The Plan B Loophole

Prescription Testosterone and the Dangers of Hormonal Manipulation

Testosterone Replacement Therapy (TRT) is a medically necessary treatment for individuals with clinically diagnosed testosterone deficiency or for those seeking a masculine transition. However, in recent years, a concerning trend has emerged: young men pursuing TRT not for genuine medical need, but as a means to enhance muscle growth and achieve an idealised, hyper-masculine physique. This phenomenon, often linked to ‘bigorexia’ or muscle dysmorphia, is being further fuelled by social media, where influencers promote testosterone as the key to strength, confidence, and physical perfection.

Adding to this issue is a new and alarming practice spreading across platforms like TikTok: the deliberate manipulation of blood test results to obtain testosterone prescriptions. One method involves the use of emergency contraceptive pills (Plan B), such as levonorgestrel or ulipristal, to temporarily suppress testosterone levels before medical evaluation. This loophole is now being exploited by individuals who do not meet clinical criteria for TRT, effectively deceiving healthcare providers into prescribing testosterone under false pretences.

Muscle dysmorphia, sometimes called ‘bigorexia’, is a body image disorder where individuals perceive themselves as inadequately muscular, despite often having above-average muscle mass. This has driven many young men to seek out testosterone, believing it to be the ultimate solution to their body image concerns. Unlike traditional anabolic steroid abuse, which is often associated with gym culture and illicit drug markets, this new wave of testosterone use is occurring within the legal framework of medical prescriptions.

The demand for TRT among otherwise healthy young men is being reinforced by online fitness communities, where testosterone is marketed as a ‘biohacking’ tool. Influencers and self-proclaimed ‘health experts’ frequently downplay the risks of exogenous testosterone use while exaggerating its benefits, leading to an increasing number of patients seeking prescriptions from doctors and telehealth services.

A 2023 FDA warning highlighted concerns about the growing recreational use of testosterone and related anabolic agents, particularly among young adults influenced by online misinformation (FDA, 2023). Similarly, research published by Healthy Male has shown that increased social media exposure correlates with higher rates of testosterone misuse and disordered body image behaviours (Healthy Male, 2023).

Social media has played a key role in the normalisation of testosterone use beyond its medical indications. Platforms like TikTok, Reddit, and YouTube feature content that portrays TRT as a shortcut to achieving peak masculinity, with minimal discussion of potential health consequences.

This phenomenon mirrors the ‘SARMs-to-steroids pipeline’, where individuals initially experiment with Selective Androgen Receptor Modulators (SARMs) before transitioning to stronger anabolic agents. SARMs, originally developed for conditions such as muscle-wasting diseases, have gained popularity for their perceived anabolic benefits with fewer androgenic side effects. However, research has shown that their safety profile differs considerably from that of testosterone, and they have been associated with significant health risks (Basaria, 2010). The U.S. Pharmacist journal has also raised concerns about the recreational use of SARMs, emphasising their unapproved status and potential long-term consequences (U.S. Pharmacist, 2022).

Similarly, the ‘TRT pipeline’ sees young men using hormonal manipulation tactics—such as artificially lowering their testosterone levels—to obtain prescriptions. What starts as a seemingly harmless attempt to optimise health can quickly escalate into long-term hormone dependency.

The recent rise of the ‘Plan B trick’ on social media exemplifies how far individuals are willing to go to obtain testosterone prescriptions. Emergency contraceptive pills containing high doses of progestins can suppress the hypothalamic-pituitary-gonadal (HPG) axis, leading to a temporary decrease in endogenous testosterone production. When taken shortly before a blood test, this suppression can create the illusion of hypogonadism, leading doctors to prescribe testosterone unnecessarily.

Pharmacists and healthcare professionals should be aware of the potential signs of this practice, such as:

• Young, otherwise healthy men presenting with low testosterone levels without classic symptoms of hypogonadism.

• Frequent changes in testosterone levels across multiple tests.

• Patients inquiring about or purchasing emergency contraceptive pills without a clear indication.

• People presenting with scripts for human growth hormone (HGH) and testosterone.

Beyond the ethical concerns of deception in medical practice, this trend raises significant health risks. Unnecessary TRT can lead to long-term suppression of natural testosterone production, cardiovascular complications, infertility, and mental health disturbances.

As frontline healthcare providers, pharmacists play a crucial role in mitigating the misuse of TRT. Key strategies include:

• Informing individuals about the risks of inappropriate testosterone use and debunking social media myths.

• Monitoring repeated requests for GHG, testosterone or emergency contraception in cisgendered male patients.

• Communicating with doctors to ensure thorough diagnostic evaluation before prescribing testosterone.

Much of the attention is focused on transgender people seeking hormone replacement therapy (HRT), despite them representing only approximately 0.9% of the Australian population (Australian Bureau of Statistics, 2022). Paradoxically, what is too frequently overlooked is the much larger population of cisgender young men, who are increasingly being influenced by social media platforms like TikTok.

This trend is not just a health concern; it is a moral one. We must question why society is so focused on the small percentage of transgender people seeking HRT, while allowing, and even encouraging, large groups of impressionable young cisgendered men to pursue unnecessary hormone treatments to meet a social media-driven aesthetic. The consequences of this misguided push for ‘perfection’ will be far-reaching—affecting not only the physical health of these young men but also their mental well-being as they chase a narrative that is as dangerous as it is unrealistic.

I cannot help but think that we need to shift our focus away from the fear of transgender healthcare and turn our attention to the real, often invisible, harm being done to young men under the guise of self-improvement. It is essential that we balance the conversation and address the health risks affecting both transgender and cisgender populations equally, with compassion, education, and evidence-based practices.

The exploitation of the ‘Plan B loophole’ highlights a growing issue at the intersection of medicine, social media influence, and body image disorders. Pharmacists and healthcare providers must remain vigilant against prescription manipulation while fostering responsible conversations about testosterone use. By prioritising patient education and ethical prescribing practices, we can help prevent the unnecessary medicalisation of young men in pursuit of an unrealistic ideal.

Raising awareness about this trend is crucial—not only to protect individual health but also to uphold the integrity of evidence-based medicine in an era where social media misinformation continues to shape patient decisions.

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References

Australian Bureau of Statistics. (2022). Estimates and characteristics of LGBTI+ populations in Australia. ABS. https://www.abs.gov.au/statistics/people/people-and-communities/estimates-and-characteristics-lgbti-populations-australia/latest-release.

Basaria, S. (2010). Androgen abuse in athletes: Detection and consequences. The Journal of Clinical Endocrinology & Metabolism, 95(4), 1533-1543. https://doi.org/10.1210/jc.2009-1579

Healthy Male. (2023). SARMs in Australia: What you need to know. Retrieved from https://healthymale.org.au/health-article/sarms-in-australia-what-you-need-to-know

Sinha-Hikim, I., Cornford, M., Gaytan, H., Lee, M. L., & Bhasin, S. (2022). Recreational use of selective androgen receptor modulators (SARMs). U.S. Pharmacist, 47(8), 22-28. Retrieved from https://www.uspharmacist.com/article/recreational-use-of-selective-androgen-receptor-modulators

U.S. Food and Drug Administration. (2023). FDA warns against use of selective androgen receptor modulators (SARMs) among teens, young adults. Retrieved from https://www.fda.gov/consumers/consumer-updates/fda-warns-use-selective-androgen-receptor-modulators-sarms-among-teens-young-adults