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Review article: Biomedical intelligence

Vol. 153 No. 5 (2023)

Evidence of use and users of image- and performance-enhancing drugs in sports in Switzerland: a scoping literature review and implications for Swiss drug policy

  • Muriel Kruijver
  • Philip Bruggmann
  • Raphael Magnolini
Cite this as:
Swiss Med Wkly. 2023;153:40080


BACKGROUND: “Image- and performance-enhancing drugs” are widely used in sports worldwide to improve body image and performance goals. In view of the growing research interest and use of these substances, and the paucity of data on the situation in Switzerland, we conducted a scoping literature review on evidence of the use and users of these substances in Switzerland.

METHODS: A scoping review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement. We searched PubMed/Medline, Embase and Google Scholar for articles published before August 2022. Primary outcomes were evidence of the use and users of image- and performance enhancing drugs in Switzerland. We used a narrative synthesis approach for data analysis.

RESULTS: Overall, 18 studies were reviewed, which in total comprised 11,401 survey participants, 140 interviews and 1368 toxicologically analysed substances. Articles were mostly peer-reviewed (83%) and mostly included evidence from professional athletes (43%). The mean publication year was 2011. In most articles both outcomes (78%) were evaluated simultaneously. We demonstrate that image- and performance-enhancing drugs appear to be prevalent among athletes and non-athletes in Switzerland. A wide variety of substances exist, and the type of substances used varied by age, motivation, sex and sports discipline. The main motivations for using these substances were, among others, image- and performance enhancement. The main route of acquisition of these substances was the Internet. Furthermore, we demonstrated that substantial proportions of these substances, as well as supplements, may be counterfeit. Information on image- and performance-enhancing drug use was acquired from different sources.

CONCLUSIONS: Although evidence of image- and performance-enhancing drug use and its users in Switzerland is scarce and there are major gaps, we demonstrate that these substances are also prevalent among athletes and non-athletes in Switzerland. Furthermore, high proportions of substances acquired from unregulated drug markets are counterfeit, which puts users in a situation of unpredictable risk when consuming them. Overall, the use of these substances may pose a substantial risk to individual and public health in this possibly growing and often insufficiently informed and medically neglected user community in Switzerland. There is a great need for future research, as well as prevention, harm-reduction and treatment programmes for this hard-to-reach user community. Doping policies in Switzerland should be critically reviewed as simple medical care and evidence-based treatment for non-athlete image- and performance-enhancing drug users is excessively criminalized under the current legislature, leaving possibly over 200,000 image- and performance-enhancing drug users in Switzerland with inadequate medical care.


