Background
Anabolic androgenic steroids (AAS) are synthetic derivatives of the male endogenous sex hormone testosterone, which exhibits both anabolic (protein-synthesizing) and androgenic (masculinizing) effects. These drugs were originally used only in the context of elite sports [
1]. Today, however, AAS are used by a far wider range of groups outside of sports and athletics [
2,
3]. The use of AAS has therefore become a subject of considerable scientific interest in addiction and psychiatric research.
Epidemiological studies on this topic are notoriously difficult to conduct in a reliable manner since AAS usage is largely clandestine, partly because the drugs are illegal and partly because usage tends to take place in closed sub-cultural settings. Despite these problems, we know that the current use of AAS is relatively widespread in many countries, including Sweden, which is the site of the current study. AAS are found in both cities and smaller communities [
3]. The majority of users are male [
4,
5] and most of the users begin using the drugs in their teens or early twenties [
6].
It has been noted that AAS are often combined with alcohol [
7] and other drugs of abuse [
8] as well as with testosterone releasers, anti-estrogens [
2,
9] and other medications [
10,
11]. The reasons usually given for this are that the combination both increases the effects of AAS and decreases various physical and psychological side effects. Side effects from AAS use reported in men include impotence and infertility due to inhibited endogenous testosterone production. In women, increased virility, including deepening of the voice, changes in libido and clitoral enlargement, occurs as a consequence of AAS use [
12]. Other known side effects include atherosclerosis, hypertension, dilated cardiomyopathy and sudden death. Psychiatric side effects include irritability, aggressiveness, mood swings, decreased impulse control and suicidal or homicidal behaviour [
12].
AAS continue to be used, despite knowledge of these potentially serious side effects. The most commonly reported motives for using AAS are enhanced performance in sports, improved physical appearance, increased body size and aggressiveness, strengthened libido and an enhanced sense of well-being [
3,
13‐
15]. Other justifications for continuing with AAS include self-fulfilment accounts, condemnation of condemners (a way of shifting focus from the user's own deviant acts) and denial of injury [
16].
Most studies regarding motives for using AAS and combinations of drugs are based on athletes. To the best of our knowledge, there are no studies exploring why and how non-athletic users have started to use a combination of drugs. It can therefore be said that the pathways for the development of mixed abuse are inadequately described. It has been proposed that AAS abuse can be a gateway to the use of other drugs of abuse [
17‐
19] and alcohol abuse [
20] but the empirical grounds for these conclusions are fairly weak.
Although AAS have been studied extensively in recent years, the perspectives of the users themselves are only sparsely described, despite in-depth knowledge among users about the drugs, their effects, their possible side effects and how they can be combined [
6,
8,
21]. It has also been reported that AAS users find it problematic that doctors and other healthcare staff have a limited understanding of the issue [
15,
22‐
24]. There are thus many reasons to pay greater attention to the users' own stories about the development of their abuse patterns and how their use of different combinations of drugs has developed.
There are a few articles in the scientific literature based on case reports [
16,
25‐
27] describing the development of AAS use from the user's perspective. Todd [
25] performed in-depth interviews with American weight-lifters concerning AAS use from the athletes' perspective. His conclusion was that the largest group of AAS users seems to be "average guys who just want to get bigger and stronger as fast as they can". Monaghan [
16] interviewed 67 bodybuilders and weight-lifters concerning their motivation for use of AAS. One important finding was that most AAS users generally expressed a positive view about the effects of AAS. Olrich & Ewing [
27] interviewed ten men about their experiences with these drugs. Nearly all of them described predominantly positive experiences. Their feelings of affirmation extended well beyond the walls of the gym and their narratives suggested feelings of elevated status in most social environments. The authors suggest that the users enjoyed benefits linked with the "embodiment of masculinity" in our culture. The authors therefore stress that all measures to address AAS abuse, both prevention and treatment, must be designed on the basis of these results, since the decision to stop using AAS means foregoing experiences of powerfully enhanced masculinity.
