Illicit use of androgens and other hormones: recent advances

Nonconforming gender expression and adolescent anabolic-androgenic steroids misuse

BACKGROUND

Gender nonconformity (GNC) is an under-researched area of adolescent health that is of increasing interest to researchers and general public. However, little is known about whether it is associated with anabolic-androgenic steroids (AAS) misuse. We aimed to investigate the association among high school students using a cross-sectional design.

METHODS

We pooled the 6 school districts data from the Youth Risk Behavior Survey in 2017 and 2019. We compared the prevalence of AAS misuse among gender nonconforming and conforming students. AAS misuse was determined on the reported experience of lifetime non-prescription steroid use. GNC was derived from perceived gender expression and sex. We estimated the sex-stratified adjusted odds ratios (AORs) for the association of GNC with AAS misuse after adjusting for race/ethnicity, grade, and sexual orientation.

RESULTS

The study population consisted of 17,754 US high school students including 9143 (49.67%) female students. Among female students, GNC was significantly associated with moderate (AOR, 3.69; 95% CI 1.28-10.62; P = 0.016) and severe (AOR, 5.00; 95% CI 1.05-23.76; P = 0.043) AAS misuse, but not with any AAS misuse (AOR, 0.85; 95% CI 0.34-2.14; P = 0.734). Among male students, GNC was significantly associated with any (AOR, 4.75; 95% CI 2.93-7.69; P < 0.001), moderate (AOR, 4.86; 95% CI 2.66-8.89; P < 0.001) and severe (AOR, 4.13; 95% CI 1.43-11.95; P = 0.009) AAS misuse. We did not observe a dose-response relationship between GNC and any AAS misuse in female and male students.

CONCLUSIONS

This study suggests that AAS misuse is associated with GNC among female and male adolescents.

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.

Appearance and Performance Enhancing Drugs and Substances: The Role of the School Nurse

The purpose of this article is to provide the school nurse with the ability to recognize performance and appearance enhancing substance use and understand treatment and prevention strategies to reduce associated health risks. The use of appearance and performance enhancing drugs and substances, also known as "doping," has been an ethical and health issue in sports for many years. It is vital that school nurses learn to recognize performance and appearance enhancing substance use to ensure student athletes and exercisers receive the care and education they need. Commonly used performance and appearance enhancing substances include anabolic-androgenic steroids, stimulants, diuretics, growth hormone, and supplements. Signs and symptoms that may look similar to other health concerns include palpitations, stunted growth, acne, severe headaches, muscle cramps, dizziness, and dehydration, but some long-term severe complications occur as well. Doping can lead to severe and sometimes permanent organ damage, including liver, kidney, and heart disease. The school nurse can play a key role by working with parents, coaches, school counselors, and educators to foster an anti-doping culture.

Women's Experiences of Using Anabolic Androgenic Steroids

Anabolic androgenic steroids are used by women to increase their muscle mass and because of their performance-enhancing effects. Despite permanent/high risk of side effects, knowledge is inadequate. Our aim has been to deepen understanding about women's use of anabolic androgenic steroids. This phenomenological study is based on the reflective lifeworld research (RLR) approach. Lifeworld interviews were conducted with 12 women, aged 21-56 years, about their experiences of using anabolic steroids. The results show that women experience a sense of pride when they successfully achieve their goals. This is the driving force, triggering tension between suffering and success. Our research adds important knowledge from a reflective lifeworld perspective and shows that women's use of anabolic androgenic steroids is a complex phenomenon. Understanding and knowledge are important in order to be able to meet and support women in their fears and difficulties.

Education Interventions to Improve Knowledge, Beliefs, Intentions and Practices with Respect to Dietary Supplements and Doping Substances: A Narrative Review

The misuse of dietary supplements and doping substances is commonly associated with toxicity, nutritional imbalances, and health and psychological consequences. This is alarming especially in light of the increasing prevalence of the use of dietary supplements and doping, particularly among young adults including athletes. There is evidence that education interventions can lead to improved knowledge, intentions, and practices. However, no review has summarized and evaluated the effectiveness of such interventions. The aim of this article is to review the characteristics, contents and effects of education interventions that were designed and implemented to improve knowledge, attitudes, beliefs and intentions with respect to the use of dietary supplements and doping agents in different populations. PubMed, Scopus, CINAHL, PsycInfo and Google Scholar were searched for English-language education interventions targeting dietary supplements and doping substances. A total of 20 articles were identified and have generally provided consistent findings. Most interventions reported a significant improvement in knowledge on dietary supplements and doping agents. Unfortunately, the heavy reliance on self-reported assessment tools limits the validity of these interventions, with almost all articles targeting athletes and adolescents.

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.

The Type of Substance Use Mediates the Difference in the Odds of Sexual Risk Behaviors Among Adolescents of the United States

Background

Although the relationship between sexual risk behaviors and substance use has been established, It remains to be studied if different types of substances have differences in the odds of sexual risk behaviors. Therefore, we aimed to identify the prevalence of sexual risk behaviors in high school students of the United States (US) and study the difference in the odds of sexual risk behaviors for various substances.

Methods

We performed a retrospective cross-sectional study using Youth Risk Behavior Surveillance System (YRBSS) data of 2019 that nationally represents US high school students in grades 9-12. We identified individuals with sexual risk behaviors as participants with four or more lifetime sexual partners and who did not use a condom during the last intercourse.

