Identifying a typology of men who use anabolic androgenic steroids (AAS)

Androgen abuse: Risks and adverse effects in men

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

The Association Between the Nonmedical use of Anabolic-Androgenic Steroids and Interpersonal Violence: A Meta-Analysis

The nonmedical use of anabolic-androgenic steroids (AAS) by athletes and the general population is a public health concern. One particular concern relates to the link between AAS use and violence. Although there is a growing body of research on the association between AAS and violence, results as to what the relationship is seem to be mixed. The aim of this meta-analysis is to improve our understanding of what the current evidence base indicates regarding the relationship between the use of AAS and interpersonal violence. In total, 14 studies with a total of 16 samples met the inclusion criteria, comprising a total sample size of 137,055 participants. The findings show that there is a significant association between AAS use and interpersonal violence (r = .21 [95% confidence intervals (CI): 0.15, 0.27], p < .00001), although small. It is however unclear what the direction of this relationship is as almost all studies failed to demonstrate whether AAS use occurred prior or subsequent to the violent behavior. Risk of bias for most studies was moderate or high. Three potential moderators, AAS use via self-report or testing, interpersonal violence via self-report or criminal records of violent behavior, and proportion of males, were nonsignificant. Although a meta-analytic relationship between AAS use and interpersonal violence was found, it is unclear to what extent AAS causes violent acts. We need to carefully consider the role of mediating factors, and that the relationship between the two could be part of a broader context as opposed to AAS being the cause of violence.

Masculine enhancement as health or pathology: gender and optimisation discourses in health promotion materials on performance and image-enhancing drugs (PIEDs)

The consumption of performance and image-enhancing drugs (PIEDs) is commonly pathologised in public health discourse as stemming from an unhealthy relationship to masculinity, and is often framed as intrinsically 'risky' and fundamentally at odds with 'good health'. This article examines Australian health promotion materials on PIEDs to analyse their role in shaping notions of good health, normal gender and appropriate self-improvement. To do so, it draws on the work of Butler, Law and Latour to consider how these materials co-constitute men and their health, often in problematic ways. First, we examine the ways in which PIEDs are constituted via a politics of the 'natural', then consider how the health promotion materials on PIEDs participate in the regulation of appropriate, healthy masculinity, and conclude by examining how adolescent masculinity is co-constituted with PIEDs. We observe a key tension between health promotion's avowed interest in improvement and optimisation and its treatment of PIED consumers as aberrant, vulnerable and insecure subjects whose drive to enhance and optimise is characterised by pathology and addiction. We conclude by arguing that health promotion materials on PIEDs fail to acknowledge the exceedingly normative character of enhancement practices in contemporary society.

Men, bodywork, health and the potentiality of performance and image-enhancing drugs

In a qualitative study on masculinity, embodiment and sexuality, we interviewed men who were recreational gym-goers about their bodywork practices in Melbourne, Australia. We also asked whether the men had used performance and image-enhancing drugs (PIEDs) as an adjunct to their bodywork practices. While none had used PIEDs, all were considering, or had considered, using them. We found that participants held varying opinions on PIED use and those who used them. The literature on PIEDs noted men's concerns with body appearance and health and focused largely on individual problematic use, but non-users were not mentioned. A second issue in the literature focused on social influences on PIED use, but again with no mention of non-users. Discussion on risk reduction as a public health response did not mention non-users either. This paper, therefore, reports on non-users' thoughts on, regular exposure to, and considerations of PIEDs and other men who use them. We propose that PIEDs might more usefully be understood as an everyday, if contradictory, consideration within most men's bodywork and health practices. We argue that PIEDs constitute a discursive practice exposing a potentiality that engages non-users also and this requires new health promotion approaches.

Innovative Reports on the Effects of Anabolic Androgenic Steroid Abuse-How to Lose Your Mind for the Love of Sport

Anabolic-androgenic steroids (anabolic-androgenic steroids, AAS) are testosterone-derived compounds whose popularity and use are constantly growing. Chronic use of AAS leads to many hormonal and metabolic disorders in the human body, which often lead to permanent health damage. Changes affect the following systems: cardiovascular, musculoskeletal, reproductive, digestive, and nervous. We decided to collect the existing knowledge in the literature and enrich it with the latest research reports in the field of degenerative effects of AAS on the nervous system. The work aimed to increase public awareness of the dangers and consequences of AAS use and improve it with the latest research on the neurodegenerative effects of AAS. We hope that our work will contribute to raising public awareness and reducing the use of AAS.

