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  • Hi, welcome to Gender Analysis. In recent years, prescription testosterone has become

  • a booming industry around the world. From 2001 to 2011, the percentage of men over 40

  • in the US who were prescribed testosterone replacement grew from about 0.8% to 2.9% - more

  • than a threefold increase. And data from 41 nations shows that yearly testosterone sales

  • have increased from $150 million in 2000, to $1.8 billion in 2011. Meanwhile, chains

  • of "low T clinics" focusing on testosterone therapy have opened dozens of locations across

  • the country. So, what's behind this growth? Let's take a look at one commercial for prescription

  • testosterone gel:

  • "I have low testosterone. There, I said it. See, I knew testosterone could affect sex

  • drive, but not energy or even my mood. That's when I talked with my doctor. He gave me some

  • blood tests - showed it was low T. That's it. It was a number."

  • Companies selling these medications increased their spending on testosterone ads from $14

  • million in 2011, to $107 million in 2012, using a snappy new name like "low T" and the

  • promise of a quick and easy pick-me-up for older men. If your T is low, you feel bad;

  • if your T is higher, you feel goodright? This is the approach that's fueled an explosion

  • in testosterone usage. The problem is, it's not just a number. In reality, "low T" levels

  • are uncertain, the symptoms are vague, and the relationship between levels and symptoms

  • really isn't so direct.

  • The concept of "low testosterone" implies there's a level that's considered low. Interestingly,

  • there isn't really a medical consensus on what that level is. A report by the American

  • Urological Association described hypogonadism as a total testosterone level lower than 300

  • nanograms per deciliter. However, that same report also defined "true hypogonadism" as

  • less than 150 to 200, and later said that levels from 200 to 346 are in a "gray zone".

  • Other studies and sources have defined low testosterone as less than 230, 250, 280, 319,

  • 325, or 350. One laboratory test considers levels as low as 132 to be normal. The Endocrine

  • Society actually acknowledged that their panelists couldn't agree on 200 or 300 as a lower limit

  • when deciding whether to treat older men who have low testosterone symptoms. According

  • to one article in the Cleveland Clinic Journal of Medicine: "There is no general agreement

  • on the acceptable normal range of testosterone". Another article adds: "There are no absolute

  • testosterone levels below which a man can unambiguously be stated to be hypogonadal."

  • This is not a merely theoretical dispute. As Dr. Lisa Schwartz pointed out, defining

  • low testosterone levels as below 230 nanograms per deciliter would classify 7% of men aged

  • 50 or older as having low T. But moving the cutoff to below 350 would expand this to 26%

  • of that population. Meanwhile, there's a substantial gap between the testosterone levels that most

  • medical authorities aim for during treatment, and the levels that "low T clinics" aim for.

  • The Endocrine Society suggests that levels of 350 to 750 nanograms per deciliter are

  • best, while the Cleveland Clinic recommends levels of 400 to 600. However, Dr. Jeffrey

  • Life of Cenegenics Elite Health prefers to aim for 800 to 1000, the Apex Clinic in Oklahoma

  • City lists a goal of 800, the New Jersey Virility Center recommends 600 to 800, and the Total

  • Male Medical Center describes 800 to 1100 as "optimal levels". More T Clinics claims

  • that levels over 700 "can profoundly improve your quality of life by increasing your energy,

  • mental clarity, sex drive, sleep quality, muscle mass, and overall health." So, one

  • test might show that a man has low testosterone, while a different test indicates his levels

  • are normal. Another man might have levels that are firmly within all these "normal"

  • ranges, but a "low T clinic" would think he still needs more.

  • But low T levels are only half the story. What about the condition itself, and its symptoms?

  • Hypogonadismthe insufficient production of testosterone in men - is a real condition.

