Anabolic-Androgenic Steroid Use in the Eastern Mediterranean Region: a Scoping Review of Extant Empirical Literature

The use of image- and performance-enhancing drugs particularly anabolic-androgenic steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with mainstream populations using these drugs for aesthetic purposes. Prevalence has been predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature from the Eastern Mediterranean region described and mapped what is known about the extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects. The review highlights a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review underscores the need to carry out further research, particularly qualitative and quantitative studies with both genders, and cognisant of the complexities of culture and religiosity.

was associated with the death of a 22 year old (Boulad 2003), bacterial and fungal infections in the event of sharing injecting equipment, and the transmission of blood borne viruses (ACMD 2010;Bates et al. 2017;Bates and McVeigh 2016). Appropriate harm reduction interventions targeting AAS users are crucial to preventing these adverse outcomes (Glass et al. 2019).
In terms of prevalence of this phenomenon, Sagoe and Pallesen (2018) have suggested that AAS use is generally recorded as more prevalent in Western countries, Brazil and the Middle East, and less widespread in Asia and Africa. Studies carried out in Eastern Mediterranean countries indicate that the use of AAS, whilst low, is on the rise and therefore a growing concern. Hence, we conducted a scoping review of extant empirical literature to describe and map what is known about the relatively new phenomenon of AAS use in the Eastern Mediterranean.

Methods
Scoping reviews are increasingly utilised as independent research methodologies to address broader research questions in comparison to systematic reviews (Arksey and O'Malley 2005;Khalil et al. 2016;Levac et al. 2010;Peters et al. 2015). They are usually conducted to identify gaps in knowledge, examine the extent (i.e. size), range (i.e. variety), and nature (i.e. characteristics) of the evidence on a certain topic or question (in this case, AAS use in the Eastern Mediterranean), summarise findings from a heterogeneous body of knowledge, or set agendas for future research and policy directives (Arksey and O'Malley 2005;Brandt et al. 2014;Daudt et al. 2013;Levac et al. 2010;Tricco et al. 2016). Scoping reviews are defined by Tricco et al. (2016) as 'a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. ' We adhered to Arksey and O'Malley's (2005) five stage iterative process scoping review methodology. These stages included the following: (1) identifying the essential research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collecting, summarising, and reporting the results. The process was underpinned by the research question (What do we know about AAS use in the Eastern Mediterranean region?) and reviewed all available published empirical literature in the English language on this topic. There was no restriction on date. To enable the broadest picture of current knowledge and perceptions relating to this issue, we included policy documents and international and national reports, online reports, conference proceedings, commentary pieces, and editorials, in addition to articles in scholarly peer reviewed journals. The search was implemented in April 2019. We used the following databases: Web of Science; Cochrane Library; MEDLINE; PsycINFO; SPORTDiscus; Social Science Citation Index; Conf Proceedings Citation index; PubMED; Science Direct; and Researchgate. A thorough list of key search terms used in AAS research articles known to the research team (who had public health, addiction, and clinical specialisms) informed the search strategy (see Table 1).
Eligibility criteria focused on use of AAS in Eastern Mediterranean Countries, i.e. Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen (WHO, 2019). Inclusion and exclusion criteria were discussed and agreed with all members of the research team. Clinical case reports, case series, and laboratory analysis only studies were excluded. The initial search identified 477 articles; and following initial screening, 355 were removed for lack of relevance, with the remaining 122 screened for inclusion in the study. Finally, duplicates (n = 51) and further records excluded for lack of relevance were removed (n = 32), leaving 39 records in total (see Fig. 1).
The 39 records were charted and thematically analysed, as per Arksey and O'Malley (2005). A table was created using Microsoft Word to chart relevant data (year of publication, author, location, method and aim, key findings, and conclusion) and to analyse the extracted data thematically to identify commonalities, emergent issues, and gaps in the literature. A trial charting exercise of several records was conducted by the lead author as recommended by Daudt et al. (2013). This was followed by a team consultation to ensure consistency with the research question and the scoping review aim, and to identify prior categories to support further data extraction and charting. The textual dataset was re-read numerous times by author one to gain familiarity with the data and identify and code emerging themes. The charted data was analysed and systematised by thematic manual coding, which organised the data and subsequently structured into themes through patterns identified in associated categories (Crossley  (Boos et al. 2011;Cassler et al. 2013) as their results showed that n = 0 AAS users were found in their studies, leaving a final number of 37 included studies in the review (see Fig. 2). Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects.

