Image and Performance Enhancing Drugs (IPEDS)

"Bodybuilding has a long history of performance-enhancing substance [PES] 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]."

"The market for image and performance enhancing drugs has undergone seismic changes in the last two decades and, as has been alluded to above, its partial digitisation has created something of a dual space of commerce (Gibbs, Forthcoming). Before presenting an overview of the supply-side of the market however, it is worth considering the production of IPEDs. According to Turnock (2020), most anabolics steroids in the UK are produced in domestic ‘underground labs’ (UGLs) (Coomber et al. 2015), with raw powders imported from ‘producer’ countries like China, Egypt, Greece, Thailand, Turkey, and India (Antonopoulos and Hall 2016; Brennan et al. 2018; Llewellyn and Tober 2010; Denham 2019). Underground labs can be defined as illicit operations where IPEDs, most commonly anabolics androgenic steroids, are produced from these imported powders outside of registered pharmaceutical manufacture. These operations vary in scale from minor set-ups with minimal expertise, to large-scale production staffed by highly specialised (but illicitly operating) staff capable of producing a wide range of enhancement drugs beyond just AAS (see Gibbs Forthcoming, for an overview of the UK UGL market). The public health challenges of such production are widely reported, encompassing product dosing, hygiene, and contamination (Llewellyn and Tober 2010; Coomber et al. 2015). Analogous substances like post-cycle therapy drugs and human growth hormone, on the other hand, are generally produced in licit pharmaceutical laboratories in jurisdictions with more lax regulations and subsequently imported or removed from domestic pharmaceutical supply chains by illicit actors (Fink et al. 2019).

"As has been alluded to above, empirical evidence indicates that the bulk of IPED transactions occur between peers operating within sporting or fitness-related contexts (van de Ven and Mulrooney 2017; Sagoe et al. 2014), and can broadly be characterised as social supply (Coomber et al. 2014; Begley et al. 2017). Accordingly, literature around IPED supply tends to ascribe a pivotal role to one’s social network or community (Bates et al. 2017; Greenway and Price 2018). Coomber et al. (2014) note that their participants overwhelmingly sourced IPEDs from ‘connected friends’, whilst Fincoeur et al. (2015: 241) suggest that some suppliers are subject to a process of normalisation due to their IPED-using peers, and thus do not view themselves as ‘real dealers’. In this sense, they conceptualise the suppliers in their sample as ‘cultural products’ who engage in a process of ‘cultural reciprocity’ in consumer-supplier interactions, whereby financial gain is less important than other benefits (e.g., respect, reputation, or acknowledgement of expertise) within an ‘enduring relationship’ between the two parties (Fincoeur et al. 2015: 242; van de Ven and Mulrooney 2017). In practice, Antonopoulos and Hall (2016: 707) note that social supply tends to occur in ‘discreet places’ in gyms, such as toilets and changing rooms, and sellers rarely approach prospective customers, relying instead on their personal network of trusted users. However, Coomber and Moyle (2014) critique the concept of social supply on account of its dismissal of the fundamentally economic nature of drug transactions. Addressing this, they coined the term ‘minimally commercial supply’ to acknowledge the inevitable economic exchange taking place.

