Facilitators and Barriers to Health Care Access Amongst people using Image and Performance

Enhancing Drugs in Wales

Findings & Outcomes

report

About Public Health Wales Public Health Wales exists to protect and improve health and wellbeing and reduce health ine-qualities for people in Wales. We work locally, nationally and internationally, with our partners and communities. The Substance Misuse Programme works to address both the current and emerging public health threats in Wales and in line with the overarching strategic objective to ‘reduce health inequalities, and prevent or reduce communicable and non-communicable disease, wider harms and premature death related to drugs and alcohol’.

Substance Misuse ProgrammePublic Health WalesNumber 2 Capital QuarterTyndall StreetCardiff CF10 4BZTel: 02920104496

www.publichealthwales.org/substancemisuse

About Public Health Institute

The Public Health Institute at Liverpool John Moores University specialises in applied research addressing health issues at all levels from policy development to service delivery. Public Health In-stitute is committed to a multidisciplinary approach to public health and works in partnership with health services, local authorities, judicial bodies, environmental services and community groups.

Influencing health service design and delivery, as well as health related policy, the Public Health Institute’s research has been at the forefront of the development of multi-agency strategies to pro-mote and protect public health.

Public Health InstituteLiverpool John Moores University3rd Floor Exchange StationTithebarn StreetLiverpool L2 2QP

https://www.ljmu.ac.uk/research/centres-and-institutes/public-health-institute

Acknowledgements: The research team and Public Health Wales would like to thank all those that contributed to this work.

Research Team: Public Health Wales: Josie Smith, Dean Acreman, Gareth Morgan.Public Health Institute, Liverpool John Moores University: Prof Vivian Hope, Dr Conan Leavy.

Suggested citation: V Hope, C Leavy, G Morgan, D Acreman, D Turner and J Smith. Facilitators and barriers to health care access amongst people using image and performance enhancing drugs in Wales: Findings & Outcomes Report. Public Health Wales, 2020

Contents

1 Executive summary 1 1.1 Key findings 1 1.2 Recommendations 1

2 Introduction 3 2.1 Background & context 3 2.2 The study 5

3 Method & Participants 6 3.1 Interviews with people using anabolic-androgenic steroids 7 3.2 Interviews with those providing services 7 3.3 Evidence Gathering & Synthesis Event 7

4 Findings and observations 9 4.1 Motivations, knowledge and information 9 4.2 Identity, stigma, and service engagement 14 4.3 Service delivery, practices and policy 18 4.4 Suggested recommendations for service improvement 25 4.5 Consensus on preliminary recommendations for service improvement and development 26

5 Conclusions & Recommendations 29

6 References 30

Building on the national surveys of image and performance enhancing drug use undertaken in both 2015 and 2016 (available at: www.ipedinfo.co.uk), a qualitative research project was undertaken in Wales to explore the barriers and facilitators to health care access amongst people using anabolic-androgenic steroids (AAS) and other image and performance enhancing drugs (IPEDs). The aim of this research was to identify low cost (<£5k) or no cost service improvements and interventions to encourage early engagement with health and related services by people using IPEDs in order to reduce health harms, be they physical, psychological and/or social. This study utilised data and ideas gathered through semi-structured qualitative interviews with individuals using anabolic–androgenic steroids and those providing community-based health and related services that should be accessed by this group and an Evidence Gathering and Synthesis Event which involved a wide range of stakeholders. Ideas for services improvements identified through these activities were then synthesised into a number of recommendations.

Whilst this work was undertaken in Wales, in light of the findings from the previous IPED surveys and extensive engagement with this population across England, Scotland and Wales, the findings and recommendations are considered to be generalizable to the wider UK population using AAS and other image and performance enhancing drugs.

Within this study reported durations of AAS use varied from a couple of years to several decades and motivations for use were varied and often changed over time. However, it was often perceived by individuals that their motivating factors were often undervalued or misunderstood by health professionals, with little credit being given to other lifestyle commitments e.g. diet and training. All participants using AAS had experienced or witnessed harmful side effects linked in part or fully to AAS use, however the majority of participants minimised the health risks. Concerns were raised by all participants groups regarding the availability and accessibility of evidence based information for both people who use AAS and other IPEDs and frontline professionals.

Most participants perceived their AAS use to be problematic in terms of incurring social risk, many felt judged by friends, family, work colleagues, and health care services. This negatively impacted on their willingness to disclose AAS use to health professionals and to seek appropriate healthcare. Facilitators to service engagement included non-judgemental and knowledgeable staff who were willing to acknowledge participants’ own expertise and offer targeted services.

It was widely recognised by all that there was a growing use of online technologies by individuals using AAS as a method in obtaining injecting paraphernalia and accessing metabolic testing. Such services were commonly viewed as more convenient and accessible when compared to traditional methods, and highlighted the importance for wider outreach and engagement services.

1

1.1 Key findings

1 Executive Summary

2

a.

b.

c.

d.

e.

f.

Government bodies, academic institutions and health services to provide resources and undertake a review with the aim of developing the evidence base on the use of online technologies (including social media) to facilitate effective health service engagement and e-clinics. This work should include online advice and triage clinics targeted towards young people using AAS currently not engaged with existing services

Public health bodies, community substance misuse leads and commissioners to develop best prac-tice guidance on the implementation of effective assertive outreach services and adaptation of health and social care settings to optimise on-site engagement

In collaboration with registered professional bodies (including; RCGP, RCN, RCPsych, GPhC), public health bodies to develop value-based ‘AAS for healthcare professionals’ training and knowledge shar-ing opportunities (including e-learning and GP cluster events). Products to be embedded as a core training programmes within NHS Trusts/Health Boards and community health services.

Adopting a ‘whole person’ approach, substance misuse commissioning boards to undertake a bienni-al comprehensive network mapping and gap analysis exercise of local health and social care services accessible to individuals using AAS. The mapping and gap analysis exercise should include:• Substance misuse and harm reduction• Physical health, mental health and wellbeing• Diet, nutrition, exercise and training advice • Sports injury• Sexual health and wellbeing

This work should lead to the development of a local/regional service directory for dissemination via outreach services, local health and social care expert AAS fora and establishment of dedicated AAS health and well-being clinic sessions within existing services

Public health bodies and AAS leads to produce the following essential documents:• A ‘What to expect’ document developed for distribution across gyms/fitness venues aimed at owners, managers and staff on working with AAS outreach services• Collation of all local/regional AAS health and social care directories for inclusion on national websites e.g. IPEDInfo.co.uk• A written statement on the implications and importance of AAS disclosure during a medical consultation or treatment

Public health bodies in collaboration with UK wide academic institutions to undertake research to establish a robust prevalence estimate of AAS use and evidence of harms associated with use.

1.2 Recomendations

Evidence suggests there has been a rise in non-prescribed use and injection of image and performance enhancing drugs (IPEDs), particularly anabolic-androgenic steroids (AAS) and associated drugs, in the United Kingdom over recent decades. In particular, the estimated number of 16 to 59 year olds reporting lifetime use of anabolic steroids in the Crime Survey for England and Wales has increased from 194,000 in 2005/06 to 271,000 in 2015/16.1. The survey is likely to be unreliable for rare events like anabolic steroid use and so it may under-estimate the extent of their use; however, data from needle and syringe programmes also indicate that use of IPEDs is likely to be increasing. 2.

The motivations for using AAS and other associated IPEDs are varied, and these and the other drivers of use have probably changed over time. Among longer established groups of people using AAS and associated drugs, such as bodybuilders and strength athletes, who have been most studied, being “bigger, stronger” is typically the rationale. However, there are a wide range of issues impacting on use and a more complex picture of interrelated factors associated with body image, masculinity, psychological well-being and early influences has emerged.3. 4. 5.

The use of IPEDs, including AAS, for aesthetic purposes probably represents the most common driver of their use in the UK.6. Recent work to develop typologies of AAS use has identified four broad types of people using these drugs: the expert, the athlete, the wellbeing, and the YOLO (You Only Live Once) types (Figure 1).7. 8. Though these groupings are likely to need further refinement, they illustrate the heterogeneity of those using AAS and associated IPEDs.

There are a diverse range of IPEDs that are being used, these include, “fat burners”, tanning agents and a range of hormonal products designed to assist or accelerate physical or physiological changes, as well as AAS. Whilst some of these substances are recognised medical preparations, some are sold as ‘research chemicals’ with little or no clinical testing.10. These drugs are frequently sourced illicitly. Evidence from testing of seized products shows a significant proportion are counterfeit or home produced, and as such; are of highly variable quality, may contain substances other than those reported on the label, have varying dose strengths, or have a high bacterial load; all of which can contribute to potential serious health risks and harms.

A number of potential health risks have been identified with the use and injection of AAS and other associated IPEDs. Many well established harms of AAS are comparatively minor (e.g. acne), however other harms include more severe physical (e.g. cardiovascular disease, damage to the liver) and psychological (e.g. mood changes, increased aggression) problems.9. 10. 11. Many IPEDs, including AAS, can be injected, and so their use can lead to health issues that result from poor or unhygienic injection practice, including soft-tissue damage and infections.12. 13. 14.

A lot of people I train with I know wouldn’t want to go to A&E or wouldn’t want to go to their doctor and they wouldn’t want any record of them using steroids. (DA01)

3

“”

2 Introduction

2.1 Background & context

A TYPOLOGY OFMALE STEROID USERS

AND THEIR RISKSEffectivenessEffectivenessLOW HIGH

Ris

ks

Risks

HIG

H

THE YOLO TYPE THE ATHLETE TYPE

THE EXPERT TYPETHE WELL-BEING TYPE

LOW

Design: Human Enhancement Drugs Network, Birmingham City University, Public Health Institute (LJMU) and Aalborg Antidoping (Aalborg Municipality, DK)

Reference: Christiansen, Vinther & Liokaftos. 2016. Drugs: Education, Prevention and Policy, 1-11.

More information is available at www.humanenhancementdrugs.com

A TYPOLOGY OFMALE STEROID USERS

AND THEIR RISKSEffectivenessEffectivenessLOW HIGH

Ris

ks

Risks

LOW

HIG

H

THE YOLO TYPE

THE WELL-BEING TYPE THE EXPERT TYPE

Motivated by impatience, curiosity and influence from peers and authoritative role models.

Focus on asserting his masculinity (e.g. impressing girls and advancing upwards in the male hierarchy).

Little to no concern about side effects and towards general health

Aims at immediate benefits.

Low level of ‘steroid knowledge’ - based on lore and advice from ‘gym rats’

Risk-taking lifestyle (e.g. recreational drug use andis more likely to end up in fights than the other types)

Little concern about diet, training and recovery

Motivated by vanity and/or wishes for restoration or rejuvenation

Focus on well-being, moderation and peer recognition (e.g. during summertime)

Considers side effects and wants to play it safe

Aims at slight improvements

Medium level of knowledge – based on own experience, online fora and other users

Wants to improve his quality of life and has a relaxed take on nutrition

Focus on healthy living and are typically older

Motivated by competitive aspirations

Focus on performance(e.g., skills, size, and definition).

Concerned with side effects but willing to run health risks in order to fulfil sporting ambitions.

Aims at maximising benefits by combining different steroids (stacking) with other performance and image enhancing drugs (polypharmacy)

Medium to high level of knowledge – based on medical assistance and experience from his sporting community.

Plans training and diet according to season – avoids recreational drugs.

Dedicated to the athlete life style

Motivated by lay scientific curiosity and a fascination with pharmacological performance enhancement.

Focus on muscularity, learning and knowledge sharing.

Very concerned with side effects and wants to play it safe

Aims at optimising benefits with a perceived sensible drug regimen

High level of knowledge – based on various sources including scientific papers

Values health and monitors his body systematically (e.g. in collaboration with physician)

Offers advice on harm reduction to others and seeks recognition as a source of expertise on steroids.

Design: Human Enhancement Drugs Network, Birmingham City University, Public Health Institute (LJMU) and Aalborg Antidoping (Aalborg Municipality, DK)

Reference: Christiansen, Vinther & Liokaftos. 2016. Drugs: Education, Prevention and Policy, 1-11.

More information is available at www.humanenhancementdrugs.com

Figure 1: A typology of men using anabolic-androgenic steroids and their risk by Christiansen, Vinther & Liokaftos (2016)

Whilst it is clear that there are harms associated with the use of AAS and associated IPEDs (figure 2), the uptake of healthcare and prevention services related to these is often poor.15. Data indicates that people who use these drugs will often choose to either wait for symptoms to go away or self-medicate with ‘natural remedies’, over the counter medication, or diverted pharmaceuticals.16. 17.

18. For example, findings from the recent national IPED Info survey* indicated that more than half waited for symptoms of side-effects to go away on their own without seeking medical help/advice, and a third self-medicated.6. In part, this reluctance to use healthcare services is probably due people being cautious about disclosing their use of AAS and other IPEDs to professionals, and so using peers for advice on use, preventing harm and managing any side-effects.19.

