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

1 Feb 2009

Public health impact and implications of the use of anabolic androgenic steroids (AAS) and associated drugs amongst the male general population / James McVeigh. - Liverpool : Liverpool John Moores University (LJMU), 2009

  • Doctoral thesis, Liverpool John Moores University
  • DOI: 10.24377/LJMU.T.00010247


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.

A qualitative analysis of the factors that protect athletes against doping in sport

13 Apr 2014

A qualitative analysis of the factors that protect athletes against doping in sport / Kelsey Erickson, Jim McKenna, Susan H. Backhouse. - (Psychology of Sport and Exercise 16 (2015) 2 (January); p. 149-155)

  • DOI: 10.1016/j.psychsport.2014.03.007



To explore the protective factors against performance enhancing drug (PED) use in sport.


Ten competitive athletes (M = 5, F = 5) representing five different sports (field hockey, boxing, football, triathlon, rugby) were recruited through convenience sampling to undertake a semi-structured interview to enable a qualitative analysis of athletes' lifelong athletic careers.


Verbatim transcripts were analysed using an established three-stage coding process to identify the common themes within the narratives.


Personal and situational protective factors were identified in the accounts. Personal factors included: (i) a strong moral stance against cheating; (ii) an identity beyond sport; (iii) self-control; and (iv) resilience to social group pressures. Situational factors included secure attachments to people at all stages of the athlete's life. This facilitated both the promotion of moral decision making and assisted in the development of anti-doping attitudes. When situational factors – such as a pro-doping climate – arose, key attachments in the athletes' lives interplayed with personal factors to reduce the risk of doping.


These findings offer insights into factors that protect competitive athletes against using PEDs in sport and further our understanding of the complex interaction between risk and protective factors at individual, psychosocial and societal levels among competitive athletes. As a complex behaviour, doping in sport cannot be prevented by solely focussing on the individual athlete; contextual factors beyond the athlete's control also impact on this behaviour. Thus, a paradigm shift is warranted to move beyond an athlete-centred approach to anti-doping.

Dangerousness of Drugs : A Guide To The Risks And Harms Associated With Substance Misuse

1 Jan 2003

Dangerousness of Drugs : A Guide To The Risks And Harms Associated With Substance Misuse / David Best, Samantha Gross, Louisa Vingoe, John Witton, John Strang; National Addiction Centre (NAC). - Department of Health, 2003

The purpose of this report is to provide a basic reference
document, targeting non-medical practitioners and others who
work with drug issues, with a core set of risk factors associated
with a range of licit and illicit substances commonly used in the
UK. The document revolves around a set of tables which
outline the chronic and acute problems associated with each of
these substances, and factors that mediate or moderate the risk;
while the remaining text attempts to provide a brief overview of
how to make sense of the information contained in the tables
and what other issues are worthy of further consideration in
examining drug-related risk.

Performance-enhancing drugs snare nonathletes, too

1 Feb 2009

Performance-enhancing drugs snare nonathletes, too / Marifel Mitzi F. Fernandez, Robert G. Hose. - (The Journal of family practice 58 (2009) 1 (February); p. 16-23)

  • PMID: 19141266

High school athletes aren’t the only ones seeking an edge. Here are the red flags and unexpected drugs to watch for.

Drivers of illicit drug use regulation in Australian sport

3 Feb 2021

Drivers of illicit drug use regulation in Australian sport / Bob Stewart, Daryl Adair, Aaron Smith. - (Sport Management Review 14 (2011) 3; p. 237-245)

  • DOI: 10.1016/j.smr.2011.02.001


Most Australian sport stakeholders not only believe that government regulation is a good thing, but also assume that intervention in the drug-use problem will improve sport's social outcomes and operational integrity. In this paper we examine the regulation of illicit drug use in Australian sport through an interrogation of two cases: the Australian Football League and the National Rugby League. Using Pierre Bourdieu's conceptual frames of social field, capital, and habitus, we aim to secure a clearer understanding of the drivers of Australian sport's illicit drug regulations by (1) identifying those stakeholders who set the drug regulation agenda, (2) revealing the values and dispositions that underpin these regulations, and (3) explaining how dominant stakeholders go about sustaining their position and marginalising those stakeholders with opposing drug regulation claims. Our results show that Australian sport's drug-use regulations are driven by a set of values and dispositions that views sport as an instrument for shaping the character of its participants, and drugs as a threat to sport's moral fabric and good standing. The dominant stakeholders, comprising the Commonwealth Government, its sport agencies, and the major governing bodies for sport, imposed these values and dispositions on peripheral stakeholders by designing a drugs-in-sport social field that yielded capital and power to only those participants who endorsed these values and dispositions. Peripheral stakeholders – including players, their agents, and drug-treatment professionals – who mostly shared different values and dispositions, were sidelined, and denied the opportunity of adding to their already limited supplies of capital, power, and policy making influence.