"Crucially, access to this ‘partial’ offline market (Fincoeur et al. 2015) is guarded by symbolic barriers, meaning that those without the prerequisite cultural or bodily capital cannot gain access (Maycock and Howat 2005; Coomber and Turnbull 2007; Antonopoulos and Hall 2016). However, whereas these cultural battlements have traditionally limited the consumer base to community embedded ‘expert’ users (Christiansen 2020), discernible shifts have occurred that have ushered in a new wave of prospective buyers. Firstly, a raft of literature points to a professionalisation of the IPED market. Fincoeur et al. (2015), drawing upon the axes of commercialisation and cultural embeddedness, contend that IPED supply has become more professionalised and profit driven. This is supported by Salinas et al. (2019), who found that their sample’s consumption ‘transcended IPEDs to encompass a much broader cocktail of substances’ (Salinas et al. 2019: 49) including recreational drugs like cannabis and cocaine (see also Turnock 2021b). As such, this polydrug use is facilitated by increasingly ‘market-oriented dealers’ (Fincoeur et al. 2015: 244), with fewer ties to the fitness community and, crucially, with no qualms about selling to non-culturally embedded customers. Secondly, changes in the global accessibility of IPEDs have occurred due to the rise of online selling. Hall and Antonopoulos (2016: 64) note that the market ‘has in some respects moved online’, and therefore customers who lack cultural and bodily capital can circumnavigate traditional barriers to supply. Such customers, termed ‘occasional users’ (Antonopoulos and Hall 2016: 702), are the principal target for online sellers, who can offer a ‘virtual relationship’, mimicking that of the gym community. As a result, the authors describe the online IPED market as ‘decentralized, highly flexible with no hierarchies, and open to anyone’ (Antonopoulos and Hall 2016: 708). Finally, recent scholarship has examined changes in the motivation to use IPEDs and the impact of a focus on medicalised ‘wellbeing’ rather than conventional sporting consumption (Underwood et al. 2021). This includes users sourcing products online as self-prescribed testosterone replacement therapy (TRT) (Dunn et al. 2021; Harvey et al. 2021; Turnock 2022) as part of a wider pharmaceuticalisation of health (Williams et al. 2011; Nettleton 2013; Morrison 2015)."

"Steroids

"In 2023 lifetime prevalence of anabolic steroid use was 1% in all grades. In general, lifetime, past 12-month, and past 30-day use have decreased, sometimes unevenly, since highs in the early 2000s.

"Anabolic steroids, sometimes used for muscle development including in body building, were rendered illegal to purchase or sell without a prescription in the Anabolic Steroids Control Act of 1990. Prevalence of use fell among 12th graders for a couple of years thereafter, but then increased some. Use for all grades peaked around 2002 and have since declined substantially.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns.

"Creatine

"Creatine is not a hormone or a drug but a nutrient found in the skeletal muscle of most animals. It is used to reduce the recovery time of muscles, to increase muscle mass, and to thereby enhance performance for high-intensity, short-duration exercises. It is readily available over the counter, which undoubtedly helps to explain the substantial levels of use we have found among teens.

"Past 12-month use maintained the large increases that took place last year, from 2021 to 2022. All grades levels are at the highest recorded since the project first began tracking use of this substance in 2001. Prevalence in 2023 was 12% in 12th grade, 11% in 10th grade, and 5% in 8th grade.

"These results are consistent with the possibility of an increase in the proportion of adolescents involved in fitness and weightlifting during the pandemic. Lasting increases since 2021 also took place for the performance-enhancing drug androstenedione, which is sometimes used with creatine.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns.

"Androstenedione

"Androstenedione, a precursor to testosterone, is a performance-enhancing substance that was scheduled by the Drug Enforcement Administration early in 2005, making its sale and possession no longer legal.

"In 12th grade, past 12-month prevalence was 1.4% in 2023, and maintained most of the large increase that took place last year, when it jumped to 1.9% in 2022 from 0.6% in 2021. The current higher levels in 2023 are a departure from the long-term decline that started at 3.0% in 2001 and decreased to 0.5% by 2019.

"These results are consistent with the possibility of a lasting increase in the proportion of 12th grade students involved in fitness and weightlifting during the pandemic. Lasting increases also took place since 2021 for the performance-enhancing drug of creatine.

"The survey stopped tracking this drug among 8th and 10th graders after 2014, when prevalence levels were less than 1% in these grades.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns."

"A total of 142 unique CEs [Cognitive Enhancers] were identified by NPSfinder®. They were divided into 10 categories, including plants/herbs/products (29%), prescribed drugs (17%), image and performance enhancing drugs (IPEDs) (15%), psychostimulants (15%), miscellaneous (8%), Phenethylamines (6%), GABAergic drugs (5%), cannabimimetic (4%), tryptamines derivatives (0.5%), and piperazine derivatives (0.5%). A total of 105 chemically different substances were uniquely identified by NPSfinder®. Only one CE was uniquely identified by the EMCDDA; no CE was uniquely identified by the UNODC."