Anabolic-Androgenic Steroid Use: Patterns of Use among a National Sample of Canadian Adolescents and Young Adults

Background

Androgenic-anabolic steroid (AAS) use is relatively common among international recreational and community samples and is associated with several deleterious side effects and health consequences that have not been studied recently among a large Canadian sample. Therefore, the purpose of this study was to assess and describe characteristics of AAS users compared to non-AAS users among a national sample of Canadian adolescents and young adults.

Methods

Data from 2,774 adolescents and young adults from the Canadian Study of Adolescent Health Behaviors were analyzed. Participants were recruited via social media advertisements and completed the survey online. Survey items measured sociodemographics, AAS use, AAS side effects, motives for AAS use, AAS administration, body satisfaction, other illicit substance use, mental health, and violence involvement.

Results

Among the overall sample, 1.6% of participants reported lifetime AAS use, with the majority of users being White, heterosexual males. Most users strived to gain weight, with main motives for AAS use including increased muscularity and strength, and improved appearance. Most AAS users were satisfied with their body compared to non-users. Approximately one in five users had AAS dependence and experienced multiple adverse side effects. Few differences between users and non-users in self-reported mental health were found.

Conclusion

Findings indicate that AAS use among a community sample of Canadian adolescents and young adults is an important health issue, particularly given the relatively high occurrence of AAS dependence and adverse side effects reported by users. Findings support the need for education and intervention efforts from healthcare professionals. Further investigations among Canadian AAS users may provide more insight regarding the unique supports these individuals require.

Androgenic-anabolic steroids use among bodybuilders in western Iran: application of ridge logistic regression model

INTRODUCTION

Nowadays, the use of androgenic-anabolic steroids (AAS) by competitive and non-competitive bodybuilders and its side effects have become a major public health problem. Many studies have focused on determining the role and severity of various factors in AAS use, but the existence of collinearity between the factors leads to the non-significance of important factors. The study aimed to determine factors affecting the androgenic-anabolic steroids use in Iranian bodybuilders.

METHOD

This descriptive-analytical study was performed on 280 male bodybuilders (142 non-competitive and 138 competitive bodybuilders) in Hamadan, west of Iran, in 2016. The participations were recruited a multistage sampling method. A self-administrated questionnaire was used, which included parts such as intrapersonal, interpersonal, and behavioral factors affecting on AAS use. To solve the consequences of collinearity was used ridge logistic regression model (RLRM) in R.3.5.1 software.

RESULTS

The mean age of bodybuilders was 25.21 years (SD = 6.31). The prevalence rate of AAS use among non-competitive and competitive bodybuilders was 27.5% and 34.1%, respectively. Factors such as age, time of starting bodybuilding, attitude, physical self-concept, behavioral intention, coach and friend use AAS, alcohol consumption, and supplement use were associated with AAS use among non-competitive and competitive bodybuilders.

CONCLUSION

The results of the study indicated that a combination of intrapersonal, interpersonal and behavioral factors was effective on the androgenic-anabolic steroids use among Iranian bodybuilders. Adequate education about the side effects of AAS and improvement of individual skills seem to be helpful in reducing AAS use.

Doping and sports endocrinology: anabolic-androgenic steroids

The use of anabolic steroids affects not only professional athletes but also the general population (bodybuilders, gym clients, and adolescents). In the first case, its use is prohibited and sanctioned by the World Anti-Doping Agency and Olympic committees. For the other users, it is difficult to establish its prevalence since many obtain the products via the internet. The reasons for its use are varied and different forms of use and other types of users have been described. Among the side effects of steroid use, hypogonadism is the most frequent cause for endocrinological consultation. After a general introduction to doping, this review describes the historical background of anabolic-androgenic steroids, their classification, forms of use, physiological effects, adverse effects on different organs and systems, treatment of hypogonadism, as well as detection methods.

Exercise Selection and Common Injuries in Fitness Centers: A Systematic Integrative Review and Practical Recommendations

Weight resistance training (RT) is an essential component of physical conditioning programs to improve the quality of life and physical fitness in different ages and populations. This integrative review aimed to analyze the scientific evidence on the relationship between exercise selection and the appearance of musculoskeletal injuries in physical fitness centers (PFC). The PubMed or Medline, EMBASE or Science Direct, Google Scholar and PEDro databases were selected to examine the available literature using a Boolean algorithm with search terms. The review process was performed using the five-stage approach for an integrative review and it was reported according to the PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSiST) guidelines. A total of 39 peer-reviewed articles (Price index = 71.7%) met the inclusion criteria and evaluated the link between exercise selection and the incidence of injuries in exercisers who regularly attend PFC. Most injuries occur to the shoulders, elbows, vertebrae of the spine, and knees. Although the injury etiologies are multifactorial, the findings of the reviewed articles include the impacts of overuse, short post-exercise recovery periods, poor conditioning in the exercised body areas, frequent use of heavy loads, improper technique in certain exercises, and the abuse of performance- and image-enhancing drugs. Practical recommendations addressed to clinical exercise physiologists, exercise professionals, and health professionals are given in this paper. The exercise selection in RT programs requires professional supervision and adhering to proper lifting techniques and training habits that consider the anatomical and biomechanical patterns of the musculoskeletal structures, as well as genetic, pedagogical, and methodological aspects directly related to the stimulus-response process to mitigate the occurrence of RT-related injuries in PFC.

