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 good – right? 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?

Hypogonadism – the 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 negatives – they'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 screener – but 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 levels – and 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 factors – vaguely defined levels, vaguely defined symptoms, and a vague relationship

between the two – have 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 fascinating – and

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 medications – because

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 treatment – is 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 end – one 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

that, just waiting for the first consultation can take even longer. The Nottingham clinic

reports a waiting time of about 6 months, the Sheffield clinic reports a wait of 49

weeks, and the Charing Cross clinic has a waiting list that's 12 months long. A 2012

audit of Scotland's Lothian clinic found a waiting time of 68 weeks. For perspective,

68 weeks after I made my first appointment, I had been on hormones for over a year. And

a study by the NHS in 2013 found that patients in northwest England traveled a median of

214 miles for their gender clinic appointments. That's about the same distance as driving

from New York City to Boston. The situation in Canada isn't much better. In January 2013,

the Centre for Addiction and Mental Health in Toronto stated there was a waiting time

of one year for a first appointment. In August, the Centre actually published an open letter

asking family doctors to start prescribing hormone therapy for trans people. And by October

of 2013, The Star reported that their waiting list had grown to 16 months. That's a long

time to wait to see a doctor.

Now, some people might think that this is simply a statistical inevitability – that

trans people must be incredibly uncommon compared to cis men with low testosterone, so naturally

there are fewer resources available. But if we're really so rare, then in a world where

even the private Low T Center already has 53 clinics in 12 states, it should be trivial

to provide for what little we need. Yet in reality, we're not that rare. Let's consider

the prevalence of symptomatic low testosterone. Thanks to uncertainty surrounding the symptoms

and levels, this can be interpreted somewhat freely. In 1999, the makers of AndroGel stated

in marketing materials that hypogonadism affects about a million men in the US. In 2000, they

estimated the potential market as 4 to 5 million men. And by 2003, they were claiming that