Navigating Risks and Reducing Harm: A Gendered Analysis of Anabolic–Androgenic Steroid Users Within the Risk Environment Framework

Abstract

Introduction: The existing body of literature on harm reduction for those who use anabolic–androgenic steroids (AASs) predominantly concentrates on men, thereby neglecting the unique challenges faced by women in this context. Using a risk environment framework, the aim of this study was to examine the gendered harm reduction practices of male and female AAS users. The study explores their awareness of the potential harms associated with AAS use, the strategies they employ to manage those risks, and the support systems they utilize for harm reduction. Methods: The study employed purposive sampling to recruit 25 individuals (16 females and nine males) who used AAS. In-depth, semi-structured interviews were conducted and transcribed; thematic analysis was employed. Results: Both male and female users were aware of the risks and side effects of AAS. They also often trusted coaches for advice regarding AAS use, and some found peer support for open discussions. Participants also indicated the importance of verifying the legitimacy and safety of AAS. Men considered these to be manageable while women aimed to avoid them, particularly the masculinizing effects. Women downplayed the persistence of side effects and fertility challenges. Harm reduction strategies involved both men and women monitoring their health through personal cues and blood tests. However, women placed a greater emphasis on various physiological measures in their health monitoring practices. Post-cycle therapy was less discussed among women. Discussion: Overall, the study provides insights into the awareness, strategies, and support systems employed by men and women who use AAS for harm reduction purposes. There is a need to adopt a comprehensive harm reduction approach that recognizes the unique needs and experiences of women who use AAS. We emphasize the need for comprehensive education, supportive healthcare providers, and responsible coaching to minimize potential risks and ensure the well-being of individuals using AAS.

Introduction

Androgens have widespread effects throughout the body, affecting reproductive tissues, muscles, bones, hair follicles, liver, kidneys, and various systems such as the hematopoietic, immune, and central nervous systems (Mooradian et al., 1987). These hormones have androgenic effects, associated with masculinization, and anabolic effects, related to protein building in muscles (Mooradian et al., 1987). In male fetuses, androgens stimulate the development of male reproductive structures and external genitalia (Wilson et al., 1981). During puberty, androgens contribute to the growth of testes, external genitalia, and male accessory reproductive glands (Wilson et al., 1981). They also induce secondary sexual characteristics such as deepening of the voice, hair growth, and increased sebaceous gland activity and influence the central nervous system, while promoting anabolic effects on skeletal muscles, bones, and linear growth until growth plate closure (Wilson et al., 1981). Androgens, such as testosterone, are crucial for reproductive function, maintenance of skeletal muscles and bones, cognitive function, and overall well-being in men (Kicman, 2008). Anabolic–androgenic steroids (AASs) are oral and injectable derivatives of testosterone that were developed to enhance the anabolic effects while minimizing the androgenic effects (Kanayama & Pope, 2018; Wilson & Griffin, 1980). AAS have legitimate medical uses, however, are well known to significantly increase muscle growth and strength (Mottram & George, 2000). Their use among men can pose several medical risks, including suppression of normal hormone function, adverse effects on lipoproteins, and hepatotoxicity in the case of oral administration (Pope et al., 2014); furthermore, the adverse effects of AAS use can be long term (Kanayama & Pope, 2018).

While the physiological effects of AAS in men have been extensively studied, our understanding of their effects in women is still limited and requires further investigation (Dunn et al., 2023a). This knowledge gap holds clinical importance as women are markedly more susceptible to numerous adverse consequences associated with AAS utilization. Early research from Malarkey et al. (1991) revealed significant negative health effects in female weightlifters using AAS. These women experienced extremely high levels of testosterone, surpassing normal male concentrations in some cases. They also exhibited reduced levels of sex hormone-binding globulin and thyroid-binding proteins, along with a notable decrease in high-density lipoprotein cholesterol. These findings raise concerns about potential health risks, including premature atherosclerosis. Further health risks for women include voice deepening, excessive growth of facial and body hair, alopecia, disturbances in menstrual patterns, clitoral enlargement, and diminished breast size (Börjesson et al., 2016; Gruber & Pope, 2000; Ip et al., 2010). Although the usage of AAS among women is increasingly recognized (Abrahin et al., 2017; Havnes et al., 2021b; Piatkowski, Lamon, et al., 2023; Scarth et al., 2022), there remains a significant dearth of knowledge regarding women who use AAS.

