Performance Enhancement & Health 1 (2012) 39–47

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Performance Enhancement & Health

journal homepage: www.elsevier.com/locate/peh

“Will steroids kill me if I use them once?” A qualitative analysis of inquiries

submitted to the Danish anti-doping authorities
Ask Vest Christiansen a,∗ , Jens Bojsen-Møller b
a
Department of Public Health, Section for Sport Science, Aarhus University, Dalgas Avenue 4, DK-8000 Aarhus C., Denmark
b
Norwegian School of Sport Sciences, Department of Physical Performance, Sognsveien 220, N-0806 Oslo, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Background: The Danish strategy for fighting the use of anabolic androgenic steroids in fitness centres
Received 2 December 2011 is likely the most comprehensive of its sort in the world. It is instituted in the national anti doping
Received in revised form 17 April 2012 organisation, Anti Doping Denmark (ADD), and consists of doping controls, educational campaigns, and
Accepted 8 May 2012
anonymous counselling through a web-based email service.
Aim and method: Inquiries that were submitted to ADD’s web-based counselling service over an 18-month
Keywords:
period were explored with the aim to identify and analyse differences in concerns and approach to the
Anabolic androgenic steroids
counselling service. Two categories of inquiries were the focus of attention: (1) those addressing side
Anti-doping education
Recreational athletes
effects of anabolic steroids and (2) those addressing concerns for receiving a positive doping test after
Doping controls the use of supplements.
Harm reduction Results and discussion: In the first category four different types of approaches were identified and inquirers’
Denmark concerns analysed: (a) those that lacked knowledge on anabolic steroids, (b) those that had experienced
side effects, (c) those that expressed knowledge of anabolic steroids, and (d) those that presented potential
harm reduction dilemmas for the service. The second category revealed noteworthy concerns as a result
of the legislation on the issue.
Conclusion: The approach to the counselling service and the knowledge of health consequences of the
drugs consumed differed substantially between the two categories and groups of inquiries.
Implications: In order to educate the target group about anabolic steroids there is a need for the involved
organisations to consider harm reduction policies in adjunct with the often applied zero tolerance
approach.
© 2012 Elsevier Ltd. All rights reserved.

1. Background training environments (Anti Doping Danmark, 2012c). However, in

line with a few other countries the national anti-doping organi-
During the last decade increased academic and media attention sation in Denmark, Anti Doping Denmark (ADD), has by law had
has been allotted to the use of performance enhancing substances the obligation to not only fight the use of performance enhanc-
outside elite sports. Especially the use of anabolic androgenic ing substances within elite sports, but since 2005 also to address
steroids (hereafter: anabolic steroids) associated with training in the use of drugs in fitness centres and gyms (hereafter: gyms)
fitness centres have been studied and debated (e.g. Barland & (Retsinformation, 2004). The Danish strategy for fighting drug use
Tangen, 2009; Bilard, Ninot, & Hauw, 2011; Christiansen, 2009; in gyms is very likely the most comprehensive of its sort in the
Eklöf, Thurelius, Garle, Rane, & Sjöqvist, 2003; Evans-Brown & world, and is unique in that ADD control officers can perform dop-
McVeigh, 2009; Grogan, Shepherd, Evans, Wright, & Hunter, 2006; ing controls on any individual exercising in a gym that is part of
Kanayama & Pope, 2012; Klein, 1993; Mangweth et al., 2001; the national anti-doping scheme. Under the scheme, which in 2010
Monaghan, 2001, 2002; Parkinson & Evans, 2006; Pope, Phillips, embraced approximately 80% of all Danish gym-members, doping
& Olivardia, 2000; Probert, Palmer, & Leberman, 2007; Skårberg, controls are conducted in agreement with the World Anti Doping
Nyberg, & Engstrom, 2008; Striegel et al., 2006; Thompson & Cafri, Code (WADC) (Steele et al., 2010; Anti Doping Danmark, 2012c).
2007). Unlike the situation in elite sports there is no international Thus, gym members are tested and sanctioned according to the
coordinated effort to fight the use of drugs in fitness and strength same standards as elite athletes. The strategy for fighting drug use
in gyms is thus largely in line with that in elite sport, in that it
consists partly of doping controls, partly of educational campaigns
∗ Corresponding author. Tel.: +45 87168182. and an elaborated website (Anti Doping Danmark, 2012b). Besides
E-mail address: [email protected] (A.V. Christiansen). being a comprehensive source of information, the website also

2211-2669/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.peh.2012.05.002
40 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47

