Boardroom Viagra or dangerous hype – does this man really have a cure for the male midlife crisis?
The offices of Dr Harry Fisch are on a swanky stretch of Park Avenue where doormen dress like Colombian generals and tiny, hairless dogs wear cashmere jumpers. A fleet of these well-dressed canines flows up the pavement behind three professional dog-walkers as I turn into a white tiled foyer – they look like a half-pint pack of fabulous foxhounds.
Into this clinic, dodging the miniature terriers, come middle-aged men dogged by a feeling that they are not quite all they once were. They think the lead may have disappeared, figuratively speaking, from their pencils. They come here to be sharpened, figuratively speaking. They think they might need a bit more testosterone. They want Fisch to give it to them.
“I do this more than anyone else, right?” he says, reclining slightly behind a sturdy wooden desk. He has seen thousands of men who suffer a lack of bounce in their bungee. The walls of his office are lined with plaques declaring him one of New York magazine’s “Best Doctors” in successive years. On a shelf behind his head there is a monument to the New York Jets and a rather striking head shot of a gorilla. I thought it might be a reference to the male gender in a hairier form, but Fisch says he just liked the picture. A colleague saw him staring at it in a local art gallery and bought it for him for Christmas. “Look at that,” he says, delighted to be asked about it. “Isn’t that a crazy-assed picture?”
A urologist and fertility expert, Fisch is a leading proponent of the idea that men, like women, possess a biological clock. The quartz crystal driving the mechanism is testosterone, which declines slowly and steadily after men pass the age of 30. “The most important hormone a man has is, wait, lemme think a second… Testosterone!” he says. “It’s made in the testicles…The testicle is the size of a walnut. If it’s the size of a cherry you got a problem. OK.”
And we’re off. He explains things simply and carefully; at one point he literally draws me a picture. “Did anyone examine your testicles?” he asks, almost in passing. They need to be examined more, apparently. (Also, I’m wondering if I need to buy some cherries on the way home.)
Fisch hails from Brooklyn, where his parents owned a sweet shop. His voice has a melodic quality, which serves him well on the phone-in show he hosts each week on the radio station of Howard Stern, the “shock jock” who specialises in raucous discussions about sex in all its forms. Fisch is also the medical expert on IsItLowT.com, a website sponsored by the makers of a testosterone gel. The site poses a list of questions likely to trouble any man in his middle years. Do you lack energy? Is your sex drive diminished? Are you less good at sport than you once were? Do you fall asleep after dinner? Answer yes to a few of those and you are advised that you might be suffering from hypogonadism, or low testosterone.
Thanks to websites such as this and similar educational campaigns by large drug companies, legions of men have repaired to their physicians, driven by the tantalising prospect that what they thought was the side-effects of getting old was in fact a hormone deficiency easily corrected. Over the past 12 years, following the development of gels that could be slathered on like antiperspirant each morning, the global market for testosterone has exploded. A recent survey by The Medical Journal of Australia showed global sales rising from $150 million in 2000 to $1.8 billion in 2011. Figures from 2012 suggest the market was worth $2 billion (£1.22 billion) in the United States alone, and like crack or Krispy Kreme doughnuts or Justin Bieber, testosterone treatments have crossed the Atlantic as thousands of British men have started wondering if they too might need a little more mustard in their sandwich. According to the Health & Social Care Information Centre, 300,000 NHS prescriptions for testosterone are issued each year – five times the number dispensed two decades ago.
Fisch says testosterone levels decline at around 1 per cent a year when men pass 30, but stress, obesity, sleeplessness and all the other unnatural shocks that middle-aged flesh is heir to can cause it to slip away faster. “Imagine a man of 50,” he says. “Overweight, ponytail at the back, and he buys a Porsche, right? You know what I call that? Meno-porsche. They are feeling they don’t have the oomph, they are feeling that car will bring them the sex appeal and the sexuality that they need. They need to check their testosterone first.”
Is he saying that testosterone treatment could entirely banish the male midlife crisis? Could this be the end of fortysomething fellows abandoning their wives and rushing off in pursuit of fast cars and fast women? “I can’t say that for a fact,” he says. “I’m just saying you need a normal level of testosterone at all ages.” He is also saying: “Before you buy a Porsche, go to a doctor and check your testosterone level.” There could be a less expensive cure for what ails you.
