What bodybuilders do to their bodies - and brains

Creating a physique that can win at the highest level of professional bodybuilding requires superhuman self-discipline, intense training and genetic good fortune. Increasingly, say the people familiar with the culture and its consequences, it cannot be done without illicit drugs and a willingness to push a body to - or past - its limits.

More than a dozen scientists, trainers, judges and competitors interviewed for this report said that just earning a pro card, an amateur's ticket to the pro ranks, is very difficult without anabolic steroids. Winning a marquee title drug-free? Several people laughed at the question.

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"Impossible," said Harrison Pope, one of the country's leading anabolic-steroid researchers.

The behemoths who win the best-known and most lucrative titles barely resemble the iconic, classically muscled champions of the past, such as Arnold Schwarzenegger, who won the sport's premiere title, Mr. Olympia, seven times between 1970 and 1980.

"Arnold Schwarzenegger would not win today," said Brad Schoenfeld, a professor at Lehman College in New York and author of several books on bodybuilding and muscle growth. "He would not even get a pro card."

Although bodybuilders spend years lifting weights and honing each muscle, they don't need to demonstrate strength for the judges beyond the ability to hold poses onstage.

They only need to look strong.

Some competitors - and a growing legion of young, mostly male admirers - chase that look by diving into a reckless pharmacological game of whack-a-mole that insiders say has grown more intense and dangerous as sheer size has trumped the "Greek god" ideal of previous generations.

They stack various steroids and other muscle-building drugs, then add in compounds intended to burn fat, blunt appetite or sap water from below the skin. They might counteract the worst side effects with another arsenal of medications, vitamins and supplements.

The result can be outlandish physiques that appear indestructible but are often quite fragile.

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The goal: 'A mass of muscle'

Judges say that in general, the ideal body should taper from a wide back to a narrow waist. In theory, no part should be disproportionately large or small. Skin should look almost shrink-wrapped over muscles so well-defined they appear to have been carved by a sculptor. Stage presence counts.

Those types of bodies are still rewarded in "natural" shows, which drug-test competitors, and in some divisions of typical bodybuilding competitions, judges say. Women in the bikini and figure categories and men in physique categories are very fit but not huge, and entrants in the men's classic physique and women's physique categories are larger but look more like the old-school ideal.

But since the advent of enormous bodybuilders dubbed "mass monsters" in the 1990s, size has often trumped aesthetics in the crowd-favorite open categories in which the largest men and women compete, Schoenfeld said. "When people go to the zoo, they want to see lions and tigers," he said, "not cats and dogs."

Jim Rockell, head judge for Mr. Olympia for nearly 20 years through 2013, said the biggest bodies now tend to win the open division no matter how grotesque they appear.

"They're overdoing steroids, overdoing growth hormones, oils and whatever else," he said. "It's pretty nasty."

"Oils" refers to an oil-based concoction that can be injected into muscles - often calves, biceps and shoulders - to make them temporarily appear larger.

"There's no real aesthetic look to their bodies," Rockell said. "They're just a mass of muscle."

Some bodybuilders don't hide their drug use. Current and former competitors at all levels talk openly about it on podcasts, in YouTube interviews and on social media.

Some preach caution and moderation; others advocate trying just about anything to get bigger. Trainers lament that young people in gyms - whether they plan to compete or not - often ask what they should take before learning what their bodies can do without drugs. And the drugs are easy to get, especially online.

"The quantities and the doses and the regimes that they're doing are insane compared to what people were able to get their hands on 10, 20, 30, let alone 40 years ago," said Stuart Phillips, a muscle physiologist at McMaster University in Hamilton, Ontario.

All the steroids in the world, however, couldn't pack Mr. Olympia-winning muscle onto most people. The rare bodybuilders who attain it start with a genetic gift for gaining muscle that they usually discover soon after they begin weight training.

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This is how lifting weights builds muscle:

Each muscle contains thousands of individual fibers, and the body grows and maintains them using amino acids that come from protein in food.

Inside each fiber are segments called sarcomeres, lined up end to end in rows and stacked like bricks in a wall.

