The aetiology and trajectory of anabolic- androgenic steroid use initiation

14 Pages·2014·0.74 MB·English

Sagoeetal.SubstanceAbuseTreatment,Prevention,andPolicy2014,9:27
http://www.substanceabusepolicy.com/content/9/1/27
REVIEW Open Access
The aetiology and trajectory of anabolic-
androgenic steroid use initiation: a systematic
review and synthesis of qualitative research
Dominic Sagoe1*, Cecilie Schou Andreassen1,2 and Ståle Pallesen1
Abstract
Background: Toour knowledge, there has never been a systematic review and synthesisof thequalitative
literature on thetrajectory and aetiology of nonmedical anabolic-androgenic steroid (AAS) use.
Methods: WesystematicallyreviewedandsynthesizedqualitativeliteraturegatheredfromsearchesinPsycINFO,
PubMed,ISIWebofScience,GoogleScholar,andreferencelistsofrelevantliteraturetoinvestigateAASusers’agesof
firstuseandsource(s),historypriortouse,andmotives/drivesforinitiatinguse.Weadheredtotherecommendations
oftheUKEconomicandSocialResearchCouncil’squalitativeresearchsynthesismanualandthePRISMAguidelines.
Results:Atotalof44studiespublishedbetween1980and2014wereincludedinthesynthesis.Studiesoriginated
from11countries:theUnitedStates(n=18),England(n=8),Australia(n=4),Sweden(n=4),bothEnglandandWales
(n=2),andScotland(n=2).OnestudyeachoriginatedfromBrazil,Bulgaria,Canada,France,GreatBritain,andNorway.
ThemajorityofAASusersinitiatedusebeforeage30.Sportsparticipation(particularlypowersports),negativebody
image,andpsychologicaldisorderssuchasdepressionprecededinitiationofAASuseformostusers.Sourcesoffirst
AASweremainlyusers’immediatesocialnetworksandtheillicitmarket.Enhancedsportsperformance,appearance,
andmuscle/strengthweretheparamountmotivesforAASuseinitiation.
Conclusions:OurfindingselucidatethesignificanceofpsychosocialfactorsinAASuseinitiation.Theproliferationof
AASontheillicitmarketandsocialnetworksdemandsbetterwaysofdealingwiththeglobalpublichealthproblem
ofAASuse.
Keywords:Anabolic-androgenicsteroids,Metasynthesis,Narrativesynthesis,Systematicreview,Aetiology,Trajectory,
Qualitativeresearch,Interview
Background concern regarding the validity and reliability of survey
Severalqualitativeinvestigationshavesoughttounderstand researchon AAS use [2]. Moreover, it hasbeensuggested
the aetiology and trajectory of nonmedical AAS use initi- that the failure of health practitioners and public health
ation. However, to our knowledge, there has never been a officials to appreciate people’s perception of antecedents
systematic review and synthesis of the qualitative literature and risk factors is a major hindrance to the success of
onthisimportantareaofnonmedicalAASuse.Aninvesti- publichealthinterventions[3,4].Hence,dataoninitiation
gationofthistypeisimportantbecauseaglobalperspective and trajectories of AAS use are important for prevention
of nonmedical AAS use initiation is necessary for the purposes.
understandingofthisglobalpublichealthproblem[1]. We carried out, as far as we are aware, the pioneering
A review and synthesis of the qualitative research on systematic review and synthesis of the qualitative studies
AAS use initiation is also important in light of expressed presenting data on the initiation of nonmedical AAS use.
The United Kingdom’s Economic and Social Research
Council’s manual on the synthesis of qualitative literature
*Correspondence:[email protected]
[5] indorses the formulation of research questions or hy-
1DepartmentofPsychosocialScience,UniversityofBergen,Christiesgate12,
5015Bergen,Norway pothesispriortosynthesis.Theresearchquestionsguiding
Fulllistofauthorinformationisavailableattheendofthearticle
©2014Sagoeetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain
Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,
unlessotherwisestated.
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the present study were: (a) at what age(s) do AAS users total of 7,724 were settled on after eliminating duplicates.
have their debut?, (b) what are the psychosocial histories After evaluating the 7,724 papers based on titles and
of AAS users prior to the initiation of AAS use?, (c) what abstracts,95full-textpaperswereretrievedforscreening.
arethesourcesofAASusers’firstAAS?,and(d)whatare After initial screening of the 95 full-text papers, 68 pa-
themotivesanddrivesforinitiatingAASuse? perswereidentified.Ofthe68papersscrutinized,35stud-
ies met the following key criteria for inclusion: (a) studies
Method presentedoriginalinformationontheexperiencesofAAS
Searchstrategyandinclusioncriteria users (b) studies employed qualitative approaches in data
We conducted a comprehensive literature search in Psy- collection (interviews, focus groups, or case studies) and
cINFO,PubMed,ISIWebofScience,andGoogleScholar. presentation of results, and (c) studies were published in
The following keywords: ‘anabolic steroid’, ‘doping’, and English. Four recent studies [6-9] and five others [10-14]
‘performanceenhancingdrug’,wereeachusedincombin- were later discovered and included in the analysis. We
ation with ‘interview’, ‘focus group’, and ‘qualitative’ for again inspected the characteristics of extracted studiesfor
searches in PubMed and ISI Web of Science. Due to un- similarities to curb duplicate extraction and synthesis.