Results

Out of 11,191 participants, 463 (3.9%) engaged in sexual risk behaviors. The prevalence of substance use, including anabolic steroids (11.5 vs. 1.1%), cocaine (27.2 vs. 2.0%), marijuana (87.1 vs. 34.7%), alcohol (92.4 vs. 54.3%), e-cigarette (90.3 vs. 48.0%), and traditional cigarette (62.2 vs. 21.6%) was higher in participants with sexual risk behaviors compared to participants with no sexual risk behaviors (p<0.0001 for all substances). In regression analysis, anabolic steroid use was associated with the highest odds of sexual risk behaviors (adjusted odds ratio (aOR):4.87, 95%CI: 2.48-9.57; p<0.0001) followed by cocaine (aOR:3.80, 1.80-8.00; p=0.001), marijuana (aOR:3.36, 1.64-6.89; p<0.0001), alcohol (aOR:2.41, 1.05-5.55; p=0.039), electronic vapor products (2.05, 1.004-4.19; p=0.049), and traditional cigarette use (aOR:1.58, 1.10-2.28; p=0.016). We did not find a statistically significant increase in the odds of sexual risk behaviors for the rest of the substances.

Conclusion

Although the prevalence of sexual risk behaviors is low, the prevalence of substance use is significantly higher in participants with sexual risk behaviors. Among the different types of substances, anabolic steroid use has the highest odds of sexual risk behaviors. Therefore, clinicians should remain vigilant for anabolic steroid use when screening adolescents for substance use. Further large-scale randomized studies are needed to study the effects of anabolic steroids on sexual risk behaviors.

Men´s experiences of using anabolic androgenic steroids

Purpose: Anabolic androgenic steroids (AAS) are used by men for their aesthetic and performance-enhancing effects and are associated with risk for side effects. Our research aims to deepen knowledge and understanding of men´s experiences of using AAS.

Method: This phenomenological study is based on the reflective lifeworld research approach. Lifeworld interviews were conducted with twelve men about their experiences of using AAS.

Results: By using AAS, men strive towards a muscular, strong and athletic ideal. Self-imposed demands, self-discipline and performance accelerate male physical development. The perfect male body ideal thus attained is fragile from both an existential and a biological perspective. The perfect self-image can easily be shattered by adversity. A man’s very existence may be jeopardized if the use of AAS is revealed to others or if the body is let down by illness.

Conclusions: Men´s use of AAS is a complex phenomenon. It partly concerns a traditional view of masculinity that is reflected in the community. It requires both broad and deep knowledge and understanding to be able to meet men using AAS in their problems and vulnerability; a meeting that is hampered by their low trust in healthcare, and by the fact that AAS are illegal.

Knowledge and beliefs about the use/abuse of oral contraceptive pills among males: A mixed-method explanatory sequential study in community pharmacy settings

BACKGROUND

Oral contraceptive pills (OCPs) are considered one of the most important birth control methods globally. However, these pills were designed for female administration rather than males. This study was designed to investigate patterns of OCPs use and abuse among Jordanian males, according to the community pharmacists' observations.

METHOD

A mixed-method explanatory sequential study was conducted using an online self-administered survey, followed by semi-structured in-depth interviews for registered pharmacists, assistant pharmacists and pharmacy interns. The interviews were utilized using a conceptual framework. Inductive thematic analysis and descriptive/regression analyses were completed using Nvivo and SPSS, respectively.

RESULTS

A total of 158 questionnaire responses and 22 interviews were included in our analysis. Around half (48.4%) of the questionnaire responses confirmed that males could use OCPs for hair growth enhancement, muscle gain and acne treatment 12.7%, 31.7% and 4.4%, respectively. Through the interviews, the participating pharmacists highlighted that males use OCPs mostly for bodybuilding purposes, according to recommendations by their coaches at the gym. The most abused OCPs containing estrogen (Ethinyl estradiol) and progestins (Drospirenone or Levonorgestrel).

CONCLUSION

This study provided insight into unexpected uses of OCPs by males in Jordan. Community pharmacists have a crucial role in the management of OCPs use and abuse. However, restricted regulations and monitoring must be released and implemented on the community to limit such practices.

Male Anabolic Androgenic Steroid Users with Personality Disorders Report More Aggressive Feelings, Suicidal Thoughts, and Criminality

Background and objectives: Anabolic androgenic steroids (AAS) are mainly used for aesthetic and performance-enhancing reasons. Their use is a growing public health problem and concern for society because of their adverse effects. The primary aim of this study was to identify psychiatric and personality disorders and to measure anxiety and depression in AAS users. Materials and Methods: Fifty-six males who actively contacted the Anti-Doping Hot-Line and wished to stop using AAS were included. Structured Clinical Interviews Diagnosis-I and -II were used to diagnose psychiatric and personality disorders. The Brief Scale for Anxiety and Montgomery Asberg Depression Rating Scale (subscales from the Comprehensive Psychopathological Rating Scale) were used to measure changes in anxiety and depression. Structured Clinical Interviews Diagnosis-I and -II were performed at one time point. Anxiety and depression were measured at inclusion and after six months. Urine samples were collected for an analysis of AAS and drugs of abuse. Results: All participants reported some adverse effects that they associated with AAS use. In total, 56% and 52% of the cohort fulfilled the criteria for Structured Clinical Interviews Diagnosis-I and -II diagnoses, respectively. A significantly increased risk of reporting aggressive feelings/behaviors (Odds Ratio (OR) = 4.9; Confidence Interval (CI) 0.99-25, p = 0.04), suicidal thoughts/attempts (OR = 4.6, CI 95; 0.99-21, p = 0.04) and criminality (OR = 6.5, CI 1-39, p = 0.03) was found among individuals with AAS use fulfilling the criteria for personality disorders compared with those without such AAS use. The Brief Scale for Anxiety score decreased from the median of 15 at inclusion to 10 at the follow-up visit six months later (p = 0.01, n = 19). Conclusions: Our findings indicate that among individuals with AAS use, those with a personality disorder report more aggressive behaviors, suicidal thoughts/suicidal attempts, and criminality than those without a personality disorder.