Expanding the Gendered Discourse on Steroids

Existing research on the relationship between gender and the use of performance and image-enhancing drugs (PIEDs) such as AAS has predominantly focused on men and masculinity (Andreasson & Henning, 2022). This dominance of male-centric perspectives can be observed both in the context of sports and in gym and fitness settings (Sverkersson et al., 2020). As a result, AAS and other muscle-building substances, often associated with male attributes, have received significant attention in discussions surrounding AAS use (Andreasson & Johansson, 2021; Henning & Andreasson, 2021). Additionally, studies on AAS-using communities have highlighted the presence of male-dominated subcultures (Henning & Andreasson, 2022; Underwood, 2017). Certainly, Underwood (2017) has demonstrated that male AAS enthusiasts perceive their usage is shaped not only by practical advantages but also by social benefits. The discourse of these social benefits has often been discussed in relation to the significance of homosocial relations within image and performance enhancing drug (IPED) cultures within the remit of a “male lens” (Piatkowski et al., 2020; Underwood & Olson, 2019). However, understanding IPED use goes beyond gender mediation; it serves as a means of expressing and accomplishing gendered identities (Piatkowski, Lamon, et al., 2023). Therefore, the gendered discourse on doping has traditionally revolved around men, muscles, and masculinities (Piatkowski, Lamon, et al., 2023). However, there are indications of changing dynamics in recent times.

The research pertaining to women and their utilization of AAS has witnessed considerable growth. While earlier studies predominantly focused on women bodybuilders (Börjesson et al., 2016; McGrath & Chananie-Hill, 2009; Shilling & Bunsell, 2009), there has been a shift toward a more nuanced portrayal of women AAS users, encompassing a broader range of user groups with distinct motives and experiences (Chegeni et al., 2021; Börjesson et al., 2021; Havnes et al., 2021a, 2021b; Piatkowski, Lamon, et al., 2023; Piatkowski, Robertson, et al., 2023; Scarth et al., 2022). However, a significant challenge faced by research on women in this context entails overcoming the influence of male-dominated practices. Moreover, women have proven to be a hard-to-reach population for some researchers and practitioners (Henning & Andreasson, 2021). Except for female bodybuilders who benefit from a certain level of subcultural acceptance of drug use practices (Kotzé et al., 2020), women often conceal their usage due to societal stigma (Piatkowski, Lamon, et al., 2023). Consequently, they may bypass harm reduction services, given that drug use is perceived as a male-oriented, transgressive, and embarrassing behavior (Meyers et al., 2021). Nonetheless, recent literature has begun to present individual narratives that shed light on the intricate and diverse experiences of women and their engagement with AAS (Campbell et al., 2021; Piatkowski, Robertson, et al., 2023). There is an emerging recognition of the imperative for adopting a gender-sensitive framework in the context of harm reduction, wherein the distinct needs and experiences of women are duly considered from multiple perspectives (Ettorre, 2004; Shirley-Beavan et al., 2020). Research has demonstrated that women experience AAS use differently from men and, therefore, may have their own unique needs when considering health management and harm reduction (Piatkowski, Lamon, et al., 2023).

Currently, the body of literature regarding AAS consumers and harm reduction focuses closely on men (Bates et al., 2021; Bonnecaze et al., 2021; Dunn & Piatkowski, 2021; Piatkowski, Hides, et al., 2022). Research posits that men who use AAS and experience harms often continue using it due to a perceived inability to get help, anxiety regarding muscle loss, and fear that sudden cessation will cause more harm (Griffiths et al., 2017). Further, despite front-line health workers interacting with AAS users more regularly than in previous years, they report being unprepared to meet user's needs (Dunn et al., 2014). As a result, AAS consumers generally turn to peers for support and advice (Tighe et al., 2017) opting for these “safe spaces” free of judgment (Piatkowski, Hides, et al., 2022). These trends in harm reduction practices for men, however, may not translate to women who use AAS. The challenges facing women who use AAS are likely to contribute to further isolation and stigma (Piatkowski, Lamon, et al., 2023), as is substantiated by research with women who use and inject substances more broadly (Gibson & Hutton, 2021; Iversen et al., 2015). Ultimately, more research is required to understand how these challenges are experienced and navigated by AAS-using women.

