Among the bodybuilders Gavin Francis discusses in his essay from the October 22 issue of the Review, the most surprising is surely Leopold Bloom, the hero of Ulysses, who keeps in a drawer (along with his stash of pornographic postcards) a chart measuring his progress with “Sandow-Whiteley’s pulley exerciser,” a real device invented by the man who organized the first strongman competitions in Great Britain. (Bloom’s “biceps 9 in and 10 in” probably did not qualify.) The dream of getting shredded is not new, but the idea of breaking the body to build it back stronger has perhaps never been taken so literally as it is by today’s bodybuilders. From unregulated steroids that reduce lifespan to “looksmaxxing” exercises that require smashing one’s own bones, bodybuilding is suffering from “an epidemic of abuse,” Francis writes, “evolving into a public health emergency, quickened by digital culture.”
Francis is a physician in Scotland who has seen the fallout from this abuse firsthand. Since 2014 he has written for the Review on public health subjects ranging from vaccine skepticism to mental health diagnoses and prostate cancer. His writing about medicine, Oliver Sacks, the NHS, and much else has also appeared in The Guardian, Lancet, and the London Review of Books, among other publications, and he is the author of eleven books, including, most recently, The Unfragile Mind: A Physician’s Call for Restoring Hope and Humanity to Mental Health Care, which published earlier this year. The first episode of Gigantic Fantastic, his radio series about the bodybuilding world, will be broadcast on BBC Radio 4 on November 16.
I wrote to Francis this week to discuss steroid abuse, shrinking testes, and the public health crisis fueled by gray-market drugs.
Chandler Fritz: In your work as a physician you’ve seen many young men who are using unregulated steroids. When did the uptick in these patients begin?
Gavin Francis: The increase among young men who are not athletes or serious bodybuilders began to accelerate with the rise of social media over the last ten years—before that the men who used anabolic steroids were more likely to be competing at sports or involved in bodybuilding itself. Staff who work at harm reduction clinics set up specifically to help men who use steroids tell me that twenty years ago there were fewer users, and those users took longer breaks between cycles at lower doses. There’s a culture now of not only increasing doses but maintaining high doses for longer periods of time in the background, so that some men never take a break from added steroids. We’re also seeing perfectly fit young men wanting extra testosterone, styled as “testosterone replacement therapy,” even though their testosterone levels are physiologically normal.
Young men have always been vulnerable to content that suggests that they could get better results in the gym if only they would try some commercial product or other, and today those products include testosterone, synthetic steroids, substances that mimic testosterone, human growth hormone, or experimental peptides. The market for profiting off male body anxiety is nothing new. But the amazing reach of the Internet, which offers near-limitless sources of often conflicting information, combined with the speed of biotechnology developments, has created a world in which it’s harder to convince people of an evidence-based position. Instead, people tend to trust the influencers (or, as I heard them called recently, “illfluencers”) who don’t challenge but reinforce a particular view. And so in this field, as in so many other fields of cultural life now, we are seeing greater polarization and entrenched positions. Someone can always point to a fringe view that’s backed up by a different source somewhere on the Internet.
Part of what I find fascinating about steroid use is that it is a kind of paradoxical habit: to become a “manlier man,” a guy takes drugs that, at least in reproductive terms, shrink his manhood. What does the willingness to take on the risk of infertility tell you about the desire to use steroids?
Our bodies are amazing, and the balance of different forces of growth and repair is held in part by our hormones. When your body senses that you have too much circulating steroid, it gives up on the production of your natural testosterone in an attempt to bring the levels back to a normal physiological state, and that’s why taking external, “exogenous” steroids causes a man’s testicles to shrink.
Often the men don’t care initially about their fertility because paternity and fatherhood and family life are not something that male gym culture takes much notice of—it’s largely focused on muscle appearances and work with weights—and it seems a very distant concern for young people. Men see other men online who they admire, and their priority is how quickly they can achieve a particular look, and their substance abuse is exacerbated as they come to rely on more drugs to recover from muscle injury after strenuous workouts. It’s only later, if and when they want to start a family, that the issue arises, and often the medical services they come into contact with—endocrinologists and fertility doctors—hear these men express regret for their past usage pattern. That regret is less visible online because men don’t tend to shout about failing fertility. It’s considered unmanly to mention it, but when you work in the medical profession you know how common it is.
Many people are familiar with the performance-enhancing drugs used by athletes like Ben Johnson, Barry Bonds, and Lance Armstrong on their way to breaking records. What’s the difference between those steroids and these new gray-market drugs you write about, like CJC-1295, GHK-Cu, and Ipamorelin?
The new substances you mention are not steroids at all, but peptides, which are short biological molecules, strings of amino acids like little proteins, that are intended to mimic natural signaling molecules in the human body. The intention of peptide users is to have the muscle-building effects of anabolic steroids without the side effects of infertility, oily skin, acne, liver inflammation, and so on. Insulin is a peptide, so are endorphins, so are the “skinny jabs” such as Mounjaro and Ozempic. The ones used in bodybuilding are not licensed as medications because almost all are experimental—some even have a warning label reading “for experimental use only.” And we don’t have nearly enough data yet to know which ones are going to be safe in the long run, and at which doses.
