The Science Behind Performance and Image-Enhancing Drugs
Imagine a 23-year-old bodybuilder pushing through an intense workout, his muscles burning with fatigue. In his gym bag sit vials of synthetic testosterone and oral steroids—substances he believes are essential to achieving his ideal physique. Meanwhile, in another part of the city, a young professional prepares for a weekend social scene that intertwines sexual activity with specific psychoactive substances to enhance experience and reduce inhibitions.
Though these scenarios appear disconnected, they represent facets of the same growing public health phenomenon: the rising use of chemical substances to modify body, performance, and intimate experiences.
The world of performance and image-enhancing drugs (PIEDs) has expanded dramatically beyond competitive athletes to include recreational gym users, biohackers, and participants in specific sexual subcultures. From anabolic steroids to chemsex drugs, these substances represent a complex intersection of societal pressure, psychological vulnerability, and neurochemistry.
PIED use has moved from competitive sports to mainstream fitness and lifestyle enhancement, creating new public health challenges.
The use of substances to enhance physical appearance and performance has moved solidly into the mainstream. While traditional anabolic steroids remain prevalent, Selective Androgen Receptor Modulators (SARMs) have emerged as increasingly popular alternatives, particularly among younger demographics.
The global SARM market was valued at an estimated $476 million in 2025, reflecting a 400% increase in online vendors since 2020 4 . These substances are predominantly sourced from the gray market (70%), with private messaging groups and international clinics supplying the remainder.
| Population | SSU Prevalence | Chemsex Prevalence |
|---|---|---|
| General Population | 29.40% | 12.66% |
| Women | 25.78% | 3.50% |
| Sexual Minority Men (Spain) | - | 21.10% |
Source: 2025 systematic review and meta-analysis 1
Parallel to the world of physical enhancement, sexualized substance use (SSU) and the more specific practice of chemsex have gained increasing attention in public health research.
A 2025 systematic review and meta-analysis revealed that SSU affects nearly one-third of the general population, while more specific chemsex practices show a prevalence of 12.66% 1 . Among women specifically, SSU prevalence is notably high at 25.78%, though chemsex participation is significantly lower at 3.5% 1 .
This data challenges the common perception that these practices are confined to specific demographics, highlighting their relevance across population groups.
The motivations behind anabolic steroid and SARM use are complex and multifaceted. For many, these substances represent a solution to deep-seated body image concerns.
The National Institute on Drug Abuse notes that steroid use is often associated with muscle dysmorphia, a form of body dysmorphic disorder characterized by a preoccupation with perceived inadequate muscularity 6 .
The market infrastructure supporting this demand has become increasingly sophisticated. Online pharmacies account for approximately 40% of distribution, leveraging social media and digital platforms to reach consumers 9 .
Chemsex, defined as the intentional use of psychoactive substances to enhance sexual experiences, typically involves specific drugs like mephedrone, GHB/GBL, and methamphetamine 1 .
Participants often seek to prolong sexual encounters, intensify sensations, and reduce inhibitions 1 . The practice has developed its own cultural footprint, with specific vocabulary, scenes, and codes 2 .
Research identifies several factors associated with chemsex participation, including being a migrant, financial stress, openly living one's sexuality, older age, steroid use, and living with HIV 2 .
The health impacts of non-medical anabolic steroid use can be severe and sometimes irreversible. The National Institute on Drug Abuse catalogues potential damage including:
Perhaps equally concerning is the black market nature of these substances. A 2025 Swiss pilot study implementing drug checking services for anabolic steroids found that over half (52%) of user-provided samples were fake 3 .
Sexualized substance use carries its own distinct risks. The altered decision-making processes under the influence often lead to unsafe sexual behaviors, including condomless sex and sharing drug paraphernalia 1 .
Consequently, participants face increased susceptibility to sexually transmitted infections including HIV, abuse, and non-consensual sexual activity 1 .
The 2024 Spanish study of sexual minority men engaging in chemsex identified three distinct typologies of sessions with varying risk levels 2 . Approximately 23.2% of participants engaged in higher-risk sessions, which was associated with younger age, steroid use, living in bigger municipalities, openly living their sexuality, and living with HIV 2 .
As traditional enforcement approaches have struggled to curb the growth of this market, public health researchers have explored innovative harm reduction strategies. A compelling 2025 Australian study published in the Harm Reduction Journal implemented and evaluated a specialized drug checking service for anabolic steroids to determine whether providing consumers with detailed information about product composition would influence their usage decisions 8 .
The sequential explanatory mixed-methods study involved chemical analysis of 58 community-submitted AAS samples followed by interviews with 25 consumers 8 . Participants submitted samples of their substances to dedicated checking services between April and August 2024.
Researchers analyzed them using:
After analysis, participants received detailed reports about their samples' actual composition versus what was advertised. Researchers then conducted semi-structured interviews to explore how this information influenced perceptions and behaviors.
Source: 2025 Australian drug checking study 8
The chemical analysis revealed significant product quality issues. The qualitative findings proved particularly revealing. Follow-up interviews indicated that receiving concrete evidence about product inconsistencies led consumers to:
Re-evaluate their trust in specific sources and suppliers
Adopt more cautious approaches to usage initiation and dosing
Reconsider long-term usage practices based on accurate information 8
The Australian drug checking study utilized several sophisticated analytical techniques that provide insights into how scientists verify substance composition and purity.
This technique enables rapid screening of samples without extensive preparation. It works by ionizing sample molecules directly from their solid or liquid state, providing quick identification of active compounds through mass analysis 8 .
A more precise method that separates complex mixtures (liquid chromatography) before analyzing component masses with high accuracy. The Orbitrap mass analyzer provides exceptional mass accuracy and resolution 8 .
Particularly useful for analyzing tablets, capsules, and powders, this technique measures how samples absorb infrared light at different wavelengths, creating a molecular "fingerprint" that can identify specific compounds 8 .
Used in the Swiss drug checking study, this method vaporizes samples to separate components (gas chromatography) before identifying them through mass analysis. It's particularly effective for quantifying steroid concentrations 3 .
These analytical techniques form the foundation of modern drug checking services, transforming subjective consumer experiences into evidence-based chemical analysis.
The rising abuse of anabolic steroids and chemsex drugs represents a multifaceted public health challenge situated at the intersection of neuroscience, psychology, and sociology. These substances tap into fundamental human desires for acceptance, performance, and connection, while posing significant risks that users often underestimate or misunderstand.
The tension between consumer demand and regulatory control continues to create dangerous black markets where product quality is unpredictable and harmful substances proliferate. However, emerging evidence about drug checking services offers promising direction.
Moving forward, effective responses will need to balance realism and compassion, acknowledging the complex motivations behind use while providing evidence-based interventions.
Integrating steroid checking into existing harm reduction services
Developing honest educational campaigns based on actual user experiences
Training healthcare providers to recognize and address these issues without stigma