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.

The current status and future of andrology: A consensus report from the Cairo workshop group

BACKGROUND

In attempting to formulate potential WHO guidelines for the diagnosis of male infertility, the Evidence Synthesis Group noted a paucity of high-quality data on which to base key recommendations. As a result, a number of authors suggested that key areas of research/evidence gaps should be identified, so that appropriate funding and policy actions could be undertaken to help address key questions.

OBJECTIVES

The overall objective of this Consensus workshop was to clarify current knowledge and deficits in clinical laboratory andrology, so that clear paths for future development could be navigated.

MATERIALS AND METHODS

Following a detailed literature review, each author, prior to the face-to-face meeting, prepared a summary of their topic and submitted a PowerPoint presentation. The topics covered were (a) Diagnostic testing in male fertility and infertility, (b) Male fertility/infertility in the modern world, (c) Clinical management of male infertility, and (d) The overuse of ICSI. At the meeting in Cairo on February 18, 2019, the evidence was presented and discussed and a series of consensus points agreed.

RESULTS

The paper presents a background and summary of the evidence relating to these four topics and addresses key points of significance. Following discussion of the evidence, a total of 36 consensus points were agreed.

DISCUSSION

The Discussion section presents areas where there was further debate and key areas that were highlighted during the day.

CONCLUSION

The consensus points provide clear statements of evidence gaps and/or potential future research areas/topics. Appropriate funding streams addressing these can be prioritized and consequently, in the short and medium term, answers provided. By using this strategic approach, andrology can make the rapid progress necessary to address key scientific, clinical, and societal challenges that face our discipline now and in the near future.

[Doping in elite and popular sport : What orthopedic and trauma surgeons should know]

The spectacular doping raid during the Nordic World Ski Championships in Seefeld in winter this year is not the first time that illegal performance enhancement by taking drugs is in the spotlight of public interest. Kicked off by the so-called Festina scandal of the 1998 Tour de France, the serial exposure of further doping offences continues up to the present day. Less well-known to the general public is the high prevalence of doping under hobby and amateur athletes. Physicians are confronted by this group of patients in the practice much more frequently than by elite athletes, who are mostly treated in closed medical networks. The aim of the article is to provide an overview of the medical aspects including the most frequent substance classes and the current legal foundations of the anti-doping movement. Furthermore, the official definition of doping and the structure of the anti-doping agencies are presented.

Supraphysiologic-dose anabolic-androgenic steroid use: A risk factor for dementia?

Supraphysiologic-dose anabolic-androgenic steroid (AAS) use is associated with physiologic, cognitive, and brain abnormalities similar to those found in people at risk for developing Alzheimer's Disease and its related dementias (AD/ADRD), which are associated with high brain β-amyloid (Aβ) and hyperphosphorylated tau (tau-P) protein levels. Supraphysiologic-dose AAS induces androgen abnormalities and excess oxidative stress, which have been linked to increased and decreased expression or activity of proteins that synthesize and eliminate, respectively, Aβ and tau-P. Aβ and tau-P accumulation may begin soon after initiating supraphysiologic-dose AAS use, which typically occurs in the early 20s, and their accumulation may be accelerated by other psychoactive substance use, which is common among non-medical AAS users. Accordingly, the widespread use of supraphysiologic-dose AAS may increase the numbers of people who develop dementia. Early diagnosis and correction of sex-steroid level abnormalities and excess oxidative stress could attenuate risk for developing AD/ADRD in supraphysiologic-dose AAS users, in people with other substance use disorders, and in people with low sex-steroid levels or excess oxidative stress associated with aging.

Appearance/Image- and Performance-Enhancing Drug Users: A Forensic Approach

Image- and performance-enhancing drugs include a wide range of substances used to promote physical changes to enhance appearance. Anabolic androgen steroids are the most widely used image- and performance-enhancing drugs along with a wide variety of additional substances. The aim of this study was to identify the pathological changes pertaining to the cardiovascular system possibly involved in the death and characterize the substances associated with steroid use and their possible role in the death. A series of deaths involving image- and performance-enhancing drug users were selected. Nandrolone and testosterone were the most frequently identified steroids. The most commonly illegal drugs found were tetrahydrocannabinol, cocaine, and methadone. Antidepressants, opioids, benzodiazepines, and barbiturates were also found. These findings highlight that results obtained from postmortem investigations should be meticulously evaluated to understand the weight that each identified substance may have played in the death process and exclude any alternative causes of death.

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

BACKGROUND

Despite recognition that the Anabolic Androgenic Steroid (AAS) using population is diverse, empirical studies to develop theories to conceptualise this variance in use have been limited.

