A Systematic Review Investigating the Psychosocial Factors Influencing Initiation, Use and Subjective Experience of Performance and Image‐Enhancing Drugs in Women Who Weight‐Train

ABSTRACT

Issue

Performance and image‐enhancing drug (PIED) use among women is a growing phenomenon, particularly within weight‐training populations. Despite increasing prevalence, research on the psychosocial factors involved in women's PIED use remains emergent and fragmented.

Approach

This systematic review of mixed methods studies uses an integrative approach to explore perspectives, motivations and psycho‐social factors associated with women's use of PIEDs within weight‐training populations. The review also investigates gendered experiences that may exist among women who use PIEDs.

Key Findings

Following screening, 22 articles were included in the review and five key themes emerged from the analysis. Women's experiences with PIEDs were found to be significantly shaped by pressures to conform to societal beauty standards and gendered expectations. Unlike men, who often receive guidance from peer‐driven “bro‐science”, women navigate PIED use largely in isolation, which increases potential risks. The stigma surrounding PIED use in women, particularly related to side‐effects such as virilisation, further deters open discussions and engagement with healthcare services.

Implications

These findings highlight the importance of developing gender‐specific educational materials and harm‐reduction initiatives to address the unique challenges faced by women using PIEDs. Additionally, health services should be equipped to engage with this population in a non‐judgmental manner and offer tailored support.

Conclusions

There is a clear need for further research into women's experiences with PIEDs. Gender‐sensitive approaches to education, prevention, and healthcare are essential to mitigating the risks associated with PIED use among women in weight‐training communities.

Summary

• This review synthesises the existing empirical literature on psychosocial factors influencing women's use of performance‐ and image‐enhancing drugs (PIED) in weight‐training contexts.

• Findings indicate that women's initiation and use of PIEDs are shaped by aesthetic motivations, gendered power dynamics and limited access to female‐specific information or support.

• High rates of disordered eating, body image disturbance, and trauma histories were reported across studies among women who use PIEDs, suggesting complex intersections between mental health and substance use.

• Male influence and dominance in information networks contribute to misinformation, risk‐taking and secrecy, underscoring the need for harm‐reduction and education strategies tailored to women.

• The review highlights significant evidence gaps, particularly in longitudinal, large‐scale and intervention‐based studies, calling for more inclusive and gender‐informed research and policy responses.

1. Introduction

In recent decades, there has been a notable surge in the use of performance and image‐enhancing drugs (PIED) across various fitness and sporting domains. PIEDs are broadly defined as pharmacological or hormonal agents used with the primary intent of enhancing physical performance or appearance [1, 2]. Once limited to top professional athletes [2, 3, 4], studies indicate that non‐medical PIED use has doubled within Australia over the past two decades [4]. The 2022–23 National Drug Strategy Household Survey reported that 0.2% of Australian adults (aged 14 and over) had used steroids non‐medically in the previous 12 months [5]. While this provides a proxy measure for steroid use in the Australian population, it does not capture other commercially available PIEDs, nor does it provide sex‐disaggregated data. PIEDs, ranging from anabolic‐androgenic steroids (AAS) to non‐steroidal compounds such as selective‐androgen‐receptor‐modulators, hold the promise of rapid physical transformations, including muscle gain, fat reduction, and enhanced strength and endurance [1, 6, 7]. Yet, PIEDs are also associated with a gamut of adverse effects spanning organ damage, psychological distress, infertility, and infection [1, 6].

Researchers have noted worldwide growth in the use of PIEDs among women, potentially linked to a concurrent increase in women's participation in strength sports [8]. Furthermore, it has been observed that the rise in women's PIED use has coincided with the evolution of women's bodybuilding and consequently, changing societal beauty standards for women from very slim physiques to ‘toned and strong’ [9].

Despite this increasing prevalence, the majority of research to date has primarily focused on identifying the psychosocial factors associated with men's PIED use. Studies have characterised men's PIED use as a means to fix perceived psychological, social and aesthetic deficits, for example, to compensate for feelings of inadequacy, social marginalisation, lack of masculine capital and aesthetic insecurities [10]. Others have framed PIEDs as tools for men's self‐actualisation and identity construction, whereby men pursue an aspirational or idealised version of their physical selves [11]. A recurring theme in the literature has been the correlation between men's PIED initiation and body image dissatisfaction or body dysmorphia [12, 13, 14] as well as certain personality traits (narcissism, poor self‐esteem, perfectionism, impulsivity, obsessive compulsive traits) [15, 16]. Additionally, ethnographic studies have highlighted the close relationship between physical appearance and social themes such as status and power, and PIED use as an avenue to achieve an aesthetic associated with power and masculinity [17]. This connection between PIED use, masculinity and social status has been observed to influence the way knowledge about these substances is shared among men. In male‐dominated fitness and bodybuilding spaces, “bro science” has emerged as an informal, community‐driven body of knowledge, where peer support and shared experiences serve as primary sources of information [18]. This peer‐driven culture not only provides practical advice but also helps to normalise and legitimise PIED use among men [18].

1.1. PIEDs Among Women

Comparatively fewer studies have been conducted on PIED use in women, despite the vastly different effects that PIEDs can have on women's bodies compared to men's. In particular, PIEDs (especially AAS) have the potential to lead to virilisation in women, given many are testosterone based [8]. Recent studies have suggested that the way in which women typically use PIEDs may also differ significantly from men's use, including a preference for oral substances as opposed to injectables [19, 20].

In qualitative research, it has been suggested that there may be distinct psychosocial determinants shaping women's engagement with PIEDs, involving gender dynamics and certain psychological traits/profiles [21, 22, 23]. While men's initiation is often framed around performance enhancement, social status, or muscular idealism, women's initiation is more frequently described as being influenced by aesthetic ideals linked to femininity, self‐surveillance, and body control. Such motivations are deeply embedded in gendered cultural norms that celebrate strength and leanness while still penalising overt muscularity [21, 22, 23].

The role of men in women's initiation to and experience of PIEDs has been a common theme in the literature, which provides evidence of hegemonic masculinity in decisions and discussions about PIED use [19, 21]. Women's access to PIED‐related knowledge and substances themselves often occurs through male intermediaries (partners, coaches, peers), potentially reinforcing gendered hierarchies in gym culture, contributing to misinformation and limiting women's autonomy [19, 21, 24]. Additionally, women who use PIEDs have reported facing significant stigma, compounded by the fact that muscle‐building and PIED use are traditionally seen as masculine domains [19].

Furthermore, virilisation from PIEDs has been highlighted as a source of shame and distress for some women, creating further social isolation and marginalisation [9]. Unlike men, who increasingly access PIEDs through semi‐formalised medical channels such as testosterone replacement therapy clinics or online telehealth providers, women have very limited access to comparable medical oversight or harm‐reduction services [9]. The absence of legitimate or gender‐specific clinical pathways contributes to women's continued reliance on informal and often unreliable sources of information, exacerbating marginalisation and potential health risks [20, 25].

Similar to the literature on men, a great deal of the existing research has focused on psychopathology and personality traits common among women who use PIEDs. These include elevated rates of eating disorders/disordered eating patterns [9, 23, 26, 27], body dysmorphia [23, 27], and higher levels of obsessiveness, anhedonia, and narcissism [16]. Furthermore, some studies have also highlighted a high incidence of past trauma among women who use PIEDs [19, 21, 26]. Collectively, these findings highlight the complex interplay of psychological, social, and cultural factors that shape women's engagement with PIEDs, which are broadly conceptualised in this review as psychosocial phenomena. A recent critical review argued that gendered and sociocultural norms strongly influence how women's PIED use is framed in research and public discourse, often casting it as deviant, pathological, or a transgression of femininity [28]. Their analysis calls for greater sensitivity to women's agency, identity, and contextual factors when studying PIED use. The present review builds on these findings by systematically synthesising empirical evidence on how women themselves experience PIED use psychologically and socially, offering an evidence‐based foundation for understanding the gendered dynamics they identify.

1.2. The Current Study

Despite an emerging body of research on psychosocial factors influencing PIED use among weight‐training women, existing evidence is fragmented and remains difficult to interpret due to its interdisciplinary nature and substantial heterogeneity. Nonetheless, a comprehensive synthesis of this evidence is needed to identify knowledge gaps, assess evidence quality, and inform future research and practice. This systematic review aims to consolidate findings on the psychosocial experiences of weight‐training women who use PIEDs, exploring perspectives, motivations, gendered, and contextual factors that influence initiation, experiences of, and continued use of these substances.

