking of performance and image-enhancing drugs (PIED) into Australia, and the characteristics of individuals and groups involved.

METHODS

Data was collected from judges' sentencing comments. Searches were conducted using the Australasian Legal Information Institute database across all states in Australia, for the period of January 2010 to December 2021. After removing duplicates and cases which did not meet the inclusion criteria, 31 cases were included in the analysis.

RESULTS

Across the 31 cases, 37 individuals were named as being involved in the supply and/or trafficking of PIEDs, with three cases involving an unknown number of individuals. One case named four actors involved in the supply and/or trafficking of PIEDs, three cases involved three actors, four cases involved two actors and 17 cases involved one actor. In 20 of the 31 cases, individuals operated alone. Over half (19 of the 37) of the individuals were health professionals. The majority (n = 17) of cases involved prescription as the method of acquisition, while seven cases involved the importation of PIEDs.

DISCUSSION AND CONCLUSION

The small number of cases identified, with the majority involving only a single actor, and half of the cases involving those in the medical profession. The findings suggest that discrete occurrences of trafficking involves individuals or small groups that do not appear to be linked to large-scale networks or networks involving the supply and trafficking of other illicit substances.

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

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.

#Sponseredathlete: the marketing of image and performance enhancing drugs on Facebook and Instagram

This article sets out to investigate the marketing of image and performance enhancing drugs (IPEDs) on the social media platforms Facebook and Instagram. Drawing upon a 'connective' ethnographic exploration of IPED use and supply, the paper first outlines a supplier typology on these platforms, before shedding light on the marketing strategies employed by sellers in order to overcome the inherent distrust of online sales and build a trustworthy brand. Techniques identified include athlete sponsorship, the sharing of bodybuilding fitspiration content, self-objectification, posting images showcasing transformation photos and customer feedback, and seasonal sales and promotions. Analysis encompasses the centrality of product branding, the overlaps between licit and illicit market advertising strategies, and the affordances of the platforms under study. Finally, conclusions relating to the implications of these findings to scholarship, policy, and regulation are offered.

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

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.

Testosterone, identity and the body: Exploring cultural definitions of disorder

Medically-sanctioned testosterone administration has seen increasingly widespread application in the treatment of gender dysphoria (GD). Yet, by comparison, this approach is not medically accepted for those who are experiencing muscle dysmorphia (MD), a specifier of body dysmorphic disorder (BDD), despite both conditions reflecting incongruences between self-perception, identity and phenotype, and both currently being classified as mental health disorders. Rather, by stark contrast, those with MD are largely treated with psychological intervention to accept themselves as they physically are and the illicit use of testosterone for muscle-related body perception purposes is generally subject to criminal justice enforcement actions. In this commentary, we examine attempts to distinguish between the use of testosterone for gender-affirming hormone therapy in the case of GD and for aesthetic (muscle enhancement) use in the case of MD, as well as explore the implications of this disparity. Moreover, we consider how such disparity in policy and practice may be understood, in part, as an example of a bias reflecting the selective pathologizing of anabolic-androgenic steroid (AAS) use, socio-cultural evolutions in gender identity and expression and, more broadly, the manner in which culture defines disorder and its appropriate response.

The Impact of the COVID-19 Pandemic on Male Strength Athletes Who Use Non-prescribed Anabolic-Androgenic Steroids

