IT’S easy to dismiss people who use performance- and image-enhancing drugs (PIEDs) such as anabolic–androgenic steroids (“steroids”). We probably think of them as vain, hulking meatheads, concerned only with their own reflection in the mirror, how much chicken breast they’ve eaten, how many muscle tops they own, and walking around yelling “do you even lift, bro?” at unsuspecting passers-by. While there are probably some out there that match this description, the public perception of steroid users often does not align with reality, and our stereotypes of this group may be causing more harm than we realise.
In recent years there has been an increased focus on the use of and harms related to PIEDs, a term that encompasses a range of substances used to enhance performance or body image. These can include legally available substances, such as creatine and multivitamins, to substances that may be obtained without a prescription or used in a way other than originally prescribed, such as human growth hormone, erythropoietin, and the aforementioned steroids. The increased focus on these latter substances comes from data which suggest that their use may be increasing. While the general population prevalence of steroid use, for example, is quite low (approximately 0.1% of the population reported using steroids in the past year), the numbers of seizures of PIEDs at the border, steroid arrests, and people attending needle and syringe programs (NSPs) for injecting equipment related to steroids and PIEDs, might suggest that the number of people using these substances (mostly men) is on the rise.
The possibility of an increase in the use of these substances raises a number of concerns. The major worry centres on who is using these substances and what they know about them. A recent review of Australian studies that have specifically recruited PIED users, conducted by myself and colleagues, found that most participants have been men, aged in their mid- to late 20s, who identify as Australian and speak English as their main language at home, identify as heterosexual, have completed secondary school or a post-secondary qualification, and are employed fulltime. More recent studies have found a high prevalence of use by men from culturally and linguistically diverse groups, and men who are same-sex attracted. Taken together, these are not likely to be elite competitive athletes, but rather average men attending the local gym who are trying to look a a little more impressive, or people who might be involved in the non-competitive bodybuilding subculture.
A striking finding that has been consistent over the many decades of research here and in countries such as the United States is that PIED users are a highly educated group, with a sophisticated understanding of the pharmacology of these substances and how to best use them. They are also willing to share this information, providing advice and recommendations on what, how much, and when to use, and what the potential effects of use may be. The term “broscience” is used to signify the word-of-mouth knowledge regarding the use of these substances that bodybuilders and weightlifters share, and reflects just how heavily this community relies on its members. Peers are, and have always been, an important source of information about PIEDs. Traditionally, information was shared among friends and fitness trainers, or in fitness magazines and underground steroid handbooks. The internet, however, has transformed knowledge sharing. There are websites hosting forums dedicated to sharing information about PIEDs. What should I use to increase my muscle size? Has anyone used this product? How long should I use it for? I injected deca into my shoulder yesterday and now it’s really sore, is there something wrong? With a few clicks, I can access some of the best minds in the world and the almost encyclopaedic information they offer.
Our recent research (here; here; and, here) illustrates that PIED users want to take control of their health, and are concerned with monitoring it while using PIEDs. Using these online forums to seek information is one approach. Encouragingly, our analysis of the discussions in these online forums showed that PIED users acknowledged the limitations of their own knowledge, actively encouraging engagement with health professionals prior to, during, and after PIED use. This, however, poses a problem. PIED users tend to report a somewhat negative experience in their interactions with medical professionals, especially GPs (here; and, here). There has been a general distrust of the medical profession stemming back to the late ’70s, when the American College of Sports Medicine deemed steroids to be ineffective, a surprise to those who had been using these substances and seeing the positive benefits.
This distrust of the profession makes discussing use and harms related to use difficult. While some steroid users have reported having no problems disclosing their use to their primary health carer, most relate negative experiences with medical professionals: PIED users report that practitioners have no knowledge of these substances and their effects, judge them, or discontinue care once PIED use is disclosed. This highlights the tension that exists: PIED users see themselves as healthy, non-drug-using people who just want to continue use but ensure that it is safe, while medical practitioners may work within a framework focused on prevention. Where does this leave the 22-year-old electrician who has started using nandrolone so he can be a bit stronger at work, maybe look a little bit better on the weekend so he can attract a girlfriend or boyfriend, but is experiencing some swelling at the injection site 2 days after his latest injection?
If PIED use is increasing, the medical profession needs to start reconsidering its role. I’m not suggesting that GPs start prescribing winstrol to any man who wanders into their rooms. What I am saying is that there is a role to play in helping to prevent and reduce harm. If the 22-year-old electrician discloses use, do you tell him that steroid use is harmful, and he should stop, or do you ask him if he’s considered monitoring his health while he takes them?
PIED users talk in their own language. They don’t talk about “harm” or “harm reduction” in the traditional sense. They talk about what substances to avoid, what symptoms to be aware of, how to inject safely. By working with this community in their own language, health professionals can play a role in both reducing the traditional stigma that this community believes is attached to them, while also providing medically sound information that complements the “broscience” that is too often the sole information many receive. In particular, online forums may be a place where the medical community and the PIED community could meet and learn from each other.
Dr Matthew Dunn is a Senior Lecturer in Public Health at Deakin University and a Conjoint Senior Lecturer at the National Drug and Alcohol Research Centre. He is the Victorian representative for the Australasian Professional Society on Alcohol and other Drugs (APSAD).
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