Update 3/12: Earlier this month, the Food and Drug Administration announced that all testosterone products must be labeled to include information about the possible increased risk of cardiovascular problems as a result of using the drug. The evidence is not overwhelmingly clear. Some studies have found the risk. Others have not. But the FDA advisory committee that recommended the labeling concluded, "in general, the available studies informing the cardiovascular safety signal with testosterone therapy are limited in scope, quality, design, and size. Nonetheless, there was agreement amongst committee members that a weak signal of cardiovascular risk had emerged from results of recent large epidemiologic studies."
The sleeves on Dr. Paul Campion’s maroon shirt are rolled back, revealing paisley cuffs, a passel of bracelets on his right wrist, and an elegant watch on his left. His knick-knacks rest in wooden cubbies behind him: a conch shell, a decanter, an ostrich egg, a Japanese warrior sculpture, two beakers, and a molecular model of glucose.
At 56, he’s in better shape than he was in his 30s. He flips through pictures on his iPhone 6 showing me the belly he carried three years ago, before he began taking testosterone supplements. In recent photos, his abdominals look like a sculpture of Morse code.
The old, pre-testosterone Campion was an ophthalmologist, an eye doctor, in the wooded wonderland north of San Francisco. “I was just at the gym watching the 30-year-olds at the pull-up bar building muscles in three weeks. And I’m at the pull up bar and nothing’s happening,” he recalls. “I’m not feeling good. I’m sleepy all the time. All I want to do is sit down and eat potato chips and watch TV. Something’s not right.”
So he went to Cenegenics, a medical start-up that trains physicians to run their own “age management” practices. They updated his diet, put him on a new workout regimen, and started giving him testosterone. Within six months, his body fat was down to nine percent. “That’s pretty hard to maintain—I’m closer to 12 percent now,” he humblebrags. After his personal success, Cenegenics asked if he’d like to take their training course, so he did, and quickly, he found himself switching specialties and business models. He became a testosterone doctor.
Clinics like his don't work like most doctors' offices do, where they are limited by what insurance companies will pay for. This is an all-cash business. The initial session costs $5,000, and the monthly charges are over $1,000. Clients get their blood work done every three months, so that Campion can keep tabs on how their “hormonal balancing” is going. Most patients lock into a permanent testosterone regimen, as Campion has. “I will take testosterone for the rest of my life,” he says.
Three and a half years after completing the training, Campion works in downtown San Francisco, across the street from the TransAmerica Pyramid, which is home to several investment banking firms and other companies with the words "partners," "group," or "capital" in their names. It’s a fascinating corner of the city, occupied by bankers in the Pyramid, the late Mayor Alioto’s family law offices across Washington, the Scientologists in the triangle at the foot of Columbus, and then this big office building, 655 Montgomery, filled with lawyers and fund managers and, on the 14th floor, the very discreet clinic.
It's so quiet inside 655 Montgomery that I can barely hear my footfalls on the plush carpet as I approach Cenegenics' office. There are no windows out onto the hallway. The office is designed for maximum privacy. Patients are generally seen one at a time, or kept in separate rooms throughout their seven-hour initial physical. Down the hallway, there’s a fancy machine for measuring body fat and a workout room, where a physiologist tests clients’ bodily functions—like the VO2 max test beloved by cyclists. Then Campion takes over and determines if the regimen should include testosterone and/or other muscle-boosting substances like DHEA (which Campion also takes himself).
Testosterone is not just any drug. It’s not nitrous oxide out of a balloon at a Phish show or a little weed in a brownie. "T," (as it is known) is, by most accounts, as close to a direct anti-aging medication as science has yet produced. It can be manufactured cheaply in large quantities, and the risks seem manageable for most people. Users report increased energy, more muscle mass, decreased body fat, greater sex drive, and a general sense of well-being. In short, it's one of the most transformative substances a human can take.
“Testosterone is ridiculously powerful,” Campion says. “I can tell you from experience, the feeling of well-being, of focus, and of masculine energy are massively increased. It’s like you’re back to being 35.”
That power—along with a heavy dose of pharma company marketing—is why millions of American men are obtaining testosterone from doctors in various forms. According to a study by University of Texas epidemiologist Jacques Baillargeon, nearly four percent of men in their 60s are taking testosterone. The number of men between 40 and 64 went up 77 percent from 2010 to 2013 to 1.5 million men. Abbvie, maker of a popular testosterone gel, makes more than a billion dollars a year from the sale of AndroGel. In 2013, 14,000 kilograms of testosterone were sold in the United States. That might not sound like much, but a typical adult male has just 0.000000035 kilograms of testosterone floating around in his bloodstream. There is a lot of extra T in the hormonal composition of the country—and it only accounts for the legal sales.
