#13: Build Me Up, Buttercup? (The Steroids Episode)
COMMUNITY VOICE: Fiore Barbini | HEALTHCARE EXPERTS: Jason Nagata, MD, MSc; Kevin Kapila, MD | COMMUNITY REVIEWER: Eric Kutscher, MD
SHOW NOTES
Anabolic, androgenic steroids (say it five times fast)
Defining terms
Androgen
Something that is “masculinizing” (binary, we know)
Promote the development of secondary sex characteristics like hair growth, voice deepening, skeletal growth, and – drum roll – muscle mass growth
AnabolicL means it makes parts of the body grow (like muscles!)
Where does testosterone play into this?
It’s one kind of androgenic, anabolic steroid!
When folks say supplemental testosterone they often mean a medication or supplement (whether it’s actually testosterone or not) whose intended or primary effect is to grow muscle mass
Testosterone for the sake of muscle growth is used in cycles. Cycles are usually 1-2 weeks, and then folks “cycle off”, meaning have a period without outside-of-the-body (exogenous) testosterone
The legality of it all
Where this all started:
With the International Olympics Committee, which banned the use of testosterone among its athletes.
As a result (with some steps in between, including the emergence of a black market), testosterone became a Schedule Three narcotic (read: more paperwork and monitoring to get the med prescribed)
Bottom line:
Yes, testosterone is banned in certain contexts (performance enhancement), but is not illegal.
In fact, clinicians can prescribe it in certain medical situations such as:
Gender affirmation
Low testosterone (medically known as hypogonadism) to help maintain bone health (among other things)
Disclosure: a fantastic documentary, and also, what we recommend if you’re using steroids
Why should I talk about my steroid use with my primary care provider?
An informed and affirming provider will want to talk to you about steroids - to understand why you’re using and to help keep you safe
What you can expect:
Run through general risks, benefits, side effects and any recommended lab monitoring
Ideally, the conversation will be customized to help you understand how your steroid use may intersect with your other medical conditions (if any) or medications (if any) to ensure you stay as healthy as possible
So why doesn’t everyone discuss steroid use with their PCP?
Stigma! (see above, "The legality of it all,” for more)
Testosterone use for muscle building is not part of many health care providers’ training, and folks might be understandably concerned that their clinicians won’t have answers (spoiler alert: some won’t, but all will have access to resources to help them get the right info!)
Steroid use harm-reduction strategies
Rule 1: if using, inject
Why not oral testosterone?
The oral form won’t reach your muscles - it’ll go straight to your liver (which cleans out the steroids) through a process called “first-pass metabolism” that happens when we swallow things
End effect: less muscle-building, more liver damage (not cute!)
Why is injecting better?
It bypasses, or skips, the breakdown in the liver.
So the hormone gets to the muscle (and everywhere else in your blood) and, after doing its work, is later broken down in the liver
Rule 2: if injecting, inject safely!
The big takeaway: sterile, single use needles will prevent the spread of blood-borne disease
This guide from Fenway Health reviews safe injection techniques (though the audience here is folks using T for gender affirmation, the principles are the same)
Here’s a video tutorial if you’re more of a “moving picture” kind of gal
Rule 3: optimize steroid quality
The problem
Supplemental steroids can be variable in quality/content because of the whole “not regulated by the FDA” thing
When supplemental steroids have been studied, there have been big mismatches in what’s on the product label and what’s actually in the pill
To help ensure what you’re getting is…well…what you want, experts recommended:
Buying in person if possible (more of a vested interest in repeat customers)
If buying online, buy from a part of the world where steroids are regulated
Rule 4: know the side effects
Steroids have a multitude of impacts on the body - from liver to cholesterol
Knowing which side effects you’re more at risk for - and trying to mitigate them - is our harm reduction dream (FYI, primary care providers can be helpful with this!)
Side effects (besides big pecs)
Wait, but what about my pecs?
Different bodies react differently to testosterone. Using steroids, even with a weight lifting routine and bulking diet, doesn’t guarantee the bodies we see in deodorant commercials. (remember commercials?)
Even without exercise you will likely gain some muscle mass, but are more likely to get more muscle if you do muscle-targeted exercises, like weight lifting
Liver
What steroids do here: general toxicity (if you’re feeling fancy, the scientific terms for what happens to the liver include steatosis and fibrosis)
How to harm reduce:
Be mindful of alcohol intake while cycling steroids (your liver also does the work of breaking down alcohol)
Get regular testing of liver function with your doctor (particularly if you are at risk for/already have a liver-related medical condition)
Red blood cell levels
What steroids do here:
Stimulates red blood cell growth
If your red blood cells are too high, you can get “thick” blood. The concern with this is a higher stroke risk.
