A feminist analysis of women’s performance and image-enhancing drug use: epistemic injustice and resources for rethinking enhancement harms

Abstract

This article examines women’s accounts of using performance and image-enhancing drugs in the context of fitness and strength-training. It explicitly engages in a mode of feminist knowledge production to rethink the harms women experience as a feature of epistemic injustice and gendered discrimination rather than personal inability, consumption or drug effects alone. Drawing on theorisations of epistemic agency and injustice (Fricker, 2007; Haraway, 1988) alongside 10 qualitative interviews with women who use substances for strength-training in Melbourne, Australia, we attend to the social and political features of drug consumption, and women’s accounts of bodily transformation and harms. Women overwhelmingly described consumption in relation to enhanced autonomy, with substances functioning as technologies of self-realisation within domestic and work responsibilities and gendered relations of power, as well as a route to enhanced social lives. In contrast to epistemically authoritative discourses in which women have little knowledge of the substances they are consuming and knowingly downplay the potential for side effects, our participants possessed detailed forms of knowledge and skill, and actively sought to monitor and prevent side effects, including virilisation, in the absence of reliable, gender-sensitive health information and healthcare. The most pressing forms of harm women experienced were gender-related stigma and discrimination, and insufficient gender-specific healthcare, related, in part, to epistemic exclusion and injustice in research and healthcare. By prioritising women’s accounts and attending to embodiment and social practices, our analysis complicates normative knowledge claims about women’s risk, coercion and pathologies, and suggests new epistemic resources for understanding women’s consumption as socially and materially meaningful, and enhancement harm reduction more broadly.

Introduction

Women’s ‘performance and image-enhancing drug (PIED) consumption’1 is thought to be increasing among women who participate in competitive bodybuilding and fitness and strength-straining [46], yet detailed knowledge on women’s experiences is scare and remains an under-studied phenomenon. Why has women’s substance consumption for fitness and strength-training been neglected for so long in the research and harm reduction agenda in Australia? And why is the knowledge produced focused on such a limited set of issues? In a previous scoping essay, the first author argued that the narrow focus in the existing literature on a limited set of methods and issues risks obscuring the diverse meanings and practices of women’s substance consumption for fitness and strength-training, and genders agency in ways that further entrench assumptions of women’s vulnerability and passivity [13]. While there has been a burst of welcome research in this area [10, 45, 46], including on the gender-specific health information gap regarding women and anabolic–androgenic steroid use [44], the scope of much of this work remains quite narrowly focused on negative health effects, virilization and fertility, and hormonal side effects. Drawing on feminist work on the politics of knowledge production [22, 23], and more recent theorisations of epistemic agency and injustice [18, 33, 47], we develop feminist knowledge on women’s lived experiences to better attend to neglected social meanings and dynamics of consumption. In doing so, we challenge the knowledge asymmetry in this field and emphasise the epistemic agency of women as subjects and producers of knowledge.

Drawing on 10 qualitative interviews with women who use substances for strength-training in Melbourne, Australia, we attend to their accounts of the social and political features of drug consumption, bodily transformation and harms. Women overwhelmingly described consumption in relation to enhanced autonomy, with substances functioning as technologies of self-realisation within domestic and work responsibilities and gendered relations of power, as well as a route to enhanced social lives. In contrast to epistemically authoritative discourse in which women have little knowledge of the substances they are consuming and knowingly downplay the potential for side effects, our participants possessed detailed forms of knowledge and skill, and actively sought to monitor and prevent side effects, including virilisation, in the absence of reliable, gender-sensitive health information and healthcare. The most pressing forms of harm women experienced were gender-related stigma and discrimination, and insufficient gender-specific healthcare, related, in part, to epistemic exclusion and injustice in research and healthcare. By prioritising women’s accounts and attending to embodiment and social practices, our analysis complicates normative knowledge claims about women’s risk, coercion and pathologies, and suggests new epistemic resources for understanding women’s consumption as socially and materially significant, and enhancement harm reduction more broadly.

Background

While research suggests that men consume PIEDs at much higher rates than women, the overall prevalence of consumption among women is unknown, with limited national or international data sources and few targeted studies (See [46]). PIEDs commonly include anabolic androgenic steroids, anti-oestrogenic agents, beta agonists (e.g. clenbuterol), stimulants, human chorionic gonadotrophin, human growth hormone and other prohormones, various peptides and insulin [35]. The most common anabolic–androgenic steroids used by women are thought to be Stanozolol and Oxandrolone [1, 29]. These may be preferred as they produce fewer effects classified as androgenic, often referred to as ‘virilisation’, and may be considered ‘milder’ or ‘less masculine’ by women consumers [54]. Research also suggests that women tend to consume different substances than men, such as ephedrine, clenbuterol, human growth hormone, human chorionic gonadotropin and peptides [4].

