"I Want It All, and I Want It Now": Lifetime Prevalence and Reasons for Using and Abstaining from Controlled Performance and Appearance Enhancing Substances (PAES) among Young Exercisers and Amateur Athletes in Five European Countries

Psychosocial predictors of doping intentions and use in sport and exercise: a systematic review and meta-analysis

OBJECTIVE

To conduct a meta-analytic review of psychosocial predictors of doping intention, doping use and inadvertent doping in sport and exercise settings.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Scopus, Medline, Embase, PsychINFO, CINAHL Plus, ProQuest Dissertations/Theses and Open Grey.

ELIGIBILITY CRITERIA

Studies (of any design) that measured the outcome variables of doping intention, doping use and/or inadvertent doping and at least one psychosocial determinant of those three variables.

RESULTS

We included studies from 25 experiments (N=13 586) and 186 observational samples (N=3 09 130). Experimental groups reported lower doping intentions (g=-0.21, 95% CI (-0.31 to -0.12)) and doping use (g=-0.08, 95% CI (-0.14 to -0.03), but not inadvertent doping (g=-0.70, 95% CI (-1.95 to 0.55)), relative to comparators. For observational studies, protective factors were inversely associated with doping intentions (z=-0.28, 95% CI -0.31 to -0.24), doping use (z=-0.09, 95% CI -0.13 to to -0.05) and inadvertent doping (z=-0.19, 95% CI -0.32 to -0.06). Risk factors were positively associated with doping intentions (z=0.29, 95% CI 0.26 to 0.32) and use (z=0.17, 95% CI 0.15 to 0.19), but not inadvertent doping (z=0.08, 95% CI -0.06 to 0.22). Risk factors for both doping intentions and use included prodoping norms and attitudes, supplement use, body dissatisfaction and ill-being. Protective factors for both doping intentions and use included self-efficacy and positive morality.

CONCLUSION

This study identified several protective and risk factors for doping intention and use that may be viable intervention targets for antidoping programmes. Protective factors were negatively associated with inadvertent doping; however, the empirical volume is limited to draw firm conclusions.

Profile of gym-goers who do not use performance-enhancement substances

Introduction

Currently the use of prohibited performance-enhancing substances (PES) in fitness and gym settings is a public health concern as adverse health consequences are emerging. Understanding the characteristics of gym-goers who do not use these substances could lead to an important complement to the ongoing research about risk factors for PES use. The aim of this study was to identify the profile of PES non-use in gym-goers.

Methods

In total, 453 gym-goers (mean age = 35.64 years; SD = 13.08 - measure of central tendency location and measure of absolute dispersion, respectively) completed an online survey assessing sociodemographic factors, exercise characteristics, gym modalities, peers, social influence, attitudes, subjective norms, beliefs, intentions, and self-reported use of PES.

Results

Decision Trees showed that being a woman, training less frequently, not practicing bodybuilding and having a negative intention to consume PES were identified as characteristics of non-users of PES.

Discussion

These results may support evidence-based anti-doping interventions to prevent abusive use of PES in the fitness context.

Self-Affirmation and Image/Performance Enhancing Drug Use in Recreational Exercise

Objectives: The use of image and performance enhancement drugs (IPEDs) in recreational sport represents an emerging public health and societal problem. The present study investigated whether self-affirmation changed exercisers' intentions to use IPEDs, via the effects of mental construal and message acceptance. Method: Sixty-eight exercisers who self-reported IPEDs use participated in the study and were randomly assigned to either a self-affirmation or a control group. All participants read a health-related message about the 10 consequences of IPEDs and subsequently completed a survey measuring message acceptance, mental construal, doping intentions and IPEDs-related social cognitive variables. Results: There were no significant differences between the self-affirmed and the control groups. Hierarchical linear regression analysis further showed that message acceptance, subjective norms, and situational temptation were significantly associated with intentions to use IPEDs. Conclusion: Our findings raise the possibility that for recreational exercisers IPED's use is seen mostly as a health-related matter than a socio-moral transgression.

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.

Performance-enhancing drugs and the Olympics

The rules of fair play in sport generally prohibit the use of performance-enhancing drugs (PEDs). The World Anti-Doping Agency (WADA) oversees global antidoping regulations and testing for elite athletes participating in Olympic sports. Efforts to enforce antidoping policies are complicated by the diverse and evolving compounds and strategies employed by athletes to gain a competitive edge. Now between the uniquely proximate 2021 Tokyo and 2022 Beijing Olympic Games, we discuss WADA's efforts to prevent PED use during the modern Olympic Games. Then, we review the major PED classes with a focus on pathophysiology, complexities of antidoping testing, and relevant toxicities. Providers from diverse practice environments are likely to care for patients using PEDs for a variety of reasons and levels of sport; these providers should be aware of common PED classes and their risks.

