Research paper
An exploratory study of image and performance enhancement drug use in a male British South Asian community

https://doi.org/10.1016/j.drugpo.2015.03.002Get rights and content

Highlights

  • British South Asian male use of IPEDs and involvement in bodybuilding are increasingly prevalent.

  • Use of IPEDs among British South Asian males occurs due to physical inadequacy and media images.

  • British South Asian male IPEDs use is grounded in product safety beliefs and peer legitimisation.

  • Targeted education, outreach and NSP for ethnic communities are warranted.

Abstract

Background

Consumerism of image and performance enhancement drugs (IPEDs) is a world-wide public health concern. Given anecdotal reporting of increased normalisation of IPED use and uptake of British South Asian male IPED users at UK needle and syringe exchange services, the study aimed to explore use of IPEDs among this under-researched ethnic group.

Methods

20 in depth interviews were conducted with a purposive sample of British South Asian males attending harm reduction outreach in the North East of England. The interviews explored motives for use of IPEDs, sourcing routes, information seeking, injecting behaviours and cultural and community sensitivities around IPED use among this group. The data was collected and analysed using the Interpretative Phenomenological Analysis approach (IPA).

Results

Motives for use centred on the achievement of enhanced definition and density of muscle, and improved recovery from training and injuries. All participants reported initial stimulation of interest and triggers to seek information on IPEDs due to social media, community and peer messages. Diverse forms of IPED use were described, with rational and moderated use common among older participants. In contrast younger participants adopted more excessive use in seeking short cuts to attaining muscle size. Sourcing of androgenic–anabolic steroids (AAS) and growth hormones from originating countries (Pakistan, India) was reported, along with diversification of entrepreneurial activity into IPED dealing networks. Sellers were generally reported to provide effective and reliable products and mentoring to inexperienced users. Group injecting practices were common. IPED use was observed by some as health promotion medium within religious contexts. Crime deterrence and drug abstinence occurred for some while involved in AAS cycles.

Conclusions

The study is intended to contribute to health policy and practice debate around the targeting of dedicated education, outreach and harm reduction for ethnic groups engaged in IPED use.

Introduction

Emergent use of image and performance enhancement drugs (IPEDs) for aesthetic and functional body enhancement presents a significant global public health challenge, and particularly given its recent displacement from bodybuilding and athletic sub cultural groups into mainstream gym populations (Brennan et al., 2013, Evans-Brown et al., 2012, Kanayama et al., 2010, McVeigh et al., 2012, Sagoe et al., 2014). For males, changing aesthetic body ideals are grounded in the discrepancies between media imaging and average male bodies (Leit et al., 2002, Leit et al., 2001, Pope et al., 2000:2001; Tiggemann, Martins, & Kirkbride, 2007). Increased reporting of rates of male body dissatisfaction in particularly Westernised societies are evident (Adams et al., 2005, Agliata and Tantleff-Dunn, 2004, Kaminski et al., 2005). Value is placed on muscle development, definition and size by virtue of its association with male status and hegemonic masculinity (Drummond, 2002, Frederick et al., 2007, Kimmel and Mahalik, 2004).

Common IPEDs include androgenic anabolic steroids (AAS), human growth hormone (HGH), insulin-like growth factor-1, thyroid hormone, human chorionic gonadotropin, insulin, ephedrine, pseudoephedrine, clenbuterol, clomiphene, gamma hydroxybutyrate, diuretics, laxatives, 2,4-dinitrophenol, tamoxifen, danazol, and melanotan I and II (Juhn, 2003, Kanayama et al., 2012, Parkinson and Evans, 2006, Van Hout, 2014). Typical use of among males centres on use of AAS for fat loss, increased muscle mass and strength gains (Evans, 2004, Kanayama et al., 2010, Pope and Brower, 2009), and increasing in popularity in recent times (Trenton and Currier, 2005, Baker et al., 2006). AAS use commonly occurs within poly enhancement and illicit drug taking repertoires (Bahrke et al., 2000, Cornford et al., 2014, Juhn, 2003, Kanayama et al., 2003a, Kanayama et al., 2003b:2010:2012). Detailed user information is available on Internet drug forums and ‘underground’ guides (Roberts and Clapp, 2006, Llewellyn, 2009, Kanayama et al., 2009), with sourcing from less than creditable points of supply (Baker et al., 2006). Harmful effects of AAS use include liver, cardiac, psychological and dependence problems (Cafri et al., 2005, Cole et al., 2003, Darke and Torok, 2014, Kanayama et al., 2009, Olivardia et al., 2000, Schmidt et al., 2004).