This review adopts an interpretive, integrative approach, thematically synthesising both qualitative and quantitative findings. Weight‐training environments were selected as the focus of this review for several key reasons. First, they represent the highest documented prevalence of non‐medical PIED use internationally [2, 6], offering the most concentrated population/context [2, 6]. Second, in these settings, PIED use is often motivated by aesthetic goals such as muscularity and leanness, which can be tied to performance in body‐building competitions (a significant subset of weight‐training population where PIEDs use occurs) or sociocultural ideals [11, 27]. Third, weight‐training contexts, as opposed to other professional sporting contexts, where athletic performance is a primary outcome, often operate outside of anti‐doping regulation and surveillance [6, 7]. As the aim of this review was to understand the psychosocial aspects of women's PIED use, weight‐training settings provided the most concentrated and relevant context, while being distinct from performance‐driven, surveillance‐shaped contexts of other competitive sporting contexts.

We conducted a mixed‐method systematic review using an integrative synthesis approach to draw together both qualitative and quantitative data, enabling a more holistic and comprehensive understanding of women's engagement with PIEDs [29, 30]. By synthesising research on predictors of initiation, usage patterns, and gender‐specific experiences and correlates, this review provides an essential evidence base to guide policymakers, healthcare practitioners, and other stakeholders in developing targeted interventions for harm‐reduction and support and advancing research in this space.

2. Methods

A mixed‐methods systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA). The protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022326712). As the quantitative findings were narratively synthesised rather than meta‐analysed, reporting was also guided by the Synthesis Without Meta‐analysis framework [31] to ensure transparent presentation of quantitative results. A comprehensive search was undertaken across PubMed, PsycINFO, Scopus, Web of Science, and CINAHL using combinations of terms relating to: (i) women; (ii) weight‐training contexts; (iii) PIEDs; and (iv) psychosocial or experiential factors. The complete database‐specific search strategies, including full Boolean operators and filters, are provided in Appendix A.

Initial searches were not limited by time period and no limitations were placed on study location or language, as long as an English translation was available; however, all included studies were published in English, so translation was not required. Searches were conducted on 16 May 2022 and an updated search was conducted on 17 June 2024.

2.1. Inclusion and Exclusion Criteria

This review focused on women with experience of both weight‐training (recreational or competitive contexts) and PIED use. Participant inclusion criteria were: (a) self‐reported woman or female participants; (b) current or past (lifetime) involvement in weight‐training (no frequency or duration threshold); and (c) current or past involvement in PIED use. PIEDs were defined as substances listed on the ‘All Times’ List of Prohibited Substances and Methods from the World Anti‐Doping Authority. Examples include injectable and oral AAS (e.g., testosterone, trenbolone, oxandrolone), selective‐androgen‐receptor‐modulators (e.g., ostarine), and peptide or hormone‐based agents (e.g., human growth hormone, insulin) [32]. Studies focusing solely on non‐prohibited substances or ‘sports supplements’ (such as creatine, beta‐alanine, BCAAs, pre‐workout blends) were excluded. There were no restrictions on the class/type of PIED or the reason for use.

No minimum threshold for frequency or duration was applied, as the objective was to examine experiential and psychosocial dimensions rather than to evaluate behavioural prevalence or intensity. Use of PIEDs was based on participants' self‐report within the included studies, recognising that individual studies applied their own eligibility criteria for “meaningful” PIED use, which varied across designs (see Table 1).

TABLE 1.

Characteristics of included studies.