Furthermore, people who use AAS and other IPEDs may not perceive themselves as a ‘drug user’, as they are not using psychoactive drugs including cocaine or heroin,20. and so may not access specialist drug services and harm reduction interventions such as needle and syringe programmes. Recent studies indicate that the levels of blood borne viral infections among those injecting IPEDs are higher than among the general population 21. and that worryingly many of these infections remain undiagnosed.22. Thus, there is a need to improve access to health and prevention services for this group.23.

People who use AAS and other IPEDs can experience a range of preventable acute and chronic health problems due to the effects of the substances they use on their bodies. These potential harms could be reduced through regular metabolic testing and prompt health care seeking in response to symptoms of a possible problem. The little available evidence indicates that regular metabolic testing is limited, and typically done privately, and those using IPEDs may not always recognise symptoms or readily access health services in response to these.

In addition to the harms associated with the use of AAS and other IPEDs, evidence indicates a range of additional risk behaviours common amongst some of those using these drugs including sexual risk taking (Figure 2), which may result in sexually transmitted infections, psychoactive drug use and high alcohol consumption levels.6.

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4

* Available at: http://www.ipedinfo.co.uk/resources/downloads/2016%20National%20IPED%20Info%20Survey%20report%20FINAL.pdf

Figure 2: National IPED Info Survey findings infographic. Public Health Institute & Public Health Wales (2016)

To take part in our 2016 survey visit www.ipedinfo.co.uk or ask:

Survey closes December 1st 2016.

* Statistics taken from Hope, VD et al. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ pen 2013; 3:e003207.

Injected... in past year:

ANABOLIC STEROIDS 73%

GROWTH HORMONE 26%

MELANOTAN 10%

HUMAN CHORIONIC GONADOTROPIN 21%

Sexual behaviour:

81%

48%

ONE SEXUAL PARTNER

LAST YEAR

43%

TWO OR MORE

SEXUAL PARTNERS LAST YEAR

7%

NO SEXUAL

PARTNERS LAST YEAR

HAD UN- PROTECTED

SEX IN THE PAST YEAR

Infections:*

HEP B 8.8%

HEP C 5.5%

HIV 1.5%

Adverse effects in past year:

TESTICULAR ATROPHY (25%)

PAIN AT INJECTION SITE (26%)

GYNAECOMASTIA (12%)

INCREASED AGGRESSION

(17%)

MOOD SWINGS

(26%)

ABSCESS, SORES OR OPEN

WOUNDS (2%)

Drug use in past year:

CANNABIS+

24%

ECSTASY+

10%

COCAINE*

22%

SPEED* 7%

Injection sites:

GLUTEUS 82%QUADRICEPS 47%

DELTOID 32%TRICEPS 7%BICEPS 5%ABDOMEN

4%PECTORAL

3%

FRONTBACK

IPEDS 2015 SURVEY RESULTSipedinfo.co.uk

This report presents the key findings and recommendations from a research study that aimed to evidence the barriers and facilitators to accessing health services among people injecting AAS and other associated IPEDs. The focus of this work was to identify low cost/no cost (that is at a cost between £0 and £5K per annum) service delivery modifications that could improve the availability and acceptability of prevention initiatives and early health care interventions for this group. These interventions should aim to address one or more areas of health, including physical and psychological health and well-being, injecting site infection, injury identification and treatment including use of analgesia and risk of dependency, hepatitis B vaccination and blood borne virus testing.

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5

2.2 The study

This study utilised three data collection activities involving people from across Wales.

Two sets of semi-structured qualitative interviews explored understandings of the harms associated with using AAS and other associated IPEDs, and the barriers and facilitators to accessing health services, involving:a. Individuals using anabolic–androgenic steroidsb. Individuals providing community-based health and related services that should be accessed by this group.

An Evidence Gathering and Synthesis Event which involved a wide range of stakeholders including providers of a range of NHS primary and secondary care services

Recruitment for the two sets of interviews took place in a number of selected local areas across Wales. Though these were pragmatically selected, they were geographically diverse reflecting a mix of urban and more rural settings. Participants in the Evidence Gathering and Synthesis Event were from across Wales. This study was approved by LJMU Research Ethics Committee.

The semi-structured interviews with men aged 18 years or over who were using AAS were conducted face-to-face. Participants were recruited from three regions in Wales; North East Wales, South and South East Wales Valleys, and Cardiff. The recruitment approach aimed to include participants who were using AAS for: ‘occupational’ reasons, those engaged in amateur competitive sport, and those whose use was for aesthetic purposes.

Participants were recruited in each area through individuals working in community settings and in specialist gyms who come into contact with people who are using AAS. These individuals acted as ‘gatekeepers’ introducing possible participants to a researcher and/or facilitated the study researcher’s access to recruitment settings. Interviews were undertaken between autumn of 2017 and summer of 2018, and were usually audio recorded, where the participant didn’t want to be recorded detailed field-notes were made. All participants provided written consent before being interviewed, and could opt out of the study at any point. The interviews were undertaken by trained researchers in a private safe space, convenient for the interviewee and lasted between 30 and 75 minutes. An agreed topic guide was followed during the interviews that explored their use AAS and other IPEDs, their knowledge and experience of harms related to use of these and health service engagement.

A total of 17 participants were recruited from three regions in Wales; North East Wales (5), South and South East Wales Valleys and Cardiff (12). There ages ranged from 20 years to 53 years old. The participants report durations of AAS use that varied from a couple of years to several decades.

All of the participants were men, and they included people who were using AAS for ‘occupational’ reasons, those engaged in amateur competitive sport, and those whose use of anabolic–androgenic steroids was for aesthetic purposes. Of the interviews, 13 were audio recorded and detailed field-notes were made for the four who declined to be recorded.

63 Method & Participants

1.

2.

3.1 Interviews with people using anabolic–androgenic steroids (AAS)

3.1.1 The participants

Semi-structured interviews were undertaken with invited individuals who were employed in, or led, community-based health, social care or related services that were being, or could have been, accessed by people who use AAS. These interviews lasted between 30 and 45 minutes, and were conducted either face-to-face or, when this was not practical, by telephone.

A list of relevant service providers was accessed through Public Health Wales and service directories. Those identified were initially emailed information about the study. Agreement to participate and the arrangements for interview was then established via telephone. All participants provided written consent before their interview, and were able to opt out of the study at any point.

The interviews were conducted by a trained researcher in a private and safe environment, usually at the person’s place of work. Semi-structured interviews were then completed following an agreed topic guide which explored: their role in current service provision, their knowledge of the use of AAS and other IPEDs, and their understandings of possible barriers and facilitators to service access.

The interviews were digitally recorded, and the researcher took additional field notes as needed to support the interview process. The recordings themselves were used in the analyses, alongside interview notes.

Interviews were completed with eight service providers during the autumn of 2017 and the winter of 2018. Participants worked in a range of settings including, needle and syringe programmes, drug use related outreach, community pharmacists, and professionals involved in the provision of community based sport and fitness related healthcare. All were currently working in roles that involved direct contact with people using IPEDs, and had been in their current role for at least several years.

The Evidence Gathering and Synthesis Event for the study was held in Cardiff on the 7th November 2018. It brought together a range of people including those from healthcare, public health, and the drug use fields, with people who had experience of using AAS and gym owners. Its overall aim was to explore options for service delivery developments that could improve the uptake of health services by those using AAS and other IPEDs for acute health issues; the prevention of health problems; and providing harm reduction interventions. The focus was on practical and low cost ideas for service delivery developments.

The day operated under the ‘Chatham House Rule’ to encourage frank and open discussion. Participates didn’t have name badges and they were not provided with a list of fellow participants.

The Evidence Gathering Event was structured on the COM-B behaviour change model. The first part of the day involved structured mixed groups discussions to explore issues impacting on service uptake using the following four questions:

Question 1: Can you identify, explain and discuss lifestyle factors or behaviours that may influence early engagement amongst IPED users for physical, psychological and social/relationship issues?

Question 2: Can you identify, explain and discuss social and environmental factors that may influence early engagement amongst IPED users for physical, psychological and social/relationship issues?

73.2 Interviews with those providing services

3.2.1 The participants

3.3 Evidence Gathering & Synthesis Event

8Question 3: Can you identify, explain and discuss policy and practices (of providers) that may influence early engagement amongst IPED users for physical, psychological and social/relationship issues? Question 4: Can you identify, explain and discuss access and quality issues within existing health and related services that may influence early engagement amongst IPED users for physical, psychological and social/relationship issues?

The discussion in each group was led by an experienced facilitator and a scribe took detailed notes, and as needed asked the group to validate the recording of key points. After the groups session all participants came together for an interactive feedback session to allow reflection on the groups’ discussions.

After lunch the key findings from the two sets of interviews undertaken as part of this study (see sections 3.1 and 3.2 above) were then presented and then discussed. Service delivery developments that were generated from both the interviews and during the group work in the morning were then developed by the study team into a set of suggested outline options for service delivery developments and improvements. The participants were then asked to vote on whether they supported each of these using an anonymous interactive smart phone application. The voting choices for each of the suggested options were: ‘Strongly Agree’, ‘Agree’, ‘Disagree’, or ‘Strongly Disagree’.

In this section the conclusions arising from the study findings are presented. A summary of findings from the semi-structured interviews conducted with people using AAS, service providers and the Evidence Gathering and Synthesis Event that underpin these conclusions and the recommendations are also presented within this section.

Findings have been categorised and tabulated into the following core themes: • Motivations, knowledge and information • Identity, stigma and relationship with services• Service delivery, practices and policy

In addition, the preliminary recommendations for service improvements that developed from the interviews and during the Evidence Gathering and Synthesis Event have been summarised in this section.

Both the observations and evidence related to the first theme Motivations, knowledge and information from qualitative interviews with people using AAS, service providers and the Evidence Gathering and Synthesis Event discussions are detailed in Table 1 (T1).

In this study a wide range of motivations were reported by the participants using AAS which had contributed to the initiation and continuation of use; these included meeting sporting or body building goals, but also confidence and body image issues. A common theme was that the motivations for using AAS and other IPEDs change throughout someone’s life, making categorisation difficult and dependent on other life goals, physical and mental health at the time.

Perceptions amongst service providers about why people used AAS and other IPEDs were often related to the types of clients they had engaged with. Overall the participants felt that the predominant group of people using AAS and other IPEDs were those using these drugs for aesthetic enhancement purposes. Use of these substances for aesthetic enhancement was seen as a reflection of the increasing social pressures related to male body image. These pressures were perceived by services as being widespread in society generally, but also as being important within many social networks and in gym and fitness environments [T1 row 1.1].

Knowledge and information surrounding both the short and long term effects of AAS use was typically well recognised amongst the interviewed participants using AAS. However, perceptions of safety were often relativized in the context of the use of other substances, participating in other healthy lifestyle behaviours (e.g. weight training and exercise, managed diet), and taking personal responsibility around their use [T1 rows 1.2, 1.3].

94 Findings and observations

4.1 Motivations, knowledge and information

4.1.1 Motivations for use

4.1.2 Perceived risk and harms

Amongst service providers, the accessibility of reliable and appropriate knowledge and information related to the use and effects of AAS and other IPEDs by those using or thinking about use, was another common theme [1.2]. There were concerns that many people using these drugs relied on internet forums, websites, their peers, and their ‘dealers’ for information about what to use and how to use AAS and other IPEDs. Information from these sources, though sometimes robust, is often incomplete, and sometimes inaccurate and misleading. Furthermore, sexual health risks and risk of blood borne viral infection were often underestimated. It was felt making access to reliable, neutral and scientifically based information was seen as an important area for action. Such information is available on a number of websites, though these sites may need some further development to ensure they are up-to-date, engaging and accessible. It was suggested that better signposting of people to these reliable sources of information using a range of means would be useful.

All interviewed participants using AAS had experienced or witnessed harmful effects linked in part or fully to the use of AAS. Whilst the potential impact of such side effects were recognised by most, in some cases impact was trivialised or disregarded [T1 row 1.4]. In the main, the management of side effects varied depending on its perceived nature by the individual. For example, effects perceived as cosmetic in nature (e.g. gynecomastia, acne, testicular atrophy) tended to be self-treated, whereas most felt they would seek medical advice for more serious side-effects that involved major organs [T1 row 1.5]. Discussions between service users and service providers surrounding side-effects often related to cosmetic and acute health effects rather than long term impacts associated with use. Concerns were raised within all participant groups about the levels of knowledge and understanding of the use of AAS and other IPEDs amongst those delivering services that are, or should be, being used by people using AAS and other IPEDs. There were particular concerns in relation to those staff working in pharmacies providing needle and syringe programmes, due to the high staff turnover and limited time for training, and also amongst primary care providers. It was suggested training should be available through easy to access routes, such as, online courses including refresher training. The training should cover approaches to effective engagement with this group, in addition to providing understandings of the reasons for, and nature of, AAS and other IPED use.

For Table 1 - see overleaf.

10

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ng s

uch

prot

ocol

s va

ried

.

Conc

erns

wer

e ra

ised

am

ongs

t the

ser

vice

pro

vide

rs

and

evid

ence

gat

herin

g ev

ent s

urro

undi

ng th

e so

urce

and

orig

in o

f inf

orm

atio

n ob

tain

ed b

y in

divi

dual

s us

ing

AA

S. W

ith m

any

obse

rvin

g in

form

atio

n ha

ving

bee

n ob

tain

ed fr

om n

on-o

ffici

al

onlin

e so

urce

s, fo

rum

s an

d pe

ers.