Table 1 (p < 0.01, Student’s t-test) than those who stated present or pre-
Affiliation of the enquirers. Absolute and relative number of queries and the distri-
vious use of such substances (26 years, SD = 10) (Bojsen-Møller &
bution on gender within each affiliation-category.
Christiansen, 2010). These figures are in line with what has been
Affiliation Number of queries Gender distribution found for users of the Swedish anti-doping hotline (Eklöf et al.,
Absolute Relative (%) Male Female Unknown 2003; Sjöqvist et al., 2008).
The majority of questions involved reference to a certain
Gym 763 55 672 46 45
Sports 174 12 116 24 34 substance or group of substances. While most questions were
Relative/peer 160 11 63 78 19 concerned with either anabolic steroids or creatine and protein
Health personnel 9 1 supplements, there were also a number of questions on other
Other 11 1 7 2 2 dietary supplements (Table 2). Also this distribution is comparable
Unknown 281 20 103 28 150
to that of Eklöf et al. (2003).
Total 1398 100% 967 180 251 When comparing to elite sports, where use of drugs is usu-
Adopted from Bojsen-Møller and Christiansen (2010). ally concealed (e.g. Møller, 2010; Waddington & Smith, 2009), it
is noteworthy that 15% of inquirers indicated current or previous
use of anabolic steroids or similar drugs; a figure that is in line with
offers anonymous counselling. Individuals in search for informa- the 17% found by Eklöf et al. (2003). Taking into account that the
tion on performance enhancing drugs and other related substances recipient of the inquiry was an anti-doping organisation it was sur-
can either make a telephone call to the hotline service or submit prising that an additional 15% of inquirers indicated that they were
questions via the website, and ADD’s consultants will then provide planning or considering use of such substances (Bojsen-Møller &
inquirers with an answer. Anti doping hotline services also operate Christiansen, 2010). In the Swedish study this category of inquirers
in Sweden, Norway, Holland and France (Bilard et al., 2011; Eklöf amounted to only 6% (Eklöf et al., 2003). This indicates that ADD’s
et al., 2003; Sjöqvist, Garle, & Rane, 2008). service is considered a trustworthy platform for information on
Contact with ADD’s consultancy service is voluntary and open performance enhancing drugs for individuals considering such use.
for everyone. Therefore especially inquiries to the web-based ser- Such individuals might turn to ADD because they on the one side
vice are often characterised by spontaneity and openness on the do not rely on the knowledge dispersed from other sources within
inquirer’s part. With its spontaneous and easy access structure the environment, and on the other mistrust physicians’ knowledge
the database thus constitutes a content rich and fruitful research on the issue (Pope, Kanayama, Ionescu-Pioggia, & Hudson, 2004;
observatory for insight into inquirers’ interests, motives, experi- Grogan et al., 2006).
ences, behaviours and concerns related to doping. However, the The quantitative analysis of the database is beneficial in that it
open structure also entails that the only information available is provides an overview of who is using the anti-doping counselling
that which the inquirer chose to submit. system, what types of questions they are generally asking, con-
In this article inquiries that were submitted to ADD’s web-based cerning what class of drugs. Such information is useful in getting to
counselling services over the 18-month period from 1 January know general concerns among users and potential users of drugs
2006 to 30 June 2007 are analysed with a qualitative approach. and dietary supplements. On the other hand the quantitative analy-
The data material has previously been quantitatively examined sis does not provide much understanding of the interests, motives,
and categorised (Bojsen-Møller & Christiansen, 2010). Although behaviours, experiences, concerns and meaning these individuals
the web-based system automatically required submission of ques- attribute to using potentially harmful drugs.
tions in one of seven categories, a large number of inquiries were As noted, the voluntary nature of inquiry submission to ADD’s
posted in wrong categories. Combined with the fact that the indi- web-service means that the submitted inquiries are characterised
vidual inquiry only contained the information the inquirer chose to by spontaneity and nearness to the thoughts and feelings of
provide, the researchers re-categorised all inquiries into an infor- the inquirer. At the same time most inquiries are short, usually
mation matrix resembling that of Eklöf’s group in their study of between 50 and 150 words, and only include the content cho-
Swedish anti-doping hotline inquiries (2003). Thus, a total of 1398 sen by the inquirer. The disadvantage is that it is not possible to
inquiries were categorised with respect to question type, age and gather additional information as in a qualitative interview; the
gender of the inquirer, the affiliation of the inquirer (e.g. competi- advantage that inquirers voluntarily provide information regard-
tive sport or the gym-sector), whether he or she used or considered ing concerns, meaning and purpose which they were not invited to
using substances, what type of substance(s) and whether the provide. The database of inquiries thus makes up fruitful observa-
inquirer expressed concerns regarding personal health or regard- tory for research with a possibility to gain insight into the meaning
ing the legal status of a specific drug or substance (Bojsen-Møller behind drug- and supplement use. As emphasised by others (e.g.
& Christiansen, 2010). Monaghan, 2002; Skårberg et al., 2008; Grogan et al., 2006), if
The typical user of ADD’s counselling service was a male researchers want to understand why drug users behave as they
between 15 and 25 years who exercised in a gym. A majority of do, it is necessary to study the social meanings they attach to med-
inquiries came from individuals doing non-competitive gym exer- ically defined risk behaviour. The authors consider the inquiries in
cise. Approximately 10% were posted by individuals participating the database to be a unique entry to such knowledge.
in sports, and only a fraction of these (less than 0.5%) were elite ath-
letes. Almost all questions that were posted by individuals training
in gyms were from male inquirers (94% male, 6% female) (Table 1). 2. Purpose and research questions
Competing bodybuilders would typically use other Internet forums
than ADD for obtaining information about anabolic steroids. Thus, The present analysis focused on inquiries from individuals train-
subjects in this study are not experienced bodybuilders, but are to ing in gyms. Two categories of inquiries were examined: (1) those
be found on a continuum from the semi-experience gym users at addressing the use of anabolic steroids and their side effects and
one end to the novice at the other. (2) those expressing concern for obtaining a positive doping test.
The available age data (age was known for only 25% of all There are two basic premises for this focus: (a) the explicit soci-
inquirers) indicate that individuals who considered use of anabolic etal concern for the use of anabolic steroids in gyms, and (b) the
steroids or similar drugs were younger (19 years, SD = 5) than the exceptional legislative steps taken in Denmark (including the use of
average inquirer (25 years, SD = 11), and were significantly younger doping controls in gyms) to counter this use (Anti Doping Danmark,
 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47 41

Table 2
Drugs in question. Total absolute and relative distribution of relevant drug/supplement in questions, and the distribution with respect to affiliation of the enquirer (gym or
sport) and gender.

Number of queries Distribution (%) Gym sector Sport Male Female

AAS 374 34 227 4 284 40

Prohormones. 53 5 41 1 48 3
HGH 37 3 20 3 26 6
Insulin 5 0 4 – 5 0
EPO/blood doping 35 3 0 1 7 2
Stimulants 10 1 8 – 3 1
Creatine/protein suppl. 237 22 194 15 209 11
‘Fat-burner’ suppl. 67 6 41 1 30 23
Dietary suppl. 171 16 104 17 120 14
Other 100 9 18 30 42 9

Total 1089 100%

Adopted from Bojsen-Møller and Christiansen (2010).

AAS, anabolic androgenic steroids; HGH, human growth hormone.

