How masculinity is impacted by testosterone deficiency

Justin Dubin, MD

According to Justin Dubin, MD, the main issue with treating testosterone deficiency is that men are too embarrassed to discuss or seek help for their intimate medical conditions. Testosterone deficiency is highly associated with a lack of manhood. To destigmatize this condition, Dubin advises clinicians on how to create a comfortable space for their patients and advises patients on how to be comfortable with talking about their deficiency. Dubin is an andrology fellow at Northwestern University in Chicago, Illinois.

What are the stigmas associated with testosterone deficiency?

Before we get into the issues and stigmas of testosterone deficiency, I think it's really important that we first define what testosterone deficiency is. The clinical diagnosis of testosterone deficiency is made only when patients meet 2 specific criteria. Number 1: They have to have a total testosterone level less than 300 ng/dL. We have to have 2 separate labs confirming that and that's according to the [American Urological Association (AUA)] guidelines. And ideally, the lab should be drawn in the morning when your testosterone is at its highest. The second criteria is the patient needs to display signs and symptoms of low testosterone or testosterone deficiency. That includes things like decreased energy, decreased endurance, decreased performance, fatigue, loss of body hair, reduced muscle mass, poor memory, obesity, decreased libido, reduced erectile function, [etc.] So, combining the symptoms with the low testosterone labs gets you a diagnosis of testosterone deficiency.

The thing with testosterone deficiency, if we're going to talk about it as a stigma, is [it's] actually more common than you think. The data shows that testosterone deficiency is seen in about 20% of men overall, and it increases to about 30% of men over 70, and about 50% of men over the age of 80. The data [also] shows that on average, men's testosterone levels decline about 1% each year. When we're talking about testosterone deficiency and the stigma around it, [however] I don't really know if the stigma is about the deficiency itself [or] really about how guys don't want to talk about their health and they may try to fix their problems without consulting an appropriate doctor. The signs and symptoms that we talked about, [the ones] I mentioned before, are really key aspects of how men view their masculinity, right? They need to be strong, they need to have energy, they need to have a strong libido, [and] they need to have good erections. It's part of their identity as being a man. They don't want to talk about their bad erections, obviously. They don't want to talk about their lack of energy, their inability to perform at work. These are important things that they're embarrassed to talk about. And despite guys feeling and looking poorly, there's this idea that as men they have to just strap up, man up, tough it out, and get through it themselves without any help. Sometimes they don't want to talk about it to anyone, and they figure, "Hey, maybe I can figure it out on my own." [They] go online, buy these testosterone boosters, or go to a men's health clinic, where they don't really know what's going on, to just get treated for whatever it is. I think that idea that men don't need help, or even worse, that they can't be helped or that they can fix this issue themselves, is really what we need to destigmatize. We need to try and fix this problem because, at the end of the day, we as urologists can absolutely help men struggling with testosterone deficiency. But really, the first thing we need to do is get them in the door.

How do these stigmas impact the management of patients with this condition?

I think the biggest thing [with] management is what I alluded to earlier. If we don't see these guys, we really can't manage them, right? Now, we know that a majority of men don't even have primary care doctors, which confirms that this stigma of masculinity may be preventing men from not only seeing their urologists, but from seeing any doctor whatsoever. But I think there's this other stigma that we talked about where men think there isn't anything we can do. We see these guys, they come in, they feel bad, [and] they took a testosterone booster, or they took some kind of testosterone [from] their friend or [from] a clinic—[a supplement] that they never even talked about the risks or the benefits of. One of the major issues that you see is that testosterone replacement itself can cause infertility. That's a major side effect. I'm [an] andrologist, so I see sexual medicine [and] I see infertility, and we do often see guys who feel bad, are down in the dumps. They went and got testosterone, but they were interested in fertility, and their sperm parameters have been compromised, and they didn't know. That's something that is important. That's why it's important to talk with your doctors about these issues. We are there to guide you; there are other ways to treat you based on your family plan, based on your goals. And that's what we're there for.

What's important to know is that having testosterone deficiency doesn't just mean you have only testosterone deficiency. Studies actually show that men with low [testosterone] actually have higher rates of other comorbidities. They have higher rates of obesity, diabetes, heart disease, [and] high blood pressure. Men with testosterone deficiency actually have higher rates of all-cause mortality. So, there are other things at play here. The major health implications associated with low testosterone are something that we really want to stress for our patients, and it's one of those classic things. Once in a while, the guy comes in, he's overweight, he's not feeling great. And I go, "Hey, what's your medical history?" [They say,] "Doc, I don't have any medical problems." [I say,] "When was the last time you went to the doctor?" [They say,] "About 40 years ago." So, it's one of those things [where] if you don't get checked up [and], of course, you're never going to be diagnosed with something, but you very well could have hypertension, diabetes, [or] obesity. That's why staying on top of it and going to talk to your doctor as soon as you start to feel these issues is really, really important.

