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Advances in Social Sciences Research Journal – Vol. 12, No. 1

Publication Date: January 25, 2025

DOI:10.14738/assrj.121.18241.

Coutinho, L. F. D., Nascimento-Salgado, L. V., Monteiro-Bontempo, V., & Martins-Chaves, R. R. (2025). Stigma, Taboo, and Public

Health: A Sociological and Bioecological Approach to the Use of Performance and Image-Enhancing Drugs. Advances in Social

Sciences Research Journal, 12(1). 264-272.

Services for Science and Education – United Kingdom

Stigma, Taboo, and Public Health: A Sociological and

Bioecological Approach to the Use of Performance and Image- Enhancing Drugs

Luis Felipe Duarte Coutinho

ORCID: 0009-0003-0323-4611

Faculty of Medical Sciences of Minas Gerais,

Belo Horizonte, Brazil

Leonardo Vaz do Nascimento-Salgado

ORCID: 0009-0002-3811-5201

Faculty of Medical Sciences of Minas Gerais,

Belo Horizonte, Brazil

Valentina de Monteiro-Bontempo

ORCID: 0009-0004-8992-3430

Faculty of Medical Sciences of Minas Gerais,

Belo Horizonte, Brazil

Roberta Rayra Martins-Chaves

ORCID: 0000-0001-6182-9232

Federal University of Minas Gerais Belo Horizonte, Brazil

ABSTRACT

Background: This article provides an interdisciplinary review of performance- enhancing and image-enhancing drugs (PEDs) through sociological and

bioecological lenses. The analysis reveals a growing and complex trend of PED use

among recreational users. Methods: Utilizing Bronfenbrenner’s bioecological

theory along with covering books, reports, anti-doping notes, observational studies

and systematic reviews, this review explores how different pressures influence PED

use. Goffman’s concept of stigma highlights the marginalization PED users

encounter, as they are often associated with cheating or health risks. Findings: The

article examines how different systems spread unrealistic body ideals, which

intensifies pressures on individuals to normalize PED use. The western cultural

dynamic connects PED use to both physical aspirations and deeper self-worth

issues related to body image and it is the duty of healthcare professionals not only

to refuse such prescriptions but also to actively engage in prevention and public

awareness efforts regarding the dangers of PEDs. Interpretation: Emphasizing the

need for an empathetic yet firm medical approach, the article advocates for

healthcare professionals to engage openly with PED users to foster supportive

dialogues with. Such engagement is crucial for effective public health interventions

that can address both the physical and psychological risks of PED use, ultimately

contributing to a more health-centered societal perspective on performance and

body image. In conclusion, this article emphasizes the urgent need to reframe the

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Coutinho, L. F. D., Nascimento-Salgado, L. V., Monteiro-Bontempo, V., & Martins-Chaves, R. R. (2025). Stigma, Taboo, and Public Health: A

Sociological and Bioecological Approach to the Use of Performance and Image-Enhancing Drugs. Advances in Social Sciences Research Journal,

12(1). 264-272.

URL: http://dx.doi.org/10.14738/assrj.121.18241

conversation around PEDs, recognizing their complex social underpinnings to

better approach affected individuals.

Keywords: Behavioral Sciences, Performance-Enhancing Substances, Public Health

INTRODUCTION

Performance-enhancing drugs (PEDs) include various compounds used to boost muscle

strength, enhance bone density, and increase red blood cell production, contributing to

anabolism while reducing catabolism.1 While doping was initially associated with elite sports,

its prevalence has notably risen among non-elite athletes, where recreational users seek

aesthetic gains or recreational use.2 Today, the use of PEDs, such as anabolic steroids (AAS), has

become an epidemic and despite a significant amount of scientific evidence, the majority of the

public, as well as the medical community, continues to mistakenly view it as an isolated issue.2

Despite AAS being the most notable type of PEDs, the World Anti-Doping Agency’s (WADA)

Prohibited List 2024, highlights a wide range of performance-enhancing substances with

diverse pharmacological properties, including aromatase inhibitors, selective androgen

receptor modulators, growth hormone secretagogues, hormonal precursors, stimulants and

diuretics.3 The use of performance-enhancing drugs (PEDs) without legitimate medical

indication poses a serious health risk and has no ethical support in medical practice. The

prescription of these substances for aesthetic or physical enhancement purposes is prohibited

worldwide, as it exposes patients to severe adverse effects. Therefore, it is the duty of

healthcare professionals not only to refuse such prescriptions but also to actively engage in

prevention and awareness efforts regarding the harms caused by the indiscriminate and

amatory use of PEDs.