usuallyhighsuperfluousreturnsfromtheabovepermuta- Thus, a total of 44 articles were included in the analysis.
tionofkeywords,‘anabolicsteroid+doping+performance TheliteraturesearchstrategyadheredtoShawetal.’s[15]
enhancing drug+interview+focus group+qualitative’ recommendations for finding qualitative research as well
was used in searches in PsycINFO and Google Scholar. as the Preferred Reporting Items for Systematic Reviews
The literature search was completed in June 2014. From and Meta-Analyses (PRISMA) guidelines [16]. Figure 1
aninitialpoolof10,106hits,7,720articleswereevaluated presents the process of the search and selection of rele-
after removing duplicates. In addition, a manual check of vantstudiesaccordingtothePRISMAguidelines.
reference lists of identified studies was conducted in
searchofpotentialunidentifiedstudies.Searcheswerealso Dataextractionandsynthesis
conductedinonlinedatabasesandwebsites.Weidentified The first author scrutinized and selected studies. Smith
4 new articles through this grey literature search. Thus, a et al.’s [17] Interpretative Phenomenological Analysis
Figure1Flowdiagramofsystematicliteraturesearch.
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(IPA) wasusedtoanalysethestudies becauseitfacilitates studies in the sensitivity analysis, our themes or results
in-depth exploration of the meanings of experiences [18]. did not change. Consequently, we retained them in the
Eachfull-textpaperwasregardedasatranscript.Thefirst final analysis. Similarly, the removal of the study charac-
author read through the full-text papers several times, teristics generated from the studies originating from the
gaining an overall sense of the themes in the studies United States did not affect the quality of our themes or
throughthisprocess.Thesethemeswerethenhighlighted. results. Thus, they were also retained in the final ana-
We developed a standardized data extraction form unto lysis. The sensitivity analysis therefore indicated a strong
whichthefirstauthorandanotherreviewerindependently synthesisofincludedstudies.
extractedthefollowingdatafromtheincludedstudies:au-
thor name and publication year, country, study type, type
Descriptionofstudies
of AAS users involved in the study, and recruitment site
A total of 44 studies were included in the metasynthesis.
or mode. These characteristics are presented in Table 1. Participants’ages ranged from 14 to63 years.The yearof
The first author independently coded the full-text papers publication of the studies ranged from 1980 [19] to 2014
according to the presence or absence of the following
[6-9,11]. Studies originated from 11 countries although
themes: (a) age(s) of first use, (b) history prior to use, (c) most originated from the United States (n =18), followed
source(s) of first AAS, and (d) motive(s)/drive(s) for initi- byEngland(n=8),Australia(n=4),Sweden(n=4),both
ating use. These characteristics are presented in Table 2. England and Wales (n =2), and Scotland (n =2). More-
Statistical inferences have little meaning in qualitative
over, one study each originated from Brazil, Bulgaria,
synthesis. However, the presence of a theme in multiple Canada, France, Great Britain, and Norway. Twenty-nine
studiesmaybeevidenceofthevalidityofthetheme[4].In
studies [6-8,12,19-21,25-27,30-36,38-47,49,51,52] used in-
this regard, we have presented all the studies that fall
terviews, six were case studies [14,22,28,29,45,53], one
undereachtheme. used interviews and focus groups [9], and eight [10,11,
13,23,24,37,48,50] used interviews supported by a ques-
Qualityofextraction,includedstudies,andsynthesis tionnaire. For the eight studies that used both interviews
To assess the quality of the extraction, we calculated and questionnaires, we relied on the qualitative results
inter-reviewer reliability for the two reviewers in SPSS generatedfromtheinterviews.
version 20 (IBM Corp.) [54]. Sensitivity analysis is con-
ducted in the synthesis of qualitative research to exam-
Narrativesynthesis
ine the effect of the exclusion of high or poor quality
Wefoundthatmajorityofstudieshadparticipantsinitiat-
studies on the overall findings. We assessed the rele-
ingusebeforetheywere30yearsold.Inaddition,histories
vance of the included papers according to the four
of negative body image, psychological disorders such as
themes: (a) age(s) of first use, (b) history prior to use, (c)
moodanddepressivedisorders,andparticipationinpower
source(s) of first AAS, and (d) motivation(s) for use (see
sports preceded initiation of AAS use for most persons.