Background: One sub-population potentially affected by the COVID-19 pandemic are strength athletes who use anabolic-androgenic steroids (AAS). We examined links between disruption in AAS use and training due to the pandemic and mental health outcomes in this population, hypothesising: (a) the pandemic would be linked with reduced training and AAS use; and (b) athletes perceiving greater impact on their training and AAS use would report increases in detrimental mental health outcomes. Methods: Male strength athletes using AAS (N = 237) from 42 countries completed an online questionnaire in May 2020. A sub-sample (N = 90) from 20 countries participated again 4 months later. The questionnaire assessed pre-pandemic and current AAS use and training, alongside several mental health outcomes. Results: At Time 1, most participants perceived an impact of the pandemic on AAS use (91.1%) and/or training (57.8%). Dependent t-tests demonstrated significant reductions in training frequency (t = 7.78; p < 0.001) and AAS dose (t = 6.44; p < 0.001) compared to pre-pandemic. Linear regression showed the impact of the pandemic on training was a significant positive predictor of excessive body checking (B = 0.35) and mood swings (B = 0.26), and AAS dose was a significant positive predictor of anxiety (B = 0.67), insomnia (B = 0.52), mood swings (B = 0.37). At Time 2, fewer participants perceived an impact of the pandemic on AAS use (29.9%) and/or training (66.7%) than at Time 1. Training frequency (t = 3.02; p < 0.01) and AAS dose (t = 2.11; p < 0.05) were depressed in comparison to pre-pandemic. However, AAS dose had increased compared to Time 1 (t = 2.11; p < 0.05). Linear regression showed the impact of the pandemic on training/AAS use did not significantly predict any mental-health outcomes. However, AAS dose was a significant negative predictor of depressive thoughts (B = -0.83) and mood swings (B = -2.65). Conclusion: Our findings showed impact of the pandemic on the training and AAS use, reflected in reduced training frequency and AAS dose. However, whilst we detected some short-term consequential effects on mental health, these did not appear to be long-lasting.

The pharmaceuticalisation of 'healthy' ageing: Testosterone enhancement for longevity

The United Nations estimates that the world's population will reach 8.5 billion by 2030, and the populations of most countries are expected to grow older. This is case for many developed countries, including Australia, the United Kingdom, Canada, the United States of America, and member states of the European Union. Older cohorts will comprise a larger proportion of overall populations, driven in part by our increases in life expectancy. An ageing population poses challenges for governments; notably, older people tend to have multiple, chronic health conditions which can place a burden of health budgets. At the same time, we are witnessing a shift in how we respond to the health needs of our populations, with global drug policy acknowledging that some substances are contributing to increased morbidity and mortality (e.g. opioids) while others may have beneficial therapeutic effects (e.g. psylocibin, cannabis). There is general agreement that as men age their levels of testosterone decrease, and there is some evidence to suggest that there have been population-level declines in testosterone which are not associated with age. Anecdotally, testosterone is accessed by men seeking to self-medicate in the belief that they are experiencing low testosterone levels. There has also been a rise in anti-ageing clinics in the United States, providing access to testosterone replacement therapy (TRT). The non-medical use of testosterone can result in a number of adverse health events, including complications from the use of black market or underground products. Placing testosterone under a new prescribing regime may address some of these concerns, but is society ready for this change, and if so, what would this regime look like? This paper will explore the issue of how society responds to enhancement for longevity, or how we increasingly use pharmaceuticals to address and prevent illness, with a specific focus on testosterone and testosterone deficiency.

Testing the boundaries: Self-medicated testosterone replacement and why it is practised

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) problematization 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 repair/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.

Anabolic-androgenic steroid use among women - A qualitative study on experiences of masculinizing, gonadal and sexual effects

BACKGROUND

Female users of anabolic-androgenic steroids (AAS) are at risk of developing masculinizing side effects. This study explores how the development of masculinizing effects has been experienced and processed by women with current or previous AAS use.

METHODS

Individual, semi-structured interviews were undertaken among 16 current or previous AAS-using women. The interviews were recorded, transcribed verbatim and thematically analyzed.

RESULTS

Almost all of the women were introduced to AAS and advised about what substance(s) to use, how much to use and how to use it by a trusted male partner, friend or coach. For some, AAS initiation was an impulsive choice, while others wanted to overcome stagnation and/or prepare for fitness competitions. Many were unprepared for the unwanted masculinizing effects, but some experienced these to be outweighed by the desired effects. Masculinizing effects that could be mediated by hair removal or breast implants were easier to process than a deepened voice. As very few women were open with others about their AAS use, the voice change could disclose use and was often accompanied by feelings of shame and regret. Absence of menstruation and its return following cessation were used to monitor effect, normal function and safety when deciding when to start a new cycle. Clitoral enlargement gave rise to shame and reduced self-esteem, but negative emotions could be reduced by a positive partner response. Increased libido was common and gave rise to positive and negative experiences, depending on life situation, partner status, whether the partner used AAS simultaneously and whether genital changes had also been experienced.

