Tuesday, March 4, 2014

Emasculated Cis Men, Black Box Warnings, and Testosterone Supplementation

There's an organization trying to get the FDA to put a "black box" warning on testosterone drugs such as Androgel in light of the fact that it can cause an increase in cardiovascular problems.  This is the most serious medication warning that the FDA can put on a drug.  This is, reasonably, something that has trans men and other trans folk who use testosterone--or perhaps more importantly, those who are seeking it--very worried.

An increase in risk for heart disease (and plenty of other medical problems) is something transgender men and other transgender people who use testosterone have been aware of for a long time, and practically all of us are aware that we are taking a risk when we take this drug.  In fact, depending on where we get them, there's a good possibility we have been lectured about it on multiple occasions.  It's something told to us by our therapists, by our doctors, by relatives who search online for any reason to get us not to transition, and by other trans men.  In the documentary series "Transgeneration" for instance, there is a trans man considering testosterone who states that taking it shaves ten years off of your life.  There really isn't any evidence to support that being true with modern methods of taking it, but it's a good example for how pervasive the idea that testosterone is potentially deadly is in the trans male and otherwise testosterone-using trans community.  Many of us show up to the doctor already being aware of these health risks.

In fact, over-blowing the health risk to trans folk is one of the reasons so many of us attempt Natural Transitioning (NT), a cocktail of over-the-counter supplements mixed with a strict diet and exercise regimen that is meant to coax the body to produce more testosterone on its own.  People who try this (largely ineffective for major changes and extremely expensive) method of transitioning often cite the dangers of hormone replacement therapy when justifying their decision.

That said, the worry among trans men here is that a drug whose risks we already are reasonably well aware of is going to be even more difficult to access, and all because cis men are feeling emasculated by drug advertising.  And that's the purpose of what I'm writing here.  I'm not here to write some glowing endorsement of testosterone as if it's perfectly safe (it isn't) and as if all relevant trans folk should be taking it (not all of us should be or want to be).  I'm here to write about how direct advertising of drugs hurts people.

First, let's talk about these ads.  It's worth a giggle to mention that when I tried doing a search for a YouTube video showing an Androgel ad, the first result I got was actually for Axe instead.  A typical Androgel commercial stars an older man talking about how things just aren't how they used to be for him.  He doesn't have as much energy as he used to, and his libido is starting to suffer, so his doctor diagnosed him with "Low T."  Now that he is taking testosterone, he can do all the things he used to do when he was younger and more virile.  This is a subtly emasculating class of advertisements.  Men tend to (erroneously) associate testosterone levels with masculinity, so a man who has a normal level of testosterone being told that some irritating effects of aging are a result of the fact that his testosterone levels aren't the same as he was in his twenties or thirties can easily get roped into that emasculation.  Androgel is in effect saying that getting older is making you less of a man.

It's worth mentioning at this point that I'm in no way saying that Androgel or any other testosterone supplement shouldn't be used for the purposes these advertisements are suggesting provided the risk is worth the reward.  I'm a big fan of informed consent.  Hell, I'm even pretty comfortable with testosterone being used for bodybuilding if somebody is aware of the risks involved.

But direct advertising of testosterone supplements specifically uses that subtle emasculation I was just describing to shame men into asking their doctors about hormones.  Although the ads themselves are directed toward older men, younger men are also absorbing these messages (it's not an uncommon occurrence for a younger cis man, in his 20s or 30s, to ask me about anything from whether or not it would give him more energy to whether or not it would increase his penis size).  Admittedly, some of these inquiries aren't directly based on the actual commercials themselves so much as they are a side-effect of having testosterone being advertised literally everywhere.  It's not just the emasculation of older men.  It's the preconceived notions we already have about testosterone and the myth that having lots and lots of it is desirable for men.

Testosterone-envy is something that is used in a lot of ludicrous man-vertising.  On my way to work I'd constantly pass this billboard for Dr. Pepper Ten that had in bold letters the word "TASTEosterone."  If we even continue allowing direct advertising of pharmaceuticals (something that's banned in a lot of countries for damn good reasons), it should be a responsibility of testosterone drug manufacturers to understand the baggage they are working with and adjust their tactics accordingly.  Of course, they won't do that, because peoples' irrational beliefs about testosterone are some of their best marketing tools.  There's a reason these companies are currently subject to a lot of lawsuits, after all.

Finally, I'm going to come full circle and talk about how much of the risk of testosterone is talked about when you're a trans person going through that process.  When a trans man goes on testosterone, like I said, there's a good chance he will have gone through multiple hoops where he has been lectured about just what sorts of things he's doing to his body.  I mentioned them above, but to elaborate based on my own experience:
  1. Trans men, especially older, more conservative trans men who had been on hormones for years, have written lots of essays insisting younger trans guys consider maybe they aren't trans, on the basis that testosterone and surgery are very extreme and cause increases in risk for cardiovascular and other diseases.
  2. Then your relatives, even very well-meaning ones, will send you article after article about the risks of hormone replacement therapy.  Maybe when you come out to your parents or tell them you're about to go on hormones they'll sit you down and make sure you are really, really sure that you want to go through with this because they heard something about a bodybuilder who died from a stroke or something.
  3. Then you might have to go to therapy if you can't find an informed consent program where if your therapist concentrates in gender identity they may dedicate entire sessions to talking about your soon-to-be cardiovascular risk.  My letter that I had to take to my doctor dedicated an entire paragraph to insisting I knew about this risk.
  4. Finally you go to your doctor.  My first visit for hormone replacement began with a nurse going over the risk.  Then when the doctor came in, she not only repeated the same information, but had me read it and sign a form explaining that I'd read it and understood that there would be cardiovascular risks.
  5. That "finally" was actually a lie, because every new doctor I go to after over two years of hormone replacement makes a point of making a big deal out of the risks of my medication.  The last time I went to the ER I had two unnecessary tests done because I was on testosterone.
What disconcerts me about this isn't so much that people are telling me or anybody else the risks of my medication--yes, I already know them, but I also am well aware that there are trans boys out there who are flippant about them--it's that I can't imagine a cis man going in for a low-T diagnosis being treated with this much apprehension.  In other words, I have a very real fear that there are going to be barriers placed on trans folk getting their hormones because people trust cis men to know their hormone needs more than they trust trans folk to, despite the fact cis men are being targeted for manipulative advertising in ways trans men generally aren't.