Table 2). Each theme was scored ‘1’ thus yielding a pos-
We also found that sources of first AAS were mainly
sible total score of ‘4’. Subsequently, we excluded studies
users’ immediate social networks and the illicit market.
that scored ≤2 out of 4 on the themes and investigated
Furthermore, we found that motives for AAS use were
the effect of the exclusion on our synthesis and results.
mainly enhanced sports performance, appearance, and
Moreover, as most of the included studies were con-
muscleorstrength.
ducted in the United States, we excluded the United
States studies to investigate the effect of the exclusion
onthequality ofoursynthesisandresults. AgeofAASuseinitiation
Of the24 studies that presented the ages at which partici-
Results and discussion pants initiated AAS use, initiation ages ranged from 14 to
54 years.However, only 5 of the 24 studies presented par-
Strengthofextraction,includedstudies,andsynthesis
ticipantsthatinitiatedAASuseafterage30consistentwith
Theinter-reviewer reliability forthereviewers wasfound
to be Kappa =0.82 (p <0.001) indicating very good evidence that about 80% of AAS users initiate use before
age 30 [56]. It must be noted that some studies did not
agreement between the two reviewers [55]. Consensus
specify the ages at which someor all respondentsinitiated
was reached on discrepant extractions through further
AASuse(SeeTable3).
review and discussion.Thirty-eight (38) ofthe 44 studies
scored≥3out of4onthethemesandwerethusdeemed
to be of high relevance. Six studies [31,36,37,41,46,52] Pre-initiationhistory
scored ≤2 out of 4 on relevance and were therefore Prior to initiating AAS use, participants had diverse back-
excluded in the quality analysis. However, when we grounds including sports (particularly power sports)
removed the study characteristics generated from these participation, maladaptive relationships, psychopathology,
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Table1QualitativestudiespresentingdataonAASuseinitiation
Firstauthor,year, Country/countries Studytype AASuser(s) Recruitmentsite(s)/mode
reference
Annitto1980[19] USA Interview 17-year-oldmalebodybuilder Clinic
Bardick2006[20] Canada Interview 8maleweightliftersaged21to35years Gymnasium
Bilard2011[21] France Interview 203bodybuilders Voluntary
Boyadjiev2000[22] Bulgaria Casestudy 20-year-oldmalebodybuilder Clinic
Copeland2000[23]and Australia Interviewand 100persons(6female) Gymnasium,sportsshopsand
Peters1997[24] questionnaire† aged18to50years associations,syringeexchange
centre,radiointerviews,
advertisements
Cornford2014[9] England Interviewand 30malesaged20to40years Syringeexchangecentre
focusgroup
Fudala2003[25] USA Interview 7malesaged22to33years Gymnasiumandcommunity
Grogan2006[26] England Interview 11bodybuilders(6female) Gymnasium
aged20to39years
Gruber1999[27] USA Interview 5femalebodybuilders Gymnasium
Hegazy2013[28] USA Casestudy 28-year-oldmale Clinic
Joubert2014[7] England Interview 6malesaged26to42years Addictioncharity
Katz1990[29] USA Casestudy 23-year-oldmalebodybuilder Gymnasium
Khorrami2002[30] USA Interview 2maleweightliftersaged Voluntary
24and29years
Kimergård2014[6,8] EnglandandWales Interview 24malesaged21to61years; Gymnasium,prison,steroid
meanage34years clinicandcharity,syringe
exchangecentre
Klötz2010[31] Sweden Interview 33maleprisonersaged21to52years Prison
Korkia1993[12] England,Scotland, Interview 110persons(13female) Gymnasium,clinic,syringe
andWales aged16to63years exchangecentre
Korkia1996[13] England Interviewand 15females;meanage28years Notspecified
questionnaire†
Kusserow1990[32] USA Interview 72(6female)persons(mostlyadolescents); Notspecified
14to25years;meanage20years
Malone1995[33] USA Interview 77(6female)powerliftersand Gymnasium
bodybuilders
Maycock2005[34],2007 Australia Interview 42males Gymnasium,nightclub,
[35] community
McKillop1987[36] Scotland Interview 8malebodybuildersaged Gymnasium
17to32years
Midgley1999[37] England Interviewand 50malebodybuildersand Gymnasiumandsyringe
questionnaire† weighttrainersaged17to46years exchangecentre
Nøkleby2013[38] Norway Interview 9maledrugusersaged22to35years Clinic
O’Sullivan2000[39] Australia Interview 41malesaged16to36years Clinic
Olrich1999[40] USA Interview 10maleweightlifters;9aged Gymnasium
18to35years,1aged57years
Pappa2012[41] England Interview 9athletesaged19to26years Communityviasnowball
sampling
Petrocelli2008[42] USA Interview 37malegymusersaged19to43years Gymnasium
Pope1990[43] USA Interview 3malearrestedweightlifters Justicesystem
aged23,24,and32years
Pope1993[44] USA Interview 55bodybuilders;meanage28years;3 Gymnasium
bodybuilders;19years,26years,27years
Pope1996[45] USA Casestudy 16-year-oldmale Clinic
Pope1996[45] USA Interview 9maleprisoners Prison
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Table1QualitativestudiespresentingdataonAASuseinitiation(Continued)
Rashid2000[14] USA Casestudy 40-year-oldmale Clinic
Schwingel2012[46] Brazil Interview 147malepowersportspeople Exerciselaboratory
aged18to42years
Scull2013[47] USA Interview 7malestrippers Stripclub
Skårberg2007[48] Sweden Interviewand 18maledrugusers;meanage35years Clinic
questionnaire†
Skårberg2008[49] Sweden Interview 6drugusers(2female) Clinic
Skårberg2009[50]and Sweden Interviewand 32maledrugusers18maledrugusers;mean Clinic
2007[48] questionnaire† age35years
Tallon2007[11] Scotland Interviewand 30malesaged18to43years;meanage Gymnasium
questionnaire† 27years
Todd1987[51] USA Interview 2persons(27-year-oldfemaleweightlifter;1 Notspecified
formermaleNFLplayer)
Vassalo2010[52] USA Interview 39maleathletesaged18to35years Acquaintances
Walker2011[10] England Interviewand 41males;20to30years(majority) Syringeexchangecentre
questionnaire†
Wilson-Fearon1999[53] England Casestudy 29-year-oldbodybuilder Notspecified
†Wereliedonthequalitativeresultsgeneratedfromtheinterview.