Source	MMAT score	Study design	Participants and setting	Study aims	Method	Study outcomes
(Abrahin et al., 2017)	Moderate (4/5)	Survey	Females who engaged in resistance training N = 361 (W) Brazil	Evaluate use of AAS among Brazilian women and develop user profile	Self‐administered, anonymous, close‐ended questionnaire. One‐off Descriptive statistics	‐Primary reason for use aesthetic—Friends, physicians and sports teachers most common sources of AAS ‐Side effects: acne, menstrual irregularity, water retention, voice deepening, clitoral enlargement
(Ainsworth et al., 2021)	High (5/5)	Interpretive phenomenological analysis	Females with lived experience of AAS use N = 4 (W) UK	Explore experiences, perceptions, and perspectives of AAS‐using females through their journeys of starting, using, and coming off AAS	Semi structured interviews 1× ‘bracketing interview, 1 study interview IPA	‐Preparation and anxiety (before use) ‐Deviation from feminine identity (during) ‐Turbulence from cessation ‐Rediscovering femininity
(Andreasson et al., 2021)	High (5/5)	Adapted (web‐based) qualitative case study	Women‐only section of bodybuilding forum Sweden	‐Describe and analyse how doping community reacts to women‐only forum ‐How issues related to PIED use and gender are addressed by women	Threads in women‐only bodybuilding forum selected One‐off search Qualitative case study approach	‐Women create a subculture by sharing knowledge ‐Women, their bodies and experiences become unspoken ‘norm’ ‐Space allows women to challenge patterns of hegemonic masculinity
(Andreasson, 2020)	High (5/5)	Ethnographic	Participants were drawn from existing pool of participants involved in a larger ethnographic project on PIED use. N = 26 (20 M, 6F) Sweden	In what ways can the participants' commencement of doping be described and understood? How can the narratives of doping use be understood and analysed in terms of exit processes? In what ways can the processes of becoming and unbecoming a fitness doping user be understood analytically?	Interviews, observations and naturalistic conversations with PIED users. Formal semi‐structured interviews 40 days observation, One‐off interviews Narrative synthesis	‐Initiation of PIEDs often represents a ‘crossing of barriers’ of gender ‐For women who use PIEDs there is a barrier of gender as women seek to maintain femininity while gaining competitive edge ‐High level of secrecy involved in PIED use due to the legal ramifications and stigma ‐Discontinuing PIEDs can be a difficult process due to social identity and mental health effects
(Auge & Auge, 1999)	High (5/5)	Naturalistic observation	All participants were currently earning living from bodybuilding or associated activities, had been involved in at least one competition within the last year, pursuing further success via bodybuilding competitions N = 17 (14 M, 3 W) USA	Accurately gain data surrounding drug use from professional calibre bodybuilders via naturalistic observation	Naturalistic observation of everyday/training routine and informal interviews 1 year Descriptive statistics	‐Females generally using lower dosages of PIEDs than males ‐All participants had considered risk–benefit ratio of using PIEDS, ‐Few were in contact with a doctor but did not see their drug use as a long‐term health concern; ‐All reported daily use of non‐drug supplements
(Borjesson, 2016)	Moderate (4/5)	Case study	Female AAS and clenbuterol users recruited through Anti‐Doping Hot‐Line, during the years 1998–2004. N = 8 (W) Sweden	To identify the pattern of AAS and clenbuterol use in women and ‐compare with similar data reported in men Causes for initiating use, co‐use of other doping agents and narcotics, reported and observed side effects	Urinalysis and pathology Interview with study nurse Results compared with male data used for previous study. 6 years Descriptive statistics	‐Average duration of anabolic agent use before contacting health care was 58 days ‐AAS side‐effects included voice changes, clitoral enlargement, body hair growth, ‐Clenbuterol side‐effects included tachycardia and depression ‐Women generally used less substances than men, 3 women reported co‐use of narcotics ‐Women more likely to seek help from healthcare service at earlier stage as a result of side effects ‐Men in close relationships with women may motivate and influence women's decisions to use PIEDs
(Borjesson, 2021)	High (5/5)	Case study‐ Reflective Lifeworld Research	Female participants recruited after making contact with anti‐doping hotline N = 12 (W) Sweden	Provide understanding of women's experiences using AAS and contribute important knowledge and understanding	Semi‐structured Interviews One‐off Real Lifeworld Research	‐ Intense stigma and secrecy around use specific to women ‐Womens' initiation of PIEDs and decisions around use almost universally led by men (boyfriends, coaches)—Women need to ‘keep up appearances’ and maintain social norms to avoid social rejection and shame ‐Strong perfectionism directed towards the pursuit of achieving the perfect body—The body acts as a status symbol and social tool
(Goldfield, 2009)	Moderate (4/5)	Cross‐sectional	‐Women who were either competitive bodybuilders or recreational weight‐trainers recruited from various gyms N = 45 (F) Canada	‐Compare CFBBs and recreational female weight‐training controls on eating related and psych characteristics	Self‐report questionnaires related to demographics, body image, disordered eating, anabolic steroid use One‐off MANOVA and chi‐square	‐High rates of weight and shape preoccupation, body dissatisfaction, bulimic practices, and anabolic steroid use in both groups but more frequently in CFBBs ‐CFBBs appear to share several eating‐related behaviours with women with bulimia nervosa
(Gruber & Pope, 2000)	High (5/5)	Observational field study	Women aged 18–65 who had competed in at least one bodybuilding competition or have lifted weights 5× p/week for the past 2 years N = 75 W USA	Investigate psychological and psychiatric effects of AAS in females	Structured Interview Structured Clinical Interview for DSM‐IV [19] Physical examination Pathology and urinalysis T‐test analysis	−64% AAS users reported adverse psych reactions such as labile mood, irritability and aggression; ‐Over 50% of female AAS users reported symptoms consistent with hypomania −10 female AAS users described depressive symptoms after discontinuation ‐AAS users more likely to use other PIEDs or recreational substance than AAS non‐users ‐Eating disorder history reported in AAS users and AAS non‐users but more common in AAS users −100% of AAS users reported muscle dysmorphia‐type body dissatisfaction
(Gruber, 1999)	High (5/5)	Case report	10 out of 75 female weightlifters reported having been sexually abused/assaulted. N = 75 (F) (large sample) N = 10 (population of interest) USA	To explore the prevalence of compulsive weight‐lifting activities and PIED use among female victims of sexual assault	Structured Interview: Structured Clinical Interview for DSM‐IV 12, physical examination, including determination of body fat using callipers; laboratory tests for chemistries, haematology, and urinalysis One‐off Descriptive statistics and case report	‐All but one participant reported that weightlifting activities increased following sexual assault ‐Stated a desire to be ‘bigger’ and ‘stronger’ which they believed would prevent further attacks from men ‐All reported that being bigger and stronger made them feel safer and replaced a sense of helplessness and vulnerability with a feeling of control. ‐All 10 participants developed muscle dysmorphia −7 out of 10 participants began using PIEDs to increase size and strength
(Havnes, 2021)	High (5/5)	Case study	Females with past or present AAS use (minimum of one cycle) N = 16 (F) 6 were presently using, 10 were previously using (at time of interview) Norway	To explore how the development of masculinising, gonadal and sexual effects and how these have been experienced and processed by women with current or previous AAS use, in arenas outside of elite sports	Semi‐structured interviews Latter half of interviews had a more flexible design to allow previous interview findings to be incorporated. One‐off Thematic analysis	‐Primary motivations for AAS use were aesthetic ‐Secondary motivations included desire for belonging, self‐protection and emotional flattening—Several women reported histories of mental illness, especially eating disorders ‐Women usually introduced to AAS by a trusted male and were sometimes given incorrect advice—Side effects such as voice changes revealed AAS use to outsiders ‐Common side effects included menstrual disruption, clitoral growth and increased libido ‐Side‐effects resulted in shame and low self‐esteem after discontinuation for several women
(Henning et al., 2019)	High (5/5)	Netnography	Threads in ‘women and steroids’ section of a bodybuilding forum UK	‐Investigate meaning attached to women's doping ‐How doping can be understood in regards to gender and spatiality ‐Implications for women's communication on forums	Relevant forum threads identified, transcribed and analysed One‐off search Thematic analysis	‐Discussions often dominated by men's voices and experiences
(Ip, 2010)	Moderate (4/5)	Web‐based survey	Participants recruited on bodybuilding forums to complete survey. N = 12 (W) USA	To provide an in‐depth analysis of 12 female self‐reported AAS users.	Web‐based survey on relevant internet forums (demographics, AAS and other PIED use) 5 months Descriptive statistics, t‐tests, Fisher exact test	‐Female AAS users reported using an average of 8.8 PIEDs in their routine. ‐When survey was completed with male AAS users and data was compared, female AAS users more likely to have met criteria for substance‐dependence disorder, have been diagnosed with a psychiatric illness, and have reported a history of sexual abuse male AAS users and female non‐AAS users
(Irving, 2002)	High (5/5)	Prevalence study	Middle and high school students as part of Project EAT. N = 4746 USA	‐Assess the prevalence of steroid use to gain muscle in a large population‐based sample of adolescent males and females ‐Identify personal, socio‐environmental, and behavioural factors of potential relevance to the nutritional and physical health of adolescents that use anabolic steroids.	Anthropometric measures self‐report questionnaires related to weight/shape concerns, psychological measures, health/nutrition knowledge and attitudes, sports involvement, physical activity, eating habits, substance use One‐off Descriptive statistics	‐Steroid use more common in males than females (5.4% vs. 2.9%) ‐Disordered eating associated with both male and female steroid users ‐Female steroid users more likely than non‐users to report that their weight had been important to them in the past 6 months and that they would like to weigh more ‐For females, steroid use was correlated with trying marijuana and other drugs but not with alcohol or smoking
(Peters, 2001)	Moderate (4/5)	Correlational	Participants all trained at least 4× week for at least 1 h with free weights. Participants considered steroid users if they had used steroids within last year, considered non‐users if they had never used steroids N = 208 (109 M, 89 W) USA	What effect do gender (female or male) and steroid consumption status (non‐use or use) have on body dissatisfaction? What effect do gender (female or male) and steroid consumption status (non‐use or use) have on body distortion?	‘Figure‐rating’ task to test body image distortion and dissatisfaction. One‐off 2 × 2 ANOVA compared between four groups (male AAS‐users, male non‐AAS‐users, female AAS‐users, female non‐AAS‐users)	‐High levels of body dissatisfaction/distortion across both males and females ‐No significant effect of steroid use/non‐use on dissatisfaction or distortion ‐Female bodybuilders generally perceived themselves as less muscular than objective outsiders when compared to male bodybuilders
(Piatkowski, 2023)	High (5/5)	Case study	Participants included (i) males or females who competed with or coached female strength athletes using AAS and (ii) female and male strength athletes who used AAS. N = 21 (9 M, 12F) Australia	‐Gather perspectives from men and women on the unique challenges surrounding women's use of AAS, ‐Investigate how women's AAS practices differ from those of men	Semi‐structured interviews One‐off Thematic analysis	‐Women predominantly used oral compounds over injectables ‐Some women reported that the use of injectables came with significant physical and psychological changes
(19)	High (5/5)	Case study	Women who had used PIEDs N = 38 (W) (28 online survey, 10 in‐person interview) Australia	To explore women's motivations for PIED use, examine negative health effects related to use, and to understand how interpersonal relationships facilitate use.	Open‐text surveys and interviews One‐off Content and thematic analysis	‐Three overarching themes: socialising women's use, facilitating women's use and PIEDs exacerbating existing issues ‐Women often discussed being introduced to PIEDs by men or men playing roles in decisions around PIED use ‐Previous mental health issues exacerbated by PIEDs commonly discussed
(Skarberg, 2008)	High (5/5)	Case Study	Patients of an addiction clinic who had a history of AAS use and were attending the clinic for what they believed were AAS‐related problems. N = 6 (4 M, 2 W) Sweden	To improve understanding of the development of multiple drug use in patients seeking treatment at an addiction clinic for AAS‐related problems	In‐depth semi‐structured interviews (social background, substance use, development of total drug use and subjective experience of side‐effects) One‐off Narrative synthesis	‐Both women described difficult upbringings ‐PIED initiation associated with gym training in teens/early twenties ‐Women used fewer substances than men ‐Women were introduced to PIEDs by a man ‐Reported medical and psychological problems related to use ‐Reported strong knowledge and confidence in use
(Strauss, 1985)	Moderate (4/5)	Case study	Women who weight‐trained regularly and had consistent use of AAS (greater than one cycle) N = 10 (F) USA	To investigate patterns of AAS use (type, frequency, amount), reasons for used, observed effects and their feelings surrounding these effects	Structured Interviews One‐off Descriptive statistics	‐AAS used in ‘cycles’ with multiple substances often taken at once ‐All participants reported increased muscle size and strength from AAS use—Most noted side effects such as voice deepening, clitoral growth, increased facial hair, aggressiveness, menstrual irregularities—Participants generally reported that these side effects were tolerable to them but they did not believe they would be to other women
(Sverkersson, 2020)	High (5/5)	Netnography	Female members of the Flashback forum 51 threads were selected that were initiated by a female community member. Sweden	To investigate the ways in which women talk about and rationalise their use of PIEDs, their potency and potential gendered side‐effects.	Immersion in forum, forum user selection, forum search using keywords 8 months Thematic analysis	‐PIED use can be largely understood from hegemonic patterns ‐Women have gained a greater voice in online activity around PIED use ‐Women's perspectives critiqued by men ‐Forums allow women space to freely share experiences, give female‐specific advice around harm reduction, dosing, side‐effects
(van den Berg, 2007)	High (5/5)	Survey	Study formed part of Project EAT‐II. Participants who took part in the first study were contacted at the 5‐year mark. N = 2516 (1130 M, 1386F) USA	To determine if there were predictors for steroid use at a 5 year follow‐up, controlling for demographic variables	Self‐report questionnaires related to weight/shape concerns, psychological measures, health/nutrition knowledge and attitudes, sports involvement, physical activity, eating habits, substance use 2 time‐points over 5 years Descriptive statistics and logistic regression (stratified by gender)	−1.5% of male and female adolescents reported having used steroids for muscle gain, with no significant difference in prevalence between genders. ‐Female time 2 steroid users had higher BMIs were less satisfied with their weight, had poorer nutrition knowledge and concern for health ‐Participation in weight‐related sport predicted steroid use in female adolescents.
(Van Hout & Hearne, 2016)	High (5/5)	Netnography	Sites with female use and had active forum activity 23 discussion threads included UK	Explore female use of CJC‐1295, a synthetic growth hormone, from the perspectives contained in Internet forum activity.	Systematic Internet search was conducted using variation of the term “CJC‐1295”; and combined with “forum.” One‐off search Empirical Phenomenological Psychological method of analysis	‐Female forum users had good knowledge in the use of PIEDs and polysubstance use ‐CJC‐1295 use came from desires for weight loss, increased muscle strength/size, youthful skin, improved sleep and injury healing ‐Concerns and conflict over female‐specific advice in substance use/dosing

