IPED harm reduction from the user perspective - PowerPoint Presentation

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IPED harm reduction from the user perspective

Mair UnderwoodUniversity of Queensland, Australia

Setting the sceneAnthropologist who has immersed herself in online enhanced bodybuilding communities for 4+ years.talked to hundreds, observed thousands, and had in-depth communication with 34 enhanced recreational bodybuilders.

in-depth interviews (face-to-face, phone and video conference) were conducted with 34 enhanced recreational bodybuilders. recruited primarily through online interactions. Average age = 32 yearsAustralia (n=18), the U.S. (n=10), the UK (n=2), Canada (n=2), Germany (n=1), and India (n=1). varying levels of experience with AAS (few months to decades). ‘Key cultural consultants’ = 3. Bjorn is one of these.

IPED harm reductionvery little engagement with people who use IPEDs.primarily conceptualised

from an outside perspective. People who use IPEDs constructed as ‘risk takers’ and are seen as recipients of care rather than as actors in harm reduction.two quite distinct discourses on IPED harm reduction: outside and inside.

The outside perspective on IPED harm reductionPrimarily based on science, more objective and detached.

Baggage:Science denied the benefits of these drugs (up until as late as 2000!) and has since largely ignored the benefits, instead overstating the risks and harms.divide between people who use IPEDs and those who seek to study them and provide support for them.focussed on issues like BBV:My research participants find the focus on BBV offensive and stigmatising

because they see themselves as different from other drug users (and in many ways they are). They suggest that it:demonstrates ignorance of the range of risks involved/avoids the complexity of the issueresults in ineffective services because people who inject IPEDs are deterred from engaging with health services and academics.

increases existing divides between bodybuilders on the one hand, and service providers and academics on the other.Underwood, M. (2019) The unintended consequences of emphasising

blood-borne virus in research on, and services for, people who inject image and performance enhancing drugs: A commentary based on enhanced bodybuilder perspectives.

International Journal of Drug Policy

67(May):19-23.

The inside perspective on IPED harm reduction Isolated harm reduction strategies have been described in the academic literature:

post cycle therapy (Griffiths et. al., 2017)self-phlebotomy (Brennan et. al., 2018).My research participants know how to prevent BBV. More concerned with the life-threatening, long-term risks of IPED use:heart health, cholesterol, liver function, blood pressure and high hematocrit levelsMost concerned with the more immediate and likely harms that are the result of hormonal imbalances – ‘sides’ (side effects).

e.g. Mood swings, changes in energy levels, changes in libido and sexual function, gynecomastia etc. do have injection related concerns : post-injection pain, abscess and bacterial infection.They would prefer service providers talk to them about infection in general, rather than BBV specifically.

Different definitions of harm reductionpeople who use drugs define harm reduction differently from most people who do not use drugs.

From an outside, ‘expert’ perspective harm reduction is purely about the reduction of harm. It is something outside experts help people who use drugs to do.But for the users of the drug, harm reduction is about reducing harm and maximising benefit. It is about the balance of benefit to harm.

The inside perspective on harm reduction: Grounded harm reductionreducing the harms whilst still experiencing the benefits that inform use. altering the ratio of harm to benefit.

more subjective perspective on harm reduction:how the individual negotiates the balancing of harm to benefit based on their own particular values, norms, and beliefs. may be informed by science, but it is primarily practice based.every person who uses drugs is already always engaged in harm reduction.

The privileging of science and the desire for supportPeople who use IPEDs are extremely diverse

My participants = more risk averse end of the spectrum, ‘expert users’.They are building their bodies in very careful and considered ways and they like to use science to do so.These individuals really want to practice IPEDs in an evidence-based way, and often desire the support of well-informed health professionals.

Privileging of science‘Age of “Enlightenment’:

[There has been] a very clear shift in the collective mindset of strength culture: it’s no longer enough to know that things work; it’s become far more important to know why they work. … Over the course of the past two decades, research has gained an almost deific [resembling god] status in the fitness industry. Studies are considered by many to be the final word on any issue [online bodybuilding article].relatively common in bodybuilding discussions to link to PubMed abstracts when debating the harms or benefits of IPEDs, or how to reduce their harms. very little science on which to base IPED practice. There is virtually no research into the doses and combinations of drugs that most use.

Science has different priorities than does bodybuilding. Scientists are typically trying to treat, prevent or reduce harm, not enhance the body.So when there is science on the drugs that are used, it is about these drugs being used in very different ways and for very different purposes than what enhanced bodybuilders use them for.

Supplementing the science: BroscienceWhile experimentation is done at an individual level, these experiments are compared and contrasted online, and thus a shared knowledge of these drugs is developed.

Bro-science: A practical template for bodybuilding based on a combination of the available theoretical scientific evidence (either directly or as, correctly or incorrectly interpreted by third parties) and the results of self experimentation and the experiences of others who have experimented on themselves or others before, in order to come to a working applicable whole for purposes of training, nutrition, supplement or IPED use [Mark].

Desire for support from health professionals

AAS use whilst in open and honest communication with a non-judgmental and well-informed health professional (who is working from a solid scientific foundation) who supervises use and monitors health, and assists with the prevention and treatment of harm, including:Regular ‘bloodwork’ (before, during and after use), in order to determine effectiveness of use, and actual or potential harms. hormone levels (e.g. testosterone, prolactin, oestradiol, thyroid hormones, cortisol, insulin), kidney and liver function (E-LFT), lipids (HDL and LDL), gonadotrophins (LH/FSH), and iron (

haemoglobin and haematocrit). Post-cycle therapies (‘PCT’) to restore natural testosterone production and fertility, and to address testicular atrophy, including:SERMs (Selective Estrogen Receptor Modulators), such as Clomid (clomiphene citrate) and tamoxifen citrate (

Nolvadex)HCG (Human Chorionic Gonadotrophin). Aromatase inhibitors, primarily Aromasin

,

Arimidex

and Letrozole- used to control estrogen (and indirectly prolactin according to some).