The emerging popularity of testosterone has opened up whole new business models for entrepreneurial doctors. Chains of shops that provide the hormone have exploded all over the United States, especially across the South. How many millions more men might be willing to try testosterone if it was easy to acquire, and a clinic happened to implant itself in an adjacent office building or a local strip mall, next to an abandoned video store and the Starbucks?
We don’t need to look ahead at human genetic engineering, brain implants, or crazy designer drugs to see the real future of our relationship with our bodies. The rise of testosterone use isn’t a drill for future body hacking—it is body hacking playing out right now across the American heartland, with a substance that was first synthesized in 1935. And in the coming years, the battles over T’s use are going to be repeated for future drugs that give people—anyone with money, at least—the power to transform the body beyond its innate abilities and configurations.
The crux of the medical ethics issue is this: are people taking testosterone to cure a disease, or are they taking it to transcend the limitations normally imposed on an aging human body?
Campion, for one, insists that his testosterone clinic is meant to promote well-being, not to cure disease, even though he uses the tools of medicine. “Our philosophy is to stay out of medical buildings, even though we are medical doctors, because we don’t want to be sick-oriented,” Campion says. “I don’t prescribe any ‘sick’ medicines. I prescribe hormones and supplements.”
There’s another complex set of ideas at play, too. The testosterone story is easy to tell in a way that focuses on older, wealthy men. They’re the ones who want to recapture the penis power of their fading youth. Theirs might seem a fairly predictable narrative about power and reinforcing gender norms at all costs.
But the story of testosterone can’t be told without including the experience of trans men. They’ve pioneered ways of thinking about testosterone, the body, and gender identity that other men need to hear.
Perhaps it is easy to sneer at aging investment bankers tottering down to the doctor to get juiced. Consider, though, the case of a trans man who wants the biochemistry he feels to match his gender identity. In both cases, in the traditional way of thinking about medicine, doctors would have to label the men diseased before they could receive the drug that allows them to change in the desired ways. And if there is a logic to supporting the trans man in his quest for bodily autonomy, should the same reasoning extend to everyone else?
These are not merely abstract, philosophical questions. What’s at stake is not only the ethical future of the medical community, but the boundaries of a human life.
Here’s how the classical medical model is supposed to work. Let’s start with cis men, those who had an M stamped on their birth certificates. A man goes to a doctor. He says he has X and Y problems, maybe low energy and sex drive, plus a gut. The doctor runs some bloodwork, finds the man has testosterone concentrations on the low end of the spectrum, and diagnoses his condition as hypogonadism. Testosterone becomes the treatment for that condition. That's the clinical guideline provided by The Endocrine Society, the nation's foremost professional association of hormone-focused doctors, at least.
Harvard urologist Abraham Morgentaler has been an outspoken proponent of testosterone replacement therapy for years. He’s written several books on the topic, including Testosterone for Life, which is so embarrassing to read on the train, I would have gladly hidden it inside a copy of Penthouse. An older man beams from the cover, his arm around his young-looking wife. They’ve been biking along a coast line. Promises are made in red text inside an orange circle: “Recharge Your Vitality, Sex Drive, Muscle Mass & Overall Health!”
Morgentaler’s view is simple: testosterone is like any other drug. Hypogonadism, in which free testosterone levels fall below a rather ill defined threshhold, is like any other disease.
“Men have symptoms that are related or possibly related to a deficiency of a hormone and if the symptoms are bothersome, then the men will undergo a trial of treatment and it is often but not always successful,” Morgentaler said. “This is what we do in medicine. There is nothing that’s different.”
But is it really that easy? Is there nothing different? Testosterone falls as men get older, so isn’t giving them testosterone, pretty directly, an attempt to reverse aging?
He restated my argument, as if he’d heard it a thousand times. “The drop in testosterone is natural because it occurs so commonly and therefore it is a natural part of aging. So why should we treat something that is normal aging?” he said.
“And the response is that almost everything we treat in medicine is age-related. Aging is related to bad eyesight, bad hearing, bad joints, bad hearts, bad blood vessels, and cancer. We treat all of these without trying to minimize or diminish them that they are age related. And they are, no less than deficiency of testosterone.”
One might concede the point: prevalence and age-linkage do not make testosterone different.
What makes testosterone different is testosterone itself.
Testosterone isn’t like giving someone bifocals or sticking a stent in someone’s heart. Testosterone is a key part of the body’s basic communication and regulatory systems. Hormones partially control how the genes coded into a genome get used. Change someone’s testosterone level, and you change the whole organism.