CONCLUSION

Women who use AAS are at risk of developing irreversible masculinizing effects that are difficult to process and that may negatively influence self-esteem, social life and sexual function, both during and after use. More gender-specific information about women and AAS use is needed.

A focused netnographic study exploring experiences associated with counterfeit and contaminated anabolic-androgenic steroids

Background

A primary consequence of illicit drug markets and the absence of regulation is the variable quality or purity of the final product. Analysis of anabolic-androgenic steroid seizures shows that these products can contain adulterated products, product not included on the label, or product of unsatisfactory standard. While the potential negative effects of counterfeit anabolic-androgenic steroids (AAS) use is a recognised risk associated with use, no study has explored personal experiences associated with use. The aim of the present study was to use online discussion forums to investigate and explore the experiences associated with the purchase and consumption of counterfeit AAS among consumers.

Methods

An online search was conducted to identify online forums that discussed counterfeit or contaminated AAS; three were deemed suitable for the study. The primary source of data for this study was the ‘threads’ from these online forums, identified using search terms including ‘counterfeit’, ‘tampered’, and ‘fake’. Threads were thematically analysed for overall content, leading to the identification of themes.

Results

Data from 134 threads (2743 posts from 875 unique avatars) was included. Two main themes were identified from the analysis: (1) experiences with counterfeit product and (2) harms and benefits associated with counterfeit product.

Conclusions

The use of counterfeit or contaminated substances represents a public health concern. Those who report using performance and image enhancing drugs such as AAS for non-medical purposes report consuming these substances and experiencing harm as a result. Consumers take steps to limit coming into contact with counterfeit or contaminated product, though recognise that many of these have limitations. The implementation of accessible drug safety checking services may provide an opportunity to provide consumers with information to assist them with making healthier choices.

Evaluation of performance-enhancing drugs seized by Israeli enforcement agencies 2012-2017: implications for policy and regulatory change

Background

Illicit performance-enhancing substances are used mostly by athletes to enhance performance in sports, and by bodybuilders to gain muscle and body mass. Among performance-enhancing substances, the most common and known substances are anabolic-androgenic steroids, which are associated with a range of short and long-term adverse medical and psychiatric effects.

While the sale and distribution of performance-enhancing substances are considered criminal offenses per the Israeli local pharmacy ordinance, the use and personal possession of these substances are not. Presently, the Division of Enforcement and Inspection of the Israel Ministry of Health cooperates with police and customs agents in performance-enhancing substance-related enforcement activities, which chiefly include seizures carried out at suspicious sites. Moreover, the Division of Enforcement and Inspection provides professional guidance, lab analysis services, and expert opinions on the toxicological and pharmaceutical nature of products seized.

This paper presents a contemporary sub-analysis of registered seizures of performance-enhancing substances carried-out by Israel enforcement agencies. The main aim of this analysis is to characterize current patterns of performance-enhancing substances, thus providing the possibility of better assessment of current enforcement and health policy.

Methods

A sub-analysis of 712 seizures of performance-enhancing substances seized by Israeli enforcement authorities during a six-year period ranging from January 2012 to December 2017.