The Present Study

This article employs the risk environments framework as a theoretical framing to investigate the experiences of male and female AAS users in practicing harm reduction and assessing the effects and safety of their substance use. The risk environments framework examines the convergence of various sociostructural factors that shape drug use behaviors and the associated risks (Rhodes, 2002, 2009). In understanding AAS use, it is crucial to consider the broader context, including individuals’ motivations, prior knowledge, and experiences (Hanley Santos & Coomber, 2017). Many AAS users have limited knowledge and rely on information from peers or suppliers, which can be inaccurate or incomplete. By examining the social contexts and the cultural significance individuals assign to risk practices (Duff, 2010), this research seeks to understand the manifestation of risk management behaviors among AAS users, informing harm reduction practice and education more broadly. Scholars contend that substance use is unequivocally a spatially situated corporeal practice, influenced by overarching economic, political, and cultural frameworks (Duff, 2016). Consequently, within the substance-using community, individuals and collectives formulate their distinctive principles, goals, and methodologies for navigating the complexities associated with drug use (Duff, 2015). Highlighting the significance of praxis, AAS consumption emerges as an embodied undertaking characterized by distinct rituals and customs, molded by localized cultures and norms (Piatkowski, Gibbs, et al., 2023), of which gendered practice remains sorely underrepresented.

The primary aim of this study was to examine the harm reduction practices and the evaluation of effects and safety among a group of male and female AAS users. Specifically, the research aimed to investigate potential gendered differences in their approaches to harm reduction. By analyzing these differences, the study aimed to contribute valuable insights that can inform educational initiatives and interventions targeting AAS use. In this context, the risk environments framework, accounting for elements of space, embodiment, and practice, was employed to explore the complex interplay between risk and enabling environments, thereby providing a comprehensive understanding of the behaviors and practices exhibited by individuals involved in AAS use.

Methods

Sampling and Recruitment

The data for this study emerge from two qualitative projects, of which the interview data from AAS consumers is analyzed. A sample of 25 AAS users (M_age = 35.8 years, SD = 7.8) tapping into the extended community networks of the first author for participant selection. Utilizing the researcher's established peer status within the AAS community facilitated recruitment and ensured a diverse range of men and women engaged in AAS use for the qualitative investigation. The cohort comprised 16 female users and nine male users. Participants were reimbursed for their time with a gift card. Ethical approval was granted from each University Human Research Ethics Committee (Approval Numbers: 2022-156; 2023/257).

Materials and Data Collection

The studies employed a qualitative approach, conducting individual semi-structured interviews to gather data from participants. Components of the interviews focused broadly on exploring participants’ perspectives regarding women's harm reduction practices in relation to AAS. The overarching research inquiries of the studies centered on the intricate interplay between AAS use and harm reduction within the community. One study specifically delved into the gendered dimensions of AAS experiences, while the other elucidated harm reduction practices within a mixed-gender cohort, collectively contributing to a comprehensive understanding of harm reduction strategies in the context of AAS use. Participants were asked questions such as: Could you tell me a little bit about your steroid use? Are there any specific harm-reducing practices you engage in? Do you ever think about what stopping steroids would look like? How do you know whether your steroids are what it says on the label? Can you tell us about a negative health experience you have had from using steroids? The interviews were conducted online, and the audio recordings were transcribed automatically. To ensure accuracy, the transcripts were carefully reviewed for errors. On average, the interviews lasted for a duration of 35 min and 50 s (SD = 8 min 20 s, range 23–117 min).

Data Analysis

Immediate reflective notes were recorded after each interview to enhance the reliability of final transcripts. Reflexive thematic analysis, as outlined by Braun and Clarke (2019) was systematically applied to the data, initially contributing to transcript dependability. Multiple research team meetings were held to scrutinize coding decisions, reflect on emerging themes, and identify patterns (Braun & Clarke, 2023). Verbatim quotations were then compiled to exemplify each theme, with titles and excerpts systematically collated. For subsequent transcripts, corresponding extracts were listed under existing themes, with new themes identified as they emerged. These themes were methodically organized and conceptually supported using relevant examples from multiple transcripts. A comprehensive review of all 25 transcripts was conducted to refine themes further. The first author then assessed the relevance to specific subsets of data and initiated theory testing, employing abductive conceptualization (Neale, 2021). This phase involved connecting the findings to the risk environment theoretical framework (Rhodes, 2009), ensuring alignment with established literature for broader applicability and theoretical generalisability. In addition, the first author engaged in reflexive practice by acknowledging his own lived experience of AAS as a male. In doing so, he acknowledged that his experiences and the experiences of peers in this area can be quite complex, transcending traditional gender performativity (Butler, 2004). This reflexivity underscores the dynamics of gender performativity within the research process, with both authors recognizing their male gender, thereby shaping the lens through which the analysis developed. The acknowledgment of lived experiences and gender dynamics enhances the nuanced exploration of themes and aligns with the principles of reflexive thematic inquiry (Braun & Clarke, 2019). Throughout this iterative process, discussions among the two authors ensured alignment and progression toward more abstract perceptions grounded in verbatim indications (Braun & Clarke, 2022). This multistage approach bolstered the analytical framework's reliability and rigor.