I’m interested in the mutual influence between medicine and culture—the way we understand our lives through stories—and using experimental peptides before they are understood seems like a classic case of what so many myths warn about: the risks of overreaching. Peptides tinker with the body’s fundamental mechanisms for growth, healing, and inflammation, which can lead to a cancerous overgrowth of tissue and trigger immune problems in some people. Like Icarus flying too close to the sun, or the sorcerer’s apprentice setting into motion a process that then he can no longer control, using these drugs reflects our human urge to push boundaries and try to get something for nothing. But medical history is littered with stories of drugs that were thought to be wonderful when they first appeared and were quickly found to have dark and terrible effects—think thalidomide, Fen-Phen, oxycodone, heroin.
The world of illicit steroid use seems to have some overlap with the world of maximizing longevity, though as you note steroid use substantially decreases life expectancy. Does the market for longevity drugs pose similar risks for public health?
There are so many different approaches promoted to enhance longevity, but aging is such a complex process involving so many different elements of our physiology that it’s difficult to say. For example, online you’ll see some sites promoting immune suppressant medications as longevity drugs; one example would be sirolimus. This group of medications is used to prevent the rejection of transplanted organs or to suppress autoimmune conditions, and so the rationale goes that if aging is in part caused by inflammation in the body, then by suppressing the immune system you can live longer. But in the body nothing is ever that simple—the drug also seems to enhance some aspects of the immune system, and going onto it seems to increase the risk of infections, thrombosis, diabetes, lung problems, and so on, all of which might shorten your life, or certainly make it more miserable. There’s a reason it hasn’t been licensed for use as an anti-aging drug.
Another approach by the anti-aging community has been to use different diabetes drugs. I mentioned the GLP-1 agonist drugs above, the “skinny jabs” such as Ozempic—there’s a suggestion that they too might have an effect on lifespan, but it turns out that it’s very tricky to separate the beneficial effect of the drug from the beneficial effect of simply losing weight. We know that obesity is bad for your body’s longevity, so it stands to reason that if you carry less weight on your body you’ll have a good chance of living longer. Another class of diabetes drugs being explored in this regard are the SGL2 inhibitors such as dapagliflozin and empagliflozin—these help your kidneys to push glucose out of the bloodstream and into the urine. Some of my patients feel dreadful on them, but some have no side effects at all. And as with the GLP-1 agonists it’s difficult to tell whether any possible longevity benefits are direct effects of the drug, or whether they’re a side effect of having less sugar in the blood. Meanwhile, they bring their own suite of risks: back pain is a common side effect, as are urine infections, prostatitis, and skin reactions.
The “ideal” form of the male body has been represented differently across history, from classical sculptures to soldiers to beefcake models in men’s magazines. What ideal do you think young men today have in mind when they do these various looksmaxxing exercises, like “bone-smashing” and “zygo pulling”?
Feeling anxious about how you look is nothing new in human culture! But I think we’re living through an extraordinary time—a biotechnology boom in which it feels to many people, both inside and outside the scientific community, that anything might be possible. And given that culture is now so tied to trends and developments online, fads can take over very quickly and spread around the world in minutes. Modern medicine seems astonishing in its reach and power, and its successes tend to leave the impression that, medically speaking, humanity can do anything and we can reinvent ourselves very easily. From my side of the consultation desk the power of medicine is less impressive. The idea that anything is possible has spilled over into youth culture: if you don’t like your face, change it. There’s a worrying overlap with the impulse to self-harm, which is on the rise among adolescents and taking new forms. We also know that as a behavior it’s contagious: if you know someone who self-harms you are much more likely to do it yourself. The rise of self-harm influencers—people for whom demonstrating their distress online has become a source of income and validation—is a terrifying new development.
You’re going to explore many of these themes in Gigantic Fantastic, a BBC radio show about bodybuilding that comes out next month. What can listeners expect to learn from the show that wasn’t covered in your essay?
It takes a broader look at myths of strength around the world, at how times (like ours) of economic precarity and conflict foster greater admiration for overt expressions of muscled masculinity. It goes deeper into the history of admiration for strongmen, and how commercial medicine and commercial medical practitioners have always tried to profit from men’s anxiety over their physical and sexual prowess. Some men who use steroids know exactly what they’re doing and take a carefully judged risk, while others are pursuing a fantasy and have lost (or never had) a particular goal for their use.
The series digs more deeply into the idea of health meaning “wholeness,” and that it must always represent a balance: “health”means something different at eighteen than it does at eighty. Manliness also has different meanings across time periods: in the 1950s “Mr. Britain” and “Mr. America” were still assessed on elements of character as well as of musculature, and I’m curious about how we moved from that culture of self-improvement tied to overall well-being to the kind of steroid-boosted freaky bodies that win those competitions today. Gigantic Fantastic also explores the development of steroids themselves, their physiological effects, as well as other image and performance-enhancing drugs and their dangers.
As part of my research for the series I attended some of the UK’s harm-reduction clinics to meet and talk with a broad range of men who use steroids. That experience gave me a much deeper understanding of the scene than I’d encountered solely interviewing users in gyms. I also interviewed the clinicians who work in those clinics, to ask their impressions of how the scene has changed over the last twenty years, how they see it evolving into the future, and find out the most effective approaches for addressing the problems of steroid use. The radio series takes in interviews with academic hormone specialists, including the team at Imperial College in London who are conducting some of the most exciting and innovative research in this area. Finally, I speak with natural bodybuilders who are turning away from the synthetic scene: men who insist that you don’t have to be gigantic to look fantastic.