In 2002, The New Yorker ran a profile of Morgentaler. In it, Morgentaler concludes two visits with patients using roughly the same line, “If I had a magic wand and I could do anything for you, what would it be?” The patients name different things—“the energy thing” or “the problem with orgasm”—but the solution is the same, testosterone.
Testosterone can be a magic man wand.
Six years ago, Kortney Ziegler, an Oakland entrepreneur and filmmaker, walked into a San Francisco health clinic specializing in transgender care and said that he wanted testosterone.
“I told the doctors, 'You know what? I socially live as a male, and I would like to medically transition, and it was that easy. And the doctor was like, 'Okay, these are the specs of taking testosterone. When would you like to start?' I was like, ‘Whoa, I don’t need any kind of psychological evaluation or proof of anything?’ And they said, ‘Well, you live as a man. Who are we to stop you from shifting your body in the way that you see fit?’”
The doctors at the clinic gave him his first injection of testosterone in the office. By later that day, his voice was changing, getting scratchier. “Now, my face is wider. My hands are bigger. I gained a shoe size. Even in this past year, I’ve gone through significant changes,” he told me. “My hair pattern has changed. Where I grow hair has changed. I look at pre-T pictures and I’m like, whoa! Even my forehead has changed." Watching his body go through these changes fascinated him week by week, year by year. “I thought it would hurt,” he said. “It doesn’t. It didn’t.”
Bodybuilders of the Arnold Schwarzenegger era and baseball players of the Barry Bonds era have given us a series of caricatures of what testosterone can do to a body. But Morgentaler told me steroid users aim for testosterone levels 50 to 100 times normal T levels. So, that’s not what happens when you undergo testosterone replacement therapy.
And yet, the effects of testosterone on the body are still fascinatingly powerful at lower levels. The New York Times Magazine ran an article about trans men at women’s colleges late last year. While the piece largely dealt with the blowback that gender-fluid and trans men have experienced at women’s colleges, it included a description of what happened to one man when he started to take testosterone.
“Having been on testosterone for two years at that point, Jesse no longer looked like a woman trying to pass as a man,” Ruth Padawer wrote. “His voice was deep. His facial hair was thick, though he kept it trimmed to a stubble. His shoulders had become broad and muscular, his hips narrow, his arms and chest more defined.”
What struck me about this list was not that these changes made him a man—that much he’d confirmed before the therapy—but the sheer breadth of the alteration. This is the same person with the same experiences and memories and genome. And yet, put testosterone into his veins, and his body morphs in ways that defy other adult human experiences. I reread the paragraph: The shape of his hips changed. Tell me that’s not a magic wand.
Six years after he began taking testosterone, Ziegler now gives himself an injection every Friday afternoon. As the week goes on, the drug ebbs out of his body. “I feel it when it’s not there,” he said. Because he hasn’t had a hysterectomy, his body still produces estrogen. If he completely stopped taking T, he’d eventually menstruate, a thought which alone traumatizes him. So, Ziegler—like Campion—is committed to taking testosterone for the rest of his life, assuming that his liver continues to be able to process the hormone.
If he’s changing so much on the outside, what’s happening internally, to the person who started taking the hormone six years ago? “It makes me think of a lot about being in a body at all and how our everyday being and physical presences shape our spiritual beings,” Ziegler said.
As these stories show, it is no longer really the case that one must be diagnosed with a disease to get testosterone from a doctor. Individual doctors are slowly blurring the edges of acceptable medical practice so that they can provide what their patients want. They've taken a stab at resolving what our society has not been able to decide: should a more-or-less healthy person who merely wants to change his or her body with a drug be allowed to?
After all, the doctors are merely helping their patients do what modern society wants them to do. In Ziegler’s case, taking testosterone actually reduces his gender fluidity, helping people read him as a man in all social contexts. It makes him more legible to society. And the aging cis men who take testosterone can stay more productive at work and home with a hormonal tailwind.
“No matter what you consider a disease or condition, the fact remains that by the time you reach 40-45, virtually every man has lowering T. That’s a natural state of being as you slowly poop out. But we’re around a lot longer than that,” said Campion. “I say, why not stay in the optimal shape that you have? Hormones, we know, keep you useful. So why the heck aren’t we using them?”
University of Texas professor John Hoberman, author of an exhaustively researched book, Testosterone Dreams, argues that the fact that testosterone helps people meet societal aspirations is why it’s so difficult to regulate. Taking T isn't making you turn on, tune in, and drop out; it's helping you tune up and keep working.