METHODS

In this study, using cluster analysis and multinomial logistic regression, we identify typologies of people who use AAS and examine variations in motivations for AAS use across types in a sample of 611 men who use AAS.

RESULTS

The cluster analysis identified four groups in the data with different risk profiles. These groups largely reflect the ideal types of people who use AAS proposed by Christiansen et al. (2016): Cluster 1 (You Only Live Once (YOLO) type, n = 68, 11.1%) were younger and motivated by fat loss; Cluster 2 (Well-being type, n = 236, 38.6%) were concerned with getting fit; Cluster 3 (Athlete type, n = 155, 25.4%) were motivated by muscle and strength gains; Cluster 4 (Expert type, n = 152, 24.9%) were focused on specific goals (i.e. not 'getting fit').

CONCLUSION

The results of this study demonstrate the need to make information about AAS accessible to the general population and to inform health service providers about variations in motivations and associated risk behaviours. Attention should also be given to ensuring existing harm minimisation services are equipped to disseminate information about safe intra-muscular injecting and ensuring needle disposal sites are accessible to the different types.

Three classes of steroids in typical freshwater aquaculture farms: Comparison to marine aquaculture farms

This study provides a comprehensive analysis of the occurrence of androgens, glucocorticoids and progestogens in typical freshwater aquaculture farms in comparison with marine aquaculture farms. The results showed that more steroids were detected in the marine aquaculture farms. For all aquatic products, the total concentrations of steroids in fish muscle were 22-2000ng/g, which were much higher than those detected in crabs, shrimps or mollusks (0.5-8.1ng/g). Based on the hazard index of the selected steroids, most water samples were in the low or medium risks. Some banned steroids were identified in the freshwater shrimps and all marine products, indicating that there may be certain health risks by the consumption of these aquatic products in the studied aquaculture farms. Furthermore, the total contributions of steroids in China were estimated to be 2300kg/y and 1200kg/y from freshwater fish culture and shrimp-crab culture, respectively.

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review

Injecting use of image and performance-enhancing drugs (IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme (CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention.

Structural Brain Imaging of Long-Term Anabolic-Androgenic Steroid Users and Nonusing Weightlifters

BACKGROUND

Prolonged high-dose anabolic-androgenic steroid (AAS) use has been associated with psychiatric symptoms and cognitive deficits, yet we have almost no knowledge of the long-term consequences of AAS use on the brain. The purpose of this study is to investigate the association between long-term AAS exposure and brain morphometry, including subcortical neuroanatomical volumes and regional cortical thickness.

METHODS

Male AAS users and weightlifters with no experience with AASs or any other equivalent doping substances underwent structural magnetic resonance imaging scans of the brain. The current paper is based upon high-resolution structural T1-weighted images from 82 current or past AAS users exceeding 1 year of cumulative AAS use and 68 non-AAS-using weightlifters. Images were processed with the FreeSurfer software to compare neuroanatomical volumes and cerebral cortical thickness between the groups.

RESULTS

Compared to non-AAS-using weightlifters, the AAS group had thinner cortex in widespread regions and significantly smaller neuroanatomical volumes, including total gray matter, cerebral cortex, and putamen. Both volumetric and thickness effects remained relatively stable across different AAS subsamples comprising various degrees of exposure to AASs and also when excluding participants with previous and current non-AAS drug abuse. The effects could not be explained by differences in verbal IQ, intracranial volume, anxiety/depression, or attention or behavioral problems.

CONCLUSIONS

This large-scale systematic investigation of AAS use on brain structure shows negative correlations between AAS use and brain volume and cortical thickness. Although the findings are correlational, they may serve to raise concern about the long-term consequences of AAS use on structural features of the brain.

Qualitative and Semiquantitative Analysis of Doping Products Seized at the Swiss Border

BACKGROUND

Substances developed for therapeutic use are also known to be misused by athletes as doping agents and, outside of regulated sport, for image-enhancement. This has generated a market for counterfeit doping substances. Counterfeit doping agents may be of poor pharmaceutical quality and therefore constitute health risks to consumers.

OBJECTIVES

This study aims to investigate the pharmaceutical quality of 1,190 doping products seized at the Swiss border.

METHODS

Swiss customs authorities seize incoming shipments potentially containing doping agents. Qualitative and semiquantitative analyses were performed in order to test for prohibited doping substances. The main analytical methods utilized for characterizing confiscated compounds were liquid chromatography-high resolution mass spectrometry, polyacrylamide gel electrophoresis with subsequent in-gel tryptic digestion and identification of peptidic compounds using nanoliquid chromatography-tandem mass spectrometry, and electrochemiluminescence immuno assay.

RESULTS

For 889 (75%) of the analyzed products, the label suggested the content of anabolic agents, for 146 samples (12%) peptide hormones or growth factors, and for 113 items (9%) antiestrogens, aromatase inhibitors or other metabolic modulators. For the majority of the investigated products, the pharmaceutical quality was an unsatisfactory standard: nonapproved substances were detected and less than 20% of the products contained the claimed substance in the respective amount.

CONCLUSION

A comprehensive sample of confiscated doping products was analyzed, allowing for monitoring of developments regarding the use of doping substances in Switzerland and for anticipating future trends and challenges in sports drug testing. An alarming number of tested products was of substandard pharmaceutical quality.