Historically, PIED consumption was thought to be mainly limited to women who participated in competitive bodybuilding and elite sport, although this may be changing [30, 44]. The increasing centrality of health optimisation imperatives in medical paradigms [31], along with the normalisation of gym and fitness cultures [3, 49] and changing norms around feminine physique and body ideals [11, 56] mean that more women are likely consuming PIEDs for general health and fitness purposes [25, 34]. Women use PIEDs for muscle growth, strength development, weight loss, improved healing or recovery from injury, and improvements in overall health function [57]. Some PIEDs, for example, peptides and human growth hormone, have a wider uptake among women for broader health enhancement, wellbeing and wellness, and anti-ageing purposes [43, 57].

Literature review

Knowledge of women’s experiences of substance consumption for fitness and strength-training based on qualitative research is limited, with few studies focused on non-bodybuilders’ experiences. Recent research suggests that women commonly begin using steroids and associated substances through the advice and guidance of male partners, friends and coaches [19, 24]. Concerns have been raised about whether such relationships and advice from third parties constitutes peer pressure or coercion [10, 46]. In contrast, Andreasson and Johansson [3, 5] found that greater involvement in general gym and fitness cultures may lead to a ‘habituation process’ through which consumers’ growing ambitions and heavier training schedules lead to the increasing normalisation and acceptance of PIEDs. Most recently, research from Piatkowski and colleagues has explored the gendered harm reduction practices of women and argued for the development of gender-sensitive health information and harm reduction services given the potential for greater isolation and stigma among women consumers [44, 45].

However, the dominant focus of research on women’s consumption to date is the potential for virilisation or ‘masculinising’ side-effects, which features in almost all research on women’s consumption [24, 27, 10]. Studies suggest that women are concerned about becoming ‘too’ muscular, developing excessive body hair, clitoral enlargement, voice deepening, changes to the menstrual cycle and increased libido [1, 6, 54, 57]. One of only a few qualitative studies conducted with women focuses exclusively on virilisation effects [2]. Another study focuses specifically on the experience of gendered and sexual effects to argue that women ‘are at risk of developing irreversible masculinizing effects’ [24], p. 1). The extent to which masculinising hormonal effects function as a significant concern for women (rather than researchers) who use PIEDs is unclear. Notably, feminist research on women bodybuilders argue there is a ‘widely professed “concern” with women athletes’ use of steroids’ because of claims regarding irreparable hormonal harm [39, 42]. Schippert [51] asks why hormonal changes are formulated as health risks as it is unclear on what grounds ‘lower voices, hairy faces or bodies, and even a greater than average clitoris’ constitute a health risk (2007, p. 162). They argue that the ‘perceived danger’ might be ‘more accurately described as women ‘posing the “health” risk of transgressing gender’ (2007, p. 162).

There is a substantive body of feminist literature on women’s bodybuilding [7, 20, 26, 28], which examines bodybuilding and steroids as ‘gender-threatening’ technologies [7, 38]. Research examines whether women’s extreme muscle-building constitutes feminist resistance or recuperation, subversion or reproduction, of traditionally defined feminine norms [7, 20, 34]. As Schippert [51] writes, feminist work has demonstrated both to be the case and suggests a more contextual reading that takes account of the contingency of bodily meanings in particular contexts, their unwitting implication in normative networks and also, slippages and side effects of disruption, agitation and subversion. Notably, the stigma that women bodybuilders experience, in which ‘gender-transgression’ elicits almost constant social harassment and revulsion [20, 50] is an important theme, and one we return to in this article. While work on women’s consumption experiences is developing, overall, this literature identifies a narrow range of interests and priorities for women who use substances for fitness and strength-training. In the following section we introduce feminist theorizations on epistemic agency and injustice to make sense of the political implications of these research practices and findings in relation to social justice and equity.

Approach

This article draws on concepts of epistemic agency and injustice to challenge common knowledge asymmetries in PIED research that have hindered the development of knowledge rooted in women’s experiences. Feminist, postcolonial and critical race scholars have debated the politics of particular knowledge practices in relation to the privileging of particular epistemic values, norms and knowledge claims [22, 23, 37, 41, 53]. In the development of feminist standpoint epistemology, for example, knowledge is approached as socially situated and contingent, often authorising the perspectives of dominantly situated knowers and de-legitimatising marginalised subjects [21]. A feminist epistemology is a form of knowing grounded in ‘situated knowledges’ that challenge the supposedly objective and universal perspective of science [22]. By generating detailed, necessarily partial and situated research, feminists have been able to produce less ‘partial and distorted results […] than those supposedly guided by the goal of value-neutrality’ ([23], p. 49). Writing specifically about race and postcolonialism, Gayatri Chakravorty Spivak [53] famously argued that subaltern persons are denied opportunities for self-representation and realisation through epistemic violence, which obstructs non-Western subjects and approaches to knowledge. Aileen Moreton-Robinson writes about epistemic violence in an Australian context in relation to how Aboriginality continues to be defined through white patriarchal knowledge activities within anthropology and the law. She argues that patriarchal whiteness operates ‘as a raced and gendered epistemological a priori within knowledge production’ that subsequently erases the different ontological and epistemological commitments of Aboriginal subjects (2011, p. 414).

