This report presents findings from a collaborative research project undertaken in 2006 by Drug and Alcohol Services South Australia (DASSA), National Drug and Alcohol Research Centre (NDARC), and Streetwize Communications. The project consisted of a qualitative field study of users and key informants on the use of performance and image enhancing drugs (PIEDs) and was funded by the Australian Government Department of Health and Ageing Drug Strategy Branch. The aim of the study was to explore the motivations, behaviours, risks and physical and psychological harms associated with the use of PIEDs.
The study design encompassed a national qualitative survey of 69 users of PIEDs from three target groups: adolescent males, members of the gay community, and occupational users (i.e., those engaged in the security industry); and a survey of 24 key informants who have good knowledge of the three target groups. Interviews were conducted within metropolitan and rural locations in NSW, Victoria, Queensland, South Australia and Western Australia. The majority of user participants were employed males who ranged in age from 18 to 58 years. All key informants were employed, and they ranged in age from 31 to 59 years.
Participants interviewed reported on a range of topics including experiences of PIEDs use, attitudes to information use, harm reduction strategies and experiences with health services. Motivating factors given for PIEDs use focused on physique and body image, with an increase in body size, strength, and muscle tone reported as valued outcomes for all three target groups. Participants also attributed gains in physique and body image to social benefits or advantages in occupational and sporting fields. Some users also reported being motivated by their experience of a heightened sense of energy, or a lift in mood whilst using PIEDS.
Participants had various attitudes to the experiences of risks associated with PIEDS use. PIEDS users commented on their attitudes to the following perceived risks: roid rage and changes in mood, damage to vital organs (kidney, liver and heart), breast development, testosterone imbalances, testes shrinkage, sexual infertility, diminished sexual performance, hair loss, blood borne viruses, injecting harms (such as skin infections and abscesses), infections resulting from the use of counterfeit or contaminated products, cancers, acne, anaemia, diabetes and injuries to the ligaments and tendons. Key informants reported they were concerned that whilst PIEDs users were aware of the need to use sterile equipment, they were unaware of other safer injecting practices. Participants expressed different opinions about how common roid rage was amongst PIEDS users. Some users thought it was very rare, others disagreed, particularly if high doses or injectibles were used. Some users reported that they thought their personal susceptibility to the risk of roid rage was low because they were not taking high doses of PIEDS, or were not using them long-term. In addition, some participants reported that they used medications to counter effects, or used anger management, stress reduction, and self monitoring techniques to reduce social harms related to roid rage and swings in mood.
Users expressed common concerns about short-term and long-term harms associated with PIEDs use and reported that they would stop using if they experienced serious health problems that would ix result in severe long term negative consequences. Participants described physical changes such as breast development, shrunken testes, or baldness as particularly undesirable side effects and some participants reported that they would contemplate ceasing use if they experienced these harms. Importantly, side effects relating to sexual function were frequently nominated as issues of great concern to participants in the young male group.
The impact of PIEDs use on personal relationships (partners and parents in particular) was mentioned as possibly motivating a decision to cease use. Some participants indicated that changes in personal circumstances, such as getting married and having children, or changing jobs would also be likely to result in them choosing to stop using PIEDs. In additions, participants reported that they would think about stopping PIEDS use in the future if they needed to stop training, had reached their body building or competition goals, were no longer working in their occupation, or were no longer able to afford to buy PIEDs.
User perceptions of some of the difficulties and potential difficulties of ceasing PIEDS use were also explored. Difficulties mentioned included the fear of losing the physical benefits already achieved, experiencing a negative impact on their training regime, living with testosterone imbalance or living with unsightly breast tissue. Participants also perceived a certain amount of peer pressure to continue using PIED.
Participants had various attitudes to the experiences of risks associated with PIEDS use. PIEDS users commented on their attitudes to the following perceived risks: roid rage and changes in mood, damage to vital organs (kidney, liver and heart), breast development, testosterone imbalances, testes shrinkage, sexual infertility, diminished sexual performance, hair loss, blood borne viruses, injecting harms (such as skin infections and abscesses), infections resulting from the use of counterfeit or contaminated products, cancers, acne, anaemia, diabetes and injuries to the ligaments and tendons. Key informants reported they were concerned that whilst PIEDs users were aware of the need to use sterile equipment, they were unaware of other safer injecting practices. Participants expressed different opinions about how common roid rage was amongst PIEDS users. Some users thought it was very rare, others disagreed, particularly if high doses or injectibles were used. Some users reported that they thought their personal susceptibility to the risk of roid rage was low because they were not taking high doses of PIEDS, or were not using them long-term. In addition, some participants reported that they used medications to counter effects, or used anger management, stress reduction, and self monitoring techniques to reduce social harms related to roid rage and swings in mood.