negativeselfandbodyimage,deviantbehaviour,andabuse competitors contributed totheirdecision to
ofotherdrugs(SeeTable4). exploreuse(p.319).
The most prominent feature of AASusersprior toiniti-
ation of use was participation in power sports such as AAS users also showed psychological syndromes such
bodybuilding,powerlifting,and weightlifting. Thisemerged as mood and depressive disorders as well as troubled
in23studies[11-14,17,18,21,22,24-27,32,34-37,41,43,45,50, psychosocial histories including divorce, having suffered
52,55]. It emerged in Maycock and Howat’s study [34] rape, poor parental connectedness or involvement, and
thatusers: poorsocial support[14,25,27,28,44,45,48-50]priortothe
initiation of AAS use. In one study [27], five females
…had beenweighttraining forthree yearspriorto initiatedAASuseaftertheexperienceofrape:
initiatinganabolic steroid use. However,11ofthe
interviewed subjectsinitiatedusewithin oneyearof Noneusedsuch drugspreviously…Indeed,priorto
startingweight training(p.319). experiencing rape,thesefivewomen believedthat
takinganabolic substances wasaweakness…
Similarly, participation in other sports such as athletics, Subsequent totheirrape, theyjustifiedthedecision to
cycling, hockey, and football emerged as a prominent fea- startusinganabolicsubstancesasbeingnecessary to
ture of AAS users backgrounds prior to initiation of AAS gainmusclemassandstrength, because they thought
use [7,11,22,25,30,32,38,41,49,52]. This is exemplified by itwasimpossibletogrow bigorstrongenough
JoshinBardicketal.’sstudy[20].Joshwasahockeyplayer “naturally”(p.275).
who“neededtotakesteroidstobecomethebest”(p.138).
Similarly, Maycock and Howat [34] highlighted associ- AlsoevidentasafeatureofAASuserspriortoinitiation
ation with‘complacent’ trainers or coaches as a feature of ofAASusewaseatingdisorderssuchasanorexianervosa
AASuserspriortotheinitiationofAASuse(p.319). [25,44]. Pope et al. [44] present the cases of four persons
Also, Gruberand Pope [27] recount the story of Ms. A. who initiated AAS use due to anorexia nervosa and
who“tookallofthesupplementsandergogenicdrugsthat reverse anorexia nervosa. Negative body image as well as
her trainer recommended, including large doses of ana- low self-esteem and low self-efficacy also emerged as
bolicsteroids”.InMaycockandHowat’sstudy[34]: features of AAS users prior to the initiation of AAS use
[7,10,25,30,32,34,35,42,44]. Cases 01 and 02 of Fudala
Fouroftheinterviewed sampleindicatedthat etal.’sstudy[25]recountthestoriesofamalewho“stated
complacency bytrainersandcoaches contributed thathewasusingAASsbecausehelackedself-esteemand
totheirdecision toconsideruse.Thefailure of was not good-looking.” and another who initiated AAS
coachesandofficialstoinvestigate largeincreases use because he “felt small and [needed to] become more
inbody massandstrength achievedbyother musculartoaccomplish[his]goals”(p.123).