Phlebotomy if necessary: AAS result in an increase in

haematocrit

, high levels of which can result in death. It is sometimes necessary to reduce

haematocrit

through phlebotomy (bloodletting).

While ideal practice includes these harm reduction strategies, there is much debate about when these harm reduction strategies should be performed.

I see a family doctor here in [city in Canada] who is young, fresh out of med school and helps me with all my steroid related issues. He prescribes clomid for my recovery. He prescribes dopamine agonists for when I am injecting nandrolones. I have unlimited free blood work, constant ECGs, the works. He has it all locked away in a hidden digital file and told me to never go to any of the older doctors in the office that he shares as they wouldn't understand

[Tony].

Lack of engagement with health professionalsenhanced bodybuilders typically do not engage with health professionals in their harm reduction efforts.

There are numerous reasons for this:Fear caused by the illegality of use:If they [users] do go [to the doctor], they lie about what they're doing... How can a doctor fix you if you mislead them? [Mason].They may feel judged or misunderstood by health professionals.

They may feel more knowledgeable than health professionals.… although I feel relatively capable of evaluating the risks involved, at the end of the day I'm not qualified in the slightest and I'm certainly not an endo. There is a huge amount of information I don't know and I'd rather feel dumb and have someone better informed educate me than be the one who has to lead blind GPs in monitoring health. The fact that I know more than most users and some GPs genuinely unsettles me. I know enough to know I don't know much at all, and what I don't know could be very important

[Bjorn].support enhanced bodybuilders desire has not been proven to be effective scientifically:In the end general practitioners and even

endrocrinologists

don’t know anything. There hasn’t been the medical research done into it really. … A doctor can’t say to you, ‘take this drug it will stop side effects’ because they can’t legally do it. Even if steroids were legal, if it hasn’t been proven through clinical trials, they can’t say it … GPs are evidence-based practitioners

[Jack].

Community-based harm reductioncommunities of practice and share ways to maximise benefit while reducing harm.

While much discussion is focussed on maximising benefit, there is also a fair amount of encouragement to practice caution.For example, in response to a post from a bodybuilder beginning use of trenbolone at 400mg, one bodybuilder responded:Way too much tren for your first time with the drug. I got tremendous results from 120mg of

tren E. … Tren isn’t a drug to just fuck around with. Unless you have a contest in the next 8 weeks I’d drop it completely or cut dose in half [Facebook comment].

Discussions are focussed on practice, so when it comes to harm reduction discussions are mostly focussed on those harms of the drugs that are very likely/certain and more immediate – what they tend to term ‘sides’ i.e. side effects - than the possible long-term harms about which they can do little.

Health monitoringIn line with the dawning of the ‘age of enlightenment’ there is an increasing expectation that individuals who practice IPEDs have regular bloodwork performed.

… like 8 years ago when I started I barely saw a thing [in online AAS groups] about bloodwork. But nowadays it’s huge, a lot of people do it [Calum].If you don't have access to bloodwork, I don't think you should touch it [AAS] because you are playing with fire at that point [Brax].The results of bloodwork may be posted online for discussion.

Indeed, if an individual complains of side effects, they are commonly asked by other community members to provide their bloodwork so members of the community can attempt to explain their experience of side effects.

Working around the medical systemBecause bloodwork can be hard to access, private companies are sometimes used,the IPED community has even crowd funded its own labs for this purpose.

Phlebotomy is sometimes advised by members of the community to reduce high haematocrit.In order to let blood safely some advise individuals to lie about being an injecting drug user in order to donate blood and thus obtain a professional phlebotomy. There is much uncertainty among bodybuilders about the risk of these donations to individuals who may receive the blood.

Uncertainty and trusthat harm can be reduced significantly, but harms can also be caused.

There is a great deal of uncertainty in these communities.PCT: always, taken only if indicated by bloodwork, or only if trying to conceive?Aromatase inhibitors: as a preventative, or only if bloodwork indicates a need?community experts:trusted by members of these communities to interpret science and theorise from it, and to provide that practical template for bodybuilding practice.

tend to combine a body that demonstrates that there knowledge leads to results, and an ability to talk about the science convincingly.Varying levels of education and ability to interpret the science.Some are criticised as ‘pubmed

ninjas’: those who ‘cherry pick’ from the scientific literature and make ‘invalid extrapolations’ [forum comments].There does appear to be considerable room for harm as a result of ill-advice.e.g. one community expert with no scientific or medical training not only advised on IPED use and harm reduction but on unconnected issues like diabetes treatment.

The opportunityI suggest that the best way to reduce drug harm is to bring together the inside and outside perspectives on drug harm reduction.

To make the outside perspective on drug harm reduction more grounded in the experience of these drugsAdd more objectivity to the user perspective on harm reduction.Given the recent emphasis on science and health monitoring among IPED using communities there is a great opportunity to collaborate to reduce harm.I think the IPED communities I discussed really demonstrate the benefits of a grounded approach to harm reduction that:acknowledges harm reduction as a balancing of drug benefit and drug harmacknowledges harm reduction as a collaboration between outside ‘experts’ and those with lived experience of the drug who are already always

practising harm reduction.Exactly what Penington aims to do

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