Grogan et al. [
26] interviewed five women and six men using snowball sampling. Again, a major finding was that most of the users in this study reported largely positive experiences of AAS. The majority felt that moderate use of AAS was nonproblematic and that the risk of serious side effects was not a sufficient deterrent to put them off using the drugs. Information from the healthcare sector regarding AAS was generally disbelieved, particularly since it differed from their personal experience. The importance of noting users' largely positive experiences is stressed, and cooperation with the body building community was reported as being decisive for the outcome of any programme.
In earlier studies, we have described a group of AAS users from an addiction clinic in terms of their social backgrounds, current social situation [
28] and total drug use pattern [
29]. These studies revealed that AAS abusers often come from problematic family backgrounds, have a history of major problems in school, have considerable social problems in daily life and have common histories of polysubstance drug use. In the present study, we aim to complement these data by using in-depth interviews to focus on the users' own perspectives of their experiences with AAS.
The aim of the study was thus to let AAS users' own stories serve as a point of departure for examining the various consequences of development of drug usage among a group of people seeking help at an addiction clinic. The participants were selected to capture as wide a variation as possible in experiences.
Discussion
As far as we are aware, this study is the first in which patients from an addiction clinic describe the development of their multiple drug use including doping agents (hormone preparations sometimes in combination with other drugs) from a subjective perspective. A primary finding from the patients' narratives is that the use of AAS can develop under widely varying conditions in terms of social background, timing of initiation, development of multiple drug use, and the associated physical and psychological problems. Despite these significant variations, certain common features in the patients' stories are discernible.
Most of the patients in this study describe childhoods with many problems, including physical or psychological abuse. Their problems extended into their time at school and affected both their social and academic achievements. In an earlier study [
28], we found social problems to be highly overrepresented among AAS users compared with gym users who were not taking drugs. Negative experiences of school-mates have also been revealed in other studies [
34]. It is important to remember, however, that some AAS users describe positive childhoods, which means that there is no straightforward relationship between upbringing and abuse of AAS [
28].
All of the patients in this study began using AAS in association with gym training. Most of them were in their late teens, which tallies with earlier reports [
6]. The use of AAS continued for between nine months and 16 years. This variation in the duration of AAS use reflects the variations found in clinical addiction treatment practice. For four of these patients, AAS was the first drug they had ever used, while one of them had used alcohol as a first drug and another had used other drugs of abuse (predominantly amphetamines). The only gender-related differences we noticed were that the women used fewer AAS drugs than the men.
In this study, we found that the participants started gym training with the addition of dietary supplements and were later advised to add AAS and other hormones to enhance the effects of training. To prevent AAS-related problems and to enhance the AAS effects, they added various pharmaceuticals, such as ephedrine, testosterone releasers and anti-estrogens, and also alcohol. Some of them also later added other drugs of abuse, such as amphetamine, to further enhance the effects on their training.
A common reason for taking AAS seems to be the experience of reaching a plateau in training effects, leading them to seek possibilities for enhancement. As noted in an earlier study [
35], others started AAS to increase body size and muscle strength. Two patients in our study who began using AAS because they wished to compete in bodybuilding believed that AAS use was essential for success in this field. It is of interest that neither of these two patients mixed the hormones with other drugs of abuse.
For two other informants, use of AAS was soon associated with use of other hormone preparations, different drugs of abuse, medications, alcohol, and dietary supplements. This was, however, not the case for the two who wished to compete. The reasons given for the increasing numbers of preparations were to increase the effects of training and the effects of the AAS or to reduce what were believed to be side effects of AAS. In a case description by Wilson-Fearon and Parrot, a male bodybuilder described how he used a cocktail of drugs before competing [
36] and Pope and Kanayama [
24] describe a case of an AAS user starting to use opioids after getting "pain in his 'delts' from military presses".
Several of the patients spoke of a great interest in learning more about AAS and other hormone preparations. They readily talked about the underground literature (books, magazines) and web sites where detailed descriptions could be found of which preparations and drugs can and, according to some authors, should be taken with AAS. The fact that information is sought through these media has also been noted in a previous study [
37].
The knowledge held by many patients about combining various preparations has clearly become extensive after taking the drugs for some time. This indicates that they felt that their careers were dependent on their considerable knowledge about which drugs can be taken in combination with AAS. In a study by Grogan et al., this was reflected in the comment "I know more than my doctor", particularly when it came to knowledge of the positive and negative effects of AAS [
26].
