Title: Female doping: observations from a data lake study in the Hospital District of Helsinki
and Uusimaa, Finland
Version: 1 Date: 13 Apr 2023
Reviewer's report:
Thank you for the opportunity to review this paper Female doping: observations from a data
lake study in the Hospital District of Helsinki and Uusimaa, Finland. I would like to commend
the Authors on their work and the accompanying manuscript. This was an interesting read and
would be of interest to BMC Women’s Health readership more broadly.
A challenge in the field of doping research, particularly related to anabolic steroid use, is
to understand female use and side effects. The authors use medical records to investigate
female doping and comorbidities in Finland among those who take contact with the health
services, including medical diagnoses of both psychiatric and somatic conditions, along with
hematological parameters. The results indicate that psychiatric and substance use disorders
were common among this population, which is not surprising but contributes to the paucity
of knowledge about females who use AAS. While the manuscript is relevant for the issue
of combordities among female AAS users, this important health concern should be more
thoroughly explored. The manuscript lacks a cohesive rationale and thorough and clear
presentation of statistical tests and results. Several changes are needed to specify both how and
why the authors made the methodological and analytical choices in order to better understand
the scientific contribution.
General comments for entire manuscript:
1. Apply careful consideration when using “female” (referring to biological sex) and
“women” (referring to gender), particularly as two patients are identified as transsexual.
2. Consider the phrase “doping using females” – doping is an action rather than a noun and this
phrasing might confuse readers.
3. I commend the Authors on the significant effort in identifying and compiling information
from medical records, however I believe the manuscript will benefit from clarifying the rationale
of including both diagnostic and hematological findings throughout.
Abstract
4. Line 9: The first sentence is not a complete sentence
5. Line 9: Write out HUS
6. Line 13: What does “qualitative data” refer to here? Records of doping use?
Introduction
7. Define doping early in the introduction (do you mean AAS or other types of PIEDs as well?)
8. Line 45: consider changing “adored” to “idealized” or “preferred.”
9. The introduction around lines 60-75 could be more robust. Recent publications may be
relevant as they provide female-specific findings. (i.e.  Piatkowski et al. (2023). Polysubstance
use practices among women using anabolic-androgenic steroids (AAS); Chegeni et al. (2021).
Aggression and psychological distress in male and female anabolic-androgenic steroid users:
A multigroup latent class analysis; Scarth et al. (2022). Psychopathology among anabolic-
androgenic steroid using and non-using female athletes in Norway)
10. Lines 112-116: the aim is quite vague, and does not address any specific research question.
In addition, while the introduction provides a thorough background of potential health effects,
it is not clear what the knowledge gaps that the authors aim to fill are. Please specify what the
study aims to add to the current state of knowledge.
Methods:
11. General comment: The methods section could use additional organization – particularly the
first section on “study sample” seems to contain methods for both the search process and study
sample which could be two distinct sections.
12. Figure 1 is nice and informative, but could benefit from adding numbers to several of the
boxes (i.e. how many were removed through manual processing, how many had male social
security number, etc.)
13. Line 126 HUS should be defined when it first appears (line 121?)
14. Line 129: while I am not familiar with Finnish (so I may miss something), it seems that the
search could contain additional terms, particularly related to non-AAS PIEDS. If the aim is to
cover doping in the broadest sense as the title implies, it may be relevant to include terms for
substances such as ephedrine, peptides/HGH, EPO, etc.
15. Line 135: were records screened by one person or was there some consensus for quality
check?
16. Line 137: explain “reliably classified”
17. Line 145: how many were excluded for this reason?
18. Line 150: same comment as above re: quality control of manual processing
19. Line 150: Specify “classification” (i.e. of doping status? Or something else?)
20. Do you have information regarding when/why/how blood samples were taken and how they
were processed?
21. Statistical analysis: please specify which variables were compared and between which
groups
Results:
22. General comment: statistically significant/non-significant tests are mentioned several times
throughout the text, without test statistics or a clear understanding of which variables were
compared between which groups, or how many statistical tests were computed. Please add a
table with full results of all statistical tests done.
23. Line 236-238: what specifically differentiates acute and non-acute? Consider moving some
of this information to the Methods section
24. In Table 2, I am assuming that since n=2 is sometimes specified, then when no n is specified
this particular condition appears in 1 patient? If this is correct, it may be beneficial for readers
to clarify this information in a caption
25. Line 252-253: SUD is often comorbid with other psychiatric conditions, which are often
comorbid with somatic conditions. Consider additional analysis to investigate how common
comorbidity is in this population (i.e. how many have 2, 3, 4+ diagnoses)?
26. Line 287: specify what indicated long-term use (what is considered long term?)
27. Figure 3: it would be interesting to know how many laboratory measurements are available
for a given phase – AAS are often taken in cycles and it would be interesting to see if there are
females going on and off several times and how this influences measurements over time
Discussion:
28. Line 364: consider the addition of other recently published works regarding contact and
experiences with healthcare providers, in addition to findings regarding psychiatric morbidity
among females who use AAS: i.e. Amaral, J. M. X., Kimergård, A., & Deluca, P. (2022).
Prevalence of anabolic steroid users seeking support from physicians: a systematic review and
meta-analysis. BMJ open, 12(7), e056445; Henriksen, H. C. B., et al. (2023). Health service
engagement, side effects and concerns among men with anabolic-androgenic steroid use: a
cross-sectional Norwegian study. Substance Abuse Treatment, Prevention, and Policy, 18(1),
1-11; ); Chegeni et al. (2021). Aggression and psychological distress in male and female
anabolic-androgenic steroid users: A multigroup latent class analysis; Scarth et al. (2022).
Psychopathology among anabolic-androgenic steroid using and non-using female athletes in
Norway
29. It may be relevant to mention the prevalence of the observed diagnoses in the general
(Finnish) population to get an idea of how the AAS group differs.
30. Limitations section should discuss external validity
31. The discussion should interpret the hematology findings more thoroughly, particularly for
readers who may be less familiar with these measures. The manuscript would benefit from more
clearly connecting the laboratory and diagnostic findings throughout.