These examples from earlier feminist, critical race and postcolonial engagements with the ethics and politics of knowledge production have informed the concept of ‘epistemic injustice’, which aims to illuminate the harms and injustice wrought by epistemic exclusion. Coined in the work of political philosopher Miranda Fricker, epistemic injustice refers to ‘a kind of injustice in which someone is wrong specifically in her capacity as a knower’ ([18], p. 20). Pohlhaus argues that epistemic injustices can be understood as epistemic in three ways. First, they wrong particular knowers in their capacities as knowers. Second, they cause epistemic dysfunction by distorting how we understand a particular issue or hindering inquiry into particular knowledge issues. Third, they accomplish these harms within and sometimes through ‘epistemic practices and institutions’ ([47], p. 13). She also suggests that one way to think about the varieties of epistemic injustice is to ‘consider how persons may be systematically subject to injustice generally speaking and to understand epistemic injustices as intertwined with (and reinforcing) relations of dominance and oppression’ (2017, p. 16). In this sense, epistemic injustice is constituted through practices of knowing that modulate and amplify existing differential power relations. The concept of epistemic injustice has been mobilised widely across various disciplines and empirical topics in medicine and healthcare [9] where issues such as authority, credibility, equity and marginalisation are a feature.

Importantly, questions about epistemic agency have been a central feature of critical drug scholarship over the last decade. Critical work on addiction knowledge practices [16], alcohol research and policy [40], injecting [58], hepatitis C [14], drug education [12], healthcare relationships [15], evidence-making practices [48], ontopolitically-oriented research [17] and more have sought to explore how authoritative knowledge practices delimit the kinds of knowledge claims that marginalised subjects can make. In Campbell and Ettore’s [8] work on gender-sensitive drug treatment for women in the UK and the US, they develop the concept of ‘epistemologies of ignorance’ to explain why drug treatment continues to get delivered in ways that are ignorant to women’s needs. They argue that knowledge practices in drug research and treatment have overlooked the ‘gendered, classed, and racialised power differentials that structure the lives of drug-using women’ (2011, p. 1). This dominant epistemological approach defines what women need as divorced from feminist political thought. Building on this scholarship, we use the grammar of epistemic injustice to interrogate why women who use PIEDs have such diminished standing in this field, why they are attributed such limited epistemic agency and how this epistemic injustice affects the development of health information and healthcare practices.

Method

Our analysis draws on data gathered for a qualitative research project investigating gender and digital media in women’s substance consumption for fitness and strength-training (See Toffoletti, Fomiatti & Pienaar, in press, for work on social media), [55] collected as part of the first author’s Alfred Deakin Postdoctoral Fellowship. Designed in conversation and collaboration between the authors, the project explicitly aimed to develop feminist, gender-sensitive knowledge on women’s experiences of consumption. Using a purposive sampling strategy, the first author interviewed 10 women who consumed substances in the context of fitness and strength training. Women were recruited with the assistance of the second author KS, who until recently was the only dedicated, national steroid drug and alcohol outreach worker in Australia. KS has been embedded in Australian strength-training and PIED networks and communities for the last 20 years. She circulated the details of the study throughout her networks and personally invited women who use PIEDs to participate in the study. In addition, a recruitment flyer (‘Tell us about your experiences using substances for fitness and strength-training [e.g. steroids, clenbuterol, SARMs, growth hormones, thyroid medications and peptides]’) was circulated through social media, drug consumer organisations and health organisations. While we had initially aimed to interview 20 women for interviews, recruitment among this group is notoriously challenging due to gender-based stigmatisation and limited gender-sensitive health services. After several months of recruitment which yielded no further participants, we decided to cap recruitment at ten participants.