Abbreviations: AAS, anabolic‐androgenic steroids; ANOVA, analysis of variance; BMI, body mass index; CFBB, competitive female bodybuilders; MANOVA, multivariate analysis of variance; MMAT, Mixed Methods Appraisal Tool; PIED, performance and image‐enhancing drugs.

Only primary empirical research (qualitative, quantitative or mixed‐methods) was eligible for inclusion. Reviews, commentaries, editorials, conference abstracts and prevalence‐only studies were excluded, as the aim was to synthesise original psychosocial evidence rather than secondary interpretation. Studies involving mixed‐sex or mixed‐gender samples (male and female) were included only where results were disaggregated by sex and/or gender to enable extraction of findings specific to female participants. Studies with exclusively male participants, or those that did not differentiate findings by sex and/or gender, were excluded. However, it must be noted that most included studies did not clearly distinguish between sex and gender, and many used the term “women” while reporting on biological sex. Because of this inconsistency in primary reporting, we were not always able to determine whether trans women were included in all studies. We acknowledge that reporting of sex and gender terminology was inconsistent across included studies and where necessary, we followed authors' original usage while noting these variations as a limitation.

To align with the review's aim of exploring psychosocial factors involved in initiation and experiences of PIEDs, included studies had to address some aspect of psychosocial phenomena. For the purposes of this review, psychosocial phenomena were defined as psychological, emotional, and social processes that shape or arise from individuals' experiences of PIED use. This included constructs such as motivation, identity, stigma, body image, self‐perception, interpersonal relationships, social norms, and mental health. Studies were therefore required to examine at least one of these dimensions. Studies that only reported on prevalence were excluded.

2.2. Study Selection

Covidence software facilitated screening. In total, 5480 citations were retrieved from electronic databases with 220 duplicates removed. Titles and abstracts were screened independently by two reviewers. Articles marked ‘yes’, ‘maybe’ or a combination of both proceeded to full‐text review. Where there was a No/Maybe or Yes/No vote, the two reviewers discussed the articles according to the criteria to make a final decision. At this stage, 5068 studies were excluded. Inter‐rater reliability at this stage was shown to be moderate (κ = 0.57).

The remaining 192 studies underwent full‐text review by two independent reviewers, with inclusion decisions recorded alongside reasons for exclusion. Disagreements were resolved by a third reviewer. This resulted in a list of 21 studies for inclusion. Reference lists of the selected studies were hand‐searched, yielding seven additional studies, of which one was included, resulting in a total of 22 studies (see Figure 1).

FIGURE 1.

PRISMA flowchart. Note: Converted to image format for legibility. “Wrong intervention” = studies examining substances not classified as PIEDs under the WADA Prohibited List (e.g., creatine, protein powders); “Wrong outcome” = physiological or biochemical focus with no assessment of psychosocial factors (e.g., physiological or prevalence‐only studies); “Wrong study design” = excluded article types lacking empirical data such as reviews, commentaries, or editorials. Numbers have been reviewed and corrected for consistency with the screening log. Source: Page MJ, et al. BMJ 2021;372:N71. Doi:10.1136/bmj.n71. This work is licensed under CC BY 4.0. To view a copy of this licence, visit: https://creativecommons.org/licenses/by/4.0/ .

2.3. Appraisal

The methodological quality of included studies was assessed using the revised Mixed Methods Appraisal Tool (MMAT) [33]. This tool is designed to assess studies across different designs (qualitative, quantitative and mixed methods) and has been used in several mixed‐methods systematic reviews. One reviewer conducted the full assessment of all included studies, and a second reviewer independently cross‐checked a sample to ensure consistency and methodological rigour. Any discrepancies were discussed and resolved through consensus. Although the MMAT does not support numeric scoring, studies were categorised as high (all 5 criteria met), moderate (3–4 criteria met) or low quality (≤ 2 criteria met) for descriptive purposes only. Included studies generally met the MMAT‐checklist criteria (see Supporting Information).

2.4. Extraction

Data was extracted by one researcher, using an Excel‐based template and cross‐checked for accuracy and completeness by a second researcher. Extracted components included participant demographics, PIED use (type, patterns, history of use), psychological traits and mental health indicators, and relevant sociocultural or environmental factors.

2.5. Analysis and Synthesis

The mixed‐methods synthesis was informed by the contemporary Joanna Briggs Institute guidance for conducting mixed‐methods systematic reviews, which outlines principles for integrating qualitative and quantitative evidence within a single synthesis to generate comprehensive, practice‐relevant insights [30]. The analytic process combined these integrative principles with the approach outlined by Thomas and Harden [29], which involves coding extracted data, grouping these codes into descriptive themes, and developing higher‐order analytical interpretations from those themes.

Unlike most systematic reviews that primarily focus on quantitative data and statistical synthesis, this approach qualitises quantitative data, allowing for a richer, more nuanced understanding of the data. This method is particularly useful for capturing complex psychosocial phenomena and is especially well‐suited for topics that require the integration of multiple qualitative studies and an exploration of participant experiences in relation to complex social and health behaviours. Given the diverse nature of the methodologies in the included studies, this form of analysis offers the flexibility to incorporate varied data types while maintaining methodological rigour. It also accommodates the generation of higher‐order new interpretive insights, which are particularly relevant for shaping interventions, health messaging and discourse surrounding women's PIED use.

NVivo software was used to aid in the analysis and synthesis process. The studies were first categorised according to study type/design, and quantitative data was translated to qualitative descriptions. Following extraction, the next stage of synthesis involved generating descriptive themes for each article from the extracted data. Initial coding was conducted by the lead author, and a second author independently reviewed a sample of the coding to ensure consistency and accuracy. The developing codes and preliminary themes were then discussed among the wider author team, who contributed to decisions regarding how themes were grouped, refined, and which findings were prioritised for reporting. The similarities and differences that emerged between the extracted data were pooled into groups, themes, and categories. A table was generated (Table 2) to report on the key themes, categories, and concepts emerging from the literature. Finally, analytical themes that may describe or encapsulate the descriptive themes were explored and developed through a consensus‐based discussion among the authors. The conceptual relationships between these analytical themes were mapped visually to produce Figure 2, which illustrates the overarching thematic structure and interconnections identified through the synthesis.

