As millions of men turn to testosterone injections, Eddy Lawrence investigates a new global craze
Plato, Hemingway, Flight Of The Conchords – all have wrestled with that fundamental question, what makes a man a man? Finally, thanks to the miracle of science, we have a definitive answer, namely ‘a testosterone:blood ratio of 300 nanograms per decilitre (ng/dL) or higher’. Finding out our gender essence depends on masculine midichlorians may not be romantic, but like E=mc2, this seemingly simple formula requires a lot of explaining.
You see, this particular magic number is considered to be the threshold for a condition called hypogonadism, better known by tabloid readers, bodybuilders and hypochondriacs under its alias of ‘male menopause’, a vitality-sapping horrorshow. And one that has given rise to the low testosterone (‘low T’) industry, which last year raked in more than $1.6bn in the US, and is already on the rise here in the UK.
The New Viagra
It’s hardly surprising that the threat of low-T has caught the masculine imagination. The symptoms of hypogonadism read like the Emasculation Top 40 – lowered libido, erectile dysfunction, loss of muscle mass, lower sperm production and increased body fat. Pumping yourself full of manliness-imparting testosterone doesn’t merely kill off these symptoms – it induces muscle growth and fat loss.
Keep injecting testosterone and, without any exercise whatsoever, you’ll end up with a collar measurement like Thing from the Fantastic Four.
It’s no secret that vanity is a factor in the booming Testosterone Replacement Therapies (TRT) industry. In the US, hundreds of low-T clinics have sprung up to dispense hormone-booster shots, patches and even implants. The Low-T Center chain (which promises a walk-in diagnosis within 45 minutes) calls its waiting rooms ‘Man Caves’, and peppers its advertising with mid-life crisis-crushing phraseology such as ‘Get back in the game! Getting older doesn’t have to feel like it!’ Who wouldn’t like more resilient erections, Gladiator-sized guns and ejaculate by the litre? Which is why the pharma marketing world is calling low-T ‘the new Viagra’, and forecasting that the testosterone industry will rival erectile dysfunction’s $5.7bn annual turnover by 2017.
There’s just one fly in the hormone-boosting ointment, though. Hypogonadism may be more of a marketing issue than a medical one.
Splash It All Over
In much the same way that one-time superman Pelé was chosen to destigmatise erectile dysfunction, low-T has its own footballer-turned-cheerleader. Daryl Johnston, who played 11 seasons for the Dallas Cowboys, was diagnosed with low-T in 2009. Shortly afterwards, he began fronting ad campaigns for AbbVie’s AndroGel, now the market-leading treatment for hypogonadism, with sales last year totalling more than one billion dollars.
Aside from celebrity endorsement, AndroGel’s market advantage is its convenience. Testosterone is readily absorbed through the skin, making this topical treatment a convenient alternative to injections and implants. Although it does have its own drawbacks – the packaging features a warning to avoid skin-to-skin contact, in order to prevent you transferring testosterone to others and making them dangerously manly, which sounds like a PornHub category waiting to happen (depending on your feelings for Conchita Wurst).
But surely, you might think, simply popping a testosterone pill would be easier than smearing yourself in the liquid equivalent of Rod Stewart? And it would. It would also vastly increase your chances of serious liver disease. Even the comparatively safe methods of TRT raise the risk of side effects including thrombosis, heart attacks, sleep apnea and – irony of ironies – infertility. But despite the clearly signposted risks, the queues outside the low-T clinics continue to grow rapidly.
Hypogonadism, or at least the perception of it, is on the rise in the UK, with an increase in prescriptions for TRT of 90 per cent from 2000 to 2010. Which is curious for two reasons. Firstly because the National Institute For Clinical Excellence, which issues treatment guidelines to the NHS, recommends hormone therapy only as a last resort, preferring specific drugs for erectile dysfunction or psychotherapy for mood disorders. Secondly, because critics point out that diagnoses of ‘unequivocal’ hypogonadism have risen by just 21 per cent during 2000 to 2010 – suggesting that patients are driving the growth in TRT through pester power.
“There is no science,” claims Dr Richard Quinton, consultant endocrinologist and specialist in hypogonadism. “There is no evidence-based science. It’s driven by pharma marketing, and the desire of some US physicians to generate an income stream for themselves.”
But what does that mean for the UK, where pharmaceutical companies are forbidden from advertising prescription medicines directly to consumers? “There has been a lot of pharma marketing directed at GPs,” says Quinton. “There’s a buyer campaign called Improve The Man, which is still running, but the leading endocrinologists aren’t a part of it.”
Big (Pharma) Bucks
For now, however, the treatments available in the UK remain too expensive to have encouraged universal NHS uptake. Thus middle-aged men in Britain may be more inclined to go private.
Dr Richard Petty is one of the founders of Harley Street’s Wellman Clinic, and has been in the testosterone game for 35 years. His practice delivers testosterone via intramuscular ‘depot’ injections (to ensure a slow release of the hormone and prevent unhealthy spikes), viewing topical treatments as inefficient to the point of being ‘practically homeopathic’.
Petty argues that the ability to easily measure testosterone, and thus diagnose hypogonadism, is in its relative infancy, having only been developed in the past 30 years. Therefore any rise in diagnoses or prescriptions is likely down to increased awareness and understanding of the condition: “[Testosterone treatment] is now seen not to be the province simply of bodybuilders and illicit athletes, but a high proportion of middle-aged men. Half of all men over 50 have a relative lack of testosterone, which can cause symptoms, and males are much more aware of what the symptoms might be.”
A Potent Cocktail
There’s no doubting that, for anyone diagnosed with chronic post-puberty hypogonadism, TRT can make a real difference to quality of life. Genuine low-T can lead to distressing consequences such as erectile dysfunction and osteoporosis. But in much the same way Viagra diffused from medical necessity to elective party pill, the perception is that low-T treatments have become a lifestyle option. Particularly in the US, where it makes paying for healthcare more bearable: “Well, I may have spent half my earnings on insurance, but at least I got this two per cent increase in erectile turgidity.”
But critics cite the vague nature of so many low-T symptoms – a decrease in ‘motivation’ or ‘mental clarity’ is hard to prove clinically, after all – as a symbol of rampant overprescription (if not downright misdiagnosis). Not to mention the fact that many signs of low-T overlap neatly with the symptoms of such terrible afflictions as overwork, a hangover or having kids to look after. It will be interesting to see how the low-T trend develops in Britain where rules for advertising medicines are far more stringent than the US.
Let’s face it, when it comes to sperm motility, most men wouldn’t notice if their semen brought home a swimming gold from Rio. But for anyone less comfortable in their skin, it’s another thing to panic about. The concern among many doctors – both here and in the US – is that the low-T game preys on the kind of man whose inner R Lee Ermey berates him for not producing enough sperm to hang a sheet of flock wallpaper, while actually exposing him to greater dangers. After all, low-T provides a handy way for those with low self-esteem to blame nature for self-diagnosed failings.