Racing Clean in a Tainted World: A Qualitative Exploration of the Experiences and Views of Clean British Elite Distance Runners on Doping and Anti-Doping

Background: Doping has been a prominent issue for the sport of athletics in recent years. The endurance disciplines, which currently account for 56% of the global anti-doping rule violations in athletics, appear to be particularly high risk for doping. Objective: Using this high-risk, high-pressure context, the main purpose of this study was to investigate the human impact of doping and anti-doping on "clean" athletes. The secondary aim of the study was to better understand the reasons for, and barriers to, competing "clean" among this group of athletes. Method: Semi-structured interviews were conducted with 11 elite distance runners from the UK to explore: (1) the reasons and motivations for competing clean. (2) Perceptions of the anti-doping system, and experiences of being part of that system. (3) Views on the prevalence and causes of doping and the impact of doping on the lives of clean athletes. The interviews were audio-recorded, transcribed verbatim, and analysed using Reflexive Thematic Analysis. Results: Four major themes were identified: (1) The participants in this study have not been tempted to use prohibited substances or methods; they compete in their sport for the personal satisfaction of seeing how good they can be, rather than in pursuit of winning at all costs. (2) Anti-doping does not currently prevent doping effectively and is not implemented evenly across the globe. (3) Doping was perceived as a major issue and was felt to be borne out of certain sporting cultures in which doping is enabled. (4) Doping has impacted the careers of clean athletes in irreversible ways and presents a continuing challenge to the psychological preparation for competition. Conclusions: Clean athletes suffer negative consequences from both doping and anti-doping. ADOs must collaborate across borders to ensure a more even implementation of anti-doping activities, to facilitate a more level playing field on the global stage. ADOs must also acknowledge the existence of a large group of athletes who would never consider deliberately doping and make anti-doping work for these athletes too.

Using Behavioural Reasoning Theory to Explore Reasons for Dietary Restriction: A Qualitative Study of Orthorexic Behavioural Tendencies in the UK

Orthorexia Nervosa (ON) has gained increased attention in academia since 1997. However, like other “Exia” conditions, there is debate around its inclusion in the Diagnostic and Statistical Manual of Mental Disorders. This study aimed to examine the experiences of those following a diet indicative of ON in the United Kingdom. This information is essential to the development of diagnostic criteria and classification of ON. Behavioural Reasoning Theory was used to explore reasons contributing to the development of ON. Ten individuals (two males and eight females), aged 23–35 years, took part in semi-structured interviews. Inductive thematic analysis was used to analyse the results. Four themes emerged from the data—journey, social, rules/control, and ethical considerations which highlighted contributing factors to the development of ON behaviours, the impact of these behaviours on individuals' social lives, and a strive for control. These findings are the first to suggest that ON involves a more complex set of behaviours than current definitions and proposed diagnostic criteria suggest and highlight the need to consider a variety of reasons for restricted diet when developing diagnostic criteria, screening tools, and classification in the DSM.

One Does Not Fit All: European Study Shows Significant Differences in Value-Priorities in Clean Sport

Doping violates the Spirit of Sport and is thought to contradict the values which underpin this spirit. Values-based education (VBE) has been cited as a key element for creating a clean sport culture across age groups. Culturally relevant VBE requires understanding of the values that motivate athletes from different countries to practice their sport and uphold clean sport values. WADA's new International Standards for Education makes this study both needed and timely. Overall, 1,225 athletes from Germany, Greece, Italy, Russia, and the UK responded to measures assessing their general values, Spirit of Sport values, and their perceived importance of “clean sport”. MaxDiff analysis identified the most important values to participants based on their respective country of residence. Correlation analysis was conducted to assess the relationship between importance of clean sport and Spirit of Sport values. There were significant differences between participant nationality and their perceived importance of clean sport [F_{(4, 1,204)} = 797.060, p < 0.000], the most important general values (p < 0.05), and Spirit of Sport values (p < 0.05). Moderate positive correlations were observed between the perceived importance of clean sport and honesty and ethics (r = 0.538, p < 0.005) and respecting the rules of sport (r = 0.507, p < 0.005). When designing the values-based component of anti-doping education programs, athletes' different value-priorities across countries should be considered.