The 10 participants were aged between 22–58 years and used a wide variety of oral and injectable substances including: boldenone undecenoate, nandrolone, methylpiperidinopyrazole, testosterone, clenbuterol, anavar, stanozole, trenbelone, masteron, as well as human growth hormone, human chorionic gonadotropin, anti-oestrogen and peptides. At the time of the interviews, six women were consuming substances, and four were not. All participants were asked how they identified their gender and sexual orientation. All participants identified as women, seven identified as heterosexual, two as gay and one as bisexual. Ethnicity was self-reported by participants, along with parents’ birthplaces. Seven participants reported they were Australian, two participants reported they were Australian-Western European and one reported Indian-Australian. Participants were also asked why they were or had consumed substances, with eight reporting for general fitness or training and three for competitive bodybuilding (although seven women had historically competed in one or more body-building competitions). As we noted at the outset of this article, one of our central concerns in this project was to explore how gender shaped the concerns of women who use PIEDs and how we could rethink harm reduction through the concept of epistemic injustice. Importantly, our analysis of epistemic injustice would have been strengthened by including women from more diverse racial and ethnic background to foreground intersecting inequalities, exclusions and injustices. However, given recruitment challenges, this paper primarily focuses on epistemic injustice experienced predominantly by white women.

All participants provided informed written consent. The first author conducted in-depth semi-structured interviews exploring experiences of physical training, products and patterns of consumption, experiences of consumption and cessation, social relations and consumption, health advice and monitoring and social media consumption. Interviews ranged from 45 to 90 min in length. Aside from two interviews conducted on zoom, the rest were conducted in-person at public places such as libraries and cafes. All participants were reimbursed with an $100 AUD giftcard for their time and contribution to the research. Interview recordings were transcribed verbatim and the transcriptions were imported into NVivo 11. A coding framework was developed by the first author using a combination of methods: codes were identified in response to the project’s aims and previous research on PIED consumption, and in collaboration with the second author. All data was coded by the first author using an iterative process that reflected the preliminary coding frame but was also sensitive to new and unexpected themes, allowing them to develop and be incorporated into the coding framework. Following the completion of coding, an analytical frame for this article was developed in response to the new themes that emerged through coding: agency and autonomy, accumulating knowledge and skill and gender-based harassment. Concepts of epistemic exclusion and injustice were used to illuminate these novel experiences and dynamics of consumption and to explore their omission in research. The study was approved by Deakin University’s Human Research Ethics Committee (2022–150).

Analysis

In what follows, we draw on in-depth interviews with women to explore the main themes that emerged in this data set. First, we explore a relatively obvious topic, but one which has been entirely neglected to date: how substances are valued and enjoyed by the women we interviewed. Building on findings in a recent article that women engaged in proactive health monitoring practices [44], we then explore the detailed forms of knowledge and skill women accumulate in the absence of reliable, gender-sensitive health information and healthcare. Finally, we challenge the epistemologically authoritative focus on harms as negative health effects to explore harm beyond physiology through detailed accounts of gender-related stigma, harassment and discrimination, and insufficient gender-specific healthcare. Following Campbell and Ettore, we wish to emphasise that the purpose of identifying epistemic harms is not only to make feminist observations and construct feminist theories, but to affect changes that actively address the social, structural, and cultural relations that marginalise women. To this end, we conclude by synthesising some epistemic resources developed through out analysis that may be used for rethinking enhancement harms and developing a more gender sensitive harm reduction, and ways of apprehending and enacting women’s agency and enhancement practices.

Enhanced agency and autonomy

When asking women to describe their consumption, responses were diverse and wide-ranging. Some women described wanting to lose weight and cultivate lean, hard bodies for strength-training and weight-lifting competitions, others wanted to build size, strength and lifting capacity in the gym, others wanted to maximise training and recovery, and some were hoping to ameliorate the undesirable effects of ageing, assist with pain management or enhance other health and wellness-related goals. However, the significance of substances in women’s lives exceeded these stated motivations by scaffolding a greater sense of autonomy and new agentic capacities and enabling new social infrastructures. For example, substances were valued for the routine, organisation and efficiency they afforded in women’s lives, often beyond fitness and recreational settings. Monica (43, personal trainer) who had not used any enhancement substances for the past 10 months, explained that ‘things start to fall into place’ when she’s on a cycle:

The result [of my last cycle] was that I was on top of everything in my life. Like, I slept well. I ate amazing. I was very organised. I had no aches and pains.

Others described a greater sense of optimism and purpose when using substances. Jessica (39, disability support worker), who had recently finished a cycle of Anavar, stanozolol and anti-estrogen medications described how ‘within a couple of weeks’ of taking substances ‘everything for me just comes to life.’ She described recovering more quickly and feeling more confident and motivated at the gym. Claire (30, personal trainer), spoke about how substances affected her mood and confidence and, in her opinion, were integral to improved focus, productivity and career success:

You just feel confident. I feel like my business gets better because […] even though I’m confident in myself now, there’s a different level of confidence. I don’t know, you just believe in yourself differently. You believe so strongly about how you think, and no one can try and sway your mind. You have more energy. Like, you just want to fly out of bed in the morning, and you’re like “okay”, and your mind is just focused differently. You have more get up and go.

