More informationon AndroGelTM AndractimTM is available here: UniMed	THE TESTOSTERONE EFFECT TIME MAGAZINE THE TESTOSTERONE EFFECT APRIL 24, 2000 VOL. 155 NO. 16 Are You Man Enough? Testosterone can make a difference in bed and at the gym. And soon you'll be able to get it as a gel. But it's a risky substance. And is it really what makes men men? BY RICHARD LACAYO Whatever else you may think about testosterone, you can tell it's a hot topic. Every time you mention that you happen to be writing about it, the first thing people ask is "Can you get me some?" (Everybody, even the women.) Maybe that's not so surprising. If there is such a thing as a bodily substance more fabled than blood, it's testosterone, the hormone that we understand and misunderstand as the essence of manhood. Testosterone has been offered as the symbolic (and sometimes literal) explanation for all the glories and infamies of men, for why they start street fights and civil wars, for why they channel surf, explore, prevail, sleep around, drive too fast, plunder, bellow, joust, plot corporate takeovers and paint their bare torsos blue during the Final Four. Hey, what's not to like? Until now, it was easy to talk about testosterone but hard to do much about it. About 4 million men in the U.S. whose bodies don't produce enough take a doctor-prescribed synthetic version, mostly by self-injection, every one to three weeks. But the shots cannot begin to mimic the body's own minute-by-minute micromanagement of testosterone levels. So they can produce a roller coaster of emotional and physical effects, from a burst of energy, snappishness and libido in the first days to fatigue and depression later. The main alternative, a testosterone patch, works best when applied daily to the scrotum, an inconvenient spot, to put it mildly. Some doctors recommend that you warm that little spot with a blow dryer, which may or may not be fun. All of that will change this summer when an easy to apply testosterone ointment, AndroGel, becomes generally available for the first time by prescription. The company that developed it, Illinois-based Unimed Pharmaceuticals, promises that because AndroGel is administered once or more a day, it will produce a more even plateau of testosterone, avoiding the ups and downs of the shots. Though the body's own production of this hormone trails off gradually in men after the age of 30 or so, not many men now seek testosterone-replacement therapy (not that they necessarily need to) or even get their T levels tested. But replace the needles and patches with a gel, something you just rub into the skin like coconut oil during spring break at Daytona Beach, and suddenly the whole idea seems plausible. Testosterone, after all, can boost muscle mass and sexual drive. (It can also cause liver damage and accelerate prostate cancer, but more on that later.) That makes it central to two of this culture's rising preoccupations: perfecting the male body and sustaining the male libido, even when the rest of the male has gone into retirement. So will testosterone become the next estrogen, a hormone that causes men to bang down their doctor's doors, demanding to be turned into Mr. T? Do not underestimate the appeal of any substance promising to restore the voluptuous powers of youth to the scuffed and dented flesh of middle age. If you happen to be a man, the very idea is bound to appeal to your inner hood ornament, to that image of yourself as all wind-sheared edges and sunlit chrome. And besides, there's the name: testosterone! Who can say no to something that sounds like an Italian dessert named after a Greek god? But testosterone is at issue in larger debates about behavioral differences between men and women and which differences are biologically determined. A few Sundays ago, the New York Times Magazine ran a long piece by Andrew Sullivan, 36, the former editor of the New Republic, in which he reported his own experience with testosterone therapy. In two years he has gained 20 lbs. of muscle. And in the days right after his once-every-two-weeks shot, he reports feeling lustier, more energetic, more confident and more quarrelsome--more potent, in all senses of the word. Looking over the scientific research on testosterone, Sullivan speculated on the extent to which such traits as aggression, competitiveness and risk taking, things we still think of as male behavior, are linked to the fact that men's bodies produce far more testosterone than women's bodies. His answer--a lot--was offered more as an intuition than a conclusion, but it produced a spate of fang baring among some higher primates in the media and scientific world, since it implies that gender differences owe more to biology than many people would like to believe. Three researchers wrote the Times to complain that Sullivan had overstated their thinking. In the online magazine Slate, columnist Judith Shulevitz attacked Sullivan for favoring nature over environment in a debate in which nobody knows yet which is which. In the days that followed, Sullivan fired back at Shulevitz in Slate, she attacked again, and other writers joined in. If testosterone use becomes a true cultural phenomenon, expect the conversations about its role in gender differences to become even more, well, aggressive. So just what does testosterone actually do for you? And to you? And how does it figure among the physical and environmental pressures that account for head-banging aggression, or even just the trading pit on Wall Street? One reason testosterone enjoys a near mythical status is that myth is what takes over when conclusive data are scarce. Though testosterone was first isolated in 1935, hormone-replacement therapy is one of the few areas of medicine where