Profile of AAS Users in the Middle East
The quantitative studies from Iran (n = 14), Saudi Arabia (n = 7), Kuwait (n = 4), Lebanon (n = 2), United Arab Emirates (n = 1), Iraq (n = 2), Jordan (n = 2), Pakistan (n = 3), Sudan (n = 1), and conference proceedings from Bahrain (n = 1) generated a total of 5425 current and former AAS users. A total of 5371 of these were male and only 6 were female. Three studies did not detail whether the AAS users were male or female ( Participants were from Iran, Saudi Arabia, United Arab Emirates, Kuwait, Lebanon, Jordan, Iraq, Bahrain, Pakistan, and Sudan, with no notable differences in age ranges between countries. Those aged 18-34 years reported using AAS to a greater extent than other age groups (14-17 and 35-59 years). Not all studies reported on background characteristics such as marital status, employment status, and education. Studies that did report on demographics are presented in Table 3.

Gymnasium Practice in the Eastern Mediterranean Region
Gymnasium practice was not reported by twenty-one peer reviewed journal papers ( Sepehri et al. 2009;Sobhanian et al. 2013;Tahtamouni et al. 2008;Uddin et al. 2019;Zafar et al. 2018). The remaining fifteen papers did not state the type of settings they recruited participants from. Users reported using gymnasia for less than 6 months (n = 31), more than 6 months (n = 165), more than 2 years (n = 107), more than 4 years (n = 54) and one paper reported 11 months to 10 years (Jalilian et al. 2011). Users spent between two and five days (n = 75), more than three days (n = 18), and more than five days (n = 72) per week at their chosen gymnasium. Reasons for attending a gymnasium included bodybuilding, muscle building, professional training and daily gym practice (Al Bishi and Afify 2017;Al-Falasi et al. 2008;Alharbi et al. 2019;Althobiti et al. 2018).