As

such

kno

wle

dge

abou

t the

long

er te

rm h

arm

s, th

e sa

fety

of i

llici

tly-

obta

ined

AA

S an

d ot

her I

PED

s, or

wha

t was

‘saf

e’ us

age

of th

ese

drug

s am

ong

thos

e us

ing

them

was

va

riabl

e. F

urth

erm

ore,

thos

e us

ing

AA

S an

d ot

her

IPED

s te

nded

to u

nder

estim

ate

thei

r sex

ual h

ealth

ris

ks a

nd ri

sk o

f blo

od b

orne

vira

l inf

ectio

n, s

uch

as,

HIV

and

hep

atiti

s C.

Part

icip

ant

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Evid

ence

gat

herin

g ev

ent

Evid

ence

“Erm

, I’d

be

lyin

g if

I sai

d it

was

n’t a

n ae

sthe

tic a

spec

t to

it, I’d

be

lyin

g if

I sai

d th

at.”

(DA

07)

“Er,

wel

l with

box

ing,

I mig

ht sa

y it’

s to

get fi

t, er

m, b

ut m

ore

vani

ty

real

ly.”

(DA

08)

“... i

t is a

bout

bod

y im

age,

it is

pee

r pre

ssur

e, w

antin

g to

look

goo

d,

wan

t to

have

bet

ter m

uscl

es th

an so

meo

ne e

lse

at th

e gy

m...”

(G

M08

)

“aes

thet

ic re

ason

s [ar

e th

e m

ost c

omm

on],

it’s t

he p

ress

ure

in te

rms

of m

ale

body

imag

e ha

s defi

nite

ly I w

ould

say

has d

ram

atic

ally

in

crea

sed

in th

e la

st o

ne o

r tw

o de

cade

s, ce

rtai

nly

now

ver

y m

uch

mor

e pr

essu

re fo

r men

to lo

ok a

cert

ain

way

, go

to g

yms,

and

enga

ge w

ith a

t lea

st so

me

elem

ent o

f hea

lth a

nd fi

tnes

s, th

ey a

re

sayi

ng th

at fi

t is t

he n

ew ri

ch; I

thin

k th

at is

the

larg

est p

opul

atio

n ta

king

it, t

o lo

ok a

cert

ain

way

”. (G

M05

)

“Mal

es n

ow m

ore

awar

e of

the

body

shap

e“. (

GM

04)

“I th

ink

the

side

effe

cts a

re p

oten

tially

ove

r egg

ed. I

t’s o

nly

thos

e us

ing

huge

dos

es, o

ver l

ots o

f cyc

les a

nd se

vera

l yea

rs, w

ho te

nd to

su

ffer.”

(D

A10

)

“Fro

m m

y ex

perie

nce,

I hav

e fo

und

them

to b

e ve

ry sa

fe to

be

hone

st. T

he o

nly

thin

g th

at is

eve

r in

ques

tion

is so

urce

and

lab

and

legi

timac

y.” (D

A07

)

“I th

ink

as lo

ng a

s you

’re n

ot a

busi

ng it

... I’

m b

lasé

abo

ut it

, inj

ectin

g st

eroi

ds, i

t doe

sn’t

even

ent

er m

y he

ad, t

he ri

sks.”

(C0

1)

“I th

ink

it ca

n be

as s

afe

as a

nyth

ing,

to b

e ho

nest

, if i

t’s u

sed

corr

ectly

.” (D

A02

)

“I th

ink

if it’

s don

e co

rrec

tly a

nd y

ou’v

e go

t the

righ

t sor

t of a

dvic

e -

it’s s

afe.”

(D

A06

)

Sour

ces

of in

form

atio

n w

ere

typi

cally

onl

ine,

and

oft

en b

ased

on

anec

dote

s, or

lite

ratu

re s

umm

arie

s, an

d fr

om n

on-o

ffici

al s

ourc

es.

The

inte

rnet

was

per

ceiv

ed a

s th

e m

ain

sour

ce o

f inf

orm

atio

n,

with

inte

rnet

sea

rche

s an

d fo

rum

s us

ed to

see

wha

t oth

ers

are

usin

g. S

ome

peop

le a

lso

sour

ced

deta

il ab

out w

here

and

how

co

mpo

unds

are

mad

e, in

clud

ing

qual

ity o

f pro

duct

ion.

Peo

ple

are

inte

rest

ed in

wha

t wor

ks, w

hat d

oesn

’t w

ork,

inte

rpre

tatio

n of

blo

od te

sts,

wha

t sup

plem

ents

to ta

ke, e

tc.,

but q

ualit

y of

in

form

atio

n ac

cess

ed o

nlin

e ab

out t

hese

is n

ot a

ssur

ed.

>

12N

o.

1.3

1.4

1.5

Them

e

Perc

eive

d ris

k an

d ha

rms

Perc

eive

d ris

k an

d ha

rms

Perc

eive

d ris

k an

d ha

rms

Obs

erva

tion

Rela

tivi

zed

risk

taki

ngA

mon

gst t

hose

usi

ng A

AS,

the

risk

from

AA

S us

e w

as o

ften

rela

tiviz

ed to

oth

er fo

rms

of d

rug

use

and

as s

uch

perc

eive

d as

saf

e.

Min

imis

ing

the

impa

ct

All

part

icip

ants

usi

ng A

AS

had

expe

rien

ced

or

witn

esse

d ha

rmfu

l effe

cts

linke

d in

par

t or f

ully

to

the

use

of A

AS

or o

ther

IPED

S. F

or th

e m

ost

part

, par

ticip

ants

thou

ght t

hey

wer

e se

nsib

le a

nd

mod

est i

n th

eir u

se, a

nd th

at it

was

oth

er p

eopl

e w

ho ‘a

buse

d’ A

AS

and

who

ther

efor

e su

ffere

d th

e m

ore

seve

re c

onse

quen

ces.

How

ever

, in

som

e ca

ses

clos

er s

crut

iny

iden

tified

inci

denc

es w

here

th

e im

pact

of s

ide

effec

ts w

ere

dow

n pl

ayed

or

disr

egar

ded.

Cons

ider

ed ri

sk ta

king

O

vera

ll, p

artic

ipan

ts u

sing

AA

S do

wnp

laye

d ri

sks,

em

phas

ised

thei

r ow

n ra

tiona

l use

and

m

inim

ised

thei

r exp

erie

nces

of h

arm

s. M

ore

seve

re

cons

eque

nces

of A

AS

use

wer

e ac

know

ledg

ed

impl

icitl

y or

exp

licitl

y an

d ge

nera

lly a

scri

bed

to

‘mis

use’

by

youn

ger,

irre

spon

sibl

e or

less

edu

cate

d us

ers.

Serv

ice

prov

ider

s al

l not

ed th

at th

e pe

ople

usi

ng A

AS

and

othe

r IPE

Ds

also

dow

n pl

ayed

risk

s as

soci

ated

w

ith th

e us

e of

thes

e dr

ugs.

This

was

rela

ted

to a

cu

ltura

l per

spec

tive

that

see

s th

e us

e of

IPED

s as

be

ing

rela

ted

to b

eing

in ‘g

ood

heal

th’ a

nd ‘fi

t’.

It w

as o

bser

ved

that

sev

eral

par

ticip

ants

usi

ng

AA

S lis

ted

a nu

mbe

r of m

inor

or a

ccep

tabl

e si

de-

effec

ts w

hich

wer

e vi

ewed

as

cosm

etic

(inc

ludi

ng

gyne

com

astia

, acn

e, b

oils

) and

wou

ld ty

pica

lly b

e ig

nore

d or

sel

f-tr

eate

d.

Inte

rest

ingl

y, a

mon

gst s

ome

serv

ice

prov

ider

s it

was

fe

lt an

y se

rvic

e us

er c

once

rns

abou

t the

har

ms

that

m

ight

aris

e fr

om u

se o

f AA

S an

d ot

her I

PED

s w

as

mai

nly

focu

sed

on th

e ac

ute

harm

s pa

rtic

ular

ly th

at

can

have

an

aest

hetic

effe

ct, s

uch

as, g

ynec

omas

tia,

acne

, moo

d, a

nd a

bsce

sses

.

Part

icip

ant

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Evid

ence

“I th

ink

it ca

n be

use

d at

a sa

fe le

vel,

like

any

drug

, lik

e al

coho

l, lik

e to

bacc

o…

I thi

nk it

’s ve

ry sa

fe to

be

hone

st, s

afer

than

recr

eatio

nal d

rugs

.”

(C01

)

“Did

n’t h

ave

any

dam

agin

g eff

ects

.” (C

O3)

Sub

sequ

ently

he

wen

t on

to d

escr

ibe

bein

g ho

spita

lised

for a

car

diac

eve

nt a

ttrib

uted

at

leas

t in

part

to h

is u

se o

f AA

S. T

his

prom

pted

him

to g

ive

up

taki

ng A

AS

afte

r tw

o de

cade

s of

use

.

“I do

n’t r

eally

find

I get

bad

side

effe

cts i

n re

gard

to m

ysel

f.” (

DA

08).

But l

ater

reco

unte

d ha

ving

an

oper

atio

n ou

tsid

e th

e U

K to

trea

t hi

s gy

neco

mas

tia a

nd a

lso

stom

ach

pain

s, pa

infu

l tes

ticle

s, an

ab

sces

s re

quiri

ng d

rain

ing

and

“rea

lly b

ad m

enta

l pro

blem

s”

(DA

08) w

hen

he c

ame

off A

AS.

“In re

gard

to, a

s you

say,

thin

gs li

ke m

y liv

er, m

y ki

dney

s, th

ings

lik

e th

at, t

hen,

y’k

now

, defi

nite

ly, d

efini

tely

, go

to th

e do

ctor

s. W

ith

thin

gs li

ke a

s I d

id w

ith g

ynec

omas

tia a

nd th

ings

like

that

, I’d

try

and

trea

t the

m m

ysel

f. Th

e m

ore

visu

al st

uff, I

try

and

do m

ysel

f.” (

DA

08)

“If I w

as h

avin

g he

art i

ssue

s for

exa

mpl

e, o

r I w

as h

avin

g so

me

sort

of

kid

ney

issu

es, t

hen

yeah

, no,

I wou

ld g

o to

the

GP

‘cos a

t the

end

of

the

day,

whi

le I w

ould

n’t b

e ha

ppy

beca

use

I kno

w w

hat t

heir

resp

onse

wou

ld b

e (‘W

ell,

it’s s

elf-i

nflic

ted’

) the

y st

ill h

ave

a du

ty o

f ca

re to

trea

t me

... a

t the

end

of t

he d

ay m

y he

alth

is u

ltim

atel

y so

rt

of a

bit

mor

e im

port

ant t

han

my

prid

e.” (

DA

07)

“I’m

not

conc

erne

d ab

out a

ny si

de e

ffect

s rea

lly, n

one

of m

y pe

ers

have

exp

erie

nced

any

thin

g an

d I k

now

guy

s in

thei

r 50’

s and

60’

s w

ho w

ere

usin

g ba

ck in

the

1980

’s. I

supp

ose

from

the

ones

you

he

ar a

bout

any

thin

g to

do

with

my

hear

t con

cern

s me.

I’m

doi

ng

this

to b

e at

my

best

and

not

to m

ess m

y he

art u

p. B

ut I’m

confi

dent

in

wha

t I’m

doi

ng. I

hav

en’t

had

any

bloo

d pr

essu

re o

r oth

er te

sts.

I ca

n’t r

emem

ber t

hat l

ast t

ime

I wen

t to

a G

P to

be

fair.

” (D

A11

)

“[so

me]

peo

ple

will

say

I bou

ght t

hem

off

the

inte

rnet

... [

They

will

sa

y] ‘y

eah

I don

’t re

ally

kno

w w

hat I

am

taki

ng’...

as l

ong

as th

ey ca

n ge

t the

end

resu

lts, i

t doe

sn’t

put t

hem

off

at a

ll” (

GM

03)

“The

ben

efits

of h

avin

g a

mor

e m

uscu

lar b

ody,

and

bei

ng b

ette

r th

an so

meo

ne in

the

gym

, is w

orth

som

e of

the

side

-effe

cts w

hich

th

ey p

ossi

bly

don’

t bel

ieve

will

hap

pen

to th

em“

(GM

08)

Tabl

e 1

Cont

inue

d ov

erle

af.

13Pa

rtic

ipan

t

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Evid

ence

gat

herin

g ev

ent

Evid

ence

gat

herin

g ev

ent

Evid

ence

“...th

eir c

once

rns a

re m

ore

cosm

etic

, siz

e of

test

icle

s, gy

neco

mas

tia,

acne

, tho

se so

rt o

f thi

ngs.