"NPSfinder® identified 35 molecules (out of the total of 4,204) that were described by psychonauts as having cognitive enhancing effects, such as improved memory, alertness, attention, and concentration. A further 107 molecules were previously described as CE (7–9), although psychonauts did not explicitly describe them as CE. Since psychonauts experiment with novel substances in order to intentionally experience altered states of consciousness, it is to be expected that their interest also extends to the world of CEs. Among the CEs that they have been discussing online, there are mostly molecules that are known to have nootropic properties, are not illegal, and are likely to be easily available on the market (such as racetam compounds, modafinil and its derivatives, methylphenidate and its derivatives and food supplements). Our results showed that NPSfinder® could be employed as an Early Warning System tool to help clinicians with keeping their knowledge up-to-date with the growing numbers and types of nootropics in the increasingly difficult-to-follow online market."

"Harms surrounding AAS [Anabolic-Androgenic Steroids] 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."

"With the growing availability of AAS [Anabolic-Androgenic Steroids] through online platforms [71, 72] the traditional reliance on social networks and healthcare providers for access to injecting equipment and safer use information has diminished [73–76]. This unregulated supply of AAS and other PIEDs from online sources is accompanied by misleading information regarding the benefits and risks associated with their use [13, 23], posing significant concerns. Given the potential harms of AAS use among the general population [14, 77], current evidence indicates the potential of their growing impact on the health of this substance cohort globally [78, 79]. Therefore, enhanced harm reduction measures are imperative to effectively engage with the increasing diversity of individuals currently engaged in AAS use [41, 80], particularly considering the potential for emerging dangers associated with the uptake of harsher AAS varieties [81]. Our data indicate that community pharmacies represent sites which can establish an enabling environment conducive to harm reduction for this group, and so we provide an immediate practical application of doing so drawn from our data.

"To enhance privacy and confidentiality, community pharmacies can utilise dedicated spaces more effectively, such as private counselling rooms, where AAS consumers can have confidential discussions with pharmacists [55, 82]. Increasing awareness among both pharmacists and consumers about these private spaces has been met with receptivity in relation to mental health [82] and licit substance use [59]. As trust is a crucial component in the pharmacist-consumer relationship, pharmacists have a professional responsibility to establish community pharmacies as ‘safe spaces’ where individuals feel comfortable discussing their health concerns, including AAS use. By adhering to the Code of Ethics, which prioritises the health and wellbeing of consumers [83], pharmacists should set aside judgments and create a non-judgmental environment that fosters open communication. However, our findings revealed a knowledge gap among pharmacists regarding these substances, highlighting the need for further training and education initiatives. Despite this gap, pharmacists demonstrated receptivity to learning and enhancing their understanding of AAS and other PIEDs, indicating a potential for improved engagement in harm reduction efforts within community pharmacy settings. Further research is needed to understand knowledge gaps, training needs, and the effectiveness of educational interventions for pharmacists in addressing AAS use. These efforts can contribute to fostering a conducive environment for harm reduction for AAS consumers, a necessity that demands immediate attention."

"Cognitive enhancement may be defined as “the amplification or extension of core capacities of the mind through improvement or augmentation of internal or external information processing systems” (1). Both non-pharmacological and pharmacological enhancers are sought by the general public in order to improve performance during studying and at work by increasing concentration, motivation and accuracy, via physical, behavioral and biochemical activities (2).

"Cognitive enhancer drugs (CEs) are also known as “nootropics” (from the Greek ‘nous’ meaning ‘mind’ and ‘trepein’ meaning ‘turning/bending’), a term initially penned by Corneliu Giurgea when piracetam was found to exhibit memory-enhancing properties in clinical trials (3, 4). Cognitive enhancer drugs such as modafinil improve cognition in very specific ways such that it enhances “pattern recognition memory, digit span recall, and mental digit manipulation” (5)."