AAS Regimes of Use in the Eastern Mediterranean Region
Sourcing of AAS was not investigated by more than half of the included studies (Al Ghobain et al. 2016;Allahverdipour et al. 2012;Al Nozha and Elshatarat 2017;Alsamani et al. 2017;Angoorani and Halabchi 2015;Asr et al. 2018;Bahri et al. 2017;Bordbar et al. 2014;Fijan et al. 2018;Jabari et al. 2016;Jalilian et al. 2011: Karfargard et al., 2015Khullar et al. 2016;Khidir and Mahmoud 2018;Melki et al. 2015;Mohammad 2014;Razavi et al. 2014;Rezaie, 2017;Saeidinejat et al. 2017;Zafar et al. 2018). However, research conducted in Saudi Arabia, United Arab Emirates, Kuwait, Iran, Iraq, Lebanon, Pakistan, and Jordan did report sourcing. Purchasing from friends, gym trainers, and coaches were the primary sourcing routes in these countries. Other sourcing routes included sourcing via gym members, training partners, the black market, online purchasing, pharmacists, physicians, veterinary surgeons, fitness stores, and purchasing abroad and bringing home. One military based study reported sourcing on site (Boos et al. 2010), i.e. the Contingency Operating Base and the PX retail store on base.
Duration of AAS use was only reported in a small number of articles (Al Bishi and Afify 2017; Alsamani et al. 2017;Asr et al. 2018;Bahri et al. 2017;Sobhanian et al. 2013) and ranged from less than 1 month to more than 5 years. One study in Saudi Arabia reported that 69.7% of AAS user participants simply had no knowledge of their duration of AAS use (Jabari et al. 2016). Twenty-five papers did not report duration of AAS use.
Thirteen studies in United Arab Emirates, Saudi Arabia, Kuwait, Sudan and Iran did not report on the reasons for AAS use (Al-Falasi et al. 2008;Alharbi et al. 2019;Allafi et al. 2019;Al Nozha and Elshatarat 2017;Alsaeed and Alabkal 2015;Angoorani and Halabchi 2015;Althobiti et al. 2018;Bahri et al. 2017;Bordbar et al. 2014;Jalilian et al. 2011;Kargarfard et al. 2015;Khidir and Mahmoud 2018;Razavi et al. 2014). Reasons for use of AAS were largely stated as being to improve image, appearance, and overall physique; to increase muscle mass and improve strength and power; achieve 'attractiveness'; to improve athletic performance; to increase chances of winning bodybuilding competitions; to increase self-confidence and social recognition; and due to advice or recommendation from friends, trainers, and physicians. Other less predominant reasons for use were to increase sex drive, weight gain, fat burning, aid recovery, unspecified medical reasons, and to enhance energy.
The adverse effects of AAS use were not investigated by all studies, with twenty-four papers not reporting on these effects. Self-reported effects by the remaining studies in Kuwait, Bahrain, Saudi Arabia, Iran, and Jordan were aggression, depression, sexual problems, increased appetite, acne, hair loss, gynecomastia, mood changes, fluid retention, headaches, increased hair growth, cardiovascular problems, psychiatric issues, and hepatic and renal damage (Allafi et al. 2019;Alsamani et al. 2017;Althobiti et al. 2018;Bahri et al. 2017;Haerinejad et al. 2016;Hussain et al. 2018;Razavi et al. 2014;Tahtamouni et al. 2008;Uddin et al. 2019;Wazaify et al. 2014). The study by Habeeb et al. (2012) stated that most AAS users reported the use of only dietary supplements initially, but on recommendation of others, initiated the use of AAS to improve performance.

Knowledge and Understanding of the AAS Concept and Adverse Effects
Studies included in this review reported on user's knowledge of the AAS 'concept' (i.e. their understanding of and expected outcomes of AAS use). Thirteen studies in Kuwait, Iran, Iraq, and Jordan did not examine user's knowledge and understanding of either AAS concept or adverse effects (Allafi et al. 2019;Allahverdipour et al. 2012;Angoorani and Halabchi 2015;Asr et al. 2018;Boos et al. 2010;Fijan et al. 2018;Habeeb et al. 2012;Hussain et al. 2018;Jalilian et al. 2011;Khullar et al. 2016;Sepehri et al. 2009;Sobhanian et al. 2013;Tahtamouni et al. 2008). It was noted that most participants in these Eastern Mediterranean countries were aware of the anabolic effects of AAS such as increased muscle mass, bodybuilding effects, increased in body weight, and increased muscle strength (Al Bishi and Afify 2017;Al-Falasi et al. 2008;Mohammad 2014). In relation to adverse effects, several papers in Saudi Arabia, United Arab Emirates, Kuwait, and Iran reported an inadequate level of self-reported knowledge overall amongst participants (Al Bishi and Afify 2017;Al-Falasi et al. 2008;Alharbi et al. 2019;Alsaeed and Alabkal 2015;Althobiti et al. 2018;Bahri et al. 2017;Jabari et al. 2016;Khidir and Mahmoud 2018;Mohammad 2014;Rezaei 2017;Uddin et al. 2019;Wazaify et al. 2014;Zafar et al. 2018). Less than half of the participants of the study by Al-Falasi et al. (2008) in the United Arab Emirates had any knowledge of either physical or psychological adverse effects A high number of participants of the study by Alharbi et al. (2019) in Saudi Arabia answered 'I don't know' when also asked about their awareness of these adverse effects. Haerinejad et al. (2016) reported that the majority of participants had no knowledge of adverse effects prior to use. One study reported that although users (n = 16) had knowledge of adverse effects, they continued to use AAS (Kargarfard et al. 2015).
One study reported that overall, it was believed that the benefits of ASS on muscle growth outweighed its adverse harmful effects (Alsaeed and Alabkal 2015). Bordbar et al.'s (2014) study in Iran found that a small number of participants believed that athletes should be allowed to use AAS for athletic performance. Jabari et al. (2016) in Saudi Arabia found that 77% of participants who self-declared knowledge of the adverse effects of AAS would still recommend them to friends. Hitti et al. (2014) noted that users of AAS were more likely to consume alcohol daily than non-AAS users.

