Regular Article
Psychother Psychosom 2000;69:19–26
Psychiatric and Medical Effects of
Anabolic-Androgenic Steroid Use in
Women
Amanda J. Gruber Harrison G. Pope Jr.
Biological Psychiatry Laboratory, McLean Hospital, Belmont, Mass., and the Department of Psychiatry,
Harvard Medical School, Boston, Mass., USA
Key Words
Anabolic-androgenic steroids W Eating disorders W Body
dysmorphic disorder W Gender identity disorder W
Ergogenic substance abuse W Substance abuse W Women
Abstract
Background: Although numerous studies have docu-
mented the psychiatric and physiological effects of ana-
bolic-androgenic steroids (AAS) in males, virtually no
studies have investigated the effects of illicit AAS use in
women. Methods: We performed psychiatric and medi-
cal evaluations of 75 dedicated women athletes, re-
cruited by advertisement primarily from gymnasiums in
the Boston, Mass., area. Results: Twenty-five (33%) of
the women reported current or past AAS use. Users were
more muscular than nonusers and reported use of many
other ‘ergogenic’ (performance-enhancing) drugs in ad-
dition to AAS. Some described a frank syndrome of
ergogenic polysubstance dependence, often with signifi-
cant morbidity. Fourteen (56%) of the users reported
hypomanic symptoms during AAS use and 10 (40%)
reported depressive symptoms during AAS withdrawal,
but none met full DSM-IV criteria for a hypomanic or
major depressive episode. Nineteen (76%) users re-
© 2000 S. Karger AG, Basel
ABC
Fax + 41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/journals/pps
ported at least one adverse medical effect associated
with AAS use. Perhaps the most interesting findings
were several unusual psychiatric syndromes reported by
both the AAS users and nonusers. These included rigid
dietary practices (which we have termed ‘eating disor-
der, bodybuilder type’), nontraditional gender roles and
chronic dissatisfaction and preoccupation with their phy-
siques (a syndrome which we have termed ‘muscle dys-
morphia’). Conclusions: Dedicated women athletes ex-
hibit not only AAS abuse, but use of many other ergo-
genic drugs, sometimes associated with significant mor-
bidity. In addition, these athletes frequently display sev-
eral psychiatric syndromes which have not previously
been well described.
Copyright © 2000 S. Karger AG, Basel
Introduction
An extensive literature has documented the physiologi-
cal [1–3] and psychological [4–7] effects of anabolic-
androgenic steroids (AAS) in men, but little has been writ-
ten about the effects of these drugs in women. However,
substantial numbers of women in the US abuse AAS. For
example, data from the 1993 National Household survey
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[8] suggest that 145,000 American women have abused
AAS at some time in their lives (95% confidence interval
64,000–830,000). Studies of high school populations have
produced much higher estimates, with 0.5–3.2% of high
school girls reporting that they had used AAS at least once
[9–15]. These findings imply that AAS use among wom-
en, once restricted only to a small number of elite athletes
[16–18], may now be evolving into a commoner public
health problem in the US.
To assess the physiological and psychological corre-
lates of AAS use in women, we performed a study compar-
ing dedicated women athletes who reported use of AAS
with those who had not. This investigation represents, to
our knowledge, the first large controlled comparison be-
tween a group of steroid-using women athletes and a
group of women athletes who have not used these drugs.
Method
We placed advertisements in gymnasiums in the Boston, Mass.,
area, seeking women aged 18–65 ‘who had competed at least once in
a bodybuilding or fitness contest’ or who had ‘lifted weights in the
gym at least 5 days per week for at least 2 years’. The advertisement
explained that subjects would be paid $100 to participate in a ‘psy-
chological interview, a physical examination and blood and urine
tests’. The focus of the study on AAS was not revealed in the adver-
tisement, although the text stated that ‘if you have used any perfor-
mance-enhancing drugs you must be comfortable with answering
questions about them in this confidential interview’. Respondents to
the advertisement were screened by telephone to ensure that they
met the criteria for inclusion in the study and were then invited for
an interview.
The study interview consisted of: (1) basic demographic ques-
tions; (2) questions about history of weightlifting, other athletic activ-
ities and participation in bodybuilding or fitness competitions, if
any; (3) detailed questions about the use of AAS, if any; (4) the Struc-