Stressing a muscle, such as by lifting heavy weights, prompts the body to beef up that muscle by adding more sarcomeres within each fiber, like adding rings to a tree trunk. With each additional ring, the fibers - and therefore, the muscles - get bigger.

New blood vessels grow around the fibers to ferry fuel to the ever-larger muscles so they can handle the higher workload. Veins stretch and become more prominent.

At some point, the muscle hits a genetically determined ceiling beyond which it can't grow any more.

Steroids raise that ceiling.

"Steroids" in this Washington Post report refers to anabolic androgenic steroids - "anabolic" means muscle-building and "androgenic" means masculinizing. They include testosterone and hundreds of synthetic compounds that mimic it. They are different from corticosteroids, which are commonly prescribed to treat inflammation, skin diseases and other conditions.

Natural testosterone is produced mainly by the testicles (a lot) and ovaries (a little). A flood of it dramatically transforms male bodies during puberty, and a much lower but steady natural supply helps grow and maintain muscle in adult men. Estrogen probably does more of that work in adult women, Phillips said.

Some anabolic steroids have legitimate medical uses, such as treating muscle-wasting diseases, testosterone deficiency and delayed puberty. But they can come with serious side effects for people who abuse them, and most are banned by U.S. law without a doctor's prescription. The National Physique Committee and IFBB Pro League, the largest U.S. amateur and professional bodybuilding federations, do not routinely test for drugs. Jim Manion, who runs both federations, declined to answer specific questions about testing and issued a company statement saying, "The health, safety and welfare of all our competitors has, and always will be, of utmost importance to us."

In otherwise healthy people, steroids supercharge the body's muscle-building capabilities and shorten the recovery time needed between workouts. People can train harder and more often, adding more rings to the trees than their genes would otherwise allow.

How many extra rings they can add varies widely by person. Pope, a professor of psychiatry at Harvard Medical School and director of the biological psychiatry laboratory at the university's McLean Hospital, came up with a formula to estimate the amount of muscle a person could gain without drugs based on measurements of their bodies. He said some recent bodybuilding champions exceed the formula's upper limit by 50 percent.

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The price: Chaos within

Some drugs commonly used by bodybuilders can cause immediate illness and even death. Steroids, barring a rare reaction, are not among them. But large doses can cause hormonal upheaval in nearly every major system in the body.

"Steroids get sort of a break when in fact they are an illicit drug like any other," Pope said. "And like lots of other drugs, if they're used in small quantities, their effects are relatively modest, and if they're used in larger quantities, for longer, their effects become increasingly dangerous."

The long-term ramifications are just beginning to be understood, in large part because scientists cannot ethically give large doses of illegal drugs to volunteers in clinical trials.

Even if they could, there is no standard regimen to test.

Bodybuilders choose their own combinations of drugs, supplements and dosages, often based on word of mouth, internet influencers or recommendations from a coach or dealer. Buyers don't always know what they're getting, because fake and contaminated products abound in the underground supply chain, several trainers and bodybuilders said.

But as the people who began using large doses of steroids and other performance-enhancing drugs in the 1980s and 1990s reach middle age and beyond, the consequences are becoming clearer, especially in the heart, the reproductive system and the brain.

-The cardiovascular system

Although many drugs commonly used in bodybuilding can affect the heart, researchers consider steroids to be a prime suspect in the dangerously enlarged hearts that some bodybuilders develop, according to a sweeping 2014 statement from the Endocrine Society.

When the heart's pumping chamber, the left ventricle, gets too big and its walls grow too thick, it can't pump as well, said Onyedika Ilonze, an Indiana University cardiologist who specializes in heart failure and has treated steroid abusers with the condition.

The heart gets weaker, which can lead to congestive heart failure. High doses of steroids also raise blood pressure, increase cholesterol and seem to increase the risk of an irregular heartbeat, blood clots, heart attacks and strokes.

Bodybuilders might try to mitigate heart problems, taking hypertension medications when blood pressure gets too high, for example, or by donating blood when steroids cause the overproduction of red blood cells.

