In talking to harm reduction service providers, it became clear that they all had experienced an increase in the number of steroid users in their local area:
…should we give out needles to steroid users? And I think: yes, we should. Because there is many people using it. It's probably the number one drug of choice right now. (Female service provider, steroid clinic, site 1)
In addition, they all reported various risk behaviours of steroid users such as inadequate injection technique and needle sharing—although service providers' reports of sharing varied significantly:
They learn to inject from one another. So if you got someone who hasn't developed a good technique then that will be passed on as well…sometimes they will be using too short a needle and not leaving enough to stick out in case it snaps off…The whole sharing of equipment, we know that is going on. We still hear these tales about where the gym owner has pre-filled syringes under the counter and walks out and injects gym members. (Female service provider, NSP, site 9)
Aside from these two main findings, four themes emerged from the analysis of the accounts of service providers and steroid users (dealt with below):
All steroid users reported having easy access to sterile needles and syringes from harm reduction service sites. However, when steroid users were asked about their injecting practices, they tended to ignore or at least make their risky behaviours seem less hazardous than they actually were, impeding, in some cases, the uptake of advice about safe injections.
Secondary distribution involves distribution of sterile needles and syringes through social networks of IDUs and has been shown to improve needle coverage in hard-to-reach groups of opioid users [6, 41]—although care must be taken when extrapolating this finding to steroid users. On the one side, secondary distribution was attributed with greater access to sterile injecting equipment in hard-to-reach groups of steroid users and on the other side service providers expressed concern because this approach limited engagement with vulnerable groups of young steroid users. It became obvious that service providers faced a trade-off between high needle availability and personal contact with users.
When talking to service providers, disagreements about the boundaries of harm reduction for steroid injectors arose. A few service providers provided steroid users with information about the use of specific types of anabolic steroids whereas a majority rejected this policy. The dilemma here is that service providers may offer this information in the hope that steroid users will come to them for advice or they may choose not to and thereby leaving users with potentially uncertain information from peer users in gyms.
Availability of interventions designed particularly for steroid users varied across services. However, in steroid clinics, the use of medical examinations of steroid users was well established. The aim of medical examinations was to make users aware of adverse reactions to their use of anabolic steroids. Yet it was clear that users who underwent periodic examinations also felt less at risk from the use of these drugs.
‘We offer advice around injection technique’
It was clear that steroid users in this study saw themselves as different from other IDUs. In their opinion, steroid users do not share used needles with other users whereas this was believed to be the case with users of opioids and stimulants:
No bodybuilders that I know share. I mean you hear of what are called druggies, people who use other stuff. I don't mix in those circles to be honest. (Steroid user, NSP, site 6)
It came across that the drugs steroid users were taking seemed to create these differences. One steroid user expressed that ‘steroids aren't addictive, it's a hormone’ (Steroid user, NSP, site 6). From his perspective, steroid users would not therefore use these drugs compulsively and would not therefore borrow needles from other users—even though weight training, motivations to improve body image satisfaction and IPED usage appear to be characterised by obsessive and compulsive behaviour in some anabolic steroid users . In these ways, it seemed that steroid users attempted to distance themselves from risk behaviours practiced by intravenous drug users, similarly to what Simmonds and Coomber  found in their study of needle distribution policies and IDUs in South West England. Although steroid users tended to view the potential hazards of steroid use as minimal, this did not mean that they did not practice risky behaviour. For instance, two steroid users admitted to having reused their injecting equipment. Several had suffered ‘lumps’ or abscesses at the injection site which may have been caused by incorrect injecting technique or from the use of non-sterile products. Furthermore, a service provider noted complications of injecting into the buttock:
I asked if his [client's] injecting technique was okay and he said: ‘Yes, I’ve been injecting for a number of years.’ I said: ‘Just humour me and show me where you have been injecting’. So he said: ‘Right in the middle of my buttock.’ I said: ‘Well you do realise the sciatic nerve runs very close to where you are putting your finger? He said: ‘Oh, yes. I think I might actually have hit it a couple of times.’ (Male service provider, steroid clinic, site 2)
Other service providers expressed concern with the use of small needles that might break inside the muscle:
That needle is too bendy to go into a muscle and it's designed for intravenous use. So I rather advise them not to use it in case it ‘snaps’. (Female service provider, steroid clinic, site 1)
However, while service providers in this study generally encouraged clients to use a large needle for steroid injections, steroid users had many reasons for why they preferred to use a smaller one instead, such as being worried that a large one would cause them pain: ‘there is no way I'm putting that [needle] up my arse’ (Steroid user, steroid clinic, site 1). In other cases, the decision to use small needles was based on advice on injecting technique from other users.