“Once upon a time, respectable society feared contamination by illegal and disreputable drugs that were consumed by social deviants,” he writes. “Now regulators are concerned about a growing demand for legal drugs that serve socially sanctioned goals such as productivity, physical attractiveness, and sexual viability. The ‘threat’ posed by such drugs originates in the very system of values that sanctions their use, and it is a paradox that has put regulators in an untenable position.”
A new medical model has emerged that Hoberman calls the “client-centered libertarian medicine.” Doctors become service providers, and the people formerly known as patients are their clients. This is not really a joke: In the Uber-for-everything world of individual commercial desire trumping all, why not Uber for testosterone?
The entrepreneurial medical model around testosterone pays little attention to previous cultural norms that previously constrained prescribing it. “Could any Tom, Dick, or Harry find a doctor to put them on hormones on the basis of little or no testing evidence? The answer is yes,” Hoberman told me. “Part of the problem is that it is no longer possible to rely on American doctors generically speaking to practice responsible medicine with hormones. You can’t do it.”
This emergent industry is not primarily composed of high-end, coastal practices like Campion’s. Low-T business startups are blooming across the country, many run by entrepreneurial doctors who did not specialize in endocrinology, urology, or any related subfield. By our count, the four largest chains alone—BodyLogic MD, Low T Center, Ageless Men’s Health, and LowTestosterone.com—have added more than 150 locations since the late 2000s. (And that’s to say nothing of the small chains like Epoch Health, or the thousands of general “anti-aging” clinics that deploy a full array of pharmacological options.) In mid-2013, Low T’s private jet-owning founder, Mike Sisk, publicly claimed he would take his company public when it had $100 million of annual revenue, which he anticipated reaching in 2014 or 2015.
“That’s a whole industry that is, to me, an opaque phenomenon right now,” Baillargeon—the University of Texas epidemiologist—told me. “I haven’t seen any real rigorous scientific studies of the low-T private clinics. It’d be interesting to know how many young guys with normal testosterone levels get treatment from those types of places.”
The sketchiest corners of the testosterone industry can be found on the Internet (oh, Internet), where websites broker connections between men seeking testosterone therapy and networks of doctors who have some affiliation with the web service. One, Andrologix, claims thousands of patients. (Suffice to say: stock-image shadiness abounds.) The gray-market, mostly-unregulated nature of these services has led to some investigations, including one by the FDA, which found that fully half of the men taking T hadn’t actually been diagnosed with the disease hypogonadism. A full quarter of them did not even have blood work done before they were given hormones.
A paternalist would blanch at these statistics, but perhaps they're not such a big deal. After all, we already let people drink, smoke, scuba dive, and spend 12 hours a day hunched in front of a computer. What if a nation full of lightly-regulated, cash-only testosterone clinics is what liberty looks like in practice?
That’s certainly the position of Julian Savulescu, an Oxford philosopher and somewhat notorious proponent of human enhancement. “I think aging is the greatest evil that we face. Two-thirds of people die through aging. I’m all for turning off the effects of aging,” Savulescu told me. “And I’m totally behind the idea of human enhancement.”
Savulescu has reached his position through what he calls a common sense approach that discards “mystical thinking” or “religious morality” about the sanctity of the human body. If there are large benefits to be had by enhancing human beings with relatively minimal risks, then, he argued, we should do it. “It’s just an outdated way of thinking that says, ‘The only thing that matters is disease,’” and not more general well-being (there's that word again!) as expressed through one’s biological body.
“People want to chop off healthy limbs, or a healthy penis, or they don’t want to get old or they want to have sex at the age of 85. There is nothing unreasonable about those things,” he said. “It doesn’t have to be 100 percent safe. Life is never 100 percent safe.”
And yet, when it comes to testosterone, Savulescu, who is 51, doesn't think that the messy American compromise of entrepreneurial doctors handing out boatloads of testosterone prescriptions is the right approach. Men can't be expected to adequately assess the medical risks of taking testosterone, he said. “And I wouldn’t want some guy who opened up a clinic to make money selling testosterone telling me what the data was,” he said.
Worse, he said, the look-the-other-way American compromise to human enhancement through testosterone means that data is not being captured about any of the generally healthy people who are taking testosterone and other enhancers.
“There are all these people on modafinil [a cognitive enhancer], testosterone, growth hormone, and we have no idea what’s happening to them. That data is available,” he noted. “This idea that the only way that we proceed is through a randomized, double-blind, controlled trial for some disease—it’s deeply out of kilter for modern life. And we ought to be thinking about experiments in a much wider range of instances. We don’t have to put everyone in a laboratory, but we should be getting data.”