“ (G

M01

)

“I th

ink,

they

kno

w a

bout

the

risks

, but

they

cho

ose

not t

o, [p

ause

] th

ink

abou

t the

long

term

cons

eque

nces

, bec

ause

it e

asie

r not

to

thin

k ab

out i

t” (

GM

03)

“The

re is

a la

rge

belie

f – a

nd th

is is

real

ly p

reva

lent

in th

e co

mm

unity

–

that

, yes

I hav

e ta

ken

ster

oids

and

ther

e ar

e so

me

risks

, but

I don

’t sm

oke,

I don

’t dr

ink,

and

I exe

rcis

e ev

ery-

day,

unl

ike

my

peer

s, so

th

eref

ore

I am

hea

lthie

r.” (

GM

05

Man

y pe

ople

who

use

ana

bolic

–and

roge

nic

ster

oids

and

oth

er

IPED

s w

ere

perc

eive

d by

the

part

icip

ants

to b

e aw

are

that

ther

e ar

e po

tent

ial h

arm

s, bu

t als

o to

thin

k th

at th

ey ‘w

on’t

happ

en to

m

e’. H

owev

er, t

he p

artic

ipan

ts p

erce

ived

that

if s

omeo

ne h

ad

a m

ajor

or s

igni

fican

t hea

lth e

ffect

it w

ould

mak

e th

em s

eek

heal

thca

re, b

ut m

inor

one

s w

ould

pro

babl

y no

t.

Will

ingn

ess

to s

elf-m

edic

ate

prob

lem

s w

as fe

lt to

be

com

mon

am

ongs

t peo

ple

usin

g an

abol

ic–a

ndro

geni

c st

eroi

ds a

nd o

ther

IP

EDs

as m

any

alre

ady

try

to s

elf-m

anag

e th

e co

mm

on s

ide-

effec

ts o

f use

.

Tabl

e 1

Cont

inue

d fr

om p

revi

ous

page

.

In this study a wide range of motivations were reported by the participants using AAS which had contributed to the initiation and continuation of use; these included meeting sporting or body building goals, but also confidence and body image issues. A common theme was that the motivations for using AAS and other IPEDs change throughout someone’s life, making categorisation difficult and dependent on other life goals, physical and mental health at the time.

The observations and evidence related to the second theme Identity, stigma and service engagement from qualitative interviews with participants using AAS, service providers and Evidence Gathering and Synthesis Event discussions are summarised in Table 2 (T2).

It was clear from both the interviews with people using AAS and those delivering services, as well as from the evidence gathering event, that issues related to stigma, particularly embarrassment, about the use of AAS and other IPEDs was an important issue for people using these drugs [T2 rows 2.1, 2.3]. People using AAS and other IPEDs were concerned about disclosing their use of these drugs, this was often related to being concerned about people judging them and being stigmatised because of their use of these drugs. A key consequence of this was a reluctance to engage with services, particularly if these services, or some service staff, were felt to be unknowledgeable or perceived as potentially being judgemental.

Further exploration of the embarrassment experienced by participants using AAS, observed that such feelings tended to manifest themselves during specific points within their AAS using career. In most cases, this was at the point of needing to seek health care advice due to realised health and wellbeing concerns linked to their AAS use. Such individuals described themselves as educated and knowledgeable around potential side effects and yet had made a confident decision to use. However, where they had found themselves in a situation where their use had resulted in them suffering from adverse effects it was at this point participants said they felt/would feel embarrassed [T2 row 2.3].

The findings indicate that service engagement strategies for this group will probably be most effective if they focus on ensuring staff have an understanding of the reasons and drivers for the use of AAS and other IPEDs [T2 row 2.2]. Individuals interviewed who were using AAS claimed that they often felt that their motivations for use were misunderstood, seen as a way of “cutting corners”, and little acknowledgment was placed on the diet and training regimes that accompany use. It was felt that staff who have some understanding of the reasons as to why people use these drugs will offer a more empathetic, non-judgemental and understanding service.

144.2 Identity, stigma, and service engagement

For Table 2 - see overleaf.

>15Ta

ble

2: S

umm

ary

obse

rvat

ions

and

evi

denc

e re

lati

ng to

Iden

tity

, Sti

gma

and

Serv

ice

Enga

gem

ent t

aken

from

qua

litat

ive

inte

rvie

ws

wit

h pa

rtic

ipan

ts u

sing

AA

S, s

ervi

ce p

rovi

ders

and

Evi

denc

e G

athe

ring

and

Syn

thes

is E

vent

dis

cuss

ions

No.

2.1

Them

e

Iden

tity

man

agem

ent

and

rela

tions

hip

with

se

rvic

es

Obs

erva

tion

Soci

al ri

sk ta

king

M

any

of th

e pa

rtic

ipan

ts u

sing

AA

S pe

rcei

ved

thei

r us

e to

be

prob

lem

atic

, if n

ot fo

r the

ir h

ealth

, the

n in

term

s of

incu

rrin

g so

cial

risk

. Suc

h in

divi

dual

s fe

lt ju

dged

– b

y fr

iend

s, fa

mily

, wor

k co

lleag

ues,

ph

arm

acis

ts, G

Ps, a

nd h

ospi

tal s

taff.

Thi

s im

pact

ed

on th

eir w

illin

gnes

s to

dis

clos

e A

AS

use

to h

ealth

pr

ofes

sion

als

or to

see

k tr

eatm

ent f

or h

ealth

pr

oble

ms

(eith

er A

AS

or n

on-a

nabo

lic–a

ndro

geni

c st

eroi

d re

late

d).

It w

as c

lear

that

som

e pa

rtic

ipan

ts u

sing

AA

S ha

d ex

peri

ence

d so

cial

risk

taki

ng A

AS,

suc

h as

be

ing

rega

rded

as

a ch

eat,

a dr

ug d

eale

r, or

a d

rug

addi

ct, a

nd th

ere

was

a w

idel

y sh

ared

feel

ing

that

he

alth

pro

fess

iona

ls d

isap

prov

ed o

f AA

S an

d ot

her

IPED

s an

d he

ld p

eopl

e w

ho u

sed

them

per

sona

lly

culp

able

for t

heir

sym

ptom

s.

Part

icip

ants

usi

ng A

AS

reco

unte

d oc

casi

ons

whe

n th

ey h

ad a

ltere

d th

eir b

ehav

iour

to a

void

fe

elin

g ju

dged

. And

a n

umbe

r of p

artic

ipan

ts fe

lt pa

rtic

ular

ly s

tigm

atis

ed b

y he

alth

pro

fess

iona

ls.

This

con

tras

ts s

tron

gly

with

oth

er s

ocia

l en

viro

nmen

ts w

here

AA

S an

d ot

her I

PED

use

is

acce

pted

and

whe

re th

e ex

pert

ise

to u

se th

em

to m

ake

‘gai

ns’ i

s re

spec

ted.

As

one

resp

onde

nt

expl

aine

d, h

e co

uld

wal

k in

to a

ny g

ym in

the

wor

ld

and

“It’s

like

bei

ng in

the

Mas

ons.”

Part

icip

ant

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Evid

ence

“I ru

n a

busi

ness

, so

if so

meb

ody

seen

me

in th

ere.

.. y

ou g

et c

lass

ed

as a

dru

g de

aler

.” (C

O3)

“I kn

ow st

eroi

ds a

re fr

owne

d up

on a

nd th

ey’re

not

exa

ctly

lega

l.”

(DA

06)

“A lo

t of p

eopl

e ou

t the

re d

isap

prov

e an

d m

ake

it qu

ite c

lear

they

di

sapp

rove

esp

ecia

lly w

ith a

lot o

f spo

rts g

over

ning

bod

ies..

. the

re’s

a bi

g cr

ack

dow

n ac

ross

eve

ry sp

ort a

t the

min

ute.

I th

ink

they

[p

eopl

e us

ing

anab

olic

–and

roge

nic

ster

oids

] don

’t w

ant p

eopl

e kn

owin

g th

at th

ey’re

doi

ng it

, tha

t the

y’re

che

atin

g I g

uess

... t

hey

hide

it, n

ot o

nly

from

thei

r GP,

but

they

’re p

roba

bly

wor

ried

that

fa

mily

, frie

nds a

nd lo

ves o

nes a

re g

oing

to fi

nd o

ut.”

(DA

06)

“I th

ink

ther

e’s q

uite

a st

igm

a at

tach

ed to

ster

oid

user

s. I k

now

pe

ople

who

’ve

been

to h

ealth

care

pro

fess

iona

ls, b

een

to th

eir d

octo

r, be

en to

A&E

, and

they

feel

ost

raci

sed,

whe

re fo

r abu

sers

like

her

oin

addi

cts,

are

trea

ted

whe

re th

e ad

dict

ion

is co

nsid

ered

an

illne

ss.

Ster

oid

user

s ...

I th

ink

are

trea

ted

like

it’s s

elf-i

nflic

ted,

like

they

’ve

brou

ght i

t on

them

selv

es a

nd th

ey’v

e on

ly g

ot th

emse

lves

to b

lam

e.

I thi

nk p

eopl

e do

look

dow

n on

ster

oid

user

s.” (

DA

01)

“I’m

not

telli

ng m

y do

ctor

I’m o

n th

e ge

ar. I

thin

k m

edic

al p

eopl

e te

nd to

look

dow

n on

you

if y

ou a

re. I

t’s y

our f

ault

you’

re in

her

e [h

ospi

tal].

..” (C

03)

“You

’re n

ot ju

dged

by

the

harm

redu

ctio

n te

am. W

here

as if

you

go

to a

che

mis

t, yo

u’re

just

a d

rug

addi

ct...

the

y do

n’t w

ant t

o kn

ow...

G

oing

to A

&E ..

. the

y re

ally

do

frow

n on

the

fact

that

you

’ve

done

it...

I t

hink

they

look

at y

ou w

orse

than

like

the

hero

in u

ser..

. Som

ebod

y w

ho ta

kes s

tero

ids i

s bot

here

d w

hat s

omeb

ody

thin

ks ..

. peo

ple

who

do

bod

y bu

ildin

g ha

ve u

sual

ly g

ot lo

w se

lf-es

teem

any

way

, tha

t’s

why

they

star

t doi

ng it

in th

e fir

st p

lace

.” (C

01)

“You

see,

the

dang

er is

... it

is a

ll un

derg

roun

d...

I thi

nk m

edic

al

peop

le te

nd to

look

dow

n on

you

if y

ou a

re [u

sing

ana

bolic

–an

drog

enic

ste

roid

s]. I

t’s y

our f

ault

you’

re in

her

e. Y

ou k

now

, whe

n I

was

in h

ospi

tal I

did

n’t g

et th

at fa

ct, b

ut I e

ven

said

to m

y co

nsul

tant

: I k

now

I pro

babl

y br

ough

t mys

elf i

n he

re. I

hol

d m

y ha

nds u

p,

y’kn

ow, a

nd n

ot m

any

peop

le w

ould

say

that

, but

I adm

itted

it.”

(C

03)

16Ta

ble

2 co

ntin

ued.

Tabl

e 2

cont

inue

d ov

erle

af.

No.

2.2

Them

e

Iden

tity

man

agem

ent

and

rela

tions

hip

with

se

rvic

es

Obs

erva

tion

Mis

unde

rsto

od/u

nder

valu

ed m

otiv

atio

nsA

num

ber o

f par

ticip

ants

usi

ng A

AS

felt

that

he

alth

pro

fess

iona

ls o

ften

mis

unde

rsto

od p

eopl

e’s

reas

ons

for u

sing

AA

S an

d ot

her I

PED

s an

d/or

did

no

t cre

dit p

eopl

e w

ho u

se A

AS

for e

xper

tise

in

achi

evin

g sp

ortin

g or

aes

thet

ic g

oals

. Co

mm

ents

mad

e du

ring

the

serv

ice

prov

ider

in

terv

iew

s su

ppor

ted

this

bel

ief,

whe

re m

any

repo

rted

that

the

peop

le th

ey s

aw w

ho w

ere

usin

g,

or th

inki

ng a

bout

usi

ng, A

AS

and

othe

r IPE

Ds,

wer

e do

ing

so b

ecau

se th

ey w

ante

d to

get

a q

uick

er

resu

lt. T

hat i

s, th

ey w

ante

d to

impr

ove

thei

r bod

ies’

appe

aran

ce m

ore

quic

kly

or w

ith le

ss e

ffort

.

Part

icip

ant

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Part

icip

ants

usi

ng A

AS

Evid

ence

gat

herin

g ev

ent

Evid

ence

“To

be th

e be

st I c

an e

very

day

. I w

ant t

o be

the

stro

nges

t I ca

n, th

e fit

test

I can

and

in th

e be

st sh

ape

I can

.” (D

A11

)

“I th

ink

it’s b

asic

ally

dow

n to

stig

ma.