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Table2CharacteristicsofqualitativestudiespresentingdataonAASuseinitiation
Firstauthor,year, Initiationage(s) Historypriortouse Source(s) Motive(s)/drive(s)foruse
reference
Annitto1980[19] 16years Weightlifting Illicitmarket Appearance
Bardick2006[20] Notspecified Weighttraining Notspecified Appearance,confidence,media,
personalsecurity,psychological
well-being,sports
Bilard2011[21] Notspecified Bodybuilding Friends,dealers,others, Appearance,muscle,physiological
relatives,teammates recovery,psychological,sports,
sportsnorm,other
Boyadjiev2000[22] 19years Bodybuilding,cycling Notspecified Sports
Copeland2000[23] 14to46years; Notspecified Coaches/trainers,dealers, Appearance,muscle,other,
andPeters1997[24] mean25years doctors,friends,gym physiologicalrecovery/injury
employees,other, prevention,sports
pharmacists,mailorder
relatives,veterinarians
Cornford2014[9] ≤30years(n=14) Notspecified Notspecified Muscle,personalsecurity,
physiologicalrecovery,sports
Fudala2003[25] ≤26years Negativebodyimage, Notspecified Appearance,psychological
poorself-esteem,psy-
chologicaldisorders,
troubledbackground
Fudala2003[25] ≤31years Negativebodyimage, Notspecified Appearance,muscle
lowself-efficacy,trou-
bledbackground
Fudala2003[25] 17years Football Relative Appearance,muscle,sports
Fudala2003[25] 26years Troubledbackground Notspecified Appearance,muscle
Fudala2003[25] 21years Bingeeating, Notspecified Notspecified
psychological
disorders,troubled
background
Fudala2003[25] 27years Troubledbackground, Friend Sports
weightlifting
Fudala2003[25] 24years Bodybuilding Notspecified Sports
Grogan2006[26] 15years,16years, Bodybuilding Notspecified Appearance,media,occupational,
18years,19years, sports,sport/socialnorm
20years,21years,
23years,29years
Gruber1999[27] Notspecified Polydruguse, Trainer Appearance,muscle,personalsecurity
psychological
disorders,troubled
background
Hegazy2013[28] 22years Polydruguse, Friends Appearance,muscle,recovery
psychological
disorders,troubled
background
Joubert2014[7] 16to24years Lowself-esteem, Notspecified Appearance,confidence,familyinfluence,
negativebodyimage, muscle,peerinfluence,personalsecurity,
troubledbackground psychologicalwell-being,self-esteem,
socialpressure
Katz1990[29] 21years Bodybuilding Notspecified Sports
Khorrami2002[30] Notspecified Football,negative Gymemployee Appearance,familyinfluence,muscle,sports
bodyimage,
weightlifting
Kimergård2014[6,8] 16years;mean Notspecified Notspecified Appearance,muscle,occupational,sports
age25years
Klötz2010[31] Notspecified Notspecified Notspecified Aggression,appearance,muscle,other,
psychological,sports,sport/socialnorm
Korkia1993[12] Weighttraining Muscle,physiologicalrecovery,sports
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Table2CharacteristicsofqualitativestudiespresentingdataonAASuseinitiation(Continued)
16years,18years, Coach,dealers,doctors,
32years,54years friends/teammates,gym
owner/employee
Korkia1996[13] 19years,23years Notspecified Friends,gymowners/ Muscle,sports
employees,husbands/
boyfriends
Kusserow1990[32] 14years,15years, Football, Coach/teamdoctor,dealers, Aggression,sportsscholarship,appearance,
17years,18years, bodybuilding, doctors,friends/teammates, coaches’approval,famousathletes,media
≤25years† negativebodyimage, gymemployees,pharmacists, influence,parentalapproval,peerinfluence,
polydruguse veterinarians sexualattraction,sports
Malone1995[33] 24years Weightlifting Notspecified Appearance,muscle,injuryprevention/recovery,
sports,sportnorm
Maycock2005[34] 24years,25years Complacenttrainers, Dealers Appearance,aggression,coaches’approval,
and2007[35] negativebodyimage, peerinfluence,sexualattraction,sports
weighttraining
McKillop1987[36] Notspecified Notspecified Notspecified Aggression,injuryprevention/recovery,muscle,
sports
Midgley1999[37] Notspecified Notspecified Notspecified Appearance,injuryprevention/recovery,
psychologicalwell-being,muscle,peer
influence,sports,sexualattraction
Nøkleby2013[38] Notspecified Otherdruguse, Friend Appearance,muscle,psychologicalwell-being,
sports/exercise sports
O’Sullivan2000[39] Notspecified Notspecified Friends,gymdealers, Appearance,muscle
medicalpractitioners
Olrich1999[40] 23years Bodybuilding Notspecified Appearance,curiosity,occupational,peerinfluence,
psychologicalwell-being,social/sexualattraction,
sports,sport/socialnorm
Pappa2012[41] Notspecified Athletics Notspecified Appearance,concentration,curiosity,muscle,
socialinfluence,sports,sportnorm
Petrocelli2008[42] Notspecified Long-termexposure Dealer,friend,external appearance,confidence,muscle,
tomusclemagazines, internet,gymdealer psychologicalwell-being,sexualattraction
negativebodyimage,
weighttraining