research on men lags behind that on women. What we do know is that testosterone is an androgen, as the family of male sex hormones are called, and these hormones, in turn, are made up of the fat known as steroids. Both men and women produce testosterone in their bodies, men in the testes and adrenal glands, women in the adrenal glands and ovaries. But men produce much more--the average healthy male has 260 to 1,000 nanograms of testosterone per deciliter of blood plasma. For women the range is 15 to 70. But because men differ on how effectively their bodies process the substance--for instance, some have more receptors around their body that absorb it--a man on the low end of the normal range can still have all the testosterone he needs for normal sex drive and other benefits. In healthy men, levels also vary during the day, peaking around 8 a.m., which is why men commonly awaken in a state of sexual arousal, and dropping as much as half before bedtime. Testosterone is the substance that literally turns boys into boys in the womb. In the first weeks after conception, all embryos are technically sexless. Around the sixth week of gestation, the presence of the Y chromosome in males triggers a complex set of signals that cause a surge in testosterone. Among other things, that sets in motion the formation of the penis and testes. In adolescence, boys undergo another eruption that deepens their voices, causes hair to form on their bodies and allows their muscles to enlarge. Testosterone in the blood of teenage boys can jump to as high as 2,000 nanograms, which helps explain teenage boys. One possible danger of easy-to-use testosterone is that it might become a temptation to younger males looking to bulk up at the gym. Not many of them would be able to demonstrate the diminished T counts that would allow them to get it legally from their doctors, but the potential for a black market in AndroGel is not hard to imagine among teens and guys in their 20s--and older--who hear stories about a new substance stronger than the supplements available over the counter and easier to use than anabolic steroids that are injected. For teens in particular, the dangers of testosterone overload are not just acne and breast development but a shutting down of bone growth--though they may be at an age that makes them almost deaf to the risks. For older men, studies indicate that high levels of T do not necessarily cause prostate cancer but do fuel the growth of tumors once they occur, which is why chemical castration is one means of treating the disease in the advanced stages. Gay men may have been one of the first populations to talk up testosterone replacement, which is often part of the treatment regimen for hiv-positive men like Sullivan, author of the New York Times Magazine piece. They produced a buzz about increased sex drive and better results at the gym, things that happen to be of interest to a lot of straight men too, especially middle-age baby boomers looking to put themselves back in the driver's seat as far as their sex drive is concerned. "These men already come in asking for [testosterone]," says Dr. Louann Brizendine, co-director of the program in sexual health at the University of California, San Francisco. "This generation came out of the sexual revolution. They really identify themselves as sexual beings. And they don't want to give that up." At 66, Gene Teasley, who operates a family business that makes banners in Dallas, is a decade older than the baby boomers, but he gets the idea. About nine years ago, he went to his doctor complaining of less interest in sex. Since then, he has been getting testosterone shots once every two weeks. "I've enjoyed the results not just in the sexual way but also in a broader way of feeling healthier. I have more of a desire to work out, be outdoors and do more athletic things," he says. "Everybody wants to feel like they felt in their 20s and 30s." Some researchers are taking seriously the still controversial notion of "male menopause," a constellation of physical changes, including fatigue, depression and drooping libido, that they believe can be traced to the decline of hormones, including testosterone, in men over 50. Others are not so sure. "One thing we have to recognize is that the decline in testosterone is also intertwined with changes, such as decrease in blood flow, and psychological and social changes too," says Dr. Kenneth Goldberg, medical director of the Men's Health Center in Dallas. "Simply expecting to take men who are androgen deficient and expecting testosterone to fix it all--it just can't be." Yet even the passage of time doesn't guarantee that a particular man's testosterone will decline to a level that much affects how he feels, at least not by middle age. Middle-age men who preserve the body weight they had in their 20s may have no falloff at all, while overweight adult men of any age tend to have lower testosterone levels. This means that a couple of the goombahs on The Sopranos are probably deficient, though maybe I should let you be the one to tell them that. Once you get past the proven links between testosterone, libido and muscle mass, the benefits of having higher levels of testosterone become harder to prove, though no less interesting to hear about. Just how much of a role does this play in producing behaviors such as aggression, competitiveness and belligerence? Men who take testosterone by injection routinely report that in the first days after the shot, when their T counts are especially high, they feel increased confidence, well-being and feistiness--what you might call swagger. They also describe feeling snappish and fidgety. Jim--not his real name--is a family therapist who was 40 when he started