It’s

stig

ma

and

a la

ck o

f un

ders

tand

ing

or a

lack

of k

now

ledg

e on

a G

P’s p

art c

oz th

ey ju

st

thin

k yo

u do

it a

nd y

ou w

anna

be

bigg

er, f

aste

r, st

rong

er, a

s big

as

you

can

get a

nd, y

ou k

now

, the

y do

n’t t

ake

it in

to a

ccou

nt th

at so

me

peop

le w

ho c

hoos

e th

at li

fest

yle,

don

’t ch

oose

it li

ghtly

and

they

will

do

it a

nd th

ey w

ill h

ave

ultim

ate

com

mitm

ent t

o it

– th

ey ca

n te

ll yo

u ev

eryt

hing

they

eat

, the

y tr

ack

all t

heir

mac

ros,

ever

ythi

ng is

ca

lcul

ated

, the

ir tim

ings

, the

ir st

acks

, y’k

now

, whe

n th

ey g

o in

to P

C,

they

kno

w e

very

thin

g ab

out i

t and

they

’ve

com

mitt

ed so

muc

h tim

e bu

t the

n th

ey ca

n ju

st g

et p

oo-p

ooed

by

a do

ctor

goi

ng, ‘s

tero

id u

ser,

out y

ou g

o.”

(DA

07)

“I th

ink

othe

r peo

ple’s

per

cept

ions

of s

omeo

ne w

ho u

ses

perf

orm

ance

enh

anci

ng d

rugs

is th

ey a

re, y

ou k

now

, 225

pou

nds,

an

arse

hole

, coz

they

’ve

got s

uch

ange

r pro

blem

s. I t

hink

oth

er p

eopl

e’s

perc

eptio

ns a

re w

here

the

issu

es li

es. I

’m n

ot e

mba

rras

sed

- it’s

just

ot

her p

eopl

e th

ink,

they

exp

ect y

ou to

be

like

som

e ra

ge m

onst

er a

nd

that

you

’re g

oing

to b

e hu

ge.”

(DA

07)

“bec

ause

I thi

nk w

e ar

e na

tion

of q

uick

fix,

we

wan

t eve

ryth

ing

now

, w

ant i

t tod

ay”

(GM

03)

“Peo

ple

wan

ting

to c

ut co

rner

s” (

GM

04)

“A lo

t of p

eopl

e I t

rain

with

I kno

w w

ould

n’t w

ant t

o go

to A

&E o

r w

ould

n’t w

ant t

o go

to th

eir d

octo

r and

they

wou

ldn’

t wan

t any

re

cord

of t

hem

usi

ng st

eroi

ds.”

(DA

01)

It w

as n

oted

that

som

e pe

ople

saw

the

use

of A

AS

and

othe

r IP

EDs

as a

‘qui

ck fi

x’ to

get

ting

a be

tter

bod

y or

bei

ng fi

tter

.

17Ta

ble

2 co

ntin

ued

from

ove

rlea

f.

No.

2.3

Them

e

Iden

tity

man

agem

ent

and

rela

tions

hip

with

se

rvic

es

Obs

erva

tion

Perc

eive

d st

igm

a an

d sh

ame

Perc

eive

d ne

gativ

e at

titud

es o

f GPs

, A&

E st

aff a

nd

phar

mac

ists

inhi

bite

d pa

rtic

ipan

ts u

sing

AA

S fr

om

disc

losi

ng th

eir A

AS

use

or a

tten

ding

ser

vice

s fo

r AA

S re

late

d sy

mpt

oms.

Thi

s st

igm

a/sh

ame

even

pre

vent

ed o

ne o

r tw

o pa

rtic

ipan

ts s

eeki

ng

trea

tmen

t for

non

-AA

S re

late

d sy

mpt

oms

sinc

e th

ey fe

lt th

at s

taff

wou

ld b

lam

e al

l affl

ictio

ns o

n th

eir A

AS

use

and

wan

ted

to a

void

“a le

ctur

e”.

It is

als

o im

port

ant t

o re

cogn

ise

that

sim

ple

emba

rras

smen

t can

del

ay o

r pre

vent

par

ticip

ants

fr

om e

ngag

ing

with

hea

lth p

rofe

ssio

nals

with

A

AS

rela

ted

sym

ptom

s. T

his

is w

hat d

rive

s so

me

peop

le w

ho u

se A

AS

to s

elf-

trea

t or p

ay fo

r pri

vate

tr

eatm

ents

.

Thes

e pe

rcep

tions

wer

e re

flect

ed w

ithin

the

serv

ice

prov

ider

inte

rvie

ws,

as m

any

reco

gnis

ed th

e pe

rcei

ved

soci

al s

tigm

a ar

ound

the

use

of A

AS

and

othe

r IPE

Ds.

Som

e no

ted

that

this

stig

ma

coul

d be

a

barr

ier t

o se

ekin

g he

lp, p

artic

ular

ly fo

r a p

robl

em

that

mig

ht b

e re

late

d to

that

per

son’

s us

e of

AA

S or

ot

her I

PED

s.

Part

icip

ant

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Evid

ence

gat

herin

g ev

ent

Evid

ence

“I w

as re

ally

em

barr

asse

d w

hen

I wen

t to

the

GP,

I pla

y ru

gby

and

was

taki

ng a

ban

ned

subs

tanc

e. I

know

it’s

not i

llega

l, bu

t peo

ple

look

at i

t lik

e it

is. I

didn

’t kn

ow w

hat t

he G

P w

as g

oing

to sa

y, I f

elt

like

a ki

d go

ing

to th

e he

adm

aste

r. I t

hink

peo

ple

have

that

opi

nion

th

at th

ey a

re g

oing

to b

e ta

lked

at a

nd a

lmos

t as i

f the

y ar

e go

ing

to

have

a ro

w.”

(DA

09)

“Whe

n th

ere’s

act

ually

som

ethi

ng w

rong

with

me

and

it’s c

ause

d by

st

eroi

ds, t

hat’s

whe

n I f

eel r

eally

sort

of e

mba

rras

sed.

” (D

A08

)

“Stig

ma

is a

big

one

, um

m, t

here

is a

lso

a bi

t of s

ense

of d

enia

l abo

ut

it, if

don

’t ge

t dia

gnos

ed w

ith a

hea

rt p

robl

em, I

don

’t ha

ve a

hea

rt

prob

lem

, as I

don

’t ha

ve sy

mpt

oms.”

(G

M05

)

“... i

f som

ebod

y go

es to

GP

with

a so

re in

ject

ion

site

... I

thin

k so

me

don’

t wan

t to

adm

it th

at is

how

thei

r bod

y de

velo

ped

by so

rt o

f ch

eatin

g w

ith A

S...”

(GM

08)

Peop

le u

sing

AA

S an

d ot

her I

PED

s re

luct

ance

to d

iscl

ose

thei

r use

of t

hese

dru

gs to

hea

lth a

nd re

late

d se

rvic

es m

ay b

e co

mpo

unde

d by

peo

ple

feel

ing

emba

rras

sed

by a

ny h

ealth

pr

oble

ms;

as

thes

e co

uld

be s

een

as s

elf-i

nflic

ted,

or i

mpl

y th

ey

had

used

inco

rrec

tly o

r inc

ompe

tent

ly.

The observations and evidence related to the third theme Service delivery, practices and policy taken from qualitative interviews with participants using AAS, service providers and Evidence Gathering and Synthesis Event discussions are detailed in Table 3 (T3).

A range of issues related to service accessibility and acceptability were noted, including service opening times, service locations, and the environments in which services were provided. For many of the participants interviewed who were using AAS, the topic of confidentiality and the fear of their use of AAS and other IPEDs being recorded within medical records and notes was seen as a significant barrier in engaging with healthcare services [T3 row 3.1]. Their concerns ranged from the fear of being judged at a later date to medical records being passed to employers occupational health departments. This has led to a number of approaches being adopted amongst those individuals including; self-treatment of minor side effects, use of online services to access blood testing and injecting paraphernalia [T3 row 3.3]. There were varying opinions on whether co-provision of services for those using AAS and other IPEDs alongside those for people using psychoactive drugs was appropriate [T3 row 3.2]. Provision of stand-alone services with separate infrastructure is likely to be costly, and probably not sustainable where these would be delivering similar interventions to those provided to people using psychoactive drugs, such as, the provision of clean sterile injecting equipment through needle and syringe programmes. However, in relation to more specialist services focused on IPED specific issues, standalone services may be more practical if these were hosted within generic services. The form and practicalities of such services needs further examination, but the recent development of such a service in Newport, Gwent provides a possible model. The development of such service requires further exploration of a range of delivery models, for example, shared care systems with GPs and e-clinics. Such methods could facilitate ease of access to specialist services across Wales, particularly in rural areas.

The resultant problems with engagement was a very common concern raised repeatedly during the study. Participants suggested various approaches that could be used to improve engagement with services; however, the provision of services by informed, empathetic, and non-judgemental staff was seen as being key to improving engagement [T3 row 3.4]. Some participants indicated that service staff were sometimes overly concerned about not having a complete understanding of the nature of the drugs involved and their use; however, in many settings such knowledge is not necessary to engage with this group. For example, in needle and syringe programmes focusing on harm reduction and practical messages related to injection technique could be an effective approach to engagement. In relation to engaging clients about testing for sexually transmitted and blood borne viral infections, discussions focused around sexual risks are probably a more appropriate and effective approach, than discussions related to risk of infection transmission through injecting.

The use of outreach approaches to access people using AAS and other IPEDs, or who might be thinking about using these drugs, in gyms and other fitness venues was felt to be particularly important; however, there are a number of barriers to this, in particular gaining the support of the venue owners [T3 row 3.3]. Such outreach activities may be particularly effective if they involve credible messengers and peers in their delivery.

18

4.3 Service delivery, practices and policy

4.3.1 Barriers and facilitators to service engagement

For Table 3 - see overleaf.

The provision of more generic well-being services – either through outreach or in fixed sites – focusing on health, wellbeing and fitness, particularly if targeted at young people, may have a role preventing use and supporting other approaches to fitness, such as, diet and training, as well as reducing harm among those who go on to use AAS and other IPEDs.

Related to this, there was concern among those providing services about the lack of access to metabolic testing and treatment interventions for those using AAS and other IPEDs, as currently there are no approved treatment interventions [T3 row 3.5]. Concerns about the provision of, and access to, care for mental health issues for those using IPEDs was very common among the participants. Mental health issues may underpin the use of AAS and other IPEDs for some people, and so being able to address these issues is an important aspect of an effective response.

From a policy perspective, service providers and evidence gathering event attendees were particularly concerned about the lack of guidance in relation to providing services to those who use IPEDs, and the related lack of clear and well-defined care and referral pathways for them [T3 row 3.7]. It was suggested this needs to be addressed through development of guidelines on appropriate responses to the use of AAS and other IPEDs for health and wellbeing service providers. There was also support for the provision of guidance to the operators of gyms and fitness venues so as to support outreach, harm reduction interventions, and early identification of those who are experiencing problems related to their use of AASs or other IPEDs.

19

4.3.2 Policy issues

>20

Tabl

e 3:

Sum

mar

y ob

serv

atio

ns a

nd e

vide

nce

rela

ting

to S

ervi

ce D

eliv

ery,

Pra

ctic

es a

nd P

olic

y ta

ken

from

qua

litat

ive

inte

rvie

ws

wit

h pa

rtic

ipan

ts u

sing

AA

S, s

ervi

ce p

rovi

ders

and

Evi

denc

e G

athe

ring

and

Syn

thes

is E

vent

dis

cuss

ions

No.

3.1

Them

e

Barr

iers

to s

ervi

ce

enga

gem

ent

Obs

erva

tion

Avo

idin

g do

cum

enta

tion

on

med

ical

reco

rds

Furt

her t

o th

e co

mm

ents

rela

ted

to th

e st

igm

a of

us

ing

IPED

s, m

any

part

icip

ants

usi

ng A

AS

desc

ribed

th

eir r

eluc

tanc

e to

eng

age

in h

ealth

care

ser

vice

s or

dis

clos

e us

e as

a w

ay o

f pre

vent

ing

it be

ing

docu

men

ted

on th

eir m

edic

al re

cord

s. It

was

felt

that

by

doin

g so

it w

ould

pre

vent

futu

re n

egat

ive

repe

rcus

sion

s.

Such

fear

s an

d be

liefs

wer

e al

so re

cogn

ised

as

part

of

the

serv

ice

prov

ider

inte

rvie

ws.

They

add

ed th

at

in s

ome

case

s th

is s

tem

med

from

con

cern

s th

at

heal

th re

cord

s co

uld

be tr

ansf

erre

d to

occ

upat

iona

l he

alth

ser

vice

s an

d eff

ect c

urre

nt a

nd/o

r fut

ure

empl

oym

ent.

Part

icip

ant

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Evid

ence

gat

herin

g ev

ent

Evid

ence

gat

herin

g ev

ent

Evid

ence

“I pa

id a

nd h

ad [m

y bl

ood

test

s] se

nt o

ff be

caus

e I d

idn’

t wan

t tha

t go

ing

dow

n as

a n

egat

ive

on m

y m

edic

al re

cord

, sam

e as

a lo

t of

peop

le I k

now

bec

ause

of t

he st

igm

a in

volv

ed. T

hey

just

go

thro

ugh

your

med

ical

reco

rds g

oing

, ‘Ah,

I see

you

’ve

been

taki

ng st

eroi

ds.’

It’s j

ust t

he n

egat

ive

stig

ma

and

the

lack

of u

nder

stan

ding

.” (D

A07

)

“I w

ould

n’t w

ant a

nyth

ing

writ

ten

dow

n on

any

reco

rd w

ith m

y na

me

that

I use

ster

oids

. The

re’s

so m

uch

nega

tivity

... I

know

peo

ple

who

are

so fr

ight

ened

to g

o to

a n

eedl

e ex

chan

ge in

case

they

get

se

en...