2012c; European Commission, 2007; Retsinformation, 2004). Fur- As is the case for all institutions with a public interface, some
ther, if public institutions aim at countering illicit drug use, it is individuals express their critique or lack of respect by submitting
imperative to study the social meanings which drug users attach parodic or hoax inquiries. Thus, the authors have been posed with
to their risk practices, in order to enhance the communication with the additional challenge of assessing each query for genuineness.
this group. While a few inquiries have been discarded on this behalf, others
In the present study the meaning and content of the above which had a content suggesting that they could be hoaxes (e.g. #1
two categories of inquiries, are examined with respect to the fol- and 3 below), have been kept due to an overall assessment of the
lowing question: What are the motives, interests and concerns frequency of such questions, their wording, spelling, syntax, and
for individuals who submit inquiries about performance enhanc- grammar.
ing substances to ADD? And subsequently; what consequences for When there is reference to specific trade names of drugs in the
anti-doping education can be drawn from this? Thus, whereas the inquiry, brief explanations of the drug in question are provided in
quantitative study described who used ADD’s inquiry service, the footnotes the first time they appear (except for dietary substances).
present study aims to provide some understanding of how and why The clinical conditions inquirers address will not be considered.
inquirers use the counselling service and put this into perspective ADD’s specific replies to the inquiries are not considered in the
of present anti-doping education. Hence, the object of study has present analysis; however the authors are familiar with the insti-
shifted from quantification of data subtracted from all inquiries, tution’s overall policy and from communication with consultants
to interpretation of content and meaning embedded in a certain on the service we are well aware of the spectrum of replies for the
category of inquiries. various kinds of inquiries.
The established information matrix from the quantitative study
enabled us to extract inquiries that involved use of anabolic steroids
3. Design and methods
or the consideration of such use as well as inquiries involving issues
of concern for consuming a banned substance, which could poten-
The analysis focused on inquiries from subjects that have used,
tially result in a positive doping test and a subsequent ban. After the
use or consider using anabolic steroids and involve an interest in
relevant inquiries were extracted from the database (611 in total)
or concern for a drug’s potential side effects (427 out of the total
the content of each inquiry was coded for further analysis using
1398). Since Danish legislation requires ADD to perform doping
qualitative data analysis software (ATLAS.ti, version 6.2).
controls on recreational athletes in gyms, the analysis also consid-
From the coding of the material of the first category of inquiries
ered inquiries expressing concern for obtaining a positive doping
(subjects that have used, use or consider using anabolic steroids),
test and the resulting ban (184 out of the total 1398). Inquiries
four different ways of approaching the web-service appeared.
from individuals asking general questions about training, diets, cre-
The first three (’Lack of knowledge’, Traditional hotline users’,
atine, protein, herbal products and other diet supplements have
‘Ethnopharmacists’) will be analysed under the heading ‘Side
thus been omitted. Inquiries from individuals participating in sport
effects’, while the fourth group posses a separate challenge for anti-
(recreational or elite) have similarly been omitted. Also telephone
doping education and will therefore be analysed separately under
calls to the hotline service have been disregarded since the archived
the heading ‘Dilemmas for the counselling service?’ Hereafter the
information was limited and did not allow for qualitative analysis.
second category of inquiries; ‘Concerns for positive doping test’ will
The present analysis is thus exceptional in that it builds on
be analysed.
written material from subjects voluntarily submitting inquiries
to an anti-doping organisation, expressing their questions and
concerns, whereas previous analysis on anti-doping consultancy 4. Results and discussion
programmes have relied on material collected from telephone con-
versations (Eklöf et al., 2003; Bilard et al., 2011). 4.1. Side effects
Virtually all inquiries submitted to the ADD were in Danish so
the examples presented in the following have been translated by 4.1.1. Lack of knowledge
the authors. While spelling and grammatical errors have been omit- A number of inquiries came from boys or young men who con-
ted in the translated examples, we have attempted to maintain sider use of anabolic steroids and who know that there is some
the style and framing of the questions as close to the original as sort of relationship between male hormones and their genitals, but
possible, in order to mediate an image of the subject behind the are not quite sure what this entails, and therefore sometimes make
inquiry. extraordinary assumptions:
42 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47

