Abstract
Existing data reveals prevalent performance and image-enhancing drug (PIED) use in specific global regions and higher rates among athletes, however, research on performance-enhancement experiences among elite untested athletes is lacking. Drawing on conceptual frameworks that emphasize the intersection of context and practice, this research aims to gain insights into the subjective perspectives, motivations, and challenges faced by athletes in managing and optimizing their performance while using PIEDs. In-depth interviews were conducted with seventeen strength sports athletes, including powerlifters and bodybuilders, who had competed at national and/or international levels within untested federations. Thematic analysis was employed to examine the interview data within a social constructivist ontology. Findings revealed that PIEDs have dual roles as tools for enhanced recovery and heightened training stress, a delicate balance that aligns with Foucault’s notion of self-transformation through technological advancements. These substances exerted power beyond consumption events with long-term psychological effects such as anxiety and irrational behavior emerging as key concerns. Peers with lived experience were key actors in the relationship between responsible drug management, however, the need for informed guidance was acknowledged. Non-human actors, notably biometric data tracking, played a pivotal role in guiding substance consumption. The study underscores the need for further research and tailored frameworks to support the health and well-being of athletes in this domain while addressing the broader implications of PIED use in public health discourse. Specifically, this study highlights the significance of integrating lived experiences and social contexts, emphasizing the need for nuanced harm-reduction strategies in this space.
Introduction
Performance enhancement in high-level athletes involves strategic efforts to achieve and maintain peak performance levels, representing the peak of the performance optimization process (Kimiecik and Jackson Citation2002). Athlete development emphasizes the optimization of athletic performance through a range of training strategies that encompass both physiological and psychological aspects (Terry and Bertollo Citation2020). While various sports receive substantial attention in this domain, strength sports, despite their unique physical and mental demands, have garnered relatively limited scrutiny. Strength sports, including powerlifting, bodybuilding, and strongman competitions, involve athletes competing in weight-class divisions and require a combination of physical strength, endurance, and technique (Moore et al. Citation2019; Piatkowski et al. Citation2023a, Citation2023d). Powerlifting focuses on the three main lifts: squat, bench press, and deadlift, with athletes aiming to lift the heaviest weight possible. Bodybuilding emphasizes muscular development and symmetry, with competitors showcasing their physiques through posing routines. Strongman events test overall strength and include activities like lifting heavy objects, carrying loads, and pulling vehicles. Notably, a recent review highlights the potential benefits of performance enhancement interventions encompassing both physical and psychological aspects for athletes in strength sports (Alexander et al. Citation2019). However, it is crucial to consider external factors that can impact performance, such as the use of performance and image-enhancing drugs (PIEDs).
Epidemiological data indicates a greater prevalence of PIED use in certain regions, namely Europe, the Middle East, North America (specifically the USA), Oceania (encompassing Australia and New Zealand), and South America (Sagoe & Palleson, Citation2018). Further, within the domain of athletes, the incidence and prevalence of use surpass those observed in the general population (Hearne et al. Citation2021; Sagoe & Palleson, Citation2018). Significantly higher rates of PIED use have been observed in groups of athletes such as bodybuilders and weightlifters (Dunn and Piatkowski Citation2021; Sjöqvist et al. Citation2008). Jokipalo and Khudayarov (Citation2021) found that 100% of athletes surveyed in Finnish doping-untested strength-sport federations reported using anabolic-androgenic steroids (AAS) and other substances. It is noteworthy that the doses and polypharmacy observed among competitive doping-untested strength-sport athletes are higher than those reported among recreational gym users (Sagoe et al. Citation2015; Piatkowski et al. Citation2022b). However, the experiences of performance enhancement among elite-level untested athletes, particularly in the context of strength sports, remain relatively understudied. Qualitative health research has increasingly emphasized understanding the subjective experiences and meanings that individuals associate with health and illness (Sothern and Reid Citation2018). In this study, we aimed to explore the lived experiences of elite strength athletes who use PIEDs, shedding light on their perspectives, motivations, and challenges within the realm of performance enhancement. To guide our inquiry, we draw upon relevant conceptual frameworks that provide a deeper understanding of the social, psychological, and ethical dimensions involved in the use of these substances in strength sports. Therefore, the current study sought to explore how elite strength athletes who use PIEDs manage and optimize their health and performance.