What would you advise to patients in terms of overcoming these stigmas at both an individual and a societal level?

If you're a guy out there, and you're struggling with some of the many symptoms that we discussed, or you're struggling with [just] one of these symptoms, or you're just worried about your overall health, I think there are 2 important things you really need to know. One [is] that it's important to talk to your doctor about your health issues and concerns. Being a man is not defined by how you shrug off your problems. Being a man is about facing your problems head on and overcoming them. You're not weak for seeking help. In fact, getting help in these situations, especially with testosterone deficiency, can literally make you stronger. We could be giving you testosterone [and] improving your muscles, so we could literally be making you stronger.

I think recently, as a society, we've actually been doing a better job in the last few years of changing that narrative. We really need to continue to embrace and support men who take care of themselves. The other thing that is in line with this is [the fact that] as guys, we often get stuck in this cycle of a busy schedule that includes work and family responsibilities and leaves a little time for [ourselves]. What you need to understand is that if you don't talk to your doctor or your local urologist about your health issues, you won't really be able to perform mentally, physically, [or] emotionally at the top level in your daily life that you should be or you want to be. If you don't take care of yourself now, [then] in the long run, you really won't be able to take care of anything or anyone. At the end of the day, health issues one way or another are going to catch up to you, and the best thing you can do is really be on top of it. So, I want to stress that.

My other point here is that we as urologists can treat your testosterone deficiency. The truth is a lot of guys want to do the exercise, they want to change their lifestyle, and they want to change their diet, which is very, very important. But sometimes, it's really not enough. Sometimes these guys just have low testosterone, you feel down, and you can't get over that hump. There have been studies showing that testosterone deficiency in obese men creates this cycle where it's hard to lose weight because you have difficulty getting energy to go to the gym [and] you're not able to perform in your daily activities [in the way] that you would like. There's data that shows that giving these guys testosterone results in weight loss—and sustained weight loss at that. So, we can help make you feel better, and I don't want you going to the GNC or buying these products online—these testosterone boosters—or just doing your thing without talking to your doctor. There [are] so many ways that we can treat you. We can help you with lifestyle change, and choices, we can talk about testosterone injections if it's indicated, we can talk about gels [or] other oral medications. There are a lot of different ways that we can help you improve your overall health.

What is the urologist’s role in destigmatizing testosterone deficiency?

It's doing exactly what we're doing now—making guys feel comfortable about talking about their health issues. I always say, "[It's] just guys being dudes." [It's] just hanging out, talking about their health issues, and making it a casual conversation. We really need to do this, and we need to break down the barriers that prevent men from seeing health care providers. This opportunity is part of that process, so I'm really excited to be talking about this today. I've seen this in clinic a lot. Many times, how it works is [that] guys talk amongst themselves. Sometimes they don't want to talk about their health issues until their health issues are solved. You'll see a guy, he comes in, he's complaining of low energy, [and] you find out he has low testosterone. He fulfills the criteria, he's a good candidate for therapy, and we get him on something. A couple months later, he's back, he's feeling great, and then in the next few months, you see some other guys. Maybe some of his boys trickle in because they weren't feeling great [and] they heard about their friend feeling much better. And so, now they're willing to come to the doctor. It's this secret society of how guys want to feel better, but they won't talk about it until it's appropriate. So, we really need to get people more comfortable, and we need to create this safe, comfortable, welcoming environment for men to talk about the things that they need to talk about.

Is there anything else you feel our audience should know about this specific topic?

The focus of today's talk has been really destigmatizing this idea of what makes you a man and overcoming that idea [and] seeing a doctor. It's important to mention that when choosing someone to see for these issues, I highly recommend seeing your primary care doctor or urologist. I mentioned that there's these health clinics out there, [but] sometimes they'll just take your money, they'll give you medicine, [and] you're not going to think twice about it. I've seen this before [and] a lot of urologists have seen this before. You also see these online supplement companies that claim to boost your testosterone. These are these kinds of medications, these supplements, [are] not studied [and] they're not FDA approved. Who knows what could actually be in them. You [have] to be careful about these things. You have to be careful about your health because, at the end of the day, you only have one life to live, and we want to make sure it's the best one possible. I want you to be comfortable talking about these things, I want you to seek proper advice, and I want you to be aware that there are potential risks and benefits with kinds of choices that you make, especially when we're talking about doing testosterone, and potential fertility issues. If you're a person, a young guy who's worried you have low testosterone, and you still want treatment, guess what? There's good news. We don't have to give you necessarily testosterone to improve your testosterone levels. There are other medications we can do that don't compromise your fertility. So, that's why it's important. This is a conversation that we can have together, and shared decision-making is always important. I want to help you achieve your goals, and I want you to be the best person that you can be and the best man that you can be, however you define that. That's what we're here for. Not just me, all other urologists, and I would say all other doctors as well.