The social perception of performance enhancement and body modification: A systematic review and meta-analysis on anabolic steroids, tattoos, and cosmetic surgery

To our knowledge, few studies have attempted to explore the social perception of targets engaged in performance enhancement and body modification, and none has done so through a systematic review and meta-analysis. We conducted a meta-analysis on the social perception of anabolic-androgenic steroids (AAS), tattoo, and cosmetic surgery targets. Eligible experimental studies were identified through electronic database and ad hoc searches up to July 2025. We estimated effect sizes, in terms of the standardized mean difference, for the social perception ratings of the targets involved in the abovementioned practices on demographic, health, and psychosocial factors. Results from 34 studies with 9114 participants on AAS, tattoo, and cosmetic surgery were analyzed. Regarding performance enhancement, observers perceived the AAS (vs. no-AAS) target as less likely to display instrumental aggression, but having higher reactive aggression, lower sportspersonship, higher neuroticism, and lower agreeableness. Regarding body modification, the tattoo (vs. no-tattoo) target was perceived as more artistic, yet of a lower socioeconomic status, more offender typical and reoffend likely, and having lower hireability and competence. Furthermore, the cosmetic surgery (vs. no-cosmetic surgery) target was perceived as more attractive, approachable, trustworthy, and healthier, but also as less competent. Overall, observers show mixed perception of performance enhancement and body modification targets. The strong negative perceptions on competence, criminality, personality, and sportspersonship-especially considering the enhancement and modification overlap-highlight the extent of stigmatizing evaluation associated with these practices behaviours. Preventive, therapeutic, and occupational interventions may benefit from adjusting for the identified social perceptions.