Users expressed common concerns about short-term and long-term harms associated with PIEDs use and reported that they would stop using if they experienced serious health problems that would ix result in severe long term negative consequences. Participants described physical changes such as breast development, shrunken testes, or baldness as particularly undesirable side effects and some participants reported that they would contemplate ceasing use if they experienced these harms. Importantly, side effects relating to sexual function were frequently nominated as issues of great concern to participants in the young male group. The impact of PIEDs use on personal relationships (partners and parents in particular) was mentioned as possibly motivating a decision to cease use. Some participants indicated that changes in personal circumstances, such as getting married and having children, or changing jobs would also be likely to result in them choosing to stop using PIEDs. In additions, participants reported that they would think about stopping PIEDS use in the future if they needed to stop training, had reached their body building or competition goals, were no longer working in their occupation, or were no longer able to afford to buy PIEDs. User perceptions of some of the difficulties and potential difficulties of ceasing PIEDS use were also explored. Difficulties mentioned included the fear of losing the physical benefits already achieved, experiencing a negative impact on their training regime, living with testosterone imbalance or living with unsightly breast tissue. Participants also perceived a certain amount of peer pressure to continue using PIEDs.
Reported harm reduction strategies included: identifying high quality products that were less likely to have side effects; drinking water to flush out the kidneys; having regular blood tests for kidney and liver function; taking medications to counter harms (e.g. to re-activate testicular function), and taking low doses of PIEDS. A wide range of information sources were identified by participants including: websites; internet forums; magazines; medical journals; dealers, general practitioners and other PIEDS users. However, participants expressed uncertainty about the credibility of information across the various sources. Information was considered reliable if it reported both the negative and positive effects of PIEDs and it came from a credible source. Some participants reported that they could not find any specific information on the negative effects of PIEDS and reasons why not to use. Potential information sources identified included hotlines, personal trainers, information sessions and youth educations strategies were identified as. Perceived information needs included: information on dosages; medications to counter side effects; product information (including counterfeit products); safer injecting practices; health harms and symptoms that require a medical intervention and medical services, and body building. Participants noted that there were different levels of knowledge about PIEDS use. In particular, concern was expressed about the level of knowledge held by young men because of their age and the length of time they had been using PIEDs. Some members of the young male group also reported more difficulty in accessing and understanding information available on PIEDs use.
Participants sought a variety of ‘services’ from health professionals such as general practitioners including: information and advice; monitoring health; health care for specific PIEDs related problems such as abscesses, and prescriptions for a range of pharmaceutical PIEDs products. Health professionals’ lack of PIEDs related knowledge was reported by PIEDs users to be a potential barrier to accessing health care, as some users regarded themselves as more informed than their health care provider. Users also reported that potential negative reactions from health professionals (e.g., disapproval, and or denial of access to treatment), presented a barrier to accessing health services and or disclosure of their PIEDs use.
Overall, the findings of this study confirm previous research suggesting that the desire for an improved body image is a major motivating factor for PIEDs use. This study also supports conclusions from previous research highlighting the need for evidence based non-judgmental, practical information that addresses areas of interest and concern to PIEDs users and health care professionals.
Several key recommendations are made as follows:
Incorporate PIEDs information, including short and long-term health concerns, within current school-based drug prevention programs.
Produce a booklet addressing common misunderstandings about PIEDs use and harm reduction strategies. x Incorporate information about PIEDs in education courses for personal trainers that is provided through recognized training institutions.
Review current security industry personnel training to ensure the emphasis is on the use of ‘talk down’ methods, rather than ‘size’ when dealing with difficult clientele.
Provide information based training on PIEDs use to medical practitioners and other health professionals and NSP workers. x Provide information to sporting clubs about the use of PIEDs, with the view to promoting the dissemination of preventive messages through these organisations.
Develop a ‘high quality’ website which provides information to those contemplating PIEDs use, and disseminates information about PIEDs use to health professionals.
Consider the introduction of drug testing for PIEDs in industries where PIEDs use is likely to be common.
Future Research
It is also recommended that the following research be conducted to support the development of prevention strategies.
Despite barriers to access, research within the fitness industry should be conducted to explore current attitudes towards the use of PIEDs by both management/owners and employees, with the aim of identifying acceptable ways of distributing PIEDs related information through gymnasiums.
Further research into the harm reduction strategies currently employed by users should be conducted to assess whether they are effective and to ensure that they are not causing greater harm.