(#1) They say that if you introduce testosterone semen produc- are willing to take, even if they consider themselves to be well
tion stops and the testicles shrink! But since the body also grows informed on the issue.
on testosterone, you should actually stop masturbating (coz’ you
don’t have enough testosterone in your body) if you want to 4.1.2. Traditional hotline users
grow. Or is that of no importance? Unsurprisingly there are a number of individuals who use the
What is worrying is that some of these young men seem com- web-service to inquire about side effects they have experienced in
mitted to engage in anabolic steroid usage even though their connection with the use of anabolic steroids. Most of these indi-
knowledge is scarce; often they only have trained for a short period viduals now know that they were naïve when they began using
of time, are still relatively immature and may not have stopped anabolic steroids. Some simply describe their symptoms and ask
growing. The person in the example below has also learned that for guidance: (#5) “Six months ago I was stupid enough to use testos-
there might be side effects, but he nevertheless wants to be more terone for 6 weeks. Suddenly I get sore nipples. This has now developed
muscular: into small hard balls that grows and grows! What do I do? Should I con-
tact a doctor?” Gynecomastia (the formation of male breast tissue)
(#2) Hi, I’m a 17 year old boy who stopped training because I was is a well-known side effect related to anabolic steroid use, which in
impatiently waiting to see muscles. Now I’ve started training strength training milieus often is referred to as ‘bitch tits’. Another
again and have thought a lot about taking steroids or some- inquirer has experienced a stinging sensation in his arms which
thing else, but I’m also afraid that the penis will get smaller or now causes anxiety:
that I’ll get sore nipples. I’ve tried creatine and protein pow-
der but didn’t really feel it did any good and therefore I want (#6) I have a question that I want an answer to as quickly as
to try steroids. But I’ve also heard that there are many different possible, because it worries me a lot. I am currently on a well
things within hormones that you can take. Is there one of them thought-out cycle consisting of Test E [testosterone enanthate],
where the penis doesn’t shrink and you don’t get sore nipples stacked with Dianabol, which I started almost 2 weeks ago. For
and pimples? What should I do? I want to get bigger quicker. the last few days I’ve had a strange feeling in my arms and hands.
The arms feel a bit like the growing pains we can have in the legs,
It is general knowledge that there are health risks associated but it isn’t just the joints but rather the WHOLE arm. The hands
with anabolic steroid use. But some are apparently willing to take feel a bit like a bloated balloon. My conclusion would be that it
even psychological risks as long as their penis is not affected, as was fluid accumulation, given that this is normal. But I’m not
can be seen from this young man with unusual priorities: (#3) “Hi, sure and therefore hope for a solid answer I can really use.
I’m 15 years and want to take Thai.1 Are there any side effects to the
cock? I don’t care if I get sick in the head I just want to know if any- Yet others have not only experienced physical but also psycho-
thing happens with the cock.” What is evident from these examples is logical side effects:
that although muscles might be considered to be the most power- (#7) I am soon a man of 20 years. For a month ago I stopped my
ful visible signifier of maleness and masculinity, developing bigger first and final cycle. I’ve been (un)lucky enough and had “only”
muscles is still not of such importance that the young men in ques- one adverse reaction: I’ve got a depression, and my question
tion are willing to sacrifice their penis – or indeed their manhood is how long it takes before my hormone production is back to
– to become manlier. Whereas some express limited knowledge normal? To all of you who consider steroids: Keep your hands
regarding the substances they consider taking, others want to con- off it. It’s not worth it.
vey the message that they have spent time acquainting themselves
with the drugs they consider using. Usually this means that they are Examples 5–7 are typical for individuals who have experi-
more specific in their questioning, although the topic of anabolic mented with anabolic steroids and subsequently suffered clinically
steroids’ potential effect on one’s manhood is still paramount: well described adverse effects and now seek professional advice
on how to deal with their symptoms and perhaps get some relief
(#4) Hi, I consider going on a steroid cycle. I’ve been on a small for their anxieties. Some even address other users of the web-
one before with Dianabol (Thai pills). I will continue this but service directly, informing them about the potential risks involved
also combine with Test E2 and EQ (Ganabol).3 I can live with the in steroid use:
few side effects, and I have read a lot about the different issues.
So I’m not that concerned as regards my health and in addition (#8) Beware! You play with YOUR LIFE! I know it’s not what you
I don’t take large doses. But how big is the risk of becoming want to hear, but after only 8–9 cycles, it [steroids] has done me
sterile? Do you have any documentation on that? permanent harm! I can’t sleep on my left side due to pain from
the area around the heart, there’s a stinging sensation in my
The fact that Ganabol is a trade name for the anabolic steroid arm and it goes to sleep. I still have problems with my potency
boldenone, which is developed for veterinary use, mostly for treat- 2 years after and I’ve experienced that I’m in a bad mood almost
ment of horses, is illustrative of the kind of risks some individuals every day. And then of course there are all the other things such
as hair loss, etc. Good luck!

1
Such examples of real people with real concerns and sufferings
When ‘Thai’ is mentioned it is usually with reference to a 2, 5 or 10 mg tablet-
version of the anabolic steroid Methandienone, commonly known as Dianabol and
are part of the core rationale for having a public funded web con-
often imported from Thailand. Dianabol was developed by John Ziegler after he sultancy service where users of anabolic steroids can be advised on
attended the world championships in weight-lifting in 1954 as a team doctor, and how to deal with their symptoms and one can seek to convince
saw how the testosterone using Soviet athletes outperformed the American ath- potential users not to use anabolic steroids. However, although
letes. Sources: http://en.wikipedia.org/wiki/Methandienone [visited 10 May 2011]
there are quite a few inquiries pertaining to the specific experience
and (Todd, 1987).
2
Test E is short for testosterone enanthate which is an oil-based injectable steroid. of adverse effects, they do not dominate the group of inquiries on
It has been used for treatment of male hypogonadism and investigated as a poten- anabolic steroids.
tially highly effective male contraceptive.
3
Equipoise (EQ), Ganabol, Equigan and Ultragan are all trade names for the 4.1.3. Ethnopharmacists
anabolic steroid boldenone. Boldenone is an anabolic steroid developed for
veterinary use, mostly for treatment of horses. In the US it is not indicated
Fifteen percent of all inquirers inform ADD that they seriously
for use in humans and is only available through veterinary clinics. Source: consider using anabolic steroids (Bojsen-Møller & Christiansen,
http://en.wikipedia.org/wiki/Boldenone [visited 18 April 2011]. 2010), and many of these want to know what kind of anabolic
 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47 43