There is little doubt within the medical profession that men who truly lack testosterone benefit greatly from having their stock replenished. It helps their bodies to build muscle mass, it increases the blood cell count and it quickens the metabolism.
Exposure to testosterone in the womb endows unborn boys with male features. Their testosterone production shuts down from the age of six months until it surges back into life to kick-start puberty. A small minority (roughly 1 in 600) suffer from Klinefelter’s Syndrome, a chromosomal disorder that causes low testosterone.
“In extreme cases they will not go through puberty,” says Dr Richard Quinton, an endocrinologist at the Institute of Genetic Medicine, Newcastle University. “Our record in Newcastle for the oldest man to go through puberty is 67.”
The man had married but never had children; he was able to have sex but had precious little sex drive. “He presented with muscle weakness. Then the penny dropped. Someone asked him to drop his trousers: he had very small testicles, a very small penis, not much in the way of pubic hair.”
Besides subjecting boys to puberty, testosterone improves visual and spatial perception, possibly even map reading. “There are female cabbies with ‘the Knowledge’, but not many,” says Quinton. In America, baseball batters have taken testosterone less for the muscle strength it bolsters but for the heightened perception it affords them as they stand over the plate.
An intriguing account of what else testosterone might do was offered by a New York writer and psychotherapist who was born female but became male. A normal level of the hormone in a man ranges from 300-1,000 nanograms per decilitre of blood; Griffin Hansbury took a dose that pushed his testosterone level to 2,000 nanograms per decilitre. Recounting his experience on the radio show This American Life, he recalled his mind flooding with “aggressive, pornographic images, just one after another”. Besides gazing helplessly at women’s ankles, breasts and bottoms, he found himself staring longingly at a Mustang as it revved past him on Fifth Avenue and “just getting this jolt in my pants, this very physical, visceral, sexual reaction to seeing a red convertible”.
If this offered a partial explanation for the phenomenon that is Jeremy Clarkson, an even odder revelation followed. “I became interested in science,” he said. “I cannot say it was the testosterone. All I can say is that this interest happened after T[estosterone]… I found myself understanding physics in a way I never had before.”
The doctors I speak to all think it unlikely that testosterone turns one into a rocket scientist – it is perhaps a regressive idea, though it would make the poets smile. “It’s natural the Boys should whoop it up…” wrote W.H. Auden in Moon Landing. “We were always adroiter/ with objects than lives.”
There is, however, evidence that testosterone may improve one’s reading skills and concentration. One of Fisch’s patients, a 45-year-old investment banker, tells me that before undergoing treatment to boost his testosterone level, he had struggled to read The Wall Street Journal in the afternoon. Once again, I begin to fear for my own testosterone levels: I find the Financial Times tough at 9am after a double macchiato.
“I would read the same article six or seven times without getting it,” the banker says. His job involved long hours: a dawn commute into New York, evening calls to Asia. Testosterone treatment – referred to in some quarters as “boardroom Viagra” – perked him up considerably. He even found himself able to read The Wall Street Journal. “Now I breeze through it, I have great comprehension, great focus,” he says. Lucky chap.
Another Fisch client to whom I speak over the phone describes an extraordinary sense of rejuvenation that flowed from his treatment. He is 55 and also does not want to be named. “I’d gained a lot of weight,” he says. Exercise left him exhausted. “I was thinking, boy, this getting old stuff really sucks,” he says. He was found to have a brain tumour in the pituitary, which regulates testosterone production. “Dr Fisch said: ‘With your levels of testosterone I’m surprised you were even walking around.’ ” He began using a testosterone gel, applying it after his morning shower. He began working out again and he shed more than seven stone. “I feel 20 years younger,” he says, a feeling endorsed by his GP, who has pronounced him as fit as a man half his age. “Talk about the fountain of youth; it really is.”
This idea of testosterone as a potential elixir of youth has been cherished by a great many old men who are now dead. In the 19th century, a Frenchman named Charles-Édouard Brown-Séquard, a pioneer of endocrinology, sought to rejuvenate himself via injections of fluid drained from the testicles of guinea pigs and dogs. “He showed he could pee further and stay awake after six o’clock at night,” says Dr John Morley, an endocrinologist who hails from South Africa and now works at Saint Louis University in Missouri. “I’m getting older now and I wouldn’t mind either of those things.”