TABLE 2.

Summary of Psychosocial factors in PIED use based on stage of use.

Stage of use	Psychosocial phenomena
Motivations for Strength Training	Improve body image, social belonging, address mental health concerns
Influences Leading to PIED Use	Personal aesthetic goals alongside social pressure, particularly from males within gym environment
Positive Experiences of PIED Use	Rapid increase in strength, performance and body composition, increased wellbeing and confidence, positive side effects such as increased libido
Negative Experiences of PIED Use	Social isolation, secrecy, psychological distress, dissatisfaction with virilisation
Discontinuation of PIED Use	Often prompted by fears of virilisation, social issues and legal ramifications Marked by depression, loss of identity
Variability in Experiences (across stages)	Conflicting findings across studies include: (i) experiences of empowerment versus shame associated with changes to appearance; (ii) male‐dominated influence versus emerging women‐led peer networks in online spaces; (iii) inconsistent associations between body dissatisfaction and PIED use; (iv) psychological distress versus satisfaction throughout PIED use

Abbreviation: PIED, performance and image‐enhancing drug.

FIGURE 2.

Thematic map of psychosocial phenomena identified in synthesis of included studies. Note. PIED, performance and image‐enhancing drug. Solid lines show links between themes and sub‐themes; dashed lines show relationships between higher‐order themes.

3. Results

The 22 studies included in this review spanned several countries including USA (8), Sweden (6), UK (3), Norway (1), Australia (2), Brazil (1) and Canada (1). They were published between 1985 and 2024, reflecting nearly four decades of evolving cultural and sporting contexts (pre‐2000, n = 3; 2000–2009, n = 6; 2010–2019, n = 4; post‐2020, n = 9) and differed substantially in methodological orientation (see Table 1). Specific methodologies included structured and semi‐structured interviews, surveys, observational data, physiological measures and internet forum‐based discussions/“netnographies” (discourse surrounding women's PIED use in online forum spaces). Sample sizes ranged from n = 1 to n = 4746. Earlier studies (pre‐2010, n = 9) more frequently employed medical or psychiatric frameworks focused on pathology and side effects, whereas more recent studies (post‐2010, n = 13) more commonly used qualitative approaches centred on lived experience and social context (including online spaces). These differences were noted when synthesising findings across studies.

Of the studies that directly recruited participants (i.e., not netnographical or online observational designs; n = 18), 11 studies featured only female participants, while seven surveyed both male and female participants. Participants included competitive bodybuilders, competitive strength athletes, and recreational bodybuilders/strength athletes. Four studies focused on specific clinical populations, such as women in substance‐use treatment or victims of sexual trauma. Results were analysed quantitatively (10 studies), qualitatively (11 studies), and using mixed‐methods (1 study). Table 1 contains a summary of included studies. Of these, 16 were classified as high quality and 4 as moderate quality based on the MMAT criteria. No studies were rated as low quality. Five key themes were identified from the included studies: (i) body image; (ii) information sharing and the influence of male voices; (iii) mental health and PIED use; (iv) negotiation of the meaning and limits of femininity; and (v) social factors and effects of lifestyle and PIED use, as displayed in Figure 2.

3.1. Body Image

3.1.1. Body Image Disturbance as a Pre‐Cursor to Weight‐Training

Across studies examining pre‐cursors to weight‐training and PIED use, women frequently reported histories of body dysmorphia, body image disturbance, and disordered eating [9, 34, 35, 36]. In quantitative studies, between 33% and 64% of female PIED‐using participants reported significant body dissatisfaction, while 27%–60% reported a current or past history of disordered eating or related body image disturbance [13, 23, 34, 36, 37, 38]. For some, these concerns directly influenced their decision to begin weight training. The ‘fit, muscular’ ideal promoted in gym spaces was often seen as a positive alternative to the thin, fashion‐model body ideal many had previously internalised [34]. As their bodies began to align more with this ‘fit, muscular’ ideal through training and diet, many women across several studies reported increased self‐confidence [9, 25, 37, 39, 40, 41].

3.1.2. Meaning Attached to Body Image

Some participants characterised the body as a status symbol, where the ability to deliberately manipulate its appearance was perceived as a reflection of personal traits such as discipline, control, achievement and self‐worth [25, 41, 42]. Becoming closer to the ideal body represented willpower, strength and value as a person, whereas deviating from it represented weakness and a lack of self‐discipline [25, 42]. This often led to highly regimented management of training and dieting, which could take priority over other aspects of life [35]. This was especially pertinent when women began competitive bodybuilding pursuits.

3.1.3. PIEDs as a Tool to Aesthetic Success and Satisfaction

Two primary motivations for initiating PIEDs emerged from the integrated analysis of data across the studies. For competitive bodybuilders, PIEDs were used to gain a competitive advantage and manipulate their bodies to meet category‐specific physique requirements [34, 39]. Conversely, other women discussed PIEDs as a means of assisting them in becoming closer to their idealised body image [25, 39], compared to competition standards. Common among both narratives was the initiation of PIEDs as an aesthetically motivated decision, alongside strict dieting and regimented training schedules [23, 26, 34, 39]. Synthesis revealed that, in studies examining the initial effects of PIEDs on body composition, all women reported experiencing changes seen as desirable [9, 25, 37, 39, 40, 41].

3.1.4. Continuing Body Image Concern

Following PIED initiation, despite their bodies aligning more closely with their ‘ideal’ (either externally or internally driven), participants across several studies frequently reported ongoing body dissatisfaction [23, 25, 34, 37]. This included concerns of too much body fat, too little muscle development, or dissatisfaction with body shape [23, 25, 34, 37]. Among competitive bodybuilders, dissatisfaction was especially tied to poor competition outcomes [21, 23]. This dysmorphia and ongoing dissatisfaction are summarised below:

Despite hard training and the use of AAS [anabolic androgenic steroids], women may still feel that they are not achieving what they want. The feeling of dissatisfaction persists even though their muscles are getting bigger. Their distorted body image makes it difficult for them to perceive their own bodily changes realistically [25].

Some researchers noted that increased muscle development could coincide with the development of muscle dysmorphia [25, 26, 34, 37]. Among studies reporting quantitative data, 50%–60% of women reported continued or worsened body dissatisfaction following initiation of PIEDs, with many reporting an increased drive for muscularity and leanness, leading to tighter dietary control and escalation in PIED dosage [23, 25, 30, 35].

3.2. Information Sharing and the Influence of Male Voices

3.2.1. Peer Education, Gatekeeping and Gendered Knowledge Networks

The social and legal implications of PIED use meant that information about substances was often not readily available for study participants and thus, peer‐education was relied on for decision making processes [21, 39, 42, 43]. However, authors noted that peer‐education led by and specific to women was a rarity, in both in‐person settings and online spaces. Many women described having to engage in guesswork about their PIED use (compound types, dosing, risk), based on male‐oriented information and advice [9, 42].

A study participant described this struggle:

I read about it on different scientific pages and tried to find different forums about girls who might have tried it before, but it was not easy to find. I just gathered what I found and read through and came to a conclusion. Research among men is easier to find. I ended up trying to implement the same for myself [9].

The role of male‐dominated peer networks in women's decisions around PIED use was frequently discussed across the studies and featured at various stages of women's use. In studies exploring initiation, almost all women reported being introduced to PIEDs by a male figure in their life such as a partner, coach, colleague or fellow athlete [9, 19, 21, 35, 37, 44].

Börjesson and colleagues summarised:

The women are usually led by men who give them advice based on how men use AAS. They request first‐hand information about how AAS works in a female body but rarely exchange experiences with each another [25].

This often led to heavy reliance on male advice for compound type, dosage and cycle planning. Several women described either not being warned about female‐specific side‐effects of substances or being assured by these male intermediaries not to worry [9, 21, 25]. Others were misinformed or given incorrect substances, with long‐term consequences. In Havnes and colleagues' study (2021), this process is described by both the researchers and participants:

As she did not dare to inject herself, she asked a male friend to assist, and she described his reaction to the planned cycle: ‘What the hell, that's way too little, you can't inject such small amount. That won't work for you’ … So, he added more [9].

