#399： The Vast Influence of Testosterone on Our Bodies, Minds, and the World We Live In
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Summary
Testosterone is what makes men strong, courageous, and ambitious, but on the other hand, it can contribute to prostate cancer and asocial aggression. My guest, Dr. Charles Ryan, an oncologist that specializes in prostate cancer, walks readers through the benefits and downsides of testosterone in his new book, The Virility Paradox.
Transcript
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Brett McKay here. Welcome to another edition of the Art of Manliness podcast. Testosterone.
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It's what makes men, well, men. My guest today argues that this hormone is a paradox. On the
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one hand, it makes men physically strong, courageous, and ambitious. But on the other
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hand, testosterone can contribute to prostate cancer and asocial aggression. My guest's
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name is Charles Ryan. He's an oncologist that specializes in prostate cancer. And in his
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book, The Virility Paradox, he walks readers through the upsides and the downsides of testosterone.
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We begin our conversation discussing testosterone's role in prostate cancer growth and how Charles
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artificially lowers T levels in cancer patients to prevent its growth. Charles then walks us
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through how our exposure to testosterone in the womb, yes, when you were a fetus, has a huge role
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in how we respond to testosterone later on in life. We then delve into the positives and
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negatives of testosterone, including the way it decreases the risk of Alzheimer's but increases
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your chance of balding. We end our conversation discussing whether TRT is the fountain of youth
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for older men or can turn young guys into beasts. After the show's over, check out the show notes
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at aom.is slash virility. And Charles joins me now via clearcast.io.
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So you published a book called The Virility Paradox. Tell us about your background. What got you
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thinking about testosterone? It's all about testosterone. What got you thinking about testosterone
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and wanting to write a book about it? Yeah, so I'm a medical oncologist and I focus on the
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management of prostate cancer. Actually, I focus on two diseases, prostate cancer and testicular
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cancer. And so both of them tend to involve testosterone. But most importantly, prostate
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cancer is a disease that is driven by testosterone and the management of it for many patients, if not
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most ultimately, is the depletion of testosterone in a way to sort of cut off the fuel supply to the
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cancer. And ultimately, this disease, in those who die of it, it becomes resistant to these effects and it
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figures out a way that cancer does to make its own testosterone, to be really sensitive to
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testosterone. So testosterone is all around prostate cancer and it's really the central
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foundation or the foundation of how we think about it and manage it.
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So I imagine as you've reduced testosterone in patients, you've seen, you know, effects of that,
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like in their personality, things like that. Yeah, absolutely. And that's one of the really
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interesting things as an oncologist in the management of cancer. This is really the only
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cancer. I guess ovarian and breast would be the others potentially, but more so prostate. This is the
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only cancer where to treat the cancer, we have to deplete a chemical that is so fundamentally important
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to identity as testosterone is to the identity of a male. And that's something that we've done,
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you know, for a generation now, since the 1940s, when it was first discovered that you could do this.
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And interestingly, as I've been practicing medicine for many years now, I've had many,
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many people who've sort of worked in my clinic or met my patients, reflected almost jokingly,
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you know, your patients seem so nice in a way. And I used to sort of joke back with them and say,
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of course, they're nice. Of course, these men are nice. They have no testosterone,
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which is not always the case, of course. But that sort of joke in a way, or that observation
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percolated within me over the course of many years. And I actually began to think maybe there's
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actually something to this. And so I started researching it. And I started, you know, gaining
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an appreciation for all of the other factors, things that testosterone does to our bodies and
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our brains and ultimately to our society. And that was the genesis of starting to write the book.
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And once it hit me, I started digging into the research on it outside of the world of prostate
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cancer and really began to realize that this chemical, this hormone has lots of roles in our
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So before we get into those roles testosterone plays, and not only in the individual, but into
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society, I mean, I'm curious about this link between testosterone and prostate cancer. I guess
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without getting too technical and complex, like why is it that testosterone drives prostate cancer?
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Sure. It's actually pretty simple. You know, the prostate is an organ that is involved in
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reproduction. It's a reproductive organ. It doesn't really develop until puberty. And it develops during
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puberty because of the rise of testosterone. And the prostate's normal function in life is to create
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some of the fluids that are in semen that protect sperm and allow us to reproduce. So it's every bit
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linked to our fertility and to reproduction. And it comes to life, so to speak, at puberty and is driven
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by testosterone. And so, you know, a lot of people, a lot of men over as they age get enlargement of the
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prostate, but not prostate cancer. And that in a way is also driven by long-term stimulation from
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testosterone. So it makes sense then, if you think about cancer, that a cancer that arises from this organ
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that is driven by testosterone would itself be driven by testosterone. And that is in fact the
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case and has been known for 80 years. So yeah, the enlargement of the prostate, that's something if
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you have to get up a lot to go to the bathroom, that's one of the signs your prostate might be
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enlarged. Right. So a lot of men, as they age, their prostate gets big. And so what happens is
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it, the prostate sits, by the way, right at the base of the bladder. And so when the bladder is
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emptying, when you're urinating, if the prostate's big, that process stops early. And so the bladder
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doesn't empty. And so you have to go to the bathroom more often. And so that's what's a
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common condition called benign prostatic hypertrophy or BPH. But it's a really common reason why men have
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to get up at night to pee. And that begins, you know, at different ages in men, but frequently as
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early as age 35 or 40, then people start to have that phenomenon. Right. I've heard, I don't know if this
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is true, but like if, if a man lives long enough, you're probably going to get prostate cancer. I
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mean, it's like a disease that of old age, basically that it's almost inevitable.