taking the shots because of fatigue and a so-so interest in sex, which had led him to get his T levels tested. The first day or two after the shot, he says, he's on pins and needles. "My fiance knows to steer clear. I tend to be short-tempered, more critical, and I go around the house looking for problems. I live out in the country, so right after I get the shot I get out the weed whacker and the chain saw, and I just go crazy." Gee. Even putting aside for a moment the much increased danger of prostate cancer, do we really want men to turn later life into a hormonal keg party? The thought could be mildly exasperating to women, who might be forgiven for greeting the news with the same feelings china shop-keepers have for bulls. But this is the point at which the discussion of testosterone veers into the metaphysical. Outside the bedroom and the gym, just what does testosterone do for you? Studies in animals have repeatedly shown that testosterone and aggression go hand in hand. Castrate species after species, and you get a pussycat. Boost the testosterone with injections and the castrated animal acts more like a tiger. In one study of men, when the testosterone levels were suppressed (in this case by researchers using medications) libido and dominant behaviors dropped. But when a mere 20% of the testosterone was added back, libido and domination climbed to the levels where they had started. Which suggests that men do not need much of the stuff to go on doing whatever it is they have already learned to do. Other studies have shown that men with naturally higher testosterone levels are more aggressive and take-charge than men with slightly lower levels. When two sports teams meet, both teams will show an increase in testosterone during the game. "In the face of competition, levels of testosterone will rise," says Alan Booth, a sociologist at Penn State University. "This prepares the competitor and may help increase the chances for a win. It could be that the rise in testosterone has physical benefits, such as visual acuity and increased strength. But only the winning team continues to show high testosterone after the game." For this exercise, you don't even have to picture the Packers vs. the Vikings. The T boost also happens during nonphysical competitions, like chess games and trivia contests. Whatever the game, in evolutionary terms this makes sense. Among the primates from whom we are descended, the victorious male in any encounter may have needed to maintain high testosterone levels in the expectation that his position in the pecking order would be challenged by the next guy coming up. But here it gets complicated. Does higher testosterone produce more aggressive behavior? Or does the more aggressive male--whose aggression was learned, say, at home or in school or in the neighborhood or on the team or in the culture at large--call for a release of testosterone from within himself for assistance? And if testosterone really does determine male behaviors like aggression, then what are we to make of the fact that although testosterone levels are pretty equal in prepubescent children, boys and girls already demonstrate different behaviors? What we know for certain is this: aggressive behavior and testosterone appear in the same place. And aggressive behavior seems to require some testosterone in your system. But researchers have yet to show conclusively that adding a little more in males who already have a normal range of the stuff does much to make them more aggressive or confrontational. In one study, Dr. Christina Wang of UCLA found that men with low testosterone were actually more likely to be angry, irritable and aggressive than men who had normal to high-normal levels of testosterone. When their testosterone was increased during hormone-replacement therapy, their anger diminished and their sense of well-being increased. "Testosterone is probably a vastly overrated hormone," says Robert Sapolsky, a Stanford University biologist and author of The Trouble with Testosterone. All the same, there are social implications connected to the one area in which we know for a fact that testosterone matters--sex drive. Married men tend to have lower testosterone. It's evolution's way of encouraging the wandering mate to stay home. (In newly divorced men, T levels rise again, as the men prepare to re-enter the competition for a mate.) If aging men start to routinely boost their testosterone levels, and their sexual appetite, to earlier levels, will they further upset the foundations of that ever endangered social arrangement called the family? "What happens when men have higher levels than normal?" asks James M. Dabbs, a psychology professor at Georgia State University. "They are just unmanageable." Dabbs, the author of Heroes, Rogues and Lovers, a book about the importance of the male hormone, is another researcher who believes that T counts for a lot in any number of male moods and behaviors. "It contributes to a boldness and a sense of focus," he insists. It's possible for the scientific community to come to such disparate conclusions on the stuff, not just because the research is slim but because the complexities of human behavior are deep. If we're verging on a moment when testosterone will be treated as one more renewable resource, we may soon all get to focus more clearly on just what it does. But if men, in a culture where the meaning of manhood is up for grabs, look to testosterone for answers to the largest questions about themselves, they are likely to be disappointed. One thing we can be sure of is that the essence of manhood will always be something more complicated than any mere substance in the blood.
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