Conceptual framework
Doing, as practice, refers to the intentional and voluntary actions through which individuals not only establish rules of conduct but also seek to transform themselves (Foucault Citation1985). Such practices entail conscious and deliberate choices and the specific actions that follow from them (Simons Citation1995). Foucault refers to these practices as "technologies of the self," which allow individuals to effect transformations in their bodies, souls, thoughts, conduct, and way of being, with the ultimate goal of attaining happiness, purity, wisdom, perfection, or immortality (Foucault Citation1988, p. 18). Concrete practices that contribute to these transformations include everyday activities through which individuals regulate their conduct and develop their individuality, such as fashioning their corporeality, managing their sexuality, engaging in spiritual practices, self-education, and knowledge development (Simons Citation1995). Importantly, these practices are not created by the self; rather, individuals modify existing cultural techniques and strategies to more deeply individualize their subjective experiences (Foucault Citation1988). It is at the intersection of context and doing, or practice, that Duff (Citation2007) suggested a conceptual logic exists for a more comprehensive interrogation of distinct drug use settings and the broader understanding and contextualization of drug-related harms. Duff (Citation2011, Citation2012) has argued that the various human and non-human entities involved in instances of drug use are integral to understand how "structural" or "contextual" effects are generated, organized, and utilized during such events. We argue that performance enhancement, particularly through PIEDs, emerges from contexts that are created and modified during drug use – in this case strength sports. By examining the interactions among various actors, entities, and objects within the context of performance enhancement, particularly about PIED use in strength sports, we can gain insights into the dynamics of these events.
Methods
Sampling and recruitment
Ethical approval was granted by the University Human Research Ethics Committee (Approval 2021/648). Seventeen interviews were conducted online (via MS Teams) with strength athletes in Australia between May and June 2022. A purposive sample of participants was recruited via researcher contacts and through snowball sampling. Specifically, participants were invited by the interviewer to consider extending the opportunity to others within their network who might share an interest in participating, allowing for an organic expansion of the participant pool. Participants were eligible to be included if they were strength athletes who competed at an elite level for their respective sport. The strength sports included bodybuilding, powerlifting, and strongman/woman. Elite level was deemed by the athletes’ participation in a national level competition in these sports. Interested participants were asked to contact a member of the research team; all interviews were conducted by the first author.
Data collection
Interviews were between 28 and 126 min in duration (M = 44.1 min, SD = 9.5 min) and conducted online. A semi-structured interview schedule was used. The questions included a list of prompts. The prompts were, firstly, related to gaining information about the participant and building rapport, such as their years competing in strength sports as well as their PIED use. Specific questions related to the study and its aims followed these initial prompts. Examples include: How do you manage your performance leading up to the competition? How do you manage the demands of training? Can you tell me about ways that you manage your overall health and wellbeing? What are your strategies for improving performance? No reimbursements were offered for participation.
Data analysis
The analysis of the data was conducted from a social constructivist perspective Adams (Citation2006). This ontological stance was deemed appropriate due to the understanding that knowledge is collaboratively constructed through the interaction between the researcher and participants, with the research aims and theoretical framework guiding the analysis of data and the subsequent findings (Sparkes and Smith Citation2014). The interviews were recorded and transcribed, and the transcripts were reviewed by the authors. The qualitative data were imported into NVivo for analysis. The first author generated codes and developed themes based on the data, with input from the other authors (Braun and Clarke Citation2021). The analysis process involved reflexivity and reflection on positionality and biases (Braun and Clarke Citation2019). Regular team meetings were held to discuss coding decisions, themes, and emerging patterns. The approach aimed for collaborative and reflexive analysis to gain a nuanced understanding of the data (Braun and Clarke Citation2023). The first author is active in community engagement with those involved in strength sports who both do and do not dope. He also provides ongoing harm reduction through professional networks. Prior to the study he was active in the strength sports community and is familiar with the perspectives of those who lift weights for esthetic and performance reasons. His personal insight allowed for deeper exploration during the interviews (Zampini et al. Citation2021). The coauthors also reflected on their biases and perceptions during research team meetings, around those involved in strength sports as well as those who use drugs.
