Image and Performance Enhancing Drugs (IPEDS)

"Harms surrounding AAS are mostly discussed in general terms, while specific differences between compounds are seldom discussed. Underwood [7] posits that there is a need, particularly regarding trenbolone, to discuss individual compounds. Trenbolone is an AAS, derived from the nandrolone group but differing from nandrolone by an addition of a double bond between C10-C9 and C11-12 [8]. Although originally used by veterinarians on livestock to increase muscle growth and appetite [9], injectable trenbolone was originally adapted for use by bodybuilders from the dissolution of Finaplix H pellets [10] who refer to the compound as ‘tren’. Trenbolone was not originally designed for oral routes of administration [9]. Further, the liver readily metabolises natural AASs except when that AAS has been modified to pass through the liver without destruction, known as 17-alkylated AAS [11] of which trenbolone is not one, and therefore is commonly injected by users [7, 12]. Trenbolone possesses strong anabolic properties and nutrient partitioning effects, boosts the mineral absorption and improves lean muscle mass [9] and, therefore, is often used to enhance the strength gains and protein synthesis which comes from strength training [13]. It has also been found to have the secondary effects of stimulating appetite, reducing fat deposition and decreasing the rate of catabolism [14]. Trenbolone likely represents an attractive option to AAS users given it has been found to be significantly more potent than testosterone [14]. Specifically, trenbolone has a binding affinity for the androgen receptor three times as high as testosterone [14]. Trenbolone is available in a number of preparations: the shortest esterified version available is trenbolone acetate, with a half-life of 1–2 days; trenbolone hexhydrobenzylcarbonate, which has a half-life of approximately 8 days; and trenbolone enanthate, which has a half-life of 11 days [15]. Trenbolone and nandrolone are considered to be closely linked given they are both 19-Nor AAS [1, 16].

"Treatment with 19-Nor AAS—nandrolone group—can cause significant alterations in the density of serotoninergic receptors in animals [17] leading to an established AAS-serotonin link which is believed to underpin why AAS are associated with changes in emotional states and behaviour [18]. Trenbolone, specifically, has been linked with not only cardiovascular issues [10] but also with extreme instances of violence [12]. Short term side effects of trenbolone which have been identified include insomnia, high blood pressure and increased aggression and libido [14]. Research has suggested these instances of psychological and emotional instability are attributable to modulated serotonin receptor activity and associated with decreased serotonin neurotransmission [16]. Indeed, nandrolone and trenbolone (the two 19-Nors) [19] have been identified as the most neurotoxic of AAS [16] and, therefore, warrant further exploration in the risk profile for psychological harm to users."

"Past 12-month use of anabolic steroids in 12th grade are similar for males and females, at 1.3% and 0.9%, respectively. Use of other substances for body building and performance is substantially higher for males. In 2022 past 12-month use of androstenedione was 2.8% for males and 1.1% for females, while prevalence of creatine was 18.6% for males and 5.2% for females."

"Importantly, trenbolone was discussed as having the most deleterious consequences for users which fits with extant work [7]. The data suggests a number of psychosocial harms arising for trenbolone users including the increased social vigilance required which may lead to social difficulties. Specifically, participants reported a decline in patience and attributed trenbolone to being responsible. If they did not ‘filter’, trenbolone users expressed the potential for breakdown in their relationships being directly related to uncharacteristic behaviour (‘tren-me’). Those who had personally used trenbolone reported an extreme shift in risk profile for psychological harms, with users reporting increased aggression and violent behaviour, as well as other emotional and impulsivity regulation issues, fitting with recent work with trenbolone users [7]. Those who did not use trenbolone also reported the readily observable effect of trenbolone on their peers, leading them to behave uncharacteristically. AAS users should be cognisant of the potential for significant harms that may result if they add trenbolone to their regime, while health-care providers working with this group may consider screening specifically for this AAS when working with this client group. These findings are important within the context of ongoing development for harm reduction frameworks for those using AAS both in Australia and internationally.

"Participants understood the potential adverse effects arising from their use of AAS but persisted using regardless and this may be due to the reinforcing properties of AAS. AAS may have reinforcing psychoactive effects including increased self-confidence and aggressiveness, even though they are not generally considered intoxicating substances [33]. For men, the androgenic effects of exogenous AAS may cause suppression of the hypothalamic–pituitary–gonadal axis and sometimes translates into AAS withdrawal syndrome [34] which may cause individuals to be prone to effects of dysphoria and, thus, increase the likelihood of resuming AAS use. However, the present sample did have a number of female users, one of whom reported multiple instances of trenbolone use. Therefore, the mixed gender cohort for this study may be explained through other theoretical frameworks. For example, research has also demonstrated AAS may also have direct rewarding properties, mediated directly via the effects on their metabolites on plasma membranes [35]. Therefore, we propose our data more likely substantiates this hedonic pathway, given that the cohort was mixed and also expressed similar views in their discussions around AAS."