How to harm reduce:
Get your red blood cell levels checked before/during/after a cycle
If needed, you can have your blood drawn (known as phlebotomy) to lower the red blood cell levels. You can donate too, but we know better than most how fraught that can be
Prostate health
What steroids do here:
If you have one, may get bigger (testosterone fuels prostate growth)
A bigger prostate can sometimes cause complications with peeing, like starting and stopping a lot or having to push
This may theoretically place folks at higher risk for prostate cancer, but this is theoretical and there is no firm evidence to support this
How to harm reduce:
Consider early prostate cancer screening (can be done via blood test or via rectal examination - depends on your provider)
Keep an eye on any changes to your ability to urinate and consider talking to your primary care doctor if you’re feeling any symptoms (there are medications that can help!)
Heart health
What steroids do:
Lower your “good” cholesterol
The risk to your heart muscle is…complicated.
There isn’t enough data (surprise, surprise)
There is some concern that more muscle also means more heart muscle. When the heart gets thick there can be complications with the electricity and pumping. But, again, this hasn’t been clearly studied.
How to harm reduce:
Let your primary care provider know you’re using steroids
We know, broken record - but the truth is, they can screen your cholesterol more frequently and counsel you on nutritional changes to help keep the numbers where we want them!
Fertility
What steroids do here: testosterone may permanently decrease sperm production for those who have testicles
How to harm reduce: consider banking
Dependence
Some folks who use testosterone for long enough (years) may turn off their own testosterone production.
So there is a risk with repeated use (again – probably years) that when you want to stop testosterone your body will not start to make its own again.
Sports injuries
What testosterone does here: they’re common while weight-lifting in general, but risk increases with larger volume of exercise and higher weights
How to harm reduce:
If you’re feeling pain while working out, listen to your body and take a break from that exercise/workout
Get things checked out if the usual combo of “rest, ice, compress and elevate” doesn’t give you relief
Bodies, bodies, bodies
The mental health tie-in
Body dysmorphia is common in cisgender men considering or using steroids. (When we say “body dysmorphia” we mean: stress, anxiety and a preoccupation/obsession with “not enough muscles”)
We don’t talk about this enough, since most of our “body dysmorphia” content focuses on restrictive behaviors (read: anorexia, bulimia), which are far more common in cis women
Not all steroid use equates to psychiatric diagnosis! But, the line between cosmetic use and physical/mental harm in pursuit of a goal is important to reflect on.
The “why” behind it all
Muscularity can be a form of power - in a world where queer bodies have often felt threatened, brawn can feel protective
As Fiore, our community voice, points out, steroid use is one of many forms of cosmesis that exist (read: Botox, buccal fat removal)
But…yeah, it’s complicated
Many medicines deemed “cosmetic” can carry stigma
Steroids - and the muscles they bring - have helped to set challenging and often unrealistic body ideals within the queer men’s community, ideals that aren’t always inclusive of folks who are genderqueer, whose bodies have aged, or who live with disabilities
TRANSCRIPT
Barbini: I, as a gay man, loved big pecs. Always have. Ever since I was a child. I could name the first sets of pecs that I saw on TV. Will I ever look like those people? I know I won't, because I don't follow all of the regimen that goes around with it. But: I can always get closer. And like I said, I think as humans, we're always a work in progress from the beginning to the end.
[QHP THEME MUSIC BEGINS]
Gaby: Welcome to Queer Health Podcast. We are a podcast about queer health topics for sexual and gender minorities.
Sam: My name is Sam. I use he/him pronouns and I'm a physician in training to be a primary care doctor.
Gaby: My name is Gaby. My pronouns are she/her. And yeah, same job title as Sam.
Richard: And I'm Richard. I use he and him pronouns and I'm the director of LGBTQ clinical services at Bellevue Hospital in New York City.
Gaby: You are listening to QHP, season 2, episode 3:, Steroids for Queer Men.
[QHP THEME MUSIC ENDS]
Gaby: At the very beginning of this episode, you heard our community voice, Fiore Barbini, discussing, well…pecs, mirrors and body image ideals.
Sam: Three things that all make my heart rate go up for different reasons.
Richard: Fortunately, today's episode is not about what makes Sam's heart rate go up. Today's episode is about anabolic androgenic steroids.
Sam: Sorry. Did you say anabolic bibababadababa steroids?
Richard: …exactly.
Gaby: Anabolic androgenic steroids, which means supplemental steroids that work to grow muscle mass. You can also sometimes hear that called supplemental testosterone.
Sam: Before we get you a more detailed definitions of bibababadababa anabolic steroids, we wanted to, as always, narrow in on today's topics focus.