Systems mapping to understand complexity in the association between image and performance enhancing drugs (IPEDs) and harm

BACKGROUND

Effective harm reduction work is needed to prevent and respond to the harms associated with image and performance enhancing drug (IPED) use and the diverse needs of IPED communities. Methods based around understanding and mapping complex systems have previously been applied to advance thinking on a range of complex health issues. We applied a systems perspective to explore factors that contribute to IPED-related harms in the UK and to identify harm reduction priorities.

METHODS

An illustrative systems map was developed based on methods for mapping complex systems with expert stakeholders. Participants in two online workshops debated the important factors contributing to harm amongst people who use IPEDs and helped to refine and clarify the map. Discussions using the map reflected on where in the system intervention is needed and the policy implications.

RESULTS

Stakeholders (n=18) identified 51 distinct factors as being important determinants of IPEDs-related harms, and the connections between them. These were grouped under nine domains that formed this system: identity, cognitive processes, beliefs about risk and harm, health and wellbeing, social environment, beliefs about healthcare, healthcare providers, interventions, and IPED markets. Four harm reduction priorities identified through reflexive discussion included providing a wider range of interventions, improving engagement between the IPED communities and healthcare professionals, new approaches to disseminating information in the community, and early intervention.

CONCLUSION

Systems mapping methods are a useful approach to engage stakeholders to discuss drug use issues. A comprehensive policy response is required to this complex issue that recognises diversity in IPEDs communities, their decision-making, and their intervention and service needs, as current approaches are failing to adequately address important areas of harm. Engaging with a wide range of stakeholders is critical to generate new insights that can help respond effectively to reduce the risk of health harms.

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

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.

Anabolic Steroids Use Is Associated with Impairments in Atrial and Ventricular Cardiac Structure and Performance in Athletes

PURPOSE

Despite potential severe cardiac side effects, anabolic androgenic steroids (AAS) are increasingly used by strength athletes. However, previous echocardiographic studies focused on the left ventricular (LV) strains but did not assess LV twist and untwist mechanics. Moreover, left atrial (LA) function has been often neglected, and its stiffness, an important determinant of LA reservoir function, has never been challenged. The aim of this study was to investigate the effects of AAS on LA and LV morphologies and functions in strength athletes.

METHODS

Fifty subjects including 20 strength-trained young athletes age 32.0 ± 8.5 yr with a mean duration of AAS use of 4.7 ± 1.8 yr (users), 15 athletes with no history of AAS use (nonusers) and 15 sedentary controls underwent speckle tracking echocardiography to assess LA and LV morphology and function.

RESULTS

Users showed higher LA reservoir dysfunction than nonusers (33.7% ± 10.9% vs 44.9% ± 9.9% respectively, P = 0.004) and higher LA stiffness (0.13 ± 0.05 vs 0.19 ± 0.08 A.U., respectively; P = 0.02), higher LV mass index and lower global and regional LV diastolic and systolic dysfunction (global longitudinal strain: -15.5% ± 3.2% vs -18.9% ± 1.8% respectively; P = 0.003), with a drop of LV twist-untwist mechanics (untwisting velocity: 61.5°·s-1 ± 20.2°·s-1 vs 73.7°·s-1 ± 16.1°·s-1 respectively, P = 0.04). There were significant correlations between LV mass and LV apical rotation (P = 0.003, r = 0.44) and diastolic longitudinal strain rate (P = 0.015, r = 0.33).

CONCLUSIONS

Our results showing significant LA and LV remodeling and dysfunctions in young AAS using athletes are alarming. Screening echocardiography based on speckle tracking echocardiography parameters for early diagnosis, as well as a stronger awareness in athletes and in physicians are warranted in this context.

[Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users]

Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users Abstract. The prevalence of anabolic androgenic steroid (AAS; anabolic steroids) use in recreational sports is underestimated. Due to the influence of social media, an increase in AAS use in recreational sports and in the general population is to be expected. AAS use is associated with significant physical and mental health consequences, and the psychiatric consequences include the risk of developing addictive behaviour. The widespread stigmatization of AAS use also by professionals often undermines users' trust in physicians and drives them into the arms of so-called "gurus." The tightening of anti-doping practices in sports and an exclusively prohibitive stance have so far failed to convincingly curb the problem in recreational sports. Harm reduction strategies could help patients to get the help they need from primary care providers.

Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users

The prevalence of anabolic androgenic steroid (AAS; anabolic steroids) use in recreational sports is underestimated. Due to the influence of social media, an increase in AAS use in recreational sports and in the general population is to be expected. AAS use is associated with significant physical and mental health consequences, and the psychiatric consequences include the risk of developing addictive behaviour. The widespread stigmatization of AAS use also by professionals often undermines users' trust in physicians and drives them into the arms of so-called "gurus." The tightening of anti-doping practices in sports and an exclusively prohibitive stance have so far failed to convincingly curb the problem in recreational sports. Harm reduction strategies could help patients to get the help they need from primary care providers.

Anabolic androgenic steroids used as performance and image enhancing drugs in professional and amateur athletes: Toxicological and psychopathological findings

OBJECTIVE

The use of anabolic androgenic steroids (AASs) as performance and image enhancing drugs (PIEDs), once restricted to professional athletes, now includes amateurs and regular gym visitors. AAS use is associated with psychopathology, yet this relationship is complex and not fully understood. We aimed to assess the presence of AASs and other misused substances in athletes' biological samples and link toxicological to psychopathological findings.

METHODS

A multicentre, cross-sectional study in fitness centres in Italy recruited 122 professional and amateur athletes training in several sports (84 men; age range = 18-45 years). Athletes completed questionnaires, interviews, and toxicology testing for AASs, other PIEDs, illicit drugs, and non-prescribed psychotropics. Toxicology was conducted in blood, urine, and hair.

RESULTS

Self-reported and toxicologically detected use rates of AASs and other misused substances showed slight-to-fair agreement (Fleiss' κ = 0.104-0.375). There was slight-to-moderate agreement among the three biological samples used for AAS testing (κ = 0.112-0.436). Thirty-one athletes (25.4%) tested positive for AASs. More sport hours/week, narcissistic or antisocial personality disorders, and higher nonplanning impulsiveness scores predicted AAS use (pseudo-R²  = 0.665). AAS users did not differ significantly from non-users in major psychopathology, but their Hypomania Checklist-32 score, which also predicted AAS use, was significantly higher (p < 0.001), suggesting increased odds for cyclothymic disorder or subthreshold hypomania.

CONCLUSIONS

Our results have implications for studying AAS users, as they identify a cluster of variables that may be relevant in future understanding of AAS use risks (e.g., personality disorders). Possible disagreements between AAS assessment methods should be considered when implementing harm reduction interventions, such as needle and syringe distribution, health education, and counselling, as well as surveillance programmes.

Anabolic-Androgenic Steroid Misuse: Mechanisms, Patterns of Misuse, User Typology, and Adverse Effects

Anabolic-androgenic steroids (AAS) encompass a broad group of natural and synthetic androgens. AAS misuse is highly prevalent on a global scale, with the lifetime prevalence of AAS misuse in males being estimated to be around 6%, with 15 to 25% of male gym attendees using it at any one time. AAS are associated with sudden cardiac death, neuropsychiatric manifestations, and infertility. The average AAS user is unlikely to voluntarily declare their usage to a physician, with around 1 in 10 actively engaging in unsafe injection techniques. The aim of this paper is to review the current evidence base on AAS with emphasis on mechanisms of action, adverse effects, and user profiles that are most likely to engage in AAS misuse. This paper also reviews terminologies and uses methods specific to the AAS user community.

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

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.

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

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

Injection of Anabolic Steroids in Men Who Had Sex with Men in Madrid and Barcelona: Prevalence Correlates and Role as a Risk Factor for Transmitted Infections

This study describes the prevalence of anabolic-androgenic steroid (AAS) injection, their main correlates, and the prevalence of specific AAS injection risk behaviours among men who have sex with men (MSM), an area insufficiently addressed in scientific research. Participants were HIV-negative MSM attending four HIV/STI diagnosis services: two clinics and two community programmes in Madrid and Barcelona. Participants answered an online self-administered questionnaire. Crude and adjusted lifetime prevalence and prevalence ratios (PRs) were calculated by different factors and using Poisson regression models with robust variance. Of the 3510 participants, 6.1% (95% CI: 5.3-6.9) had injected AAS before and 3.5% (95% CI: 2.9-4.2) had done so in the last 12 months. In the multivariate analysis, AAS injection was independently associated with being over 40 years old (aPR = 3.6; 95% CI: 2.0-6.5) and being born in Latin America (aPR = 2.5; 95% CI:1.9-3.4), and was less strongly associated (aPRs of around two) with having been recruited into STI clinics, having ever been paid for sex before, injected drugs, used drugs for sex, having been diagnosed with an STI before, and having been diagnosed with HIV at the recruitment consultation. Only three participants, 1.4%, of those who had injected AAS before had shared AAS or equipment for preparation or injecting before. Conclusions: In contrast to drugs, AAS injecting behaviours do not play a relevant, direct role in the transmission of blood-borne infections among MSM. However, AAS injectors have a higher prevalence of sexual risk behaviours. These findings should be confirmed using new studies that employ other sampling procedures.

