In summary, it is clear a large number of AAS users seek out information and support, predominantly from online fora and from experienced AAS users. Professionals are trying to tailor support to AAS users where resources allow but few studies have explicitly asked users what type of support they need. There is potentially a large number of AAS users who have not been surveyed as they are not accessing local substance use services or choose not to complete surveys for fear of being classified as ‘junkies’ [60].

One key purpose of a review is to identify gaps in the literature [61] and IPED users seemed to reject the ‘medical model’ that doctors are the experts as they give credibility to advice from people who have used [33] stating that doctors lacked credibility as they did not have personal experience [36]. This perspective is more aligned to a social care perspective with the substance user being the expert in their own use, hence the trust in experienced users. One reason given for this lack of credibility was that IPED users felt that the advice from professionals was not balanced and focused on health harms whilst ignoring the benefits [33]. Many argue for professionals to be better informed [53, 55] so as to be able to challenge the doses in ‘steroid bibles’ [37]. In a society where men are affected by images of the idealised male body image [62,63,64], and negative messages from others, it is unsurprising that men adopt a range of strategies to become more muscular [65,66,67]. Many of the short-term effects of AAS use are reversible and not as life-threatening as the long-term effects and the severity of side-effects could be reduced with early access to health services [55]. Consequently, having the appropriate support in place for AAS users is vital and some recommend that peers could have a positive role in harm minimisation [68].

The literature was sparse on the support that women access and want; this was not unexpected as the majority of AAS users are male [69]. Dennington et al’s. report [33] was the only one to include transgender people. This is a population that has not traditionally been identified within the research, but one small study found that transgender youth had 26.6 times greater odds of AAS use without a prescription than cisgender male respondents [70]. It is worth considering that this group may be using AAS as part of the transition from female to male [71], but this is not necessarily the case and therefore more research on support for women and the transgendering population would be useful, particularly aligned to support needs.

Online information

Many users sought AAS information from the internet, but the majority of online material presents a pro-use position [72], can be incorrect or even dangerous [73] and sites may sell steroids [74], which could put users at risk and could perpetuate the impetus to use. Andreasson and Johansson [75] suggest that the online community with its openness and acceptance of AAS use is part of a culture of learning and education for novices. They believe such communities can be seen to normalise AAS use, the idea of obtaining an ‘ideal masculine body’ without using AAS becoming a fantasy.

Support services

Most support from professionals has a harm minimisation focus. AAS users are already less likely than traditional injecting substance users to engage in risky injection practices [76] which could explain the low uptake for BBV tests. However, AAS use does increase sex drive [77] so this could increase sexual risk taking and may explain why HIV tests uptake was higher than BBVs. Users also sought help from sexual health clinics [53]. If, however, IPED users do not perceive this as a risk, they may not be engaging with services, and might be accessing NSPs simply because the needles are free. Three studies evidenced that guidance on injecting came from AAS dealers [8, 40, 43]. This is concerning as dealers often trivialised potential risks [37]. A good harm minimisation strategy could be for gyms to provide a safer injecting service [78] and this outreach service has been provided in some UK gyms [39]. However, gyms are often reluctant to provide anything that would suggest that their clientele may be using AAS [79]. For people who wish to access PCT there are few services available. Hence the need to reconsider PCT support due to the perceived needs linked to mental and physical health [42].

Only two studies [38, 55] showed that AAS users seek support for potential mood changes or underlying psychological issues. Kanayama et al. [69] concluded on the basis of seven studies that 30% of illicit AAS users develop dependence based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria and therefore it is a valid diagnostic entity. The DSM 5 [80] states that some individuals with muscle dysmorphia (MD), a form of body image disturbance, use AAS. Moreover, one study found that men using AAS for image-related reasons reported higher levels of MD and eating disorder symptomology [79, 81] suggesting there is a need for more awareness raising and that people showing such symptoms should be supported through appropriate gender specific interventions [82]. No study evidenced a need for support aligned to stopping AAS use. Traditionally, UK substance misuse support services offer talking treatments, and group and one-to-one sessions for people dependent on substances, yet there was no evidence in the UK studies of AAS users accessing these services.

Previous studies have advocated that specialist steroid services, created with input from AAS users are needed [39]. There are comparatively few specialised support services for people who use AAS and those few dedicated Steroid Clinics, often publicly-funded harm reduction initiatives, are subject to the ‘whims’ of local funding and resourcing. It would be useful to investigate ways of engaging AAS users with health services [6]. A useful strategy could be through health professionals engaging with online fora as a mechanism for harm reduction providing the language used is that of the forum and not of health professionals [44]. This would need to include strategies to overcome the lack of trust AAS users have in professionals. This review echoes these recommendations and suggests that there is a case to consider AAS users as a different population to traditional substance users. The AAS users accessing NSPs are more likely to be those who are injecting AAS and not those who take AAS orally. People who only use oral AAS are therefore potentially an even harder to reach population who are nevertheless putting themselves at risk. Dennington et al.’s [33] report examining current users’ views on the information and support provision found opposing views on types of support offered depending on the individual perspective of the user. Recent studies have identified distinct types of AAS user, each with different motivations for use [59, 83]. Differing motivations could be one reason why AAS users have differing opinions on the support offered. Consequently, offering information and support through a range of services and mediums and targeted at the different types of AAS use could be beneficial.

Barriers to accessing support

This review did not explore why people may not access the information and support that is currently available to them. However, several studies highlighted reasons as to why AAS users chose not to access specific services. When it came to accessing NSPs, pharmacies, and doctors, AAS users spoke of a fear of stigma or embarrassment [33, 39, 41, 43, 55], and there were several other reasons given for not accessing professional services [33, 36, 37, 41, 42, 55, 58]:

perceived lack of trust or lack of knowledge from professionals

fear of judgemental reactions

inability to obtain drugs wanted for PCT

the need for private health insurance

cost and difficulty of booking advance appointments

not wanting to be identified as ‘drug’ users or as visiting such support services

Generally, AAS users do not see themselves as “typical” drug users [33, 43]. Consequently, a key barrier for accessing NSPs [33] was the presence of other types of substance users. Another consideration could be the link between AAS use and MD [84, 85] as research suggests that people with MD may be in denial of this as a problem [86] and may not link it to their use of AAS. A lack of recognition of an underlying psychological problem would mean AAS users would not naturally seek any type of psychological support.

Using AAS requires more preparation, research and planning than other illicit drug use, and users take a strategic approach looking to minimise harm and maximise results [58]. This could explain why AAS users justify their use as being different from other types of people who use illicit substances. Whilst many felt a stigma in attending NSPs, others felt these offered a discreet service [41]. This area of barriers to accessing services requires further investigation.

Weaknesses and strengths

As the search was limited to English language papers, this could have excluded some studies. In studies where participants were recruited from NSPs, the authors have presumed that AAS users were accessing those services, predominantly to obtain injecting equipment. Another limitation is that data came from different countries, which influences information and support available and willingness to take part in surveys, e.g. AAS use in Australia and America is illegal, whereas in the UK, it is legal for personal use, but it is illegal to supply. A further challenge has been to identify the types of substances used within the literature and exactly what information and support is related to which substance. However, as it is likely that people who use AAS are also using these in combination with a number of other substances to either achieve their aims or mitigate side effects, it is plausible that the support and information they seek is similar. To our knowledge, this is the first scoping review on the types of support accessed, and support wanted.