Gaby: So, here are the things that we will be talking about.
Number one, why we are centering this episode on steroid use among cis gay, bisexual, and queer men.
Two, how steroids work and the effects both, you know, desired and undesired, that people taking them might expect to see.
Three, how to keep you safe if you are using steroids. And so that's gonna be some harm reduction.
And then four, which is where this episode is really going to head towards the back half, a lot of dialogue about how steroids - the big pecs that they bring -are wrapped up in conversations about body ideals and body image within the queer community.
[TRANSITION MUSIC]
Richard: Our discussion today won't be about testosterone as a gender affirming hormone in trans, non-binary folks. Today we're gonna be focusing on cisgender, gay, bisexual, and queer men who are taking testosterone to get well, big pecs.
Gaby: Right. And that's because there are a few big differences here. So trans folks who are taking T for gender affirmation don't make the hormone in their bodies and they're receiving the hormone from a prescription, which means that they're getting a regulated pharmaceutical grade version of the drug. And also that means that they're following with a primary care provider or some other healthcare expert to get lab work and other symptoms monitored.
Richard: It's important to note here that testosterone became "illicit," if you will, in part because the International Olympics Committee banned it as a performance enhancer and then an underground market was born and Congress started trying to control its distribution and use, even though there were significant questions about whether or not its use actually led people to dependence on it. And that's how it became a schedule three narcotic, which made testosterone a lot harder to get, but also really hard for scientists to study how it impacted people's bodies.
Gaby: As a result, the steroids that folks are using for muscle building aren't regulated, so that means the FDA hasn't tested and confirmed that what's on the label is what's in the bottle, and even that what's in the bottle is safe or recommended for human consumption. . And that does create a divide between folks who get T -and I'm saying T because it's pretty much one of the only steroids like this that we use regularly in the medical world -prescribed to them and those who don't get T prescribed to them. And it's an important distinction because one of these groups of people is more firmly under the auspices of the medical community and the other isn't.
Richard: And often does not talk to their healthcare provider about the testosterone that they're using, because it's seen as being something illicit.
Gaby: And look: of course, I hope that anyone using T or other steroids is gonna feel comfortable disclosing to a primary care provider. And also, I get that it's complicated to bring up using a substance that is outside of a prescription. That being said, some people do talk about this with their primary care doctors, and that's with doctors like our first guest, Dr. Kapila.
Kapila: I'm a primary care physician and a psychiatrist at Fenway Health, which is an LGBTQI health center in Boston. I'm grateful that like most of my patients are pretty open about what they're using. And that there's that kind of environment, because I think the worst thing is if someone doesn't talk about it.
Richard: It is the worst, but also we understand why a lot of people don't want to.
Kapila: Scare tactics suck. They don't really work with people, so I think among providers, we need to- I don't think it's done out of malice. It's just to take a breath and, and be like, if someone's doing this, there's a reason why they're doing it. And let's just be more curious. So I just go through it with them just so we can have the open conversation. But I will always be honest and say, I'd rather you not do it.
Richard: Healthcare providers are often not trained about the impact of testosterone for muscle building. So there's not, like, a guidebook about how we should be screening people. And so: if you bring it up to your healthcare provider, we hope they will be affirming and have that conversation with you. Some people won't know that much about it.
Gaby: And even if they don't know that much about steroid use, they can help troubleshoot if things start to feel off.
Barbini: I've always been very upfront with my doctor of what I'm taking. Not being honest with him would it be a detriment to me because he can't then accurately ascribe what the problem may be if I'm starting to experience something.
Richard: And for Fiore, his doctor has been more than just someone to troubleshoot side effects with. He's been someone fewer can be vulnerable with, and yes, even disagree with.
Barbini: And there have been times where he just will be full stop. That's too much for you. And I've told him, "I don't care. You know, is there a problem right now?" You know what I mean? We don't always agree on the decision. But we have the conversation.
[TRANSITION MUSIC]
Gaby: Trigger warning! Actually, this is mostly a trigger warning for me: things are about to get a little bit scientific thanks to our next guest, Dr. Jason Nagata.
Nagata: I am an Assistant Professor of Pediatrics specializing in adolescent and young adult medicine and eating disorders particularly in boys, men and sexual and gender minorities.
Richard: Dr. Nagata runs us through a description of how steroids work.
Nagata: At a basic level and androgen is a sex hormone that promotes the development and maintenance of male sex characteristics. Testosterone is the principle secreted, androgen and men and androgens have both androgenic or masculinizing effects. And then also lead to the development of male, secondary sex characteristics,
Richard: And these masculinizing effects include changes in hair growth patterns, so some increased body hair, and often decreased head hair due to male pattern baldness. So, I must have a lot of testosterone if you've ever Googled a picture of me. And then changes in voice depth and body fat distribution.