Results

The Intersecting Risk Environment

Men and women tended to acknowledge that there was a level of awareness present among those using AAS and that they were somewhat prepared to face the many potential harms. For instance, among men, these harms were components of the “side effects” that could be experienced. These effects were seen as manageable and mild. Among women there was a strong desire to avoid experiencing masculinizing effects, indicating a conscious awareness of some of the obvious risks and potential negative consequences associated with AAS use for women.

P1 [Male]: [Speaking on AAS harms]. That's a given. Everyone who uses this stuff [AAS] is going to have some sort of side effects, some of which aren’t pleasant, but most of which are manageable and pretty mild.

P14 [Female]: It's something that I want to avoid obviously, virilisation. Yeah, it's like a big concern of mine.

Among male AAS users, there was significant discussion around the perceived risks and significant impact associated with the use of AAS among women, compared to men. Male users expressed a deep concern for women who engage in AAS use, acknowledging that it can be a life-altering experience for them.

P11 [Male]: For them [women] its life changing [AAS].

P13 [Male]: For us [Men] it is okay to fuck up. You can blast grams of gear [AAS] without worrying too much about what will happen. Well, I mean, like you might get some acne, or you might get some gyno [gynecomastia] if you don’t manage it [the use] right.

These views were paralleled by women who highlighted the lack of awareness and understanding among their peers regarding the potential consequences and long-term effects on their reproductive health. There was a sense of naivety among women using AAS, indicating a disconnect between their expectations and the reality of the impact on their bodies. Some women may underestimate the persistence of side effects and the challenges they may face in terms of fertility, pregnancy, and post-AAS recovery.

P8 [Female]: Women are so naive about what they've done to their bodies and then can't understand why they fail to fall pregnant or they fail to carry a child to term or why their body just doesn't return. They think all the side effects are going to go and it's just going to return back to normal.

These discussions around harms arising from poor education were echoed by other women's experiences with female peers. Particularly, those women who were younger, and who were more motivated by competition, were willing to take higher levels of risk.

P25 [Female]: I see girls like in their 20 s and they are just chasing it so bad and so hard. And they'll do whatever it takes. And they go, I call it going down the rabbit hole. They go down to Alice in Wonderland, they go down the rabbit hole, and they just don't consider the ramifications of what they're doing.

Given the way men and women have positioned their awareness and experiences of risks for females, the next sections attempt to disentangle how those risks are managed.

Gendered Strategies and Supports for Harm Reduction

Health-Checking Behaviors

As a result of the potential for significant harm, some participants emphasized the importance of medical testing to confirm the quality and impact of the AAS they are using. Men mentioned getting blood tests, with elevated testosterone levels indicating the authenticity of the compounds.

P13 [Male]: Because I get blood tests and things like that… I do some testing. If my testosterone is through the roof, it usually means that what I'm taking is real.

However, men also emphasized reliance on personal cues to monitor their health. This is suggestive of a personalized and self-aware approach to self-assessment and self-care in the context of AAS use.

P15 [Male]: I do more like mood and behaviour markers. Am I feeling negative or positive? How am I waking up? Am I waking up refreshed or not? Am I motivated? Am I focused? That sort of stuff.

Men also discussed how these experiences determine the authenticity of the AAS they are taking. They related increased libido to the use of Masteron [Drostanolone], indicating its legitimacy. These self-perceived indicators become important factors in determining the presence and effectiveness of AAS.

P11 [Male]: I could usually tell with Masteron because, you know, usually my sex drive goes through the roof. The last time I used DHB [Dihydroboldenone], I'm pretty sure it was just oil because the times that I've used a different brand, I became a monster.

Women had several strategies they engaged in, intended to prevent or mitigate harm. One of the common strategies included health-checking behaviors, where women spoke about monitoring their health through objective measures.

P3 [Female]: That's obviously why we have testing protocols in place, just to make sure that I don't have any adverse effects. Keeping an eye on liver and kidneys and all those sorts of things.

Many women also reported performing blood tests either through a healthcare provider or via online services available to them.

P1 [Female]: So, I get my bloods done at least twice a year, if not four times.

P2 [Female]: I get my bloods done through, there's an online service.

Gendered differences did emerge concerning the frequency and extent of health monitoring behaviors. Men reportedly perform these behaviors as well (Piatkowski, Hides, et al., 2022), however, female participants were more robust in their procedures. Some conducted blood work before, during, and after cycles to monitor their health. These monitoring behaviors reflect a proactive approach to health, with individuals seeking medical confirmation of their AAS use.

P9 [Female]: Yeah, I do blood work before a cycle, sort of mid, then if I'm changing anything, I will, you know, always look at bloods.