Measurement of Motivation States for Physical Activity and Sedentary Behavior: Development and Validation of the CRAVE Scale

Physical activity, and likely the motivation for it, varies throughout the day. The aim of this investigation was to create a short assessment (CRAVE: Cravings for Rest and Volitional Energy Expenditure) to measure motivation states (wants, desires, urges) for physical activity and sedentary behaviors. Five studies were conducted to develop and evaluate the construct validity and reliability of the scale, with 1,035 participants completing the scale a total of 1,697 times. In Study 1, 402 university students completed a questionnaire inquiring about the want or desire to perform behaviors "at the present moment (right now)." Items related to physical activity (e.g., "move my body") and sedentary behaviors (e.g., "do nothing active"). An exploratory structural equation model (ESEM) revealed that 10 items should be retained, loading onto two factors (5 each for Move and Rest). In Study 2, an independent sample (n = 444) confirmed these results and found that Move and Rest desires were associated with stage-of-change for exercise behavior. In Study 3, 127 community-residing participants completed the CRAVE at 6-month intervals over two years- two times each session. Across-session interclass correlations (ICC) for Move (ICC = 0.72-0.95) and Rest (ICC = 0.69-0.88) were higher than when they were measured across 24-months (Move: ICC = 0.53; Rest: ICC = 0.49), indicating wants/desires have state-like qualities. In Study 4, a maximal treadmill test was completed by 21 university students. The CRAVE was completed immediately pre and post. Move desires decreased 26% and Rest increased 74%. Changes in Move and Rest desires were moderately associated with changes in perceived physical fatigue and energy. In Study 5, 41 university students sat quietly during a 50-min lecture. They completed the CRAVE at 3 time points. Move increased 19.6% and Rest decreased 16.7%. Small correlations were detected between move and both perceived energy and tiredness, but not calmness or tension. In conclusion, the CRAVE scale has good psychometric properties. These data also support tenets of the WANT model of motivation states for movement and rest (Stults-Kolehmainen et al., 2020a). Future studies need to explore how desires to move/rest relate to dynamic changes in physical activity and sedentarism.

Perceived Motivational Climates and Doping Intention in Adolescent Athletes: The Mediating Role of Moral Disengagement and Sportspersonship

Doping is an important issue in competitive sports and poses potentially irreversible consequences to athletes. Understanding the psychological process underlying antecedents and doping intention will inform policy and prevention. This study aimed to test the psychosocial mechanisms of doping in adolescent athletes using an integrated model. In this model, we examined the associations of perceived motivational climate (i.e., task-involving and ego-involving), moral variables (i.e., moral disengagement and sportspersonship), and attitudinal variables (i.e., perceived pros/cons of doping and perceived cons of not doping) with doping intention. We further investigated whether the moral variables mediated the relationship between perceived motivational climate and doping intention. A cross-sectional survey was employed in the present study. Six hundred and fifteen Chinese adolescent athletes (mean age = 15.68 ± 1.67 years) completed questionnaires measuring demographic information and the variables mentioned previously. Structural equation modeling showed that the hypothesized model had a good fit and explained 64.1% of the variance in doping intention. Task-involving motivational climate indicated both directly and indirectly negative associations with doping intention via sportspersonship. The ego-involving motivational climate was positively associated with doping intention via moral disengagement. Among perceived pros/cons of doping and perceived cons of not doping, both perceived cons of doping and cons of not doping were positively associated with doping intention with a small effect size. This study confirmed the roles of tasking- and ego-involving motivational climates, moral variables, and attitudinal variables on doping intention. These research findings may provide new insights for the future of intention-based doping prevention programmes.

The role of sexual minority stress and community involvement on disordered eating, dysmorphic concerns and appearance- and performance-enhancing drug misuse

Prior research has established that sexual minority (SM) individuals are more likely to experience disordered body image behaviors and concerns than heterosexual individuals. This increased risk may be explained by minority stress theory - that SM individuals are subject to SM-specific stressors, leading to health disparities - but this has not yet been fully examined. Furthermore, this theory states that SM community involvement may mitigate negative outcomes. The current study examines whether minority stress is associated with screening positive for an eating disorder, screening positive for body dysmorphic disorder, and appearance- and performance-enhancing drug misuse in a sample of SM individuals (483 women and 479 men) in the US. This study also examines whether the effect of minority stress is moderated by SM community involvement. Logistic regressions were conducted for each type of minority stress (internalized homophobia, sexual orientation concealment, and heterosexist discrimination) interacting with community involvement. After correction for multiple comparisons, all minority stressors and community involvement were positively associated with increased odds of disordered body image behaviors and concerns, with no evidence of a buffering effect for community involvement. The lack of a buffering effect is contrary to minority stress theory and may inform future prevention efforts.

