The unseen risks: Rising testosterone use among youth without medical indication

Physique-focused culture has exploded among adolescents and young adults, as has the nonmedical use of exogenous testosterone. Often obtained through nontraditional sources such as medical spas, online clinics or street vendors, testosterone is increasingly used to enhance athletic performance, build muscle or sculpt an “ideal” body image with the goal of attaining an unachievable physique. Many youth are also experimenting with performance-enhancing drugs (PEDs).

This growing trend brings a cascade of health and psychosocial concerns. Physicians are uniquely positioned to intervene using a whole-person approach focused on education, prevention and individualized care.

A clinical disconnect

Testosterone replacement therapy (TRT) is FDA-approved only for men with clinically confirmed hypogonadism. Yet healthy young adults, between the ages of 16 and 40, are increasingly using testosterone off label, often without formal evaluation or oversight. These individuals may never receive basic safety labs like CBC, testosterone levels or PSA screening, as recommended by the American Academy of Family Physicians, Class C evidence.

For those unwilling to stop exogenous testosterone use, physicians can still mitigate harm. Monitoring hemoglobin and hematocrit helps reduce the risk of erythrocytosis and thrombosis. Even when initiated outside of traditional care, regular lab work and follow-up are essential. Mitigating risks will also create a strong rapport between patient and physician, which will foster further discussions of possible discontinuation in the future.

Social media’s influence on testosterone culture 

The normalization of steroid use is fueled, in part, by social media platforms like TikTok, Instagram and YouTube. Influencers promote dramatic body transformations with vague terms like “optimization” or “TRT,” often omitting the use of PEDs. In fact, some influencers entirely omit the truth about their transformations or progress.

“Fake nattys,” or influencers who falsely claim natural physiques while secretly using steroids, create unrealistic expectations. This can lead to body dissatisfaction, anxiety and depression among teens and young adults, some of whom turn to PEDs believing it’s the only way to achieve similar results. 

Direct-to-consumer clinics further blur the line between medical necessity and cosmetic enhancement. 

Clinicians can screen for social media influence and body image concerns during routine visits. Early, judgment-free conversations can delay or prevent harmful experimentation.

Unregulated access and expanding PED use 

When denied testosterone by a physician, young adults may turn to alternative, often unregulated, sources. Some clinics prescribe hormones based on vague symptoms or minimal lab data, while black-market sources, commonly used in gym subcultures, may provide contaminated or counterfeit products. Individuals may face pressure from peers at their local gym to try these unregulated products.

Beyond testosterone, teens and young adults are increasingly using other PEDs. These include anabolic-androgenic steroids (AAS) like trenbolone and nandrolone; selective androgen receptor modulators (SARMs) such as ostarine and ligandrol; and agents like human growth hormone (hGH), IGF-1 and clenbuterol. Though often marketed as safer, these substances are unregulated and linked to cardiovascular, hepatic, metabolic and psychiatric complications.

It’s our job as clinicians to remain vigilant when evaluating unexplained symptoms or rapid body changes. It’s essential to consider the broad spectrum of PED use and educate patients on both legal and health risks.

Health complications in males and females 

As PED use increases, so does the incidence of serious health effects in both sexes. In males, common issues include hypertension, dyslipidemia, hepatic dysfunction and early-onset myocardial infarction or stroke. Psychiatric symptoms like aggression, mood swings and psychosis are also reported, especially among those using multiple agents at once or taking high doses.

Females face risks including virilization, menstrual irregularities, ovulatory dysfunction and long-term endocrine disruption. Irreversible effects, such as voice deepening or clitoromegaly, can persist even after stopping use. Unfortunately, these long-term effects are not foreseeable from a preventative aspect, so discussion on this topic can often cause frustration.

Both sexes are at elevated risk for venous thromboembolism (VTE) and mental health challenges. As these issues and complications present in younger patients, early recognition and education are critical for prevention and harm reduction. 

Long-term health risks 

Starting steroid use during adolescence or early adulthood can result in lasting harm. Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal (HPG) axis, potentially causing persistent hypogonadism, infertility or reduced libido, even after stopping use.

Chronic exposure is associated with early-onset cardiovascular disease, coronary artery calcification, liver damage and structural cardiac changes. Psychiatric issues, including mood instability and cognitive decline, may persist well beyond the period of active use. These outcomes highlight the importance of early education, routine screening and proactive counseling, especially in adolescents and young adults.

Cardiovascular risks: What the data says 

The 2023 TRAVERSE trial studied TRT in older men with pre-existing cardiovascular disease and symptomatic hypogonadism. While no significant increases in major adverse cardiovascular events were found, the study reported higher risks of acute kidney injury, atrial fibrillation and pulmonary embolism in this patient population.

Though these findings cannot be applied to younger, healthy individuals using testosterone, as they did not cover this exact patient population, testosterone in younger individuals without medical need have not been truly studied. A 2024 Frontiers in Neurology review noted increased rates of stroke and thromboembolic events among transgender men on testosterone compared to cisgender females. High-intensity training and polypharmacy can further amplify these risks in young users.

Fertility and hormonal health in both sexes 

Exogenous hormones can seriously impair reproductive health. In males, testosterone reduces LH (luteinizing hormone) and FSH (follicle stimulating hormone) levels, suppressing spermatogenesis. This can cause testicular atrophy and infertility. While recovery is possible, it may require further medical intervention and is not completely guaranteed to reverse the effects.

In females, PEDs disrupt normal hormone cycles, causing amenorrhea, ovulatory dysfunction and long-term fertility issues. Virilizing effects such as facial hair growth, voice changes and clitoromegaly may not fully reverse after discontinuation.

Because many young users are unaware of these consequences, clinicians should provide counseling early, especially for those considering future fertility.

A growing public health issue

Testosterone and PED use among adolescent and young adult populations without clinical indication is a growing public health issue. Driven by aesthetic culture, social media and unregulated access, young people face real, often underappreciated risks.

Through early identification, non-judgmental communication and comprehensive education, physicians can play a central role in protecting this vulnerable population.

Related reading:

Peace of mind or prescription risk? A DO weighs in on at-home antibiotic kits

Motorsports medicine: An emerging subspecialty ripe for growth