"These findings from the present study suggest that trenbolone use may be linked to increased verbal aggression among males using AAS, particularly at higher doses. This extends on current literature highlighting the potential effects of AAS on non-physical aggression (Chegeni, Pallesen, et al., 2021), of which trenbolone is a potent example. Notably, the HAARLEM study, which also used the Buss and Perry Aggression Questionnaire, observed an increase in the 'Anger' subscale among people using AAS but did not find elevated physical aggression (Smit et al., 2021). Additionally, one participant in the HAARLEM study discontinued trenbolone use due to agitation, which resonates with our findings that trenbolone may exacerbate psychological distress and aggression. This underscores the importance of considering trenbolone alongside other AAS when examining the impact on aggression and violence. It raises the possibility that trenbolone's effects might have been confounding the understanding of other AAS effects in previous studies given that scholarly work regarding AAS often remains generalised. Recent research indicates that the harms associated with these drugs may vary depending on the specific type used (Piatkowski et al., 2023b, 2024; Underwood, 2022). Our data supports preliminary qualitative work (Piatkowski et al., 2023b) in suggesting that AAS could be categorised into groups based on their associated risks. For example, 'higher-risk' drugs like trenbolone may promote more severe physical and psychosocial effects (Aknouche et al., 2021; Piatkowski et al., 2023b, 2024; Rahmani et al., 2014; Underwood, 2022; Zelleroth et al., 2024), while lower-risk drugs like testosterone pose milder risks (Eu et al., 2023a,b). However, further consideration and differentiation of the multitude of AAS are needed to provide a more nuanced understanding of their effects. Therefore, moving forward, there is a critical need for research to differentiate between various AAS types and to conduct more comprehensive studies."

"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 [Anabolic-Androgenic Steroid] 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."

"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]."

"Outside of animal or clinical use, trenbolone has three times the androgen receptor binding affinity of testosterone (Yarrow et al., 2011) and thus is renowned for its ability to rapidly increase lean muscle mass while minimising fat accumulation or promoting fat loss. Nevertheless, these benefits are accompanied by significant risk. Trenbolone is associated with cardiovascular complications (Aknouche et al., 2021). Short-term side effects include insomnia, high blood pressure, and increased libido (Aknouche et al., 2021; Piatkowski et al., 2023b). Furthermore, trenbolone exposure in brain cell cultures has been found to lead to significant cell damage, resulting in cell death (Zelleroth et al., 2019). Trenbolone's toxicity was reduced when cells were treated with a drug that blocks the androgen receptor which suggests that trenbolone's harmful effects are largely due to its interaction with this receptor (Zelleroth et al., 2019). The psychosocial effects of the drug are also evident (Aknouche et al., 2021; Piatkowski et al., 2023b, 2024; Underwood, 2022) with studies reporting relationship issues, impulsivity, and violent behaviour. Research indicates that people who use trenbolone experience a decline in patience. They also attribute trenbolone to being responsible for relationship breakdowns due to uncharacteristic behaviour ("tren-me"), an effect observed and reported by AAS-using peers who do not use Trenbolone (Lamb et al., 2024; Piatkowski et al., 2023b). Drawing the evidence together, trenbolone has been recognised as disproportionately related to AAS harms and requires further exploration regarding its risk profile."

"In the medical field, insulin is predominantly recognised as a fundamental component of treatment for type 1 diabetes mellitus and frequently employed in managing type 2 and gestational diabetes mellitus [1]. Pharmacological insulin is typically delivered via subcutaneous injection, and to enhance insulin replacement for individuals with diabetes, manufacturers have created diverse insulin formulations, such as insulin analogues [2]. This has led to the development of insulin analogues with rapid onset, appearing in the bloodstream within 5–10 min of injection and dissipating within 4–6 h, while longer-acting insulins can persist in the system for over 24 h [2]. Extensive knowledge on the adverse effects of insulin has been accumulated through diabetes treatment, where it serves a clear therapeutic role [1]. While individuals with diabetes may grapple with weight gain [3] notably, however, hypoglycaemia stands out as the most frequently observed side effect [2] and its significance is magnified by the potential progression to a coma and, ultimately, death [4]. Nevertheless, in the context of gyms and the fitness community globally, insulin takes on a distinct reputation that spans the domain of enhancement rather than therapy. We recognise the evolving landscape where medicinal products, including insulin, are increasingly sought after for non-health-related purposes, blurring the lines between lifestyle enhancement and medical treatment. Hall posits that this phenomenon reflects a broader trend in late capitalism's ‘economy of the self’, where pharmaceutical drugs are utilised to enhance various aspects of life, from performance at work to image in social contexts, thereby raising pertinent public health concerns [5]. For insulin specifically, its' appeal stems from its potential to induce weight gain, owing to its anabolic effects on both muscle and adipose tissue [6], rendering it an enticing choice for those seeking to increase their muscle mass and overall physique [3, 7, 8].