Adverse Effects, Health Service Engagement, and Service Satisfaction Among Anabolic Androgenic Steroid Users

There are a number of adverse health effects associated with the use of anabolic androgenic steroids (AAS), ranging from mood disturbances to gynecomastia and impaired sexual function. Despite the potentially serious nature of adverse effects, evidence suggests that users are reluctant to seek medical assistance. This study explores factors associated with health service engagement and treatments related to service satisfaction among a sample of AAS users. The analyses are based on a sample of 195 respondents from the Global Drug Survey 2015 who reported using steroids in the previous 12-month period and experiencing concerns about adverse health effects. The results indicate reluctance among AAS users to engage with health services, with only 35.23% reporting that they visited a doctor when experiencing concerns about adverse effects. Concern about sexual function increased the likelihood that users engaged with health services, while concern about changes in sexual organs decreased the odds of service engagement. Among AAS users who engaged with health services, individuals who received a mental health assessment or diabetes test rated the service as more helpful than those who did not; a finding that resonates with literature indicating a desire among AAS users to monitor the health impacts of their drug use and respond to issues as they arise. While more research is needed, the present results underscore a need for nonjudgmental health services aimed at assisting AAS users to monitor adverse effects and minimize harm through early intervention.

The multi-factorial origins of Chronic Traumatic Encephalopathy (CTE) symptomology in post-career athletes: The athlete post-career adjustment (AP-CA) model

CTE has two prominent components: the pathophysiology that is detected in the brain postmortem and the symptomology that is present in the interval between retirement and end of life. CTE symptomology has been noted to include memory difficulties, aggression, depression, explosivity, and executive dysfunction at early stages progressing to problems with attention, mood swings, visuospatial difficulties, confusion, progressive dementia, and suicidality (e.g. McKee et al. (2012), Omalu et al. (2010a-c), McKee et al. (2009)). There are a number of assumptions embedded within the current CTE literature: The first is the assumption that CTE symptomology reported by athletes and their families is the product of the pathophysiology change detected post-mortem (e.g. McKee et al. (2009)). At present, there is little scientific evidence to suggest that all CTE symptomology is the product of CTE pathophysiology. It has been assumed that CTE pathophysiology causes CTE symptomology (Meehan et al. (2015), Iverson et al. (2016)) but this link has never been scientifically validated. The purpose of the present work is to provide a multi-factorial theoretical framework to account for the symptomology reported by some athletes who sustain neurotrauma during their careers that will lead to a more systematic approach to understanding post-career symptomology. There is significant overlap between the case reports of athletes with post-mortem diagnoses of CTE, and symptom profiles of those with a history of substance use, chronic pain, and athlete career transition stress. The athlete post-career adjustment (AP-CA) model is intended to explain some of the symptoms that athletes experience at the end of their careers or during retirement. The AP-CA model consists of four elements: neurotrauma, chronic pain, substance use, and career transition stress. Based on the existing literature, it is clear that any one of the four elements of the AP-CA model can account for a significant number of CTE symptoms. In addition, depression can be a chronic lifelong co-morbid condition that may be present prior to an athletic career, or may be developed secondary to any of the model elements as shown in Fig. 1. Notably, neurotrauma is a necessary, but not a sufficient condition, for the development of CTE symptomology.

The Stigma of Anabolic Steroid Use

Little is known about the stigma of anabolic steroid use despite clear implications for treatment-seekers and for public policy development. We investigated the predictors of steroid stigma and contextualized the results by comparing steroids with marijuana. Undergraduates ( N = 304) completed measures of drug stigma, exposure to drug users, and history of drug use. Participants stigmatized steroid use more than marijuana use—a very large effect. Participants reported less exposure to steroid users. Nevertheless, 15% of participants reported having a steroid-using friend. History of drug use, but not exposure to steroid users, predicted lower steroid stigma. Drug use and exposure both predicted lower marijuana use stigma. The amount of stigma expressed toward steroids is commensurate with that of “hard” drugs, such as heroin, likely constituting a formidable barrier to treatment. The public’s difficulty empathizing with male body image insecurities may partially explain why exposure to steroid users did not predict lower stigmatization.

Transport of manure-borne testosterone in soils affected by artificial rainfall events

Information is very limited on fate and transport of steroidal hormones in soils. In this study, the rainfall simulation tests were conducted with a soil slab reactor to investigate the transport of manure-borne testosterone in a silty-clay loam soil under six controllable operation conditions (i.e., three rainfall intensities and two tillage practices). The properties [e.g., rainwater volume, particle size distribution (PSD)] of the slurry samples collected in runoff and leachate at different time intervals were measured; their correlation with the distribution of testosterone among runoff, leachate and soil matrix was analyzed. The results indicated that more than 88% of the testosterone was held by the applied manure and/or soil matrix even under the rainfall intensity of 100-year return frequency. The runoff facilitated testosterone transport through both dissolved and particle-associated phases, with the corresponding mass ratio being ∼7 to 3. Soil particles collected through runoff were mainly silt-sized aggregates (STA) and clays, indicating the necessity of using partially-dispersed soil particles as testing materials to conduct batch tests (e.g., sorption/desorption). No testosterone was detected at the soil depth >20 cm or in the leachate samples, indicating that transport of testosterone through the soil is very slow when there is no preferential flow. Tillage practice could impede the transport of testosterone in runoff. For the first time, results and the methodologies of this study allow one to quantify the hormone distribution among runoff, leachate and soil matrix at the same time and to obtain a comprehensive picture of the F/T of manure-borne testosterone in soil-water environments.