tured Clinical Interview for DSM-IV [19] to assess lifetime history of
DSM-IV [20] Axis I psychiatric disorders, and (5) medical history.
As the study progressed, we added more detailed questions about:
(6) eating patterns, (7) use of ‘ergogenic’ (performance-enhancing)
drugs other than AAS and (8) body image, including questions about
‘muscle dysmorphia’ (MD), a syndrome of obsessional preoccupa-
tion with muscularity which we have described elsewhere [21]. We
then conducted a physical examination, with special attention to the
masculinizing effects of AAS, such as hirsutism, acne, deepening of
the voice and loss of breast tissue. Gynecological examination for
clitoromegaly, however, was not performed in this primarily psy-
chiatric investigation. Percent body fat was calculated by using calip-
ers to measure the thickness of 3 skinfolds – triceps, suprailiac and
quadriceps – and then using the equation, body fat (%) = 0.445x –
0.001x2 + 0.563y – 0.553, where x is the sum of the 3 skinfolds in
millimeters and y is the subject’s age in years [22 and Jackson AS,
pers. commun.]. All interviews and physical examinations were per-
formed by the authors, who were not blinded to the subject’s reported
history of AAS use. The subject’s fat-free mass index (FFMI) was
20 Psychother Psychosom 2000;69:19–26
then calculated using an equation which we have previously devel-
oped for men [23], but without the small correction for height used in
the male equation. Specifically,
FFMI = W ! (100 – % body fat)/100
,
H2
where W is weight in kilograms and H is height in meters. Finally, we
obtained laboratory tests for standard chemistries, hematology and
urinalysis, and urine screen for abuse of drugs. We also obtained
urine screens for AAS in 21 of the 25 self-reported AAS users and 25
of the 50 self-reported nonusers. All subjects signed informed con-
sent to the study, which was approved by the McLean Hospital Insti-
tutional Review Board.
The significance of differences between the groups of AAS users
and nonusers was calculated using the t test for continuous variables
and exact tests, ordered or unordered, for 2 ! n contingency tables.
Significance levels are presented without correction for the number
of comparisons; thus, the reader should bear in mind that some dif-
ferences, especially those of marginal significance, may represent
chance associations.
Results
A total of 75 women were examined. Of these, 67 were
recruited from the New England area, either through gym-
nasium advertisements or by referral from previous sub-
jects. Eight additional women were recruited to enrich the
sample with AAS users; 5 of these were from a bodybuild-
ing competition in Houston, Tex., and 3 were from a gym-
nasium in Los Angeles, Calif.
Twenty-five (33%) of the women reported current or
past AAS use (‘users’) and 50 (67%) denied AAS use
(‘nonusers’). No significant differences (p 1 0.1 in all com-
parisons) were found between users and nonusers on basic
demographic variables such as age (users 31.0 B 5.9
years; nonusers 32.3 B 7.9 years), years of weightlifting
(users 7.7 B 4.5 years; nonusers 8.4 B 5.7 years), or the
proportion who were never married (users 13, 52%;
nonusers 22, 44%), college graduates (users 12, 48%;
nonusers 39, 52%) or the number who identified their eth-
nicity as Caucasian (users 25, 100%; nonusers 43, 86%) or
their sexual preference as heterosexual (users 21, 84%;
nonusers 45, 90%).
Features of the AAS Users
Among the 25 users, 14 (56%) reported current and 11
(44%) only past use of AAS (table 1). Of the 14 women
reporting current AAS use, 11 received urine screens for
AAS; all 11 exhibited at least one AAS in their urine. Ten
of the 11 women reporting only a past history of AAS use
received urine testing; 1 tested positive for AAS. This
woman reported finishing a course of intramuscular nan-
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Table 1. Current use of specific AAS reported by 25 women AAS Table 2. Self-report
users
Subject Self-report of Drugs found on
AAS Lifetime (n = 25) Current (n = 14) No. drug(s) used urine testing
n % n %
1 oxandrolone oxandrolone
2 methenolone nandrolone, methenolone
Stanozolol 19 76 2 14
3 testosterone nandrolone
Methenolone 17 68 4 28
4 nandrolone nandrolone
Nandrolone 17 68 6 42
5 methenolone boldenone
Oxandrolone 10 40 1 7
6 nandrolone nandrolone
Mesterolone 6 24 2 14
7 mesterolone mesterolone
Boldenone 3 12 2 14
8 boldenone, nandrolone boldenone
Testosterone esters 3 12 1 7
9 nandrolone, stenazolol, nandrolone
Methandienone 1 4 0 0
methenolone
Oxymetholone 1 4 0 0
10 nandrolone, boldenone, boldenone
methenolone
11 nandrolone, oxandrolone nandrolone
12 nandrolone1 nandrolone