Discussion
We present here the first known attempt to map and describe extant literature on the use of AAS in the Eastern Mediterranean, an emergent phenomenon in the region, and one which we speculate is at early stages of diffusion. Countries where publications were located include Saudi Arabia, United Arab Emirates, Kuwait, Iran, Iraq, Lebanon, Jordan, Bahrain, Afghanistan, Pakistan, and Sudan. Whilst we adhere to the robust Arksey and O Malley protocol for scoping review, we recognise that this review is compromised due to the following limitations. Firstly, only empirical studies were included in the search and investigative journalist reports were not included thus limiting the scope. Secondly, some studies were undertaken in the same country, whereby we do not know if individuals participated in more than one survey, creating a potential overlap, and over estimation of numbers of AAS users. Thirdly, it is unclear as to whether participants were citizens of these countries or whether they were foreigners from other more Westernised cultures. Western influences potentially impact on a country's body ideals, perceptions of masculinity, popularity of exercise and experimentation, and use of enhancement drugs. Religion or faith of the participants was not asked; therefore, we cannot assume that participants are of the Islamic faith. Lastly, some studies did not provide extensive detail on all countries participating in their surveys. Hence, this scoping review should be viewed with caution as it cannot provide an accurate contemporary interpretation of AAS use in the Eastern Mediterranean region. It does however give us insight into the phenomenon at early stages of diffusion with regard to rationales for use, knowledge around use, regimes, locations of use, and sourcing routes.
The use of AAS for performance and image enhancement is a growing concern in these countries; however, knowledge, understanding, and awareness of health harms related to AAS appear to be varied and somewhat limited. Most studies in this review reported AAS users as single and in fulltime employment, highlighting high rates of employment, similar to studies in the UK (Baker et al. 2008;Begley et al. 2017;Greenway and Price 2018), Australia (Jacka et al. 2017), and the USA (Pope et al. 2014a(Pope et al. , 2014b. Educational status of AAS current and former users in the Middle East was highest in the 'higher education' range which corroborates research in Australia (Cohen et al. 2007) and the USA (Westerman et al. 2016). Duration of the use of AAS was underreported overall; the maximum length of use reported was 5 years, indicating that the use of AAS amongst some gym populations in the Middle East is clearly established. However, when compared with studies in the UK (Baker et al. 2008;Begley et al. 2017;Greenway and Price 2018), Australia (Jacka et al. 2017), and the USA (Pope et al. 2014a(Pope et al. , 2014b, it is evident that this phenomenon is at an early stage of diffusion. This has implications for design of culturally appropriate health-related interventions underpinned by harm reduction and cessation supports in the Eastern Mediterranean. We underscore implications for normalisation of this form of enhancement drug use amongst athletes and gym goers (Mulrooney et al. 2019), with this review providing a key starting point for interventions prior to normalisation of use. There is growing evidence of the possibility of deleterious effects of long-term AAS use on the health of a user's brain ) and cognitive defects in long-term high dose users (Kanayama et al. 2013).
Research has indicated that factors contributing to decisions to use AAS include beliefs and personal traits . Building muscle and enhancing physique and training aspects were the primary reasons for gymnasium attendance amongst individuals reporting AAS use in the Eastern Mediterranean. Some less predominant reasons for AAS use centred on desire to increase sex drive, weight gain, fat burning, help improve an injury, medical reasons, and for more energy. Literature shows that AAS are used for the improvement of physique, increased muscle mass, strength enhancement, and athletic performance enhancement Brennan et al. 2016;Ip et al. 2011;Ip et al. 2015;Zahnow et al. 2018). Masculinity is a social construct, as is femininity, and is associated with specific values and cultural contexts (Darwish, 2009). The review suggests that AAS use is overwhelmingly male indicating the presence of this masculine culture, with only a small number of studies reporting female use. This largely reflects the evidence from established literature outside the Eastern Mediterranean, where female use exists at much lower levels than male use and is characterised by stigma and secrecy (Chandler and McVeigh 2014;Ip et al. 2010;Sagoe et al. 2014aSagoe et al. , 2014b but to a lesser extent than males (Brennan et al. 2016).