While heart damage from steroids usually builds over years, diuretics can stop the heart very quickly.

Diuretics, or "water pills," are among the most common and most dangerous drugs used by bodybuilders. Competitors might use them to shed water shortly before a show, mostly because they don't want excess fluid under the skin to obscure their muscle definition. But "drying out" the wrong way can have consequences that range from uncomfortable to deadly.

Diuretics prompt the kidneys to release sodium and potassium along with water. A balance between those key electrolytes is needed to regulate the heart's electrical function.

Competitors who upset that balance have "locked up" with full-body cramps and passed out, sometimes onstage. Some have died after using diuretics, including Czech bodybuilder Alena Kosinova, who locked up backstage before a contest in Spain last year. She was able to answer questions about the diuretics she had taken before convulsing and losing consciousness.

-The reproductive system

"As a general principle, anytime you take a hormone, you turn off your natural production of that hormone," said Brad Anawalt, an endocrinologist who is a professor at the University of Washington School of Medicine and a consultant for the U.S. Anti-Doping Agency.

Because testosterone is a key reproductive hormone, some of the most obvious and best-documented effects of taking steroids show up in the reproductive system.

The chaos starts in the brain, where the flood of new hormones alerts the hormone managers, the hypothalamus and pituitary gland, that the body has too much testosterone.

The pituitary stops making two key hormones that serve as messengers to reproductive organs.

When those messages stop arriving in the male system, the testicles stop making testosterone within hours, Anawalt said. Sperm production declines within days or weeks and drops to near zero in most men within a few months. Testicles often shrink by 25 to 35 percent.

When a person stops using steroids, the body's machinery takes a while to rev up again. So for a while, that person is producing no natural hormones and is not taking outside hormones. Sex drive plummets along with erectile function. It might take a year or more for sperm production to return to normal, and recent research has shown that about 5 percent of men never fully recover.

Pope said he hopes word gets around to young bodybuilders.

"The prospect that they might get a heart attack when they're 60, that's not likely to register particularly strongly in somebody who wants to get more muscular in the next two months," he said. "But the prospect that you could permanently lose some of your sex drive or your erectile function? That, it seems to me, is something that a young man would stop and think about a little bit more."

In the female reproductive system, when the same two hormone messengers are silenced, the ovaries get fewer messages to prepare egg follicles, release eggs and prepare the uterus for a fertilized egg.

The uterus can atrophy. Women can become infertile, sometimes permanently.

-The brain

"Roid rage" does not come close to encapsulating the complex repercussions that steroids appear to have on some users' brains.

Researchers have linked steroid abuse to aggression and violence, major mood disorders, insomnia, depression and, in rare cases, psychosis and suicide. Other evidence points toward chronic dependence, and a few studies suggest cognitive decline in long-term users.

One of the many things scientists have not yet figured out is why a few people have extreme psychological reactions and most others have none.

Pope said the tendency toward aggression may have to do with how steroids affect the amygdala, which is the seat of emotions and impulsivity, and its interplay with the prefrontal cortex, where decisions are made.

Mike Israetel, co-founder of an online training and nutrition company and an amateur bodybuilder who competes at the national level, said steroids make him feel anxious, like "a pincushion of emotions." Israetel, who also has a PhD in sports science, described the psychological push and pull, using the example of a highway tailgater.

"If I'm not on anabolic steroids at the time," he said, "I go: 'Oh, that person's awfully close. I'm just going to try to scoot over to let them pass.' It is no big deal. . . . When I'm on a lot of steroids, my initial - and it's very important to say my initial - inclination is to be something like, 'How dare that person!'" Then he hopes they'll turn to give him a dirty look, so they can see he's not someone they want to "interact with physically."

A fraction of a second later, he will think, "This is insane, of course I don't mean any of that stuff," he said. "But that process of having to rein in the not-so-good angels of our nature continuously over the course of the day, it gets to be pretty exhausting."