"Bodybuilding has a long history of performance-enhancing substance use. The early forms of PES in bodybuilding were simple remedies such as caffeine, alcohol, and opiates. However, the emergence of anabolic-androgenic steroids in the mid-20th century revolutionized the sport and transformed it into what we see today [5]. In the early days of bodybuilding, natural training methods and diet were the only ways to achieve a well-sculpted body. However, with the rise of the anabolic steroid industry in the 1950s, athletes started experimenting with testosterone and other substances to enhance their performance. By the 1960s, anabolic steroids were widely used in bodybuilding circles, rapidly increasing muscle mass and strength gains [6].

"Since then, the use of performance-enhancing substances in bodybuilding has evolved dramatically. Athletes now use various substances, including human growth hormone, insulin, diuretics, stimulants, and others, to gain a competitive edge. Additionally, the methods for administering these substances have become more sophisticated, including intravenous injections, transdermal patches, and oral dosages [7]. The use of performance-enhancing substances in bodybuilding is driven by several factors, including the desire to achieve a competitive edge, the pursuit of the perfect physique, and the pressure to meet societal beauty standards. In addition, some athletes may feel that they need to use PES to keep up with others using them [8]. Moreover, using PES can also provide psychological benefits, such as increased confidence and self-esteem. For many athletes, bodybuilding is a way of life, and they are willing to go to great lengths to achieve their goals [9]."

"Anabolic steroids are a class of synthetic substances that mimic the effects of the male hormone testosterone in the body. Bodybuilders and other athletes use these substances to increase muscle mass, strength, and endurance as well as to shorten recovery times after workouts. Anabolic steroids are also used medically to treat delayed puberty, muscle wasting, and osteoporosis [10]. Anabolic steroids are associated with numerous health risks, both short-term and long-term. Anabolic steroid use can cause acne, hair loss, and mood swings in the short term. It can also lead to liver damage, cardiovascular disease, and hormonal imbalances. Anabolic steroids can increase blood pressure and cholesterol levels, increasing the risk of heart attack and stroke. Additionally, they can cause the development of breast tissue in men, a condition known as gynecomastia [11].

"Long-term use of anabolic steroids can lead to even more serious health consequences. It can cause kidney damage and increase the risk of prostate cancer. It can also lead to infertility, impotence, and reduced testicular size. Anabolic steroid use can also cause psychological effects, including mood swings, aggression, and depression [12]. In addition to the health risks associated with anabolic steroid use, legal and ethical concerns exist. Anabolic steroids are banned by most sports organizations, including the International Olympic Committee (IOC) and the World Anti-Doping Agency (WADA). These substances are illegal in many countries, including the United States [13]."

"Human growth hormone (HGH) is a hormone naturally produced by the pituitary gland and plays a crucial role in stimulating growth, cell reproduction, and regeneration in humans. It is important in childhood for normal growth and development, and in adulthood, it helps to maintain muscle mass and bone density and regulate metabolism. HGH also significantly affects the immune system, cognitive function, and mood [14]. HGH is a performance-enhancing substance used in bodybuilding to increase muscle mass, reduce body fat, and improve athletic performance. The use of HGH in bodybuilding is often combined with other substances, such as anabolic steroids, to achieve greater results [15]. However, using HGH in bodybuilding is associated with various health risks. One of the most significant risks is the development of diabetes, as HGH use can cause insulin resistance and impaired glucose tolerance. Other side effects of HGH use include joint pain, carpal tunnel syndrome, and an increased risk of heart disease and stroke [10,12,15].

"Furthermore, studies have shown that long-term HGH use may increase cancer risk, particularly in the digestive system, such as colon, pancreas, and stomach cancer. This risk is likely due to the growth-promoting effects of HGH, which may stimulate the growth of cancerous cells [1,6,15]. It is important to note that using HGH in bodybuilding is illegal without a prescription and is classified as a controlled substance in many countries. The misuse of HGH can result in serious health consequences, and it is important to raise awareness about the risks associated with its use in bodybuilding. Healthcare professionals should also be vigilant about using HGH and other performance-enhancing substances in their patients and work towards preventing and treating the associated health issues [6,8]."