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Yeah, it is. And it is an age related disease. Now there's a couple of points there. I think that
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your statement is largely true. I've heard that ever since I started studying medicine as well.
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The epidemiologic data say that about one in six American men will get prostate cancer. A lot of men
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will get prostate cancer that is not that aggressive. And it's, it's a cancer, interestingly,
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that doesn't always need treatment. So that's, that's interesting. But the other thing about it is
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getting back to the testosterone idea is that this is a cancer that is, again, being driven by
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sort of the chronic persistent stimulation from testosterone. And so the longer we get, if we have
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testosterone in our bodies, that may increase the likelihood of this occurring. Okay. And we'll talk
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about that later on when we talk about TRT, because we'll discuss, I want to discuss that a bit.
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So let's talk about, let's move away from prostates and just sort of, you know, what are some of the
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attributes that we know that testosterone drives in men, but also women too?
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Yeah. So we can think about this in sort of both the positive and the negative way, which is that,
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you know, I attribute, I credit testosterone with a lot of really great things in life, such as our
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ability to be strong, our ability to, to navigate space, to defend ourselves, to, and I'm going way
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back now, even in our evolution, to hunt, to fight off aggressors, to be aggressors, insofar as that can
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be a good thing, and to explore the world. I mean, I think that that's pretty well, you know, sort of
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known anthropologic phenomenon that, that this, that this chemical and other processes, you know,
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have helped create our, our ability to, to build the beautiful world that we have and survive the
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aggressors that we face. So that's a, a sort of a positive way to look at it. Testosterone can keep
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our bodies fit, not only muscular, lean by reducing fat in our bodies. It can also help with certain
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aspects of cognition, even memory and other aspects of our, of how we think. There's a lot of evidence
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to show, and we know this from treating prostate cancer by, by taking testosterone away, that
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testosterone may help prevent things like diabetes and muscle loss, or sorry, bone loss, bone thinning
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rather, and, and other aspects like that. So it's no question in my mind that testosterone is an
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important part of health, both for men and women, mostly for men, because the quantities in men are
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about 10 times higher than they are in women. But that's, you know, and that's a topic of, of
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conversation in the book. The other, you know, issue around testosterone and, and what it does to
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health is, of course, it drives reproduction, drives libido, drives, like I said, the prostate and
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keeps it, keeps the reproductive organs going. It's really sort of one of the, one of the fuels of the
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reproductive system. So without testosterone world, as I say in the book somewhere, I think the world
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would be a lot less exciting place. And in fact, we probably wouldn't have evolved to the point where
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we are today. And what about the negatives? So the negatives are things that a lot of it comes from
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some experimental psychology and other aspects. And some of this might be intuitive to the listeners.
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Too much testosterone, too much aggression could be a problem. And I write a chapter and mention
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very frequently, empathy, for example, and, and lack of ability to sense the emotions in others,
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giving testosterone to research subjects has been shown to reduce their sensitivity to the emotions
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of others. It's been shown to sort of reduce moral ambiguity, like people are willing and able to make
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decisions that may be difficult decisions, like hurting others or killing others, even
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in experimental models. And in part of, in the book, I also talk, I try to bring it into sort of the
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modern world and talk about how, you know, we're not out there all hunting for our food and fighting
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wars every day, but things like higher testosterone levels in men whose partner has recently given birth
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is associated with a decreased level of attentiveness to the newborn. There has been studies that I cite,
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one of them in the book, responsiveness to a crying infant. You can actually measure
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brain activity when a crying infant is in your midst. And they, and the researchers have shown that
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higher testosterone activity reduces or delays the responsiveness of this. And so this gets in a
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little bit to the empathy idea and our ability to connect with the emotional state of others,
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but also as I think is important and it's fairly consistent research, you know, shows that our
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parenting and our parental involvement is, is related to testosterone. So men with higher
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testosterone levels even have been shown to spend less time with their kids. There is a higher rate
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of divorce and marital strife and relationship problems in men with higher testosterone. And so
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those are behavioral things related to higher levels of testosterone. In terms of physical health
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related to higher levels of testosterone, you know, there, what, what we get on that level has to do
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mostly with what we learn from people who, who are taking anabolic steroids, which is not exactly
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taking testosterone, but it's taking chemicals with a testosterone like activity. And we know that there
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can be problems associated with the heart problems associated with potentially even affecting bone health
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in a negative way in certain circumstances. And so that's something that is slightly related to the
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natural levels of testosterone, but really comes at the extremes. So yeah, that's the virility paradox.