Of course, the FDA is structured precisely to do those randomized, double-blind, controlled trials, and only them. Its other job is to make sure that drugs are only used to treat diseases. So, is there a need for a new regulatory agency that could handle other types of treatments, I asked? Yes, certainly, Savulescu said.
“I think it should be the Human Well-Being Regulatory Authority,” he said. “And it should be about looking at biologics and the sorts of interventions that the FDA looks at, just not in terms of disease but human well-being.”
Such a hypothetical agency could ensure the safety of drugs and drug prescribers without constraining precisely what they would be used for. And it would gather data on the outcomes of the pharmaceutical regimens that people chose to follow. It goes without saying that this would be a radical, radical departure from the current way of regulating drugs in America.
In some ways, trans men and their health care providers have already converged on a model that works somewhat like Savalescu’s hypothetical Human Well-Being Regulatory Authority. They call it “informed consent,” said Emiliana Lombardi, a sociologist at Baldwin Wallace University who has studied transgender health care.
In the past, many trans men went to the testosterone black market rather than face being denied care or having to accept being labeled as having a disorder. These days, though, in states like California, a different model has taken hold. Now, doctors explain the risks of hormone therapy and regularly monitor the men taking hormones. In many clinics, the doctors do not presume to be functioning on the classical medical model of “treating a disease.” Instead, the doctors understand their role as enabling trans men to create the bodies that they want to live in and through.
“Before, it required a three-month relationship with a psychotherapist before they could write the letter to get permission. In some cases, it was upwards of a year before they could get permission to access treatment,” Lombardi said. There are still clinics that use the old models, but among people who care for trans patients, consensus has arrived.
Trans people haven’t only pioneered sensible health care models. They’ve also been forced to reckon with the idea of masculinity in ways that many cis men have not. In her doctoral dissertation at the University of Iowa on testosterone use in cis and trans men, anthropologist Alexis Ruth Matza found that cis men tend to ignore their bodies unless something goes wrong.That’s not a privilege that trans men have. They must try to understand the connection between body and mind, testosterone levels and manhood.
Manhood is the central preoccupation of the sales pitch for T. One typical Androgel commercial takes place on a construction site in which men literally construct the Androgel brand name at building-scale. Androgel’s website tells visitors, “You are a man. You want facts. You get down to business. You might have low testosterone. You don’t like wasting time. You’re visiting this site for a reason.”
One surprising fact about the geographical distribution of testosterone takers is that they're concentrated in more politically conservative states—Tennessee, Texas, places like that. The Low T Center has 12—twelve!—locations in Dallas/Ft. Worth alone. These are red states. Places where gender norms are even more rigorously enforced than in other parts of the country. Places where trans men have been subject to violence for expressing their identities.
The demand for testosterone, then, is not solely determined by the hormone-producing Leydig cells of American men’s testicles or the pharmaceutical companies’ advertising. The way our society requires men to feel and act creates the social context for the explosion of “low T” and the emotional resonance of testosterone marketing.
“Society requires men to look a certain way and women to look a certain way. On the one hand, there are a lot of barriers for trans people," the sociologist Lombardi said. "But at the same time, there is a lot of pressure to cis people to maintain a certain gendered appearance in life, for both men and women."
Trans people have tried to show that gender is something people perform and navigate, according to the standards of the people they’re surrounded with, not something they're born with. Some men might have penises, but not all of them. “Being a man” is a continual process of identity and biological creation.
So, you want to perform manhood more easily? Take some testosterone. The sheer fact that properties of “manhood” can be conferred by an injection should destabilize our notion of how fixed in our bodies and identities we are. Toby Beauchamp, a University of Illinois gender studies professor, argued in a 2012 journal article about testosterone regulation that the demand for testosterone “overtly demonstrate[s] the fluidity of sex and gender categories.”
And yet, those same vials are being used by cis men to adhere more closely to the rigid gender norms to which most men in the country aspire. The demand for testosterone didn't come from nowhere; it came from men wanting to be seen as manly. And if some country did create a Human Well-Being Regulatory Authority, understanding why people would want to take a drug like testosterone would be as important as assuring its safety.
Six years after the first vial of testosterone entered his bloodstream, Ziegler is still thinking through his own transformation. “I wonder how my body affects my emotions and how my soul has changed,” he said. “Am I any different?”
Hoberman, the author of Testosterone Dreams, thinks that's a question many more of us will be asking in the coming years. “The 21st century is going to be a testing ground for what the human race decides to do in terms of its own self-transformation,” he said.
In fact, as the growth of testosterone usage proves, we’ve already begun.