Strong, silent and stigmatized

Iff Samuel¹, Claussen Malte Christian^2,3,4
1 Bern, Switzerland
² Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Zurich, Switzerland
³ Private Clinic Wyss AG, Münchenbuchsee, Switzerland
⁴ Psychiatric Services Grisons, Chur, Switzerland

The global lifetime prevalence rate of all image and performance enhancing drugs (IPED) is unknown, however it is 6.4% in men an 1.6% in women for anabolic androgenic steroids [1]. IPED are widely used in the bodybuilding scene and have found a bigger audience through social media platforms. Risk groups for IPED use are young men, leisure athletes, general gym goers, elite athletes and bodybuilders. The main drivers for IPED use are increased muscularity and performance. Abuse of performance enhancing drugs in elite sports (doping) is well recognized, however IPED abuse is a public health problem that is often overlooked and should be addressed by the medical community.
The long-term use of IPED can have significant, long-lasting negative effects on health that can only be successfully managed by professionals addressing both the physical and psychological aspects. Besides the desired enhanced musculature, IPED affect negatively almost every other system of the body, with the most profound side effects on the cardiovascular system, the endocrine system and the psyche. The early side effects may include high blood pressure, dyslipidaemias, sleep apnoea, erythrocytosis, hepatitis, reduced kidney function, suppression of own sexual hormone production, acne, gynecomastia, alopecia androgenica, mood swings, and aggression. The long-term side effects may include remodelling of the heart, arrythmias, arteriosclerosis, hepatic tumours, CKD, tendon injury, infertility, prostate tumour and depression [2]. Primary care physicians are most likely to encounter patients using IPED, but it is also likely that every specialist will at some time or another be managing problems directly related to IPED use. Treating physicians should not only have the appropriate knowledge concerning the effects of IPED in order to give appropriate advice and inform their patients about the potential health consequences, but also have an insight into the psychology of IPED use. Kanayama et al. have described the effects that can lead to addiction to IPED causing a dependence syndrome [3]. Anabolic, androgenic and hedonistic effects together make it very hard for individuals to stop IPED use. Furthermore, those using IPEDs may not see themselves as addicted and justify their use as a component of their perceived healthy lifestyle. According to a review by Harvey et al, IPED users may not seek medical services because of fear of stigma or embarrassment. Some don’t trust the knowledge from professionals, have a fear of judgemental reactions, or did not get prescription medicine they needed. None the less, IPED users seek information on health harms and symptoms, on harm minimisation, and help for health issues [4]. However IPED users scored the knowledge of physicians as no more reliable than their friends, specific internet sites, or steroid dealers furthermore studies also have shown that physicians have limited knowledge in this area (5). In some European countries, legal frame works concerning anti-doping (applying to all individuals, not just professional athletes) can further inhibit access to medical services from both a physician and patient perspective.
The issues around IPED use are complex, from the psychological drivers to the negative effects on both physical and mental health. Physicians, especially those working in primary care and where applicable those working with athletes specifically, need to appreciate the wide spread use of IPEDs within their patient cohorts. They need to identify individuals using or at risk or using IPEDs and provide appropriate information in a non-judgemental manner and refer to specialist medical and psychiatric services when required.

Corresponding author

Dr. med. Samuel Iff
Bern, Switzerland
samuel.iff@gmail.com

References

1. Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol. Mai 2014;24(5):383-398.
2. Kanayama G, Hudson JI, Pope HG. Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: a looming public health concern? Drug Alcohol Depend. November 2008;98(1-2):1-12.
3. Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG. Treatment of anabolicandrogenic steroid dependence: Emerging evidence and its implications. Drug Alcohol Depend. Juni 2010;109(1-3):6-13.
4. Harvey O, Keen S, Parrish M, van Teijlingen E. Support for people who use Anabolic Androgenic Steroids: A Systematic Scoping Review into what they want and what they access. BMC Public Health. 31. Juli 2019;19(1):1024.
5. Laure P, Binsinger C, Lecerf T. General practitioners and doping in sport: attitudes and experience. Br J Sports Med. August 2003;37(4): 335-8-discussion 338.