Nagata: So that's androgenic effects, but then also anabolic effects, which refer us to increases in skeletal, mass, and strength.
Sam: Mirror, mirror on the wall - where the fuck are my pecs?
Richard: I think that's the Disney queen I was referring to…
Gaby: Don't Sue us Disney, Sue them! I don't want any pecs!
Sam: What I was, uh, trying to ask was how long before steroids make a difference in visual muscle mass?
Richard: The short answer is a few months, but it really depends because thanks to the lack of regulation, there are so many different forms with many different side effects.
Nagata: Talking about like appearance and performance enhancing drugs and supplements is a very complicated topic because there are so many different types. Many of them are illegal or not approved by the FDA. So it's a little bit hard to even know what people are using.
Gaby: And as people start to pack on the muscle, there's a delicate dance happening between the timing of that desired muscle and the timing of undesired effects, which we sometimes hear called side effects.
Nagata: Steroids can cause, you know, serious , liver, kidney and, and also neuropsychiatric effects.
Richard: People feel sluggish or depressed when they've gone off cycle. Some people feel agro and irritable when they're on cycle. Different things can feel different for different people. Another known health risk associated with testosterone use is elevated levels of red blood cells or "hematocrit" in the blood.
Sam: More red blood cells can thicken blood and that's associated with blockages in vessels, which translates clinically to a theoretical risk of heart attacks and strokes- bad news.
Gaby: Now this is something that we can't quantify because say it with me
Sam/Gaby [caucophonious]: lack of data!
Gaby: I thought I would be the soprano here…and I was the baritone.
Richard: Anyway, regardless of the data gap, we do know from other conditions that also raise red blood cell levels, that when the hematocrit is high enough, folks will be advised to donate blood if they're eligible- hot topic, see previous episode on this- or have blood drawn out from their body.
Barbini: I have sat in the doctor's office with the blood being drained from one arm and an IV with fluids and the other arm. You know, just to make sure that my body was in check while I was making decisions that might have adverse effects on my body, I was at the same time doing things to try and keep it as healthy as possible moving forward while I was, you know, doing those things.
Gaby: Steroids won't just impact the blood itself. They'll also impact things that are carried around in the blood. And so here we're talking about things like circulating cholesterol levels.
Richard: Specifically, it can make your good cholesterol go down, or decrease, which is another reason to let your healthcare provider know about your anabolic steroid use. So everyone can make sure the necessary lab work gets done.
Gaby: Now let's move on from the cardiovascular system to talk about how steroids also impact the prostate, which is a gland that helps with both ejaculation and urination.
Richard: And can feel really good during receptive anal sex.
Gaby: That is the word on the street. …can you – can you tell I don't have a prostate?
Richard: [laughter]
Sam: Yes.
Gaby: Prostate growth is driven by testosterone analogues or basically molecules that look like testosterone. So in theory, more testosterone- like molecules drives more prostate growth, which increases cancer risk. In theory.
Richard: And it's worth noting that steroids can also enlarge the prostate and make it difficult urinating. So you might have symptoms of feeling like you need to pee frequently or not being able to start or maintain a stream. It's a pretty common medical condition called benign prostatic hypertrophy that can happen to many people who have prostates over their lifetime, but could be aggravated or happen earlier in the setting of testosterone use.
Sam: Another big consideration with testosterone use is dependence. Many folks who start taking steroids may be unable to regain their own body's testosterone production. Therefore they become dependent on using testosterone for the rest of their life.
Kapila: The endocrine system, our hormone system is very smart and you can't screw with it cause it will bite back in some way. So what it's going to do is when you're done with this, your testosterone levels are going to drop. They probably will come back, but there's always the risk they may not come back. And some of the older guys that do it, I just sort of say that risk goes up a little bit.
Richard: Lastly, Dr. Kapila also noted that if you're planning on using sperm to conceive a child, make sure to sperm bank before your first round of testosterone, because it can decrease sperm production and motility.
Gaby: Okay, so to summarize, anabolic androgenic steroids do increase muscle mass and masculinizing characteristics, but they come with risks to many organ systems: the heart, the liver, blood levels, and also a risk of infertility. It's also worth noting that dependence is common and is to be expected if the steroids are used for prolonged periods of time and may require somebody to stay on steroids indefinitely. Lastly, jury is still out on the degree of impact on the risk of prostate cancer, but it is something that's talked about in Dr. Kapila's view. This list of side effects that we've just named is a great segue to talk about harm reduction, which is another way of saying: strategies to minimize the risk of adverse effects from steroids.