Results
Participants (N = 17) had a mean age of 33.28 years (SD = 6.64). There was a relatively even distribution of male (n = 8) and female (n = 9) athletes. The cohort competed in powerlifting (n = 14), bodybuilding (n = 5), and strongman/woman (n = 2), with an overlap between the powerlifting and strongman/woman cohorts. On average, the athletes had spent approximately 7.10 years (SD = 2.57) competing in their respective sports. All the athletes competed at an elite level in their respective sports. All of the athletes reported using AAS. They reported using testosterone or some derivative of testosterone at varied dosages, orally and/or intramuscularly. Three overarching themes were developed from the data.
Theme 1: Technological enhancement: a double-edged advancement
There was an acknowledgement that these substances acted as tools, enabling accelerated recovery and heightened training stress. However, this enhanced recovery and training capacity came at the cost of increased physiological stress. Despite being cognizant of this tradeoff, they embraced it, recognizing it as a necessary tool to push their bodies toward greater adaptation and growth. In essence, they saw PIEDs as a double-edged ‘technological’ advancement that both aided and stressed their pursuit of physical enhancement fitting with Foucault’s suggestion of these advancement being a means individuals use to ‘effect […] operations on their own bodies […] to transform themselves’ (1988: 18).
P2 [Male, Powerlifter]: These drugs allow us to recover, but they also allow to recover quicker, so we can put more stress on the body to hopefully adapt. So, yes, you’re constantly putting stress on your body. These drugs are… they’re helping yes, but they’re also helping us to accumulate more stress.
Importantly, this management was contextualized within the competitive landscape, showcasing the nuanced integration of 'spaces, bodies, and affects’ (Duff Citation2014, p. 638). Specifically, they strategically engaged with these substances during defined phases like competition preparation, employing them as a form of embodied technology. The temporal dimension of usage, particularly peaking dosages around competitions, emerged as a recurring pattern, underscoring the dynamic interplay between the athlete’s bodily engagement, the competitive space, and the desired affective outcomes facilitated by the drugs.
P8 [Female, Powerlifter]: They’re aware of it, and they’ll just put themselves in a situation where they can deal with that for six weeks while they comp [competition] prep [preparation], and then they’ll take themselves out of that situation.
Athletes exhibited a heightened awareness of the specific health risks associated with their illicit practices, primarily focusing on cardiovascular health concerns, notably blood pressure and body weight. Recognizing the physiological strain imposed by substantial gains in body mass, users emphasized the necessity of effectively managing these extreme bodily transformations. The deliberate attention to health risks underscores the recognition among athletes that their actions carry potential consequences for their cardiovascular wellbeing.
P6 [Female, Bodybuilder]: As I get further into a comp prep I know some parts of my health aren’t doing so good… more drugs means more stress on my body so I know my liver and kidneys are copping it.
P13 [Male Bodybuilder]: My blood pressure was just way too high. It was also because my body weight was way too high. Or was heavily…. Increased over a short period of time.
In navigating the intricate landscape of use, individuals actively engage with a network of resources and actors, strategically seeking guidance and knowledge from those with experience. The athletes acknowledge the multifaceted value in tapping into this diverse pool of expertise, encompassing both experienced individuals and the broader network of gym culture, mirroring the approach of generating comprehensive accounts of drug use within the larger social context (Duff Citation2011). This dynamic engagement underscores the recognition of varied 'actors’ contributing to the nuanced understanding and informed decision-making regarding these substances, reflecting the social fabric that contributes to shaping the usage dynamics.
P10 [Female, Powerlifter]: It [PIED use] plays a massive part, and you have to be really smart. Either know what you’re doing, or work with someone who knows what you’re doing.
P17 [Male, Powerlifter]: Anything I’m unsure about, especially with PEDs [performance enhancing drugs], straight to my coach, or one of the more experienced guys around the gym.
Theme 2: Extended capacities: PIEDs ‘at work’
Individuals consistently highlighted subjective and psychological effects linked to their use of PIEDs. This extends to the trend where drug effects are not merely seen as general but are attributed to specific capacities (Pienaar et al. Citation2020), with PIEDs having ‘extended capacity’ beyond consumption events. Anxiety and irrational behavior emerged as major concerns, shedding light on the nuanced relationship between drug dosage and the intensity of these experiences. Notably, participants’ cautious approach and dialogue with their coaches underscored an understanding of responsible drug management, emphasizing the need for informed guidance to mitigate potential risks associated with these substances.
