A qualitative exploration of the motivations underlying anabolic-androgenic steroid use from adolescence into adulthood

Abstract

Anabolic androgenic steroid (AAS) use is rapidly becoming a contemporary public health problem for many western countries. The British Medical Association Board of Science and Education (2002) revealed prevalence in UK fitness centres to be around 13%, whereas in dedicated bodybuilding gyms the prevalence rate peaks at almost one half of all members. This growth in AAS usage is supported by a 2000% increase in needle exchange attendance from 1991-2006 (Hoare & Flatley, 2008). Dandoy and Greige (2012) have shown that 3.30% of 9th-12th grade students in the US reported having used AAS in the past. Investigations in Canadian, Brazilian, South African and Swedish populations also confirm a cross cultural prevalence rate of between 1-3% (Adlaf & Smart, 1992; Galduroz, Noto, Nappo, & Carlini, 2005; Lambert, Titlestad, & Schwellnus, 1998; Kindlundh, Isacson, Berglund, & Nyberg, 1999, respectively). The most accurate estimate for prevalence within the UK general population has identified 293,000 people having used AAS in their lifetime, with 73,000 people having used in the past year (Crime Survey for England & Wales, 2015). The use of these misunderstood substances has added depth when the mental and physical side effects are considered. For example, Angell et al. (2012) explains case study evidence of a link between AAS use and cardio vascular disease (e.g. myocardial infarction), which is highly supported by Pope et al. (2013) with the addition of psychiatric and endocrine disorders. Also, Baggish et al. (2010) emphasised the risk of heart failure in long term users to be more severe than previously thought. The increasing use of anabolic steroids combined with a perception of limited risk in users (see Kimergård & McVeigh, 2014) therefore presents a public health issue in a state of severe incline. With the above in mind, the current study aimed to explore the reasons young males initiated AAS use and also their motives towards continued use. Two distinct theories have been associated with the use of AAS, the conduct problem explanation which associated use solely with adolescent anti-social behaviour and risk-taking behaviours, and the muscle dysmorphia interpretation which argues AAS use as representing distorted body image. Miller, Barnes, Sabo, Melnick, and Farrell (2002) rejected the argument for AAS being a mere drive for the male athletic ideal, as its usage had a strong relationship with other high risk behaviours (e.g. multiple drug use or suicide attempt). The authors argued that AAS use represents a pattern of risk taking behaviours, rather than an independent problem. Further, Nilsson, Baigi, Marklund, and Fridlund (2001) provided strong evidence for patterned, multiple drug use, which excluded cannabis and tobacco (Dodge & Hoagland, 2011). Kanayama, Hudson, and Pope (2010) introduced biological evidence for this association, explaining that both human and animal research indicates both AAS and other illicit drugs involve similar brain structures and mechanisms. Adopting a similar theoretical position to Miller, Barnes, Sabo, Melnick, and Farrell (2002), Wichstrøm and Pederson (2001) proposed that AAS use reflects only an alternative form of problem behaviour with only a secondary association with sport. Thiblin and Pärlklo (2002) strengthen this argument with the discovery that AAS use prospectively increased the risk of an antisocial lifestyle, whereas Kanayama, Pope, Cohane, and Hudson (2003) add that illicit drug use almost always precedes AAS use. In a review of recent findings Harmer (2010) highlight a wealth of recent evidence promoting the idea that AAS use rather than being focussed on muscularity and/or athletic endeavours, is part of a broader syndrome of problem behaviour, expanding that efforts to reduce rates of usage should focus on the general adolescent population as opposed to athletes. The literature and media dominant explanation for AAS use adopts the position that individuals use such substances as a result of psychological anxiety which stems from an underlying body image disorder. This explanation is the product of studies revealing AAS users to be substantially less confident and satisfied with their body image than non-users, which is further fuelled by bodybuilding (Kananyama et al., 2003; Olivardia, Pope, Borowiecki, & Cohane, 2004; Blouin & Goldfield, 1995). Pope, Gruber, Choi, Olivardia, and Phillips (1997) categorised the symptomatic expression of such feelings with the term muscle dysmorphia (MD) whereby people become pre-occupied by their degree of muscularity, and reverse anorexia (RA) which is characterised by a feeling of inadequate and reduced muscularity as muscularity actually increases significantly (Pope, Katz, & Hudson, 1993). In support of this causal explanation, Kanayama et al. (2003) highlighted that users differed significantly from non-users on symptoms of MD, whilst Kanayama, Barry, Hudson, and Pope (2006) posited that body image pathology is prominent in men with long term AAS use. Interestingly, Pope, Kanayama, and Hudson (2012) discovered that whilst many attributes showed little association to AAS use, intense body image concerns and conduct problems showed strong associations. The current body of evidence on the subject of AAS use promotes a highly disjointed understanding as to why it occurs so abundantly. There have been key evidence-based explanations which are, at a superficial level at least, linked to its use however the causal direction of each remains contested. Further to this, they are approached by a majority of researchers as separate entities with a narrow, rejecting viewpoint on the interaction of each. The purpose of the current study is to delineate both the potential precursors of AAS use and to highlight the contributions of different factors pertinent to its continued and prolonged usage.