I do

n’t t

hink

peo

ple

wan

t to

risk

othe

rs k

now

ing

outs

ide

of th

e gy

m fr

ater

nity

.” (D

A01

)

“Abs

olut

ely

will

not

talk

abo

ut it

eith

er b

ecau

se u

sing

IPED

s tha

t are

ill

egal

and

fear

repe

rcus

sion

s of t

hat,

and

also

alo

ng w

ith IP

EDs t

hey

are

usin

g ot

her i

llega

l sub

stan

ces,

so a

bsol

utel

y w

on’t

talk

bec

ause

of

fear

it m

ight

get

out

“ (G

M05

)

“[In

rela

tion

to u

sing

GPs

] the

re is

real

conc

ern

as w

ell a

bout

co

nfide

ntia

lity

and

thin

gs b

eing

on

med

ical

reco

rds a

nd th

ose

sort

of

thin

gs b

ecau

se th

ey a

lot o

f peo

ple

do h

ave

high

pow

ered

jobs

...“

(GM

01)

“Fea

r of i

t goi

ng o

n th

eir m

edic

al re

cord

s, of

bei

ng ju

dged

.” (G

M02

)

Ass

essm

ents

for n

ew c

lient

s, in

clud

ing

the

need

to g

ive

pers

onal

id

entifi

catio

n da

ta, w

ith m

any

of th

ose

usin

g A

AS

and

othe

r IP

EDs

bein

g ve

ry w

ary

abou

t giv

ing

out a

ny s

uch

info

rmat

ion.

Th

is w

as p

art o

f wid

er c

once

rn a

bout

con

fiden

tially

and

the

lack

of

priv

acy.

Priv

acy

issu

es in

clud

ed c

once

rns

abou

t bei

ng s

een

in a

ne

edle

and

syr

inge

pro

gram

me,

and

abo

ut c

onfid

entia

lity

whe

n at

tend

ing

prim

ary

care

bei

ng c

ompr

omis

ed b

y th

e nu

mbe

r of

staff

who

cou

ld a

cces

s m

edic

al re

cord

s.

Cont

actin

g a

prim

ary

or s

econ

dary

hea

lthca

re s

ervi

ce a

bout

a

heal

th p

robl

em w

ould

requ

ire d

iscl

osur

e of

thei

r use

of a

nabo

lic–

andr

ogen

ic s

tero

ids

and

othe

r IPE

Ds,

resu

lting

in c

once

rns

abou

t th

e co

nseq

uenc

es, s

uch

as in

form

atio

n ab

out t

heir

use

goin

g on

med

ical

reco

rds.

This

was

see

n by

par

ticip

ants

as

bein

g a

part

icul

arly

impo

rtan

t iss

ue w

here

ther

e w

ere

occu

patio

nal

reas

ons

for u

se.

Tabl

e 3

cont

inue

d ov

erle

af.

21Ta

ble

3 co

ntin

ued.

No.

3.2

Them

e

Barr

iers

to s

ervi

ce

enga

gem

ent

Obs

erva

tion

Perc

epti

ons

surr

ound

ing

‘dru

g us

e’ a

nd

plac

emen

t of s

ervi

ces

Se

rvic

e pr

ovid

ers

note

d th

at th

ose

peop

le th

at th

ey

saw

who

wer

e us

ing

AA

S an

d ot

her I

PED

s do

not

se

e th

eir u

se o

f the

se d

rugs

as

bein

g ‘d

rug

use’.

The

y al

l not

ed th

at p

eopl

e us

ing

IPED

s sa

w th

emse

lves

as

bei

ng d

iffer

ent f

rom

peo

ple

usin

g dr

ugs

for t

heir

psyc

hoac

tive

effec

ts.

They

wer

e al

so c

once

rned

abo

ut th

e ap

prop

riate

ness

of

gen

eric

sub

stan

ce u

se s

ervi

ces,

such

as

need

le

and

syrin

ge p

rogr

amm

es, t

o th

ose

usin

g A

AS

and

othe

r IPE

Ds,

part

icul

arly

as

this

gro

up o

ften

sa

w th

emse

lves

as

bein

g di

ffere

nt to

thos

e us

ing

psyc

hoac

tive

drug

s an

d di

d no

t wan

t to

use

the

sam

e se

rvic

es a

s th

em.

Thes

e at

titud

es w

here

mir

rore

d du

ring

the

inte

rvie

ws

with

the

part

icip

ants

usi

ng A

AS,

with

m

any

ackn

owle

dgin

g it

was

diffi

cult

atte

ndin

g se

rvic

es w

here

they

felt

they

wer

e vi

ewed

as

a ‘d

rug

user

’.

Part

icip

ant

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Evid

ence

“[th

ey] d

on’t

see

them

selv

es a

s dru

g us

ers”

(G

M03

)

“the

y vi

ew th

e su

bsta

nce

they

are

usi

ng a

s not

in sa

me

leag

ue a

s so

meo

ne u

sing

opi

ates

.” (G

M07

)

“I’ve

alw

ays f

elt t

here

’s a

bit o

f a n

egat

ive

attit

ude

tow

ards

ster

oid

user

s... I

kno

w p

eopl

e w

ho a

re so

frig

hten

ed to

go

to a

nee

dle

exch

ange

in ca

se th

ey g

et se

en, i

f the

y ca

me

away

with

ten

syrin

ges

they

wou

ld re

-use

them

.” (D

A01

)

“I di

dn’t

know

abo

ut sp

ecia

list e

xcha

nges

. I w

ould

n’t g

o an

yway

as

whe

n I g

o to

the

Chem

ist i

t’s a

pub

lic p

rem

ise/

serv

ice

and

I cou

ld

be g

oing

ther

e fo

r any

thin

g. G

oing

to o

ne o

f tho

se p

lace

s [ne

edle

ex

chan

ge] w

ould

put

me

in th

at ty

pe o

f box

, wou

ldn’

t it?

By

box,

I m

ean

drug

use

r.” (

DA

10)

“I w

ent t

o a

loca

l dru

g se

rvic

e an

d sp

oke

to so

meo

ne in

the

need

le

exch

ange

– th

at w

as h

ard

as I k

now

it’s

a pl

ace

whe

re ju

nkie

s go,

an

d th

e m

ain

door

look

s out

ont

o th

e m

ain

road

.” (D

A09

)

”You

kno

w w

hen

I use

d to

go

to in

to th

e dr

ug p

lace

s [ne

edle

and

sy

ringe

pro

gram

me]

to g

et m

y ne

edle

s... t

here

wer

e he

roin

add

icts

in

ther

e, th

ere

wer

e co

cain

e ad

dict

s... I

alw

ays t

houg

ht to

mys

elf,

y’kn

ow, I

’m n

ot w

here

you

are

– I’v

e go

t my

own

min

d, I k

now

wha

t I’m

doi

ng. I

t doe

sn’t

take

me

into

ano

ther

wor

ld b

asic

ally

. I’m

still

in

the

real

wor

ld, e

ven

thou

gh I’m

doi

ng th

at.”

(C03

)

“... a

lot o

f AAS

use

rs d

on’t

like

com

ing

in [t

o th

e ne

edle

and

syrin

ge

prog

ram

me]

whe

n th

ere

are

othe

r use

rs...

like

her

oin

user

s, be

caus

e th

ey th

ink

they

hav

en’t

got a

pro

blem

... t

hey

don’

t rea

lly co

me

in

and

have

a c

hat,

if yo

u kn

ow w

hat I

mea

n, li

tera

lly ju

st co

me

in a

nd

ask

for w

hat t

hey

wan

t and

go“

(G

M08

)

“IPED

use

rs d

on’t

like

goin

g to

NSP

... t

hey

see

them

selv

es a

s... w

e ar

e he

alth

y, w

e ar

e lo

okin

g af

ter o

ur h

ealth

, we

are

heal

th co

nsci

ous;

they

[oth

er N

SP u

sers

] are

not

” (G

M05

)

22

Tabl

e 3

cont

inue

d ov

erle

af.

Tabl

e 3

cont

inue

d.

No.

3.3

3.4

Them

e

Barr

iers

to s

ervi

ce

enga

gem

ent

Faci

litat

ors

to s

ervi

ce

enga

gem

ent

Obs

erva

tion

Acc

essi

bilit

y of

ser

vice

s an

d on

line

alte

rnat

ives

Man

y se

rvic

e pr

ovid

ers

repo

rted

con

cern

s ab

out

the

open

ing

hour

s of

ser

vice

s, su

ch a

s ne

edle

and

sy

ringe

pro

gram

mes

, as

thos

e us

ing

AA

S an

d ot

her

IPED

s w

ere

typi

cally

em

ploy

ed.

From

the

inte

rvie

ws

with

bot

h se

rvic

e pr

ovid

ers

and

part

icip

ants

usi

ng A

AS

it w

as c

lear

that

util

isat

ion

of

onlin

e se

rvic

es fo

r obt

aini

ng in

ject

ing

para

pher

nalia

an

d un

dert

akin

g m

etab

olic

test

ing

wer

e bo

th

com

mon

pla

ce. S

uch

serv

ices

wer

e vi

ewed

as

mor

e co

nven

ient

and

acc

essi

ble

whe

n co

mpa

red

to

trad

ition

al m

etho

ds o

f ser

vice

del

iver

y. T

his

refle

cts

the

issu

es w

ith a

ccep

tabi

lity

and

avai

labi

lity

of th

e ne

edle

and

syr

inge

pro

gram

mes

whe

re th

e sa

me

equi

pmen

t can

be

obta

ined

for f

ree.

Thro

ugho

ut d

iscu

ssio

ns d

urin

g th

e ev

iden

ce

gath

erin

g ev

ent i

t was

not

ed th

at o

utre

ach

serv

ices

ha

ve h

ad p

ositi

ve o

utco

mes

whe

re ra

ppor

t and

a

rela

tions

hip

has

been

mad

e w

ith g

ym o

wne

rs a

nd

clie

ntel

e.

Non

-judg

men

tal a

nd in

form

ed a

ppro

ach

Am

ongs

t the

par

ticip

ants

usi

ng A

AS,

key

fa

cilit

ator

s to

ser

vice

eng

agem

ent i

nclu

ded

non-

judg

emen

tal a

nd k

now

ledg

eabl

e st

aff w

ho

wer

e w

illin

g to

eng

age

in d

ialo

gue.

Fur

ther

mor

e,

reve

rsin

g th

e cl

imat

e of

dis

appr

oval

whi

ch p

eopl

e w

ho u

se A

AS

felt

surr

ound

ed fr

ont l

ine

serv

ices

w

as th

e m

ost p

rom

inen

t top

ic o

f con

vers

atio

n.

Serv

ice

prov

ider

s re

cogn

ised

that

sta

ff sk

ill s

et w

ithin

se

rvic

es c

ould

lim

it eff

ectiv

e se

rvic

e pr

ovis

ion.

H

owev

er, m

any

of th

e pa

rtic

ipan

ts in

this

con

text

w

ere

over

ly fo

cuse

d on

wha

t the

y pe

rcei

ved

to b

e th

eirs

, and

thei

r col

leag

ues,

limite

d kn

owle

dge

abou

t the

dru

gs b

eing

use

d. E

ven

thou

gh fo

r man

y th

is s

houl

d no

t hav

e im

pact

ed o

n en

gage

men

t ar

ound

issu

es re

late

d to

saf

e in

ject

ion

prac

tice,

se

xual

risk

, and

mot

ivat

ion

for u

se.

Part

icip

ant

Serv

ice

Prov

ider

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Evid

ence

gat

herin

g ev

ent

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Evid

ence

In re

latio

n to

acc

essi

ng n

eedl

e an

d sy

ringe

pro

gram

mes

: “...

the

y ar

e bu

ying

it [n

eedl

es a

nd s

yrin

ges]

onl

ine,

and

they

don

’t w

ant

to h

ave

to g

o in

to a

nee

dle

exch

ange

, and

they

don

’t w

ant t

o w

ait,

and

they

don

’t w

ant t

he st

igm

a; a

s wel

l it q

uite

rare

to co

me

acro

ss

som

eone

who

kno

wns

a si

gnifi

cant

am

ount

abo

ut th

em...“

(G

M01

)

“I kn

ow p

eopl

e w

ho b

uy a

ll th

eir e

quip

men

t onl

ine.

.. T

hey

buy

it on

line

for c

onve

nien

ce. Y

ou k

now

, you

coul

d ar

gue,

wel

l you

coul

d go

to a

pha

rmac

y. Y

eah,

I cou

ld g

o to

a p

harm

acy

on a

Sat

urda

y an

d Su

nday

whe

n it’

s ful

l of p

eopl

e. D

on’t

wan

t tha

t. It

’s ba

d en

ough

that

peo

ple

will

turn

aro

und

and

go ‘U

uugh

’. Li

ke I s

aid

it’s

such

a st

igm

a.”