Like Israetel, many users feel normal again as soon as they stop the drugs, but about 30 percent develop dependence on steroids, Pope said. The causes appear to be both psychological and biological.

A body-image disorder called muscle dysmorphia, nicknamed "bigorexia," causes even large men to see themselves as too small and develop an irrational fear of losing muscle. Young men are particularly susceptible, because feeling too skinny is what leads many of them to bodybuilding in the first place.

"We're an aesthetically, visually oriented culture," Phillips said. "Disney understands it, right? In 'Snow White,' the prince - he just had nice hair. Fast-forward to 'Beauty and the Beast' and Gaston - the guy is jacked!"

"It's not just the women that change, you know - diabolically tiny waists, large busts and everything else. The ideal male physique has changed as well," he said, adding, "The number one users of anabolic steroids now are young men . . . just to look good."

The biological component of steroid dependence appears to have two pathways, Pope said.

One happens during withdrawal. A user who stops taking steroids can be overwhelmed watching hard-earned muscle shrink away while dealing with fatigue, depression and loss of sexual function. The lure of returning to the drugs is strong.

But the drugs also appear to have a more immediate hook - at least in hamsters.

In a 2004 study at the University of Southern California, hamsters chose to repeatedly trigger injections of steroids directly into their brains. Nearly a quarter of them did it so often that they died, with symptoms that resembled a heroin overdose, said Ruth I. Wood, the Keck School of Medicine professor who conducted the study.

The result had nothing to do with body image, Wood said: "Hamsters don't care what other hamsters think about their muscularity."

She said it may be related to the reward center in most mammals' brains, where behavior such as having sex or winning a fight is rewarded with a small boost in testosterone that feels good.

Pope said this second biological pathway may be key to the euphoria and feelings of invincibility that some steroid users report.

-Other organs

The bodybuilding lifestyle - even without a stew of extra hormones - is rough on organs, so bodybuilders often take a variety of vitamins and supplements to promote liver, kidney, heart and gut health.

A high-protein diet and dehydration make the kidneys work harder, which can compromise their function and cause scarring and disease. Steroids and other drugs can compound the problems.

For example, taking too much synthetic thyroid hormone, as some bodybuilders do to try to cut fat, increases the risk of atrial fibrillation, an irregular heart rhythm that in turn increases the risk of strokes. The thyroid may stop producing hormones on its own.

Oral steroids and other drugs can damage the liver, the body's filtering system. Livers are resilient and usually bounce back, but long-term, heavy steroid use is more likely to cause long-term damage.

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The training: Hours in the gym

Heavy lifting is the go-to exercise for building muscle. Top bodybuilders usually spend about two hours a day in the gym - sometimes more - five or six days a week, not counting hours choreographing and practicing posing routines that will show off their best assets to the judges.

They need near-perfect lifting mechanics, said New Jersey trainer Juan Pla, a former natural bodybuilder. Lifters with poor technique can suffer shoulder, neck, lower-back and quad injuries, and even tennis elbow.

Tendon tears are common among steroid users, said several trainers and muscle specialists. Typically, tendons and muscles grow together, like matched sets. But steroids can cause muscles to grow too big for their tendons to support.

"That's when you attempt some diabolically heavy lift and you just rip a bicep tendon or you rip a pectoralis muscle‚" Phillips said. "There's all kinds of disgusting things that happen."

A 2015 study of bodybuilders done in Pope's lab found that upper-body tendon injuries are more common in steroid users than in nonusers, possibly because steroids disproportionately grow muscle in the arms and torso.

To shore up their connective tissue, steroid users might inject extra growth hormone on top of what their pituitary glands typically pump out.

Growth hormone strengthens collagen in tendons and decreases fat. But it isn't terribly selective about what it enlarges, and doses that are greater than the body normally produces can cause overgrown bones in the face, hands and feet, an enlarged heart and increased risk of heart failure, irregular heart rhythms, sleep apnea and colon cancer.

High doses can also cause water retention in the midsection and may enlarge other organs, contributing to "roid belly," in which a competitor has a distended abdomen under six-pack abs, said Schoenfeld, the muscle growth researcher.