Kapila: If they're heavy drinkers, I'll just say, if you're going to cycle, you gotta lay off the booze during that time. Cause we don't want to stress your liver out. Talk about topical acne washes, cause they're going to get bacne and acne. I do do prostate exams at a younger age. I'll start checking people. And, you know, luckily, you know, most of my patients don't mind getting a prostate exam. They're not, you know, freaking out about it. And I'll just say, just we're going to do it and be safe. If they have a strong family history, I'll say again, this is a, this is an area I can't guarantee, but theoretically, this will increase your risk.
Richard: These side effects are potentially really serious, but for some people, the benefit of steroids will still outweigh the risks.
Barbini: Even more so than the strength increase and the energy increase, seeing the physical difference in a mirror. Made me say, "oh, I can do this. This is something that I can do even as I'm, you know, crossing into my forties, you know, it's not too late there. You know, this is attainable at some degree." It's a little game of chess with yourself you're moving the pieces, but you're playing against yourself because you know this will , make you bigger, which is what you're trying to do. But at the same time, I need to watch what's going on with my liver, what's going out with my kidney, what's going on with my blood pressure, what's going on with my blood? Just to make sure that I'm not putting myself in, you know, risk for a heart attack or a stroke, because I really don't want that either in my forties.
Sam: This just in – breaking news. Being gay your forties is, in, fact a minefield.
Richard: Sam. Your late twenties are showing again. Please cover them up.
[TRANSITION MUSIC]
Richard: So we've talked about how steroids work and their effects and both desired and undesired on the body. And as Dr. Kapila highlighted, there are numerous ways to monitor and screen folks to minimize these as much as possible. But as it turns out, side effects aren't the only thing to worry about. There's also the lack of regulation around steroids, which makes it really challenging to use them safely.
Gaby: Rule number one: if you're gonna use, inject.
Kapila: There is some folklore in the community that you build differently. You build better if you do some oral steroids as well. That's not true, but I think there's a belief there. Where I will draw the line is that when people say they do oral, like tremble or something like that, or some other name for an oral steroid, just because that's so toxic to the liver and it's, it's a waste of money.
Richard: In short: testosterone taken an oral or pill form is likely to be toxic to your liver and somewhat less effective because it's also getting broken down by the liver. So it's avoided by a lot of people in the know.
Sam: If you have no idea where to start with intramuscular injections, check out some of the resources we link to in our show notes. But also, please be sure to talk to your healthcare provider if you feel comfortable doing so. The basic takeaway from injections though, is as always use unused needles.
Gaby: Alright, that seems straightforward enough. Safe injecting practices and avoid oral meds. But this gets a little more complex because, well, it's actually not that easy to be sure of exactly what you're injecting once you buy steroids.
Nagata: Even if somebody thinks that they're using a certain type of drug or supplement, they may not actually be getting what they think they're getting. You know, a lot of stuff you can purchase over the internet or over the counter. And there have been some studies that have, examined the chemical structure of things that are sold over the counter. And they often do not match up with what is listed in the ingredients, on the packaging.
Richard: Is there any way to ensure quality?
Barbini: I don't just purchase without knowing who the manufacturer is. I want you to know where they're physically coming from. Because some pharmaceutical companies are definitely more reputable in the arena of anabolic steroid production than others. While I may be purchasing things that aren't legal to be purchased in the United States for my usage here, they are legal and other places that they're being purchased from. So I'm not putting anything in my body that if used correctly should truly be dangerous.
Gaby: Dr. Kapila also cautioned against buying online.
Kapila: When someone's buying something online, it's sort of - one it's not regulated, so who the hell knows what's in it. Whereas at the gym, people want repeat customers. So if someone's buying what they think is dec –
Gaby: – one of the more commonly used steroids –
Kapila: – and they're not building up or getting the other signs of like acne, hair growth, other things like that, their testicles aren't shrinking. Then they start to know they're probably not getting something good.
Richard: Okay, so know the manufacturer, preferably someone in person or someone online, and try to find something that has an official quote, unquote stamp of approval, even if that stamp of approval is from outside the US.
[TRANSITION MUSIC]
Barbini: I'd be hard pressed to believe that there's an actual gay man who doesn't like looking at somebody with muscles. They may say they're not in some muscles. I think you still like lifting now. It might not be your thing. Maybe you think it's not attainable for you, it doesn't mean you don't like looking at somebody with a nice bod. I physically don't believe it. We're men. We're a visual species. It's just that simple.
Sam: Which brings us to a phrase we've sort of been dancing around this entire episode: body dysmorphia.