Results

This study demonstrates that Israel faces a challenge regarding the importation and distribution of illicit performance-enhancing substances. The most common substances seized were anabolic androgenic steroids (N = 539). Most seizures were carried out in the central mail processing sites, (38.4%), followed by seizures in private premises such as homes and warehouses (29.6%). Significant differences were found between anabolic-androgenic steroids and other substances, relating to place and year of seizure. Among seizures with known sources (N = 355), the most frequent geographic region given as the source of substances was Eastern Europe (47.6%), followed by East Asia (24.8%), West Asia (19.4%), and Western Europe (5.9%). Bulgaria was the country with the highest frequency of seizures (N = 71) followed by Jordan (N = 45), Thailand (N = 37) and Moldova (N = 36). Significant regional differences were found based on the variables of gender, place of seizure, and type of substance. The most frequent month of seizures was August (N = 129), followed by July (N = 119), and June (N = 118).

Conclusions

While data analysis focused on the supply side of the performance-enhancing substances market, the high number of seizures of performance-enhancing substances in Israel represents evidence of the existence of a high demand and a large consumer base for these products. Consequently, there is a need for developing further enforcement, treatment, and prevention policies that do not currently exist in Israel. Policymakers should consider prioritizing law enforcement action and incentivizing intelligence sharing to monitor suspected shipment sources and specific points of entry. Additionally, the results demonstrate that there is a need in reforming the penal law to discourage the use of performance-enhancing substances. Similar measures have already been applied in countries like Spain, Italy, and Belgium. Furthermore, policy-makers should consider enhancing health ministry agencies with a higher enforcement capacity by giving them further investigative and inquiry authority. Due to the troubling magnitude of the phenomenon, policymakers should also prioritize educational and prevention strategies.

The price and mark up of pharmaceutical drugs supplied on the black market

BACKGROUND

Research examining illicit drug markets has shown that price affects consumption and mark ups are extremely high. However, the economics of black market pharmaceutical supply remains unknown, despite increasing harms due to pharmaceuticals.

METHODS

Semi-structured, telephone interviews were conducted in Australia with 51 people involved in supplying pharmaceuticals in the previous six months. Interviews were audio-recorded, transcribed and quantitative information on costs, sale price, quantity and frequency of supply were coded and used to calculate the mark up ratio for each drug transaction 'cycle', accounting for distribution via selling, gifting and trading. Mixed effects gamma regressions were used to identify predictors of price and mark up, clustering by participant.

RESULTS

There were 29 drugs supplied over 111 cycles, including hypnotic-sedatives (38%), pharmaceutical opioids (32%), stimulants (18%) and others (12%). Sedatives were sold at lower prices than opioids and there was a negative relationship between unit price and transaction size, consistent with a discount effect. For every dollar spent acquiring the drugs, the supplier earned a median of $3.19. Cycles involving the distribution of drugs sourced via intermediaries (e.g. friends/family) had lower mark up than drugs sourced directly from the medical system.

CONCLUSION

To our knowledge, this is one of few studies to analyse economic aspects of the pharmaceutical black market from a supply perspective. There were a small number of cycles that realised large profits that may warrant different types of policy responses, however for most suppliers in our sample gross revenue and gross profit was modest.

Health care engagement behaviors of men who use performance- and image-enhancing drugs in Australia

Background: Although people who inject performance- and image-enhancing drugs (PIEDs) report fewer unsafe injecting practices, stigma and discrimination may negatively impact their access to help and information. Engagement with health care services, compared with social networks (friends, relatives, and gym associates) and the Internet and media (steroid user forums, information sites, and magazines), may be important for harm minimization. Methods: A cross-sectional Internet or in-person survey of men who use PIEDs in Australia in 2014-2015 examined differences in sources for PIEDs, injecting equipment, and anabolic-androgenic steroids (AAS) information and factors associated with having periodical medical checks related to PIEDs issues using multivariate logistic regression. Results: In total, 267 men (mean age: 25 years, SD: 8.7 years; 246 of 267 [92%] reported recent AAS injection) were recruited. Most participants sourced injecting equipment from health professionals, PIEDs from their social networks, and AAS information from the Internet and media. Self-reported AAS knowledge was high and frequent. Higher income (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.03, 4.00), ≥2 different PIEDs used in addition to AAS (AOR: 1.94, 95% CI: 1.08, 3.49), and sourcing AAS information from health care professionals (AOR: 3.14, 95% CI: 1.81, 5.46) were independently associated with periodical medical checks. Participants nominated preference for improved health services through needle-syringe programs, primary care services, and peer educator support groups. Conclusion: Men who use PIEDs in Australia consider themselves well informed but tend to use Internet and media sources, providing potentially misleading or inaccurate information. Increasing trust between men who use PIEDs and health care providers may enable delivery of PIEDs-specific information to those at greatest need.