"Insulin is a hormone that plays a crucial role in regulating blood sugar levels. The pancreas produces it, and its primary function is to help cells in the body absorb glucose from the bloodstream, which is then used for energy. In bodybuilding, insulin is often used as a performance-enhancing substance due to its anabolic effects. Insulin stimulates the uptake of amino acids and glucose into muscle cells, promoting muscle growth and repair [16]. However, the misuse of insulin can have serious health consequences. When insulin is used improperly or excessively, it can cause hypoglycemia, a dangerous condition characterized by low blood sugar levels. Hypoglycemia can cause dizziness, confusion, sweating, and even loss of consciousness. In severe cases, it can lead to seizures, coma, and even death [17,18].

"Another potential danger of insulin misuse is the development of insulin resistance, a condition where cells become less responsive to the effects of insulin. This can lead to elevated blood sugar levels and the development of type 2 diabetes [19]. In addition to these health risks, using insulin in bodybuilding is also illegal and prohibited by most sports organizations. Its use is considered doping and can result in disqualification, suspension, and other penalties. Therefore, it is important for athletes to understand the risks associated with insulin misuse and to avoid using it as a performance-enhancing substance [20]."

"Diuretics are drugs that increase the rate of urine production by the kidneys, resulting in a loss of water and electrolytes from the body. In bodybuilding, diuretics are sometimes used to help reduce water retention in the body and promote a more defined and muscular appearance on stage. The use of diuretics in this manner is sometimes referred to as "cutting water weight" [21]. However, the misuse of diuretics can have serious health consequences. By increasing the rate of urine production, diuretics can cause dehydration and electrolyte imbalances, leading to muscle cramps, dizziness, fainting, and even death in severe cases. The loss of electrolytes such as sodium and potassium can also negatively affect the heart, leading to arrhythmias and other cardiovascular complications [22].

"Moreover, the use of diuretics can also put a significant strain on the kidneys. The kidneys are responsible for filtering the blood and removing waste products, and diuretics can increase the workload on these organs. Long-term use of diuretics can lead to kidney damage, impairing their ability to function properly and ultimately resulting in kidney failure [23]. In addition to these health risks, using diuretics in bodybuilding is prohibited by many athletic organizations and can result in disqualification and other penalties. Therefore, bodybuilders need to avoid the misuse of diuretics and instead focus on healthy and sustainable approaches to achieving their desired physique [24]."

"Stimulants are a class of performance-enhancing substances some bodybuilders use to increase focus, alertness, and energy during their workouts. Some of the most commonly used stimulants in bodybuilding include amphetamines, caffeine, ephedrine, and clenbuterol. These substances are believed to enhance mental and physical performance, reduce fatigue, and improve endurance [25]. While stimulants can provide short-term benefits, their misuse can have serious health consequences. For instance, using stimulants can cause an increase in heart rate and blood pressure, leading to cardiovascular problems such as heart attack, stroke, and arrhythmia. Additionally, the misuse of stimulants can lead to addiction and withdrawal symptoms, including anxiety, depression, and insomnia [26].

"Caffeine, found in many beverages and dietary supplements, is the most widely used stimulant in bodybuilding. While caffeine is generally safe in moderation, excessive use can lead to negative side effects, including restlessness, nervousness, and insomnia. Caffeine can also increase heart rate and blood pressure and cause gastrointestinal problems such as nausea and diarrhea [27]. Ephedrine and clenbuterol are also commonly used stimulants in bodybuilding. Ephedrine is a central nervous system stimulant known to increase metabolic rate and fat burning. Still, its use has been associated with serious health risks such as high blood pressure, heart attack, and stroke. Similarly, clenbuterol, often used to promote weight loss, has been linked to heart problems and muscle tremors [28]."

"Peers and social networks are an important component of the performance and image enhancing drug (PIED) community. Past research has demonstrated the importance these networks play in the supply of PIEDS [7–9], the distribution of injecting equipment [10, 11], and the sharing of advice and information about use [12–14]. Information was shared through networks, such as friends or fitness trainers, or physical documents such as fitness magazines, underground steroid manuals, and the scientific literature [15, 16]. Face-to-face interactions followed a strict social protocol that relied heavily on establishing trust and often took place in the public domain, for example in gyms [15, 16]. Links into these networks need to be made; usually some form of friendship is needed to facilitate engagement with the PIED-using community, and a new potential member must demonstrate a level of cultural knowledge to be accepted [8]. Socialisation into the group is an important part of the process [14].