These last few accounts provide a sense of self-assurance amongst steroid users regarding their abilities to conduct safe injections. The important issue here is that self-assurance in steroid users appeared to displace acknowledgement of their risky behaviour—a finding which shares some similarities with those of other studies indicating that the harms of steroids are often trivialised or ignored by steroid users . In addition, this also appeared to act as a barrier to the dissemination of safer injecting advice. In situations of disagreements between service providers and steroid users, service providers tended to fulfil the requirements of steroid users by handing out small needles to maintain rapport with steroid users and ensure access to sterile injecting equipment.
‘Needle exchange is a core provision for us’
Most service providers reported no restrictions on the number of syringes that could be provided per visit free of charge, reflecting an emphasis on high utilisation of sterile needles and syringes to prevent disease from being spread. Alongside traditional needle distribution, interviews showed that secondary distribution of needles and syringes was accepted practice to improve the use of sterile injecting equipment. For instance, in a number of harm reduction service sites, established steroid users, such as competing bodybuilders and gym owners, were allowed to collect large amounts of injecting equipment for themselves and for others. Furthermore, interviews with steroid users/gym owners gave insights regarding outreach-based needle distribution revealing that outreach workers provided them needles and syringes which were distributed to steroid users in these gyms. In some cases, outreach work had the added advantage of acting as a bridge to other harm reduction interventions as service providers would persuade users to visit conventional NSPs. In one NSP, peer-based needle distribution was based upon informal agreements between service providers and a client. Here, service providers provided a local steroid user and gym owner with needles and syringes. In turn, he had set up a ‘syringe exchange’ in his gym including placing sharp bins in the locker room. He would state his reasons:
…because most of the members are too embarrassed to go to the exchange [NSP] themselves, and I was tired of seeing used syringes in the locker room. (Steroid user, NSP, site 4)
These various models of needle distribution were clearly ways for service providers to improve sterile needle usage amongst IPED injectors through customised policies. What these policies share is that in the view of service providers, the credibility of key steroid users in the gym using population (gym owners/competing bodybuilders) enabled them to engage with steroid users who did not access conventional NSPs. This resonates with the positive experiences from the Steroid Peer Education Project, an outreach-based needle and syringe distribution service led by a bodybuilding peer worker .
However, in other harm reduction service sites, service providers were limiting the number of syringes per visit.d Below, a service provider reflected on restrictions on needle distribution for young and inexperienced steroid users due to concern of the loss of opportunity for health education:
If you are giving a hundred needles and syringes to a young, uneducated steroid user, and if they are taking them to give out to other similar people, you are losing the opportunity to get involved with them. So you have to work with them slightly different to the older steroid user group who can be a bit more responsible in terms of their injecting. (Female service provider, Steroid clinic, site 8)
Constrained by limited funding, service providers in one NSP had started to ask for an economic contribution from steroid users to offset costs.e While this financial contribution was voluntary, and users would supposedly be provided regardless, it was meant to offset costs of steroid users collecting large amounts of needles and syringes for themselves and for secondary distribution. Whereas this might be seen as an obstacle to widespread needle availability amongst some groups of IDUs this did not seem to be the case for this user, reflecting that most steroid users in this study were employed and were able to pay for a gym membership, food supplements and drugs:
…steroid users see it as great that they don't have to pay because that is more money for protein [food supplement]. But I must be honest, when she [service provider] told about a [financial] contribution [to offset the cost], I haven't got a problem with that, because otherwise we'd be forced to buy all these things across the Internet. (Steroid user, NSP, site 6)
It was clear that these different needle distribution policies were the result of local arrangements in service delivery sites. Many of them appeared to have been developed on an ad hoc basis which resonates with findings of Spittal et al.  on the evolvement of an informal ‘loaner system’ from the formal ‘one-for-one’ approach (one clean needle for one used returned). It is also in keeping with Lipsky's  views on the wide manoeuvre room of service providers in their interpretation of policy.