  1. Mullen C, Whalley BJ, Schifano F, Baker JS. Anabolic androgenic steroid abuse in the United Kingdom: an update. Br J Pharmacol. 2020 May;():2180–98. 10.1111/bph.14995 DOI:
  2. Kanayama G, Pope HG Jr. History and epidemiology of anabolic androgens in athletes and non-athletes. Mol Cell Endocrinol. 2018 Mar;:4–13. 10.1016/j.mce.2017.02.039 DOI:
  3. Hilkens L, Cruyff M, Woertman L, Benjamins J, Evers C. Social Media, Body Image and Resistance Training: Creating the Perfect ‘Me’ with Dietary Supplements, Anabolic Steroids and SARM’s. Sports Med Open. 2021 Nov;():81. 10.1186/s40798-021-00371-1 DOI:
  4. Piacentino D, Kotzalidis GD, Del Casale A, Aromatario MR, Pomara C, Girardi P, et al. Anabolic-androgenic steroid use and psychopathology in athletes. A systematic review. Curr Neuropharmacol. 2015 Jan;():101–21. 10.2174/1570159X13666141210222725 DOI:
  5. Ip EJ, Lu DH, Barnett MJ, Tenerowicz MJ, Vo JC, Perry PJ. Psychological and physical impact of anabolic-androgenic steroid dependence. Pharmacotherapy. 2012 Oct;():910–9. 10.1002/j.1875-9114.2012.01123 DOI:
  6. World Anti-Doping Agency (WADA). Prohibited List 2021. Internet: (Accessed: 30.12.2022).
  7. Bonnecaze AK, O’Connor T, Aloi JA. Characteristics and Attitudes of Men Using Anabolic Androgenic Steroids (AAS): A Survey of 2385 Men. Am J Men Health. 2020;():1557988320966536. 10.1177/1557988320966536 DOI:
  8. Bhasin S, Storer TW, Berman N, Callegari C, Clevenger B, Phillips J, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996 Jul;():1–7. 10.1056/NEJM199607043350101 DOI:
  9. Storer TW, Magliano L, Woodhouse L, Lee ML, Dzekov C, Dzekov J, et al. Testosterone dose-dependently increases maximal voluntary strength and leg power, but does not affect fatigability or specific tension. J Clin Endocrinol Metab. 2003 Apr;():1478–85. 10.1210/jc.2002-021231 DOI:
  10. Rahnema CD, Lipshultz LI, Crosnoe LE, Kovac JR, Kim ED. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertil Steril. 2014 May;():1271–9. 10.1016/j.fertnstert.2014.02.002 DOI:
  11. Nieschlag E, Vorona E. Doping with anabolic androgenic steroids (AAS): adverse effects on non-reproductive organs and functions. Rev Endocr Metab Disord. 2015 Sep;():199–211. 10.1007/s11154-015-9320-5 DOI:
  12. Christou MA, Christou PA, Markozannes G, Tsatsoulis A, Mastorakos G, Tigas S. Effects of Anabolic Androgenic Steroids on the Reproductive System of Athletes and Recreational Users: A Systematic Review and Meta-Analysis. Sports Med. 2017 Sep;():1869–83. 10.1007/s40279-017-0709-z DOI:
  13. Fink J, Schoenfeld BJ, Hackney AC, Matsumoto M, Maekawa T, Nakazato K, et al. Anabolic-androgenic steroids: procurement and administration practices of doping athletes. Phys Sportsmed. 2019 Feb;():10–4. 10.1080/00913847.2018.1526626 DOI:
  14. Magnolini R, Falcato L, Cremonesi A, Schori D, Bruggmann P. Fake anabolic androgenic steroids on the black market - a systematic review and meta-analysis on qualitative and quantitative analytical results found within the literature. BMC Public Health. 2022 Jul;():1371. 10.1186/s12889-022-13734-4 DOI:
  15. Sagoe D, McVeigh J, Bjørnebekk A, Essilfie MS, Andreassen CS, Pallesen S. Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis. Subst Abuse Treat Prev Policy. 2015 Mar;():12. 10.1186/s13011-015-0006-5 DOI:
  16. Iff S, Butzke I, Zitzmann M, Schneiter R, Hunziker M, Quednow BB, et al. [IPED Use in Recreational Sports]. Praxis (Bern 1994). 2022;111(6):345-9. DOI:
  17. Pope HG Jr, Kanayama G, Athey A, Ryan E, Hudson JI, Baggish A. The lifetime prevalence of anabolic-androgenic steroid use and dependence in Americans: current best estimates. Am J Addict. 2014;():371–7. 10.1111/j.1521-0391.2013.12118.x DOI:
  18. Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol. 2014 May;():383–98. 10.1016/j.annepidem.2014.01.009 DOI:
  19. McBride JA, Carson CC 3rd, Coward RM. The Availability and Acquisition of Illicit Anabolic Androgenic Steroids and Testosterone Preparations on the Internet. Am J Men Health. 2018 Sep;():1352–7. 10.1177/1557988316648704 DOI:
  20. Andrea C. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation . Ann Intern Med. 2018 ; 169 : 467-473 . [Epub ahead of print 4 September 2018]. doi:10.7326/M18-0850 DOI:
  21. Greenhalgh T, Peacock R. Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. BMJ. 2005 Nov;():1064–5. 10.1136/bmj.38636.593461.68 DOI:
  22. Wikipedia contributors. (2022, December 6). Athlete. In Wikipedia, The Free Encyclopedia. Retrieved 09:24, January 14, 2023, from
  23. Nocelli L, Kamber M, François Y, Gmel G, Marti B. Discordant public perception of doping in elite versus recreational sport in Switzerland. Clin J Sport Med. 1998 Jul;():195–200. 10.1097/00042752-199807000-00006 DOI:
  24. Bélanger RE, Ohl F, Berchtold A, Lentillon-Kaestner V, Suris JC. Substance use among adolescents in the French-speaking part of Switzerland. Lausanne: IUMSP; 2010. 51 pp.
  25. Weber C, Kamber M, Lentillon-Kaestner V. Are doping substances imported into Switzerland mainly to increase athletic performance. Perform Enhanc Health. 2016;():66–76. 10.1016/j.peh.2016.06.001 DOI:
  26. Gebert A, Stamm H, Kamber M, Lamprecht M. The fight against doping from the perspective of Swiss athletes and coaches. Schweizerische Zeitschrift für Sportmedizin & Sporttraumatologie. 2019;():50–6.
  27. Mettler S, Lehner G, Morgan G. Widespread Supplement Intake and Use of Poor Quality Information in Elite Adolescent Swiss Athletes. Int J Sport Nutr Exerc Metab. 2022 Jan;():41–8. 10.1123/ijsnem.2021-0043 DOI:
  28. Stamm H, Stahlberger M, Gebert A, Lamprecht M, Kamber M. Supplemente, Medikamente und Doping im Freizeitsport. Schweizerische Zeitschrift für. Sportmedizin und Sporttraumatologie. 2011;():122–6.
  29. Lentillon-Kaestner V, Ohl F. Can we measure accurately the prevalence of doping? Scand J Med Sci Sports. 2011 Dec;():e132–42. 10.1111/j.1600-0838.2010.01199.x DOI:
  30. Lentillon-Kaestner V, Becholey S, Romand P, Ohl F. Pratique sportive et conduites dopantes chez les jeunes Suisses romands. 2009; Internet: (Accessed: 14.01.2023)
  31. Weber C, Kamber M, Lentillon-Kaestner V, Krug O, Thevis M. Seizures of doping substances at the Swiss Border—a descriptive investigation. Forensic Sci Int. 2015 Dec;:359–68. 10.1016/j.forsciint.2015.10.001 DOI:
  32. Lentillon-Kaestner V, Hagger MS, Hardcastle S. Health and doping in elite-level cycling. Scand J Med Sci Sports. 2012 Oct;():596–606. 10.1111/j.1600-0838.2010.01281.x DOI:
  33. Coquet R, Roussel P, Ohl F. Understanding the Paths to Appearance- and Performance-Enhancing Drug Use in Bodybuilding. Front Psychol. 2018 Aug;:1431. 10.3389/fpsyg.2018.01431 DOI:
  34. Lentillon-Kaestner V, Carstairs C. Doping use among young elite cyclists: a qualitative psychosociological approach. Scand J Med Sci Sports. 2010 Apr;():336–45. 10.1111/j.1600-0838.2009.00885.x DOI:
  35. Brissonneau C, Defrance J, Fincoeur B, Lentillon‐Kaestner V, Ohl F. Carrière sportive et socialisation secondaire en cyclisme sur route: les cas de la Belgique, la France et la Suisse. 2009. 132, Université de Lausanne, ISSUL- Faculté des SSP. Internet: (Accessed: 14.01.2023).
  36. Lentillon-Kaestner V. Doping use and deviance in Swiss n ational and international elite cycling. Perform Enhanc Health. 2014;():167–74. 10.1016/j.peh.2015.09.004 DOI:
  37. Weber C, Krug O, Kamber M, Thevis M. Qualitative and Semiquantitative Analysis of Doping Products Seized at the Swiss Border. Subst Use Misuse. 2017 May;():742–53. 10.1080/10826084.2016.1263665 DOI:
  38. Kamber M, Baume N, Saugy M, Rivier L. Nutritional supplements as a source for positive doping cases? Int J Sport Nutr Exerc Metab. 2001 Jun;():258–63. 10.1123/ijsnem.11.2.258 DOI:
  39. Baume N, Mahler N, Kamber M, Mangin P, Saugy M. Research of stimulants and anabolic steroids in dietary supplements. Scand J Med Sci Sports. 2006 Feb;():41–8. 10.1111/j.1600-0838.2005.00442.x DOI:
  40. Bates G. Image and Performance Enhancing Drugs 2015 Survey Results. In: Mcveigh J, editor. 2016.
  41. Leone JE, Sedory EJ, Gray KA. Recognition and treatment of muscle dysmorphia and related body image disorders. J Athl Train. 2005;():352–9.
  42. Cerea S, Bottesi G, Pacelli QF, Paoli A, Ghisi M. Muscle Dysmorphia and its Associated Psychological Features in Three Groups of Recreational Athletes. Sci Rep. 2018 Jun;():8877. 10.1038/s41598-018-27176-9 DOI:
  43. Halioua R, Deutschmann M, Vetter S, Jäger M, Seifritz E, Claussen MC. Muskeldysmorphie. Swiss Med Forum. 2019;19(0910):153-158. DOI:
  44. Solimini R, Rotolo MC, Mastrobattista L, Mortali C, Minutillo A, Pichini S, et al. Hepatotoxicity associated with illicit use of anabolic androgenic steroids in doping. Eur Rev Med Pharmacol Sci. 2017 Mar;( Suppl):7–16. DOI:
  45. Anawalt BD. Diagnosis and Management of Anabolic Androgenic Steroid Use. J Clin Endocrinol Metab. 2019 Jul;():2490–500. 10.1210/jc.2018-01882 DOI:
  46. Seitz NN, John L, Atzendorf J, Rauschert C, Kraus L. Kurzbericht Epidemio- logischer Suchtsurvey 2018. Tabellenband: Medikamenteneinnahme und Hinweise Kon- sumabhängigkeit und -missbrauch nach Geschlecht und Alter im Jahr 2018. München: IFT Institut für Therapieforschung; 2019.
  47. Bates G, Van Hout MC, Teck JT, McVeigh J. Treatments for people who use anabolic androgenic steroids: a scoping review. Harm Reduct J. 2019 Dec;():75. 10.1186/s12954-019-0343-1 DOI:
  48. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergård A, et al. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open. 2013 Sep;():e003207. 10.1136/bmjopen-2013-003207 DOI:
  49. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergård A, et al. Injection site infections and injuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking. Epidemiol Infect. 2015 Jan;():132–40. 10.1017/S0950268814000727 DOI:
  50. Federal Office of Public Health (FOPH). National Strategy on Addiction. Internet: (Accessed 07.01.2023).
  51. Santo T Jr, Clark B, Hickman M, Grebely J, Campbell G, Sordo L, et al. Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021 Sep;():979–93. 10.1001/jamapsychiatry.2021.0976 DOI:
  52. Frude E, McKay FH, Dunn M. A focused netnographic study exploring experiences associated with counterfeit and contaminated anabolic-androgenic steroids. Harm Reduct J. 2020 Jun;():42. 10.1186/s12954-020-00387-y DOI:
  53. Maghsoudi N, Tanguay J, Scarfone K, Rammohan I, Ziegler C, Werb D, et al. Drug checking services for people who use drugs: a systematic review. Addiction. 2022 Mar;():532–44. 10.1111/add.15734 DOI:
  54. Butterfield RJ, Barratt MJ, Ezard N, Day RO. Drug checking to improve monitoring of new psychoactive substances in Australia. Med J Aust. 2016 Mar;():144–5. 10.5694/mja15.01058 DOI:
  55. Measham FC. Drug safety testing, disposals and dealing in an English field: exploring the operational and behavioural outcomes of the UK’s first onsite ‘drug checking’ service. Int J Drug Policy. 2019 May;:102–7. 10.1016/j.drugpo.2018.11.001 DOI:
  56. Hungerbuehler I, Buecheli A, Schaub M. Drug Checking: A prevention measure for a heterogeneous group with high consumption frequency and polydrug use - evaluation of zurich’s drug checking services. Harm Reduct J. 2011 Jun;():16. 10.1186/1477-7517-8-16 DOI:
  57. Korf D, Benschop A, Rabes M. Pill testing, ecstasy and prevention: a scientific evaluation in three European cities. Amsterdam: Rozenberg; 2002.
  58. La Mantia A, Oechslin L, Duarte M, Laubereau B, Fabian C. Studie zu den Effekten der Drug-Checking-Angebote in der Schweiz. Bericht zuhanden des Bundesamts für Gesundheit (BAG). Luzern, Muttenz: Interface Politikstudien Forschung Beratung und Fachhochschule Nordwestschweiz FHNW; 2020.
  59. Bonnecaze AK, O’Connor T, Burns CA. Harm Reduction in Male Patients Actively Using Anabolic Androgenic Steroids (AAS) and Performance-Enhancing Drugs (PEDs): a Review. J Gen Intern Med. 2021 Jul;():2055–64. 10.1007/s11606-021-06751-3 DOI:
  60. Smit DL, de Ronde W. Outpatient clinic for users of anabolic androgenic steroids: an overview. Neth J Med. 2018 May;():167.
  61. Iff S, Butzke I, Quednow B, Gupta R, Imboden C, Claussen M. (2021). «Image and performance enhancing drugs» im Freizeitsport. Swiss Medical Forum, 21:843-847. DOI:
  62. Butzke I, Iff S, Zitzmann M, Quednow BB, Claussen MC. Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users. Praxis (Bern 1994). 2022;111(6):e339-e44. 10.1024/1661-8157/a003868 DOI:
  63. Amaral JM, Kimergård A, Deluca P. Prevalence of anabolic steroid users seeking support from physicians: a systematic review and meta-analysis. BMJ Open. 2022 Jul;():e056445. 10.1136/bmjopen-2021-056445 DOI:
  64. Diethelm D, Ege G, Claussen MC, Iff S. The criminal liability of health care professionals treating anabolic steroid users under the SpoPA. Sports Psychiatry [Internet]. 2022 Nov;():157–66. [cited 2022 Nov 19]. 10.1024/2674-0052/a000029 DOI:
  65. Kamber M, Alampi G, Marti B. Arzneimittelgebrauch im Breitensport: vergleich von Ausdauersportlern und beruflich körperlich Aktiven. Schweizerische Zeitschrift für Sportmedizin und Sporttraumatologie. 2000;:76–9.

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