Gender Differences in Health Services Access and Harm Reduction Practices Among Women Who Use Image and Performance Enhancing Drugs: Findings from a Large International Sample

Technical Summary: Gender Differences in Health Services Access and Harm Reduction Practices Among Women Who Use Image and Performance Enhancing Drugs

Problem Statement
Women who use Image and Performance Enhancing Drugs (IPEDs), including anabolic-androgenic steroids (AAS), face unique health risks distinct from men, such as virilisation (voice deepening, clitoral enlargement) and menstrual irregularities, many of which are irreversible. While qualitative research exists, there is a significant deficit in quantitative data regarding how women navigate healthcare systems compared to men. Existing literature often relies on small samples (typically <16 participants) or focuses exclusively on athletes, failing to capture the broader population of women using IPEDs for diverse motivations. Furthermore, women often rely on male-dominated peer networks for harm reduction advice, leaving them vulnerable to misinformation and strategies not tailored to their specific physiological risks. This study addresses the gap in quantitative evidence by investigating gender-based differences in healthcare access barriers and harm reduction practices within a large international sample.

Methodology

• Data Source: The study utilized data from the 2024 Global Drug Survey (GDS2024), an anonymous, web-based cross-sectional survey targeting users of legal and illegal psychoactive substances.
• Sample: The analysis focused on respondents who completed the IPED module and identified as men or women. The final sample consisted of 1,366 men and 134 women.
• Measures:
  • Demographics: Age, gender identity, country of residence, education, employment, and sexual orientation.
  • IPED History: Types of substances used (injectable/oral AAS, trenbolone, HGH, insulin, clenbuterol), age of first use, and sourcing methods.
  • Healthcare Access: Participants reported difficulties accessing specific services: General Practitioners (GPs), hospitals, pharmacies, and needle service providers/exchanges (NSPs).
  • Harm Reduction: Engagement in drug checking (testing purity) and specific methods used (home test kits, laboratory testing, other).
• Analysis: Descriptive statistics summarized socio-demographics. Chi-square tests (and Fisher's exact tests for small cell sizes) were used to assess gender differences in access difficulties and harm reduction practices. Effect sizes were calculated using Phi coefficients.

Key Results

• Demographics: The sample was predominantly White, university-educated, and employed. Women were slightly older on average (M=35.40) than men (M=32.32). Women reported later ages of initiation for most IPEDs compared to men, though a subset initiated high-risk substances (e.g., insulin, oral trenbolone) in their early twenties.
• Healthcare Access:
  • Overall, 3.7% of women reported difficulties engaging with healthcare services, compared to 20.9% of men. However, the association between gender and general difficulty accessing healthcare was not statistically significant (p = .08).
  • Specific Services: Women reported significantly fewer difficulties than men accessing GPs (3.0% vs. 17.2%), hospitals (1.5% vs. 5.3%), and pharmacies (1.5% vs. 6.6%).
  • Most Common Barrier: For both genders, GPs were the service most frequently cited as difficult to access.
  • Needle Services: Access difficulties for NSPs were rare for both groups (3.5% men, 0.7% women) and not significantly different.
• Harm Reduction Practices:
  • Drug Checking: There was no significant gender difference in the overall prevalence of checking product purity (29.6% of women vs. 31.6% of men).
  • Testing Methods: Men were significantly more likely to use laboratory testing (13.0% vs. 3.7%; p = .002). No significant difference was found in the use of home test kits (7.0% men vs. 3.0% women; p = .07).

Key Contributions

• Sample Size: This study presents the largest international quantitative sample of women who use IPEDs reported to date (n=134), significantly exceeding previous studies that typically included fewer than 16 female participants.
• Comparative Analysis: It provides one of the first direct quantitative comparisons of healthcare access barriers and harm reduction strategies between men and women in this population.
• Nuanced Findings: The study challenges the assumption of uniform healthcare access barriers by revealing that while women face fewer reported difficulties accessing specific services (GPs, hospitals, pharmacies), they still encounter a deficit in gender-specific harm reduction support.

Significance and Claims
The authors claim that while women in this sample reported fewer difficulties accessing healthcare services than men, they face a critical "deficit of gender-specific harm reduction support." The study highlights that despite comparable or better access to formal services, women often rely on male-oriented peer networks for advice, which may not address their specific risks (e.g., virilisation).

The paper argues that because women frequently engage with health services (particularly GPs, hospitals, and pharmacies) without reporting the same level of access difficulty as men, these existing points of contact represent underutilized opportunities for intervention. The authors conclude that there is an urgent need for:

1. Women-centred interventions: Tailored harm reduction education and clinical support that address specific female risks and trajectories.
2. Professional Education: Guidelines for health professionals to better support women who use IPEDs, moving beyond guidelines extrapolated from male data.
3. Improved Drug Checking: Enhanced awareness and access to reliable drug checking services, as women are less likely to use laboratory testing, which is crucial for verifying product legitimacy and avoiding masculinising effects from counterfeit or mislabeled substances.

The study maintains modesty regarding its claims, acknowledging limitations such as the convenience sampling method (which may overrepresent educated, Western, and White populations), the cross-sectional design (precluding causal inference), and the self-reported nature of the data. It does not propose new experimental interventions but rather calls for the adaptation of existing health service frameworks to be more responsive to the documented needs of women using IPEDs.