There were also some women who reported other behaviors which they believed complemented their blood testing. For some women, this included taking additional health supplements which they believed would protect their well-being.

P4 [Female]: I take but also my bloods and all of my health supplements. So, things like vitamin D and astragarlus [Huang Qi], tudca [tauroursodeoxycholic acid], and like anything that I take, like, you know, my hydration and the salt in my diet.

Women also discussed other physiological measures they monitor while cycling AAS. These included monitoring blood pressure and heart rate. By monitoring these readings, women felt more confident regarding their health. If the measures were to change drastically then women would change their dosages or compounds.

P5 [Female]: I definitely do have a slightly hypertensive blood pressure when I am on [an AAS] cycle. Just before I went back on cycle this week, I took baseline vitals like my heart, my resting heart rate, and my blood pressure. My blood pressure was in normal ranges. And then my heart rate was also at a much more healthy resting heart rate than it is when I'm on cycle. So, with this cycle, I'm actually making the point of taking weekly blood pressures and weekly heart rate readings, just to make sure that I'm not going too far off track.

Post-Cycle Therapy (PCT)

For women who use AAS, there was little discussion of complex PCT procedures that are common among men (see Griffiths et al., 2017). Some women felt that PCT was unnecessary after ceasing use. They reported little changes physically or psychologically.

P5 [Female]: I've never, I've never found that I need any buffering systems when it comes to any PEDs [performance enhancing drugs] that I do use. I don't have changes in moods or appetite or endurance in the gym or anything like that. So, I just sort of just cruise it out.

Other women spoke about their practices of tapering these compounds and gradually reducing their dose.

P8 [Female]: So, I'd spoken to someone and they're like, look, go up to 20 [mg] on the var [Anavar: Oxandrolone], then 30 [mg], then 40 [mg], and then taper off and then stay off.

In these instances, they reported some psychological effects which accompanied the reduction of exogenous hormones. However, they believed the tapering practice assisted them with managing the intermittent cessation of use.

P6[Female]: But from this one I tapered off, and you know, a little bit of low days here and there but nothing like that after the last one.

Despite the knowledge that other females who were using AAS engaged in tapering practices, this did not necessarily sway women to follow the same procedures.

P7 [Female]: So, most of the ladies, they wean themselves off or they just take smaller doses, but I just stop and then just go back into normal training without it until six weeks out of comp. Yeah. So, I just stopped.

Healthcare Providers

There was some mention of women obtaining safe injecting equipment from needle service providers (NSPs).

P5 [Female]: In PLACE, for example, there was a very friendly needle exchange program, no questions asked kind of thing.

Regarding healthcare providers such as general practitioners (GPs), women did report some engagement with them. Engaging with GPs generally acted as a function to acquire blood test referrals and perform health-checking behaviors.

P1[Female]: I see a doctor regularly to get blood tests.

P6[Female]: So, I get my blood tests all done through them and pretty much just order everything through them that I can get.

However, there were some participants who maintained a distrust of GPs. These women highlighted negative encounters characterized by judgment and a focus on advising cessation rather than supporting safer-use practices. Such experiences reinforced their reluctance to disclose their AAS use to healthcare professionals.

P2[Female]: I have a very good GP actually, but I don't know whether I trust her to be able to talk to her about it.

Women reported that poor experiences with GPs generally underscored any level of distrust. They felt that GPs met them with judgment and stigma, advising them to cease use rather than facilitating safer-use practices.

P9 [Female]: Unfortunately, from the experience that I've had with GPs in the past, anytime I am honest and tell them why I'm actually getting it, they're more focused on telling me not to [use] than actually helping me.

These views map closely to those of men who use AAS which have been documented in the literature (Dunn et al., 2023b; Piatkowski, Hides, et al., 2022), but also represented in the current data. The shared narratives suggest that, regardless of gender, individuals may encounter barriers in seeking appropriate healthcare support due to the stigma associated with AAS use.

P11 [Male]: You go to your local GP and 99% of them just say stop.

P15 [Male]: But doctors were refusing to do it… two doctors asked me to leave their consultation because they said why? Why would you do that? You know, you could die from this stuff, blah, blah.

Drug Coaching

Men who use AAS have been documented to receive advice from their coaches around their AAS use (Gibbs et al., 2022) which our data substantiates. With a comprehensive understanding of these substances, these individuals, often with lived or living experience, assume a crucial role in influencing user choices and behaviors related to drug use and associated harms, warranting consideration within the broader harm reduction landscape. However, women also mentioned a significant level of trust placed by female users in their coaches, who provide guidance and advice on substance use. This “blind faith” in coaches suggests a potentially dangerous situation where the user may unknowingly consume substances without comprehensive knowledge of their legitimacy or potential risks.