Towards a Sustainable Nutrition Paradigm in Physique Sport: A Narrative Review

Physique athletes strive for low body fat with high lean mass and have higher body image and eating disorder rates than the general population, and even other weightlifting populations. Whether athletes with a background or tendency to develop these issues are drawn to the sport, or whether it drives these higher incidences, is unknown. However, the biological drive of cyclical energy restriction may contribute to binge-eating behavior. Additionally, requisite monitoring, manipulation, comparison, and judgement of one's physique may contribute to body image concerns. Contest preparation necessitates manipulating body composition through energy restriction and increased expenditure, requiring dietary restraint and nutrition, exercise, and physique assessment. Thus, competitors are at mental health risk due to (1) pre-existing or predispositions to develop body image or eating disorders; (2) biological effects of energy restriction on eating psychology; and (3) dietary restraint attitudes and resultant physique, exercise, and nutrition monitoring behavior. In our narrative review we cover each factor, concluding with tentative best-practice recommendations, including dietary flexibility, slower weight loss, structured monitoring, gradual returns to offseason energy intakes, internal eating cues, appropriate offseason body compositions, and support from nutrition and mental health professionals. A mental health focus is a needed paradigm shift in bodybuilding nutrition practice and research.

Bodybuilding and Fitness Doping in Transition. Historical Transformations and Contemporary Challenges

This article describes and analyses the historical development of gym and fitness culture in general and doping use in this context in particular. Theoretically, the paper utilises the concept of subculture and explores how a subcultural response can be used analytically in relation to processes of cultural normalisation as well as marginalisation. The focus is on historical and symbolic negotiations that have occurred over time, between perceived expressions of extreme body cultures and sociocultural transformations in society—with a perspective on fitness doping in public discourse. Several distinct phases in the history of fitness doping are identified. First, there is an introductory phase in the mid-1950s, in which there is an optimism connected to modernity and thoughts about scientifically-engineered bodies. Secondly, in the 1960s and 70s, a distinct bodybuilding subculture is developed, cultivating previously unseen muscular male bodies. Thirdly, there is a critical phase in the 1980s and 90s, where drugs gradually become morally objectionable. The fourth phase, the fitness revolution, can be seen as a transformational phase in gym culture. The massive bodybuilding body is replaced with the well-defined and moderately muscular fitness body, but at the same time there are strong commercialised values which contribute to the development of a new doping market. Finally, it is possible to speculate on the development of a fifth phase, in which fitness doping is increasingly being filtered into mainstream gym and fitness culture, influencing the fitness doping demography.

Drug sourcing and motivations among a sample of people involved in the supply of pharmaceutical drugs in Australia

BACKGROUND

The non-medical use (NMU) of pharmaceuticals is increasing internationally, along with mortality. Previous research indicates that end-users access pharmaceuticals through social networks, however little is known about supplier sources particularly outside the US. This study examined sourcing and motivations among a sample of people involved in pharmaceutical diversion and supply in Australia.

METHODS

Semi-structured, telephone interviews were conducted with 51 people involved in supplying pharmaceuticals in the previous six months. Multi-stage recruitment involved the distribution of flyers to participants of two Australian drug-monitoring programs: the Ecstasy and related Drugs Reporting System (capturing regular psycho-stimulant users) and the Illicit Drug Reporting System (capturing people who regularly inject drugs), followed by a screening of interested participants. Interviews were audio-recorded, transcribed and analysed using a mixed methods approach. First, correlates of drug sourcing and motivations were examined including demographics, frequency and quantity of supply. Second, thematic analysis of the qualitative data was undertaken on strategies for obtaining the drugs and motivating factors.

