Review Reports - Exploring the Psychological and Social Dynamics of Steroid and Performance-Enhancing Drug (PED) Use Among Late Adolescents and Emerging Adults (16–22): A Thematic Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study explores the psychological and sociocultural dynamics of steroid and performance-enhancing drug (PED) use among adolescents and emerging adults in Turkey, revealing that such use is deeply embedded in emotional regulation, identity construction, and the pursuit of social validation.

I believe this is an interesting and thorough piece of work. I have a few simple suggestions.

In my opinion, many young people use drugs because of a distorted obsession with muscle mass. I think it would be helpful to add a bit more related evidence in the introduction.

After including 31 participants, was there no new information emerging? This needs further clarification. I feel that 31 participants might be slightly insufficient for qualitative research.

The study excluded participants with psychological disorders or those undergoing other medical treatments, but did not further specify the criteria for these psychological disorders, nor did it address whether undiagnosed mental health issues might have influenced the motivation or outcomes of PED use.

I suggest providing a brief explanation of reflexive thematic analysis. This would be helpful for readers who are unfamiliar with qualitative research.

Were the interviews conducted online? Were there any specific requirements regarding the participants' environments?

In the data analysis section, I recommend adding some references.

I suggest including a table or a description of the participants' background in the results section. This way, we can better understand which specific group of individuals these findings might apply to.

If possible, having a visual representation of the identified themes would further enhance the appeal of the paper.

Author Response

Reviewer-1

In my opinion, many young people use drugs because of a distorted obsession with muscle mass. I think it would be helpful to add a bit more related evidence in the introduction.

Author Response:

We thank the reviewer for this insightful suggestion. We agree that the introduction would benefit from a clearer linkage between performance-enhancing drug (PED) use and the psychological construct of muscle dysmorphia, which reflects a distorted preoccupation with muscularity. Accordingly, we have added a concise paragraph in the Introduction (page 4, lines 120–130) summarizing empirical evidence demonstrating that adolescents and emerging adults who internalize the muscular ideal are more likely to engage in appearance- and performance-enhancing substance use. The new text cites key studies (Pope et al., 1997; Mitchison et al., 2022; Gawash et al., 2023; Zaiser et al., 2024; Gestsdottir et al., 2021) and situates muscle dysmorphia as an important psychological driver of PED initiation.

Reviewer-1

After including 31 participants, was there no new information emerging? This needs further clarification. I feel that 31 participants might be slightly insufficient for qualitative research.

Author Response:

We appreciate the reviewer’s thoughtful concern regarding sample adequacy. In qualitative research, sample size is determined not by numerical representation but by thematic saturation—the point at which no new themes or insights emerge from additional data. In this study, we initially targeted 35–50 participants to ensure diversity and potential saturation. However, following the 31st interview, the research team observed that no new codes, subthemes, or variations in meaning were emerging across subsequent transcripts. This decision was therefore guided by the established principle of information power (Malterud et al., 2016) and thematic saturation assessment procedures (Guest et al., 2020).

Additionally, qualitative research emphasizing depth and interpretive richness rather than breadth can reach saturation within similar sample ranges, particularly in homogeneous or experientially focused populations (Braun & Clarke, 2006; Malterud et al., 2016). The final dataset of 31 participants (26 analyzed after exclusions) provided sufficient variation in gender, district, and PED use patterns to support a comprehensive thematic framework.

Reviewer-1

Author Response:

We thank the reviewer for raising this important point regarding the specification of exclusion criteria and potential undiagnosed psychological conditions. In the revised manuscript, we have clarified that the exclusion criterion for “diagnosed psychological disorders” referred to formal psychiatric diagnoses confirmed through clinical evaluation or medical documentation (e.g., major depressive disorder, psychosis, bipolar disorder, or substance dependence) as self-reported by participants or disclosed during the screening phase. This specification has been added to the Participants subsection of the Methods (page 15, lines 370–375).

We fully acknowledge that undiagnosed or subclinical psychological difficulties (e.g., anxiety, low self-esteem, perfectionism) may still have influenced participants’ motivations for PED use. Rather than constituting a methodological limitation, these latent emotional factors were central to the study’s focus on psychological and identity-based drivers. Accordingly, we have added a clarifying statement in the Limitations section (page 43, lines 1145–1150) noting that unreported or undiagnosed symptoms could have contributed to the emotional dynamics observed, which future mixed-method studies may explore through clinical screening instruments.

Reviewer-1

I suggest providing a brief explanation of reflexive thematic analysis. This would be helpful for readers who are unfamiliar with qualitative research.