In these accounts, substances were valued not only because they produced aesthetic and athletic improvements but because they invited an expansion in how women relate to themselves, their bodies and other valued social and economic practices, such as self-care, health monitoring, work performance and business management. These substance-induced changes can be understood as implicated in new forms of productivity and agency, which while normative in terms of their economic imbrications in late capitalism, were still affording new and meaningful relationships with the self and world.

Importantly, these changes were not contingent on current drug regimens but extended beyond the time of consumption, scaffolding larger feminist projects of bodily autonomy and desire. We mobilise desire creatively here to refer to the pre-subjective pursuit of bodily flows and engagements, and capacitation of drug-using bodies through drugged assemblages [36]. For example, Jen (58, community health worker), who had been using substances for over two decades, explained that substances are ‘part of her’ and ‘how I sort of see myself […] I’ve been doing it for so long, and it’s what I enjoy doing’:

It’s a part of who I am. I mean, I’ve been using and training for so long that they complement each other. And I'd be completely different person if I didn't. Like, I’d be just a bit of an arse, I reckon. And that helps with my training.

For Jen, substances and working out have not only changed her body but have been constitutive of her very self. Even in the context of pervasive harassment and transphobic discrimination around gender attribution (which we explore in further detail below), she explained that she still chooses to use substances ‘because that's more important to me than peripheral discrimination or gender discrimination from the public’. She goes on to say:

I actually said to [my employer], on a different occasion, that I'm not going to change who I am to gain superficial acceptance from people that don't accept me anyway. You can change who you are, to a certain extent, but it’s not going to make them like you any more […] And I love training. I love the way - what it does for me. So, I'm not going to change that aspect of my life.

Of note here is how Jen conceives of her training and consumption in relation to her autonomy and freedom to pursue the activities and aesthetics she desires, and more broadly the kind of life she wants to live. Like Jen, Jessica (39, disability support worker), who had been using substances since 2005, explained that substance consumption ‘shaped me into the person that I am today. It has made me resilient.’ Similarly, Claire (30, personal trainer) described the value of enhancement substances and their role in helping her develop stronger, more assertive boundaries and social relationships:

I changed very quickly [when I started using substances]. Yeah, I felt amazing. I gained so much confidence. Me and my ex-boyfriend actually broke up after that. [… laughs] Yeah, I think it actually gave me what I needed to make myself the person I wanted to be, because I was always so scared of everything. I was shy, I was timid, I never had confidence in myself, and I guess at the same time, like, meeting my coach here helped build my confidence, and gave me the self-belief.

Here, Claire describes how substance consumption afforded self-confidence and assertiveness in her intimate relationship. For these women, enhancement substance consumption cannot be divorced from contemporary gendered regimes, political contexts of discrimination and feminist projects of bodily autonomy and desire [32].

Importantly, our attention here to agency, desire and pleasure in line with the approach adopted in this article to actively resist and critique the disproportionate emphasis on vulnerability and virilisation in scientific and public health discourses. This is not to say that women do not also experience difficulties or challenges with their consumption. Some participants, such as Claire and Jessica, for example, spoke about the difficulties of cycling off substances and changes in regimens in relation to the effects on mood, libido and balancing or regulating hormones post-cycle. Others, such as Jen and Peta, spoke about concerns around cycling and cessation, both describing how concerns about ‘losing muscle’ and ‘gains’ meant it was much more likely for them to stay on low doses for longer periods of time. Peta (58, community health worker) in particular spoke about an ‘addictive’ quality she associated with being on substances, especially in relation to cessation. However, despite these challenges, the women we interviewed overwhelmingly spoke about consumption in relation to enhancement and self-definition, rather than coercion and risk. We have emphasised these accounts as part of the larger feminist project we outlined earlier to challenge the epistemic injustice that has silenced them as producers of knowledge.