P4 [Female, Powerlifter]: I had massive anxiety about running clen [Clenbuterol] this time, because the last time I ran clen it… definitely made me really anxious and irrational. I was probably taking four times the amount. I vocalised that to my coach, and said “I’m very nervous”. But he was like,” Well I think that amount is going to have a very limited effect on that”. He said “How much were you taking last time?” “Oh about five times that much” [laughs]. He’s like “Well yeah, no wonder you were off your head.”
P16 [Male, Bodybuilder]: The last bodybuilding comp I did was f**king awful though with anxiety.
There was shared concern among the cohort regarding the psychological effects of using PIEDs. They underscored experiences of themselves or of their peers who encountered significant psychological challenges upon discontinuing long-term drug use. Ultimately, participants underscored the need for education and support around safe usage practices as well as the importance of addressing the psychological changes that may accompany the cessation of drug use.
P15 [Female, Strongwoman]: I know someone… they came off after very long use and found that they lost their way. Whilst on, they’re peaking, their energy levels are all quite high, and I imagine their stress levels are quite high too. Then when coming off, they almost had a bit of an identity crisis they described it as. I think there needs to be education around safe use, and then when coming off as well, because I think that not only is there problems going on, there’s major psychological changes that happen.
The cohort expressed a wish for greater consideration and awareness among individuals using PIEDs. They acknowledged the existence of peers who had experienced significant problems because of their actions while also reflecting a shared understanding within the cohort through lived experience, reiterating the role of structurally positioned array of actors, ‘at work’ (Duff Citation2011, p. 404) surrounding the event of drug consumption. The impacts of drug consumption extend beyond the immediate temporal and physical settings, permeating various aspects of daily life (Jackson Citation2004), with the current data extending this understanding to encompass nuances of consumption.
P10 [Female, Powerlifter]: It’s [PIED use] creating long-term issues. I know that there are a couple who I train with quite regularly, that do have some very big issues [laughs], as a result of what they’ve done.
Theme 3: Non-human networks governing use
While highly personal in their impact, PIEDs as ‘technologies’ also foster new types of shared bodily and social experiences (Pienaar et al. Citation2020). In this cohort, both the physical and psychological stress inherent surrounding PIED use, training, and competition were normalized and, subsequently woven into unique networks of ‘connectors’ (Latour, 2005). These stress-induced networks prompt individuals to reflect on the influences and factors contributing to their substance use outcomes, particularly within the context of competition.
P5 [Female, Powerlifter]: Mentally it [competing] obviously gets to me…. I will always try to evaluate what I’ve done wrong… improve the next time. That means looking at sleep, diet, training, drugs, all of it.
The network relationships through which substances develop unique 'personalities’ significantly shape the meanings attributed to each substance and efforts to govern their usage (Moore Citation2004). In response to their usage of these substances, athletes typically devise systematic health management plans, drawing heavily from the information they have access to.
P2 [Male, Powerlifter]: I try to break it down and figure out why, y’know, have I slept properly? Have I hydrated?
P7 [Male, Powerlifter]: I check my blood pressure every three days. I’m always checking my resting heart rate.
Duff (Citation2007) has posited an analytical framework focused on delineating the spectrum of both human and non-human actors that manifest within and around the ‘event’ of drug consumption. Therefore, we draw attention pivotal role of non-human actors, notably biometric data tracking and analysis, for PIED consumption. These non-human elements contributed significantly by providing a logical framework to interpret and alleviate stress associated with performance fluctuations, showcasing the dynamic involvement of both human and non-human actors in this drug consumption ‘event’.
P11 [Female, Powerlifter]: I track all my biometrics, like all the data. I look at where I was at in my [PIED] cycle, and I tried it [the lift] again three days later and filmed it. It was like night and day. I looked at the data and then wasn’t stressed about it because I had a logical reason as to why that happened.
