AMA Journal of Ethics^®

We are entering a golden age of drug development. The use of…substances in athletics will grow proportionately…. It will be…critical…both medically and philosophically [1].

You cannot hold a comprehensive discussion about bodybuilding without talking about the use of anabolic steroids and other performance-enhancing drugs [2].

Widespread attention to unleashing the potential of the human body, fitness, competitive sports, and a dynamic and healthy lifestyle has allowed bodybuilding to become more observable and conventional within popular culture in the United States than ever before. Rapid advances in technology and sports medicine have given bodybuilders more options for training and exercise physiology and stronger types of anabolic steroids, human growth hormones, and testosterones. (Think only, for example, of New York Yankee all-star third baseman, Alex Rodriguez, aka A-Rod, who was suspended for the entire 162-game 2014 season for using banned performance-enhancing drugs.) This link to anabolic steroids has contributed to giving bodybuilding a negative image.

The central question this article explores is whether the phenomenon, practice, and sport of bodybuilding is rooted in an aesthetic that American culture misjudges or whether it represents a truly marginal activity ( the idea one might get from the online forum entitled “Underground Bodybuilding”). Misjudgment, here, cuts both ways: appraising a commodity—in this case, a body image—at a higher value than what it is actually worth (overprizing) or appraising a commodity—again, body image—at a lower value than what it is actually worth. In the long run, is bodybuilding merely a logical extension of a healthy lifestyle and athletic activity or the expression of an unhealthy lifestyle? Bodybuilder contributors to various online fora and their supporters argue that the public remains ignorant—yet still seems to rush to judgment—about performance-enhancing substances and the people who use them [3]. Bodybuilders complain that even their spouses, friends, and family members do not comprehend what motivates them [3].

Beneath this significant conceptual issue lies a practical one of even greater consequence—the ethics of sports medicine and a challenge to professionalism that students, residents, and other physicians are likely to confront in their education and daily practice. Previous research has discussed the unclear role of medicine as a basis for knowledge and expertise among bodybuilding participants, many of whom systematically disavow medical assertions on the use and dangers of chemical enhancements that dramatically improve physique [4]. Those data on perceptions of the medical profession, risk, and bodybuilders’ sources of medical information, suggest medicine is but one among many sources for information on the social construction of self and body in postmodern society.

The human body is physically and also socially constructed. Hence, it represents, as Anthony Synnott says, numerous and evolving personified “selves” and very different realities and perceptions of reality [5]. These meanings change across time and culture: the body can be thought of as a tomb, temple, or perhaps a corpse [5]. All agree that the body is physical, but for some (e.g., those with religious or philosophical beliefs) it is also spiritual and mystical. Bodybuilding (and biomedicine, for the most part) view the body as a machine with no absolute and universal meaning. Thus, bodybuilders can construct their physical bodies to fit the meaning that “body” has for them.

In Defense of Bodybuilding

Serious training for competition in bodybuilding requires toughness, dedication, discipline, and the willingness to denounce mediocrity, comfort, and a decadent lifestyle. Those who do not appreciate this dedication may mislabel the bodybuilder, perhaps from envy. It is not rare to hear a condescending attitude expressed toward individuals who exhibit an ultra-strong work ethic and unflinching dedication in the gym and labor intensely as they prepare for contests and competition. Upon close inspection, bodybuilding is much more than flexing muscles on a stage. Advocates note that bodybuilding fosters discipline or mental toughness, maintains good health, boosts self-confidence, and promotes rest and healthy sleep [6]. Confidence is not arrogance; the bodybuilder often leaves pieces of his or her heart in the gym or on the stage.

The Case against Bodybuilding

Arrogant. Conceited. Narcissistic. We commonly hear these adjectives used to describe bodybuilders. To be sure, some bodybuilders—both competitive and noncompetitive—are narcissistic, conceited, proud, arrogant, and even worse—obsessed with posing for and admiring themselves in mirrors and body-image-driven impression management. In short, we might characterize bodybuilders as far too “into themselves.” Although bodybuilders clearly do not have a monopoly on these characteristics, stereotypes often contain a grain of truth.