(DA

07)

“I pa

id a

nd h

ad [m

y bl

ood

test

s] se

nt o

ff be

caus

e I d

idn’

t wan

t tha

t go

ing

dow

n as

a n

egat

ive

on m

y m

edic

al re

cord

, sam

e as

a lo

t of

peop

le I k

now

bec

ause

of t

he st

igm

a in

volv

ed.”

(DA

07)

Serv

ices

wer

e pe

rcei

ved

as ty

pica

lly n

ot b

eing

ope

n at

tim

es

whi

ch a

re c

onve

nien

t for

thos

e w

ho w

ere

wor

king

or i

n ed

ucat

ion,

and

that

ther

e w

as a

nee

d fo

r var

iabl

e op

enin

g tim

es

for h

ealth

ser

vice

s, in

clud

ing

need

le a

nd s

yrin

ge s

ervi

ces,

with

so

me

indi

catin

g th

is c

an re

sult

in b

ette

r tak

e-up

.

“I th

ink

a be

tter

und

erst

andi

ng, e

duca

tion.

If a

doc

tor h

ad a

bet

ter

unde

rsta

ndin

g, I t

hink

you

wou

ld g

et a

bet

ter u

ptak

e. I

can

wal

k in

to a

ny o

f the

gym

s...

boys

will

com

e up

to m

e lik

e an

d ha

ve

the

mos

t ope

n co

nver

satio

ns w

ith m

e...

Out

of t

he b

lue,

that

’s th

e co

nver

satio

ns th

at h

appe

ns in

gym

s.” (

DA

07)

“If a

cent

re h

ad sp

ecifi

c se

ssio

n fo

r ste

roid

use

rs, t

hen

you

wou

ld

know

who

was

goi

ng to

be

behi

nd th

e do

or a

nd th

ey w

ould

be

roug

hly

awar

e of

why

you

wer

e th

ere

with

out y

ou h

avin

g to

star

t w

ith, ‘A

nd it

’s be

caus

e I u

se st

eroi

ds’.

I don

’t kn

ow w

here

you

’d o

ut it

th

ough

as I

thin

k pe

ople

wou

ldn’

t wan

t to

be se

en w

alki

ng in

, may

be

on a

n in

dust

rial e

stat

e.” (

DA

09)

“A lo

t of i

t is t

ime,

in th

at w

hen

they

com

e in

for e

quip

men

t the

y ju

st

kind

of w

ant t

o be

in a

nd o

ut th

e do

n’t w

ant t

o be

han

ging

... a

nd

may

be

priv

acy

as w

ell..

. and

then

from

our

poi

nt v

iew

wou

ld b

e co

nfide

nce

to st

art t

he co

nver

satio

n, to

kno

w th

at w

hat y

ou w

ere

sayi

ng w

as ri

ght a

nd th

at y

ou w

ere

givi

ng g

ood

advi

ce...

” (G

M06

)

23Ta

ble

3 co

ntin

ued.

No.

3.5

Them

e

Faci

litat

ors

to s

ervi

ce

enga

gem

ent

Obs

erva

tion

Ava

ilabi

lity

of h

ealt

h ch

ecks

and

met

abol

ic

test

ing

Ster

oid

spec

ific

serv

ices

wer

e a

popu

lar s

ugge

stio

n am

ongs

t par

ticip

ants

usi

ng A

AS

for i

mpr

ovin

g en

gage

men

t with

ser

vice

s. E

spec

ially

if s

ervi

ces

prov

ide

oppo

rtun

ities

for l

iver

and

kid

ney

func

tion

scre

enin

g; d

rug

test

ing

serv

ice;

hom

e vi

sits

; and

sp

ecifi

c ad

vice

on

safe

r use

and

ces

satio

n of

use

. A

com

mon

per

cept

ion

amon

g se

rvic

e pr

ovid

ers

and

prof

essi

onal

s at

tend

ing

the

evid

ence

gat

herin

g ev

ent w

as th

at th

ey w

ere

unab

le to

offe

r ser

vice

s th

at w

ere

ofte

n re

quire

d by

thos

e us

ing

AA

S an

d ot

her I

PED

s. Th

ese

conc

erns

wer

e pa

rtic

ular

ly

focu

sed

on th

e la

ck o

f acc

ess

to h

ealth

che

cks,

ECG

s, an

d m

etab

olic

test

ing,

add

ress

ing

side

effe

cts,

supp

ortin

g th

e ce

ssat

ion

of u

se, a

nd m

enta

l hea

lth

supp

ort.

It w

as w

idel

y re

cogn

ised

that

ser

vice

s off

erin

g su

ch

inte

rven

tions

saw

peo

ple

trav

ellin

g gr

eat d

ista

nces

to

att

end

sess

ions

. How

ever

, effe

ctiv

e de

liver

y m

odel

s re

quire

d ro

bust

gov

erna

nce

and

syst

ems

for i

nter

pret

atio

n of

resu

lts a

nd re

ferr

al p

athw

ays.

Furt

her c

larit

y w

ould

als

o be

nee

ded

on h

ow s

uch

serv

ices

are

fund

ed, i

nfor

mat

ion

is re

cord

ed, a

nd

clin

icia

ns/e

xper

tise

is re

tain

ed.

Part

icip

ant

Evid

ence

gat

herin

g ev

ent

Evid

ence

gat

herin

g ev

ent

Part

icip

ants

usi

ng A

AS

Part

icip

ants

usi

ng A

AS

Serv

ice

Prov

ider

Serv

ice

Prov

ider

Evid

ence

Ther

e w

ere

conc

erns

abo

ut th

e im

pact

whe

n pe

ople

eng

age

with

se

rvic

e pr

ovid

ers

and

findi

ng th

at th

ey a

re n

ot k

now

ledg

eabl

e ab

out t

he u

se o

f AA

S an

d ot

her I

PED

s. Pa

rtic

ular

ly, i

f sta

ff kn

owle

dge

and

prac

tice

is fo

cuse

d on

peo

ple

usin

g ps

ycho

activ

e dr

ugs,

such

as

hero

in, a

s th

is c

ould

be

off p

uttin

g.

Man

y pa

rtic

ipan

ts fe

lt th

at s

ervi

ce p

rovi

ders

nee

ded

to b

e w

elco

min

g, c

onst

ruct

ive

and

non-

judg

men

tal,

and

that

they

al

so n

eede

d to

feel

con

fiden

t wor

king

with

thos

e us

ing

AA

S an

d ot

her I

PED

s so

as

be a

ble

to e

ffect

ivel

y en

gage

with

them

.

“An

actu

al c

linic

run

by a

doc

tor t

o he

lp p

eopl

e ge

t off

ster

oids

, to

addr

ess t

heir

prob

lem

s. If

you

’ve

got b

ody

dysm

orph

ic d

isor

der,

prov

ide

coun

selli

ng, p

rovi

de su

ppor

t. P

rovi

de P

CT to

get

off

ster

oids

. If

you’

ve g

ot [g

ynec

omas

tia] p

rovi

de tr

eatm

ent o

r sur

gery

for

that

, it m

ay w

ell b

e yo

u ne

ed o

ther

serv

ices

but

at t

his s

tage

, I’v

e ne

ver h

eard

of o

r nev

er se

en a

ny se

rvic

es d

irect

ed a

t ste

roid

use

rs

to h

elp

them

.... I

don

’t th

ink

just

by

prov

idin

g ed

ucat

ion

or g

ivin

g st

eroi

d us

ers i

nfor

mat

ion

that

you

’re g

oing

to m

ake

any

diffe

renc

e w

hats

oeve

r; yo

u’re

just

goi

ng to

alie

nate

them

. The

onl

y th

ing

I co

uld

see

that

wou

ld o

ffer a

ny h

elp

wou

ld b

e pr

ovid

ing

test

ing

... li

ke

WED

INO

S do

test

ing

serv

ices

for s

tero

ids,

so u

sers

kno

w w

hat t

hey’

re

taki

ng is

safe

, it’s

ster

ile, a

nd th

ey a

re a

ctua

lly ta

king

wha

t the

y be

lieve

they

’re ta

king

.” (D

A01

)

“As I

’ve

only

use

d a

chem

ist,

I’d sa

y yo

u ha

ve to

kee

p th

at se

rvic

e. B

ut

from

my

read

ing,

I thi

nk th

at if

peo

ple

coul

d ha

ve b

lood

s the

y w

ould

be

abl

e to

bet

ter d

ecid

e w

hat s

tero

ids t

o ta

ke a

nd a

t wha

t dos

e, th

ey

wou

ld b

e ab

le to

mon

itor P

CT {p

ost c

ycle

ther

apy}

bet

ter a

nd m

ake

sure

it’s

wor

king

for t

hem

.” (D

A10

)

“I w

ould

hav

e lik

ed a

lot m

ore

info

rmat

ion

like

this

whe

n I v

isite

d th

e dr

ug se

rvic

e, so

I thi

nk th

e m

ost i

mpo

rtan

t thi

ng is

a b

alan

ced

info

rmat

ion

serv

ice,

goo

d, b

ad a

nd u

gly,

war

t and

all.

May

be a

le

aflet

to g

o w

ith th

e eq

uipm

ent w

hen

you

pick

it u

p w

ould

hel

p,

but I

’d p

refe

r som

eone

to te

ll m

e, so

they

can

answ

er a

ny q

uest

ions

I ha

ve.”

(DA

012)

“It w

ould

be

cool

if w

e co

uld

have

spec

ialis

t ste

roid

clin

ic in

the

even

ings

... w

here

we

coul

d off

er a

n ex

tra

ince

ntiv

e ...

spo

rts

mas

sage

or n

utrit

iona

l adv

ice

... e

ven

if w

e co

uld

have

a n

urse

that

co

uld

chec

k bl

oods

or w

hate

ver”

(GM

02)

24Ta

ble

3 co

ntin

ued.

No.

3.6

3.7

Them

e

Polic

y is

sues

Polic

y is

sues

Obs

erva

tion

Ava

ilabi

lity

of c

linic

al g

uide

lines

Dur

ing

disc

ussi

ons

that

took

pla

ce d

urin

g th

e ev

iden

ce g

athe

ring

even

t man

y hi

ghlig

hted

that

w

hils

t the

re is

will

ingn

ess

to e

xplo

re a

nd d

evel

op

pack

ages

of c

linic

al s

uppo

rt fo

r ind

ivid

uals

usi

ng A

AS

and

othe

r IPE

Ds,

the

avai

labi

lity

of c

linic

al g

uide

lines

re

late

d to

this

topi

c is

cur

rent

ly v

ery

limite

d.

Com

peti

ng o

rgan

isat

iona

l age

ndas

Prof

essi

onal

s at

tend

ing

the

evid

ence

gat

herin

g ev

ent r

ecog

nise

d co

mpe

ting

agen

das

betw

een

orga

nisa

tions

whi

ch c

an re

sult

in in

cons

iste

ncie

s in

ap

proa

ch. T

he d

ispa

rity

betw

een

the

harm

redu

ctio

n ap

proa

ches

ado

pted

by

heal

th s

ervi

ces’

vers

us th

e ab

stin

ence

app

roac

h he

ld b

y sp

ortin

g bo

dies

was

us

ed a

s an

exa

mpl

e to

illu

stra

te th

is p

oint

.

Part

icip

ant

Evid

ence

gat

herin

g ev

ent

Evid

ence

gat

herin

g ev

ent

Evid

ence

Med

ical

pro

fess

iona

l’s re

spon

ses

may

be

limite

d by

thei

r kn

owle

dge

abou

t AA

S an

d ot

her I

PED

s. Th

is c

an b

e pr

oble

mat

ic

as h

avin

g ba

sic

know

ledg

e is

impo

rtan

t to

deliv

erin

g an

effe

ctiv

e re

spon

se to

peo

ple

usin

g A

AS

and

othe

r IPE

Ds

whe

n th

ey s

eek

help

. It w

as fe

lt by

man

y pa

rtic

ipan

ts th

at in

add

ition

to im

prov

ed

trai

ning

, hea

lth a

nd s

ocia

l car

e pr

ovid

ers

need

ed s

ome

form

al

guid

ance

on

AA

S an

d ot

her I

PED

s.

Som

e pa

rtic

ipan

ts fe

lt th

ere

was

a n

eed

for m

ore

focu

s on

this

is

sue

at h

ighe

r lev

els.

The

lack

of a

join

ed u

p ap

proa

ch e

lsew

here

in

the

UK

was

see

n as

a b

arrie

r, as

this

can

resu

lt in

inco

nsis

tent

ap

proa

ches

and

mes

sage

s, w

hich

can

then

hav

e ne

gativ

e im

pact

s on

ove

rall

confi

denc

e in

ser

vice

pro

visi

on. C

ross

-bor

der

patie

nts

have

repo

rted

that

the

use

of A

AS

and

othe

r IPE

Ds

is le

ss

in th

e op

en in

Eng

land

than

it is

in W

ales

. Se

rvic

e pr

ovis

ion

and

qual

ity v

arie

s by

loca

tion,

oft

en re

flect

ing

diffe

ring

agen

das.

Throughout the course of the interviews with participants using AAS, service providers, and the Evidence Gathering and Synthesis Event a range of recommendations for service improvements were suggested for wider discussion and consideration. These are summarised below.