"However, the Internet has shifted the way those who consume substances seek and share information [17]. The Internet allows users to gain information from a large number of people without the need for potentially risky and identifying face-to-face interactions [1, 2]. Peer-led online forums in particular have been identified as common sources of information for PIED users [18] who report accessing Internet forums frequently to anonymously gain specific and detailed responses from other forum members about PIED use [19]. Furthermore, the first-hand information posted by anabolic-androgenic steroid (AAS) ‘veterans’ has been described as highly valued and is a preferred source for some who struggle to find accessible, straightforward information from reputable sources [20].

"As information has shifted to online communities, there has been an increased research focus on the use of online forums by those who engage in substance use. Davey et al. [21] explored the key characteristics of online drug forums, finding that forums can provide users with anonymity, a space to communicate with others who are engaging the same, largely illicit, behaviour that is free from geographical limitations, and a dedicated place to share information with a community of individuals with similar interests. The notion that forums and forum members are a community has similarly been identified by others [6, 22, 23]. Forum members often possess a strong identity and group cohesion, strengthened by a sense of shared experience. Drug-related forums can also function as an avenue for social support, as well as advice mechanisms for crises, such as overdoses. Knowledge exchange, particularly regarding harm reduction practices, is a key feature [6, 23, 24], with users providing what has been described as ‘lay person evaluations’ of the risks and benefits of use [25]."

"The Global Commission on Drug Policy recently advised governments to make harm reduction measures, including drug checking services, widely accessible (Bewley-Taylor & Tinasti, 2020; Buxton et al., 2020). Although there have been calls for drug checking in Australia for some time (Ritter, 2020), initially there were only two Australian trials of drug checking, both performed in a festival context (Byrne et al., 2018; Olsen et al., 2019). This comprised a fixed site trial service launched in Canberra in 2022, which has been extended and is expected to become a permanent service (Olsen et al., 2022). In February 2023, the government of Queensland (the second largest and third most populous state in Australia) announced support for the introduction of drug checking services (Australian Broadcasting Corporation, 2023). The recent recommendation to make drug checking services widely accessible aligns with the harm reduction approach, which recognises the social context and influences surrounding substance use (Bewley-Taylor & Tinasti, 2020; Buxton et al., 2020). The support for introducing drug checking services by the government of Queensland reflects a step towards implementing population-level interventions aimed at reducing drug-related harms and addressing health inequalities. While previous studies surrounding these services have focused on populations such as the nightlife/festival attendees, particularly ecstasy consumers, there is still a gap in research regarding the perspectives and experiences of those involved in the consumption of performance and image enhancing drugs (PIEDs) such as anabolic-androgenic steroids (AAS). Therefore, in the context of the Queensland government's commitment to supporting such services, this study specifically aimed to explore AAS consumers attitudes, perceptions, and needs regarding drug checking. Doing so aligns service provision with broader goal of enhancing health outcomes for this population given the high representation of AAS consumption in Queensland, accounted for by the overrepresentation of AAS-related arrests compared to other states and territories (Australian Criminal Intelligence Commission, 2021)."

"Qualitative work from Ip and colleagues examined a sample of female AAS users through web-surveys [32]. Their findings demonstrated that women experience AAS use differently to men and, therefore, may have their own unique needs. More recently, Havnes et al. [33] explored the experiences and harms of women who use AAS. Their study utilised a sample of women (n = 16) aged 18 and above who reported current or past AAS use. The authors linked AAS initiation to male partners, friends, and coaches and the participants entrusted this group with decisions about use and regarded them as reliable sources of information. The oral compounds that are reportedly often used by women, such as Oxandrolone (Anavar) and Stanozolol (Winstrol), have toxic effects on the liver, negatively affect cholesterol and lipoproteins, and increase cardiovascular risk [25]. Given the potential for health-related complications, there are some AAS users who will display help-seeking behaviours. For example, Zahnow et al. [34] have suggested that women AAS users are more likely than men AAS users to engage with a general practitioner. More recently, Havnes and colleagues have argued that few women seek information about AAS-related side effects, and that several health risks do not present symptoms, presenting a clear need to understand more about women’s AAS use [33, 35]. The potential for developing irreversible masculinizing effects from AAS is, at times, difficult for women to process and may negatively impact their well-being [33]. Specifically, the masculinizing effects that come from AAS may negatively influence self-esteem, social life, and sexual function [33], and these effects appear to be different from those male users are concerned with [36].

"Recently, there has been growing interest in the practices of women who use AAS [30, 31, 33, 37]. This development is, in part, due to the increasing recognition of the distinctive challenges and risks faced by women using substances [38, 39], particularly AAS [33, 37]. This study contributes to our understanding of gender-specific experiences of, and outcomes from AAS use. There is also a growing recognition of the need for a gender-sensitive approach to harm reduction, which considers the specific needs and experiences of women from various perspectives [40, 41]. The present study contributes to knowledge by extending our present understanding of women’s use of AAS. Firstly, the study sought to gather perspectives from both men and women on the unique challenges surrounding women’s use of AAS, irrespective of their personal use. Secondly, the study interrogated how women’s AAS practices differ from those of men specifically."