The subjective experience of AAS varied in type and severity but was pronounced and associated with considerable medical and/or psychological problems in all patients. The most commonly reported physical problems were changes in sexual potency (increased and/or decreased libido), skin lesions, testicular atrophy, acne and gynecomastia. Among the commonly reported psychological side effects were mood swings, aggressiveness, depression, jealousy and increased fixation with body image. These problems are commonly reported by AAS users, for example on the Swedish anti-doping hot-line [
7].
Aggressiveness affected four of the patients (two men and two women) and prompted three of them to actively seek out fights. The fourth patient, who already had problems with aggressiveness before using AAS, was the only one who reported aggressive breakthroughs as "roid rage". In a study by Wilson-Fearon, a competitive body builder described how he had to quit work as a security guard several weeks before competing because of problems in controlling his aggressiveness [
36].
Pathologically extreme jealousy was a major problem for four of the patients, causing severe disruptions in their relationships. Some of the other problems the patients reported included pain, hair loss or hair growth, clitoris enlargement, unfaithfulness, suicide attempts or suicidal thoughts, and emotional numbness. This emotional numbness was, however, seen as desirable by some informants since it facilitated fighting.
An important finding in this study is that most of the patients describe their early experiences of AAS as definitely positive, perhaps even as the best time of their lives. Olrich and Ewing showed that three common positive effects from AAS use were improvement of one's social status, positive peer recognition and improved vocational performance (increases in work effectiveness, alertness at work and confidence at work) [
27]. The most common positive effects described by the patients in this study were increases in strength, body bulk and self-confidence. However, the patients also said that, as their AAS use continued, the negative experiences began to outweigh the positive experiences and that this development was a necessary prerequisite for seeking treatment.
The results of this study should be viewed in light of the fact that the sample is small and specifically selected to represent the wide variations in the development of AAS abuse that we have noted in our clinical work. It should be noted that, consequently, quantitative conclusions couldn't be drawn from this study. In an earlier study [
28] we noted, however, that most AAS users at an addiction clinic had social problems from their childhoods with respect to both family and schooling. In another study [
29], we also showed that AAS use is often associated with use of other drugs of abuse, pharmaceuticals and alcohol.
Conclusion
This study shows the wide variation in patterns of development of multiple drug abuse in users of AAS. Earlier studies have demonstrated that multiple drug use is common. This study adds information on how this development can occur along different paths and for different reasons, and indicates that AAS can be a gateway to the use of other drugs of abuse. The stories told by the users provide information about AAS use from a subjective perspective, which can be important when designing treatment programmes that are adapted to this special group of patients. By listening to the patients, we can learn about what can trigger an interest in AAS, how multiple drugs can be added and what positive and negative effects can be experienced. This knowledge could help counteract the low levels of trust that AAS users often show towards health care providers.
Our objective was not to make broad generalizations but rather to show the wide variation in the patterns of development of preparation use and effects on users of AAS. We contend that care providers should see their task as two-fold. Firstly, it is important as a care provider to possess a high level of general knowledge about AAS use and the possibility of concomitant drug use in order to instill confidence in the patient at the outset of treatment. Secondly, it is important that the care provider avoids stereotypical notions of how abuse usually develops since it can take a variety of forms and have a variety of outcomes. Good general knowledge and an interest in the individual patient's particular life experience are two equally important factors in working with AAS users.
The information from this study may also be useful for policy planning. It is important that the designers of abuse prevention programmes understand the reasons for starting using AAS in order to develop a fact-based message for target groups. This information may also be important in the development of policies concerning detection of abuse and the development of assistance programmes, since AAS users often experience a range of highly desirable effects from the drugs and only seek treatment as an alternative when the negative effects outweigh the positive effects.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
KS conceived the idea for the study, participated in its design, carried out all interviews, took part in the analysis of results and drafted the manuscript. FN was active in the analysis of results and helped to draft the manuscript. IE was responsible for the design of the study and helped to draft the manuscript. All three authors have read and approved the final manuscript.