Anabolic-Androgenic Steroid Use in Sports, Health, and Society

This consensus statement is an update of the 1987 American College of Sports Medicine (ACSM) position stand on the use of anabolic-androgenic steroids (AAS). Substantial data have been collected since the previous position stand, and AAS use patterns have changed significantly. The ACSM acknowledges that lawful and ethical therapeutic use of AAS is now an accepted mainstream treatment for several clinical disorders; however, there is increased recognition that AAS are commonly used illicitly to enhance performance and appearance in several segments of the population, including competitive athletes. The illicit use of AAS by competitive athletes is contrary to the rules and ethics of many sport governing bodies. Thus, the ACSM deplores the illicit use of AAS for athletic and recreational purposes. This consensus statement provides a brief history of AAS use, an update on the science of how we now understand AAS to be working metabolically/biochemically, potential side effects, the prevalence of use among athletes, and the use of AAS in clinical scenarios.

Aggression and Psychological Distress in Male and Female Anabolic-Androgenic Steroid Users: A Multigroup Latent Class Analysis

The relationship between anabolic-androgenic steroid (AAS) use and aggression and psychological distress requires further elucidation. No previous study has examined whether the latent patterns of aggression and psychological distress are the same in male and female AAS users. Multigroup latent class analysis (MLCA) can be used to classify individuals into groups based on their responses on a set of variables, and to investigate measurement invariance across subgroups. We therefore conducted a MLCA to identify discrete subgroups of aggression and psychological distress in AAS users, and used measurement invariance to examine whether the identified subgroups can be applied to both sexes. We also examined the relationship between sex and subgroup belongingness. The sample comprised 206 AAS users (females = 58.30%) aged 14-56 (mean = 26.86, SD = 7.12) years. They completed questionnaires assessing demographics, AAS use, aggression, and psychological distress. Based on the MLCA, five subgroups were identified: high aggression moderate distress users (HAMoD: 07.63%), moderate aggression distress users (18.64%), moderate direct aggression-mild indirect aggression moderate distress users (22.95%), mild direct aggression-moderate indirect aggression-distress users (11.71%), and low aggression mild distress users (LAMiD: 39.06%). Although a homogenous five-class solution was the best model for both sexes, sex was significantly associated with the probability of subgroup membership. In particular, members of the HAMoD subgroup were more likely to be male whereas members of the LAMiD subgroup were more likely to be female. Our study provides novel empirical evidence of the idiosyncratic patterns of aggression and psychological distress among male and female AAS users.

Use of anabolic-androgenic steroids and other substances prior to and during imprisonment - Results from the Norwegian Offender Mental Health and Addiction (NorMA) study

BACKGROUND

Anabolic-androgenic steroid (AAS) use is associated with health problems and substance use. Substance use is common among inmates. This study aims to estimate lifetime and prison use of AAS and other substances, compare characteristics of groups of inmates, and describe factors associated with AAS use in a national prison population.

METHODS

Data from the Norwegian Offender Mental Health and Addiction (NorMA) Study, a cross-sectional survey of people in prisons, included sociodemographic variables and lifetime and prison use of AAS and other substances. Altogether 1,499 inmates, including 96 (6.4%) women, were divided into three mutually exclusive groups according to lifetime AAS use, non-AAS substance use and no substance use.

RESULTS

Lifetime AAS use was reported by 427 (28.5%) inmates; 6 women and 421 men. Non-AAS substance use was reported by 593 (39.6%) and 479 (31.9%) had never used AAS or non-AAS substances. Compared to the non-AAS substance group, the AAS group reported younger debut ages for nearly all non-AAS substances, higher mean number of non-AAS substances used in their lifetime (8.9, 6.6, p < 0.001), during the six months prior to incarceration (5.2, 3.1, p < 0.001), and during (2.3, 1.3, p < 0.001) imprisonment. Although 120 (8.0%) inmates used AAS during the six months prior to incarceration, only ten continued during imprisonment.

CONCLUSIONS

Lifetime AAS use is common among inmates and may be an indicator of more severe substance use problems. Screening for previous and present AAS use at incarceration and increased staff awareness are needed to tailor treatment approaches appropriately.