The worst was that I was supposed to get Winstrol, but instead he gave me Omnadren, which is testo, so I got a little … It was not good at all […] Looking back, I realise that he had no clue (Participant) [9].

Online forums were intended to facilitate open conversation among women, but male dominance persisted there too. Havnes et al. (2021) described:

She had noticed that there were few females searching information for themselves; rather, the partners of many female AAS users searched for information about women and steroid use [9].

3.2.2. ‘Sis Science’

In contrast, some studies discussed certain forums showing a growing resistance to male‐dominated narratives. In these forums, women expressed awareness that most available guidance was based on male bodies and highlighted the need for tailored information [24, 42, 44]. Sverkersson et al. (2020) characterised this pushback and initiative‐taking as the emergence of “sis‐science” (a term used to contrast with “bro‐science”) [42]. Interaction between female forum members included encouraging each other to take initiative in their research processes and drawing awareness to the common male bias in advice:

Most male trainers, boyfriends and husbands are sorting out your cycles. If you are getting your info from men, it's up to YOU to STILL do the research and know the whats/whens/where's of what you're putting in your body [44].

These findings illustrate the ongoing gender dynamics in PIED use and highlight women's increasing push for autonomy and community‐specific knowledge sharing in some spaces.

3.3. Mental Health and PIED Use

3.3.1. History of Mental Illness

Several studies identified high rates of pre‐existing mental illness among women who had used PIEDs, with prevalence estimates ranging from 60% to over 80% of participants reporting a prior psychiatric diagnosis across studies that explored this [8, 19, 22, 25, 30]. A comparative quantitative study by Ip and colleagues (focused on AAS use specifically) found that 50% of AAS‐using females in their sample had reported a prior psychiatric diagnosis, compared with 17.4% of AAS‐using males and 22.2% of non‐AAS‐using females [25]. Specifically, they found that an ADHD diagnosis was also significantly more common among AAS‐using females (16.7%) than in non‐AAS‐using females (2.2%) [26]. Qualitative studies further reinforced this pattern, noting frequent histories of depression, trauma, and psychological distress among females who used PIEDs [12, 19, 22, 31]. Across all studies, bulimia nervosa was the most frequently reported mental illness [9, 23, 26]. Quantitatively, this diagnosis was reported as occurring at significantly higher rates among PIED‐using women than PIED‐using men (25.0% vs. 0.2%) or non‐PIED‐using women (3.5%) in one study [25]. High levels of trauma, particularly sexual trauma, were also reported in some studies [9, 26, 35, 37]. In quantitative studies, female PIED‐users reported histories of sexual trauma at rates ranging from 13% [37]–41.7% [26].

3.3.2. Mental Health During PIED Use

Ten of the included studies directly examined psychological side effects of PIED use in women. Across results, reported side effects included aggression, irritability, depression, anxiety, emotional numbness, and mood swings during PIED use [9, 21, 34, 35, 40]. While most women reported these symptoms as negative, some women viewed increased aggression as enhancing competitive drive [40]. Emotional numbness was also described as advantageous in cases where there was a significant history of trauma and mental ill health [9]. Indeed, Gruber and Pope (1999) note that among female rape victims, AAS use in combination with weight training was seen as helpful in managing mental health.

Several women reported increased mental wellbeing and sense of euphoria during PIED use that contributed to their continued use [9, 34, 42]. One study found that some female participants actively using PIEDs presented with symptoms of hypomania [34]. The positive psychological effects experienced by women using PIEDs may also be attributable to the associated physical transformations that came with their use. Satisfaction with their physical appearance and identity gains was described in one study as leading to some women accepting or overlooking negative side effects [9]. One participant describes this experience:

It [steroids] does so much with your mentality, you get so strong. I mean – if you've been troubled with shame over your body, that you're not good enough and so on. I had actually never felt as well as I did that year when I took steroids [9].

Increased libido was another common, generally positively‐received side‐effect. This was especially pronounced in cases where both members of the couple were using PIEDs [9, 42].

Online forums featured open discussions around sexuality, with many women expressing pride in how PIEDs affected their sex lives.

Svekersson summarises this:

Side‐effects and the fear of masculinisation are now far away; instead, we see a clear celebration of the fitness doping lifestyle and what are seen as positive effects of the drugs. There is no shame or shyness present, but rather a positive affirmation of sexuality and desires [42].

3.3.3. Impacts of Discontinuation

Discontinuing PIEDs often triggered mental health struggles, including depression [34, 39]. This was sometimes related to physical regression, lack of goals and direction, and changes in social dynamics [39]. Andreasson and Johansson describe an identity crisis associated with ‘unbecoming’ a PIED user:

The psychological dependency [on PIEDs], is tightly interwoven with a specific lifestyle and ideas about a muscular ideal body. Quitting steroids could thus endanger the person's whole body and lifestyle project. In particular, the fear of losing a certain body and look can have detrimental effects on people's attempts to exit and stop using the drugs [39].

In summary, women's mental health experiences in relation to PIEDs were complex, ranging from severe psychological distress to improved confidence and emotional wellbeing.

3.4. Negotiation of the Meaning and Limits of Femininity

3.4.1. Boundaries of Acceptable Femininity

Women's fears surrounding virilisation and their negotiation of femininity were consistent themes across almost all studies. One study participant summarised:

I want to be physically fit but still look like a woman you know? [39]

Women's pursuit of muscle‐building, especially competitive bodybuilding, could often challenge traditional gender norms and feminine ideals. This is described by Borjesson et al., (2021):

People's views on femininity are affected by traditions and societal norms in terms of appearance and appropriate clothing. Women with large muscles are questioned by others [25].

One participant also described this, in relation to outsiders' reactions to her changing physique:

When my body got muscles, they roared with laughter at me and said that the men's department is on the other side of the street … do I need to prove that I am a girl or what … or do I look like a guy? [25].

Upon initiating PIEDs, studies that explored this theme reported that most women sought to gain competitive or aesthetic benefits from PIEDs while staying within (often self‐defined) feminine boundaries [9, 21, 39]. Decisions about substance type and dosage were regularly centred on achieving a “slim, toned and slightly muscular body” as opposed to the “bulky”, muscular frame typically associated with bodybuilders [25, 42]. Oral compounds were typically favoured over injectables, with one study noting that several women considered injectables “extreme” and more likely to result in unwanted side effects [19]. Across studies that explored virilisation, there appeared to be a point for participants where a certain level of muscle was perceived as ‘too much’ of a deviation against feminine norms; however, this point was not always clear, and was constantly in a process of negotiation [9, 21, 25].

3.4.2. Fears of and Responding to Virilisation

When using PIEDs, the added danger of virilising side effects brought new forms of negotiation into these limits. Several studies indicated that virilisation was the most common fear women held prior to PIED initiation, given the testosterone‐based nature of many substances and lack of available information on these substances that careered to female physiology [9, 21, 41, 42]. Study participants commonly discussed being unable to gain sufficient knowledge about substances prior to using them and being unprepared for the side effects that followed [9, 25].

Virilising side‐effects that women experienced, as reported across study findings, included clitoral growth, vocal deepening, hair loss, facial hair, breast reduction, skin changes and menstrual changes [9, 25, 34, 40, 41, 45]. Some women noted that these side‐effects were temporary and appeared to dissipate after ending their PIED cycle, but for others, these changes were permanent and highly distressing [9, 25]. Clitoral growth and vocal deepening were described as particularly distressing across studies [9, 21, 40].

For example:

You're standing in the mirror looking at yourself and you've got facial hair that's when you start to go to yourself what have I done to myself. I've done this to myself [9]. Yes, if not even more than that [double size], plus [enlarged] labia, which gave me huge complications … Well, not complications but rather poor self‐confidence [9].

Some women, particularly competitive bodybuilders, accepted or welcomed these effects as trade‐offs [9, 40]. Loss of menses could also be welcomed, as a sign of low body fat levels [9]. One study also suggested that among women with sexual trauma, appearing more masculine was seen as protective and thus, welcomed [37].

Overall, across studies, women appeared to weigh the risks of virilisation against the benefits of PIEDs, with personal boundaries around femininity shifting over time.