Gaby: And that's where the second half of this episode is gonna go – to how steroid use is just so intimately related to body image, as well as cultural expectations about what makes a body attractive in the gay, bi, and queer men's community. And FYI, that's actually where Dr. Kapila starts with his patients by unpacking the why behind their steroid use.
Kapila: That's the first thing I want to bring up with people. Like, why are you using it? and to me, that's like the beginning start of the conversation because it can be many different things. Like when I see someone who's really ripped in huge without doing it and they want to do more of it. I want to be curious as like, how big do you want to get, what does it mean for you to get that big?
Sam: Fiore was very clear that his use of steroids is cosmetic.
Barbini: Gays are not using these, compete or do shows. They're not certainly not trying to get in the Olympics unless they're trying to get in the shower room of the Olympics of the swim team. It is to compete with other gays in the gay bars and on Grindr and Scruff or at Steamworks. That's, what their competition is, is to compete with the other gays in those arenas, not for, you know, a bodybuilding competition or something like that.
Gaby: And listen to what Fiore says next:
Barbini: I don't look at it as there being a difference between steroids or any of that cosmetic thing. If it makes you happy and it makes you feel better about yourself, do it. If you're not hurting anyone else and it's just, you get the filler, get the Botox, get all the plastic surgery you can afford. You know, do, do what makes you feel good about you? I'm not saying that your identity should be in your physical looks, but let's be honest, feeling good about the way you look physically makes you feel better internally and therefore can make you a happier person.
Gaby: For him, steroids exist in this grouping of modern medical things that can change appearance. Things like Botox or things like every TikTok, girl's favorite, buccal fat removal. It's - not a trend, but it's not not a trend. Do you know what I mean?
Richard: So Fiore is not wrong here. I think it's really important to think about making decisions that are right for you. And as we said earlier, I think in the context of testosterone, being now illicit because of performance enhancing things, if people are using it to feel good about themselves, I don't really have a problem with that. That being said, I think that there's some harm. If you're using it at really high doses. And also thinking about what's the impact on the rest of the community. If when you sign on to like a social media app like Grindr or Scruff looking to connect with someone either sexually or romantically, and everybody has set an unrealistic body standard, that can be really challenging. How do you feel about that, Sam? Bring on the pecs.
Sam: [semi-agonized chuckle]
Gaby: Sam's eyes are both twitching in different ways.
Sam: UGH. Like, there's the politics of like body autonomy and then there's living it. And I think for, like, for me, using steroids to get a body that quote you want, there's like a political slippage in not investigating why you want that body. And it may still be very genuine, but like I've gone in and out of being like what's defining masculinity and is that internalized homophobia? And like what I find attractive, like a lot of that gets drawn in, so it's very complicated.
Richard: Yeah. Because the question of like, do I risk harming myself to conform to a body standard is a really hard question for every individual who is participating in this community to answer for themselves. What does it mean for body acceptance in the LGBTQ community overall, right? If cis gay men or cis gay bi, and queer men, are not uniformly, but are majority striving for a particular hyper-masculine body ideal. What does that mean for people who have a different body type? For people who are breaking down the gender binary? For people who are trans and nonbinary? For people who identify as women, right? All of these things maintain some kind of power structure around masculinity. And so individual decisions aside, on a community level, there is potential harm in people investing in this in the way that they do. Everyone is allowed to make their individual decisions; people should be informed about the individual decisions that they make. And also, we should consider the impact on the people that we care about! I think it's Gaby's turn now.
Gaby: Yeah. And now – for a lesbian voice no one asked for!
Richard: [laughter] Give us more Gaby!
Gaby: [laughter] Okay. Here's what I wanna focus on. So we've talked about the relationship between body ideals and the larger queer community, but what about when cosmetic desires can impact like an individual's health and wellbeing negatively? I wanna talk about that a little bit.
Nagata: So muscle dysmorphia was colloquially known as bigorexia or reverse anorexia. Technically it is a subtype of body dysmorphic disorder. And muscle dysmorphia is characterized by a preoccupation or obsession with insufficient muscularity even though in most cases in individual's billed as normal or muscular. It's more common in men and is associated with engagement in muscle-enhancing behaviors like steroids.
Sam: Pulling out some keywords here, preoccupation or obsession.
Nagata: There are certain formal criteria to have a diagnosis of muscle dysmorphia. I do think that in general, there is a spectrum of like body dissatisfaction that can be pretty common leading to something that really impairs one's mental health and leads to like really significant preoccupation or concerns about their appearance in a way that really worsens their quality of life. And when you start getting to these really significant distressing and obsessive thoughts and behaviors about one's appearance, that's sort of when it evolves into a full fledged psychiatric diagnosis.