In the United Kingdom (UK), it is not a criminal offence to possess AAS, despite being illegal to sell them. Profiles of harm reduction service users have changed, with anecdotal reporting of increased rates of uptake of injecting users of IPEDs (Advisory Council on the Misuse of Drugs, 2010, Public Health England, 2013, Whitfield et al., 2014). Of concern given its hidden nature, lack of formal prevalence data and potential for associated injecting risks (Hope et al., 2013), is the relatively low reporting of serious side effects (Evans, 2004, Trenton and Currier, 2005). In 2014, the NICE Public Health Advisory Committee (PHAC) provided guidelines for improved harm reduction service provision, and recommended further research into ethnic differences in the injecting use of IPEDs in the UK. Harm reduction services in the UK have indicated concerns for notable increases in British South Asian male IPED users accessing their services (Aujla, 2009). To date, no research has explored the use of IPEDs among this ethnic group in the UK.

Section snippets

Methods

The study aimed to explore the nature and experiences of IPED use among British South Asian males. British South Asian describes individuals with ancestry in India, Pakistan and Bangladesh but who are born in Britain or have a British passport (Alexander, 2000). A qualitative methodology was developed, which comprised of 20 in-depth interviews. Ethical approval was granted by Waterford Institute of Technology, Ireland. Purposive sampling was used to recruit participants and was undertaken by

Results

The majority were current users of a range of enhancement drugs, most commonly AAS and HGH. Most were in off-cycle periods. Those not currently using IPEDs, had experience ranging from two to ten years previous. The mean age of first time use for the 12 participants who volunteered this information was 17 years. Product nomenclature included: “Test 400”, “Deca”, “Clenbuterol”, “Anavar”, “Sustanon”, “Mass Mass”, “Dianabol”, “Mod Grf 1-29”, “Ipomaerolin”, “HGH Genotropin”, “Tamoxifen”, “Clomid”,

Informed decision making

Decisions to use, and seeking of information around dosage, cycling and poly use and injecting practices were enhanced by personal researching, peer (real life and cyber) knowledge exchange and mentoring from more experienced users.

‘Too many people use steroids without any idea of what they are doing, they need to research stuff and get as much information as possible before they try them.

Advice around appropriate use was described as primarily occurring from dealer suppliers providing after

Asian consumerism of enhancement ideals

Values around IPED use centred on physical, performance and recovery enhancement with all reporting stimulation of interest due to social media (Face Book, Twitter, Instagram), celebrities, men's magazines, Bollywood films, Internet forums and books, as well as peer messages encountered when exercising in local gyms. Stigma appeared to dilute over time while socialising within drug enhancement gym culture.

‘There used to be a time where no one used to admit to taking steroids. But as years gone,

IPED markets

Some were introduced to IPEDs (commonly AAS and HGH) when visiting their country of home origin (Pakistan, India).

‘I went to Pakistan on a visit. I overstayed my visit there so I got into training, with some professional bodybuilders who were competing for Mr Pakistan and Mr Lahore.’

Most sourced enhancement drug products from gym dealers and peers. Choice of products generally centred on peer and dealer recommendations, low reporting of side effects and reliability of the desired effect. Few

Athleticism and aestheticism

Awareness of British South Asian ethnic vulnerability to cardiovascular or sedentary type diseases was mentioned as contributory factor to increased male participation in gym training.

‘There's been a lot more awareness of going to the gym, being fit. I don’t know if it's got anything to do with cultural diseases that people do have or carry or have seen it within their family or friends. It's like, before you used to say at every corner there's an Asian shop. Now it's a gym *laughter*

Motives to

Interplay with substance use, crime and religion

Participants ranged in their experience and consumption (past and current) of alcohol and illicit drugs. Eight described never having drunk alcohol or use of illicit drugs. Half reported party drug use (cocaine, MDMA, ketamine), with a minority reporting heroin use. Triggers for current abstinence from alcohol and illicit drug use centred on religious beliefs and commitment, and ‘being clean’ and ‘sensible’ after a misspent youth.