Accumulating knowledge and skill in the absence of gender-sensitive health information

While recent work has suggested that women have little knowledge of what substances they use and downplay the potential for side effects, our study found that on the contrary women possessed detailed forms of knowledge and skill. They also actively sought to monitor and prevent side effects, including virilisation, in the absence of reliable, gender-sensitive health information. Peta (58, community health worker), for example, who had been consuming substances for many years described feeling ‘quite sensitive to [particular substances]’ so for the last several years she maintained the same regime of boldenone, nandrolone and methyl-piperidino-pyrazole, using low doses twice per week and monitoring her blood pressure. Talking about the appeal of other products for women, she described avoiding particular substances because of the potential for health risks:

I suppose when I think about two substances that people are using, then, to be lean, there’s Clenbuterol; there’s - you know, a lot of people will use T3 and T4 thyroid combinations. Women sort of look for more leaning products as well, when I think about it. […] I’ve used Clenny on and off, but I’m really sensitive to the shit. It makes me feel bleurgh, so I don’t tend to use that. Usually, with weight stuff, I’ve got to try and shift it by either doing more exercise, in terms of cardio stuff, or drop the diet down, because I get affected by even high-caffeine stuff. The T3 - years ago I tampered with that, when I think about it, but the danger is you can stuff up your thyroid. So, there’s a bit of a worry with that [too].

Not only did Peta describe detailed knowledge about how and why she assembled her current substance regimen, she also displayed care and concern about minimising potential side effects. Similarly, other women described a high level of commitment to monitoring side effects and adverse health effects, such as virilisation. Sarah (37, nurse) spoke about actively monitoring and managing her health through regular blood tests and hormone profiles:

I think beforehand I was just wanting to make sure that, you know, my hormones were good. So, before I even went on Deca for pain, I did a hormone profile, and checked all of that. I have polycystic ovarian syndrome anyway, so my test is always a little bit higher, and just sort of - I keep an eye on that regularly. I do my bloods before and after competitions, just to make sure everything’s okay. And if I change my steroid regime, I also do another hormone check to test what is the effect of that.

Later, she described monitoring virilisation effects closely to achieve her desired look and avoid looking more masculine:

I think sometimes - like, I notice if I get more hair here sometimes, and I get - like, my voice is a bit deeper than when I first - than, you know, 10 years ago - but it doesn’t sort of really bother me. I think, too, because I keep an eye on it. Like, if I notice that something is getting worse, then I would stop the amount that I’m having, or anything like that. Plus, I’m only on a very small amount.

Rather than downplaying side effects, Celia (operations manager, 42) described working to find a balance where she could cultivate muscle but avoid virilisation effects:

I still want to maintain being feminine within that, so that's why you've got to be very careful around what your take, because all of that goes out the window pretty quickly. […] Well, if you start taking too much Test, and things like that, all of a sudden you start to become very masculine. You sound very masculine, start to look very masculine, and- […] Well, obviously, your voice goes very deep […] And that's what I want to avoid.

In these examples, women take a proactive approach to avoiding side-effects, including virilisation. While women’s consumption produces new forms of knowledge acquisition and health monitoring, and relatedly epistemological resources for healthcare, it also functions as a disciplinary practice of femininity, in which women modulate their consumption and healthcare to conform to conventional gender norms, a theme we return to below.

Importantly, the absence of targeted health information and accessible and gender-sensitive healthcare made health management and monitoring challenging. Claire (30, personal trainer) spoke about seeing a doctor whose preference was to not work with women:

[… I found this doctor through] word of mouth. My coach sees this doctor, but the doctor doesn’t really like to work with women very much, because realistically, even if it’s through a doctor, they’re not really allowed to prescribe a woman a male hormone unless her hormones are imbalanced, and even if they are they’re only allowed to give a woman a certain amount of the hormone, which is a very minimal amount.

Jessica (39, disability support worker) described serious concerns around her fertility, which she had not discussed with a healthcare provider because of concerns around judgement and stigma:

I didn’t have my period for years. Just because I wasn’t cycling off properly. I wouldn’t get my period. I was constantly using Test. I just wasn’t looking after myself properly. And I mean, I do get my period now, but it’s not as it should be. It’s quite irregular. But I just feel that [I can’t have children] - you can just feel it. It’s a weird sense, but I just know. […] No [I haven’t spoken to a doctor about these concerns]. They’re very judgmental. I can’t - even if I just touch on the subject with a doctor, they’re dismissive. And I’ve never found a doctor that I’ve been able to talk to about this. […] I’m embarrassed.

In previous research on men’s PIED consumption with Suzanne Fraser and colleagues (2020), we drew on Isabelle Stengers’ notion of connoisseurship to describe the detailed knowledge on substances and injecting practices that men showcase in relation to PIEDs. A key conclusion of this work was that while men display increasing expertise and technical knowledge about PIEDs, they also wanted honest and productive relationships with medical providers. Notably, the women we interviewed also displayed technical knowledge and an appetite for specific knowledge and information relevant to women. However, as we can see from these accounts, the absence of health information and healthcare for PIED consumption has distinctly social consequences that accrue to women that are not gender neutral [8]. While much research about women’s consumption is overly focused on virilisation (often as a result of women’s naivety or inexperience in assembling consumption regimes), we suggest that limited gender-sensitive healthcare and stigma is implicated in the production of these side effects, and intensifying lasting negative effects, such as infertility, for women.