Factors associated with hepatitis C and HIV testing uptake among men who inject image and performance enhancing drugs

INTRODUCTION AND AIMS

Historically, people who inject image and performance enhancing drugs (IPED) were not perceived as being at high risk of HIV or hepatitis C virus (HCV) infection. However, recent studies indicate HCV and HIV prevalences are elevated, with many HCV infections undiagnosed.

DESIGN AND METHODS

Men who inject IPEDs recruited from community settings and specialist services, including needle-syringe programs, across UK during 2016 self-completed a questionnaire. Multivariate analyses examined factors associated with HCV/HIV testing.

RESULTS

The participants' (n=562; 24% service recruited) median age was 31 years, 4% identified as gay or bisexual, 18% had ever been imprisoned and 6% had ever injected a psychoactive drug. Those community recruited more often reported sharing drugs vials (16% vs. 8%, P=0.021) and, among those with 2+ sexual partners, poor condom use (50% vs. 36%, P=0.063), than those service recruited. Overall, one-third had ever been tested for HCV (31%) and/or HIV (34%). Testing uptake was associated with other risk factors for HCV/HIV, being recruited through services and having received metabolic tests. Participants' motivations for using IPEDs were associated with recruitment setting and HIV/HCV testing uptake.

DISCUSSION AND CONCLUSIONS

The majority were untested for HCV/HIV. HCV/HIV testing and risks were associated with recruitment through services. Previous needle and syringe program-based studies have potentially overestimated testing uptake and underestimated risk. Targeted interventions are needed, particularly for those not accessing services. The association between HCV/HIV testing uptake and receipt of metabolic tests suggests that developing a combined offer of these tests as part of health monitoring could improve uptake.

A sentinel population: The public health benefits of monitoring enhanced body builders

There is heightened recognition of the public health implications of anabolic androgenic steroids (AAS) for the use of image and performance enhancement; with increasing evidence of their long-term negative health impacts, the hazards associated with their administration (often via injection), and the variability and unpredictability of their contents. In order to optimise the effects of these drugs, together with strict dietary and training regimes, AAS users typically supplement their use with an expansive and continually evolving range of ancillary drugs. The discovery and subsequent adoption of these drugs by the broader AAS user population is largely dependent upon a minority of social influencers within the bodybuilding community. Pioneering enhanced bodybuilders who self-experiment with a diverse range of image and performance enhancing drugs (IPEDs) and ancillary drugs have been the forerunners in the development of an underground user-led literature, online discussion forums, and were early adopters of internet-facilitated drug markets. Yet the impact of their self-experimentations extends well beyond the enhanced bodybuilding community, particularly in their use of ancillary drugs. Most significantly has been their role in the diffusion of various enhancement and psychoactive drugs to the wider population. Using the theoretical framework of the 'diffusion of innovation' we consider the role that pioneering enhanced bodybuilders have played in the diffusion of various enhancement and psychoactive drugs to the wider population through a focus on three substances: dinitrophenol (DNP), melanotan II and gamma-hydroxybtyrate (GHB). With an increasing range of drugs used by bodybuilders, coupled with an expansion in the use of online forums and online platforms to purchase pharmacological and new psychoactive drugs, we anticipate this trend of diffusion amongst the wider population will continue to flourish. Therefore, we highlight the need for policy makers to monitor emergent trends, not only in the general AAS population but particularly amongst enhanced bodybuilders.

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.

Testosterona y homicidio: aspectos neuroendocrinos de la agresión

Introducción. Las tasas de homicidio, suicidio y agresión son mayores en el sexo masculino; la testosterona podría desempeñar un papel importante en el desarrollo de estos comportamientos. Objetivo. Realizar una revisión de los aspectos endocrinos y neurobiológicos de la testosterona y su relación con comportamientos agresivos, homicidas y suicidas.Materiales y métodos. Se realizó una revisión narrativa con diferentes estrategias de búsqueda en PubMed, SpringerLink, ScienceDirect y SciELO. Se incluyeron artículos de investigación, revisiones y reportes de caso publicados en español y en inglés entre 2002 y 2018.Resultados. De los 66 estudios incluidos en la revisión, más del 50% asociaron el comportamiento agresivo u homicida con niveles elevados de testosterona, hormona que podría modular la actividad de las vías cerebrales serotoninérgicas y dopaminérgicas involucradas en el comportamiento agresivo por medio de receptores androgénicos y estrogénicos. Se encontraron relaciones entre uso de esteroides anabólicos y homicidio, y entre testosterona circulante en mujeres y rasgos de personalidad antisocial. Asimismo, se observaron cambios de concentraciones séricas de testosterona en sujetos con tendencias suicidas.

