Perceptions of illicit market products

This and other studies22 ,28 have found that products claiming to contain anabolic steroids are readily accessible from the illicit market. Yet the issue of contaminated, adulterated and misbranded drugs, along with its impact on the behaviour of users, remains a neglected area of study.

Whereas a few of the respondents expressed uncertainties pertaining to the composition and sterility of drugs obtained from the illicit market, the majority remained ignorant, or at the very least, unconcerned, regarding the associated risks. However, to other users in this study, the implication was that it was difficult for them to know exactly what pharmacologically active substance(s) was in the vials they had obtained, as well as the amount of active ingredients. This undermined their ability to plan out their regimes: The biggest change I've seen in steroids is the fact that when I started using them [in the late 1980s], everything you got was pharmaceutical grade. It was from a chemist or a pharmacy. It was brought in from abroad or it was from this country. They were genuine Organon, Bayer, all these famous drug companies and they all came packaged and you knew exactly what you were using. It's completely changed now. You can't get anything pharmaceutical grade, everything is ‘underground’. (Steroid user and gym owner aged 45)

Another uncertainty was the confusion caused by anabolic steroids sold under fictitious product names such as ‘Cutstack’. This seemed to have direct impacts on the process of obtaining information about specific types of anabolic steroids: Certain steroids on the [illicit] market are called different names to what they are called in the book [the so-called ‘steroid handbook’ by William Llewellyn,29] and some steroids aren't in the book. So, I go on the Internet for that information, but each site says different things about it. (Steroid user aged 22)

Of note is that these insecurities did not seem to deter users from purchasing and using such products. However, it did appear to lead to various practices being adopted in an attempt to mitigate these uncertainties. Significantly in this respect, a number of steroid users said that getting their hands on drugs of a ‘sound quality’ came down to finding ‘someone that could be trusted’ and hence many preferred to buy from ‘local dealers’ rather than online retailers (steroid user and competing bodybuilder aged 45). In many cases, users would dismiss speculation regarding the quality and safety of the drugs because they trusted the person who had sold them: I've always used the same guy, and I never had no issues with him. I always use the same person. I never had bad ‘gear’ from him. (Steroid user aged 22)

However, given that users in many cases cannot determine accurately the quality of such products, illicit manufacturers and suppliers are able to use this to their advantage12; for example, through the deliberate misbranding of vials to increase their profit. This was of concern to some: I've heard horror stories about dealers that I talk to...there'll be a tray of vials and they'll ask, ‘what are you after?’ And they say, ‘well there's the bottles, there's the labels, take whatever labels you need and just stick them on the bottles.’ There might be some active ingredient in them but you just can't know for sure what you're getting. (Steroid user and gym owner aged 45)

Distinct to this group was that many respondents described practices relating to self-experimentation to gauge the effects of anabolic steroids. In fact, self-experimentation was widely accepted as an approach to gain first-hand experience of the effects of these drugs: I think it takes a couple of courses of steroids to be able to understand how they work properly...the first time I took steroids I probably accumulated a lot more body fat than I had anticipated, but it's all part of a learning process. (Steroid user aged 35)

This approach was used on products from the illicit market to see what the effect would be and hence to assess their quality: Maybe you could put counterfeit stuff in a normal bottle. You wouldn't know, but you do find out the difference after you've finished your course and you are not getting the results you should be getting. I think that's a risk you take, it comes in life, it comes everywhere. (Steroid user aged 27)

These accounts highlight that for many the main concern regarding an unregulated market with products of dubious provenance is either being ‘ripped off’ or at the very least failing to make the desired gains. The potential for serious adverse health consequences due to poor manufacturing of products is not generally perceived as a major issue.

Peer users and steroid knowledge: risk reduction?