  • It can be caused by injuries, infections, certain medications, pituitary disorders,

  • cancer treatment, inflammation, autoimmune disease, genetic disorders, or just normal

  • aging. Its symptoms can include lowered sex drive, erectile dysfunction, infertility,

  • loss of muscle, decreased body hair, osteoporosis, tiredness, difficulty concentrating, and even

  • breast growth. For men with hypogonadism, this is a serious issue. But when low testosterone

  • is simply the result of aging, the symptoms are often nonspecific. For instance, fatigue,

  • loss of libido, and difficulty concentrating could be caused by low T, but this can also

  • be caused by depression. And companies selling prescription testosterone frequently offer

  • symptom-based screening online. Websites for AndroGel and Testopel ask questions like,

  • "Do you have a lack of energy?", "Have you noticed a decrease in your enjoyment of life?",

  • "Are you sad and/or grumpy?", "Are your erections less strong?", and "Are you falling asleep

  • after dinner?" These screeners are based on the Androgen Deficiency in Aging Males questionnaire,

  • designed to detect low testosterone levels in older men. But the ADAM questionnaire has

  • some performance issues of its own. In the first study of the ADAM screener's accuracy,

  • it was given to Canadian doctors aged 40 to 62, and it was found to have a sensitivity

  • of 88% and a specificity of 60%. A test's sensitivity refers to how likely it is that

  • someone with a condition will receive a positive result, and specificity refers to how likely

  • it is that someone without a condition will receive a negative result. So, this study

  • showed that out of 100 men who do have low testosterone levels, 88 will get a positive

  • result from the ADAM screener, and the other 12 will receive false negativesthey'll

  • be told that they don't have low testosterone, when they actually do. Meanwhile, because

  • the specificity in this study was 60%, this means that out of 100 men without low testosterone,

  • 60 will get a negative result from the screenerbut 40 of them will get a false positive.

  • The test is broad enough to encompass a lot of the men who do have low testosterone, but

  • also some who don't. This is not an isolated finding from one study. In seven studies from

  • 2004 to 2013 using the ADAM questionnaire, its sensitivity ranged from 66.7% to 88%,

  • and its specificity ranged from 14.8% to 36.6%. When men without low testosterone take these

  • online screeners, it's possible that a majority will nevertheless be told that they do have

  • low T. As one article explained: "...the ADAM questionnaire will rarely miss the diagnosis

  • in hypogonadal individuals, but will also incorrectly identify many nonhypogonadal men.

  • The lack of specificity is not only due to the fact that many positive responses in the

  • questionnaire may be indicative of other conditions such as depression, but also because scores

  • derived from these questionnaires do not predict or correlate well with measured free and total

  • testosterone." A story in the New York Times briefly touched on the origin of the ADAM

  • questionnaire. Quote: "Dr. Morley recalls that he drafted the questionnaire in 20 minutes

  • in the bathroom, scribbling the questions on toilet paper and giving them to his secretary

  • the next day to type up. He agrees that it is hardly a perfect screening tool." Yet this

  • is the tool that sellers of prescription testosterone are using to encourage men to see a doctor

  • – a tool that could be telling up to 85 out of 100 healthy men that they might have

  • low T. Surprisingly, other screeners don't do much better. In various studies, the Aging

  • Males' Symptoms scale was shown to have a sensitivity ranging from 54% to 96%, and a

  • specificity ranging from 30% to 48.1%. A screener used by the Massachusetts Male Aging Study

  • had a sensitivity of 76% and a specificity of 49%. Ultimately, the symptoms of low T

  • don't seem to be so strongly associated with, well, low T. This is especially concerning

  • given that only 51% of men on testosterone therapy have actually been diagnosed with

  • hypogonadism, and only 75% have had a blood test to check their T levels within the past

  • 12 months.

  • But what about men who do have low testosterone? Oddly enough, low T levels can often be asymptomatic

  • men with low T might not show any signs of it. For instance, in a study of hundreds

  • of elite athletes, 16.5% of men were found to have testosterone levels below normal.