Estimating PEDs prevalence is challenging due to the reliance on laboratory tests targeting

competitive athletes, which limits general population insights. Also, variability in data coverage

also impacts prevalence estimates, as studies rarely address compounds. Nevertheless, a meta- analysis study identified a 3·3% steroid global prevalence, with rates higher in men (6·4%)

than women (1·6%), showing significant gender heterogeneity.4 It is further estimated that

among Americans currently aged 13–50 years, 2·9–4·0 million have used AAS and 1 million

may have experienced AAS dependence.

5

In Brazil, AAS use varies widely and highly heterogeneously across demographic regions, with

a general prevalence 4%, and rates of 18·4% among recreational athletes.6 Both countries

reflect similar challenges in understanding PED use, as traditional survey methods may

underreport due to social stigma or legal concerns. Studies recommend wastewater analysis as

an alternative, providing more objective, comprehensive population data.7

Therefore, this study approaches PED use from an interdisciplinary perspective, incorporating

social sciences frameworks to examine how stigma and health outcomes intersect in the

current society. Theories by Erving Goffman and Urie Bronfenbrenner provide insight into how

societal pressures and personal environments shape PED use and its consequences. Addressing

this issue through equitable public health strategies aligns with Article 25 of the Universal

Declaration of Human Rights, which emphasizes the right to health. Such strategies must also

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Advances in Social Sciences Research Journal (ASSRJ) Vol. 12, Issue 01, January-2025

Services for Science and Education – United Kingdom

consider sociocultural factors and community involvement, which is essential for developing a

healthcare system that meets the needs of every population.

BRONFENBRENNER’S BIOECOLOGICAL THEORY ON WHY INDIVIDUALS TURNS TO PEDs

Bronfenbrenner’s bioecological theory provides a framework to analyze the mindset behind

doping in Western society, linking cultural patterns and social pressures that drive individuals

to pursue “ideal” bodies artificially, whether for recreation or sports. Though traditionally

applied to children and adolescents, the theory’s focus on system interactions is relevant to

other age groups. Bronfenbrenner highlights the importance of environmental contexts on

human development, organized into systemic levels: microsystem, mesosystem, exosystem,

and macrosystem.8

The Microsystem

The microsystem comprises direct relationships within an individual’s daily environment—

family, friends, and colleagues—that directly impact behavior.8 In PED use, relationships within

the microsystem can strongly influence users' decisions, as pressure from family and friends

can shape perceptions of body image, strength, and success. Families emphasizing physical

appearance or athletic performance may encourage PED use to meet these ideals, which can

compromise young people’s well-being and lead to risky behaviors.9

Parental pressure is often significant, with some viewing their children’s achievements as

personal validations, inadvertently pushing them toward PEDs. Peer influence also plays a role;

approximately 17% of adolescent steroid users cite peer pressure as a primary factor. This peer

influence, especially in sports and bodybuilding, creates a cycle where acceptance is linked to

conformity with group norms that support PED use.10

Despite adhering to rigorous training regimens and nutritional protocols, many young people

eventually abandon these plans due to frustration. Observing peers who achieve superior

physiques through PEDs, they mistakenly attribute their own struggles to genetic limitations.

Consequently, they perceive PED use as the sole viable option to attain comparable results,

thereby justifying its use to level the competitive field.

The Mesosystem

The mesosystem encompasses interactions between various microsystems, such as family and

peer influences, which do not operate in isolation but are interdependent.8 For instance, if a

family highly values sports success and peers prioritize physical appearance, adolescents may

feel pressured to achieve in both areas. This combined influence can drive them to PEDs to

satisfy both family and peer expectations.10 For example, a teenager whose family celebrates

athletic accomplishments and whose peers praise physical appearance may feel doubly

compelled to use PEDs for social approval.

Scientific studies indicate that appearance-based compliments in social and professional

settings increase anxiety, reinforcing self-worth tied to appearance rather than competence.

This pressure can lead individuals to seek validation in physical attributes rather than personal

achievements,11 a pattern evident among youth who prioritize body image and performance

due to social influences from family and friends.