Some bodybuilders take Viagra before a workout thinking that greater blood flow will improve their muscle gain. (It probably doesn't.) Others say it increases the "pump," when muscle cells swell with fluid during a hard workout and get visibly bigger for a few minutes. The pump is why bodybuilders try to work in a few lifts or biceps curls right before stepping onstage.

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The diet: 'A mind game'

Bodybuilders train in two main phases: bulking and cutting.

Bulking is when they pile on muscle, and they may spend months eating mountains of high-protein food and guzzling protein shakes - up to 12,000 calories a day for some men. (That's about four times the amount a typical active man would need per day.) Some take appetite-boosting peptide hormones so they can force it all down.

Around mealtime, they may inject insulin, a hormone made in the pancreas, to help build muscle and temper the blood-sugar-raising effects of growth hormone. Anawalt said insulin's muscle-building capabilities are "unproven and minimally plausible" at best, and that insulin comes with risks. Too large a drop in blood sugar can cause confusion, seizures and, in rare cases, death.

All that packing on of pounds inevitably means some fat as well, so next comes the brutal cutting phase.

Bodybuilders will continue training but will cut calories - often drastically - to try to reduce body fat to artificially low levels. Huge men may subsist on food portions that would barely sustain small women.

Cutting is especially miserable for drug-free competitors who don't have chemical help, said Schoenfeld, who competed in natural contests in the 1990s. "You become very ornery and obsessed with food."

Brianny Terry, a powerlifter and bodybuilder who placed fourth in her physique class at the NPC nationals this summer, called cutting-phase dieting "terrible" and "a mind game," but she said she also appreciates the self-discipline it requires. "You learn a lot about your willpower and how deep you can dig to get through to the end goal," she said. "It's just a really bad way of promoting self-growth."

Some bodybuilders try to burn fat, fight fatigue and curb their raging appetites with legal stimulants such as caffeine, prescription drugs such as thyroid hormone or online purchases such as the potent asthma drug clenbuterol.

"Clen" is approved only for use in horses in the United States, but athletes in various sports consider it to be a "non-steroid steroid" because it is thought to preserve muscle and cut fat with fewer side effects, according to the Drug Enforcement Administration. The risks range from tremors and anxiety to high heart rate, low potassium, seizures and cardiac arrest.

A more lethal cutting drug is DNP (dinitrophenol), a toxic and literally explosive chemical once used in munitions. DNP is banned for human consumption because it revs up the metabolism so ferociously that people dangerously overheat, but it can be purchased on the internet as a weight-loss supplement. Four bodybuilders, including a 17-year-old girl, were among the deaths documented in a 2011 survey of DNP exposure in the journal Medical Toxicology.

For competitive bodybuilders, the last few weeks of cutting are show prep. That is when they try to hone their physiques, eat more carbs to plump up their muscles, shed excess water and get rid of as much remaining body fat as possible.

Some may step onstage with so little body fat that the deprivation sends their bodies into survival mode. Sleeping becomes difficult. Metabolism slows to conserve energy. Brain and immune function suffer. The reproductive system grinds to a halt.

"The look of leanness that they reach is inhuman," Pla said, "and completely unsustainable."

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The women: 'Changing your body forever'

Data on who uses steroids is scant. A 2013 review of earlier studies estimated that just 2 percent were women. But Mike Davies, who has trained 12 Ms. Olympias and guided more than 300 bodybuilders into the pro ranks, said drug use among female bodybuilders has increased noticeably in the past five to seven years.

"If a girl did any steroids or any clenbuterol or any drugs at all, it used to be a dirty little secret," Davies said. "It'd be like: 'Oh my God. She uses clenbuterol.' And now it's like: 'What do you mean you don't use clenbuterol? Your trainer doesn't have you on clenbuterol? You're not taking thyroid medication? You're not on DNP?' It's like, 'What's wrong with you?' It's normalized, and that's a crime."

Because steroids are masculinizing by definition, female bodybuilders who take them are likely to experience changes in their appearance beyond growing bigger muscles.