3.5. Social Factors and Effects of Lifestyle and PIED Use

3.5.1. Searching for Belonging

In studies that explored weight‐training initiation, several women described turning to gym environments in search of belonging and acceptance [9, 25, 41]. For some, striving towards a particular aesthetic was intertwined with a deeper desire for social approval, especially among those active in commercial gyms prior to PIED initiation [9, 37]. Women reflected on finding a sense of social belonging within the gym setting, not experienced elsewhere:

It was where I felt okay, accepted maybe. I didn't feel down like I always had [9].

One study participant explicitly linked her desire for social acceptance to her decision to begin using PIEDs, alongside aesthetic goals.

It also came from other things, like confidence, self‐esteem … Maybe it will boost my confidence and such [9].

However, as involvement with PIEDs progressed, several women experienced social isolation due to their dedication to substances and training.

I didn't care very much about what happened to my ex and that the children chose to move … I was only living for my workouts and substances [25].

3.5.2. Stigma and Secrecy

Stigma and secrecy around PIED use were reported as major factors in increased social isolation and disconnection for some women. Borjesson describes this below:

The secret use of AAS requires women to live with lies. The fear of this secret use being revealed is constant, if the physical changes and side effects were to be noticed by others and lead to social consequences and penalties [25].

The secrecy around PIED use appeared to be a result of both social stigma and fears of legal ramifications. In one of the studies, women regarded vocal changes associated with PIED use as especially distressing, as it could expose use [9]. Concerns about discovery increased anxiety and even led some women to discontinue use. For example:

I actually had nightmares that the Police would take me and my children would be alone. Then I stopped at once. That fear was horrible [25].

Overall, results across studies suggested that social motivations, such as desire for acceptance, often played a role in women's PIED initiation However, throughout PIED use, negative social experiences such as isolation, stigma and secrecy, could occur.

3.6. Correlates and Experiences of PIED Use Among Women

Based on the findings synthesised above, Table 2 summarises the key psychosocial factors reported across different stages of PIED use among women engaged in weight‐training. Across findings, several psychosocial patterns and themes emerged consistently. In particular, body image‐related concerns (including body image dissatisfaction, body dysmorphia/muscle dysmorphia and eating disorder symptomology) were reported as a key correlate in women's decisions (including initiation) and experiences with PIEDs across several studies (n = 15). Notably, this theme was discussed in both earlier (pre‐2010, n = 6) and more recent studies (post‐2010, n = 9). Similarly, mental health vulnerabilities, including depression, anxiety and trauma history, appear in findings across all decades of research [19, 25, 26, 37].

However, there were also points of divergence, both between and within study findings. For example, while some studies described women experiencing heightened shame, secrecy and worsening body dissatisfaction following PIED use [8, 18, 23], others reported that some women experienced their PIED use (and physical changes associated) as empowering or self‐determined [34, 45]. Quantitative findings also varied, with mixed evidence regarding associations between AAS use, body dissatisfaction and muscle dysmorphia [12]. Many studies framed men as primary influences in women's initiation and patterns of PIED use and described women's peer‐education spaces as limited or completely absent [8, 18, 19, 23, 31]. More recent qualitative studies however (2010 onwards) have highlighted the emergence of online spaces where women share experiential knowledge, negotiate risk and engage in harm‐reduction practices, sometimes challenging male‐dominated narratives [37, 38, 42].

4. Discussion

This mixed‐methods integrative systematic review synthesised findings from 22 empirical studies to explore the psychosocial experiences of PIED use among weight‐training women. The results provide insight into how women's decisions around PIED use are shaped by sociocultural dynamics, psychological processes, and access to (or lack of) reliable information. Across the included studies, motivations for initiating weight‐training varied but commonly included body image improvement, social connection, and mental health support. For many women, the decision to use PIEDs followed these initial motivations and was often influenced by social networks, particularly men in gym environments.

Women across the studies reported a range of positive effects from PIED use, including rapid improvements in physique, enhanced athletic performance, and increased confidence. However, these benefits frequently coexisted with secrecy, shame, and psychological distress, especially when unwanted side effects, such as virilisation, were experienced. These negative experiences sometimes led to the decision to cease PIED use, a process that could be accompanied by depression and identity loss. These findings highlight the complexity associated with women's PIED use and underscore the need for gender‐informed public health approaches.

4.1. Alignment With Male Literature

Many findings parallel existing research on men's PIED use. Studies with men who use PIEDs have long highlighted body dissatisfaction and image concerns as primary motivations for initiation [12, 13]. Similarly, several studies in this review found that body image disturbances were central to women's decisions to use PIEDs. For men, a hyper‐muscular physique was often associated with a sense of power and dominance [17, 46]. Similarly, some studies in this review indicated that for women, one's physique was also associated with social status [25, 39]. However, for women this association intersected with gender expectations and fear of social sanction. The pursuit of muscularity was often seen as deviating from traditional femininity, leading to ongoing self‐negotiation around identity. These findings suggest that while women share certain motivational parallels with men, their experiences are further complicated by gendered stigma and identity management, which require tailored support and intervention strategies.

4.2. Body Image, Secrecy and Stigma

Across the studies, body image concerns were present before, during, and after PIED use. Though many women hoped PIEDs would alleviate dissatisfaction, concerns around body image and muscularity level often worsened with use, suggesting parallels with muscle dysmorphia observed in men. This phenomenon is underexplored in women and warrants further investigation. The secrecy surrounding women's PIED use often appeared to stem from the stigma associated with muscularity and virilisation, traits traditionally aligned with masculinity. Unlike male‐dominated gym spaces where “bro science” supports informal knowledge sharing, women reported limited peer support and accessible information. Although a small body of “sis science” is emerging, it remains scarce [24, 42]. From an applied standpoint, these findings emphasise the importance of developing gender‐specific educational materials that address stigma, provide accurate health information and recognise diverse motivations for PIED use.

4.3. Gender, Identity and Femininity

A recurring theme was the tension women often reported feeling between building muscle and retaining femininity. Several studies described how participants viewed their bodies as existing within a delicate boundary between ‘acceptable femininity’ and ‘too masculine’. While women often embraced strength, many expressed discomfort or distress when they believed they had crossed a boundary into masculinity, often marked by unwanted side effects like deepened voices or facial hair. This ambiguity created internal conflict and social tension, reflecting broader societal norms around gender and appearance. The ongoing negotiation of identity that participants underwent often involved redefining personal femininity and reconciling it with the physical transformations brought on by PIED use. For some, this led to empowerment and self‐expression, while for others, it caused shame, confusion or social alienation. Given the relationship with gendered sociocultural norms in many of these dynamics, and consistent with Fomiatti and colleagues’ critique of gendered framings in the literature, our findings underscore the importance of developing research and policy approaches that move beyond moralising narratives towards gender‐sensitive harm reduction and education [28].

4.4. Mental Health

Mental health concerns were common among women who used PIEDs. Several studies noted high rates of pre‐existing mental health conditions among women who went on to use PIEDs. Furthermore, the results of quantitative comparitive studies suggest that certain mental health conditions, particularly eating disorders and trauma, may exist at higher rates among women who use PIEDs compared with men who use PIEDs, as well as compared with women who don't use PIEDs [23, 25, 26]. While prior research has identified mental illness as a potential side effect of PIED use, this review suggests that in many cases, symptoms may predate use. This highlights the importance of integrated mental health support for women using or considering using PIEDs, with services equipped to address trauma histories and disordered eating patterns.

Prospective studies are needed to further explore the relationship between PIED use and mental health outcomes, including whether PIEDs exacerbate existing vulnerabilities or contribute to new psychological difficulties. It's also possible that mental illness has been underreported in male cohorts, either due to a lack of diagnosis or gender norms that discourage help‐seeking behaviour. Future research using longitudinal and mixed‐methods approaches could clarify temporal relationships between PIED use and mental health trajectories.

4.5. Limitations in Current Research

Six of the included studies focused on AAS, with limited exploration of other classes of PIEDs, such as fat‐burners or stimulants, which are commonly used by women [19, 42, 44]. Moreover, many studies failed to distinguish between substance types when reporting on participants' experiences with PIEDs, making it difficult to assess substance‐specific effects.