Pope1990[43] 30years Weightlifting Notspecified Notspecified
Pope1990[43] 21years Weightlifting Notspecified Sports
Pope1990[43] 20years Weightlifting Notspecified Sports
Pope1993[44] 19years Anorexianervosa, Notspecified Appearance
negativebodyimage,
psychological
disorders,weightlifting
Pope1993[44] 18years Anorexianervosa, Notspecified Appearance
negativebodyimage,
weightlifting
Pope1993[44] 24years Anorexianervosa, Notspecified Appearance
negativebodyimage,
weightlifting
Pope1996[45] 14years Psychological Notspecified Appearance,confidence,muscle,psychological
disorders,weightlifting
Rashid2000[14] 38years Psychological Notspecified Appearance,confidence,muscle,psychological
disorders,otherdrug
use,troubled
background
Schwingel2012[46] Notspecified Notspecified Friends,illicitmarket Appearance,muscle,occupational,sport
Scull2013[47] 18years Malestripping Notspecified Appearance,muscle,occupational
Skårberg2008[49] 20years Troubledbackground, Friend Appearance,muscle
weighttraining
Skårberg2008[49] 21years Friend Muscle
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Table2CharacteristicsofqualitativestudiespresentingdataonAASuseinitiation(Continued)
Troubledbackground,
weighttraining
Skårberg2008[49] 16years Irritability,troubled Notspecified Curiosity,muscle
background,weight
training
Skårberg2008[49] 20years Bodybuilding,other Notspecified Appearance,sports,sportnorm
sports
Skårberg2008[49] 20years Bodybuilding, Notspecified Sports,sportnorm
troubledbackground,
Skårberg2008[49] 21years Othersports,troubled Intimatepartner Appearance,muscle
background,weight
training
Skårberg2009[50] 15to28years Troubledbackground Notspecified Appearance,muscle,sports
and2007[48]
Tallon2007[11] 18to43years Weighttraining,other Friends/trainingpartners Appearance,confidence,injury/illness
sports prevention,muscle,psychological,
sexualattraction
Todd1987[51] Notspecified Powerlifting Dealer Sports,sportnorm
Vassalo2010[52] Notspecified Football Notspecified Sportsscholarship
Walker2011[10] 20to30years† Notspecified Gymdealer Appearance,muscle
Wilson-Fearon Notspecified Bodybuilding Notspecified Sports
1999[53]
†Majority.
Use of other drugs also emerged as a feature of AAS or trainers, clinicians or health workers (doctors, phar-
users prior to the initiation of AAS use [7,14,27,28,32,38]. macists, and veterinarians), friends or teammates, gym
Nøkleby and Skårderud [38] highlighted drug use net- employees,intimatepartners,andrelatives(SeeTable5).
works as well as addiction clinics as major gateways for The illicit market emerged as a major source of AAS
theinitiationofuse.Intheirstudy,Kristiancommented: during the initiation of AAS use [8,10,12,19,21,23,24,32,
34,35,39,42,46,51]. The immediate social networks of re-
Ihavealwaysbeenofferedsteroidsat otherplaces spondents such as intimate partners, relatives, as well as
aswell, butitnevercame toanything. Butwhen friends or teammates also emerged as important sources
Igothere [addiction clinic]it(steroids) fellright of AAS [6,11,21,23-25,28,32,38,39,42,46,49] during the
inmylap.Anditwasthesame thelastplace I initiationofAASuse.
wasintreatment. It(steroids)fellright inmylap, In addition, training associates such as coaches or
andthatmade iteasy toaccept (p.495). trainersandgym employees emergedasa source ofAAS
during the initiation of AAS use [15,16,19,22,24,49,55,56].
It also emerged that many AAS users understood the Cliniciansorhealthworkerssuchasdoctors,pharmacists,
debilitating consequences of AAS but nevertheless went and veterinarians also came up as sources of AAS during
ahead to initiate use [10,32,34,40]. In Maycock and theinitiationofAASuse[23,24,32,39].
Howat’sstudy [34]: In a 1990 study of 72 current and former users [32],
the sources of AAS were: friends/teammates (n =41),
Prior toinitiating[AAS]useallofthemen pharmacists (n =22), dealers (n =17), veterinarians (n =
interviewed undertook information searches. 10), gym employees (n =8), doctors (n =3), and coach/
Theseincluded talking tofriends,gym trainers team doctor (n =1). Moreover, in a 1997 study [24], the
andinstructors,anabolic steroid users anddealers, sources of AAS were: friends (n =64), doctors (n =42),
readingmagazines,undergroundanabolic steroid dealers (n =41), pharmacists (n =18), gym employees
manualsandmedical journals andoccasionally (n =14), coaches/trainers (n =14), veterinarians (n =11),
talkingtomedicalpractitioners(p.320). relatives (n =6), mail order (n =4), and other (n =4). It
is however worthy of note that in the most recent quali-
SourcesoffirstAAS tative studies presenting sources of AAS [6,10,21,38,46],
Studies specified several sources of users’ first AAS: the the onlysourcesofAASwere theillicitmarket, relatives,
illicit market (dealers, mail order, internet etc.), coaches andfriends.