1 Discontinued 4 months prior to urine testing (see text).

drolone decanoate 4 months prior to the study visit; low
concentrations of this drug were found in her urine. In the
12 women with positive urine screens, the drugs actually
found in their urine (table 2) rarely corresponded precise-
ly with the drugs they believed that they were taking – a
Table 3. Adverse medical effects apparently due to AAS reported by
finding similar to that of our previous study of male AAS 25 women AAS users
users [4]. Of the 50 women who denied AAS use, 25
received urine testing and none was positive for AAS. Effect n %
Nineteen (76%) users reported at least 1 adverse medi-
cal effect which appeared due to AAS use (table 3). Our Voice change 14 56
Acne 12 48
anecdotal experience suggested that subjects may have
Clitoromegaly 12 48
underreported at least some of these effects. For example, Increased facial hair 10 40
several subjects who denied voice change had very deep Fluid retention 5 20
voices. Several adverse effects, such as amenorrhea, histo- Acute renal failure 3 12
ry of cervical dysplasia or cancer and bone fractures sug- Chronic fatigue 2 8
Galactorrhea 1 4
gestive of osteoporosis, were reported with similar fre-
Insomnia 1 4
quency by both users and nonusers, and may not have Muscle aches after stopping steroids 1 4
been directly attributable to AAS. These effects are dis- Total reporting negative physical effects1 19 76
cussed below. The most serious medical consequence
1 Total is less than the sum of the individual effects because many
apparently attributable to AAS use was acute renal fail-
women reported more than one effect.
ure, a phenomenon which has previously been described
in male AAS users [4]. All 3 women who experienced this
effect reported that their physicians had told them that
AAS use was at least 1 of the factors which precipitated
this condition. Of note, we did not find any subjects with While taking AAS, users reported labile mood (6, 24%),
blood pressure greater than 130/90 mm Hg, with clinical irritability (13, 52%) or behavior which others perceived
or laboratory evidence of non-insulin-dependent diabetes as aggressive (10, 40%). None of the subjects, however,
mellitus or with a medical history of cardiovascular dis- appeared to have experienced irritable mood at a level
ease – features which have been reported in an earlier sufficient to meet the full criteria for irritable mood in the
study of women with high endogenous androgen levels diagnostic criteria for psychosomatic research. Specifical-
[24]. ly, these women did not describe the feeling as distressing
Sixteen (64%) users also reported at least 1 adverse to themselves or severe enough to elicit stress-related
psychological effect apparently attributable to AAS. physiologic responses [25]. Only 1 subject reported vio-

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Table 4. Lifetime use of specific ergogenic
substances reported by 75 women athletes Substance Anabolic steroid Anabolic steroid
users (n = 25) nonusers (n = 50)
n % n %

Aminoglutethimide 1 4 0 0
Amphetamines 3 12 4 8
Androstenedione/dehydroepiandrosterone 9 36 9 18
Caffeine1 19 76 22 44
Clenbuterol 18 72 5 10
Diuretics 20 80 9 18
Ephedrine 20 80 21 42
Á-Hydroxy butyrate 5 20 1 2
Human chorionic gonadotropin 1 4 0 0
Human growth hormone 1 4 0 0
Laxatives 7 28 5 10
Nalbuphine 4 16 0 0
Other opioids 3 12 0 0
Tamoxifen 6 24 1 2
Thyroid hormones 8 32 2 4
Yohimbine 2 8 4 8

