Public health impact and implications of the use of anabolic androgenic steroids (AAS) and associated drugs amongst the male general population

Abstract

Anabolic androgenic steroids (AAS) and associated drug use is now recognised as a significant concern and an emerging public health issue. Once restricted to the elite sporting arena, recent decades have seen AAS diffuse through bodybuilding and gym culture to an increasingly image conscious general population. This portfolio of research contributes to our understanding of this phenomenon in relation to our understanding of the extent and characteristics of AAS use, emerging harms and the policy response to the issue, as summarised below. While specific prevalence is unknown, data from needle and syringe programmes (NSPs) indicate growing numbers of people who inject AAS and associated drugs. Often portrayed in the media as a homogenous group of young male, working class men, a growing body of research indicates a much more diverse population in relation to demographic characteristics and motivations for use. Further research indicates that this is by no means confined to the United Kingdom (UK) but is a global public health issue although barely recognised in some countries such as the Republic of Ireland. Changes in the specific drugs of use and the regimes employed have been identified, with a growing pharmacopeia of easily accessible and affordable peptide hormones being used as a direct result of the rise of the Internet, coupled with developments in manufacturing and transportation. Opinion, anecdote and targeted marketing on the Internet fill the void of a lack of empirical evidence in the field of AAS, image and performance enhancing drugs (IPEDs) influencing a trend towards higher dosages, multiple drugs and prolonged use. Drug use is not confined to IPEDs, with psychoactive drug use identified in populations in UK and Internationally. Our understanding of the chronic health harms associated with AAS has increased over the last 25 years, in particular cardiovascular damage, psychological harms and the potential for dependence. However, this research has made a significant contribution to the recognition and understanding of the harms associated with the administration of these drugs through injection and the impact of adulterated products as a result of the illicit market. The extent of localised infection and soft tissue injury is a cause for concern, an issue previously neglected. Of further concern is the prevalence of blood borne virus (BBV) infection within the population of AAS users. In the first studies of their kind, HIV amongst AAS injectors has been shown to be at a similar level as that in psychoactive drug injectors in the UK. Hepatitis B and hepatitis C levels were identified as being higher than in the general population, and of key concern is the low levels of awareness of hepatitis C positive status amongst AAS injectors. The UK has operated a comprehensive NSP system since the 1980s, which has seen increasing numbers of AAS injectors however, there remains barriers to engagement with this population of people who inject drugs. Data from interviews and surveys submitted here identify a level of mistrust and lack of confidence among AAS users when it comes to engaging with health professionals. The following thesis, submitted in partial fulfilment of the requirements of Liverpool John Moores University for the degree of Doctor of Philosophy spans over twenty years of academic work within the specific field of AAS use. The research provides the groundwork for the development of meaningful and successful policies and interventions to reduce harm and promote health based on the need of this population. The submission includes a brief critical reflection on the undertaken research and the engagement with the research population, drawing on my experiences, positionality and evolution of knowledge and understanding. This further informs the concluding remarks and suggestions for future research.