Self-Perceived Weight and Anabolic Steroid Misuse Among US Adolescent Boys

PURPOSE

Anabolic steroid misuse is a growing concern among adolescent boys, and chronic misuse is associated with multisystemic health consequences. However, little is known about weight related predictors of anabolic steroid misuse. We examined the prediction of lifetime anabolic steroid misuse as a function of self-perceived weight status among US adolescent boys.

METHODS

Analysis was undertaken using the 2013 Youth Risk Behavior Survey, a nationally representative data set sampling public and private high school students throughout the United States. Data from a total of 6,000 US adolescent boys were used in the present study.

RESULTS

The prevalence of ever misusing anabolic androgenic steroids was 12.6% among boys who viewed themselves as very underweight, 11.9% for boys who viewed themselves as very overweight, compared with 3.8% for boys who viewed themselves as about the right weight. Compared to boys who viewed themselves as about the right weight, boys who self-perceived themselves as very underweight (adjusted odds ratio = 6.9, 95% confidence interval: 2.7-17.7, p < .001) and very overweight (adjusted odds ratio = 3.8, 95% confidence interval: 1.8-7.7, p < .001) were significantly associated with increased risk of anabolic androgenic steroid misuse.

CONCLUSIONS

Large effect size estimates were revealed, suggesting that anabolic androgenic steroid misuse is not solely a function of boys desiring increased mass; boys who desire leanness are also likely to misuse anabolic androgenic steroids. Future prevention efforts should target not only boys who view themselves as underweight but also those who perceive themselves as overweight.

Sorption of testosterone on partially-dispersed soil particles of different size fractions: Methodology and implications

Sorption of hormones to soil particles of different size fractions (DSFs) has been studied to understand their fate and transport (F/T) in soils. Conventional studies fractionated the soil particles into DSFs by using the high speed stirring method and/or adding surfactants to fully disperse the bulk soil. However, the natural processes (e.g., soil erosion, irrigation) often are relatively mild, and many soil particles may be still in the aggregate form. In this study, a method was developed for conducting the sorption test of a representative hormone (i.e., testosterone) to bulk soils first and then analyzing the results against DSFs. Results indicated the particle size distribution (PSD) of the two representative soils tested with partially-dispersed and fully-dispersed methods was significantly different due to the attachment of clay particles on sand and silt. Testosterone was sorbed mainly by the dominant aggregates even though they might have relatively lower sorption affinity than that of clays. However, the small particles (<2000 nm), even with ∼5% mass of the bulk soil, contributed more than 30% of sorbed testosterone in the "whole" soils. The partially-dispersed soil particles of DSFs should be used to understand the transport of hormone in runoff, because using the fully-dispersed soil particles will overestimate while the whole soil method will underestimate the transport potential. With the methodology developed in this study, the sorption tests will not compromise soil's original properties (e.g., aggregates) or the competition (e.g., sorption) among soil particles, and the contribution of DSFs (particularly the partially-dispersed aggregates) to the sorption of the "whole" soil can be determined.

Recruitment to doping and help-seeking behavior of eight female AAS users

BACKGROUND

Doping with anabolic androgenic steroids in sports has now developed to a widespread use of these agents among young people outside the sport. This is of major concern to the society. The purpose of the use is mainly for aesthetic reasons and is seen as a male phenomenon. But use also occurs in women where the knowledge is scarce. Our aim was to identify the pattern of doping agents in eight female cases and compare them with similar data from men.

METHODS

Eight female users were recruited through Anti-Doping Hot-Line, a national telephone counseling service on doping issues during the years 1998-2004. The use was confirmed with urine doping analysis at the Doping Laboratory. The characteristic of use, co-use of narcotics/other doping agents, exercise pattern, adverse-side effects, family history and reason to begin was evaluated.

RESULTS

The women used on average 1.9 different anabolic androgenic steroids and clenbuterol preparations. Ephedrine and growth hormone were co-used in five and one of the women, respectively. Three women reported co-use of narcotics (cannabis and cocaine). The average duration of anabolic agent use before contacting health care was 58 weeks (range 7-104). Side effects for anabolic androgenic steroids (n = 5) included voice changes, clitoral enlargement, body hair growth, whereas women using clenbuterol (n = 2) reported tachycardia and depression. All women except one had a man in close relationship encouraging them to begin with the doping agents.

CONCLUSIONS

The use of doping agents in our eight women was different from that in male users. The women used less doping agents and were more prone to contact the health care, at an earlier stage, probably due to the adverse effects. The co-use with ephedrine, growth hormone and cannabis appeared to be in the same range as in men. This is the first study showing that a man in close relationship may motivate a woman to use anabolic agents.

Carotid Intima-Media Thickness Is Associated with Increased Androgens in Adolescents and Young Adults with Classical Congenital Adrenal Hyperplasia

BACKGROUND/AIMS

Youth with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency develop cardiovascular disease (CVD) risk factors of obesity and hypertension. Carotid intima-media thickness (CIMT), a marker of CVD risk, is increased in CAH young adults. We examined CIMT and its relationship with androgens and obesity in adolescents/young adults with CAH.

METHODS

Twenty CAH subjects (age 16 ± 3.3 years, 50% female) and 20 matched controls were studied cross-sectionally. Eight additional obese patients with CAH were included in within-group comparisons. CIMT by high-resolution ultrasound, androgens, anthropometry, bone age (BA), and metabolic/inflammatory markers were assessed.