Historians of medicine attribute Brown-Séquard’s renewed vigour to a placebo effect; his contemporaries deemed it simple lunacy.
By the Thirties, however, three groups were closing in on the stuff itself – a Swiss team was busy analysing cholesterol, a group of Dutchmen were examining bulls’ testes, and the Germans had isolated testosterone metabolite from the urine of policemen. You can track the arrival of synthetic testosterone via photographs of body-building teams. German teams from the early Thirties are like Parma ham in comparison with the côte de boeuf that came later. “They wouldn’t get a look-in today,” says Richard Quinton. “It shows the limitations of what you can achieve without testosterone and steroid abuse.”
The great testosterone boom began 14 years ago with the arrival of gels, and the efforts of pharmaceutical companies to position these as a possible salve to the vicissitudes of middle age. John Morley devised a questionnaire for the Dutch pharmaceutical company Organon BioSciences for men to complete to see if they suffered from the dreaded “low T”. In return, the company funded research at his university.
Morley says he composed the Q&A in 20 minutes while on the lavatory, scribbling it down on toilet paper. Why on the lavatory? “It’s the only place where my wife and children leave me alone,” he says. “It’s not a great questionnaire but other people have expended huge amounts of time and money and have not done much better. It doesn’t miss people with problems but it over-includes.” Men who are suffering depression may be caught in the same net, as can men who have a low libido but a normal level of testosterone.
When I took the test I was snared as well. First the fruit in one’s pants, then The Wall Street Journal, now this. Morley thinks “companies have changed the scoring system to make it much more likely that it says you are hypogonadal”.
Nearly all the doctors I spoke with agreed that testosterone is now being heavily overprescribed – to the tired, the stressed and the overweight. They were concerned that this was being done all over America based purely on the symptoms, without a blood testosterone test.
“We see accelerating testosterone prescribing in the UK, too,” says Richard Quinton in Newcastle. He notes that the Harley Street medic Dr Malcolm Carruthers, longtime proponent of testosterone treatments, had also plied an online questionnaire with which patients could test themselves for “male menopause”, and had been censured in 2002 by the General Medical Council.
There may not be the direct marketing, the “ask your doctor about your testosterone level” advertising slots on TV and radio, but, he says, “We’ve seen pharmaceutical company educational campaigns directed at GPs. We – my endocrinologists colleagues and myself – have noticed these seminars being arranged for GPs where the speakers aren’t what we consider pukka experts… We have seen pharmacological literature saying 30 per cent of men might be hypogonadal.”
He regards it as a hazardous trend. “Most people who are shadows of their former selves aren’t deficient in testosterone,” he says. Doctors should address the underlying problems by helping them to lose weight or get more sleep, he says. Giving them testosterone supplements can cause their own testicles to stop producing the hormone and shrink to cherry size, rendering them infertile. “A high level of testosterone may also be converted into oestrogen in breast tissue,” he says. “You will develop breasts.”
He also cites evidence published in The New England Journal of Medicine of a study, in which testosterone was administered to elderly patients, that had to be halted, apparently because the hormone made them more prone to blood clots, which might cause strokes or heart attacks. (Several of the other doctors I spoke to believed the study had been largely discredited.)
Dr Malcolm Carruthers is at the forefront of the testosterone debate in Britain. After 30 years spent studying and administering testosterone treatments, Carruthers hails the dawning of a new era in which testosterone medication becomes as acceptable in mainstream medicine as insulin treatment for diabetes. For years, it has been ridiculed as akin to the monkey-testicle experiments carried out in France, America and elsewhere in the early 20th century; recent evidence suggests that it can “reduce obesity, control heart disease symptoms, treat osteoporosis and even possibly benefit early Alzheimer’s disease and Parkinson’s,” Carruthers says.
While endocrinologists insist on the primacy of blood tests in determining low testosterone, Carruthers insists that they are almost irrelevant and argues that it is more important to treat the symptoms. These “can be so harmful to a man’s lifestyle and standard of living,” he says. “They can break up marriages, ruin businesses.”
