Perhaps the most challenging aspect of working with testosterone deficiency and its treatment is the resistance among the medical and non-medical community in accepting the field as legitimate and ‘mainstream’. It would be difficult to name another area of medicine where there is such long experience and abundant scientific literature and which yet evokes such strong skepticism, confusion, and negative sentiments. I believe there are several distinct reasons for this, some of which are cultural, and some of which have been created by the scientific community itself.
The first problem is that the remarkable variety of actions of testosterone in the human body makes it difficult to maintain focus on any single outcome, and makes the field vulnerable to the common criticism that ‘the benefits of testosterone treatment have not been proven’. Most pharmaceutical interventions target a primary clinical symptom or condition, and efficacy is measured for that one focus. If testosterone research were focused entirely on improvement in libido, no one could reasonably make this claim, since the data on this outcome are solid and long-established. Yet critics may point to conflicting data regarding outcomes on quality of life, or cognition, or other areas of promising research, and use the uncertainty in these specific areas as justification to reject the value of testosterone treatment in general. To address this problem, I believe it is the responsibility of researchers and clinicians in the field to distinguish to our colleagues and to the public which aspects of testosterone treatment are established (‘proven’), and which represent areas of investigation.
Another hurdle is the widespread sentiment that exists against hormonal therapies. There is no doubt that the hysteria that surrounded publication of the results of the Women's Health Initiative created increased concern regarding hormonal therapy in men. This concern has been phrased as, ‘It took us a long time to discover that hormone therapy was dangerous in women. Maybe hormone therapy in men is dangerous too, despite current evidence that it appears relatively safe.’. This attitude persists, despite more recent reviews of the women's literature that suggests that the dangers of hormone therapy were greatly overstated. Most importantly, the analogy between hormone treatment in men and women is without merit. Men are not women, and testosterone is not estrogen.
Even before the WHI, however, there existed a strong anti-hormonal sentiment in our culture. I believe some of this arises from feelings against sexuality, since the benefits of hormonal treatment are often regarded as being primarily sexual. As the wife of a 68‐year-old patient expressed it one day, ‘Doctor, I don't think it's right that my husband still wants to have sex at his age. Enough is enough.’ If testosterone treatment were used only for non-sexual reasons, for example to improve bone density, I don't believe the resistance to its use would be nearly as strong.
Another cultural hurdle is the notion that physicians tend to over-medicalize normal physiologic processes, particularly with aging. ‘Why can't we just let people age gracefully, without pills or other treatments?’ Since testosterone declines in men with age, testosterone deficiency has been considered by some a ‘normal’ or ‘natural’ part of aging. As a natural and normal process, what justification could we have for interfering with the wisdom of man's design? I find this a particularly dangerous point of view, since it is wholly false yet it appeals to our sense that what is natural is good. The flaw is to realize that 1) we interfere with ‘man's design’ with every single medical intervention, including immunizations, and 2) all of the most common medical conditions are associated with aging. Aging is associated with bad eyes, bad ears, bad teeth, bad joints, bad blood vessels, bad hearts, and cancer. We treat all of these, in order to improve the quality of our lives or to extend life. Just because something becomes increasingly common with age does not mean we should not treat it for the empty satisfaction of saying the condition is ‘natural’. If men can regain a sense of vigour, libido, and sexual function with testosterone treatment, then why does it matter if his hypogonadism occurred as a function of aging?
We physicians have also created some of our own troubles by acts of omission and commission. We have failed to provide clarity and guidance as to which features of testosterone therapy are of benefit, and which should be regarded as investigative. We have failed also in denouncing some of the outrageous, baseless claims regarding testosterone that appear in the public arena, usually for self-promotion of products or clinics. Similarly, we have been slow to distinguish medical use of testosterone therapy for androgen deficiency from the illicit use of anabolic steroids in athletics. These failures have left the public confused about testosterone.
Another important source of confusion, especially for our non-specialist colleagues, is the never-ending debate emphasizing the limitations of the various testosterone assays, and lack of consistency regarding testosterone reference values. In my opinion, the diagnosis is straightforward and does not require Web-based calculations, or use of ‘gold-standard’ assays that are found almost exclusively in research laboratories and are not available to the average clinician. I can certainly understand why so many of my colleagues throw up their hands in surrender and say they cannot diagnose testosterone deficiency except in the most severe cases. The necessary and valuable academic discussion regarding technical aspects of androgen assays has somehow come to distort the ‘big picture’ regarding the diagnosis of androgen deficiency, and created unnecessary confusion. Recommendations for blood test confirmation of androgen deficiency can be made simpler and more practical for the clinician.
Finally, I feel that we have been remiss in not tackling head-on the mythology regarding the risk of testosterone and prostate cancer. Although a long-term large-scale study has not yet been performed, there is considerable evidence indicating that higher testosterone does not represent a risk for prostate cancer development or growth. On the contrary, a growing literature suggests that low testosterone may be a greater risk for prostate cancer than high testosterone. It has even been suggested that normal levels of testosterone may prevent the development of prostate cancer. A clear statement of what is known and what is not known in this regard would be helpful for our colleagues and for the public.
There is no doubt that testosterone treatment is helpful for many androgen-deficient men. Yet the condition remains under-diagnosed and under-treated, in large measure due to cultural attitudes and also by behaviours of the scientific community. By addressing the issues outlined above, I believe we will create the opportunity to allow more men to lead a full, satisfying, and loving life.