‘Body Image’ Drugs: A Growing Psychosomatic Problem
Authors: Gen Kanayama, Harrison G. Pope Jr., James I. Hudson
Journal: Psychotherapy and Psychosomatics (2001)

Growing numbers of men and women use drugs to gain muscle, lose fat or otherwise improve body appearance or athletic performance [1, 2, 3, 4, 5, 6]. Although these substances are sometimes called 'ergogenic' (performance-enhancing) drugs, they might equally be called 'body image' drugs, because many individuals take them simply to improve personal appearance, rather than to improve performance in a specific sport [1, 2]. We focus here on the appearance aspect of these drugs, while recognizing that some individuals use them exclusively for performance purposes.Anabolic steroids are probably the best-known body image drugs. But there are many others, including hormones (growth hormone, IGF-1, thyroid hormones, androstenedione and other adrenal hormones, insulin, human chorionic gonadotropin), β-agonists (clenbuterol), stimulants (e.g. amphetamines, ephedrine, pseudoephedrine), drugs used to 'purge' fluid or calories (diuretics and laxatives), 'anticatabolics' (aminoglutethimide), drugs believed to stimulate testosterone secretion (clomiphene, cyclofenil), drugs believed to stimulate growth hormone secretion (γ-hydroxybutyrate, clonidine, levodopa) and others not in any of the above categories (such as danazol, tamoxifen, testolactone and yohimbine). Unlike classical drugs of abuse, which are typically illegal or available only by prescription in most countries, many body image drugs are available without prescription. Even anabolic steroids can be purchased without prescription in many parts of the world. And drugs such as androstenedione and ephedrine are widely sold over the counter or by mail order as 'dietary supplements'. Thus, these substances are widely used and often abused. At present, however, surprisingly little is known about the usage patterns or adverse effects of many of these drugs nor about the psychological and sociocultural factors that prompt individuals to use them. In this editorial, we review the limited present state of knowledge in this area.The abuse of body image drugs is widespread and probably increasing. Most of the available data regarding the prevalence of use of these drugs come from studies of anabolic steroid use among male high school and college students in the USA [7, 8, 9, 10]. Two of the largest studies found the lifetime prevalence of anabolic steroid use between 6 and 7% among boys 15–18 years of age [7, 8]. Taken at face value, these figures suggest that more than 1 million men in the USA alone have taken anabolic steroids at some time before reaching the age of 18, and that the total number of males of all ages in the USA who have used anabolic steroids may exceed 2 million [1]. Of course these figures may include some false-positive responses (for example, individuals who responded that they had used anabolic steroids when in fact they had used only corticosteroids) but may also include false-negative data (individuals who had actually used anabolic steroids, but who did not disclose this information). Nevertheless, even allowing for the methodological limitations of the various studies, the estimated prevalence of anabolic steroid use remains impressive.The prevalence of anabolic steroid abuse in women is more difficult to estimate, with studies in the USA producing lifetime prevalence estimates of 0.5–3.2% in girls between the ages of 14 and 18 [2]and another national study producing a more conservative estimate of 0.1% of women of all ages in the USA [9]. Less is known about the prevalence of anabolic steroid use among either men or women in other countries, but accumulating reports from the UK, for example, suggest that use is common and probably increasing there as well [11].Regrettably, little is known about the prevalence of use of other body image drugs. However, several lines of evidence suggest that it may be high. First, in a questionnaire survey of individuals attending gymnasiums in the Boston (USA) area [12], we found a strikingly high lifetime prevalence of use of over-the-counter drugs such as adrenal hormones (for example androstenedione, which is purported to build muscle mass) and ephedrine (a central nervous system stimulant found in many over-the-counter preparations purported to 'burn fat'). On the basis of these figures, we estimated that more than 1 million American men had used each of these substances, and that about 1 million American women had used ephedrine.Another line of evidence arises from a recent study of 75 women recruited from American gymnasiums [2]. Many of these women reported the use of multiple categories of body image drugs, spanning the entire range of substances listed in the first paragraph of this editorial. Presumably, men also use an equal or greater number of these same drugs – but we could find no comparable studies in men.Anecdotal evidence also strongly suggests widespread use of these drugs by both sexes. For example, detailed manuals and books are available in both the USA and Europe, listing the properties of numerous body image drugs, together with information regarding doses, effects and availability [3, 4, 5, 6]. Presumably, these manuals are marketed to large numbers of people worldwide – but the numbers are unknown.It is