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Motives/drivesforinitiatingAASuse increasedandenhanced [users’]confidence andlove
Motives for initiating AAS use were for: aggression, life,astheyclaimedhavingadefined, muscular
enhanced appearance, securing sports scholarships, en- physique allowed themtomeetandhavesexual
hanced muscle or strength, occupational (non-sporting) relationswithmorepartners(p.1194).
activities, personal security, psychological well-being or
satisfaction, physiological recovery or injury prevention, Social pressure in the form of media influence, peer in-
sexual attraction, and for sporting or competitive activ- fluence,andsportorsocialnormsalsoemergedasanim-
ities.Otherdrivesweretrainers’approval,curiosity,family portantdrivefortheinitiationofAASuse.Relatedtothis,
influence, use by famous athletes portrayed in the media, Petrocelli et al. [42] found long-term exposure to muscle
peer influence, and use of AAS as a sport or social norm magazines as a feature of AAS users prior to initiation of
(SeeTable6). AAS use. Inaddition,Joea 29-year-old male commented:
Of the above motives and drives, initiation of AAS use “I came from a solid family that stressed competition and
for enhanced appearance or body image, muscle or givingit110%.SowhenIdidn’tseetheresultsinthegym,
strength, and sports or athletic performance were most Iwenttosteroids”[22,p.10].InGroganetal.’sstudy[26],
prominent in the literature. Indeed, in a study of Austra- John,a25-year-oldindicated:
lian AAS users [24], the most paramount motives for the
initiation of AAS use were improved appearance (46%), ThemoreItrained,themoremagazinesIlookedat,
increase in size (33%), increase in strength (7%), and im- thebiggerIwantedtobe.…andtherewasanITV
proved sporting performance (6%). Case 04 of Fudala programme[aboutbodybuilders]andwhenIwatched
et al.’s study [25] also tells the storyofa 22-year-old male thesepeopleitmademefeelreallydepressed.Ididn’t
who initiated AAS use at the age of 17 “in order to lookasgoodasthem.Andithadamassiveeffecton
increasehissizeandpowerforfootball”andconsecutively mydecisiontotakesteroids.Infactitwasprobablyone
increased his AAS consumption “in order to compete in ofthebiggestreasonswhyIdidtakethemseeingother
bodybuilding events”. Paula, a 39-year-old affirms the rela- peoplebiggerthanme(p.853).
tionship between her AAS use and sports participation in
Grogan et al.’s study [26] with the confession “I will stop There is however contrary evidence of the influence of
[usingsteroids]whenIstopcompetingyeah”(p.853).Simi- media on AAS use. In Walker and Joubert’s study [10],
larly,othersinitiatedAASuseforphysiologicalrecoveryor 66% of respondents stated that the media had no influ-
injuryprevention[9,11,12,20,21,23,24,28,32,33,36,37]. ence on their desire to use AAS although these respon-
Related to enhanced sports performance, enhanced dents believed that most muscular men portrayed in the
occupational functioning also emerged as motive for the mediauseAAS.
initiation of AAS use [6,26,34,35,40,46,47]. In support of Moreover, psychological well-being emerged as an
this motive, Matt, a 33-year-old male stripper commen- important motive for the initiation of AAS use [7,10,11,
ted in Scull’s study [47]: “All the guys [male strippers] 14,20,21,25,31,37,38,40,42,45]. Specific psychological mo-
takesteroids,youknow?…See,youwon’tlastlonginthis tives for initiating use included boosting self-esteem,
industry if you don’t use steroids. They all do steroids” confidence, concentration, and overcoming psychological
(p. 567). Improved occupational functioning was again disorderssuchasdepression.
highlightedinMaycockandHowat’sstudy [35]: It is important to note however that motives for AAS
use maychange with time. For instance,inan Australian
For thedoormen andsecurityworkers,itwasabout study [24], 46% of users indicated that they initiated use
projectingphysicalcompetence; forthe power in order to improve their appearance. However, only
lifters,itwasabout projectingtheimageof brute 35% of these respondents mentioned improved appear-
strength; forthesexworkersorgaymenusing for ance as motive for their most recent use indicating
bodyimage reasons,itwasaboutthepresentation motive change in some users after initiation. Disparities
ofanaturalhealthy look. Forbodybuilders,itwas werealsodiscoveredforothermotives(p.37).Asecurity
about projectingtheirmuscles,sizeandshape worker also elucidated motive change in a recent study
(p.861). byKimergård [6]:
Sexualattractionorattractivenessalsoemergedasanim- At thismomentintime,I’mnot lookingtoget any
portant motive for the initiation of AAS use [11,32,40,42]. biggerasabodybuilder forexample.Ilike toincrease
This is highlighted by Kusserow’s [32] finding that 18% of mystrength,andnow it’smore forconditioning…
AAS users initiated use in order to “be more successful Mynextcycle, I’llbedoinga‘cutting’cycle, I’llbe
with the opposite sex” (p. 7). In addition, Petrocelli et al. dietingandgettingdowntoareasonable healthy
[42]indicatedthatAASuse: weight(p.3).