Discussion
The findings revealed that athletes demonstrated a comprehensive understanding of the amplified physiological stress resulting from PIED use and recognized the associated health risks, particularly in relation to cardiovascular health concerns which fits with extant work (van Amsterdam et al. Citation2010). These athletes strategically utilized these substances to enhance recovery during the competition preparation phase. This enhancement, however, is double-edged, offering accelerated recovery and heightened training stress while imposing increased physiological stress, a delicate balance reminiscent of Foucault’s concept of self-transformation through technological advancements. To manage the stress emerging from PIED use, athletes sought guidance from experienced individuals underlining the pivotal role of structured actors (Duff Citation2012) in informed decision-making and responsible management practices (Piatkowski et al. Citation2023c). Highlighting non-human actors, athletes employed long-term health monitoring (e.g. blood pressure, heart rate) to devise systematic coping plans for managing substance consumption. This approach showcased a proactive integration of strategies, shedding light on the intricate relationship between performance enhancement and health.
In a manner similar to the normalization of recreational drug use among youth populations (Duff Citation2005), we assert that the proliferation and normalization of PIEDs such as AAS, have resulted in a cultural shift. This shift is characterized by an increasing number of individuals, both men and women (Piatkowski et al. Citation2023a, Citation2023d), engaging in strength sports and displaying a heightened propensity for using these substances (Piatkowski et al. Citation2023b). This evolving trend extends beyond the realm of strength sports, highlighting the broader public health implications associated with the use of these substances (Sagoe et al. Citation2015; Gibbs and Piatkowski Citation2023). However, the discourse surrounding performance enhancement provides a valuable lens for understanding these transformations, particularly given PIEDs exhibit a capacity (Pienaar et al. Citation2020) permeating well beyond the confines of the consumption event. This distinction is not due to structural forces, but rather the countless ways that societies are formed in everyday life (Duff Citation2011). These structural forces have been suggested to be contextual, noting that the ‘place and time’ of drug consumption is important (Duff Citation2014). Specifically, there are contingent roles of context in the mediation of what individual’s do ‘on’ and ‘with’ drugs (Duff Citation2014, p.634).
Presently, limited evidence exists to substantiate appropriate frameworks for untested athletes who use PIEDs (Kanayama and Pope Citation2018; Hope et al. Citation2021). The current data suggest that elite strength athletes who use PIEDs understand there may be consequences to their health as a result (Lemiński et al. Citation2022). This cohort acknowledged their drug use as a mechanism that increased the ‘stress’ they were placing on their body. As a result, they also recognized the need for management and planning to mitigate the health risks associated with their drug use. Often turning to peers and coaches for harm reduction advice, something which has been documented in extant work (Gibbs et al. Citation2022; Piatkowski et al. Citation2022a), participants underscored the importance of those with lived experience in providing guidance regarding their use. That is, they would often not make choices regarding their health without consulting with these key actors. Extending on this, as Duff (Citation2014) asserts, is crucial to prioritize the examination of place as a dynamic composition of human and nonhuman elements when empirically studying the use of drugs. This emphasis is necessary to challenge the tendency to overly objectify and solidify the notions of context and structure in such analyses.
Moving beyond an analysis of PIED use within specific contexts, such as gyms and strength sports, and viewing them as assemblages (Delanda Citation2019) comprising both human and nonhuman elements, adds further depth to the implications of this study. This approach is necessary to counter the tendency in social science analysis to merely acknowledge the presence of social and structural forces in PIED use, without delving into their active involvement in specific places and times. By adequately describing the unique settings and temporal dynamics of PIED use, we gain insight into how power relations and structural influences can be resisted, reconfigured, or transformed in the context of consumption events. Notably, recognizing the value of peers and lived experiences can inform harm reduction strategies within the performance enhancement domain.
Conclusions
Although this group represents an underexplored cohort of elite athletes, the findings of this study provide important directions for future investigations concerning this novel sample; however, the data from this cohort of strength athletes may not be applicable across the entire spectrum of elite athletes. Research with more diverse samples could extend on the present findings and increase confidence in their generalizability and we underscore the importance of more international data linkage. This study emphasizes PIEDs’ dual role: enhancing recovery and increasing training stress. As a result, these substances extend their influence beyond consumption events, contributing to enduring psychological effects. Human (e.g. peers) and non-human (e.g. biometrics data) connectors, play crucial roles in guiding consumption, allowing athletes to optimize their health and performance. This response navigates the duality of technological enhancement to align with their goals. However, the study underscores the need for further research and tailored frameworks to support the health of athletes in this domain while addressing the broader implications of PIED use in global public health discourse.
Ethical statement
Ethical approval was provided by the ethics committee of Griffith University.
Patient consent
Participants provided verbal informed consent at the outset of the data collection procedure.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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