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.