RESULTS

Within the CAH group, CIMT correlated with 17-hydroxyprogesterone (r = 0.48, p < 0.05) and androstenedione (r = 0.46, p < 0.05), and was greater in obese subjects. CIMT was greater in CAH males than females, but similar among CAH females with advanced BA, CAH males with normal BA, and control males. There was no difference in CIMT between CAH and controls, although high-density lipoprotein was inversely correlated with CIMT in both groups.

CONCLUSION

CIMT is associated with increased androgens in CAH adolescents and young adults, with loss of sex differences in CAH females with excess androgen exposure. Our findings highlight the importance of hormonal control for CVD prevention in CAH.

Synthetic androgens as designer supplements

Anabolic androgenic steroids (AAS) are some of the most common performance enhancing drugs (PED) among society. Despite the broad spectrum of adverse effects and legal consequences, AAS are illicitly marketed and distributed in many countries. To circumvent existing laws, the chemical structure of AAS is modified and these designer steroids are sold as nutritional supplements mainly over the Internet. Several side effects are linked with AAS abuse. Only little is known about the pharmacological effects and metabolism of unapproved steroids due to the absence of clinical studies. The large number of designer steroid findings in dietary supplements and the detection of new compounds combined with legal loopholes for their distribution in many countries show that stricter regulations and better information policy are needed.

Netnography of Female Use of the Synthetic Growth Hormone CJC-1295: Pulses and Potions

BACKGROUND

Communal online folk pharmacology fuels the drive for short cuts in attaining muscle enhancement, fat loss, and youthful skin.

OBJECTIVES

The study used "netnography" to explore female use of CJC-1295, a synthetic growth hormone analogue from the perspectives contained in Internet forum activity.

METHODS

A systematic Internet search was conducted using variation of the term "CJC-1295"; and combined with "forum." Ninety-six hits related to bodybuilding websites where CJC-1295 was mentioned. Following application of exclusion criteria to confine to female use and evidence of forum activity, 9 sites remained. These were searched internally for reference to CJC-1295. Twenty-three discussion threads relating to female use of CJC-1295 formed the end data set, and analyzed using the Empirical Phenomenological Psychological method.

RESULTS

Forum users appeared well versed and experienced in the poly use of performance and image drug supplementation. Choice to use CJC-1295 centered on weight loss, muscle enhancement, youthful skin, improved sleep, and injury healing. Concerns were described relating to female consequences of use given gender variations in growth hormone pulses affecting estimation of dosage, cycling, and long-term consequences.

CONCLUSIONS

Public health interventions should consider female self-medicating use of synthetic growth hormone within a repertoire of product supplementation, and related adverse health consequences.

Male central hypogonadism secondary to exogenous androgens: a review of the drugs and protocols highlighted by the online community of users for prevention and/or mitigation of adverse effects

Androgen- or anabolic steroid-induced hypogonadism (ASIH) is no longer confined to professional athletes; its prevalence amongst young men and teenagers using androgens and/or anabolic steroids (AASs) is rising fast, and those affected can experience significant symptoms. Clinicians are increasingly encountering demanding, well-informed men affected by ASIH, yet lacking authoritative information on the subject may struggle to project a credible message. In this article, we overview the methods and drugs that men use in an attempt to counteract ASIH (with a view to either preventing its onset, or reversing it once it has developed) and summarize the scientific evidence underpinning these. The main channel for obtaining these drugs is the Internet, where they can be readily sourced without a valid prescription. An Internet search using relevant terms revealed a huge number of websites providing advice on how to buy and use products to counteract ASIH. Drugs arising repeatedly in our search included human chorionic gonadotrophin (hCG), selective oestrogen receptor modulators (SERMs) and aromatase inhibitors (AIs). The quality and accuracy of the online information was variable, but review of medical literature also highlighted a lack of scientific data to guide clinical practice. It is important for clinicians to be aware of the AAS user's self-treatment strategies with regard to ASIH side-effect mitigation. By ensuring that they are well-informed, clinicians are more likely to retain the credibility and trust of AAS users, who will in turn likely be more open to engage with appropriate management.

Anabolic androgenic steroids and violent offending: confounding by polysubstance abuse among 10,365 general population men

BACKGROUND AND AIMS

Anabolic androgenic steroid (AAS) use is associated with aggressive and violent behaviour, but it remains uncertain if this relationship is causal in humans. We examined the link between AAS use and violent crime while controlling for polysubstance abuse and additional suggested risk factors for violence.

DESIGN

Cross-sectional study of a population-based sample.

SETTING

In 2005, all Swedish-born male twins aged 20-47 years were invited to participate in the Swedish Twin Adults: Genes and Environment (STAGE) survey of the Swedish Twin Register (response rate = 60%).

PARTICIPANTS

A total of 10,365 male survey participants with information on AAS use.

MEASUREMENT

Data on self-reported use of AAS, alcohol and other substances, attention deficit hyperactivity disorder (ADHD) and personality disorder symptoms were linked to nation-wide, longitudinal register information on criminal convictions, IQ, psychological functioning and childhood socio-economic status (SES) covariates.