particularly difficult to study the prevalence of abuse of body image drugs because of the problem of secrecy. Abusers of these drugs are often uniquely secretive. They are naturally reluctant to disclose that their fit and muscular bodies – or their gold medals – are owed to chemicals [1]. Further, such individuals rarely come to mental health professionals seeking treatment for their drug use [1].In short, more definitive epidemiological data are clearly needed. How many men and women are taking anabolic steroids worldwide? What is the worldwide prevalence of use of body image drugs that can be purchased over the counter or via the Internet, such as androstenedione and ephedrine? How frequently are other drugs, such as thyroid hormones, human growth hormone, clenbuterol or amphetamines, taken for body image or performance purposes?Body image drugs cause significant medical and psychiatric pathology, including dependence syndromes. The various body image drugs can produce substantial medical and psychiatric morbidity and even mortality. Anabolic steroids, for example, may cause manic or hypomanic symptoms [1, 2, 13, 14, 15], sometimes leading to criminal behavior, violence or even homicide [1, 15, 16]. Withdrawal from anabolic steroids can induce prominent depression, sometimes associated with suicidal ideation or even completed suicide [15, 17, 18]. A growing literature has also described dependence syndromes with anabolic steroids [15, 19, 20]. Furthermore, preliminary data from both the UK and the USA also suggest that steroid users may go on to abuse opioid agonist-antagonists and may ultimately progress to outright opioid abuse or dependence [21, 22, 23]. Although a causal role for anabolic steroids cannot be proven in these reports, evidence suggests that these individuals were introduced to opioids through the steroid-using culture [22, 23]. Anabolic steroids also pose various medical risks, including especially an adverse effect on lipoprotein ratios – suggesting that use of these drugs for substantial periods may increase the risk for atherosclerotic disease [15, 24, 25, 26].Other body image drugs pose additional risks, especially for dedicated athletes and bodybuilders who may take a variety of these substances simultaneously. Androstenedione and other adrenal hormones may cause priapism, altered lipoprotein ratios and possibly an increased risk for gynecomastia and certain forms of cancer [27, 28, 29]. Ephedrine and other central nervous system stimulants may cause anxiety, insomnia, psychosis, mania and even fatal cardiovascular complications [30, 31, 32, 33, 34, 35]. Diuretic abuse has caused fatalities in athletes [36, 37, 38]. The hazards of laxative abuse are well known from studies of individuals with eating disorders [39]. Some other body image drugs have hardly been investigated. Clenbuterol, for example, is widely abused, but since it is a veterinary drug, its adverse effects in men and women have not been systematically studied [40, 41, 42]. The abuse of human growth hormone for muscle growth, thyroid hormones or insulin for weight loss and erythropoietin for athletic performance all carry serious known adverse effects [43, 44, 45]– but very little is known about the prevalence of these effects in actual athletes, because little is known about the nature or prevalence of illicit use of these drugs. It is common to hear accounts in the media about athletes who died unexpectedly at a young age – often prompting speculation about drugs that they may have used [1]. Unfortunately, in most such cases, little is known beyond the level of rumor.Classical models of drug abuse rarely apply to body image drugs. Unlike classical drugs of abuse, most of the body image drugs do not produce an immediate 'reward' in the limbic system. Laboratory animals, for example, will reliably self-administer opioids or cocaine, but neither rats nor monkeys are inclined to take anabolic steroids in the hopes of developing perfectly sculptured abdominal muscles. Human beings, on the other hand, may go to great lengths to use body image drugs – not to get 'high', but rather to reap benefits in terms of athletic performance, personal appearance and increased self-esteem.Of course, some body image drugs, such as central nervous system stimulants, do produce classical syndromes of dependence [35], and even anabolic steroids share some biological features with classical addictive substances [19, 20]. But biology alone cannot account for the large numbers of men and women who develop long-standing use of multiple body image drugs. We have described this phenomenon elsewhere as an 'ergogenic polysubstance dependence syndrome', in which individuals will abuse a variety of muscle-building and/or fat-burning drugs in large doses over long periods of time [2]. Even though these individuals do not display frank addiction, they display many other features suggestive of a dependence syndrome, such as use of the drugs in larger amounts than originally intended, large commitments of time and money to obtain supplies of the drugs and continued use of various drugs despite adverse physical or psychological effects. But in other respects, these individuals behave very differently from classical substance abusers: they often use body image drugs in a careful and systematic fashion; they typically regard their substance