Gaby: Our cultural bias, and even as medical providers our training in discussing disordered eating, tends towards restrictive behaviors like anorexia or bulimia. But these are much more common amongst cis women and everything that we learned doesn't attune us to talk about or bring up or screen for the desire to look more muscular.
Nagata: I think one thing to know about muscle dysmorphia is that it's really underrecognized and underdiagnosed. In the US among teenagers, a third of teenage boys report that they're actually trying to gain weight and muscle. Which is a big contrast to over two-thirds of girls who say they're trying to lose weight. There's really limited research particularly in the LGBT community on the exact prevalence rates. But not everybody who uses steroids necessarily has muscle dysmorphia
Gaby: Oop – let's take that back.
[REWIND NOISE]
Nagata: Not everybody who uses steroids necessarily has muscle dysmorphia. I think it's important that you know, healthcare providers and, or people are just aware that there are these links and so, and really to look out for these warning signs when. Goes from being just like a hobby or something that is a healthful goal towards something that's really worsening your quality of life and taking over your thoughts and and behaviors in a way that's not helpful.
Gaby: And that's the big takeaway for me. That even when steroid use doesn't seem to overlap with dysmorphia, it's really important to stay on the lookout for red flags. Like for example, people who just don't look like they're eating enough calories.
Nagata: Even if somebody is eating like a quote unquote normal amount of food intake, if they are exercising 10 hours a day, which some of our patients do, they can still get into those huge energy deficits that will lead to that same malnourished state just because of those energy imbalances.
Gaby: So in short, just because you quote look healthy doesn't mean you're getting enough calories and just having muscle mass doesn't mean the rest of your body is healthy.
Kapila: It's similar to what I tell people in recovery, like the minute you're keeping secrets or keeping things that you don't want to tell people, that's a problem. So are you hiding the amount you use from people? Like the amount you're using steroids? You've now torn your rotator cuff four times, you just got it repaired, you just got done with PT and you're, you're going and doing crazy weights at the gym again. And you're pushing through that. You're in excruciating pain. That's a red flag.
Richard: All these red flags point to the reality that having ripped muscles does not equate to good health. It can impact nutrition. It can cause exercise injuries, which I see super commonly in the clinic.
Gaby: But people get positive reinforcement when they have big muscles. And so there is this tension between looking good and maybe not feeling good.
Kapila: It's really hard because they go to the gym and everyone's like, "Wow, man, you're looking great." And then they go out clubbing and you know, everyone wants to hook up with them. So it's a very mixed message people are getting. I mean, there's maybe a little more positivity in the gay community around you know, diversity and body sizes, but the ideal is still a ripped white gay man.
[REWIND NOISE]
Kapila: The ideal is still a ripped white gay man.
Gaby: There's probably a thousand ways to psychologically unpack that statement.
Sam: We could start doing that, but (nervously) too anxious, staring at myself in the mirror, having now to put on my third t-shirt before deciding what is my best look for Saturday.
Gaby: Sam – it's Tuesday, and this is an audio-only podcast...
Sam: But, like, you get my point though. It's really hard for gay men to get dressed because of their bodies.
Kapila: I think among some people, this is a reaction to being called a feminine or a sissy or wimpy or scrawny. There's some reactive reaction there.
Richard: As someone who came out as a queer kid at a time when that wasn't acceptable, and I was made fun of in a lot of different ways, I feel like for a lot of people putting on these bodies gives them safety in a way that they might not otherwise have it in our culture.
Sam: It's one less way to be deviant, to have big muscles and look like the masculine athletic build that Us culture's paying online for. Wink, wink.
Gaby: I think that concept of being deviant is probably something that unites us within the queer community, but has different manifestations. So whether you're talking about who is meeting with the ideal of what a queer man should look like, or you're meeting the ideal of like what a palatable queer woman should look like, There's versions of this that exist across the different parts of the queer community, and it's a really deep pressure that both unites us and also silos us.
Sam: So it's all very complicated. And it's one of those conversations where everyone feels both right and wrong at the same time.
Gaby: It's talmudic.
Sam: And the rabbi's a really, really hot guy with a gorgeous masculine beard.
Gaby: Or it's Rachel Weisz in Disobedience.
Richard: Okay. We're missing the point again, y'all.
Kapila: So I think there's so there's internal stigma and external stigma and the internal stigmais: to get steroids, you've got to do it illegally. You're buying something illegal, technically illegal. And some people that's not an issue. And for other people that's aligned, they've crossed. We all have our lines in our life that we make. And like, doing things illegal is a line for some people. So they may feel guilty about that. They maybe feel guilty that they're spending too much money on that. They may want people to think they're naturally that way that they don't need, you know, so there's, you know, from the community or the people they work out with that they're sort of cheating in a way to get the body they want.