Author Response:

We appreciate this valuable suggestion. To enhance methodological clarity for readers less familiar with qualitative approaches, we have added a concise explanation of reflexive thematic analysis in the Data Analysis subsection (page 20, lines 515–525). The revised text briefly outlines the purpose and interpretive nature of this method and cites Braun and Clarke (2006) as the foundational reference. This addition improves accessibility while preserving the manuscript’s academic tone and analytic depth.

Reviewer-1

Were the interviews conducted online? Were there any specific requirements regarding the participants' environments?

Author Response:

We thank the reviewer for requesting clarification about interview procedures. As noted in the Procedure section, all interviews were conducted online via Microsoft Teams to ensure accessibility and confidentiality across districts of Istanbul. We have now added a short explanation describing how participants were instructed to prepare their environments to ensure privacy and minimize distractions. Specifically, they were asked to participate from a quiet, enclosed space using a personal device with stable internet access and headphones when possible. The interviewer confirmed at the start of each session that the participant was alone and comfortable proceeding. These details have been incorporated into the Procedure subsection (page 18, lines 455–465).

Reviewer-1

In the data analysis section, I recommend adding some references.

Author Response:

We appreciate the reviewer’s helpful suggestion. In response, we have expanded the Data Analysis subsection by adding key methodological references that contextualize our analytic process. In addition to Braun and Clarke (2006), we now cite Guest et al. (2020) to support the discussion of thematic saturation and Nowell et al. (2017) to emphasize criteria for ensuring trustworthiness and rigor in thematic analysis. These additions enhance methodological transparency and align the manuscript with established qualitative research standards.

Reviewer-1

Author Response:

We thank the reviewer for this helpful recommendation. In response, we have added a descriptive summary of participants’ demographic and contextual characteristics at the beginning of the Results section (page 23, lines 595–610). This addition includes a brief table outlining age, gender distribution, district representation, PED type, and training duration. The description clarifies the diversity and experiential background of the sample, helping readers better interpret the thematic findings.

Reviewer-1

If possible, having a visual representation of the identified themes would further enhance the appeal of the paper.

Author Response:

We thank the reviewer for this valuable suggestion. To visually summarize the analytic framework, we have added a conceptual figure illustrating the six major themes and their interconnections (Figure 1, page 26). The diagram presents how early insecurity evolves into body-centered coping, secrecy, obsession, dependency, and perceived agency—forming a cyclical developmental model of performance-enhancing drug (PED) use among adolescents and emerging adults. This visual representation improves clarity and accessibility for readers who prefer a schematic overview of the thematic relationships.

Reviewer 2 Report

Comments and Suggestions for Authors

The conclusion in the abstract reads more like a policy statement than a research summary. It would work better if shortened and written in a way that reflects the evidence more directly.

The introduction sets a strong background but is longer than necessary. Some points on body ideals and media influence appear more than once and could be merged to keep the reader’s attention. The choice of Türkiye as the study setting is very relevant, but this point should be introduced earlier to underline the originality of the work. The research gap also needs to be highlighted more directly why is it important to explore PED use among Turkish youth through a qualitative approach, and what new perspective does this study add?

The literature review is broad, but at times it feels more like a general overview than a focused lead-in to the research questions. Sections such as body ideals, hidden onset, and emotional drivers overlap and could be combined to avoid repetition. Bringing in more non-Western studies would also help strengthen the cultural contribution of the work.

The study design is solid, though there are parts that repeat information across different sub-sections, such as recruitment and ethics. These details can be brought together in one place to make the methods easier to follow. The explanation of sample size and data saturation could be clearer briefly explaining why 26 participants were sufficient would add strength. The section describing the interview guide is quite long, and it might be more effective to present the domains in a short table instead of extended paragraphs.

The thematic analysis is detailed and thoughtful, but the narrative feels heavy in places. The six themes are described well, but some trimming would help prevent the reader from feeling overwhelmed. Parts of the results also slip into discussion for instance, interpretations around protest, autonomy, and gender might be better placed in the discussion section. The table on themes is useful, though it could be improved by adding short definitions or sample quotes.

The discussion is comprehensive but occasionally repeats findings instead of analyzing them in depth. It would be useful to place more focus on what the results mean for psychology, adolescent health, and cultural research. The cultural aspects are one of the study’s strengths, and weaving these insights more consistently through the discussion would add depth. Practical and policy implications are important, but they should be kept more concise so they do not overshadow the psychological contributions of the study.

The limitations are well covered but could be expressed more briefly. The points on self-reporting and cross-sectional design could be shortened to avoid repetition. The section on future research is valuable, though it would be stronger if presented in a clear, focused list rather than a long narrative.

