Title: Psychological traits associated with anabolic androgenic steroid use and dependence: an
exploratory cross-sectional study among female athletes
Version: 1 Date: 02 Aug 2024
Reviewer's report:
I read the manuscript with great interest and must commend the authors for their excellent
work. The manuscript is well-written overall and provides significant evidence that should be
considered in the field of substance dependence in women. I have only a few concerns and
suggestions for the authors, which I outline below.
1. The authors point out: “In the same study, a higher proportion of females who used AAS
reported attention-deficit/hyperactivity disorder (ADHD) diagnoses compared to non-using
females. While it is not well-established whether attention problems represent a risk factor for
AAS dependence in women, ADHD is strongly associated with other SUD in women (33)”.
-Why do they point this out by supporting it with this quote? I do not agree with the authors
that ADHD is strongly associated with certain SUDs in women, the literature is not conclusive
on that. Furthermore, the meta-analysis cited shows in almost all of the studies analysed higher
prevalences of ADHD and substance type maladies. Perhaps the authors wanted to show that
among women, ADHD is more strongly associated with dependence on certain substances than
others.
2. In the method section:
-Referring the reader to another study to find out the characteristics of the sample may be off-
putting, as well as interrupting the reading of the manuscript. I advise authors not to point this
out in this part of the text and to mention the basic socio-demographic characteristics of the
sample (e.g. mean age, employment status, etc.) in the participants section, where the table of
characteristics of the previous study is included.
3. The authors point out: “The sample comprised females over the age of 18, who participated in
heavy resistance training. Participants were recruited through social media and online forums,
in addition to informational flyers, posters and snowball sampling. AAS use was defined as
reported current or previous use, and having completed at least one cycle of AAS. Participants
who reported no AAS use were categorized as weight-lifting controls (WLC), n=1 WLC was
removed due to a positive test for a WADA banned substance. Within the AAS group, six
females were currently using, and ten reported previous use. Use status was confirmed via urine
samples, as has been previously described”.
-This participants' section mixes aspects of the procedure and measures sections and should be
reorganised and refined. For example, the definition of the use of AAS can be included before
the definition of AAS dependency in the measures section. Furthermore, I understand that since
the authors are relying on data from a previous study, they dispense with the procedural section.
Doing this again interrupts the reading and is detrimental to the replication of results across
studies. I would appreciate the inclusion of at least a brief or summarised procedural section
with the most relevant aspects.
4. At the beginning of the results section the authors point out: “The final sample comprised 32
participants (n=16 AAS, n=16 WLC). Based on the diagnostic criteria, seven of the participants
were identified as having lifetime AAS dependence (n=7 non-dependent, n=2 missing SCID
interview)”.
-This is a first sentence that would be better integrated in the participants' section.
5. In the results section:
-The effect size (Cohen's d) is convenient to give in absolute terms without sign, unless you
want to show the direction of the effect in a contrast of related means (exceptionally), but this
is not the case in this study with independent means. This should be corrected in the text and
tables of the study.
6. In the third paragraph of the discussion section:
-The authors are providing numerical information that corresponds to the results section. In any
case, for formatting reasons, it is more coherent to discard the numerical information from the
text. If the reader wants to see the concrete values, please see table 5.
7. At the end of the sixth paragraph of the discussion section:
-I suggest that the authors include oppositional defiant disorder as another possible comorbid
diagnosis influencing these conclusions.
8. At the end of the limitations section the authors point out: “Finally, due to the cross-sectional
nature of this study, the direction of the relationships cannot be determined”.
- For this reason, and because it is not a follow-up study with related samples, it does not make
sense to include the "-" sign with Cohen's d when indicating effect sizes.
I hope that these comments are useful in strengthening the work.