In describing their experiences of anabolic steroids, it became clear that the practices, viewpoints and experiences of other users significantly affected risk behaviour, both positively and negatively. It seemed that experienced users would act as a form of regulator within the gym population; for instance by providing steroid-related information, advising users not to adopt the ‘high-dose’ regimes used by competing bodybuilders and persuading young people not to take steroids until they were older: I've always told teenagers that have asked me if they can take steroids and stuff, that it's at your own risk. You might be 5′ 7″ now, that might be as tall as you're going to get [given that anabolic steroids may shunt the normal pattern of growth,8] but if you don't take them, you might be 5′ 10″. That's always been my best plan and that works. Because they think, ‘Oh shit, I don't want to end up 5′ 7″ when I could be taller’. (Steroid user and gym owner aged 45)

In addition, a number of experienced steroid users told how they encouraged younger users to go to harm reduction services such as needle and syringe programmes to obtain sterile injecting equipment in order to prevent the transmission of blood borne viruses. Overall, belonging to peer and social groups of steroid users meant having access to and being influenced by information and advice with the potential to reduce the harms of steroid use. In these ways, norms and practices within environments may serve to establish boundaries by constructing ‘sensible’ and ‘responsible’ drug usage.

By contrast, viewpoints, shared norms and perceived wisdom of users also appeared to have the potential to increase risk. The widely accepted anabolic steroid ‘knowledge base’, passed on from user to user, is largely derived from informal self-experimentations, along with users’ interpretations of the ‘literature’ which, in many cases, was restricted to anecdotes and peer accounts of their respective self-experimentation. In instances where robust scientific evidence was considered this was normally via a third party's interpretation of findings. Here scientific studies, including animal or in vitro experiments, with limited findings can be wildly extrapolated or findings ‘cherry-picked’ to support existing beliefs or rationalise perceived effects. Even so, in the group of steroid users in this study, there was a general sense of ‘trust’ in advice from peers: I go to the gym, that's where everyone goes to train. So for everyone who's actually doing the same thing, they're all in one spot. You can get all of the information you need. Why shouldn't I trust them? Because if you look at them, and think, ‘well he must be doing something right because look at the shape of him’. They look really really good so why not trust them? (Steroid user aged 27)

The importance of this knowledge was clear, as steroid users told how they used it to decide which types of drugs and dosages to use. It was also used to distinguish between what types of anabolic steroids were considered ‘safe’: I have heard ‘Deca’ [Deca-Durabolin®; nandrolone decanoate] and ‘Sustanon’ [Sustanon® 250; containing a testosterone blend] to be the safest steroids there are, whether that is true I don't know. I have heard it off books, off people, off the Internet. (Steroid user aged 23)

The ‘proper’ use of anabolic steroids, was considered to entail variations of high doses of multiple types of anabolic steroids, provided the regimen complied with the current commonly held beliefs of synergistic efficacy, typically referred to as ‘stacking’. Moreover, the use of ancillary drugs to treat or prevent steroid induced side effects was seen as an important aspect of ‘responsible’ steroid usage. In fact, the use of ancillary drugs was perceived as the ‘sensible’ choice, rather than the reduction of steroid dosages to avoid side effects in the first place. Again, it was clear that self-experimentation was an essential part of the process: I know personally when my body requires hCG [human chorionic gonadotropin; taken by steroid users to trigger the production of testosterone in the body at the end of a steroid course]...It's hard to explain, but, for example, if you have problems with erection and things like that, then I know personally when my body needs hCG and that's usually when I take it. I know from personal experience if I need it or not. (Steroid user aged 35)

Shared guidelines among steroid users also extended to the administration of these drugs. On the one side users described injecting practices which were broadly in keeping with harm reduction messages pertaining to intramuscular injections, such as injection into the large muscle groups like the gluteus maximus (buttocks) or vastus lateralis (thigh) to promote diffusion and minimise the risk of abscess formation.5 The rotation of injection sites to avoid damage and complications was also outlined. However, injections in the smaller muscles, such as the triceps brachii (back of the arms), were also promoted among users as ways to achieve a ‘direct effect in the specific muscle’ (steroid user aged 27)—referred to as ‘spot injections’ among steroid users. There is no evidence to support this action and the likelihood of injection-related complications is increased. This practice highlights the ‘conflicts’ between information disseminated among users (promoting the perceived efficacy of ‘spot injections’) and the contradictory harm reduction message from needle and syringe programmes (injecting only into large muscle groups).

Read together, multiple factors influenced steroid-related behaviour in this group of users, with peer influence being mentioned in most cases. Some appeared to have a positive influence on the risk posed by this behaviour. However, it was clear that being part of the steroid using culture ultimately seemed to create a sense of safety among steroid users regarding their use of these drugs, which appears to be misplaced.