steroids are the most safe. They might not rely on the person who example considered a cycle consisting of Primobolan Depot4
sold them the drugs and therefore make contact with ADD whom and Turanabol,5 a variation of D-bol [Dianabol], which report-
they may regard more knowledgeable in these matters. Many add edly shouldn’t cause gyno [gynecomastia]. I’ve chosen Primo D
that they know there are risks associated with steroid use, but that [Primobolan Depot] because it has minimal side effects, leave
these risks are likely to be minimal in their case, since they will only little edema, doesn’t aromatize to estrogen, doesn’t affect the
take one cycle (or course). Some compose long, detailed questions liver, and your serum cholesterol levels will not be changed
while others keep it short and simple: (#9) “Hi ADD, What happens if either. Also the body’s own production of test [testosterone]
you try steroids just once? Will you become bigger and is it dangerous is only affected by really high doses! My plan is to run a Post
to try them for just one time?” The fact that inquirers often empha- Cycle Therapy with Nolvadex.6 Well, I just want to hear if this
sise that they will take one cycle only, indicates that they have plan is crazier than most other horror scenarios you hear about?
learned that repeated use can be health damaging. However, like And whether some of my facts are right? I mean you’ve heard
many others in the subculture they seem to believe that steroids about well functioning people who have been on juice [anabolic
used in moderation is safe (Grogan et al., 2006; Monaghan, 2002). steroids] for years! Although that isn’t my intention at all!
In spite of the potential risk they therefore still want the effect of
Again, it appears that a main theme for the inquirer is to
drug:
convince the ADD consultant that this is not a case of potential pro-
(#10) After long time’s consideration I have decided for a cycle longed substance abuse, but instead the inquirer wants to convey
that’ll blow me up a bit in my strength training. The idea is to the message that he has paid careful attention to the facts he could
inject the male hormone TESTOSTERONE into the body. This will find and now wants a second opinion on what he has learned. It is
be done over 10 weeks with 2 injections per week, i.e. 20 injec- not his “intention” to be on drugs “for years”. While he has done
tions in total. And I REPEAT, this is the first and LAST time I’ll some efforts to gain knowledge of the various drugs, he probably
try it, there’ll be no multiple cycles. I wanna hear if I’ll die from – and in line with many other inquirers – is not aware that stud-
this one time? I know my question sounds totally weird, but I ies documenting the health consequences on humans of the drugs
am a person, who cares about his wellbeing, and therefore eat and doses they inquire about, including the use of multiple drugs
very healthy and exercise a lot. I’d also like to hear if anything at the same time (so-called ‘stacking regimes’), do not exist due to
such as cardiac arrest or similar would happen to me after I’ve research-ethical reasons (e.g. Hartgens & Kuipers, 2004; Kanayama
injected the male hormone? And what are the side effects? I & Pope, 2012).
really hope you’ll answer me, as this will make me much wiser! As it further appears from the above quotes, some users of the
But I repeat; I will not go on a cycle ever again! web-service have the impression that ADD provides all sorts of
guidance. It is, however, a fixed policy that ADD consultants do
It is easy to point to the lack of coherence in a person’s attitudes not offer counselling on which anabolic steroids are safest (or least
when he stresses that he lives a healthy life and cares about his harmful) to use and/or how to use them. This guiding principle is
wellbeing, while simultaneously planning to inject testosterone. based on the certitude that no solid scientific platform for such
However, while he knows this (“I know my question sounds totally guidance exists and that in recommending one regime over the
weird”), he is not alone in framing his question this way. When other, the institution would be sending the signal that it condones
inquirers emphasise that they will only take one course, some prob- a potential harmful practice. Thus, no matter how determined the
ably do so because it is their genuine intention. It may however, also individual may seem, ADD’s consultants apply a zero tolerance pol-
serve the aim of signalling that they are in control of the situation icy and thus always advice not to use anabolic steroids. In most
and not someone that will end up as a drug addict (Kanayama & cases it is uncomplicated to employ this policy. There are instances,
Pope, 2012; Skårberg et al., 2008). It can thus be seen as a strat- however, where it may be easier said than done to balance this
egy intended to increase the chances of getting a more fact-based policy against the aspiration to provide guidance that in the best
answer related to the documented side effects of the drug in ques- possible way can safeguard inquirers’ health. More mature inquir-
tion. They know that ADD’s objective is to fight the use of doping, ers who have trained for several years, for instance, tend to have a
and they might reckon that if they appear to be unreflective (as more sophisticated approach to the subject:
some of the above inquirers), chances are that they will receive
an answer that does not relate to the content of their question, but (#12) Hey, I’m a 25 year old bloke who’ve trained for 7 years
instead one that in standardised phrases will seek to persuade them and had okay results. I just don’t grow anymore. I’ve thought
not to use drugs at all. about going on a small Primobolan cycle (200 mg/week for 8
In spite of the difference in approach and style, inquirers most
often appear to have a genuine interest in getting to know the
side effects, which, they claim, can make their risk-assessment
more informed. Following Welsh sociologist Lee Monaghan, the
4
knowledge these inquirers can be said to posses, can be cate- Primobolan (tablet form) or Primobolan Depot (injectable) is the com-
mon brand names for the anabolic steroid methenolone enanthate, or
gorised as ‘ethnopharmacological knowledge’, which is lay people’s
metenolone enanthate, which is an ester derivative of methenolone. Source:
“detailed subcultural understanding of the pharmacological prop- http://en.wikipedia.org/wiki/Metenolone enanthate [visited: 19 April 2011].
erties of particular compounds, consisting of a taxonomy of 5
Turinabol or Oral Turinabol is the brand name for 4-
different steroids, dosages, administration routes and complex Chlorodehydromethyltestosterone. It is an anabolic steroid which is a
cycling theory” (Monaghan, 2001). The interest in having such chlor-substituted version of methandrostenolone (Dianabol). Turinabol was
the first original product of Jenapharm, a pharmaceutical company from East
knowledge confirmed by an authority like ADD is visible in the Germany providing the successful East German athletes with anabolic steroids.
following example: Source: http://en.wikipedia.org/wiki/4-Chlorodehydromethyltestosterone [visited:
29 April 2011] and Spitzer (1998).
(#11) Hi ADD, I’m a (relatively) sensible guy who’ve trained 6
Nolvadex is the brand name for Tamoxifen which is used to prevent estro-
a number of years! I feel I’ve come to a standstill, and would gen related gynecomastia, resulting from elevated estrogenic levels in conjunction
like to gain the last kilos through chemistry to achieve my goal with steroid use. It is taken as a preventative measure in small doses, or used at
the onset of any symptoms e.g. nipple soreness/sensitivity. Other drugs such as
with my body. I write that I’m sensible because I’ve tried to clomiphene citrate and the anti-aromatase drugs are taken for similar purposes.
read as much as possible, and really just want to hear whether They are used to try to avoid the hormone related adverse effects of steroid use.
some of the facts I’ve been looking at may be true. I’ve for Source: http://en.wikipedia.org/wiki/Tamoxifen [visited: 29 April 2011].
44 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47