Effects of Appearance- and Performance-Enhancing Drugs on Personality Traits

Appearance- and performance-enhancing drugs (APEDs) are commonly used by adolescents and young adults in an effort to improve not only athletic performance but also physical and mental efficiency and sexual appearance. The rationale for using these drugs is grounded in the perceived importance of external appearance, the quest for health and youth, and the urge to boost one's sexual performances. Although APED users tend to be quite moderate overall, some specific subpopulations can display pathological use associated with high-risk behaviors. A wide and diverse range of APEDs is now easily accessible to almost anyone through backdoor online avenues. Common APEDs include anabolic-androgenic steroids, non-steroidal anabolics, anorectics, diuretics and ergo/thermogenics, nootropics or "cognition enhancers," licit and illicit psychostimulants, and finally, sexual enhancers. The use of APEDs appears linked to several psychopathological disorders of unclear prevalence, e.g., body image disorders and eating disorders, perfectionism, but also depression and loneliness. The role of personality traits related to APED use has been investigated in adolescents and young adults, in elite and amateur athletes, and in chemsexers and associated with the above-reported personality traits. The studies herein analyzed show that APED consumption in the general population is quickly growing into a public health concern. It is therefore essential to launch prevention and intervention projects aimed at promoting safe instrumental use of the body, not only in sports disciplines but also among the general population, and to promote psychological aid procedures for people with substance use issues, depression and anxiety, and body image disorders.

Refined Analysis of a Cross-Sectional Doping Survey Among Recreational Triathletes: Support for the Nutritional Supplement Gateway Hypothesis

Introduction: The current literature provides no consensus that nutritional supplements (NS) may provide a gateway to doping. In particular, studies in recreational athletes are lacking. Within a previous cross-sectional empirical study, our group provided first evidence that the use of NS may provide a gateway for the use of doping substances in recreational triathletes. For the present paper, we refine the analysis of the triathletes’ survey in order to provide evidence for a NS gateway hypothesis in recreational athletes.

Methods: A self-report, paper-and-pencil questionnaire was distributed to a sample of 2,997 competitive ironman and half-ironman (n = 1,076; 36.1%) triathletes. The randomized response technique (RRT) was used to assess the 12-month prevalence estimate for the use of doping substances. The prevalence for the use of NS was assessed by using direct questioning. Two-tailed (α = 0.05) large-sample z-tests were performed to assess whether the estimated prevalence for the use of doping substances differs significantly between users and nonusers of NS.

Results: The 12-month prevalence estimate for the use of doping substances is significantly higher in athletes who report using NS (20.6%) compared to those who do not (11.4%; z = 2.595, p = 0.0097).

Conclusion: The present results are consistent with the hypothesis that the use of NS provides a gateway to the use of doping substances. Therefore, doping prevention concepts should not primarily focus on preventing the use of doping substances per se, but should start one step earlier, namely by the use of NS.

The Implementation and Evaluation of a Media Literacy Intervention About PAES Use in Sport Science Students

With respect to both competitive and amateur/fitness sports, media may strongly influence young people's opinions and behaviors concerning the use of PAES (Performance and Appearance Enhancing Substances). The present investigation addressed this topic by focusing on sport sciences students' beliefs concerning the possible role of media related to the implementation and evaluation of a PAES-focus media literacy intervention conducted with sport science students. This study relied on a sample of 521 students (attrition rate 10.3%) (45.1% female, mean age = 22.6, SD = 2.20), which provided baseline data on students' levels of media literacy concerning the use of PAES (i.e. "descriptive sample"), and a sample of 248 students, who participated in and provided data on the media literacy intervention. This latter sample included a group of 128 students (44.5% female, mean age = 23.03, SD = 3.76) who actively participated in the intervention (i.e. "intervention group"), and a group of 120 students who did not (i.e. "control group", 53.3% female, mean age = 22.25, SD = 2.47). All students filled out media literacy questionnaires targeting students' awareness of media influence, their views about the realism of media content, their sense of confidence in dealing with media messages, and their positive attitudes toward PAES use. Analyses of questionnaire data showed that students are relatively aware of media influence on people's views and behaviors with respect to PAES use. At the same time, students also believed that young people do not consider media as "realistic sources" of information; nonetheless, they also did not consider themselves entirely capable of dealing effectively with media messages. With respect to the intervention, students overall appreciated and greatly welcomed the educational program on media literacy, and the analyses of intervention data across intervention and control groups showed that key media literacy variables changed over time, attesting to the overall effectiveness of the intervention.

Doping among high school students: findings from the French ESPAD survey

BACKGROUND

The increasing use of doping by youth is a growing public health concern. The present study aimed to calculate robust estimates of the prevalence of doping among French high school students and study factors related to the use of licit vs. banned agents.