We recognise that gender and religiosity are symbiotic in their relationship in that religious symbolism facilitates the male ego (Aslam 2012). In other countries, men have a higher prevalence of AAS use than females for example in the USA (Kashkin and Kleber 1989;Tokish et al. 2004;Yesalis 2001), UK , Poland (Rachoń et al. 2006), and Sweden (Lindqvist et al. 2013), and as such, these findings reflect gender differences in use found in other countries. Islamic faith however prohibits intoxication from alcohol and the use of substances or behaviours that induce addiction such as illicit drugs or gambling (Crabtree et al. 2017;Salaymeh 2015). As mentioned earlier, we do not have participant profile in terms of their citizenship or religiosity. Van Hout and Kean (2015) reported that male Muslim users of AAS and other IPEDs in the UK felt these substances led them to be in control of and promoted their perceptions of their physical and spiritual health, and were not harmful, thus circumventing religious parameters. In addition, we recognise that use of AAS in Islamic faith is discouraged and the legality of AAS is unclear in some Eastern Mediterranean countries where regulatory controls are complex and varied. Of interest is that one study, namely, Angoorani and Halabchi (2015) observed a 25% prevalence of AAS use in their all-female study. This is perhaps indicative of the lower proportion of females attending mainstream gyms (and commonly not attending male gyms) in the included studies (Donnelly et al. 2018).
Users of AAS had some knowledge of the anabolic effects of AAS and the overall AAS 'concept' such as increased muscle mass, bodybuilding effects, and increased power and muscle strength. There was however a concerning and inadequate level of knowledge around adverse effects and health problems (Al Bishi and Afify 2017;Al-Falasi et al. 2008;Alharbi et al. 2019;Alsaeed and Alabkal 2015;Bahri et al. 2017;Jabari et al. 2016;Rezaei 2017). Aggression is a reported adverse psychological effect of AAS use (Bahrke et al. 1996;Bahrke et al. 1990;Pope et al. 2000). Lack of knowledge on such adverse effects is not uncommon and has also been reported in studies in Australia (Yager and O'Dea 2014), Sweden (Nilsson et al. 2005), and the USA (Hoffman et al. 2008). Worldwide, enhanced levels of awareness and knowledge are warranted to support choices to use safely (Nilsson et al. 2005). Of those that included ROA in their surveys, injecting was reported as the predominant route of administration. This may indicate presence of only a small cohort of oral AAS users (similar to recent research by van de Ven et al. (2019)). Blood-borne virus (BBV) transmission associated with any form of injecting drug use is a major public health concern (Hearne et al. 2016;Hope et al. 2013;Van Hout 2014). Of note was that questions relating to sharing of injecting equipment or knowledge and awareness of blood-borne virus (BBV) transmission were not asked in the included records. Some records did however refer to the injection of the user by gym trainers; however, harms that may result from this practice were also not investigated further. Of note is the limited reference to support from healthcare professionals to this community. Clearly, there is a role for health professionals in relation to prevention and harm reduction with the potential for pharmacists to take the leading role.
Lastly, sourcing of AAS was reported in a limited number of studies and highlighted how AAS users are highly influenced by availability in gym settings and by coaches and trainers. Some reported being recommended to use AAS by them (Razavi et al. 2014;Fijan et al. 2018) and also sourcing their AAS from them, which supports similar research elsewhere (Fincoeur et al. 2015;Maycock and Howat 2007;Santos and Coomber 2017), given that AAS and associated drugs are illicitly manufactured and sourced ) via routes such as online marketplaces and online private sellers (Brennan et al. 2016), and with low resource countries increasingly involved in manufacture and as transit routes (Evans-Brown et al. 2009).

Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.