weeks combined with Clomid7 if my own testosterone produc- 4.2. Dilemmas for the counselling service?
tion should be suppressed). Is this in your eyes a very dangerous
cycle and can I perhaps do something better? I’ve read a lot Since it was permanently instituted in 2005 ADD has had as its
about primo [Primobolan] and everywhere you hear that the “vision [. . .] to fight the use of doping in Danish sport” (Anti Doping
side effects are minimal. What can be expected from a steroid Danmark, 2012a). Behind this vision are two main arguments: one
that is as mild as primo? is to “strengthen the fundamental values of sport”, i.e. the principle
of fair play, and the other is to “secure the health of the athletes”
Compared to practice in bodybuilding milieus the suggested
(Evald, 2009; Retsinformation, 2004). Whereas the principle of fair
dose is not high. Doses at or above 2000 mg of anabolic steroids per
play does not apply to recreational athletes of whom only very
week are not rare among competitive bodybuilders (Kanayama &
few take part in competitions (and none in this study did so), the
Pope, 2012; Monaghan, 2001; Parkinson & Evans, 2006; Perry, Lund,
health argument certainly does apply (Retsinformation, 2008). This
Deninger, Kutscher, & Schneider, 2005). However, such extreme
is known – implicitly or explicitly – by some inquirers who seem
doses almost certainly cause various adverse effects. In Parkinson
more or less determined to use anabolic steroids, while at the same
and Evans’ study (2006) of 500 anabolic steroid users 60% of
time believing that risk can be controlled and therefore inquire for
respondents reported using doses above 1000 mg per week, and
advice on how to use anabolic steroids in the safest possible way:
13% reported doses above 2000 mg/week. Of the 500 respon-
dents, 99% reported symptoms of side effects and 70% reported (#13) I want to ask a question which I believe many users of the
three or more side effects which they themselves judged to be [ADD web-] service want an answer to. Now, if one wants to try
caused by their use of anabolic steroids. In Bhasin’s groundbreak- a steroid cycle with Deca8 etc., and you know the side effects,
ing 1996-study subjects were given doses of 600 mg testosterone what can you then do to get a good result and also reduce the
enanthate per week and no serious side effects were observed side effects? How should you train, what should you eat etc. I
(Bhasin et al., 1996). But that dosage is nonetheless well above think it would be a good idea to mention it because many get
the normal production of testosterone in a healthy male which, scared when reading what you’re writing, but there are just as
although oscillating and subject to change from various parame- many who do it [take steroids] anyway. So in order to help them
ters, is around 8 mg/day (Mottram, 2011). Although approximately do it in a way so it won’t go wrong. Can you give such an advice?
4 times higher than normal production, the risk scenario of the
Another inquirer bluntly explains how he already is in posses-
regime suggested by inquirer #12 is thus different than what is
sion of a drug that he plans to use:
reported in a number of cases and in the underground literature
and on websites where detailed descriptions for various cycles can (#14) Hi, I’ve got hold on some Thai pills for a cycle that I’m
be found (Kanayama & Pope, 2012). Nevertheless, it would still going to run at some time. I plan to do 20–30 mg per day. Is this
be mandatory for the consultant to reply with the advice never dose too high and is there great risk of getting bitch tits from
to take any drugs. Besides emphasising the risky business of self- that amount? And if, can Nolvadex then prevent it if you take it
administering anabolic steroids and the possible side effects, the as soon as you feel the symptoms? I know you don’t advice on
consultant could stress that the drug in question could be adulter- this, but I expect a good answer since I strongly consider starting
ated (Graham et al., 2009), and thus encourage the inquirer to keep the cycle. Thank you.
up his work in the gym without drugs.
Yet another inquirer claims to be writing on behalf of his friend:
It is difficult to draw strict boundaries between inquirers’
approach. However, as demonstrated, individuals who inquire (#15) Hi Expert, Here’s a quick question: does it matter where
about anabolic steroids and their side effects can generally be you inject? I’ve got a friend that only does it in his biceps, but is
said to fall into three groups depending on their different ways that the correct way of doing it? He says it isn’t important ‘coz
of approaching the web-service: the first group consists of pri- it automatically diffuses to the whole body?
marily younger men who are impatient and rather unreflective of
As a state financed anti-doping agency ADD cannot advise
their praxis and whose inquiries about anabolic steroids suggest
on (‘safe’) ways to administer banned substances. Nonetheless, a
that these individuals have an experimenting lifestyle (#1, 2, 3, 4).
potential dilemma arises for the consultant in such cases. To take
Secondly, there is a group of what could be regarded traditional
#15 as an example: to inject only into the biceps is not recom-
hotline-users; individuals who have experienced side effects from
mendable, and further, when administering repeated muscle depot
anabolic steroids and inquire for advice on how to deal with the
injections, the injection site should be rotated to minimise the risk
symptoms. Part of this group uses the service as a platform to warn
of infections and cysts (Beyea & Nicoll, 1995; Evans, 1997; Rich,
others (#5, 6, 7 and 8). Finally, there is a group of individuals who
Dickinson, Flanigan, & Valone, 1999).
use or consider using anabolic steroids as a mean to enhance their
As noted, part of the legal foundation that ADD as an institution
training and get further results with their ‘body project’. Individ-
rests is to “secure the health of the athletes”, but in the case of,
uals in this group claim to be able to handle the risks and likely
e.g. #15 it becomes clear that the consultant is unable to disperse
side effects of the drugs in a calculative manner, which seems to
specific knowledge that at least in the short term could protect the
be part of a lifestyle where training and diet also play a dominating
inquirer and decrease associated health risks. With respect to #13
role (#10, 11 and 12). Together with others, some of these indi-
and #14 the problem is that although there are likely ‘better’ and
viduals, however, forms a fourth group since their approach to the
‘worse’ ways of administering anabolic steroids (Beyea & Nicoll,
web-service may lead to dilemmas for the consultants.
1995; Rich et al., 1999) such information cannot be given. The only