P11 [Male]: Yeah I’ve got a coach I listen to… we speak like have consults regularly where we talk about all of it, the whole spectrum… from training to nutrition to PEDs [performance enhancing drugs] I just follow the plan.

P4 [Female]: Especially with females like they're not, it's already quite stigmatised. Like it's a really hush hush thing. They're just going to trust the coach who is advising them to do this. Like they put blind faith in them really, that what they're taking is legit and they have no idea.

P17 [Male]: Yeah. You know, I, my wife, she's 39 years old. She just trains to be healthy, you know, But even her, you know, she's getting pressure from her trainer and it's like ohh, you should try and use human growth hormone.

AAS users did not necessarily feel they had the requisite knowledge to design their own regimes of use. Instead, they diverted to people they believed had the expertise necessary to assist them and optimize their performance.

Interviewer: [on AAS dosage] And that's through what you've learnt, or you've got someone helping you out with that?

P6[Female]: A bit of both. So, I've had some calls with NAME and he recommended a few different things.

A discussion emerged among participants regarding the utility of coaches in harm reduction, specifically “drug coaches.” Drug coaches represent individuals who advise clients specifically on their PIED and AAS use, to maximize performance and mitigate harm. Men and women reported engaging the services of drug coaches in a variety of ways.

P4 [Female]: I now have someone who I pay, who that that basically is how they earn a living is advising people on performance enhancing drugs and cycles.

P24 [Male]: I pay NAME for all my training, nutrition and PED advice.

The way AAS users engaged with these drug coaches could vary from personal consults to seminars that they reportedly attended.

P1 [Female]: Have you heard the name NAME? He's known as the drug guy in sports. He lives in the NAME. But he does a lot of consults, things like that. But he goes on, like, the harm reduction and things like that. So, he's really good to talk to as well. But I got him to do a seminar, based on female use and things like that.

AAS users believed that the longevity of their use relied heavily on the quality of the drug coaching they received. To have a drug coach who was invested in their health and assisting them in mitigating the harms that accompanied using AAS was highly regarded.

P4 [Female]: The ones that have longevity have good coaches, as in, they have a drug coach. So, the good ones will genuinely have someone who has a vested interest in their long-term health.

Peer Support

There were some women who discussed peer support from other females using AAS. Although generally there was a level of secrecy reported among women, some had formed relationships with AAS-using peers, which they used for support and open discussion.

P2 [Female]: One of the girls I train with, she's done powerlifting for a very long time at a very high level so I'm quite open with her and I think I'm the only other person that she talks to about her PED use.

Other women who engaged in these female peer-user discussions reported that they used them to evaluate their own use. They could discuss what they were using and then compare that information with multiple peers who were using it to obtain a perspective on where their use might fit along that continuum.

P5 [Female]: So, I asked a particular powerlifter, who's a female who is very comfortable opening up about her drug use. And then I correlate that with anything, like I correlate that information with a number of other people in the industry that aren't actually related to each other. So, I know that their opinion is independent of what the other person has said.

Some participants admitted to being asked by other women for information regarding PIED use. This type of behavior demonstrates that women may be attempting to seek help among each other in trusted networks or “safe spaces.”

P9[Female]: Like, I've had conversations with girls who have asked purely because they want help in that area, and then I'm more than happy to give them information on it.

These trends map onto what has been documented as occurring in the male AAS-using community (Piatkowski, Hides, et al., 2022; Tighe et al., 2017), but was also represented in the current data. The parallels between the experiences of both men and women in seeking and providing support within their respective communities emphasize the importance of peer networks in sharing knowledge, guidance, and experiences related to AAS use.

P20 [Male]: People always ask me about gear [AAS] and I'm happy to tell them and educate it as much as I can.

Drug Checking

Both women and men acknowledged that the substances they were using were black-market products. They did not know that the substances contained what they claimed to, or whether there were contaminants present. They drew parallels between other illicit substances like ecstasy, the contents of which are generally far more than just the promised 3-4 methylenedioxymethamphetamine (MDMA) powder.

P8 [Female]: I don't think anyone actually really knows. It's like taking pills [ecstasy] when you go out on the weekend or something, do you really know what's in them?

P11 [Male]: It's kind of like when I talk about recreationals. I'm, I'm a big fan of, you know, legalising things so that, you know, if my kid goes out one day and buys a pill, he knows there's 250 milligrams of ecstasy and 50 milligrams of speed in there. Rather than at the moment, it could be fucking glass. Like, yeah, I prefer to make a bad decision, but know what decision you're making.

