Research PaperImage and performance enhancing drug use among men who have sex with men and women who have sex with women in the UK
Introduction
Image and performance enhancing drugs (IPEDs) are a group of substances that people take to alter their appearance or physical abilities and include anabolic androgenic steroids (AAS), growth hormones, weight loss drugs and skin tanning agents, such as melanotan (Begley, McVeigh, & Hope, 2017). Whilst IPEDs can be consumed both orally and through intramuscular and subcutaneous injection, administration through injection is most common. Evidence indicates an increase in the range and availability of IPEDs, through online promotion and retail, with this probably related to increases in polydrug use and overall use (Sagoe et al., 2015; Salinas, Floodgate, & Ralphs, 2019). In the UK at least, this is corroborated by data indicating an increase in the number of people who are accessing needle and syringe programs that report using IPEDs (McVeigh & Begley, 2017). There are a number public health and health problems associated with the use of IPEDs, particularly AAS, such as cardiovascular conditions and sexual dysfunction (Begley et al., 2017), and injecting IPEDs in particular has been associated with hepatitis C infection (Hope et al., 2016). Polydrug use is common, with the concomitant use of a range of psychoactive substances, particularly cocaine and amphetamines often reported (Hope et al., 2017). A systematic review investigating motivations for injecting IPEDs identified numerous motivations including body image disturbance, a drive for muscularity, increasing strength and enhancing appearance (Brennan, Wells, & Van Hout, 2017).
Research into IPED use has mostly been on samples predominantly composed of heterosexual men (Hope et al., 2016; Rowe, Berger, Yaseen, & Copeland, 2017; Van de Ven et al., 2018), or samples composed mostly of gay and bisexual men recruited from gyms mainly used by this group (Bolding, Sherr, & Elford, 2002; Ip et al., 2017); with the participants often using AAS. In England and Wales, being a man who has sex with men (MSM) was associated with increased odds of HIV and Hepatitis B among men using IPEDs (Hope et al., 2016). In the USA, homosexual men using AAS reported more HIV and STI diagnoses and greater sexual risk taking behavior compared to heterosexual men using AAS (Ip et al., 2017). Therefore, both sexual risk and injecting drug use may compound a person's risk for HIV acquisition among people who use IPEDs. In terms of psychological harms, research from Australia and New Zealand found that among gay and bisexual men, thoughts about using AAS were associated with lower quality of life and greater dissatisfaction with muscularity and height, but this was not observed for actual AAS use (Griffiths, Murray, Dunn, & Blashill, 2017). A small study in the USA investigating AAS use in women, including homosexual women (3/12), found that women who used AAS were more likely to meet the criteria for substance-dependence disorder, be diagnosed with a psychiatric illness, and have a history of sexual abuse compared to women who did not use anabolic androgenic steroids (Ip et al., 2010).
Another group of IPEDs are weight loss drugs or diet pills, and in Massachusetts, USA, adolescent gay men and young lesbian and bisexual women were at greater odds of using diet pills than heterosexual adolescent men and women (Watson, Adjei, Saewyc, Homma, & Goodenow, 2017). The same trend has also been observed in Minnesota adolescents (Watson et al., 2018), and use of dieting supplements has been associated with depressive symptoms in the USA (Vrany, Hawkins, Wu, & Stewart, 2018). However, much of the research into the use of diet pills that considers MSM and women who have sex with women (WSW) focuses specifically on adolescents and is based on samples from the USA.
Overall, knowledge about the extent of IPED use among adult MSM and particularly adult WSW is currently limited. MSM and WSW experience of body image pressures that may be very different to those of heterosexual people because of their sexuality, for example the use of gay dating apps has been associated with weight stigma, objectification and social comparison among MSM (Filice, Raffoul, Meyer, & Neiterman, 2019). Furthermore, MSM may face additional pressures not experienced by heterosexual men such as a community focus on sex, status, and competition, which has found to predict mental health among gay and bisexual men in addition to more traditional community stressors (e.g. stigma and discrimination) (Pachankis et al., 2020). MSM also have an increased risk of blood borne viruses through sexual transmission (Martin et al., 2013), and this risk might be increased further through IPED use, particular where these are injected (Begley et al., 2017). The use of IPED among women is under researched compared to men, with sexuality rarely considered; we are not aware of any studies that have looked at the extent of IPED use among WSW. Studies indicate that the use of psychoactive drugs is more common among MSM and WSW than among heterosexual people (Booker, Rieger, & Unger, 2017; Office of National Statistics, 2014), thus the proportion of MSM and WSW using IPEDs may also differ to that among the general population. A better understanding of the extent of IPED use among MSM and WSW, and the associated demographic characteristics, wellbeing and psychosocial issues, is therefore needed to inform appropriate responses.
Internationally, very little research has examined the socio-demographic, psychosocial and sexual factors associated with the use of IPEDs among MSM and WSW, with the few studies undertaken typically having either small sample sizes or recruiting from a limited setting (such as a gyms), and mainly focused on MSM. We use data from a large national community survey to examine the extent of IPED use among MSM and WSW in the UK and to investigate the factors associations with their use.
Section snippets
Methods
Data were collected using an online cross-sectional survey of LGBT people living in the UK. Ethical approval was obtained from Liverpool John Moores University Ethics Committee (approval reference: 18/PHI/011). The methods of the LGBT Sex and Lifestyles Survey have been published elsewhere (Hibbert, Brett, Porcellato, & Hope, 2019; Hibbert, Porcellato, Brett, & Hope, 2019), but briefly, a national convenience sample of MSM, WSW and trans people was obtained between April-June 2018 by using
Results
Of the 4690 surveys started, 3676 participants completed the survey (completion rate 78%). There were 1663 (45%) participants who identified as MSM, and 1513 (41%) who identified as WSW (the other 500 participants did not report having sex with someone of the same gender). Participants who completed the survey were more likely to be female (48% vs. 38%, p < 0.001), in a relationship (64% vs. 57%, p < 0.01), and university educated (58% vs. 49%, p < 0.01), but did not differ on any other
Discussion
Overall, we found that IPED use in the last year was reported by around 1-in-25 MSM and WSW, and the lifetime use of IPEDs will almost certainly be higher. We found that recent IPED use was associated with a number of psychological and health problems, such as psychoactive drug use and STI diagnoses. Unsurprisingly, body dissatisfaction was associated with the use of IPEDs among both MSM and WSW. Although this differs to research among gay and bisexual men using AAS in Australia and New Zealand
Funding
This project was funded through a postgraduate Liverpool John Moores University Scholarship.
Declarations of Interest
None.
Acknowledgements
The researchers would like to thank everyone who participated in the survey, as well as CliniQ, COAST, GALOP, the Gay Men's Health Collective and LGB&T Partnership for their contribution to the design and recruitment of the survey.
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