Gender-based harassment and discrimination

Nearly all the women interviewed described wide-ranging incidents of drug- and gender-based stigma and discrimination, which contributed to a sense of abjection in public spaces and from normative femininity. Several women described invasive questioning and commentary about their substance use and bodies from strangers, colleagues and family members. For example, Sarah (37, nurse), recalled a family member telling her ‘I wouldn’t do what you do [use steroids], because it makes you look more masculine’. Claire (30, personal trainer) recounted how on several occasions strangers at the gym have asked her ‘what are you using’, reflecting in the interview that ‘somehow some people find it appropriate [to ask]’ and comment on her body. Monica (43, community service worker) described an incident where she was approached at the gym by another patron who started discussing the aesthetics of her body and eventually remarked: ‘You wouldn't look like that naturally.’ Jessica (39, disability support worker) described the pervading sense of public surveillance and hostility she experienced, which contributed to increased concerns about being in public:

You could pass anybody, just in the general public, and you could hear – you could tell by their body language to start with… You could always see it. You would be approaching a group of people, or a couple, and someone would whisper in the other person’s ear, and then they would all turn around, and […] it made you feel – it was a very anxious time. You could hear the comments. You would have people drive past, and they would yell out the windows, like, “Oh, you look like a man,” you know, but that’s, I guess, to be expected, because we’re developing our bodies to look a different way, and we’re not going to fit into what’s normal society.

In response to this harassment, several participants described dressing differently when they went out in public to conceal their bodies and look more ‘feminine’. For example, Peta described getting ‘dressed up [… to] look as feminine as possible’ and using clothes to hide her body and size. Similarly, Claire described dressing in public spaces, such as shopping centres, to conceal her muscularity.

Others described more direct harassment and discrimination around perceived gender attribution and transgression. Claire (30, personal trainer) recalled an incident where she was confronted in her own home by a tradesperson who demanded to know whether she was a ‘woman or a man’:

I actually had a steam cleaning guy come to my house, and I almost kicked him out because he actually asked me, “Do I call you a woman or a man? Do I call you a Miss or a Mister?” And I actually complained to his company, because it was embarrassing. I had never, ever, ever been asked that before.

She went on to describe that in the past she’d had ‘fights with people’ who called her transphobic slurs. This harassment and transphobia made her feel ‘paranoid’ about her appearance and affected her sense of sexual confidence and agency. Jen (57, community health worker), described myriad, serious incidents of gender-based harassment and discrimination over many years that spanned her previous workplace and multiple community settings, including gyms, leisure settings and public toilets. She spoke about being harassed in women’s toilets ‘many times’. When asked if she could provide an example, she described the following incident:

Jen: […I] was in a [leisure centre in an inner Melbourne suburb], where they told me to leave, which I wouldn’t.

RF:They told you to leave a changeroom?

Jen:Yeah. I’m not “in the right changeroom”. So, I just said, “By my age, I should know where I belong now.” So, she went out and got the manager, and the male manager actually came into the female changerooms whilst I was getting changed. […] And I’ve walked out after getting changed, and it's come over the air, “Can someone please check the female changerooms, because there’s a male getting changed in there.” Which is obviously me.

In other examples, Jen described ‘targeted harassment’ in her previous job from a senior manager who told her she was ‘too harsh looking’ when she considered applying for a promotion: ‘I was told my hair was too dark, too short, I’m harsh looking, and to “wear a skirt”’. In another incident, she was the subject of a formal complaint process after a member of the public lodged a complaint that she was wearing a woman’s uniform. This complaint process resulted in Jen being mandated, in her words, to ‘receive counselling on the way people perceived me.’ She explained that to this day these multiple and wide-ranging incidents of discrimination have ‘affected her deeply’.

The accounts we have analysed in this section suggest that women who consume enhancement substances routinely experience gender-related stigma, harassment and discrimination in their everyday lives: in public, at home, in their personal relationships and at work. As the first author has argued previously, PIEDs can only be termed enhancing until a certain gender ‘threshold’ has been exceeded, at which point the accumulation of muscle and ‘masculine’-coded effects disrupts the intelligibility of the female body and transgresses the normative ideals of the gender binary [13]. We can see this gendered dynamic play out in these accounts of discrimination around gender attribution. While we have characterised these experiences as gender-based harassment, they could also be characterised as transphobic discrimination, given they centre on perceived gender transgression. Understood in this way, these accounts, for us, gesture to the many kinds of stigmatising and discriminatory experiences that form part of the contemporary repertoire of gendered and transphobic practices and discrimination. As such, they should be understood as participating in the biopolitical performativity of a rigid, and ultimately harmful, gender binary.