The Anabolic Androgenic Steroid Treatment Gap: A National Study of Substance Use Disorder Treatment

Background:

Anabolic androgenic steroid (AAS) use is associated with serious mental and physical health problems. Evidence indicates that AAS use among people who use psychoactive substances is higher than in the general population. This study aims to estimate lifetime AAS use among patients in substance use disorder (SUD) treatment, compare characteristics of AAS and non-AAS users and identify whether AAS use was addressed during treatment.

Methods:

This cross-sectional survey included 563 (142 women, 24.2%) patients in 38 SUD treatment facilities in Norway. Respondents reported on AAS and substance use, and treatment experiences.

Results:

Lifetime AAS use was reported by 156 (28.3%) SUD patients, thereof 35.6% of the men and 8.0% of the women. Lifetime AAS use was highest among men with stimulants (55.8%) as preferred substance, and lowest among men who preferred alcohol (14.6%). Initiation of AAS use due to getting thinner following substance use was reported by 44.5% of the AAS using men. AAS users reported more severe substance use than non-AAS users. More than half (58%) of all patients had not been asked about AAS use, and 42.4% of those who were asked, experienced that treatment providers lacked expertise about AAS.

Conclusion:

Lifetime AAS use in this sample of SUD patients is common practice and comprise an underrecognized problem in SUD treatment. Given the deleterious implications to the individual and society that concomitant use of AAS may cause, it would be essential to raise the awareness about AAS use among SUD patients, and the level of competence among health professionals.

Developmental transitions during adulthood and neighborliness: A multilevel cluster analysis

Neighborliness plays a critical role in promoting social integration, and is known to positively influence health and psychosocial adjustment. We examined variation in neighborliness based on developmental transitions as well as on the neighborhood context. We examined the direct and moderating role of neighborhood factors, to determine whether the neighborhood context modified the influence of developmental transitions on neighborliness. We analyzed data from a longitudinal study of Australian communities, in addition to census data. First, we analyzed developmental transition clusters. Next, we employed multilevel modeling to assess the impact of clusters and other key factors on neighborliness. We tested interactions to determine whether the influence of cluster membership on neighborliness was modified by the neighborhood. We found evidence for direct effects of cluster membership and structural factors on neighborliness. In addition, the neighborhood context modified the influence of cluster membership on neighborliness. Our findings underscore the importance of promoting neighborhood social engagement throughout the life course.

Anabolic-Androgenic Steroid Use in the Eastern Mediterranean Region: a Scoping Review of Extant Empirical Literature

The use of image- and performance-enhancing drugs particularly anabolic-androgenic steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with mainstream populations using these drugs for aesthetic purposes. Prevalence has been predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature from the Eastern Mediterranean region described and mapped what is known about the extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects. The review highlights a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review underscores the need to carry out further research, particularly qualitative and quantitative studies with both genders, and cognisant of the complexities of culture and religiosity.

Treatments for people who use anabolic androgenic steroids: a scoping review

BACKGROUND

A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a diverse population with varying motivations. Evidence has increased greatly in recent years to support understanding of this form of substance use and the associated health harms, but there remains little evidence regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health problems.

METHODS

A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible.

RESULTS

In total, 109 eligible studies were identified, which included case reports representing a diverse range of disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings were limited throughout by the case report study designs and limited information was provided.

CONCLUSION

This scoping review indicates that while a range of case reports describe treatments provided to AAS users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.

Maintaining the healthy body: Blood management and hepatitis C prevention among men who inject performance and image-enhancing drugs

Australia's ambitious aim to 'eliminate' hepatitis C as a public health concern by 2030 requires researchers, policy makers and health practitioners to engage with populations rarely identified as a priority. Men who inject performance and image-enhancing drugs (PIEDs) are one such population, yet research suggests they have low rates of knowledge about hepatitis C. Although rates of needle-sharing in this group are thought to be low, other risks of blood-to-blood contact exist due to the use of large-gauge needles, intramuscular injecting, hard-to-reach injection sites, repeated injecting and peer-to-peer injecting. How should health initiatives engage people who might not customarily consider themselves vulnerable to hepatitis C? Drawing on the work of body theorist Margrit Shildrick, this article considers how men who inject PIEDs understand their bodies, with a particular focus on injecting practices, blood awareness and infection control, in order to inform hepatitis C prevention efforts. In our analysis, we draw on qualitative interviews with 60 men who inject PIEDs, which we conducted for an Australian Research Council-funded project focused on better understanding PIED injecting to improve health and minimise hepatitis C transmission. The interviews suggest that men who inject PIEDs closely monitor potential external infection risks, such as dirt and bacteria that might intrude upon the 'purity and security' of the body. However, less attention appears to be paid to what might be transferred out of the body and potentially to others, such as blood. Notions of trust and cleanliness, and normative perceptions of intravenous drug use, also shaped injecting practices and cursory attention to blood management. While environmental transmission poses a smaller transmission risk than needle-sharing, educating PIED consumers about it is nevertheless warranted. Focusing targeted health promotion materials on environmental blood as a potential route of hepatitis C transmission may help engage this population in prevention, and encourage more frequent hepatitis C testing.