Author Response

Reviewer-2

The conclusion in the abstract reads more like a policy statement than a research summary. It would work better if shortened and written in a way that reflects the evidence more directly.

Author Response:

We thank the reviewer for this constructive suggestion. We have revised the Abstract conclusion to better reflect the empirical findings rather than providing prescriptive implications. The new version now highlights the central evidence-based insight—that PED use among adolescents and emerging adults functions as an emotionally driven and identity-related coping strategy—while omitting policy-oriented phrasing. The revised conclusion (lines 35–40) is more concise and consistent with the study’s qualitative scope.

Reviewer-2

Author Response:

We thank the reviewer for this excellent feedback. In line with the suggestion, we have streamlined the Introduction by merging overlapping discussions on body ideals and social media influence to maintain flow and reduce redundancy (pages 2–4). We have also introduced the cultural context of Türkiye earlier in the introduction (page 2), emphasizing the unique intersection of Westernized body norms and traditional values as a key rationale for selecting this setting.

Furthermore, the research gap has been more explicitly articulated toward the end of the Introduction, highlighting (a) the lack of qualitative, psychologically grounded studies on PED use among Turkish adolescents and emerging adults, and (b) how our thematic approach offers new insight into the emotional, identity-based, and sociocultural meanings of PED use beyond prevalence or risk frameworks. These revisions strengthen the clarity, originality, and focus of the study’s rationale.

Reviewer-2

Author Response:

We appreciate this thoughtful and constructive comment. In response, we have streamlined the literature review to create a more focused conceptual progression toward the research questions. Specifically, overlapping material across the “Body Ideals,” “Hidden Onset,” and “Emotional Drivers” sections has been condensed and integrated to eliminate repetition while maintaining thematic coherence (pages 2–9).

Reviewer-2

Author Response:

We thank the reviewer for these constructive recommendations. The Methods section has been carefully streamlined to eliminate redundancy across recruitment, ethics, and procedure. These details are now consolidated for clarity and flow. The explanation of sample size and thematic saturation has been expanded to briefly justify why 26 participants were sufficient, referencing information power and saturation principles [Malterud et al., 2016; Guest et al., 2020]. In addition, the section describing the interview guide has been condensed and reformatted, presenting the nine thematic domains in a concise list format rather than extended prose. These revisions improve readability and methodological transparency while maintaining the section’s depth and rigor.

Reviewer-2

Author Response:

We thank the reviewer for these helpful observations. In response, we have condensed the Results section by shortening descriptive passages within each theme and removing repetitive examples, ensuring that the thematic narrative remains clear and focused. Interpretive statements concerning protest, autonomy, and gender have been relocated to the Discussion section, where they are now framed within a broader theoretical context.

To enhance readability and transparency, Table 2 has been revised to include brief theme definitions alongside representative sample quotes from participants, offering readers a concise overview of how each theme was derived from the data. These revisions lighten the narrative, strengthen the distinction between Results and Discussion, and make the thematic findings more accessible to readers.

Reviewer-2

Author Response:

We appreciate this valuable feedback and have revised the Discussion accordingly. Descriptive repetition of the six themes has been reduced, and the section now places greater emphasis on psychological interpretation—specifically the developmental and emotional mechanisms underlying body-based control, identity construction, and dependency.

To highlight the study’s theoretical contribution, we expanded the analysis linking PED use to core concepts in psychology and adolescent health, such as emotion regulation, identity formation, and autonomy development. Cultural interpretation has also been strengthened throughout the discussion, emphasizing how Westernized body ideals interact with collectivist and traditional values within Türkiye to shape young people’s self-concept and coping strategies.

Finally, the Practical and Policy Implications subsection has been condensed to maintain balance, ensuring that the discussion foregrounds the study’s psychological and cultural insights rather than applied recommendations. These revisions enhance depth, coherence, and focus while retaining the section’s integrative nature.

Reviewer-2

Author Response:

We thank the reviewer for this helpful suggestion. In the revised manuscript, the Limitations section has been condensed by removing redundant phrasing regarding self-report bias and the cross-sectional design. The Future Research Directions subsection has been restructured into a concise, itemized format, highlighting the most critical priorities—quantitative validation, longitudinal tracking, inclusion of underrepresented groups, cross-cultural comparison, and intervention development. These adjustments improve clarity and readability while maintaining conceptual depth.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors need to add statements of positionality and reflexivity. Specifically, what social categories do the authors occupy and might these categories be associated with the research topic, choice of theoretical frameworks? In terms of reflexivity, the authors should particularize their expectations prior to collecting any data and how the findings obtained challenged/affirmed those expectations.
Did the authors provide a definition of performance enhancing drugs when conducting the personal interviews? If not, are there any concerns that some interviewees may have perceived PEDs as supplements, protein powders, etc. whereas other interviewees may have perceived PEDs as anabolic-androgenic steroid use?
The authors note that the small sample size constitutes a limitation of the current study. However, small samples are routine with IPA. The authors also contend that limited generalizability is another concern. However, generalizability is irrelevant to qualitative research (i.e., the goal is better understanding of an individual’s lived experience and not to extrapolate from that lived experience to the broader community).
The titles of the six themes appearing in the text and in Table 1 should be the same.
Line 35: please use “empathic”