Sports, use of performance enhancing drugs and addiction. A conceptual and epidemiological review

1 Jan 2012

Sport, dopage et addictions. Délimitations conceptuelles et approche épidémiologique à partir des données de la littérature = Sports, use of performance enhancing drugs and addiction. A conceptual and epidemiological review / Pascale Franques, Marc Auriacombe, Jean Tignol. - (Annales de médecine interne 152 (2001) 7 Suppl. (November); p. 2S37-2S49)


Background. – Both the general public and non-sports medicine health professionals have recently been made aware of a large use of performance enhancing drugs among sports practicing subjects. It has been suggested that this behavior is similar to that of substance dependence. Also some have reported that practice of a sport could be in itself an addictive behavior.

Objective. – The main objective was to address the following question: is performance enhancing drug use in sports an addictive behavior?

Methodology. – We first reviewed the definition of performance enhancing drug use in sports and the diagnostic criteria of
substance dependence as they are currently accepted and attempted to determine a possible common factor. Secondly we reviewed epidemiological data from the literature according to three approaches:
a) Epidemiological studies of substance use among sport practicing and non-practicing adolescents and young adults;
b) Prevalence studies of dependence syndrome to performance enhancing drugs among performance enhancing drug users;
c) Studies of previous history of sport activities among in-treatment substance dependent subjects.

Results. – Use of performance enhancing drugs is an important and increasing phenomenon among adolescents. It is sometimes associated to risk taking behaviors for health (syringe use and sharing). Competition participants are at increased risk (up to 20% according to some authors) and some substances (anabolic steroids) are also used by non-sports practicing individuals. It has not been shown that sports practicing subjects were more at risk of using addictive substances compared to non-sports practicing subjects. It is not established that practice of a sport is by itself a risk factor for substance use. However, it could be that a subgroup of individuals that practice certain types of sports in an intensive way, that use both performance enhancing drugs and addictive substances and that engage in health risk taking behaviors have an increased risk for developing a dependence syndrome to both addictive and performance enhancing drugs. This sub-group is even more at risk because some performance enhancing drugs (anabolic steroids) could increase the risk for occurrence of a substance dependence syndrome through neurobiological actions. Yet, the few available clinical studies show that at most only half of regular users actually meet criteria for dependence. Also, one study has reported an overrepresentation of sports professionals among patients seeking treatment for heroin addiction.

Conclusion. – The large majority of sports practicing subjects have no dependence to either performance enhancing or addictive drugs. However, a subgroup of individuals that practice sports intensely and makes use of both addictive and performance enhancing drugs appear to be at increased risk for developing a substance dependence syndrome.

New challenges for agency based syringe exchange schemes: analysis of 11 years of data (1991–2001) in Merseyside and Cheshire, United Kingdom

25 Sep 2003

New challenges for agency based syringe exchange schemes : analysis of 11 years of data (1991–2001) in Merseyside and Cheshire, United Kingdom / Jim McVeigh, Caryl Beynon, Mark A. Bellis. -  (International Journal of Drug Policy (2003) 5-6 (December); p. 399-405)



The Merseyside and Cheshire Drug Monitoring Unit has collected attributable data on agency based syringe exchange program (SEP) clients between 1991 and 2001, representing 14,491 individual injectors. On first presentation to a SEP, clients provide information relating to their drug use and drug service contact. Details relating to all subsequent syringe transactions are also recorded. Over 206,000 transactions took place, accounting for 6,595,099 syringes provided and an estimated 7,184,727 returns.

There was a sixfold increase in the number of new clients using anabolic steroids (P<0.001) with these users currently constituting the largest group of new clients. The reverse is true for new heroin using clients who have significantly declined over the same period (P<0.05). Service utilisation by opiate and stimulant users has changed over time. Opiate users have attended SEP significantly less frequently (P<0.01) but obtain greater quantities of injecting equipment at each attendance (P<0.001). While the visit rate for stimulant users has fluctuated over time, this group of users are also collecting a significantly greater quantity of needles and syringes at each attendance (P<0.05).