We have spent time in this section exploring these accounts of gender and drug-based discrimination, and the harm and abjection they produce, to reformulate how harms might be understood and studied in this area. Given these encounters were a central theme to emerge in our interviews, their absence or omission in research to date can be characterised as a form of epistemic injustice [18]. In line with Pohlhaus’ [47] discussion of the features of epistemic injustice we discussed earlier, we can see how such an omission wrongs women who use substances in their capacities as knowers by distorting the kinds of harms and issues we can and should focus on in relation to women’s health and wellbeing.

Conclusion: epistemic resources for rethinking enhancement and its harms

This study invited women to describe through in-depth, qualitative interviews their experiences of using substances to work on and modify their bodies, including their motivations and consumption habits, the specific substances they prefer and modes of consumption (e.g. oral/injecting, cycles, alone or with friends), their preferences around information seeking and healthcare, experiences of cessation, social relationships and social media consumption. Given these wide range of topics, some new features of social experience have emerged that have not been a focus of contemporary research to date. In this article, we focused on three important dynamics shaping women’s consumption and wellbeing.

First, women described substances as technologies of enhanced agency and autonomy and as imbricated in desire and feminist projects of self-fulfillment in the context of gendered power relations that delimit appropriate body projects and gendered aesthetics. Second, women displayed technical expertise about substance regimens and monitored their health and side effects closely, despite having been denied epistemic authority and the absence of targeted health information or specific healthcare. The third and final theme we discussed concerned the major harm women described, which took the form of widespread gender-based stigma, harassment and discrimination. We have conceptualised this harm as specific to women who use substances in the context of fitness and strength-training but also intertwined with and reinforcing of the current violence surrounding gender attribution and trans lives and wellbeing. In line with the approach taken in this article, the absence of knowledge about these arguably ordinary and common features of consumption can be understood as a form of epistemic injustice in which very partial, narrow research questions have been used to produce women’s enhancement practices through a very limited scope. The knowledge asymmetries we have described reproduce women who use enhancement substances as passive, risky and vulnerable, with minimal, detailed engagement with women themselves. This representation enacts limited, negative accounts of their epistemic abilities (e.g. to access and make sense of health information, source reliable information, develop technical knowledge) and ultimately downplays their epistemic agency.

In concluding we argue that the epistemic norms and practices in this field urgently require reflection and adaptation and consider some of the epistemic resources [52] that might better enable women who use substances and those who research them to craft better, more just and equitable worlds. To return to Haraway, we think about epistemic resources as those things (concepts, practices, meanings, relations) in the conditions of knowledge production that might provide a better account of ‘how meanings and bodies get made, not in order to deny meanings and bodies, but in order to build meanings and bodies that have a chance for life’ [22], p. 580). To address this, a first move would be to prioritise better concepts for adequate knowing [52]. This could include concepts such as gender, stigma, pleasure, autonomy or desire – concepts that speak to a broader range of experiences than currently accounted for. It might also include concepts such as social justice, gender equality, harm reduction and intersectionality, which could invite descriptions of other interrelated features of social and political life that shape how women consume substances. Or, alternatively, we might think with processual concepts such habit, performativity or enactment that develop situated, embodied accounts beyond individual intentions and side-effects.

In addition to developing better concepts for adequate knowing, epistemic systems that allow novel resources to emerge are needed [52]. While recent research specifically focuses on women experiences, it proceeds largely without a feminist or gendered framework and is divorced from feminist political thought [8]. While researchers working in this area do not need to ‘identify’ as feminists or employ feminist frameworks, given the gendered power differentials that shape women’s lives, there needs to be closer engagement with the difference that gender makes in the lives of women who use drugs, including their access to healthcare and harm reduction practices. In addition, actively working with women who consume substances and researchers working within a feminist paradigm will better articulate how gender shapes women’s experiences and can inform gender-sensitive healthcare and harm reduction practices. Expanding epistemic systems requires sensitivity to concepts, collaborators and the parts of method that encourage or hinder knowledge production and open up space to expand our epistemic accounts. It is our belief that attending to these things will generate more diverse forms of knowledge beyond a focus on individual harms and develop the capacities of women who use enhancement substances as epistemic agents, through the creation of relevant and reliable health information and a gender sensitive knowledge base for harm reduction and social justice.

Author contribution

R.F. wrote the main manuscript text and K.S. provided two rounds of feedback. All authors reviewed the final manuscript.

Funding

This research was funded by an Alfred Deakin Postdoctoral Fellowship.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval

This research has ethics approval (Deakin University’s Human Research Ethics Committee (2022–150), which included consent protocols for participation.

Competing interests

The authors declare no competing interests.