He has been taking testosterone for 20 years. “It helps what few neurons I have left and gives me energy to persevere in trying to convince people that testosterone deficiency is far more common than conditions like diabetes.”
Back in New York, Harry Fisch also believes that men who think they may have low testosterone may simply need to sleep more and lose weight.
He says that boosting their testosterone levels enabled them to develop more muscle mass and shed pounds. His patients are often working long hours and when “I tell people to go lose weight, they say to me I’m 300lb, I can hardly breathe.” In some cases, he prescribes clomiphene citrate, a drug usually used to treat infertility in women. In overweight men, testosterone is broken down into oestrogen. High levels of oestrogen are detected by the pituitary gland which responds by lowering production of testosterone. “Clomiphene blocks the receptors in the pituitary, so the brain now tells the testicles to make more testosterone,” he says. “It’s not yet approved by the Food and Drug Administration,” he says, but he believes it soon will be.
“People like me who are in the know use this as a tool to increase the body’s own production of testosterone.” (Malcolm Carruthers advocates a similar treatment to boost a man’s natural production of testosterone.)
When I ask John Morley about this, he dismisses it rather airily. “I used it back in the Eighties,” he says. “It didn’t really help. There’s no evidence to support doing that.”
Whether or not testosterone makes patients more macho and vigorous is a debate that the medics researching and dispensing the stuff get very aerated about. “You run into all sorts of arguments about what is right and wrong,” continues Morley. “People screaming at each other in academic meetings. Going back through history there has always been this association of testosterone with something dirty. Some say it’s wrong to want testosterone; some say we need lots of it because men have to fight wars and sometimes have sex.”
I turn to a woman for guidance. Dr Frances Hayes, an endocrinologist at Massachusetts General Hospital, is one of the few female experts on testosterone. (She thinks it may be helpful, initially, when treating new patients, that she has a gender-neutral name.) “When you see so many diverse opinions it’s usually because the data isn’t compelling enough either way,” she says. For her part, Hayes believes that it can sometimes aid weight loss, but ought not to be used as a general weapon against the onset of old age.
It is not, sadly, an elixir of youth, even if it might restore one’s libido in later years. I tell Harry Fisch about a philosopher who described losing his libido as a great relief, after so many years of slavery to its impulses.
“Well, don’t listen to that philosopher,” he says. “Oh my God! That is not the way you want to lead your life. Throw his books out. He’s not worth it.”
He said he felt freed of the desire to run after women, I say.
“But that’s good! Isn’t that why you’re here on this Earth?”
He probably thought he was here to think big thoughts.
“Well, you know what? If I had to choose, I wouldn’t be choosing to be a philosopher. He clearly has some delusions… I’m not saying be Casanova but you want to have a good sex life your whole life.”
Then he asks: “Do you know what men think about the whole time? Having an erection. Are you aware of that?”
I don’t think of that all the time, I say. I don’t lust after cars either. Perhaps I really do need some testosterone.
“What’s your waist size?” says Fisch. He measures me, and then himself and calculates our respective body mass index. “That’s pretty good,” he says. “You’re underweight. I just had lunch, I’m a little bloated here, OK. You could actually gain 20lb.”
Does this mean I have lots of testosterone?
“You might,” he says. We step outside onto Park Avenue. Fisch is heading for the gym. “I go at least five days a week,” he says. “Two hours at weekends. I play tennis at least two hours during the week.”
It sounds like he’s training for the Marines.
“I have to,” he says. “You’re a lot younger than me.” So he works out frenetically and ensures he gets eight hours’ sleep each night.
Earlier, wondering if I’d ever take testosterone, it occurs to me that none of the doctors with the exception of Malcolm Carruthers takes the treatment themselves. “I really would not want to take testosterone,” says Fisch. “I’m scared of taking [it] unless I needed to because of the potential downsides of shutting down my own testosterone production. I don’t want to be on testosterone the rest of my life.”
Dr Morley’s low-testosterone test
1. Do you have a decrease in libido?
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Have you lost height?
5. Have you noticed a decrease in your enjoyment of life?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noticed a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your work performance?
If you answered yes to questions 1 or 7, or to at least three of the other questions, your symptoms may be caused by low testosterone.