FINDINGS

Any life-time use of AAS was associated strongly with conviction for a violent crime [2.7 versus 0.6% in convicted and non-convicted men, respectively; odds ratio (OR) = 5.0, 95% confidence interval (CI) = 2.7-9.3]. However, this link was substantially reduced and no longer significant when controlling for other substance abuse (OR = 1.6, 95% CI = 0.8-3.3). Controlling for IQ, psychological functioning, ADHD, personality disorder symptoms and childhood SES did not reduce the risk further.

CONCLUSION

In the general population, co-occurring polysubstance abuse, but not IQ, other neuropsychological risks or socio-economic status, explains most of the relatively strong association between any anabolic androgenic steroid use and conviction for a violent crime.

Steroids, psychosis and poly-substance abuse

OBJECTIVE

To review consequences of the changing demographic profile of anabolic-androgenic steroid (AAS) use.

METHOD

Case report and review of key papers.

RESULTS

We report here a case of a 19-year-old Irish male presenting with both medical and psychiatric side effects of methandrostenolone use. The man had a long-standing history of harmful cannabis use, but had not experienced previous psychotic symptoms. Following use of methandrostenolone, he developed rhabdomyolysis and a psychotic episode with homicidal ideation. Discussion Non-medical AAS use is a growing problem associated with medical, psychiatric and forensic risks. The population using these drugs has changed with the result of more frequent poly-substance misuse, potentially exacerbating these risks.

CONCLUSION

A higher index of suspicion is needed for AAS use. Medical personnel need to be aware of the potential side effects of their use, including the risk of violence. Research is needed to establish the magnitude of the problem in Ireland.

Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement

Despite the high prevalence of performance-enhancing drug (PED) use, media attention has focused almost entirely on PED use by elite athletes to illicitly gain a competitive advantage in sports, and not on the health risks of PEDs. There is a widespread misperception that PED use is safe or that adverse effects are manageable. In reality, the vast majority of PED users are not athletes but rather nonathlete weightlifters, and the adverse health effects of PED use are greatly underappreciated. This scientific statement synthesizes available information on the medical consequences of PED use, identifies gaps in knowledge, and aims to focus the attention of the medical community and policymakers on PED use as an important public health problem. PED users frequently consume highly supraphysiologic doses of PEDs, combine them with other PEDs and/or other classical drugs of abuse, and display additional associated risk factors. PED use has been linked to an increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Because randomized trials cannot ethically duplicate the large doses of PEDs and the many factors associated with PED use, we need observational studies to collect valid outcome data on the health risks associated with PEDs. In addition, we need studies regarding the prevalence of PED use, the mechanisms by which PEDs exert their adverse health effects, and the interactive effects of PEDs with sports injuries and other high-risk behaviors. We also need randomized trials to assess therapeutic interventions for treating the adverse effects of PEDs, such as the anabolic-androgen steroid withdrawal syndrome. Finally, we need to raise public awareness of the serious health consequences of PEDs.

Anabolic steroid-induced hypogonadism: diagnosis and treatment

OBJECTIVE

To develop an understanding of hypogonadal men with a history of anabolic-androgenic steroid (AAS) use and to outline recommendations for management.

DESIGN

Review of published literature and expert opinions. Intended as a meta-analysis, but no quality studies met the inclusion criteria.

SETTING

Not applicable.

PATIENT(S)

Men seeking treatment for symptomatic hypogonadism who have used nonprescribed AAS.

INTERVENTION(S)

History and physical examination followed by medical intervention if necessary.

MAIN OUTCOME MEASURES(S)

Serum testosterone and gonadotropin levels, symptoms, and fertility restoration.

RESULT(S)

Symptomatic hypogonadism is a potential consequence of AAS use and may depend on dose, duration, and type of AAS used. Complete endocrine and metabolic assessment should be conducted. Management strategies for anabolic steroid-associated hypogonadism (ASIH) include judicious use of testosterone replacement therapy, hCG, and selective estrogen receptor modulators.

CONCLUSION(S)

Although complications of AAS use are variable and patient specific, they can be successfully managed. Treatment of ASIH depends on the type and duration of AAS use. Specific details regarding a patient's AAS cycle are important in medical management.

The lifetime prevalence of anabolic-androgenic steroid use and dependence in Americans: current best estimates

BACKGROUND AND OBJECTIVES

Although various surveys have tracked the prevalence of anabolic-androgenic steroid (AAS) use in American teenagers and young adults, no recent surveys have assessed the lifetime prevalence of AAS use in Americans overall. We therefore analyzed serial youth-survey data to derive estimates of the lifetime prevalence of AAS use in the current American general population.

METHODS

We first determined the distribution of age of onset of AAS use, based on pooled data from nine studies. Using this distribution, we then developed equations to project the eventual lifetime prevalence of AAS use among young survey respondents, once they aged and completed the period of risk for initiating AAS. We similarly calculated the denominator of lifetimes of risk for AAS use in the total American population. We next applied these equations to four independent national youth datasets to derive current American general-population estimates for lifetime AAS use. Finally, using data from 10 pooled studies, we estimated the lifetime prevalence of AAS dependence among AAS users.

RESULTS

Age-of-onset studies consistently showed that AAS use begins later than most drugs, with only 22% of users (95% confidence interval: 19-25%) starting before age 20. Applying the age-of-onset findings to national youth datasets, we estimated that among Americans currently age 13-50 years, 2.9-4.0 million have used AAS. Within this group, roughly 1 million may have experienced AAS dependence.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Although subject to various limitations, our estimation techniques suggest a surprisinigly high prevalence of AAS use and dependence among Americans.