1 With side effects, tolerance and dependence.

lent acts while on AAS; these consisted of several bar
fights. However, she also reported having bar fights while
not on AAS. None of the nonusers reported a history of
physical violence.
Although none of the women met full DSM-IV criteria
for a mood disorder in association with their AAS use, 14
did report symptoms consistent with hypomania while
taking AAS, such as a euphoric, overconfident or expan-
sive mood (14, 56%), poor judgement (9, 36%) and
increased libido (6, 24%). Indeed, 3 of the women noted
that the euphoria was the main factor contributing to their
continued use of AAS. Ten women described depression
after discontinuing steroids, 9 of these had experienced
hypomanic symptoms while taking them. Although none
of these 10 women met full DSM-IV criteria for a major
depressive episode, all described feeling depressed or
‘down’, and decreased energy or fatigue, which dissipated
slowly over several weeks after discontinuing AAS use.
Differences Between the Groups
The users were significantly more muscular than the
nonusers. The mean FFMI of the users was 19.7 B 2.3
kg/m2, and the mean FFMI of the nonusers was 17.8 B
1.5 kg/m2 (p ! 0.001). The AAS users were also much
more likely to report use of other ergogenic (performance-
enhancing) drugs than the nonusers (table 4). The num-
bers almost certainly underestimate the true rates of
ergogenic drug use, because our initial data collection
instrument did not include specific questions about these
drugs.
Some of the subjects met criteria for DSM-IV polysub-
stance abuse and dependence, but instead of using con-
ventional drugs of abuse, they abused multiple ergogenic
drugs. For example, subjects typically displayed (1) toler-
ance, especially with ephedrine, clenbuterol and caffeine;
(2) withdrawal, especially with nalbuphine, ephedrine,
clenbuterol and caffeine, and to a lesser extent with AAS;
(3) use of the substances in larger amounts than originally
intended, with almost all the substances; (4) large commit-
ments of time and money to obtain supplies of the drugs,
especially for those not available over-the-counter, and
particularly (5) continued use of various drugs despite
adverse physical or psychological effects. We have de-
scribed the features of ephedrine use and nalbuphine use
among both men and women athletes in previous commu-
nications [26, 27].
Syndromes Common to Both Groups
Both users and nonusers reported modest lifetime rates
of Axis I DSM-IV disorders, with no significant differ-
ences between groups in the prevalence of any individual
disorder or class of disorders (table 5). In both groups,

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Table 5. Lifetime DSM-IV psychiatric
disorders reported by 75 women athletes Steroid users Steroid nonusers
Disorder (n = 25) (n = 50)
n % n %

Substance dependence
Alcohol 2 8 3 6
Marijuana 2 8 1 2
Cocaine 2 8 3 6
Polysubstance 2 8 2 4
Any substance dependence disorder1, 2 6 24 8 16
Eating disorders
Bulimia nervosa 7 28 7 14
Anorexia nervosa 6 24 6 12
Binge eating disorder 1 4 4 8
Any eating disorder1, 3 11 44 15 30
Mood disorders
Major depression 7 28 4 8
Dysthymia 2 8 1 2
Bipolar disorder 0 0 1 2
Any mood disorder1 7 28 6 12
Anxiety disorders
Panic disorder, with agoraphobia 0 0 2 4
Obsessive-compulsive disorder 0 0 2 4
Generalized anxiety disorder 0 0 1 2
Posttraumatic stress disorder 5 20 3 6
Any anxiety disorder 5 20 8 16
Body dysmorphic disorder4 2 8 3 6

1 Total is less than the sum of the individual disorders because many of the women reported
more than one disorder in this category.
2 Not including ergogenic drugs (see table 4).
3 Not including ED,BT (see text).
4 Not including MD (see text).

however, we observed several distinctive syndromes,
which to our knowledge have not previously been de-
scribed in the literature. We have called these syndromes
‘eating disorder, bodybuilder type’ (ED,BT), ‘nontradi-
tional gender role’ (NGR) and MD.
Eating Disorder, Bodybuilder Type. Although none of
the women currently met the criteria for a classic DSM-IV
eating disorder, 21 (84%) users and 34 (68%) nonusers,
including all 26 women with a past history of classic
DSM-IV eating disorders, reported ED,BT. We offer pro-
posed diagnostic criteria for this condition in the Appen-
dix. ED,BT is characterized by rigid adherence to a high-
calorie, high-protein, low-fat diet that is consumed in the
form of preprepared meals and supplements eaten at reg-
ularly scheduled intervals. Women with this disorder fre-
quently refused to eat out at restaurants or at friends’
houses because of their need to be certain that they were
ingesting the precise amounts of calories, protein, fat and
carbohydrates that they believed necessary to maintain
their physique. Some of the women with ED,BT reported
that they routinely prepared all of their meals for the day
in advance, packaging precisely measured quantities of
specific foods (tunafish, skinless chicken breast, steamed
vegetables) in small containers to be consumed at pre-
scribed hours throughout the day. If their routine was dis-
rupted, these women typically experienced intense anxi-
ety, and often engaged in compensatory behaviors such as
eating a protein bar to substitute for a missed meal.
Amenorrhea, presumably resulting from the low body fat
attained through this diet, was reported by 24 (96%) of the
users and 36 (72%) of the nonusers. Although this differ-
ence in prevalence between the groups was statistically