Gaby: Which is exactly where Fiore went with this.
Barbini: There is a contingence of the gay community that thinks that when you put this magic shot in your butt, magically, you become muscular. Like the steroids do all the work, and it's just easy. It's not easy. You don't just put a shot in you and magically you look like people on the cover of a Falcon video or the cover of a, you know, men's fitness magazine. And I think that that's a misnomer in our community. There is a segment that thinks that, "Oh, they do steroids. So it's not them." It is us. We're - I still put in six days, an hour and a half a day at the gym.
Kapila: I think I see a lot in guys, like 40 and up when you can't quite get the body you had before. They're frustrated by their workouts and, they get more attention when they're more ripped. I think as providers, if we don't deny that there's real things that happen and there's real problems in our community, there's significant, age-ism racism in our community. to say like, "Oh no, people are going to treat you just the same." No people are gonna, you know, you hit a certain age and people stop looking at you.
Sam: Richard – it's right, correct me if I'm wrong, but there's data say that when you hit 50 as a gay man, you just actually turn into a beam of light, right?
Richard: Sorry. I'm converting right now.
Sam: Sorry. I could only see you. I couldn't hear you, cuz it's hard to hear when you're photons..
Richard: …turning into a beam of light. Exactly.
Gaby: Oh, my gosh.
[TRANSITION MUSIC]
Richard: So some of the things I think are important to remember from this episode. One, there are many different reasons that people use testosterone and its derivatives, and some are linked to body dysmorphia, some are not, but all play a role in a larger conversation about body ideals within the gay, bi, and queer men's community. And two, any form of testosterone if used at very high doses can be harmful to your body. From your cholesterol levels to impact on the prostate or the liver or your blood cells. Now let's pause for a bit of harm reduction.
Sam: Know that if you're getting non-prescribed testosterone, it's not a regulated substance. So if you're injecting that there's a risk of impurity, but like Fiore said, other countries do regulate and many people buy products from those countries. Although that is not a guarantee.
Richard: Like any drug, know where you're getting it from, talk to who have used it, talk to folks at the gym.
Gaby: And one last plug for primary care providers who can play a role in your steroid journey, even if you're getting those steroids outside of a healthcare context. Primary care providers can help you think about how to lower your risk of adverse effects and can help monitor these effects for you with labs and physical exams. And look, these conversations do run the risk of stigma, but many people, our healthcare experts, our community voice, did recommend having them. If you feel comfortable.
Barbini: I feel that if you have the right doctor who is a part of your community, you can actually have these conversations with them being able to disclose that with them has been really, really helpful. I think people would be so much healthier in their choices and would be able to mitigate risk better by just having someone they could be open with. You know, any drug that you put in your body, there's a side effect for. If you're educated, you know what the side effect is then, you know, oh, this comes with that. This is normal. You also know when something not normal is happening. And so you're able to say this shouldn't be happening now. It's time to call the doctor and say, "Hey, there might be something going on."
[QHP THEME MUSIC]
Richard: QHP is a power sharing project that puts community stories in conversation with healthcare expertise to expand autonomy for sexual and gender minority folks.
Sam: Thank you to our community, voice, Fiore Barbini and our healthcare experts. Dr. Kapila and Dr. Nagata. We would also like to extend a huge thank you to our community reviewer, who helps with interviews and editing Dr. Eric Kutscher..
Gaby: Check out our website, www.queerhealthpod.com, where you can find transcripts of what we spoke about as well as show notes that summarize the takeaways of our episodes.
Richard: Help others find this information by leaving a review and subscribing on Spotify or Apple.
Gaby: We are on Twitter and Instagram. Our handle there is @QueerHealthPod, reach out to us.
Sam: And you would not be Lonnie Ginsburg if you were not being thanked at the end of every podcast for having composed our theme music.
Gaby: Iconic!
[QHP THEME MUSIC ENDS]
Sam: Opinions on this podcast are our own. They do not represent opinions of any of our affiliated institutions. Even though we are healthcare providers do not use this podcast alone as medical advice. Instead, consult with your own healthcare provider.
[PERCUSSION MUSIC]
Sam: Don't pigeonhole me as like the hot gay guy. Like, I don't wanna be pigeonholed as that guy.
Richard: Sorry. You're the hot gay guy in the podcast, Sam.
Sam: Don't pigeonhole me.
Gaby: …I thought that was me.
Sam: Don't put a pigeon in my hole.
Richard/Gaby: (raucous laughter)
Richard: And that's why that line is yours. It's the New York equivalent of gerbiling.
Sam: Ew. Although we watched that entire South Park episode in my English queer literature class, it was very bizarre. That's a story for another time.