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United States: Not controlled substances Legal to possess for "research purposes" Technically illegal for human consumption Legal to sell "for research only" Not FDA-approved for performance enhancement Reality: Research peptide companies sell openly online Payment processors accept transactions Customers rarely prosecuted for personal use Gray market more than black market Other countries: Similar gray area status in most Western nations Generally less restricted than steroids Some peptides prescription-only in some countries How people acquire them: Research peptide companies online (most common) Peptide clinics (some offer legitimate prescriptions) Compound pharmacies (prescription required) International suppliers (customs risk) Quality concerns: Legitimate research suppliers provide testing (CoAs) Quality varies by supplier Third-party testing available Generally better quality control than steroid UGLs Still need to vet suppliers carefully Head-to-head accessibility Legal risk: Steroids: High (controlled substances) Peptides: Low-moderate (gray area) Ease of acquisition: Steroids: Difficult legally, risky illegally Peptides: Relatively easy from research suppliers Quality assurance: Steroids: Poor (no oversight of UGLs) Peptides: Better (third-party testing available) Cost: Steroids: Moderate ($200-500/cycle for test) Peptides: Moderate-high ($150-400/month for GH peptides) Peptides occupy a more accessible legal space and generally offer better quality assurance through legitimate research suppliers

doi: 10.1016/S0140-6736(21)02188-7 50 DahlDOnishiYNorwoodPHuhRBrayRPatelHet al

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