  • Another study focused on 1,475 men in the Boston area aged 30 to 79. 24% of them had

  • total testosterone levels below 300 nanograms per deciliter, but only 5.6% had low T levels

  • along with symptoms. So, of all the men whose testosterone levels might be considered low,

  • three out of four did not have significant symptoms of low T. The Massachusetts Male

  • Aging Study went into further detail, grouping men aged 40 to 70 into three different ranges

  • of testosterone levels. At baseline, in the group with total testosterone levels greater

  • than 400, 40% had 3 or more symptoms of low T. Of the men with levels of 200 to 400, 42%

  • had 3 or more symptoms. Even among men with levels below 200, only 53% had 3 or more signs

  • of low T. So, a substantial number of men with these symptoms don't actually have low

  • T levelsand many men with low T levels don't have these symptoms. Dr. Ronald Swerdloff

  • points out that men's low T thresholds can be diverse. Quote: "One man might get low

  • libido at 325 milligrams per deciliter, while another might not get low libido until 450."

  • All of these factorsvaguely defined levels, vaguely defined symptoms, and a vague relationship

  • between the twohave come together to create a fertile environment for the overprescribing

  • of testosterone.

  • As a trans woman, witnessing the rise of the "low T" industry has been fascinatingand

  • more than a little frustrating. The complex that's emerged here is seemingly designed

  • to ensure that as many men as possible will be on prescription testosterone. A man might

  • feel tired, and he happens to see a commercial about how this could be low T. He'll go to

  • a site like IsItLowT.com, and a quiz that might be no more accurate than a coin flip

  • will tell him to see his doctor. And he'll make an appointment at his local "low T clinic",

  • where even normal ranges aren't considered high enough. Before you know it, we've got

  • a billion-dollar market on our hands. But many trans people require treatment involving

  • sex hormones as well. As Dr. Abraham Morgentaler writes: "It could be said that testosterone

  • is what makes men, men. It gives them their characteristic deep voices, large muscles,

  • and facial and body hair, distinguishing them from women." So it's no surprise that trans

  • men would often want more testosterone, and trans women would often want to get rid of

  • theirs and replace it with estrogen. Yet our experiences of engaging with the medical system

  • could not be more different from that of cis men seeking treatment for low T. A spokesman

  • for AbbVie described campaigns like IsItLowT.com as "disease state awareness initiatives".

  • But there are no major marketing initiatives raising awareness of transition treatments,

  • or running commercials suggesting that if you're tired and depressed, you might be transgender.

  • None of these businesses are promoting websites about gender dysphoria, or offering unhelpful

  • quizzes that tell a significant fraction of cis people to talk to their doctor about transitioning.

  • And there are no multi-state chains of clinics focusing exclusively on transition treatments

  • let alone telling cis people that even if they're healthy, transitioning can make

  • them feel even better. There is no overbroad promotion of trans medicationsbecause

  • most of the time, we don't even have access to the basics. Medical transition is recognized

  • as effective and necessary by the American Psychological Association, the American Psychiatric

  • Association, the American Medical Association, and the World Professional Association for

  • Transgender Health. Unlike "low T", transitioning isn't the subject of any real medical controversy.

  • But if you haven't yet realized you're trans, you're not going to learn about it from a

  • commercial break during Monday Night Football. Basic awareness - what it feels like, what

  • you can do about it, and where to find treatmentis mostly provided by the community via

  • ad hoc resources like internet forums and personal websites. There is no organized promotion,

  • just everyday people trying to help each other and offering what they know. It's entirely

  • possible that the current best way to find a clinic is to go to Reddit, find one of the

  • trans sections, and ask if anyone in your area knows a doctor who'll see you. That's

  • how little institutional and corporate support we have.

  • And if you do manage to find a clinic, it's often very difficult to be seen or receive

  • treatment in a timely manner. After the day I first made an appointment with a therapist,

  • it was 3 months before I had my prescriptions in hand. And in my experience, that's on the

  • lower endone of my friends has been waiting 8 months just to get an appointment with an

  • endocrinologist. Now, what if I had been looking for testosterone instead? I've had my baseline

  • T levels checked, and depending on which "normal" range you choose to apply, they were potentially

  • low even before hormones. Theoretically, I could have gone to the clinic a few miles

  • from here that's offering a month of free testosterone, told them about how little body

  • hair and muscle mass I had to start with, and received my first injection within a matter

  • of days. Countries with universal healthcare seem to have similar issues with the availability

  • of transition treatments. The NHS's Interim Gender Protocol from 2013 states that receiving

  • hormones will typically take 6 months after the first visit to a gender clinic. Before