to reflect the paradigms in use by athletes). Despite this, however, as a result of their own self-experimentation – and, in some countries, supported by the results of clandestine state-sponsored doping programmes (10) – it was already known to many athletes and their coaches that high doses of steroids could have a significant performance-enhancing effect, irrespective of the mechanism of action. It was the work of Bhasin and colleagues in 1996,

however, that demonstrated definitively through a carefully controlled study that supraphysiological doses of testosterone given to healthy men were capable of significantly increasing muscle size and strength – an effect that was enhanced by strength training. Furthermore, subsequent work from the same group has since demonstrated that these changes are associated with the dose of testosterone and, importantly, that there is considerable interpersonal variation in the response to the hormone (1). However, few other steroids, in particular the oral steroids, have been subjected to this rigorous evaluation. Alongside these effects, many users also cite

psychotropic effects (such as an enhancement of mood and confidence, increased aggression and motivation for training) and ancillary ergogenic effects (such as reduced recovery time between training) as additional and synergistic reasons for use of these drugs (11,12). These claims remain to be tested empirically.

WHO USES ANABOLIC STEROIDS AND WHY?

Within the UK it is possible to define three broad categories of steroid user, the majority of whom are male; steroid use in females appears to be limited predominantly to bodybuilders and sportswomen. It is important to note, however, that reasons for use are not mutually exclusive and the main driver varies from person to person: n Sports competitors (including elite bodybuilders) who use predominately to enhance their sporting performance n Occupational users, such as those in the security industry (eg. door supervisors, security guards), prison officers and police officers, use steroids predominately to increase body size and aggression in order to protect and intimidate others. Some people in the entertainment industry, such as dancers and actors, use steroids in order to enhance their physique for their occupation n Those who use predominately for physique/aesthetic reasons in order to enhance body image satisfaction (“body image users”) (11,12). Work by a number of researchers has suggested that

there is a complex interaction of structural and personal factors that, depending on their focus, force and context, are capable to varying degrees of driving the use of steroids. These factors include changes in social and cultural norms and ideals, media influences, parental and peer influences, age, occupation, involvement in sports and exercise, body image dissatisfaction (including muscle dysmorphia), self- esteem, negative affect, body composition, pubertal timing, drug availability and risk boundaries (11–15).

HOW MANY PEOPLE USE ANABOLIC STEROIDS IN THE UK? There is a lack of robust data on the prevalence of anabolic steroid use within the general population of the UK. This is

22

All steroid injecting clients New steroid injecting clients All other injecting clients

New other injecting clients 3,000 2,500 2,000 1,500 1,000 500 0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year of presentation/attendance

Figure 2: All and new steroid-injecting clients attending agency-based syringe exchange programmes in Merseyside and Cheshire, UK (1991–2006), with data for clients injecting other drugs shown for comparison

due to a number of factors, including the following: n Lack of resources, because of the low priority of steroid use within the National Drug Strategy (16) n Much of the detailed prevalence work was completed over 10 years ago (11,12) n Lack of an adequate national syringe exchange monitoring system n Methodological limitations of much of the recent work, which has tended to focus on small or selected populations (such as those attending “hardcore gyms”, which historically have had high prevalence of steroid use (12)), rather than the general population n Demonisation of both steroids and users by the media and wider society, which has resulted in a reluctance by many individuals to discuss their use of these drugs (15,16). Work completed in 1992 by Korkia and colleagues, on behalf of the Department of Health, found that from 1,667 participants drawn from 21 gyms from across England, Wales and Scotland, 6% of men and 1.4% of women were current users of steroids (11). Similar findings have been found in a number of settings around the Britain (12,17), while figures from the 2006–2007 British Crime Survey estimate that 32,000 individuals aged 16–59 years used steroids in England and Wales in the preceding year (with 18,000 of these aged 16–24 years) (18). In contradiction to the relative stability in steroid use published in the British Crime Survey, however, reports from across the country suggest that use of injectable steroids is on the increase, particularly in young men. For example, between 1991 and 2001 the number of new steroid- injecting clients attending agency-based syringe exchange programmes in Merseyside and Cheshire increased six- fold (19) (seven-fold between 1991 and 2006), while overall between 1991 and 2006 there was a 2,000% increase in the number of steroid injectors attending exchanges (Fig. 2). Furthermore, it appears that a significant number of these individuals are participating in a peer-distribution network by providing injecting equipment to other users (20).

Anabolic steroids in sport Although steroid use appears to have begun in a small

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