When The Adonis Complex was published in 2000, it drew awareness to muscle dysmorphia, defined as “a sort of anorexia nervosa in reverse” driving men to disordered eating, obsessive training, and steroid use.

But another increasingly relevant part of the book got far less attention.

Medicine’s original sin, the authors wrote, was claiming that testosterone and other anabolic steroids “have no proven ability to help people gain muscle mass.” Imagine a late 20th-century doctor trying to convince a testosterone-curious patient that the drugs used by countless athletes and bodybuilders didn’t do what they obviously did.

Doctors today are still struggling to catch up.

More men are using testosterone than ever before. Prescriptions for testosterone replacement therapy (TRT) increased by 27% from 2018 to 2024, including a 58% increase among men aged between 35 and 44 years, a demographic in which a physician wouldn’t expect to see symptoms associated with low testosterone. The American Urological Association estimates that perhaps a third of TRT recipients don’t meet diagnostic criteria, and as many as 1 in 4 receive prescriptions without any measurement of their testosterone levels.

Experts point to the influence of social media and the proliferation of online clinics marketing testosterone as a lifestyle product. “Social media gets people to look at things and want them,” said Thomas O’Connor, MD, an internist and clinical instructor at the UConn School of Medicine in Farmington, who specializes in treating patients taking steroids or recovering from them. What men saw and wanted was muscles, and what they learned from social media is that testosterone is the way to build them.

Alongside this trend is a growing public health concern around the use of illicit steroids and other image- and performance-enhancing drugs (IPEDs). A frequently cited estimate suggests that 3-4 million Americans use them, although that’s almost certainly a significant undercount.

Research suggests that many are reluctant to disclose their steroid use to clinicians, often because they anticipate judgment or lack confidence in the doctor’s ability to provide meaningful information or advice. A 2020 survey of more than 2000 steroid users found that doctors ranked the lowest among sources of knowledge and expertise on IPEDs — behind coaches and gurus, bodybuilding media, and other steroid users. Most participants hadn’t revealed their steroid use to their healthcare provider, and among those who had, 55% “reported feeling discriminated against” by the physician. No wonder just 37% of steroid users have sought support from physicians, according to a large 2022 meta-analysis.

TRT vs IPEDs

Most clinicians are familiar with TRT, which aims to restore a patient’s natural testosterone levels. But the broader category of IPEDs is incredibly complex, and getting more so all the time, thanks to the rise of online vendors prescribing everything from TRT to exotic combinations of peptides. It includes anabolic steroids, which are testosterone derivatives created primarily to increase muscle mass.

The difference between TRT and anabolic steroids is simple, said O’Connor: “dose.” If it involves taking more testosterone than your body would produce naturally, it’s not TRT.

In the survey of steroid users, which O’Connor co-authored, 82% said they were motivated to improve their physical appearance by adding muscle. Half of them said they wanted more strength, while just 9% listed performance in organized sports as an objective (the participants could check as many boxes as they wanted).

O’Connor has first-hand experience. He started taking steroids when he was 22 and has used them almost continually for the past 40 years. Physicians, he said, are at a huge disadvantage for understanding these drugs, their effects on users, and how difficult it is to stop using them.

“The training of doctors has not included steroids,” he said. “In medical school and residency, you can’t learn everything. I did steroids. That’s how I learned.”

But some doctors are trying to change that.

How to Begin the Conversation Without Also Ending It

Andrew J. Mock, MD, is an obesity researcher and assistant professor of preventive medicine at Loma Linda University School of Medicine in Loma Linda, California, as well as a family practice physician in Southern California. He and his colleagues developed what they describe as a case-based educational session on performance-enhancing substances for their medical students, which they detailed in a 2025 article. A large focus was on improving communication with patients.

Mock, who’s also a drug-free strongman competitor, believes a doctor shouldn’t have to take steroids to speak about them intelligently and empathetically. When a patient tells you they’re taking supraphysiologic doses of testosterone or other IPEDs, there are several good ways to move the conversation forward and one surefire way to cut it short.

“The objective here is not to win the steroid argument,” Mock said. “The second we put someone on the defensive about it, that’s when they stop talking to us.”

Mock recommends first seeking to understand why they take the drugs. Are they trying to get bigger? Stronger? More confident?

Understanding is not endorsing, he emphasized. Instead, it gives you an opening to ask a logical follow-up question: Are you getting the results you want?

Frequently, they aren’t.

A lot of them, Mock explained, are “leaning on the drug to get them there, but the other pieces are not in place.”

Asking patients about their training and nutrition is especially important because many turn to online clinics or illicit sources without first optimizing lifestyle. Strength coach Ali Gilbert, CSCS, sees men combining incompatible trends, such as high-intensity training with restrictive diet, for example, and expecting hormones to make up the difference. 

“A lot of guys associate going on testosterone with ‘I’m gonna be jacked,’” said Gilbert, founder of Silverback Coaching, an online health and performance service for men. “But there’s plenty of guys who are on TRT” and don’t have that look. “You’d never guess they were on it.”

TRT can help people train a little harder and recover a little faster, which can improve motivation. But results are still a product of effort and consistency. Gilbert finds that clients who begin TRT following the appropriate blood tests and with measured expectations tend to be happy with the choice. “They usually say, ‘I wish I’d started earlier,’” Gilbert said. But those who expect miracles end up disappointed.

The T’s and C’s for TRT

One aspect of TRT that few anticipate is that once you’re on it, you’re on it. For life or until you have a medical reason to quit. If a patient starts and then stops, the body’s endogenous testosterone production takes time to ramp up and return to its previous levels. At best, the patient ends up back where they were when they began TRT.

For steroid users, withdrawal is a serious barrier. Complications include depression, erectile dysfunction, joint pain, insomnia, and the potentially ego-crushing loss of muscle mass and strength. That’s why O’Connor and other specialists use testosterone to wean IPED users off the more powerful testosterone derivatives.

The bigger challenge, O’Connor said, is that if you start using steroids, “you’re going to enjoy it. You’re never going to do [just] one cycle.” He cautions anyone who hasn’t started to first consider the health risks, which include hypertension, high red blood cell production, cardiac hypertrophy, dyslipidemia (increased low-density lipoprotein and lower high-density lipoprotein levels), mood swings, sleep problems, upper-torso acne, and gynecomastia (enlarged breasts in men). Those things can also happen with TRT but to a lesser extent.

When beginning a conversation with a patient using steroids who presents with one or more of those side effects, O’Connor recommends focusing on health risks rather than lecturing. His opening line: “I want to be honest with you. I’m concerned.”

From there, start learning. “Seek to understand not just their current use but also their understanding of the benefits and risks,” Mock said. Show curiosity, collect more data, and tailor the patient’s workup accordingly. “It’s almost like getting permission to continue the conversation.”

Just keep in mind that a patient who’s using IPEDs, or considering them, is probably skeptical of your neutrality. They’ll come into your office with their BS detectors turned up to 11. Anything you say that sounds scolding or judgmental will confirm the worst.

Sometimes your best tactic is to admit how much you still have to learn.

“‘I don’t know’ is a great place to start,” Mock said. “I actually think that’s one of the most important things doctors say. It’s going to make them much more willing to have an open conversation with you.”

O’Connor is the owner of Testosteronology, a membership platform focused on education for men who use TRT and IPEDs. He also owns a concierge medical practice. Mock reported no relevant disclosures. Gilbert is the founder and owner of Silverback Coaching.