The risk environment of anabolic–androgenic steroid users in the UK: Examining motivations, practices and accounts of use

Abstract

Background

The numbers using illicit anabolic–androgenic steroids are a cause of concern for those seeking to reduce health harms. Using the ‘risk environment’ as a conceptual framework to better comprehend how steroid users’ practices and perspectives impact on health risks, this paper examines steroid user motivations, patterns of use, and the ways in which these practices are accounted for.

Methods

As part of a wider mixed-method study into performance and image enhancing drug (PIED) use and supply in one mid-sized city in South West England, qualitative interviews were undertaken with 22 steroid users. Participants were recruited from a local safer injecting service, rather than bodybuilding gyms, in order to access a wider cross-section of steroid users. A limitation of this approach is potential sample bias towards those showing more health optimising behaviours.

Results

The research findings highlight that patterns of steroid use varied according to motivation for use, experience and knowledge gained. Most reported having had little or no knowledge on steroids prior to use, with first use being based on information gained from fellow users or suppliers—sometimes inaccurate or incomplete. In accounting for their practices, many users differentiated themselves from other groups of steroid users—for example, older users expressed concern over patterns of use of younger and (what they saw as) inexperienced steroid users. Implicit in these accounts were intimations that the ‘other’ group engaged in riskier behaviour than they did.

Conclusion

Examining social contexts of use and user beliefs and motivations is vital to understanding how ‘risk’ behaviours are experienced so that this, in turn, informs harm reduction strategies. This paper examines the ways in which use of steroids is socially situated and the implications of this for policy and practice.

Introduction

Nationally, although difficult to measure reliably, survey data strongly suggests that the use of anabolic–androgenic steroids (hereafter referred to as steroids) is on the rise (Kimergård & McVeigh, 2014b). The Crime Survey for England and Wales estimates that in the period 2014/15 there were 293,000 16–59 year olds who had ever used in their lifetime (0.9% of the population), with 73,000 of these being use in the last 12 months (0.2%) and 24,000 in the last month (Home Office, 2015).

The numbers using steroids and other performance and image enhancing drugs (PIEDs) are a cause of concern for those seeking to reduce health harms, especially as the use of these is no longer confined to body-building enthusiasts seeking to compete. Although the use of steroids to improve and enhance performance, appearance, and musculature is well documented historically, the broadening reasons for changing one’s body (cf Fisher, 2002, McCabe and Ricciardelli, 2004, Olivardia et al., 2004, Shilling, 2003) have extended the use of steroids far beyond its origins in professional sport and bodybuilding (Evans-Brown, McVeigh, Perkins, & Bellis, 2012). Steroid use is now also part of a broader societal milieu (Kraska, Bussard, & Brent, 2010) where increasing numbers seek to optimise their bodies through an ever-widening range of licit and illicit drugs and supplements, sometimes overriding health concerns—as highlighted in the above quote.

Health risks in steroid use include serious organ damage, sudden cardiac death, reduced fertility, gynecomastia in men and masculinisation in women as well as a range of other cardiac, liver and health disorders; these, nonetheless, are not inevitable and are, for the most part, dose and administration dependent (Darke & Torok, 2014; Frati, Busardo, Cipolloni, De Dominicis, & Fineschi, 2015; Kanayama, Brower, Wood, & Hudson, 2009; Maravelias, Dona, Stefanidou, & Spiliopoulou, 2005; van Amsterdam, Opperhuizen, & Hartgens, 2010).

Concerns over numbers using and the potential for health harms have led to media hypes about steroids (Kraska et al., 2010) and to declarations that ‘Public health faces a new kind of drug problem’ (Evans-Brown et al., 2012, p.9). In addressing steroid use, many countries have adopted prohibitionist fear-based approaches to policy, especially within the professional sports arena (Coomber, 2013). Some, such as Sweden, Belgium and Denmark, have adopted zero tolerance measures to steroid use and supply both inside and outside of professional sports—actions which Mulrooney and van de Ven (2015) argue are informed by wider anti-doping policies. Fear-based approaches to dealing with drug-related harms can lead to practices which end up hurting those who were initially intended to be protected by the policy (Coomber, 2013, Reinarman and Levine, 2004; Seear, Fraser, Moore, & Murphy, 2015). Drug harms are shaped, and often exacerbated, by such wider macro-structural factors (Dalgarno and Shewan, 2005, Rhodes, 2002, Rhodes, 2009; Taylor, Buchanan, & Ayres, 2016).

In developing drug policies on steroid use, it is important to examine how macro-structural factors impact on individual lives. The spaces and places in which individuals carry out their day-to-day lives are influenced by social and structural factors that interplay to increase or reduce risk and/or harm (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Rhodes & Simic, 2005). In examining drug harms, Rhodes (2009, p.193) calls for a ‘social science for harm reduction’ grounded in a ‘risk environment’ framework − an approach that gives primacy to context, both at a macro and micro level, when understanding and seeking to reduce health harms.

The risk environment can be envisaged as the space in which multiple factors (physical, social, economic, policy) interact at different levels (micro, macro) to increase the potential of harm (Rhodes, 2002, Rhodes, 2009). The risk environment approach has had notable success in increasing understanding of why certain risky behaviours persist among groups who are either knowledgeable of the risks related to their behaviours and/or who are motivated to stop those behaviours as well as those less knowledgeable and/or motivated. There is now a growing body of work unpacking the risk environments of substance use in multiple settings, including in relation to overdose (Moore, 2004, Green et al., 2009), syringe sharing (Rhodes et al., 2003; Small, Kerr, Charette, Schechter, & Spittal, 2006; Strathdee et al., 2010), and sex work (Shannon et al., 2008a, Shannon et al., 2008b).

The risk environment approach offers a critique on a tendency in the behavioural sciences to emphasise risk practices, such as steroid use, as something primarily determined by individual action and resolved through individual responsibility (Rhodes, 2009). The use of substances – such as steroids – is socially situated, with multiple factors interacting and influencing each individual user. In developing interventions on steroid use, there is a need to understand this wider context as well as the motivations, experiences and patterns of use of steroid users. Examining social contexts of use and the social and cultural meanings individuals attach to their risk practices is vital to understanding how risk behaviours are experienced and displayed so that this, in turn, informs drug policy and practice.