‘Give information about steroids' effects’
A substantial theme was where the line should be drawn in terms of which types of harm reduction interventions should be provided. As shown below, these different perspectives on the boundaries of harm reduction were widely dependent on service providers' knowledge of issues relating to anabolic steroids.
Syringe distribution, along with advice on safer injecting practices, was viewed as essential, with a number of service providers providing additional information about the potential harms of anabolic steroids—although it was apparent that service providers in steroid clinics knew considerably more about steroid-related harm than those in conventional NSPs. In five harm reduction delivery sites, steroid users were provided with dietary services and advice about weight training as service providers believed that this could help bring about the desired effect on steroid users' physique. This approach was based upon a view that at best, improvement of body satisfaction would persuade clients not to use steroids at all:
…quite a lot of the time people will take onboard that what they are doing in the gym is not correct, or their diet, and that they can actually make some really positive changes without even going on steroids. So what we tend to say is, ‘Okay, you are thinking about using them, but your diets and training aren't correct. Go away, change all of those and come back to see me in six months time and if you are not happy with the way you have progressed let us look at it again.’ (Male service provider, steroid clinic, site 2)
However, the effectiveness of this strategy in prolonging the time before the use of steroids is difficult to determine, as it is possible that some people will turn instead to established steroid users for advice. In this study, as with others , peer influence was high with steroid users relying heavily upon information about these drugs from each other, rather than from harm reduction service providers:
You go to the gym, you get involved with people, they give you advice, you can tell them what your own feelings are. I've never had any information off drug services, all my information has been from the guy I bought the steroids from. (Steroid user, NSP, site 6)
…the drug service is just a handy place to get your needles, literally that is all. (Steroid user, NSP, site 6)
In response to peer-driven information networks in gyms, a service provider in one steroid clinic argued that clients should be advised about the use of anabolic steroids as an alternative to the ‘hokum and misinformation’ from other steroid users (Male service provider, steroid clinic, site 2). In this clinic, steroid users were provided sheets containing information about specific types of anabolic steroids including dosage, pharmacological effects, ‘stacking’, period of usage as well as potential side effects. For this service provider, this information was seen as an essential component of harm reduction:
It's a harm reduction message that you need to be making people aware that if they take nandrolone [decanoate] on its own they are not going to have a sex drive for the next twelve weeks. If someone is using a particular toxic oral steroid you might wanna make them aware that if they combined it with another steroid they can actually reduce the dosage of the more toxic one…if you got a steroid that readily converts to oestrogen, for example Dianabol [methandienone], then you might be saying to them: ‘You need to very careful about gynaecomastia’, because it's a real potential issue for you with that one. (Male service provider, steroid clinic, site 2)
Again, interviews with service providers revealed conflicting perspectives on this policy. In fact, information about anabolic steroids was limited to one steroid clinic whereas a majority of service providers did not provide such advice. A concern amongst these service providers was the unknown effects from long-term use of high doses of anabolic steroids:
We wouldn't give them specific advice on the drugs they are taking, how to take them, when to take them all that sort of stuff because it's such an unknown quantity and generally they have that guidance from other users. Whether it is accurate or not I don't know but they seem to know more than we do. Our advice will be specifically health related. (Female service provider, NSP, site 9)
Arguably, the uncontrollable nature of the illicit market makes it difficult to know exactly the active substance in drugs obtained from the illicit market which is reducing the relevance of information about specific types of steroids .