abuse as a positive aspect of a fitness program; and they rarely seek treatment for their substance use [11]. Thus, classical substance abuse models offer little insight into this form of drug dependence.By contrast, recent research on body image offers substantial insight into the abuse of body image drugs. A growing literature suggests that modern society places increasing pressures on both women and men to achieve an ideal body appearance. Several striking studies document this trend. For example, the popular girls' doll, Barbie, has been growing impossibly thin in recent decades [46, 47], whereas boys' plastic action toys, such as GI Joe, have been growing steadily more muscular [48]. The naked centerfold women in the American magazine, Playboy, have grown steadily thinner over the last generation [49, 50], as have the winners of the Miss America pageant over the same period [49, 50]. Meanwhile, the centerfold men in Playgirl magazine had gained an average of 12 kg of muscle mass over the last 25 years, while shedding 5.5 kg of fat [51]. A study in advertisements in two leading women's magazines over the last 40 years found that male models were portrayed partially or completely undressed in only 2–6% of the time in 1958, but in 22–28% of the time in 1998 [52]. Sequential surveys by the American magazine Psychology Today have documented growing levels of body dissatisfaction in both sexes: in 1973, 25% of women and 15% of men reported that they were dissatisfied with their overall appearance [53]; by 1997, these figures had climbed to 56 and 43% [54]. Similarly, recent decades have seen an international explosion in the number of gymnasiums, health clubs and other fitness facilities and an outpouring of magazines devoted to health, physical fitness and personal appearance [1].These trends are not confined to the USA. Male college students in Austria and France, when asked to choose a computer image of the body that they would like to have, chose a body with a mean of 13 kg more muscle than they actually had themselves [55]. Moreover, when asked to estimate the body that they thought women preferred the most, these students again selected a body with about 14 kg of additional muscle. By contrast, actual Austrian women chose a male body the size of an average Austrian man, with no added muscle. A recent comprehensive study of body image among women in 12 nations found widespread body dissatisfaction, with the highest levels in westernized countries, intermediate levels in countries undergoing westernization and the lowest levels in nonwesternized countries [56]. In Japan, 84% of 17-year-old girls categorized themselves as 'fat' or 'too fat' [57]. Many other studies from North America, Europe and Asia have reported that being overweight is associated with negative body image and often with additional psychiatric morbidity [58, 59, 60, 61].These trends appear to have created casualties in the form of growing numbers of individuals with body image disorders, such as eating disorders, body dysmorphic disorder and muscle dysmorphia. For example, the term 'bulimia nervosa' was not even introduced into the scientific literature until about 20 years ago [62], but the disorder is now recognized as a common psychiatric disorder in women [39]. Eating disorders in men, once considered extremely rare, are now frequently described throughout the developed world [1, 63, 64]. Body dysmorphic disorder, though long recognized [65], was only rarely acknowledged in the scientific literature before 1990. But now it has become a topic of widespread research, and it is believed to affect 1–2% of the population in developed countries [66, 67, 68]. Muscle dysmorphia, formerly called 'reverse anorexia nervosa', is a form of body dysmorphic disorder characterized by preoccupations with muscularity [69, 70]. This disorder was virtually unnoticed prior to 1993 [1, 69]but has now been described in several studies from North America, Europe and Asia [71, 72, 73]and has captured the attention of the popular media worldwide [74, 75, 76].Given these striking trends in the apparent prevalence of body image dissatisfaction, and even full-blown body image disorders, the abuse of body image drugs becomes understandable. A limited literature suggests what we would intuitively suspect: dissatisfaction with body image is associated with both lower self-esteem and use of anabolic steroids [77, 78, 79, 80]. However, this issue, like others in the area of body image drugs, remains poorly explored. Given the recent explosion of psychiatric research on disorders of body image, the time is ripe to apply this knowledge to better understand what may be an evolving epidemic of body image drug abuse.In summary, it appears critical to increase research on the problems surrounding body image drugs. In particular, we need to learn more about the prevalence and usage patterns of these substances in various countries, the morbidity (and even mortality) associated with abuse of these substances, risk factors associated with the development of abuse and ultimately the sociocultural factors underlying these problems. With a better understanding of these issues, we may be better able to calculate the public health consequences of body image drug abuse, devise appropriate therapeutic approaches and confront the societal roots of this phenomenon.