Bodybuilding can also pose serious health risks. It is erroneously believed that bodybuilding requires large increases of protein consumption. Too much protein—often consumed in the form of supplements—can cause more harm than good, straining organs, especially kidneys [6]. Excessive sweating during workouts can result in dehydration that, in turn, can cause painful cramping. And the lifting of weights can itself be dangerous without a spotter and even with one.

A Small Research Project

What image does the bodybuilding culture itself promote? To examine this question, I searched the Internet for bodybuilding fora. I found six: Bodybuilding [7]; Underground Bodybuilding [8]; EliteFitness [3]; Muscle Talk [9]; Wanna Be Big [10]; and Get Big Bodybuilding [11]. All sites have essentially the same functions, the same structure, and highlight the same general areas: supplements, chemical enhancement (anabolic steroids), blogs, workout programs, specific exercises, photo galleries, competitions, motivational content, and diet and nutrition. Not surprisingly, there is market segmentation by demographics (e.g., teens, over-35, women, personal trainers) and particular niches (e.g., power lifters, professionals, other athletes).

The EliteFitness website homepage has a tab not explicitly addressed by other sites: Sex (“Not getting laid? Click here to change things!”), demonstrating the strong perceived link between physical appearance—especially muscularity—and sexual allure [12]. For this reason, the EliteFitness site and its fora lend an extra dimension to my analysis of the bodybuilding culture while retaining the functions, structure, and specific categories of the other sites. I registered online to gain member status and was put automatically on the EliteFitness mailing list.

EliteFitness sent 44 e-mail advertisements in the next 30 days. Each ad hawked a particular product to enhance bodybuilding. Table 1 lists those product types and shows how often each type was promoted.

The overwhelming majority (40 of 44; 90.9 percent) touted the positive effects of steroids (build muscle, increase strength, burn fat, high sexual or athletic performance) without mention of dangerous side effects.

Forty of the 44 messages contained at least one image. Many contained more than one. Table 2 shows what kind of images was displayed and the frequency of usage.

In the ads with one man and one woman, there is physical contact between models and both men and women ritualistically display the characteristic youth, beauty/attractiveness, flawlessness/perfection, and sexual allure of the provocateur.

Not to be outdone, the ads with one man and two women—imply sexual activity—in fact, a ménage a trois.

Both men and women wear only bikinis, exposing a great deal of flesh. There is intimate contact between the man and women and even between the women, and all three are in bed together.

One ad featuring one woman, displays her as a passive and submissive provocateur in high heels, bent over and leaning away from—yet suggestively looking directly at—the viewer.

By contrast ads with a single man, although provocative, are less sexually suggestive than those including women.

In the ad depicting two men, one is tying a tourniquet around the arm of another in preparation for a blood test. The same preparation would be used for a steroid injection. The ad is marketing four products: Winstrol and Masteron (anabolic steroids) hGH (human growth hormone), and testosterone. Each is injectable. (Winstrol comes in oral form but with greater toxicity than the injectable form.)

Overall, the data display a clear message: inject or swallow various types of these products to increase muscle, sexual allure, and sexual libido.

People lift weights and build their bodies in other ways for a variety of reasons: to build muscle, lose fat, get stronger, become better athletes, and compete at a higher level in their chosen sports. In the 1970s, Arnold Schwarzenegger, bodybuilder and former Mr. Universe, united the physique and power of the bodybuilder with the sexual attraction of the leading man in blockbuster American movies. Since that breakthrough, men have begun to build muscle for a new reason: defining extraordinary muscularity as a measure of masculinity (Cortese A, unpublished data).

Results from the present research indicate bodybuilders are a prime marketing target for readily available and relatively inexpensive anabolic steroids. This leads me to conclude that, as a group, bodybuilders consume these products. Such behavior is considered fringe by those athletes who believe in using only natural means for attaining fitness and muscular development. My sample is relatively small and may not be generalizable across all bodybuilding sites or other types of bodybuilding groups or subcultures.

Still, the bodybuilding culture is in step with society at large. Its reliance on and promotion of anabolic steroids to achieve extreme and even freakish results is not unlike dependence on cosmetic surgery and dentistry, spray tanning, and the wearing of wigs, toupees, and artificial braids. Our culture, it seems, instills in us an unquenchable thirst for the perfect body.