7
Clomid is a trade name for clomifene citrate which is a selective estro-
8
gen receptor modulator (SERM) that increases production of gonadotropins by Deca or Deca-Durabolin is the brand name for the anabolic steroid Nandrolone.
inhibiting negative feedback on the hypothalamus. It is commonly used by male Nandrolone (19-nortestosterone) is an anabolic steroid that may be present nat-
anabolic steroid users to bind the estrogen receptors in their bodies, thereby urally in the human body, albeit in minute quantities. Nandrolone has structural
blocking the effects of estrogen, such as gynecomastia (male breast formation). modifications which reduce the likelihood of its conversion to oestrogen by aro-
It also restores the body’s natural production of testosterone. It is commonly matase enzymes, which means it has less adrogenic activity than many other
used as a r̈ecovery drugänd taken toward the end of a steroid cycle. Source: anabolic steroids. Source: http://en.wikipedia.org/wiki/Nandrolone [visited: 9 May
http://en.wikipedia.org/wiki/Clomifene [visited 9 May 2011]. 2011].
 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47 45

possible advice under the given policy would be to not use drugs doping list? While others have more concrete worries about obtain-
at all. Given the determination to use steroids that is seen in some ing a positive doping test:
of these individuals, a likely result is that the inquirer rejects the
(#17) I was in the gym working out yesterday. Then came a con-
advice and proceeds with steroid use based on the ‘ethnopharma-
trol officer and told me to be tested. I did it of course. But thought
cological knowledge’ he has acquired elsewhere (Monaghan, 2001).
afterwards whether the supplements I’ve taken are banned. I
The question thus arises whether the currently applied guidance
take some creatine, and then I have eaten some ‘Therma Power’
policy is the optimal way to secure individuals’ health in all situa-
but stopped using them more than 24 hours before the test. I
tions. An alternative framework for anti-doping consultants would
don’t suppose it will cause problems but would like to be 100%
be to integrate knowledge from harm reduction programmes that
sure because I don’t want to be thrown out of my gym because
has accumulated from this and other fields of drug use over the past
of that.
20 years. Harm reduction in this sense
The concern is understandable. Because the Danish legislation
encompasses interventions, programmes and policies that seek
on the issue is bound to the WADC the sanctions for a positive test
to reduce the health, social and economic harms of drug use to
are also in line with the WADC. A positive test – or a refusal to be
individuals, communities and societies. A core principle of harm
tested – thus not only results in exclusion from the gym in which
reduction is the development of pragmatic responses to dealing
the test was taken and from all other gyms that are part of the
with drug use through a hierarchy of intervention goals that
scheme, but (ideally) from all organised sport in Denmark for a
place primary emphasis on reducing the health-related harms
two-year period (Christiansen, 2011). Although a majority of gym
of continued drug use (Rhodes & Hedrich, 2010).
members know whether there is doping control in their gym or not
Instead of applying a somewhat detached zero tolerance policy (Steele et al., 2010), they are not all aware about the details or what
unanimously in all communication with drug users, harm reduc- constitutes a doping infringement:
tion suggests a more pragmatic approach focusing on preserving
(#18) Hello! If one takes 1 ‘Therma Power’ [tablet] in relation to
the individual’s health in his or hers specific situation, by e.g. aim-
a desired weight loss, will this then show-up in a doping control
ing at lowering doses and increasing time off drugs (Evans-Brown
in a gym? I mean do you test for this product? I took it 2 hours
& McVeigh, 2009). Harm reduction programmes concerned with
before my workout. Yes, it might be stupid, but if I’ve already
anabolic steroid use operates in both Holland and England. Here
taken it, it’s good to know whether to be nervous for several
health personnel in clinics perform health checks of steroid users
weeks. The product contains 300 mg of Ephedra 8% and 200 mg
through, e.g. urine tests, blood tests, etc. and provide consultancy
of caffeine. Thanks in advance!
in order to guide individuals towards a healthier lifestyle. The out-
patient clinic in Holland cooperates with the Dutch anti-doping In this instance the inquirer’s concern arises from the fact that
authorities, while harm reduction clinics in England are discon- ‘Therma Power’ is a slimming product that in some cases contains
nected from the sporting system (Dawson, 2001; de Ronde, 2012; the stimulant ephedrine. According to the Danish Act on promotion
Evans-Brown & McVeigh, 2009). of a doping-free sport it is WADA’s list of banned substances that
Besides the fact that this is a sensitive area where politicians constitute the framework for what an individual can test positive
are reluctant to implement what could be considered a contro- for in a Danish gym (Retsinformation, 2004). Ephedrine/Ephedra
versial policy, there are two possible explanation for why such is indeed on WADA’s list of banned substances, but being a stimu-
an approach is not part of ADD’s consultancy programme: (1) the lant the WADC state that it is only to be tested for in competitions.
institution would be sending out confusing signals as regards its Working out in a gym is not defined as an in-competition activ-
stance on the doping issue, and 2) a change in the guiding princi- ity and thus stimulants are not tested for. However, from the data
ples is judged to lead to additional ethical dilemmas. If for instance material it is evident that most inquirers are not aware of these
#15, as a result of the consultant’s advice under a different set of subtle nuances.
guidelines, adopts correct injection techniques he may experience Another consequence of having legislation bound to the WADC
fewer side effects and hence be less prone to cease his anabolic is that the principle of strict liability applies, which means that the
steroid use. individual is solely responsible for the substances found in his or
Taken together, it becomes clear that counselling on banned her urine sample following a doping test.
substances in the fitness environment is a delicate matter where
(#19) For a period I’ve eaten ‘V12 Turbo’, but the day before
unambiguous guiding principles are difficult to apply.
yesterday I was told that V12 is on the doping list. But is it really?
And if I’ve already eaten it, but never knew it was banned, what
do I do? Because if you test me, it will show I’m positive, even
4.3. Concerns for positive doping test
though I had no idea it was banned!
Less problematic are inquiries from gym members who use Irrespective of which banned drug the inquirer suspects could
dietary supplements. It is noteworthy that users of illegal sub- be present in ‘V12 Turbo’, the problem raised is of some signifi-
stances like anabolic steroids rarely inquire about the risk of getting cance. In one study 634 dietary substances bought in 13 different
caught or obtaining a positive doping test in a gym (Bojsen-Møller countries mostly from shops but including 52 samples from the
& Christiansen, 2010). This may be because they know the drugs Internet, were analysed for their content. The analysis revealed that
they consider taking are illegal both in society at large and banned 15% of the products contained anabolic steroids that had not been
in sport, and therefore they regard it to be futile to inquire about. declared on the labels of the products (Geyer et al., 2004). And even
Some users of various dietary supplements on the other hand, seem if there has been some improvement in the supplement business
unsure about the legal status of the substances they consume. Many in recent years, the US Food and Drug Administration warned in
of these inquiries are characterised by a concern that the inquirer December 2009 about a number of dietary supplements that poten-
may also be affected by the rules and regulations set up to fight tially contained anabolic steroids (FDA, 2010). A warning that was
the use of doping, although they do not consider themselves to be also circulated in Denmark (The Danish Medicines Agency, 2010).
part of the target group of the legislation. Some simply ask whether Gym members’ frequent usage of such substances is not without
the specific substance they have bought is safe to consume: (#16) risk due to WADA’s strict liability rule. To give an example: a gym-
Is ‘Animal Pak’ legal in Denmark? Or does it contain drugs from the member buys and consumes a protein powder from the Internet.
46 A.V. Christiansen, J. Bojsen-Møller / Performance Enhancement & Health 1 (2012) 39–47