Comments on the Quality of English Language

Points 1-4 are critical. Specifically, the authors need to add statements of positionality and reflexivity. The authors also need to ensure that the limitations they describe are applicable to qualitative inquiry.

Author Response

Reviewer-3

The authors need to add statements of positionality and reflexivity. Specifically, what social categories do the authors occupy and might these categories be associated with the research topic, choice of theoretical frameworks? In terms of reflexivity, the authors should particularize their expectations prior to collecting any data and how the findings obtained challenged/affirmed those expectations.

Author Response

We thank the reviewer for this valuable suggestion. We have now added a Positionality and Reflexivity Statement in the Method section following the “Data Analysis” subsection. This paragraph clarifies the authors’ social and professional backgrounds, their relation to the research topic, and the reflexive stance maintained throughout the analytic process. The statement details our expectations prior to data collection and how the emergent findings reshaped these assumptions.

Did the authors provide a definition of performance enhancing drugs when conducting the personal interviews? If not, are there any concerns that some interviewees may have perceived PEDs as supplements, protein powders, etc. whereas other interviewees may have perceived PEDs as anabolic-androgenic steroid use?

Author Response

We thank the reviewer for this thoughtful observation. Yes, prior to each interview the research team provided a clear, standardized explanation of what the study meant by performance-enhancing drugs (PEDs). The interviewer explicitly distinguished PEDs—such as anabolic-androgenic steroids, selective androgen receptor modulators (SARMs), growth hormone, insulin, and related substances—from common nutritional supplements like protein powders or creatine.

Participants were asked screening questions to confirm non-medical use of any such pharmacological substances. Only individuals who demonstrated awareness of and engagement with these specific drugs were included. Those who referred solely to nutritional supplementation were excluded during screening. This clarification ensured conceptual consistency across interviews and minimized misclassification.

We have now clarified this procedure in the Interview Protocol subsection of the revised manuscript.

The authors note that the small sample size constitutes a limitation of the current study. However, small samples are routine with IPA. The authors also contend that limited generalizability is another concern. However, generalizability is irrelevant to qualitative research (i.e., the goal is better understanding of an individual’s lived experience and not to extrapolate from that lived experience to the broader community).

Author Response

We appreciate the reviewer’s clarification. We agree that small sample sizes are intrinsic to qualitative methodologies such as interpretative phenomenological analysis (IPA) and reflexive thematic analysis, which prioritize depth and richness of meaning over numerical representation. Our reference to sample size and generalizability has therefore been reframed to emphasize transferability and contextual understanding rather than statistical inference. The revised paragraph in the Limitations section (p. XX) clarifies that the goal of this study was to capture the subjective and developmental meanings of PED use rather than to generalize findings to a population.

The titles of the six themes appearing in the text and in Table 1 should be the same.

Author Response

We thank the reviewer for highlighting this important consistency issue. In the revised manuscript, we have standardized the six thematic titles so that they appear identically in both the Results narrative and Table 2. Following other reviewers’ stylistic feedback, we also streamlined the theme headings by removing quotation-style phrases and retaining analytic, concept-driven titles. This approach enhances clarity while maintaining fidelity to participants’ voices through the illustrative quotes presented in the table and text.

Line 35: please use “empathic”

Author Response

We thank the reviewer for this observation. The term referenced has been removed during earlier revisions for clarity and conciseness. Therefore, neither empathetic nor empathic now appears in the final version of the manuscript.

Reviewer 4 Report

Comments and Suggestions for Authors

I read your paper with great interest and would like to share some suggestions for revision:

- In the abstract, indicate the nationality of the study and the main demographic characteristics of the sample.

- Why are adolescents and young adults so similar in terms of body image? What are the gender differences?

- Since PED is aimed at increasing muscle mass, suggest better defining the prototypical characteristics of the male body image and what muscularity means culturally (https://doi.org/10.1007/s12144-020-00857-3).

