Post-cycle therapy for performance and image enhancing drug users: A qualitative investigation

https://doi.org/10.1016/j.peh.2016.11.002Get rights and content

Highlights

  • Exogenous steroid use can supress endogenous testosterone production.

  • Post cycle therapy (PCT) is employed by steroid users to minimise negative health effects.

  • PCT is seen as important but difficult to access.

  • PCT may act as a harm reduction measure.

Abstract

Anabolic-androgenic steroids (AAS) are synthetic forms of the hormone testosterone and their non-medical use is related to increased muscle size, muscle mass, and strength. A primary concern regarding exogenous AAS use is its potential to suppress endogenous (natural) testosterone production. In response, some users seek out substances to use post-cycle to mitigate problems associated with the resumption of endogenous testosterone production. This study sought to understand issues related to post-cycle therapy (PCT) among a sample of performance and image enhancing drugs (PIED) users in Australia. Semi-structured interviews were conducted with 26 participants (n = 24 male) who reported the use of a range of performance and image enhancing drugs (PIEDs), including AAS, human chorionic gonadotropin, growth hormone, clenbuterol, tamoxifen, insulin, and peptides. Interviews were conducted in person or by telephone, recorded, and transcribed. Data were analysed following a process of thematic analysis. Three themes emerged: (1) access to PCT; (2) maintenance of gains, maintenance of health; and (3) PCT and links to mental health. Steroids were seen as easier to access than PCT; as such, participants tended to continue to use steroids rather than taper down their use, leading to health concerns. Participants wanted access to PCT for several reasons, including minimising any loss of muscle or strength gained through their PIED cycle; because they were concerned that they were no longer naturally producing hormones; or because they were concerned about their mental health, particularly when coming ‘off cycle’, and the need for PCT to help adjust. This study contributes to the existing literature suggesting that PCT may act as a harm reduction measure, allowing PIED users to safely reduce or cease steroid use or to address any negative effects from use, particularly those related to mental health.

Introduction

Performance and image enhancing drugs (PIEDs) are substances used to improve one’s sporting performance and/or level of visible body muscularity (Cohen, Collins, Darkes, & Gwartney, 2006; Hildebrandt, Alfano, & Langenbucher, 2010; Ip, Barnett, Tenerowicz, & Perry, 2011; Murray, Griffiths, Mond et al., 2016). Subcategories of PIEDs include muscle-builders, and within this subcategory, anabolic-androgenic steroids (AAS) have received the most public and empirical attention. AAS are synthetic derivatives of testosterone and have been demonstrated to build muscle tissue in humans at a rate that considerably outpaces those who do not use AAS (Bhasin, 2001, Bhasin et al., 1996; Griffiths, Murray, Mitchison, & Mond, 2016).

AAS use is associated with negative health effects in both the short-term (e.g., gynecomastia) and long-term (e.g., cardiovascular morbidity) (Kanayama, Hudson, & Pope, 2008). Of particular concern to users and health professionals, however, are the health effects that emanate from the impact of AAS on the hypothalamic–pituitary–testicular (HPT) axis. Exogenous administration of testosterone (i.e., AAS use) suppresses endogenous production of testosterone (Pope and Brower, 2005, Reyes-Fuentes and Veldhuis, 1993). Many AAS users resume endogenous production of testosterone following the cessation of AAS use (Kanayama et al., 2008). However, there is considerable variability among users in both the degree of recovery and the timeframe of recovery, with some users subject to chronic HPT suppression (Kanayama et al., 2008). The health consequences of chronic HPT suppression are particularly serious and include infertility, impotence, and mood disorders (Kanayama et al., 2008).

Post-cycle therapy (PCT) is an important feature of PIED use. PIED users refer to the period when they are using as “on-cycle” while the period when they are not using PIEDs is referred to as “off-cycle” (Hildebrandt, Langenbucher, Lai, Loeb, & Hollander, 2011). PCT refers to the period immediately following cessation of AAS (and of PIEDs more generally), and can be any combination of drugs and behaviours that PIED users consume and engage in after they have decided to go “off-cycle” or otherwise discontinue their PIED use. PCT is therefore one major element of the broader strategies that PIED users employ to minimise the negative health effects of PIED use, including both during and after use (see Adair (2015) for an overview of these non-PCT strategies). The specific reasons that PIED users conduct PCT might include the restoration of one’s natural hormonal functioning (i.e., functioning prior to using PIEDs) more quickly than would otherwise be possible without PCT; to more quickly reverse or mitigate the side-effects associated with PIED use (e.g., testicular atrophy); to avoid or mitigate the side-effects associated with discontinuing PIED use (e.g., mood fluctuations arising from resumption of endogenous testosterone production); and to conserve gains in sporting performance and subjective body appearance made during the period of PIED use. The evidence for these motivations, however, is largely conjectural and anecdotal.

Efforts to effectively target PIED users in the context of prevention, early-intervention, treatment, health promotion, and harm reduction are predicated on our understanding of the phenomenon of PIED use. PCT, as a component of PIED use, requires a much-improved empirical understanding; however, to date we are unaware of any published research that has specifically investigated the practice of PCT among PIED users. Therefore, the aim of this study was to provide insights, using qualitative methods, into the practice of PCT among PIED users living in Australia.

Section snippets

Sampling and recruitment

A purposive sample of PIED users was recruited through personal contacts, advertisements posted on Internet discussion boards, and snowball sampling. Participants were eligible to be included if they reported the use of any PIED, though participants were screened for entry based on any non-medical or non-prescribed PIED use, such as AAS or HGH, to ensure that participants were not solely using legally available PIEDs such as creatine. Interested participants were asked to contact one of the

Findings

In total 26 participants (24 males, two females) consented to be interviewed. The mean age was 34 years (range 21–62 years). Of these, 22 were from Queensland, two from Victoria, one from Western Australia and one from New South Wales. That the majority were from Queensland reflected the contacts of the fourth author, who through their role as a health promotion worker and involvement in the gym culture was able to build rapport with a number of participants. Most were engaged in some form of

Discussion

Non-medical use of AAS is associated with adverse health effects. Many AAS users anticipate these health effects and engage in a practice called PCT – a phenomenon ubiquitous to AAS use and about which little is known. Therefore, the aim of this study was to provide insights into the practice of PCT among PIED users living in Australia. This study found that PCT is one way in which PIED users attempt not only to maximise the physical gains they have attained during their PIED cycle, but also to

Conclusion

PCT is one way in which PIED users attempt not only to maximise the physical gains they have attained during their PIED cycle, but also to minimise any harms that may be experienced when coming off cycle. Restricted access to PCT could mean that PIED users engage in long-term PIED use rather than cycle off, which in turn may have long-term negative health effects. More research into PCT use in this population is needed.

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