Additionally, participant recruitment in several studies (n = 4) came from helplines or clinical settings, which may bias findings towards those who experienced more severe negative effects. As a result, positive or neutral experiences with PIEDs may be underrepresented in the literature. Future research should employ broader recruitment strategies, including online and community‐based sampling, to capture the diversity of women's experiences.

The temporal span of included studies in this review both highlighted key trends and presented challenges for synthesis. The consistency of some themes, particularly body‐image related concerns and certain mental health symptomology, across four decades of literature suggests that certain psychosocial phenomena may be fundamentally tied to women's PIED use, even as sociocultural factors develop and change. However, several sociocultural shifts have occurred in this 40‐year period, including increased online access, shifting gender and beauty norms, developments in medical understanding, and changing PIED‐use practices [18, 42]. It is crucial to consider these contextual factors when interpreting findings. While the limited number of included studies in this review and their significant heterogeneity did not allow for a structured temporal analysis, as evidence continues to grow in this area (41% of included studies published post‐2020), future reviews may be able to provide more comprehensive syntheses of changes in women's practices and experiences with PIEDs across time.

4.6. Implications and Future Directions

This review is the first, to our knowledge, to specifically examine the psychosocial experiences of PIED use in women who weight‐train. Historically framed as a male‐dominated issue, this review challenges that perception and highlights the multifaceted experiences of women, shaped by stigma, gender norms, and inadequate access to information. Future research should move beyond capturing prevalence and risk‐focused frameworks to examine broader psychosocial, relational, and structural factors shaping women's PIED use. This includes exploring women's decision‐making autonomy, positive or empowering motivations, the role of digital communities/social media microcultures, long‐term identity and relationship impacts, and comparative experiences across different PIED classes. Prospective and intersectional research is also needed to understand experiences across different cultural and athletic contexts.

The findings reinforce the urgent need for more research, education and tailored harm‐reduction strategies for women. Increased attention to gender‐specific patterns of use and mental health comorbidities is critical. Developing co‐designed, gender‐specific educational materials, peer‐led online harm‐reduction initiatives, and non‐judgmental clinical training for healthcare professionals are practical next steps arising from this review. A harm‐reduction approach, advocated in several studies, may provide a pathway forward [6, 47]. This approach supports informed decision‐making while bridging the divide between health professionals and the PIED‐using community. In parallel, policymakers should consider integrating women‐specific PIED information within broader drug and supplement regulation frameworks to reduce misinformation and risk.

Current drug prohibition frameworks also limit women's access to reliable information and healthcare support. Because many PIEDs are controlled substances, open discussion and harm‐reduction messaging are often constrained, reinforcing secrecy and stigma [47]. A more balanced regulatory approach, one that maintains safety while enabling evidence‐based, gender‐sensitive education and confidential support, would better protect women's health.

4.7. Strengths and Limitations of Review

This study is the first integrative systematic review to explore psychosocial experiences and PIED use specifically among weight‐training women, offering a novel synthesis of diverse qualitative and quantitative findings. An integrative review of mixed methods studies was conducted to synthesise first‐ (participant quotes, data) and second‐(author interpretations) order constructs across diverse studies and generate new interpretive insights [29]. However, several limitations should be acknowledged. The highly heterogeneous nature of included studies, with significant variation in study design (11 qualitative, 10 quantitative, 1 mixed‐methods), data collection and analysis methods, made comparisons across studies challenging though efforts to enhance rigour were applied and the integrative themes were confirmed by two raters. Nevertheless, it was difficult to draw firm conclusions about unique gendered experiences due to the small number and varying quality of included studies.

Additionally, the inclusion criteria were broadened due to the scarcity of research and no date range was applied. As a result, included studies spanned from 1985 to 2023, a period during which attitudes, policies, and social norms have shifted considerably. Some older findings may therefore be less relevant to contemporary contexts. Finally, limiting the search to English‐language publications may have introduced language bias and excluded relevant international research.

5. Conclusion

The findings of this review highlight the unique psychosocial factors influencing PIED use in weight‐training women. Key themes include body image concerns and their intersection with social dynamics, complex gendered perceptions of PIED use, and mental health challenges. A critical issue identified is the severe lack of reliable, women‐specific information on PIEDs. Due to stigma and secrecy, women often rely on guidance designed for men, which does not account for sex‐specific risks, placing them at greater risk for harm. Embedding gender‐sensitive harm‐reduction approaches within healthcare, sport, and online education spaces could help mitigate risks, foster informed decision‐making, and promote safer engagement with PIEDs. By addressing these gaps, we can foster informed, effective interventions that empower and protect the health and agency of this population.

Author Contributions

H.S. conceived the study, developed the methodology, conducted the analysis and drafted the manuscript. Z.W. contributed to study conceptualisation and assisted with study screening, data extraction, quality appraisal, data analysis and manuscript editing. L.H. and M.U. provided feedback and ongoing oversight throughout study conceptualisation, data analysis and interpretation and contributed to manuscript editing. All authors critically revised the manuscript for important intellectual content, approved the final version for publication and agree to be accountable for all aspects of the work. Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Supporting Information.

Data S2: Supporting Information.

Appendix A.

Database Search Strategy.

Search Strategy.

Systematic searches were conducted across PubMed, PsycINFO, Scopus, Web of Science, and CINAHL. The search strategy combined four conceptual categories: (i) women; (ii) strength or athletic contexts; (iii) performance and image‐enhancing drugs (PIED); and (iv) psychosocial or experiential factors. Key‐words are presented in the table below (Table A1).

TABLE A1.

Keywords in database searches.

Category 1	Category 2	Category 3	Category 4
Women*	Athlete	Performance enhancing drugs*	Athlete identity
Female	Bodybuilder*	Performance and image enhancing drugs*	Athletic injury*
Gender	Powerlifter*	PEDs	Athletic burnout
	Weightlifting*	PIEDs	Culture
	gym	IPEDs	Cultural
	Weight training	Anabolic steroids*	Experience
	Strength training	Anabolic androgenic steroids*	Psychology*
	Resistance training	Doping	Psychopathology
	Fitness	Muscle enhancing substance	Psychosocial
			Social*
			Social systems
			Social status
			Mood disorder*
			Mental illness
			Mental health

Note: The full database‐specific search dates, search strings, Boolean operators and filters are presented below (Table A2).

TABLE A2.

Database search strategy.

Search #	Date searched	Databases	Search string	Filters and limits applied
1	16 May 2022	PubMed PsycINFO Scopus Web of Science CINAHL	(women* OR female OR gender) AND (athlete OR bodybuilder* OR powerlifter* OR weightlifting* OR gym OR weight training OR strength training OR resistance training OR fitness) AND (performance enhancing drugs* OR performance and image enhancing drug* OR PIEDs OR PIEDs OR IPEDs OR anabolic steroids* OR anabolic androgenic steroids* OR doping OR muscle enhancing substance) AND (athlete identity OR athletic injury* OR athletic burnout OR culture OR cultural OR experience OR psychology* OR psychopathology OR psychosocial OR social* OR social systems* OR social status OR mood disorder* OR mental health OR mental illness)	English‐language only; all publication years
2	17 June 2024	PubMed PsycINFO Scopus Web of Science CINAHL	(women* OR female OR gender) AND (athlete OR bodybuilder* OR powerlifter* OR weightlifting* OR gym OR weight training OR strength training OR resistance training OR fitness) AND (performance enhancing drugs* OR performance and image enhancing drug* OR PIEDs OR PIEDs OR IPEDs OR anabolic steroids* OR anabolic androgenic steroids* OR doping OR muscle enhancing substance) AND (athlete identity OR athletic injury* OR athletic burnout OR culture OR cultural OR experience OR psychology* OR psychopathology OR psychosocial OR social* OR social systems* OR social status OR mood disorder* OR mental health OR mental illness)	English‐language only; no region limits; studies published since May 2022

Note: Truncation symbol (*) was used to capture multiple word endings (e.g., “athlete*” retrieves “athlete” and “athletes”). Boolean operators (AND/OR) were used to combine search terms across conceptual categories.

Schuurs H. C., Walter Z., Hides L., and Underwood M., “A Systematic Review Investigating the Psychosocial Factors Influencing Initiation, Use and Subjective Experience of Performance and Image‐Enhancing Drugs in Women Who Weight‐Train,” Drug and Alcohol Review 45, no. 2 (2026): e70112, 10.1111/dar.70112.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.