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Table3Qualitativestudiespresentingage(s)ofAASuseinitiation
Age(s)ofinitiation Studies(firstauthor,reference)
14years Copeland[23]andPeters[24];Kusserow[32];Pope[45];Tallon[11]
15years Copeland[23]andPeters[24];Grogan[26];Kusserow[32];Skårberg[48,50];Tallon[11]
16years Annitto[19];Copeland[23]andPeters[24];Grogan[26];Korkia[12];Skårberg[49];
Kimergård[8];Joubert[7];Tallon[11]
17years Copeland[23]andPeters[24];Fudala[25];Kusserow[32];Tallon[11]
18years Copeland[23]andPeters[24];Grogan[26];Korkia[12];Kusserow[32];Pope[44];Scull[47];Joubert[7];Tallon[11]
19years Boyadjiev[22];Copeland[23]andPeters[24];Grogan[26];Korkia[13];Pope[44];Joubert[7];Tallon[11]
20years Copeland[23]andPeters[24];Cornford[9];Grogan[26];Pope[43];Skårberg[49];Tallon[11]
21years Copeland[23]andPeters[24];Cornford[9];Fudala[25];Grogan[26];Katz[29];
Pope[43];Skårberg[49];Tallon[11]
22years Copeland[23]andPeters[24];Cornford[9];Hegazy[28]
23years Copeland[23]andPeters[24];Cornford[9];Grogan[26];Korkia[13];Olrich[40];Tallon[11]
24years Copeland[23]andPeters[24];Cornford[9];Fudala[25];Malone[33];Maycock[34,35];
Pope[44];Joubert[7];Tallon[11]
25years Copeland[23]andPeters[24];Cornford[9];Maycock[34,35];Tallon[11]
26years Copeland[23]andPeters[24];Cornford[9];Fudala[25];Tallon[11]
27years Copeland[23]andPeters[24];Cornford[9];Fudala[25];Tallon[11]
28years Copeland[23]andPeters[24];Cornford[9];Skårberg[48,50];Tallon[11]
29years Copeland[23]andPeters[24];Cornford[9];Grogan[26];Tallon[11]
30years Copeland[23]andPeters[24];Cornford[9];Pope[43];Tallon[11]
31to54years Copeland[23]andPeters[24];Cornford[9];Korkia[12];Rashid[14];Tallon[11]
Notspecified Bardick[20];Bilard[21];Fudala[25];Gruber[27];Joubert[7];Katz[29];Khorrami[30];Kimergård[6,8];
Klötz[31];Korkia[12,13];Kusserow[32];Maycock[34,35];McKillop[36];Midgley[37];Nøkleby[38];
O’Sullivan[39];Olrich[40];Petrocelli[42];Schwingel[46];Scull[47];Skårberg[48,50];Tallon[11];
Todd[51];Vassalo[52];Walker[10];Wilson-Fearon[53]
Notspecified:Authorsdidnotpresentage(s)ofinitiationforsomeorallparticipants.
Table4QualitativestudiespresentingAASusers’historypriortouse
History Studies(firstauthor,reference)
Anorexiaandreverseanorexia Fudala[25];Pope[44]
Complacenttrainer(s) Maycock[34,35]
Long-termexposuretomuscle Petrocelli[42]
magazines
Lowself-efficacy Fudala[25];Joubert[7]
Malesexwork Scull[47]
Negativebodyimage Fudala[25];Khorrami[30];Kusserow[32];Maycock[34,35];Petrocelli[42];Pope[44];Walker[10];Joubert[7]
Otherdrug(s)use Gruber[27];Hegazy[28];Joubert[7];Kusserow[32];Nøkleby[38];Rashid[14]
Othersports(athletics,cycling,hockey, Bardick[20];Boyadjiev[22];Fudala[25];Joubert[7];Khorrami[30];Kusserow[32];Nøkleby[38];Pappa[41];
footballetc.) Skårberg[49];Tallon[11];Vassalo[52]
Poorself-esteem Fudala[25];Walker[10];Joubert[7]
Powersports(bodybuilding, Annitto[19];Bardick[20];Bilard[21];Boyadjiev[22];Fudala[25];Grogan[26];Joubert[7];Katz[29];
powerlifting,weightlifting) Khorrami[30];Kimergård[8];Korkia[12];Kusserow[32];Malone[33];Maycock[34,35];Olrich[40];
Petrocelli[42];Pope[43];Pope[44,45];Skårberg[49];Tallon[11];Todd[51];Wilson-Fearon[53]
Psychologicaldisorder Fudala[25];Gruber[27];Hegazy[28];Pope[44,45];Rashid[14]
Troubledbackground(bullying, Fudala[25];Gruber[27];Hegazy[28];Rashid[14];Skårberg[48-50];Joubert[7]
divorce,rapeetc.)