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significant (p = 0.015 by Fisher’s exact test, two tailed), it
was not possible to determine the degree to which AAS
use, per se, may have contributed to this difference.
Nontraditional Gender Role. Although only 2 of the
women, both AAS users, met full DSM-IV criteria for gen-
der identity disorder, an additional 22 (88%) of the user
group, and 33 (66%) of the nonuser group, endorsed at
least 3 of the remaining 4 traits in DSM-IV criterion ‘A’
for gender identity disorder, both as children and adults.
While expressing no desire to be of the opposite sex, they
described a strong preference for stereotypical masculine
clothing, occupations and games or pastimes, and a strong
preference for male friends. To identify this group, we
have used the term NGR to indicate that this ego-syntonic
group of personality traits does not necessarily represent a
psychiatric disorder. We offer proposed diagnostic crite-
ria for this condition in the Appendix.
Muscle Dysmorphia. All 25 (100%) of the AAS users
and 40 (80%) of the nonusers reported a syndrome of
body dissatisfaction which we have termed MD and
described in detail in a previous publication [21]. Pro-
posed diagnostic criteria for MD, taken from this pre-
vious publication, are shown in the Appendix. Briefly, the
women with MD reported a disabling preoccupation that
their bodies were not sufficiently lean and muscular. They
often relinquished important social, occupational or rec-
reational opportunities because of a compulsive need to
maintain their workout and diet schedule. For example,
we encountered women who held degrees in law, medi-
cine or business, yet had abandoned these careers to pur-
sue an all-consuming lifestyle which involved many hours
at the gym. Despite their superb physical condition, these
women perceived themselves to be smaller and fatter than
other women who were actually less muscular and sub-
stantially fatter than themselves. Typically, their body
image distortion could not be relieved even by quantita-
tive measurements of muscle mass and percent body fat,
or even by winning competitions. They coped with their
intrusive, obsessive thoughts about not being lean or mus-
cular enough by compulsively adhering to their body-
building regimen.
Conclusions
In an observational field study, we compared 25 wom-
en who had used AAS with 50 women who had not. All
women were recruited from gymnasiums and bodybuild-
ing contests in the Boston, Houston and Los Angeles
areas. The AAS users reported a higher prevalence of oth-
24 Psychother Psychosom 2000;69:19–26
er ergogenic drug use than the nonusers, and they were
significantly more muscular than the nonusers, as evi-
denced by FFMI measurements. Also, the AAS users
reported a high rate of adverse physical and psychological
effects of AAS. In particular, 14 users reported at least
some hypomanic symptoms while using AAS, and 10
reported depressive symptoms associated with AAS with-
drawal. These findings are similar to, but less robust than,
those described in previous studies of AAS effects in men
[4, 28]. Thus, AAS may need to be added to the growing
list of drugs known to produce mood disorders [29, 30].
Among the most interesting findings of the study, how-
ever, were several novel syndromes which appeared com-
monly among both the AAS users and the nonusers. We
have called these syndromes ED,BT, NGR and MD.
These characteristic patterns of eating behavior, gender
role behavior, and body image disorder caused profound
effects on the social and occupational functioning of
women in both groups. Interestingly, we did not find
hypertension or evidence of non-insulin-dependent dia-
betes mellitus or cardiovascular disease, which one might
expect to find in muscular women, all of whom likely had
above normal levels of active androgens.
Several methodological limitations of this investiga-
tion should be considered. First, various forms of selec-
tion bias may have influenced which women presented
for study. Although our advertisements did not reveal our
specific interest in substance abuse, or in other psychiatric
disorders associated with bodybuilding in women, it is
possible that women with or without these attributes may
have been more likely to respond, and that they may have
been more likely to refer other subjects with or without
these attributes. It must also be recognized that we inten-
tionally sought very dedicated women athletes. These
dedicated athletes presumably exhibited higher levels of
AAS abuse, and possibly higher levels of associated pa-
thology, than women less involved with bodybuilding.
Finally, it should be noted that the great majority of our
subjects were recruited from the Boston area. It is possible
that women bodybuilders from other areas of the US
might show different rates of drug use and associated syn-
dromes than those reported here. For all of these reasons,
the prevalence rates of various features described for the
women in our sample may not be generalized to women