RESULTS

Drug supplies were sourced from a variety of medical and non-medical sources, primarily legitimately obtained prescriptions (47%), friends or family (18%) and dealers (14%). Suppliers using medical sources were more likely to be unemployed/retired and reported supplying for therapeutic purposes, while suppliers using non-medical sources were more likely to be employed/students, earned higher incomes and reported supplying for recreational purposes. Those who sourced via doctor shopping (IRR = 47.5) and friends and family (IRR = 10.1) distributed higher quantities, while those who sourced legitimately obtained prescriptions (IRR = 0.1) and from illicit drug dealers (IRR = 0.0) distributed lower quantities. Similar proportions supplied for financial (65%) and altruistic (61%) reasons, however the latter supplied lower quantities (IRR = 0.1).

CONCLUSION

This study offers novel insight into the diversion of pharmaceuticals from the supplier perspective. A nuanced policy approach is required to address varied supply practices by source and motive.

Defining and defending drug-free bodybuilding: A current perspective from organisations and their key figures

The use of performance- and image-enhancing drugs in the past seventy years or so has sparked a number of responses, including heated public debates, the creation of dedicated organisations and drug policies, as well as the emergence of communities of practice and belief in support of or in opposition to the phenomenon. Drug-free, known in the field as 'natural', bodybuilding has been developing since the 1970 s as a response to a dominant bodybuilding culture where the use of performance- and image-enhancing drugs has become normalised. Recent years have seen a multiplication of national and international governing bodies, competitions, and participants in drug-free bodybuilding in different parts of the globe. As the field grows, the questions of what constitutes natural bodybuilding and who can authentically represent it become central. Adopting a multi-method, qualitative approach, this article explores the ways organisations and their key figures define and defend their versions of drug-free bodybuilding. The discussion focus is on the policies, meanings and identities embedded in these different versions, and how their production and negotiation makes sense in light of antagonisms between players in the field of natural bodybuilding as well as their relation to drug-enhanced bodybuilding and the wider world of sport. In examining this previously uncharted body culture, the article explores how the use of performance- and image-enhancing drugs provokes responses and processes of contestation and differentiation. In the process, what becomes apparent is the designation and negotiation of drug-free, natural bodies as an ongoing, dynamic, social process.

Information sought, information shared: exploring performance and image enhancing drug user-facilitated harm reduction information in online forums

BACKGROUND

There is good evidence to suggest that performance and image enhancing drug (PIED) use is increasing in Australia and that there is an increase in those using PIEDs who have never used another illicit substance. Peers have always been an important source of information in this group, though the rise of the Internet, and the increased use of Internet forums amongst substance consumers to share harm reduction information, means that PIED users may have access to a large array of views and opinions. The aim of this study was to explore the type of information that PIED users seek and share on these forums.

METHODS

An online search was conducted to identify online forums that discussed PIED use. Three discussion forums were included in this study: aussiegymjunkies.com, bodybuildingforums.com.au, and brotherhoodofpain.com. The primary source of data for this study was the 'threads' from the online forums. Threads were thematically analysed for overall content, leading to the identification of themes.

RESULTS

One hundred thirty-four threads and 1716 individual posts from 450 unique avatars were included in this analysis. Two themes were identified: (1) personal experiences and advice and (2) referral to services and referral to the scientific literature.

CONCLUSIONS

Internet forums are an accessible way for members of the PIED community to seek and share information to reduce the harms associated with PIED use. Forum members show concern for both their own and others' use and, where they lack information, will recommend seeking information from medical professionals. Anecdotal evidence is given high credence though the findings from the scientific literature are used to support opinions. The engagement of health professionals within forums could prove a useful strategy for engaging with this population to provide harm reduction interventions, particularly as forum members are clearly seeking further reliable information, and peers may act as a conduit between users and the health and medical profession.