• Making it easier for those using AAS and other IPEDs to access reliable and accurate information. Information needs to be modern and relevant, appropriately targeted and engaging and available in a range of formats • Improve staff skill set through engagement skills training specific to working with those who use AAS and other IPEDs, or who are thinking about doing so • E-learning, particularly for pharmacy counter staff on key issues related to the use of AAS and other IPEDs and engaging with those who use these drugs • Better training of, and engagement with, primary care staff particularly GPs. If GPs engaged effectively with those using AAS and other IPEDs, then they could provide a route to accessing metabolic testing and psychiatric interventions, as well as responding to concerns about acute and chronic harms.

Development of specialist care services • Development of clear healthcare guidelines for providing services to those using AAS and other IPEDs• The provision of more specialist services for those using AAS and other IPEDs was suggested. In particular doctor led specialist clinics for those using these drugs. It was suggested that this could be a virtual specialist GP led clinic with shared care agreements• To develop awareness of, and improve responses to, the use of AAS and other IPEDs it was suggested that GPs with specialist interest and knowledge meet quarterly within cluster protected education time (CPET) meetings – so that they could receive training from GP to GP.

Development of existing harm reduction services • Aim to make service offer appear more engaging to those using AAS and other IPEDs. Engagement should be about offering something that those using AAS and other IPEDs want – such as providing advice on diet or fitness, or access to metabolic testing – and using this to draw people into services so that other interventions can also be delivered• Focusing interactions in generic settings, such as needle and syringe programmes, on injecting, sexual, alcohol and ‘lifestyle’ risks rather than the drug(s) being used • Making existing services more acceptable and accessible to those using AAS and other IPEDs, this could include changes to opening hours, offer of specialist sessions, or a more careful approach to providing broad based drug services as well as improving outreach.

Developing other professional networks

• Closer working between services, with clear ‘care’ pathways for those using AAS and other IPEDs • Improving access to mental health support for those using AAS and other IPEDs through a range of routes • Closer working with Sexual Health Services in relation to testing for sexually transmitted infections and blood borne virus and for access to vaccinations. This should include awareness raising among staff of Sexual Health Services to support them in identifying those using AAS and other IPEDs. This will provide opportunities within these services for referral and advice provision related to use of IPEDs.

254.4 Suggested recommendations for service improvement

Education and awareness raising

26Community and peer to peer approaches • The development of a common document for use by all gyms with ‘dos and don’ts’ for responsible, safer use of supplements, AAS and other IPEDs. With use of this enforced, i.e. gym licenses mandate on displaying harm reduction information• Increasing engagement of those using AAS and other IPEDs with services through the use of social media and outreach into gyms• Develop a peer based network to provide information and harm reduction to those using AAS and other IPEDs – as well chosen peers would be seen as credible messengers • One respondent suggested consideration be given to co-payment for metabolic testing when this was used for physiological monitoring during periods of use. The co-payment would cover only the actual cost of the test advice and interpretation provided by NHS. However, this approach could be problematic in relation to equity of service access.

The suggestions and ideas for possible service developments and improvements that arose either during the two sets of semi-structured interviews or during the discussions that took place during the morning of the Evidence Gathering and Synthesis Event were collated and compared.

These suggestions were condensed and presented to those attending the Evidence Gathering and Synthesis Event for feedback. To explore consensus for each service improvement and development options, the participants used an anonymous online voting app to indicate if they either “Strongly Agreed”, “Agree”, “Disagree”, or “Strongly Disagree” with each option. The number of participants voting on each suggestion varied slightly, with between 25 and 28 valid votes per option. See Figure 3 for voting outcomes for each service improvement and development recommendation.

The proportion indicating agreement (that is voting for either Strongly Agree or Agree) with the development and improvement options ranged from 20% to 100%. There were only two options with less than 60% agreement. There were four options where agreement was between 60% and 70%, and eight with 100% agreement. The option with least support – with only 20% indicating agreement – was “Co-payment for metabolic testing for monitoring health”. There would seem to be little support for this option, and for taking this idea further at this time.

Eight options in total had 100% agreement, and considering this high level of support these service development and improvement options should therefore be considered for further development and implementation.

4.5 Consensus on preliminary recommendations for service improvement and development

0% 20% 40% 60% 80% 100%

Development and wider promotion of awareness raising products in various formats including information leaflets, QR

code business cards provided in a range of environments and in online packs; signposting to credible online info.

Practitioners need to focus on wider health and well-being issues including psychological health as intervention, NOT soley on the drugs.

Development of e-learning module on IPEDs for Primary and Secondary Care services including GPs, Pharmacy

Development of General Practitioner to General Practitioner IPED training model within cluster.

Produce short film on how to engage with individuals using IPEDs.

Dedicated needle and syringe programme staff in all needle and syringe programme sites including pharmacy with increased

flexible opening hours.

Improved networking and communication between and within service types (all needle and syringe programmes, all IPED health and allied

professionals/services etc); development of local forums.

Establish consistant targeted and tailored health and well-being outreach services (including needle and syringe programmes)

co-delivered by health care services and peer champions.

Establish an IPED user group to scope and design an interactive app (eg - cycle and training diaries) to promote engagement.

Development of targeted/specialist services which aims to address wider well-being including: fitness, diet and

supplementation - perhaps tie in with reducing obesity and other public health programmes.

The development of a virtual General practitioner or IPED clinic available online - utilising contemporary digital health approaches.

Figure 3: Extent of consensus with the service development and improvement recommendations generated: result of voting during Evidence Gathering and Synthesis day

Strongly Agree Agree Disagree Strongly Disagree

>

27

0% 20% 40% 60% 80% 100%

Increased General Practitioner prescribing of IPED/Hormone Replacement Therapy in response to long term complications

associated with IPED use.

Tailoring of bacterial infection amd wound care initiatives e.g. ACT (Act - Care - Treat) project to individuals using IPEDs.

Introduction of co-payment system for metabolic testing for monitoring health associated with IPED use.

Increased/routine availability of drug testing services e.g. expansion of WEDINOS to submissions of IPEDs in Wales.

Increase availability of cardiac and wider health care screening (e.g. ECG testing) within health and well-being clinics.

National roll out of specialist IPED Clinics with inclusion of metabolic testing e.g. South Wales IPED Clinic model delivered in

Newport (encouraging inclusion of significant others).

Establish a formal evidenge briefing on male Hormone Replacement Therapy for health professionals (and associated others).

Formally recognise IPEDs as a substance group linked to addiction/dependency.

Develop and publish written statement in order to clarify consequences of disclosing IPED use to medical practitioner and

legal context of possession/insurance.

increase engagement with gyms and development of initiatives to improve promotion of harm reduction informastion e.g.

mandatory condition of gym licenses to displaying harm reduction information.

improved engagement within gym settings - development of a common guidance document with “do’s and don’ts” for harm

reduction and safer use.

Figure 3 continued.

28

Strongly Agree Agree Disagree Strongly Disagree

The following recommendations draw upon data generated and collated as part of this study. However, they are principally informed by the ideas generated and voted on at the end of the Evidence Gathering and Synthesis Event. The following recommendations are based on those options that had widespread support throughout this project:

Government bodies, academic institutions and health services to provide resources and undertake a review with the aim of developing the evidence base on the use of online technologies (including social media) to facilitate effective health service engagement and e-clinics. This work should include online advice and triage clinics targeted towards young people using AAS currently not engaged with existing services

Public health bodies, community substance misuse leads and commissioners to develop best practice guidance on the implementation of effective assertive outreach services and adaptation of health and social care settings to optimise on-site engagement

In collaboration with registered professional bodies (including; RCGP, RCN, RCPsych, GPhC), public health bodies to develop value-based ‘AAS for healthcare professionals’ training and knowledge sharing opportunities (including e-learning and GP cluster events). Products to be embedded as a core training programmes within NHS Trusts/Health Boards and community health services

Adopting a ‘whole person’ approach, substance misuse commissioning boards to undertake a biennial comprehensive network mapping and gap analysis exercise of local health and social care services accessible to individuals using AAS. The mapping and gap analysis exercise should include:• Substance misuse and harm reduction• Physical health, mental health and wellbeing• Diet, nutrition, exercise and training advice • Sports injury• Sexual health and wellbeing

This work should lead to the development of a local/regional service directory for dissemination via outreach services, local health and social care expert AAS fora and establishment of dedicated AAS health and well-being clinic sessions within existing services

Public health bodies and AAS leads to produce the following essential documents:• A ‘What to expect’ document developed for distribution across gyms/fitness venues aimed at owners, managers and staff on working with AAS outreach services• Collation of all local/regional AAS health and social care directories for inclusion on national websites e.g. IPEDInfo.co.uk• A written statement on the implications and importance of AAS disclosure during a medical consultation or treatment

Public health bodies in collaboration with UK wide academic institutions to undertake research to establish a robust prevalence estimate of AAS use and evidence of harms associated with use.

295 Conclusions & Recommendations

a.

b.

c.

d.

e.

f.

1. Home Office. Drug misuse: Findings from the 2015/16 Crime Survey for England and Wales: data tables, 2016. Home Office: London2. McVeigh J., Begley E., Anabolic steroids in the UK: an increasing issue for public health. Drugs: Education, Prevention and Policy, 2016: p. 1-8.3. Hanely S., G., Coomber R. The risk environment of anabolic-androgenic steroid users in the UK: Examining motivations, practices and accounts of use. Int J Drug Policy, 2017. 40, 35-434. Kimergård A. A qualitative study of anabolic steroid use amongst gym users in the United Kingdom: motives, beliefs and experiences. Journal of Substance Use, 2015. 20, 288-294.5. Tod D., Edwards C., Cranswick I. Muscle dysmorphia: current insights. Psychology Research and Behavior Management, 2016. 9, 179-1886. Begley E., McVeigh J., Hope VD. Image and Performance Enhancing Drugs: 2016 National Survey Results. Public Health Institute LJMU and Public Health Wales7. Christiansen AV., Vinther AS., Liokaftos D. ‘Outline of a typology of men’s use of anabolic androgenic steroids in fitness and strength training environments’. Drugs: Education, Prevention and Policy, 2017 vol. 24, no. 3, pp. 295-305.8. Zahnow R., McVeigh J., Bates G., Hope V., Kean J., Campbell J., Smith J. Identifying a typology of men who use anabolic androgenic steroids (AAS). Int J Drug Policy, 2018. May;55:105-112.9. Pope H.G., et al., Adverse Health Consequences of Performance-Enhancing Drugs: An Endocrine Society Scientific Statement. Endocrine Reviews, 2014. 35(3): p. 341-37510. Zahnow R., et al., Adverse Effects, Health Service Engagement, and Service Satisfaction Among Anabolic Androgenic Steroid Users. Contemporary Drug Problems, 2017. 44(1): p. 69-83.11. Kanayama G., et al., Treatment of anabolic-androgenic steroid dependence: Emerging evidence and its implications. Drug and Alcohol Dependence, 2010. 109(1-3): p. 6-13.12. Hope VD., McVeigh J., Marongiu A., Evans-Brown M., Smith J., Kimergard A., Ncube F. Injection site infections and i njuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking. Epidemiology and Infection, 2015. 143(1): 132-14013. Day C.A., Topp L., Iversen J., Maher L., Collaboration of Australian Blood-borne virus prevalence and risk among steroid injectors: results from the Australian Needle and Syringe Program Survey. Drug Alcohol Rev, 2008. 27, 559-56114. Hope V.D., McVeigh J., Marongiu A., Evans-Brown M., Smith J., Kimergard A., Croxford S., Beynon CM., Parry JV., Bellis MA., Ncube F. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open 3, 2013. e00320715. Zahnow R., et al., Adverse Effects, Health Service Engagement, and Service Satisfaction Among Anabolic Androgenic Steroid Users. Contemporary Drug Problems, 2017. 44(1): p. 69-83.16. Graham MR., Ryan P., Baker JS., Davies B., Thomas NE., Cooper SM., Evans P., Easmon S., Walker CJ., Kickman AT. Counterfeiting in performance and image enhancing drugs. Drug Testing and Analysis 2009. 135-142. Doi: 10.1002/dta.3017. Kimergård A., McVeigh J., Knutsson S., Breindahl T., Stensballe A. Online marketing of syntheticpeptide hormones: Poor manufacturing, user safety, and challenges to public health. Drug Testingand Analysis, 2014a. 6(4): 396-398. doi:10.1002/dta.163618. Kimergard A., Breindahl T., Hindersson P., McVeigh J. The composition of anabolic steroids from the illicit market is largely unknown: implications for clinical case reports. QJM-An International Journal of Medicine, 2017. 107(7): 597-598. doi:10.1093/qjmed/19. Richardson A., Antonopoulos GA. Anabolic-androgenic steroids (AAS) users on AAS use: Negative effects, ‘code of silence’, and implications for forensic and medical professionals. 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306 References

Facilitators and Barriers to Health Care Access Amongst people using Image and

Performance Enhancing Drugs in Wales

Findings & Outcomes report 2020

Facilitators and Barriers to Health Care Access Amongst people using Image and

Performance Enhancing Drugs in Wales

Findings & Outcomes report 2020