"Among men who use AAS, research has found that a group identity emerges as a result of the common interests, which centre on training, diet, and the co-occurring substance use [8, 10, 56]. Specifically, there is a level of peer-led education and harm reduction occurring within these peer networks—a ‘safe space’ dynamic [36]. These peer networks extend into online forums [57] and may be partly due to the lack of appropriate harm reduction responses and frameworks available for this group. For example, previous research demonstrates that women searching for advice and the experiences of other women regarding AAS use must navigate male contributions on internet forums [58]. For women who use AAS, our data indicate that a harm reduction dynamic does not exist presently. Females who choose to use these drugs are more secretive, and this likely has links to increased stigma as indicated by some participants. Despite the recognised health complications, these findings are indicative of barriers to meeting women’s needs for accurate information about health risks among women who use AAS, as is evidence by research with women who use and inject substances more broadly [38, 59]. More research is required to understand how these challenges are experienced and navigated by AAS-using women to inform gendered approaches to harm reduction. Future research should attempt to explore how to integrate peer-led approaches and harm reduction frameworks more effectively among women using AAS."

"The use of APEDS was common among young males in the current study, and it was more related to the drive for muscularity and sexual orientation than symptoms of EDs. In a large national sample (N = 7401) of college and university students, including both sexes in the US (ages 18–30 years), the lifetime prevalence of the use of protein supplements and creatine was 23.8% and 7.7%, respectively [30]. The corresponding lifetime figures (Table 1) in our study of young males were 31.9% and 16.5%. Male sex was related to a greater likelihood of lifetime protein and creatin supplement use in the US study [30], which might partly explain larger prevalence figures in our study of young males. Focusing on male college students (18–26 years) from the top-10 National Collegiate Athletic Association Division I universities in the US, the rate of current use of appearance- or performance-enhancing supplements was 38.9% [31]. This is a highly selected sample in which athletic performance is assumably a top priority, and a very high current rate is expected. If “current rate” in our study is defined in terms of at least monthly use of these supplements, then it will amount to 23.1%. The anonymous nature of the study might increase the truthful report of use of such substances. It has been shown that computerized surveys leads to significantly more reporting of sensitive issues (e.g., socially undesirable behaviors) [32]. In a study on the role of anonymity and privacy in survey methodology, participants reported significantly higher mean comfort levels with anonymous surveys compared to non-anonymous [33]. Given the difficulties inherent in unknown representativity of Internet-based surveys, further replications using the same methodology are warranted to arrive at a robust estimate in use of appearance- and performance enhancing supplements among young males."

"The desire to achieve a thin physique has stemmed from women’s ideal bodies traditionally being considered ‘thin’ [1]. More recently, the ideal body type for women is changing and social influences (e.g. media) have been promoting athletic female beauty ideals alongside defined and muscular body shapes for women [2, 3]. These current body image ideals for women ascribe more muscular appearances relative to historical ideals [4, 5] and recent studies have documented a shift in the cultural ideal of physical attractiveness, with women subscribing to a visibly toned ideal [6]. Robinson et al. [6] have provided evidence for this cultural shift through women’s exposure to idealised fitness images—termed ‘fitspiration’. Specifically, participants who viewed athletic ideal images (muscular and toned) reported greater body dissatisfaction than participants who viewed traditional thin ideal images [6]. It has been suggested that the process through which this muscular ideal and body sculpting process occurs is not by female’s resisting cultural norms, instead they are hyper-conforming to them through over-identification with a hyper-idealised form of what constitutes ‘acceptable femininity [7].

"To achieve this muscular body ideal men and women engage in a range of behaviours including performance and image engaging drug (PIED)/anabolic–androgenic steroid (AAS) use [8–13]. The use of PIEDs among women is not new however, as evidenced by women historically striving for a thin ideal utilising diet pills [14, 15]. Further, research has reported women also utilise other PIEDs, such as tanning agents, in an effort to modify or enhance their appearance [16]. Given the emerging body ideal of women who are seeking to achieve more muscular physiques, this group may be at risk of engaging in PIED or AAS strategies more similar to those of men. The propensity for women to engage in these strategies has been previously sequestered to women’s bodybuilding [17, 18] and, more recently, figure and bikini competitions [19]. However, overall, little attention has been given to the broader context of women regarding PIED and AAS use."