"Extant work has identified the use of insulin remains a pervasive issue within the strength training community [3, 6-8], particularly among people who use image and performance enhancing drugs (IPED). Research has demonstrated that bodybuilders are able to readily access their insulin and syringes through local sources such as friends, training partners, gym contacts, over social media [9] or community pharmacies [6, 10], however, literature points to public health issues associated with counterfeit insulin, with deaths occurring due to the use fake insulin [11]. Those who use insulin in this way often administer it without monitoring their blood glucose levels, leading to reported instances of hypoglycaemia [7, 8]. Biologically, administering insulin improperly can lead to hypoglycaemia, where blood sugar levels drop dangerously low, potentially resulting in seizures, loss of consciousness and, in severe cases, death due to lack of glucose reaching vital organs like the brain [2]. Scholars identified some time ago that it is crucial for the medical, research and fitness communities to be informed about these patterns of use and promote educational initiatives among individuals at risk [3, 6]. However, as we contend, this call has been largely unanswered as insulin use has continued to grow beyond the strength sport community and into general IPED-using communities. Among the IPED-using community more broadly, the use of insulin is reflective of a development of social drug use practices which bring alongside them increased dangers and warrant a unified harm reduction approach. Therefore, the current study sought to focus on articulations and understandings of risk in relation to insulin in narratives of IPED use."

"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."

"The final theme emanating from this exploration is the notable affordances and ‘malaffordances’ of both platforms that facilitate IPED supply. To first address the former of these, a fundamental capitalist logic undergirds the replication of mainstream marketing tactics in the social media IPED market. Facebook and Instagram, by design, lend themselves to the perpetuation of capital and the stimulation of consumer desire both as spaces of commerce (for example, in-app purchasing) and advertisement (particularly the monetisation of self-representation afforded to social media influencers (van Driel and Dumitrica 2021)). As a result, these platforms afford IPED sellers with the tools to simulate cultural proximity through the ability to post relevant content, self-objectify as an act of prosumption, mobilise sponsored athletes, and more broadly exist in the same ‘field’ (Bourdieu 1980) as their customer base. As is argued above, the digitisation of fitness is symbiotic with the burgeoning licit and illicit social media ergogenic aids market, and therefore Facebook and Instagram allow non-culturally embedded sellers (Fincoeur et al. 2015) not only access to their client base, but also a periscope into the language, self-presentation, and culture of prospective consumers. This is compounded by affordances like Instagram’s ‘story’ feature (Kurniawan 2020), which is utilised for seasonal sales and promotions as well as both platforms’ facilitation of visual content, which can be employed to share customer feedback and the host of other techniques described above.

"However, whilst social media platforms have proven to be fruitful avenues for the supply of IPEDs and other illicit substances (Demant et al. 2020; Bakken, 2021), their simplicity to use and the ease with which users can misrepresent themselves is striking. True to the current literature on the inherent distrust in online illicit drugs markets, analysis uncovered multiple elements of deception by social media IPED sellers which, ironically, potentially functioned to undermine attempts to establish a trustworthy brand. UGLs’ reported utilisation of fake accounts to create ‘buzz’ certainly speak to this challenge, as well as the potentially misleading transformation photos posted by social media resellers. This ties into a broader literature on the innate fakery and manipulated self-representation on social media, with the ubiquitous employment of filters, curated lighting, posed images, and putting forward one’s ‘best self’ (Ross 2019; Tiggemann and Anderberg 2019; Kotzé et al. 2020). Therefore, whilst social media platforms may be potent marketing tools for the seller, the customer perhaps does not benefit from this development. This has potentially negative consequences for the safety of users and the regulation of the market."

"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."

"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]."

"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]."

"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."