athletes as a whole.
Second, response bias may also have affected our
results, probably in the direction of causing us to underes-
timate the frequency or magnitude of drug use and associ-
ated pathology. Specifically, some women may have with-
held information about certain forms of drug use and oth-
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er sensitive topics. For example, several women in the
study knew one another as friends, and anecdotally told
us that their friends had not fully disclosed AAS or other
drug use to us on interview. Second, some women had
used various ergogenic drugs without even being aware of
it. For example, several remarked that they had used var-
ious ‘fat-burners’, such as Thermadrine or ma huang, but
were not aware that these substances contained ephe-
drine. Third, especially when interviewing the earlier sub-
jects in the study, we were not familiar with the extraordi-
nary range of ergogenic drugs, nor with the severe distor-
tions of body image and eating patterns experienced by
these women. Thus, we may have underestimated the
prevalence of various forms of drug abuse and other psy-
chopathology because we did not ask sufficiently specific
and probing questions about these topics.
For the above reasons, we suspect that the rates
reported here represent only a lower bound for the true
levels of ergogenic substance abuse and associated disor-
ders of eating and body image among dedicated women
athletes, including both those who have used AAS and
those who have not. Thus, subsequent investigations of
women athletes should include extensive questions about
all of these areas, to better elucidate what appears to be a
largely unrecognized public health problem.
Appendix
Proposed Diagnostic Criteria for Muscle Dysmorphia
(1) Preoccupation with the idea that one’s body is not sufficiently
lean and muscular. Characteristic associated behaviors include
long hours of lifting weights and excessive attention to diet.
(2) The preoccupation is manifested by at least 2 of the following 4
criteria:
(a) The individual frequently gives up important social, occupa-
tional or recreational activities because of a compulsive need
to maintain his or her workout and diet schedule.
(b) The individual avoids situations where his or her body is
exposed to others or endures such situations only with marked
distress or intense anxiety.
(c) The preoccupation about the inadequacy of body size or mus-
culature causes clinically significant distress or impairment in
social, occupational or other important areas of functioning.
(d) The individual continues to work out, diet or use ergogenic
(performance-enhancing) substances despite knowledge of ad-
verse physical or psychological consequences.
(3) The primary focus of the preoccupation and behaviors is on being
too small or inadequately muscular, as distinguished from fear of
being fat as in anorexia nervosa or a primary preoccupation only
with other aspects of appearance as in other forms of body dys-
morphic disorder.
Specifier: With poor insight.
Steroid Use in Women
Proposed Diagnostic Criteria for Eating Disorder, Bodybuilder
Type
(1) Refusal to maintain body fat at a healthy level (defined in women
as the level necessary for normal menstrual cycles to take place)
accompanied by a desire to maximize muscle mass.
(2) Intense fear of gaining fat or losing muscle, even though body fat
is below normal, as defined above, and degree of muscularity is
far above average.
(3) Strict adherence to a rigid diet with at least 2 of the following
features:
(a) At least 5 meals per day, consumed on a regular schedule, for
example every 3 hours.
(b) Meals all consist of high-calorie, high-protein, low-fat foods or
food supplements.
(c) A significant amount of time and money is spent acquiring,
preparing and eating these specialized meals.
(4) Disturbance in the way in which one’s body composition is expe-
rienced or undue influence of body appearance on self-evalua-
tion.
(5) Social and occupational opportunities are frequently given up
because they interfere with the composition or timing of meals.
Proposed Criteria for Nontraditional Gender Role in Women
(1) A strong preference for male characteristics and activities. In
adult women manifested by 3 (or more) of the following fea-
tures:
(a) Insistence on wearing only stereotypical masculine clothing.
(b) Strong and persistent preferences for jobs typically held by
men.
(c) Participates in the stereotypical games and pastimes of men.
(d) Strong preference for male friends.
(2) The individual is comfortable with her sex and does not actually
wish to be male.
(3) The characteristics are not concurrent with a physical intersex
condition.
(4) The characteristics have a significant effect on lifestyle, but cause
minimal distress or impairment in social, occupational or other
important areas of functioning.
Acknowledgment
Supported in part by NIDA grant R01 DA10055.
Psychother Psychosom 2000;69:19–26 25
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