Women's hips and breasts often shrink as body fat is redistributed in a male pattern. Breast implants are common among female bodybuilders. (Breast-reduction surgery is common among their male counterparts, whose bodies metabolize some of the extra testosterone into estrogen, which causes growth of breast tissue.)

Women might grow facial and chest hair. Some will get male-pattern baldness. Acne is common.

Vocal cords thicken, making their voices permanently deeper.

The clitoris may grow and become elongated, a condition called clitoromegaly that often results in painful chafing of sensitive skin.

Women who take growth hormone may grow a bigger jaw or more prominent brow ridge. Even those who do not take additional growth hormone may experience some facial changes, because steroids and testosterone stimulate the body to release more natural growth hormone than usual, said Shalender Bhasin, director of the men's health research program at Harvard Medical School.

Some steroids are thought to be less masculinizing than others, but much of the information is anecdotal, passed along in bodybuilding circles. And some women, like some men, allow the lure of quick gains to overshadow long-term consequences.

"Yes, you can still be feminine, you can still be strong and jacked," said Terry, who said she uses steroids judiciously and gets regular medical checkups, including bloodwork and cardiac tests. "But you need to make an informed decision, because once you take an exogenous hormone, you are changing your body forever."

"I know women who can't have kids, because of decisions that they made in their early 20s, or they're stuck with all these other lasting effects. . . . And that's terrible," Terry said. "They were in a sport that was so focused on their physique, and then they get out of that world and the smoke and mirrors clears and they're like, 'I'm left with this body that I absolutely hate.'"

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The reasons: Why put themselves through this?

It's rarely the money, as very few are able to support themselves with bodybuilding alone, Davies said.

For some, it's the competition.

"I love training, and I love powerlifting and bodybuilding," said Terry, 26. "But I will never sacrifice my femininity or my health for it, because I still have a life to live after this. I want kids. I want to have a family. It is risky behavior, but I'm doing the risky behavior in the most responsible way."

Others are looking for a shortcut.

Three-time Olympia competitor Jamie Pinder, who is now a coach, said young bodybuilders, egged on by social media, reach for drugs as a pathway to instant gratification. "They are skipping over the foundations of training, the foundations of good nutrition, the foundations of rest and recovery," she said. "Instead of having the mind-set of 'I'm using these drugs so I can work harder,' they're thinking, 'What drugs, how many drugs and what can I use so I can do the least amount of work?'"

Some chase success to places they hadn't planned to go.

"Often people start out not thinking about steroids, and then once they start getting caught up in winning competitions, they realize that that is necessary to win at the pro level," Schoenfeld said. Pro bodybuilder Brandon Curry, Mr. Olympia in 2019, said on a podcast that year that he didn't need to use drugs "until it became my job."

Some just like being big.

Schoenfeld said one bodybuilder told him he wanted to look like the Incredible Hulk. "I remember vividly his specific words," he said. "'I want to look like a comic book superhero.'"

Israetel, 38, began bodybuilding in high school and found he could put on muscle fairly easily. He said he did not use drugs until he was 27.

"I kept getting bigger," he said, "and I thought, 'Oh, I could look even bigger.' And then I started reading muscle magazines, and I fell in love with the idea of just becoming a freak."

Last year he placed second in the super-heavyweight division at the NPC Masters USA Championships, his best-ever finish, and just missed winning a pro card. He said he plans to compete for a few more years and hopes to achieve a certain look, then will be happy to stop.

"I'm almost to that size," he said. "These are pictures that I'll have forever, that I can look back on and say: 'Wow, I really did the thing. I really looked the part, like the part that I was truly capable of looking - within reason.'"

He estimates that bodybuilding and the drugs he has taken for it will probably take five years off his life - less, he hopes, than those who take far more drugs than he does. And he said it will be worth it - "Barely, but yes."

"If I wanted to live until I was 90 or 100," he said, "I would absolutely have never taken steroids, or I sure as hell would've quit by now."

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The Washington Post's Jenn Abelson contributed to this report.

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