‘Islamically, I knew it was completely wrong. My mum and dad

Injecting practices and risk management

All participants with exception of one reported injecting use of AAS and HGH. Oil based AAS were generally injected, with the remainder administered orally (“Winstrol”, “Dianabol”, “Anavar”). First time injecting often took place when under 18 years, involved peer injecting (friend, gym member or dealer) and in gym changing rooms, homes and private vehicles. Needles (short/long blue and green) were sourced at local pharmacies, needle and syringe exchanges, from dealers and online. No

Discussion

Consumerism of enhancement drugs is increasingly situated within body culture and contemporary social relations (Brennan et al., 2013, Gillen and Lefkowitz, 2009, McVeigh et al., 2012). Ethnic male embodiment in sporting arenas and leisure media is increasingly viewed as popular political instrument (Carrington, 1998, Daniel and Bridges, 2009, Mishkind et al., 2001, Whannel, 2002) by virtue of enhanced physicality and image challenging perceived ethnic inferiorities within cultural contexts (

Conclusion

The study is intended to contribute to health policy and practice debate around increased normalisation of enhancement drug use among ethnic groups in the UK. Similar to Maycock and Howat, 2005, Maycock and Howat, 2007, social connectivity and shared norms for IPED use, fitness training and nutrition, with dealers acting as supply mechanism and mentor for novice users were described. Given the reporting of mutual gym injecting and sharing of vials, users entrenched in peer support networks but

Acknowledgement

With thanks to Nav Khan for his support of the study.

Conflict of interest statement: No conflict of interest declared.

References (104)

  • D. Sagoe et al.

    The global epidemiology of anabolic–androgenic steroid use: A meta-analysis and meta-regression analysis

    Annals of Epidemiology

    (2014)
  • K.I. Stajduhar et al.

    Missed opportunities: Injection drug use and HIV/AIDS in Victoria, Canada

    International Journal of Drug Policy

    (2004)
  • M.C. Van Hout

    SMART: An Internet study of users experiences of synthetic tanning

    Performance Enhancement and Health

    (2014)
  • J.E. Wildes et al.

    The roles of ethnicity and culture in the development of eating disturbance and body dissatisfaction: A meta-analytic review

    Clinical Psychology Review

    (2001)
  • Advisory Council on the Misuse of Drugs

    Consideration of the anabolic steroids

    (2010)
  • D. Agliata et al.

    The impact of media exposure on males’ body image

    Journal of Social and Clinical Psychology

    (2004)
  • S. Akhtar et al.

    Hidden from heroin's history: Heroin use and dealing within an English Asian community

  • C. Alexander

    The Asian gang: Ethnicity, identity, masculinity

    (2000)
  • M.Y. Alam et al.

    British–Pakistani men from Bradford linking narratives to policy

    (2006)
  • G. Aujla

    More Asian teens using steroids

    (2009)
  • E. Babbie

    The practice of social research

    (1995)
  • M.S. Bahrke et al.

    Risk factors associated with anabolic–androgenic steroid use among adolescents

    Sports Medicine

    (2000)
  • D. Beddoes et al.

    The impact of drugs on different minority groups: A review of the UK literature

    (2010)
  • I.D. Boardley et al.

    Moral disengagement and associated processes in performance-enhancing drug use: A national investigation

    Journal of Sports Science

    (2014)
  • H. Bradby

    Watch out for the aunties! Young British Asians’ accounts of identity and substance use

    Sociology of Health & Illness

    (2007)
  • H. Bradby et al.

    Is religion or culture the key feature in changes in substance use after leaving school? Asians and non-Asians in glasgow

    Ethnicity and Health

    (2006)
  • P. Bramham

    Boys, masculinities and PE

    Sport, Education and Society

    (2003)
  • R. Brennan et al.

    Heuristics of human enhancement risk: A little chemical help?