What do the humanities (really) know about doping? Questions, answers and cross-disciplinary strategies

26 Jul 2014

What do the humanities (really) know about doping? Questions, answers and cross-disciplinary strategies / Ask Vest Christiansen, John Gleaves. - (Performance Enhancement & Health 2 (2013) 4 (December); p. 2016-225)

  • DOI: 10.1016/j.peh.2014.06.002


Recent years have brought debates about the future role of humanities research in light of sciences’ progress. In doping research, tacit biases in favour of science risk ignoring the humanities in their efforts to understand and address the doping phenomenon. This article is a continuation of the discussion on the role of the humanities and social sciences in research on drug use in sport. The article asserts that until those who wish to address the doping issues in sport begin engaging humanities and social science research alongside the natural sciences, the results from scientific experiments will remain detached from the lived experiences of the athletes, and the anti-doping campaign risks losing its legitimacy. Conversely, we will also argue against two types of drawbacks for humanistic research; one is the dismissal of the pursuit of truth in exchange of epistemological relativism. The other is the tendency to turn inward and become reluctant to use empirical tools that provide purchase on the doping issue. The article will conclude by sketching a positive account of the two fields collaborating with more porous borders but one that asks neither side to compromise its professional standards or modes of inquiry. This new account asserts that future doping research requires cross-disciplinary and collaborative research rooted in strong methodologies but conversant in both languages.

The Spirit of Sport and the Medicalisation of Anti-Doping: Empirical and Normative Ethics

1 Jan 2012

The Spirit of Sport and the Medicalisation of Anti-Doping: Empirical and Normative Ethics / Michael McNamee. - (Asian Bioethics Review 4 (2012) 4; p. 374-392)

In this article, I argue to the contrary — that Cannabinoids should be retained on the Prohibited List; that its use may be thought of as doping; and that the Spirit of Sport criterion, though vague, is still a defensible criterion for the demarcation of “doping”. To achieve this, I critically discuss the legitimacy of Cannabinoid inclusion in the light of contemporary literature on “enhancement”, and introduce the findings of a recent empirical investigation into anti-doping policy with a sample of international key actors in antidoping policy.

In the first section, I describe the definition of doping and the current state of policy flux in anti-doping, then I set out the extant and the proposed criteria for a method or substance to be considered doping (i.e., for inclusion on the Prohibited List). I review then one bioethical critique of the Spirit of Sport criterion (Foddy and Savulescu 2010), and a recent challenge by an internationally recognised group of scholars and scientists working in the field of anti-doping (the International Network of Humanistic Doping Research) to remove the criterion. I then included narrative data from key actors on the international scene of anti-doping such as Heads of National Anti-Doping Organisations, Heads of Medicine and Science in Anti-Doping Organisations, and senior members of the World-Anti Doping Agency (WADA), before arguing against their position and for the status quo.

Performance enhancement, elite athletes and anti doping governance: comparing human guinea pigs in pharmaceutical research and professional sports

5 Feb 2014

Performance enhancement, elite athletes and anti doping governance : comparing human guinea pigs in pharmaceutical research and professional sports / Silvia Camporesi, Michael J. McNamee. - (Philosophy, Ethics, and Humanities in Medicine 9  (2014) 4; p. 1-9)

  • DOI: 10.1186/1747-5341-9-4
  • PMCID: PMC3922342
  • PMID: 24499536


In light of the World Anti Doping Agency’s 2013 Code Revision process, we critically explore the applicability of two of three criteria used to determine whether a method or substance should be considered for their Prohibited List, namely its (potential) performance enhancing effects and its (potential) risk to the health of the athlete. To do so, we compare two communities of human guinea pigs: (i) individuals who make a living out of serial participation in Phase 1 pharmacology trials; and (ii) elite athletes who engage in what is effectively 'unregulated clinical research’ by using untested prohibited or non-prohibited performance enhancing substances and methods, alone or in combination. Our comparison sheds light on norms of research ethics that these practices exacerbate with respect to the concepts of multiplicity, visibility, and consistency. We argue for the need to establish a proper governance framework to increase the accountability of these unregulated research practices in order to protect the human guinea pigs in elite sports contexts, and to establish reasonable grounds for the performance enhancing effects, and the risks to the health of the athlete, of the methods and substances that might justify their inclusion on the Prohibited List.

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