Both women and men using AAS demonstrated awareness of potential risks, including concerns about receiving contaminated or mislabelled substances and the potential side effects associated with their use.

P8 [Female]: I'm just waiting for I guess for me to get a bad batch of something and for it to be dbol [Dianabol: Methandienone] or something like that and actually start growing a beard or something.

P13 [Male]: I know a girl who was again going for a big comp [competition] and she is sitting there going, “I cannot understand why I can't cut weight. Like I'm bloated, all that sort of stuff.” And I'm asking what she's taking. She's like ohh yeah, Anavar. And I'm like I'm pretty sure that's Dbol. Like just on the colour of it and her symptoms. Because if she's on Anavar she should actually have no trouble stripping weight.

Notably, some women did acknowledge the legitimacy of these substances more formally and referred to drug testing procedures. Drug testing involves consumers having their substances analyzed and receiving advice. Some women discussed how, early on in their use, they were unaware that they could test their substances.

P1 [Female]: I tried Anavar, but I didn't see any results off that. But it may have been because it wasn't legit. So, when I first started using things, I wasn't very savvy to the fact you could get test kits and everything.

However, when prompted, participants were informed of testing procedures taking place. How these procedures took place was not necessarily known or described in detail.

Interviewer: And do you get your drugs tested?

P5 [Female]: No, but a woman that I do buy them from, she gets like, the seller that she buys from the drugs are tested.

Some women had undertaken testing procedures themselves. They reported using testing kits, available in Australia, to test their substances. Testing ID Kits are presumptive tests used to indicate the presence of AAS in injectable oils as well as tablets and capsules.

P4 [Female]: I would buy PED test kits, for every single drug that I used.

Outside of the medical establishment, women spoke to the advantages of drug-checking programs for AAS users being particularly beneficial for them. Participants express their support for drug checking and emphasize the importance of ensuring the safety of the substances they consume. They acknowledge that people will continue to use these substances regardless, so providing support and resources to help them make informed choices is crucial. Participants emphasize the need for harm reduction strategies, such as drug checking, to mitigate risks associated with AAS use and promote safer practices.

P18 [Female]: I think drug checking is great, honestly because, you know, like we've discussed before, I think that the more that we can do to support people in their choice, the better. You know, because at the end of the day, people are going to do it regardless.

P22 [Female]: Yes, I want to check it because I don't want it to be some other compound that could give me nasty side effects. I also don't want to take something that's overdosed that will harm my liver.

P24 [Male]: If you could educate them, I think they'd be able to make a more informed choice, which is where the testing would come along.

Discussion

The findings of this study suggest an overlap of risk environments for men and women who use AAS, with some similarities and crucial distinctions needing to be underscored. The use of AAS among men and women appears to come alongside some level of acceptance of harm. In line with this acceptance, there are strategies that men and women use to prevent or mitigate these harms. These approaches included overarching health strategies and support network-based harm reduction. For health strategies, there were several health-checking behaviors of which blood testing was the most common testing protocol used, often performed through healthcare providers or online services. Performing blood tests to objectively monitor internal organ health has been documented as an important health strategy for male AAS consumers (Bonnecaze et al., 2021; Piatkowski, Hides, et al., 2022) and has also resulted in increased engagement with healthcare providers such as GPs who are open to providing this type of monitoring (Zahnow et al., 2017). Women reported having mixed experiences with GPs and this is reflective of male AAS-using samples generally (Dunn et al., 2023b; Piatkowski, Hides, et al., 2022). Additionally, women monitored their blood pressure and heart rate and adjusted their dosages or compounds if the measures changed drastically. As part of their health strategies, some women reported taking additional health supplements that they believed would protect their well-being, and the use of these types of supplements to support health is common among male PIED using samples (Piatkowski, Obst, et al., 2022). In contrast to men, however, women acknowledged but did not necessarily practice PCT (Griffiths et al., 2017). Women opted to taper their compounds or cease use altogether and, at times, suffered psychological consequences as a result.

Regarding support networks, both men and women's use of AAS was normally based on guidance from “expert” peers, consistent with male samples (Tighe et al., 2017), and more specifically from drug (anabolics) coaches (Gibbs et al., 2022). Drug coaches are experienced members of the community who hold dual responsibilities in mentoring and promoting harm reduction measures. They possess a unique ability to provide guidance on the usage of PIEDs such as AAS through their personal experiences and mentorship. Our data extends on previous work (Gibbs et al., 2022) demonstrating drug coaches possess a unique ability to promote harm reduction measures among their clients. However, we acknowledge research can be useful in driving the linkage between emic harm reduction and the public health response, and further work is needed in this space. Notably, there was some discussion regarding drug checking and testing. In Australia, there is significant controversy surrounding drug-checking initiatives, despite their widespread implementation internationally as a harm reduction measure (Ritter, 2020). Drug testing in terms of AAS has received little attention (Piatkowski, Puljevic, et al., 2023) and, therefore, privatized harm reduction frameworks have likely emerged as a result. Further attention from researchers is required to understand and document the drug-checking practices of this unique cohort of substance consumers.