- Remember the limitations of research in dealing with issues such as PED (https://doi.org/10.1016/j.psychres.2017.12.049).

- Lines 171-174: insert citation.

- Lines 174-175: elaborate on this passage, which I find interesting.

- Lines 196-198: insert citation.

- MD is present in both males (higher risk) and female adolescents, as demonstrated by recent Italian research. Indicate this with appropriate citations (e.g., https://doi.org/10.1080/02673843.2021.2011333). Furthermore, how has the concept of muscularity changed in the female body image?

- Which sports are most at risk for MD?

Author Response

Reviewer-4

I read your paper with great interest and would like to share some suggestions for revision:

- In the abstract, indicate the nationality of the study and the main demographic characteristics of the sample.

Author Response

We thank the reviewer for this suggestion. The Abstract has been revised to explicitly indicate the national context (Türkiye) and to summarize the key demographic characteristics of the participants, including age range and gender composition.

- Why are adolescents and young adults so similar in terms of body image? What are the gender differences?

Author Response

We appreciate this important point. We have clarified in the Introduction that adolescence and emerging adulthood represent contiguous developmental stages characterized by heightened self-evaluation, social comparison, and identity exploration—processes that make body image a central component of self-concept in both groups. We also expanded the section to highlight gender-based distinctions, noting that males typically internalize muscularity ideals whereas females emphasize leanness and balance between fitness and femininity. Corresponding sentences have been added in the Introduction and reinforced in the Discussion.

Author Response

We thank the reviewer for this insightful comment. In response, we have expanded the Introduction to clarify how muscularity operates as a cultural and psychological ideal within male body image. We now define the prototypical features of the male body ideal—emphasizing strength, size, leanness, and symmetry—and discuss its sociocultural meaning as a symbol of masculinity, control, and status. This paragraph has been added to the end of the subsection Changing Body Ideals and Pressures Among Adolescents and Emerging Adults, with reference to Fabris et al. (2022)

- Remember the limitations of research in dealing with issues such as PED (https://doi.org/10.1016/j.psychres.2017.12.049).

Author Response: We thank the reviewer for this important reminder. We have now expanded the Limitations section to explicitly acknowledge the inherent methodological challenges in researching sensitive behaviors such as performance-enhancing drug (PED) use. In line with Settanni et al. (2018) , we note that social desirability and perceived risks of disclosure may reduce honesty in self-reports, particularly when participants discuss illicit or stigmatized practices. The revised paragraph emphasizes that even with anonymity assurances, participants may underreport PED use or emotional distress, potentially leading to conservative estimates of prevalence and psychological correlates.

- Lines 171-174: insert citation.

Author Response

We appreciate the reviewer’s attention to proper source attribution. A supporting reference has been added to this section. Specifically, we have now cited Ravn and Coffey (2016) in the corresponding sentence (Line 195, revised manuscript) to substantiate the conceptual argument presented.

- Lines 174-175: elaborate on this passage, which I find interesting.

Author response

We thank the reviewer for highlighting this passage. We have expanded the paragraph to clarify the psychological mechanisms through which the body becomes a medium of emotional regulation and symbolic communication. The revision elaborates on how performance-enhancing drug (PED) use transforms the body into both an expressive and regulatory tool—linking embodiment theory with emotion-regulation frameworks and identity construction.

- Lines 196-198: insert citation.

Author Response

We thank the reviewer for this suggestion. A supporting reference has been added to substantiate the statement in Lines 196–198 (revised line: 229). The revised manuscript now cites Türksoy (2025) in this section.

Author Response

We thank the reviewer for this thoughtful suggestion. The revised manuscript now acknowledges that muscle dysmorphia (MD) and drive for muscularity occur in both males and females, with males generally at higher risk. To reflect this, we have expanded the discussion of gender differences and included a supporting citation to Badenes-Ribera et al. (2021), which examined gender-specific manifestations of muscularity concerns among Italian adolescents. We also elaborated on how the concept of muscularity has evolved in the female body image—from traditional thinness ideals toward the “fit-but-feminine” aesthetic emphasizing controlled muscularity and tone. This clarification appears in the Introduction.

- Which sports are most at risk for MD?

We appreciate this insightful question. We have added a short paragraph in the Introduction to specify which sports show the highest vulnerability to muscle dysmorphia. Consistent with prior literature, MD risk is particularly elevated in aesthetic and strength-oriented disciplines that emphasize muscular development, leanness, or weight control (e.g., bodybuilding, powerlifting, weight training, wrestling, CrossFit, gymnastics, and combat sports). This clarification has been added in the Changing Body Ideals and Pressures subsection with supporting citations.

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

Very well! Thank you!