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

BACKGROUND

Since there is a paucity of research on support for people using Anabolic Androgenic Steroids (AAS), we aimed to identify and synthesise the available evidence in this field. Gaining an understanding of the support both accessed and wanted by recreational AAS users will be of use to professionals who provide services to intravenous substance users and also to those working in the fields of public health and social care, with the aim to increase engagement of those using AAS.

METHODS

A systematic scoping review of the literature to explore and identify the nature and scope of information and support both accessed and wanted by non-prescribed AAS users. Any support services or information designed to help people who use AAS were considered.

RESULTS

We identified 23 papers and one report for review, which indicated that AAS users access a range of sources of information on: how to inject, substance effectiveness, dosages and side effects, suggesting this is the type of information users want. AAS users sought support from a range of sources including medical professionals, needle and syringe programmes, friends, dealers, and via the internet, suggesting that, different sources were used dependent on the information or support sought.

DISCUSSION

AAS users tended to prefer peer advice and support over that of professionals, and access information online via specialist forums, reflecting the stigma that is experienced by AAS users. These tendencies can act as barriers to accessing services provided by professionals.

CONCLUSIONS

Support needs to be specific and targeted towards AAS users. Sensitivity to their perceptions of their drug-use and the associated stigma of being classified in the same sub-set as other illicit drug users is relevant to facilitating successful engagement.

Anabolic-androgenic steroid users receiving health-related information; health problems, motivations to quit and treatment desires

BACKGROUND

Anabolic-androgenic steroids (AAS) are used to increase muscle strength and improve appearance, but users also carry the risk of developing physical and mental health problems. In Norway, the substance use disorder treatment system provides health care to this patient group, but few AAS users have sought such treatment. Therefore, a service was created to inform AAS users and next of kin of potential negative consequences and their treatment options. This study describes health problems, motivations for AAS cessation, and treatment desires among AAS users.

METHODS

Over four years, 232 AAS users and 60 next of kin contacted the information service and received an hour-long information session with healthcare personnel. Information about AAS use, physical and mental health problems, substance use, motivation for cessation, and whether the information seeker desired treatment were registered. Qualitative interviews were conducted among seven individuals and analyzed thematically to explore information service experiences.

RESULTS

Of the 232 AAS users, 179 (77.2%) desired treatment after completing the information session and 53 (22.9%) were unsure or did not want treatment. Those who desired treatment were significantly older, had used AAS longer, reported more physical and mental health side effects, and a higher proportion reported having children than those who did not desire treatment. Although 181 (78.0%) reported co-occuring physical and mental health problems, mental health problems were the most common motivation for AAS cessation (n = 108, 47.8%), followed by a combination of mental and physical health problems (52, 23.0%). Findings from qualitative interviews suggest that barriers to treatment may be overcome with an easily accessible service that informs about addiction treatment and facilitates the treatment entry process.

CONCLUSIONS

Healthcare professionals who encounter users of AAS should have knowledge about AAS use and adverse effects. The desire for health care reveals extensive health problems and the user group is so non-homogeneous that examination and treatment must be adapted individually with focus on physical, mental and social factors as well as possible dependence of AAS and/or psychoactive substances.

The unintended consequences of emphasising blood-borne virus in research on, and services for, people who inject image and performance enhancing drugs: A commentary based on enhanced bodybuilder perspectives

Blood-borne viruses (BBVs) are an established focus of drug research and harm reduction. While a focus on BBVs has been applied to people who inject image and performance enhancing drugs (IPEDs), research has demonstrated that there are significant differences between this group and people who inject other drugs. Furthermore, the literature on BBVs and IPED use has been misrepresented by the media and harm reduction programs, with significant consequences for how some people who inject IPEDs view academic research and health services. It seems time to ask, is our current approach to the issue of BBV among people who inject IPEDs the most appropriate, and are there ways that it could be improved to ensure that there are no unintended consequences? In this commentary I suggest ways research and harm reduction efforts could tackle the issue of BBV without exacerbating existing divides between people who inject IPEDs and the health and academic communities. These suggestions are based on the views of the enhanced bodybuilders with whom I am privileged to work.

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.