‘This steroid clinic to me is vital’
Service providers explained that steroid clinics had been set up as a result of an increase in the number of steroid users accessing conventional NSPs. In addition, providing efficient harm reduction in this group of clients required tailored health interventions as depicted in this account of a service provider who is reflecting on the opening of a steroid clinic around the mid-2000s:
There were all these steroid users coming in, and they were just getting needles, and we were telling them how to inject safely…that was when we started talking, ‘Look, these people need to have their own clinic and special services and come in and get [medically] checked out.’ So that's why we brought it up. Then we just took it to our line-manager, who took it further up [in the organisation], and we got the okay. (Female service provider, steroid clinic, site 1)
It seemed that in many cases steroid clinics were created with input from anabolic steroid users. In one clinic, for instance, service providers conducted an informal survey amongst steroid using doormen as well as members of the local gym to determine which day and at what time steroid users might prefer to come in. In the view of service providers, responding to requests of steroid users is essential in gaining engagement from this group of IDUs.
It became apparent that steroid users tended to view service providers in steroid clinics as being non-judgemental ‘because you can come here and speak openly’ (Steroid user, steroid clinic, site 3). One steroid injector preferred to drive a relatively long way to engage with a steroid clinic specifically oriented to his needs even though he was living next to a conventional NSP. Steroid users spoke of issues that were interpreted as stigma in relation to NSPs set up to deal with psychoactive drug users which may explain why the steroid users in this study preferred steroid clinics. As seen below, the sense of stigma when accessing NSPs was seen by service providers as a particular problem in outlying areas because of issues of privacy which may further account for why users in remote areas prefer to travel to steroid clinics. These findings are in line with Smith's  discussion of the socio-spatial stigmatisation relating to drug treatment facilities.
If you live in a little village somewhere, and that is your only needle exchange, and you have family that lives there, works there, the whole thing about confidentiality goes out the window. Providing services in a remote area isn't the same as in big cities where loads of people are coming and going. (Female service provider, NSP, site 9)
One steroid clinic was open one afternoon per week in the same building as the conventional NSP. However, during this time, only steroid and IPED users were allowed to come in. This programme provided a variety of measures:
We do syringe exchange, safer injecting information, the nurse will give them hepatitis B vaccinations, complete blood count [to determine infection], liver function tests, cholesterol tests, dietary advice, blood pressure and safer drug use messages. Even smoking cessation, the nurse will look at that as well. We do, recently, chlamydia and gonorrhoea screening. (Female service provider, steroid clinic, site 1)
Service providers in steroid clinics explained that the aim of medical examinations of steroid users was to advise against high doses in case of adverse tests results. For example, if medical tests indicated high blood pressure, high levels of cholesterol or injury to the liver, steroid users could be advised to reduce dosage or not to use anabolic steroids at all until tests returned to normal. However, statements from a number of steroid users suggest that having access to medical examinations made them feel safer:
Obviously I get regular tests so if there is a problem then I know what actions to take to counter those problems. Where people who take steroids continually, and don't get their blood checked, obviously they are going to run some kind of health risk because anabolic steroids tend to be associated with problems with cholesterol and it is not a good idea to stay on them constantly. (Steroid user, steroid clinic, site 3)
According to this steroid user, actions to ameliorate potential health problems included the substitution of certain anabolic steroids with others—as different anabolic steroids have different pharmacological effects in the liver—and using cholesterol-lowering drugs. While medical examinations may lead to a positive change in drug-related behaviour amongst steroid users, including dose reduction, there is also a risk that these tests induce risky behaviour such as the use of multiple drugs including auxiliary drugs for the self-treatment of adverse steroid reactions.