He discards the container and is few weeks later selected for a dop- the confusion that could arise from having a government sponsored
ing control in his gym and tests positive for nandrolone (which is anti-doping organisation apparently condoning the use of drugs.
one of the anabolic steroids frequently found in adulterated supple- This issue has also been debated in England. Those against harm
ments). Although he claims his innocence and says the supplement reduction schemes are arguing that consultants could be consid-
he consumed must have been adulterated he is still likely to get a ered complicit in recreational athletes’ drug use, while the counter
two-year ban due to the strict liability rule. The two-year ban, how- argument is that if it is known that people are going to engage
ever, does not only apply to the gym in which the test was taken, but in risky and dangerous behaviours that are preventable at com-
to all gyms that are part of the scheme, and (ideally) to all organised paratively little cost in resources, then there is a strong ethical
sport in Denmark. He is thus not only restricted from doing strength case that society ought to act to steer them away from these risks
training in his gym but also from taking up badminton or bowling. (DrugScope, 2004). This suggests that if harm reduction schemes
Hence, concerns over contamination and unintended positive tests for anabolic steroid users in gyms are to be accepted in the public
expressed by many inquirers are not unfounded. sphere, and those who run the schemes are to avoid accusations
of hypocrisy, it is necessary that control of doping among elite
athletes is institutionally separated from the units acting out the
5. Conclusion
harm reduction policy on recreational athletes in gyms. Thus, harm
reduction policies do not imply the dismantling of conventional
This study examined two categories of inquiries to ADD’s web-
drug controls or education.
based counselling service: those inquiring about side effects from
In line with the zero tolerance approach, educational cam-
anabolic steroid use, and those inquiring about concerns for obtain-
paigns aimed at avoiding anabolic steroid use have often applied
ing a positive doping test. The analysis demonstrated how inquiries
a discourse focused on classic health related ideals such as vigi-
covered a broad spectrum of motives and concerns, as well as dif-
lance, good health and moderation (Goldberg & Elliot, 2000; Møller,
ferences in the way inquirers approached the web-service. Those
2009; Nilsson, Allebeck, Marklund, Baigi, & Fridlund, 2004). There
inquiring about side effects of anabolic steroids could be grouped
is, however, much empirical evidence that these standards are
according to their approach to the service: one group consisted
not compatible with the sub-cultural values possessed by many
of individuals demonstrating lack of knowledge as regards effects
strength-training individuals using anabolic steroids (Barland &
and side effects of the hormones they expressed willingness to con-
Tangen, 2009; Grogan et al., 2006; Klein, 1993; Monaghan, 2001),
sume, another group consisted of traditional hotline-users who had
and consequently the message has not the intended impact on the
experienced side effects from anabolic steroids, while a third group
target group. This does not mean that these individuals adequately
consisted of individuals who with so-called ‘ethnopharmacologi-
can be characterised as belonging to an anarchistic drug sub-culture
cal knowledge’ claimed that risks and side effects of drugs could be
where health is simply abandoned, which is evident from the num-
handled in a calculative manner. Together with others, some in this
ber of individuals addressing health concerns in connection with
latter group pose a separate challenge to ADD’s consultants in that
anabolic steroid usage (e.g. Bojsen-Møller & Christiansen, 2010;
they inquired for health guidance while using anabolic steroids.
Monaghan, 2001). Rather, it points to differences in the cultural
ADD upholds a zero tolerance policy to drug use and have not
premises, where one side accepts the validity of potential harm
applied harm reduction policies that might be beneficial for some
minimisation through competent risk assessment and risk man-
individuals in this group. The analysis finally demonstrated how the
agement while the other rejects it. Thus, future research should
Danish scheme for fighting use of anabolic steroids in gyms has also
seek strategies for communication and education that can bridge
had an impact on individuals who demonstrated no apparent inten-
these perceived differences in knowledge and human interests.
tion of violating the anti-doping rules, but who nevertheless are
concerned for receiving a positive doping test and by so potentially
losing access to organised sport. Conflicts of interest

None.
6. Perspectives

Organisations aiming at eradicating or diminishing the use of Acknowledgments

anabolic steroids among strength training individuals in the gen-
eral population are faced with a double challenge: on the one The authors would like to thank Anti Doping Denmark for their
hand they are expected to take a zero tolerance approach, on the collaboration on this project and for giving us access to their
other, they must seek to minimise health problems among users database. There was no financial assistance with the project.
and potential users. While the two aims in most cases cause no
dilemmas, there are situations where conflicts arise. This is espe- References
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