    International Journal of Health Promotion and Education

    (2013)
  • M. Brettingham

    Football shows hijab the red card

    Times Educational Supplement

    (2007)
  • D. Burdsey

    British Asians and football: Culture, identity, exclusion

    (2007)
  • G. Cafri et al.

    The influence of sociocultural factors on body image: A meta-analysis

    Clinical Psychology: Science and Practice

    (2005)
  • B. Carrington

    Sport, masculinity, and black cultural resistance

    Journal of Sport and Social Issues

    (1998)
  • D.D. Chitwood et al.

    A systematic review of recent literature on religiosity and substance use

    Journal of Drug Issues

    (2008)
  • J. Cohen et al.

    A league of their own: Demographics, motivations and patterns of use of 1955 male adult non-medical anabolic steroid users in the United States

    Journal of the International Society of Sports Nutrition

    (2007)
  • J.C. Cole et al.

    A preliminary investigation into the relationship between anabolic–androgenic steroid use and the symptoms of reverse anorexia in both current and ex-users

    Psychopharmacology (Berl.)

    (2003)
  • R. Collins

    Legal Muscle: Anabolics in America

    (2002)
  • S. Daniel et al.

    The drive for muscularity in men: Media influences and objectification theory

    Body Image

    (2009)
  • S. Darke et al.

    Sudden or unnatural deaths involving anabolic–androgenic steroids

    Journal of Forensic Sciences

    (2014)
  • I. Din et al.

    Pakistani gangs in Bradford

    The Police Journal: September

    (2006)
  • M. Drummond

    Men, body image, and eating disorders

    International Journal of Men's Health

    (2002)
  • M.J. Duncan et al.

    Differences in physical activity levels between white and South Asian Children in the United Kingdom

    Pediatric Exercise

    (2008)
  • N. Evans

    Current concepts in anabolic–androgenic steroids

    The American Journal of Sports Medicine

    (2004)
  • M. Evans-Brown et al.

    Human enhancement drugs: The emerging challenges to public health. Liverpool: North west public health observatory

    (2012)
  • S. Farooq et al.

    Sport, physical education, and Islam: Muslim independent schooling and the social construction of masculinities

    Journal of Sociology of Sport

    (2009)
  • J. Fernandez

    Patterns in use: A study on routes of administration of Asian drug users

    Journal of Substance Use

    (2002)
  • J.A. Ford et al.

    Religiosity and adolescent substance use: Evidence from the national survey on drug use and health

    Substance Use and Misuse

    (2012)
  • J. Fountain et al.

    EMCDDA scientific report update and complete the analysis of drug use, consequences and correlates amongst minorities – Volume 2 – Country profiles

    (2002)
  • D.A. Frederick et al.

    Desiring the muscular ideal: Men's body satisfaction in the United States, Ukraine, and Ghana

    Psychology of Men & Masculinity

    (2007)
  • L.K. George et al.

    Explaining the relationships between religious involvement and health

    Psychological Inquiry

    (2002)
  • M.J. Gill

    The possibilities of phenomenology for organizational research

    Organizational Research Methods

    (2014)
  • Cited by (38)

    • Systems mapping to understand complexity in the association between image and performance enhancing drugs (IPEDs) and harm

      2022, International Journal of Drug Policy
      Citation Excerpt :

      This debate highlights that harm reduction approaches need to be appropriate to those that they are targeting and we must recognise the substantial diversity in IPED communities such as relating to types of IPEDs used (Begley et al., 2017), methods of administration (van de Ven et al., 2020), attitudes towards risk (Christiansen et al., 2016; Zahnow et al., 2018), and motivations for use (Brennan et al., 2016; Greenway & Price, 2018). While studies of IPED use in the UK have commonly focused on young white males, studies highlight IPED use amongst other demographic groups including women (Begley et al., 2017), men who have sex with men (Hibbert et al., 2021), older men (Harvey et al., 2021; Turnock, 2021), and South Asian communities (Van Hout & Kean, 2015), which adds to this diversity. There is therefore great variation in needs and preferences for healthcare, services, and interventions.

    View all citing articles on Scopus
    View full text