METHODS

The European School Project on Alcohol and other Drugs (ESPAD), a nationally representative school-based survey, was distributed across France from April to May 2015, generating a final sample size of 6642 students. Multilevel modelling was used to examine covariates of doping to enhance athletic performance in sport in this population.

RESULTS

Overall, 2.3% of students used banned agents, and 6.1% used licit and banned substances to improve athletic performance. Significant gender differences existed for both, with males more prone to doping than females. Our findings provide support for the existing gateway hypothesis that nutritional supplementation leads to doping banned agents. Multilevel modelling revealed the presence of both school and class-level influences on individual use of licit substances, vs. solely class-level factors impacting the use of banned agents, suggesting a strong peer-effect.

CONCLUSIONS

These findings support the need to engage in early doping prevention through high schools. Programmes should draw attention to the role of licit substances, including nutritional supplementation, in the progression to using banned agents and encompass the continuum of adolescent risk taking through a behaviour-based approach to doping prevention.

Self-Reported Reasons for Abstinence from Illicit Drugs

OBJECTIVE

To provide a more balanced understanding of the initiation and restraint of substance use, educators, clinicians, and researchers would benefit from a review of research assessing the reasons nonusers report for having abstained from drugs.

METHOD

Based on searches of computerized databases and the reference sections of relevant articles, we identified 15 relevant studies that assessed and quantified participants' expressed reasons for having abstained from (a) one or more named substances or (b) drugs (or alcohol and drugs) with little or no further specification. We defined as more salient those 25% of reasons in each study that were endorsed most frequently, ranked highest, or rated most influential.

RESULTS

Five reasons - concerns about physical health, lack of interest, harmful psychological consequences, personal beliefs/morals, and peer/family disapproval - were most frequently identified as salient across studies and substances.

CONCLUSION

These salient reasons are consistent with outcome expectancy and social learning models that have been proposed to explain drug initiation. To enhance the value of future research, we recommend testing whether importance ratings differ across contexts; repeatedly assessing within-subject variability of reasons across time; evaluating the association of psychological characteristics with reasons for abstaining; and continuing to evaluate which reasons for abstaining vary by type of drug, gender, ethnicity, and religiosity. We also recommend additional research comparing which reasons predict continued abstinence and which predict initiation of use during follow-up.

Understanding the Paths to Appearance- and Performance-Enhancing Drug Use in Bodybuilding

How do gym-goers who are normally not inclined to resort to appearance- and performance-enhancing drugs (APEDs) progressively normalize their use? Based on data collected through a year and a half of participant observation in a gym and 30 semi-directive interviews with practitioners with varying profiles in French-speaking Switzerland, this article examines the evolution of practitioners’ relations with APED use by articulating various levels of analysis. Associated with social vulnerabilities, the progressive normalization of APED use is concomitant with the “conversion” to bodybuilding. Our results show the extent to which and under what conditions interactions within the layout of gyms can influence practices. From refusal to normalization, our results suggest that APEDs and the associated beliefs coincide with career stages, which we aim to bring to light here.

Being in control? A thematic content analysis of 14 in-depth interviews with 2,4-dinitrophenol users

BACKGROUND

2,4-Dinitrophenol (2,4-DNP) is a compound with multiple industrial purposes. Currently unlicensed for human consumption, it is used by the gym-going population for drastic, short-term body fat loss. Nonetheless, physiological mechanisms can lead to potentially fatal hyperthermia. Reported fatal incidents have caused concern and highlighted the need for intervention. Understanding decision-making leading to 2,4-DNP use alongside the perceived outgroup attitudes is vital to forming effective harm minimisation policies targeting current and potential users. First-hand accounts from this elusive population are scarce.

METHODS

Fourteen novel and experienced users (13 male, 1 female) were recruited via "snowballing" techniques. Semi-structured interviews were conducted, comprising 28 questions. Thematic content analysis was conducted using 37 codes.

RESULTS

Four characteristic themes emerged: 1. Users considered the Internet to be a crucial multifunctional resource directly impacting their 2,4-DNP use. 2. Users "respected" 2,4-DNP, proactively taking harm reduction measures. 3. Attitudinal polarisation towards 2,4-DNP within the gym-going community was consistent in all accounts. 4. Users perceived outgroup populations to have inherently negative attitudes towards their use. These themes fell under the all-encompassing theme of "being in control".

CONCLUSION

For the first time, this study offers a rich detail of attitudes toward 2,4-DNP use by giving a collective voice to users. The element of control over every aspect of the users' life appears to be a significant contributor to the successful risk-management of 2,4-DNP use. In the absence of an established safe upper limit and effective regulatory control, education is critical to harm minimisation.