A Comprehensive Harm Reduction Environment for Steroid Use

Integrating the risk environment approach (Rhodes, 2002, 2009), which aims to elucidate how environmental factors contribute to harm and endeavors to establish supportive contexts for harm reduction, underscores the heightened vulnerability shaped by diverse environmental, social, and individual influences on women. These factors pose challenges to women in accessing health services, including harm reduction initiatives (Rhodes et al., 2005). The adoption of a risk environment approach shifts the onus for harm and avenues for change from individual responsibility to the social situations and structures that contextualize them. While this study reveals more similarities than differences in harm reduction approaches between men and women in managing the risks associated with AAS use, nuanced considerations are essential.

Examining harm reduction practices in the context of AAS, particularly the dearth of knowledge concerning the contextual facilitators of harm reduction, aligns with Duff's (2016) conceptualization of spatial practices. We draw parallels and emphasize the notion of an “enabling” place, to serve as the framework for exploring the broader social context of harm reduction irrespective of gender. Scholarly perspectives advocating for the creation of enabling environments emphasize that these environments manifest through activity and practice (Ivsins et al., 2019). Understanding the diverse ways in which environmental processes contribute to improved health, well-being, resilience, and self-efficacy offers valuable insights into the nature of these enabling environments. Furthermore, under specific conditions, these environments play a crucial role in mitigating drug-related harms for individuals and communities (Bank & Roessler, 2022). Drawing the current findings together with theory and extant work, we provide some suggestions for future research and practice through which to enhance the “harm reduction environment” of AAS use.

Research indicates that support provided to AAS users should be context-specific and tailored to their needs. It is essential to provide balanced and evidence-based advice that addresses the specific concerns of AAS users (Harvey et al., 2020). Moreover, there is a need to consider the stigma attached to AAS use and the emotional issues that arise from it, such as shame and anxiety (Bonnecaze et al., 2021; Harvey et al., 2020). Addressing these issues is thought to facilitate successful engagement with healthcare providers (Bates et al., 2021) although thus far this facilitation has been focused on male users (Atkinson et al., 2021). In light of the prevalent conceptualization of PIED and AAS use as a manifestation of male hegemonic patterns (Andreasson & Henning, 2022), an essential issue arises concerning the optimal method to revise the discourse surrounding AAS while also accounting for the perspectives and experiences of women. Women who use AAS encounter a more profound social disapproval compared to their male counterparts (Piatkowski, Lamon, et al., 2023). Given the interrelatedness of stigma and gender in the context of AAS use, the gendered nature of this behavior can also limit their access to harm reduction services and interventions.

Our data demonstrates that women who use AAS warrant further inclusion in current PIED and AAS harm reduction frameworks, however, there are unique challenges and needs associated with their use of these substances. These data indicate that women are aware of some risks associated with AAS use and, therefore, harm reduction practices have emerged from a combination of coaching and peer-driven support networks. This group is engaged in their own health and well-being, although they acknowledge their marginalization and isolation have created a suboptimal environment for healthcare practices. Although we do acknowledge there is some engagement with healthcare providers to facilitate health-checking behaviors. Further research is required to understand precisely what education and resources this group is most interested in and how healthcare could be more appropriately provisioned to them—for example, through optimizing engagement strategies of providers. These strategies are particularly important for younger women using AAS as they appear to be at a higher risk of harm.

Conclusions

One limitation of this study is that it includes predominantly women who have experience in using AAS, which may not be representative of younger initiates. Future research could include a younger sample and explore whether practices differ. It could also explore the experiences of women who have stopped using AAS and identify the strategies they used to discontinue their use. Nonetheless, this study sheds light on the gendered harm reduction practices of AAS use. To address these issues, it is crucial to adopt a comprehensive harm reduction approach that recognizes the unique needs and experiences of women, challenges gender biases, and ensures inclusivity in the development and evaluation of harm reduction services. This approach should encompass context-specific support, evidence-based advice, and strategies to address emotional issues associated with AAS use. Inclusivity and tailored interventions are key to creating enabling environments that promote health and well-being for all individuals, regardless of gender, within the realm of substance use.