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And there's both this, these positives and negatives that come with it. Right. Right. Okay. Well, let's talk
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about this sort of get into starting from the beginning, right? From when you're a fetus and how
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testosterone affects you. Well, let's talk about this testosterone sensitivity. A lot of people think if you just
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jack up your testosterone levels, it's going to have all these, you know, amazing effects on you. But
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as you talk about in the book, some people are more sensitive to testosterone. Why is that?
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I think this is probably the most important teachable moment, teachable issue I'd like to get across
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with related to testosterone, which is it's not a one size fits all thing. And there are, there are
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really three components that I term the virility triad that have to do with how sensitive we are to
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testosterone. We talk about testosterone levels as if that's all that really matters. But the other
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thing is fetal testosterone, which is how much you're exposed to before you're born. And, and then
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the other thing, and I'll come back to that. And the other thing is the androgen receptor, which is
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the sensitivity of this receptor in all of these cells to the testosterone that's there. It's like a,
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it's like a trigger, right? It's got a certain level of sensitivity. But with regards to the fetal
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testosterone, I found this to be really fascinating. And frankly, this is not something I knew in my line of
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work that when we are in about our week 15 of gestation. So I guess that's towards the end of
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the first trimester and middle trimester where testosterone levels spike in, in a fetus in both
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male and female fetuses, but it does so kind of across a whole spectrum. And so when this occurs,
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the brain is undergoing obviously a ton of development during fetal life. And the, the higher,
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the fetal testosterone, the more there may be traits related to what we might assert would be
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related to testosterone later on in life. And this has been studied by both looking at levels of
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testosterone in the amniotic fluid, and then traits in the babies that were subsequently born from those
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women, which is really interesting. And then also there's a phenomenon where you're, there's this
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thing called a 2D to 4D ratio. So if you look at your second digit, which is 2D, 2D, your, is your
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index finger. And your fourth digit is your ring finger. And if you hold up your right hand and you
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look at the ratio of how long your ring finger is to your index finger, that ratio is roughly
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proportional to the amount of testosterone that you were exposed to as a fetus. And that's because
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there are androgen receptors in our fingertips, crazily enough. And so if your ring finger is a lot longer
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than your index finger, that's actually a low ratio, like 0.75 or 0.8 or something like that,
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as opposed to 0.99. And that's higher testosterone in fetal life. And, and that, you know, that simple
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observation launched a lot of interesting research in behavioral science, if you will. One that I cite in
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the paper is really interesting. A researcher named Coates in the UK looked at this factor, 2D to 4D ratio
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in day traders in the London Stock Exchange and found that the income, the bonus of these day
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traders was directly proportional after correcting for a lot of other factors to their 2D to 4D ratio.
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And the implication was that day trading is a gamble in a way. It's a risk taking behavior.
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And it requires, you know, sort of setting aside doubt, moving forward and sort of, you know,
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making these kinds of snap decisions. And I love this paper. It was in a very respected journal,
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the Proceedings of the National Academy of Science, where they showed that the yearly bonus of those
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with the highest fourth, the highest quartile of the 2D to 4D ratio was like 10 times that of the yearly
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bonus of those in the lowest, even after they corrected for the years of trading experience.
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And so what this says is that, you know, testosterone may have affected the brains of
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these individuals most well before they were born. And this says nothing of their actual
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testosterone levels in their blood. So a fascinating area. And this has been studied
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with respect. Women have the same effect and it drives the sensitivity to testosterone. So if you give
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testosterone to somebody, then you measure their behavior or whatever after that. People who have
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different levels of this prenatal testosterone will respond differently to the testosterone that
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you give them. So that's kind of the idea that there's this altered, that there's this spectrum
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of sensitivity to what the levels of our blood testosterone do to our body.
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So if you have the longer ring finger, you respond better to testosterone?
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Yeah, it's actually in some cases the opposite because you're not, you're more malleable by
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the exogenous testosterone is one way to think about it. So the, and there's research kind of
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going in a lot of different directions, but, but yeah, I think of the prenatal testosterone from what
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I was able to gather from it as a driver of, of sort of how malleable we are by testosterone levels
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throughout life. And one of the things we don't know, which is interesting is, so for example,
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in my world of, of prostate cancer, it has been shown that the longer ring finger,
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the longer ring to index finger ratio is associated with a higher risk of prostate cancer, which kind
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of makes some sense maybe, right? But what we don't know is whether that matters in terms of
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the survival of the people and whether the cancer is more aggressive or whatever based on that. So
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we're studying that. Do they know why some fetuses are exposed to more testosterone than others?
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It's genetic really has to do with the genetics of probably both parents. And it's not something
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that's related too much to, to diet or health of the mother. Although, you know, one could imagine
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a setting where the mother is in a health impaired situation that the testosterone level could be
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lower. There have been some, some speculation about diurnal rhythms and seasons of the year,
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for example, because testosterone does undergo a little bit of a, of a rhythm with daylight and
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darkness, but that's not really been substantiated to the, to the point where I think that it's
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completely known. Okay. So you talk about some of the attributes, if you're exposed to high,
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to high levels of testosterone in the womb, you're probably going to show more what we call masculine
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traits, risk-taking that sort of not lack of empathy, et cetera. Fair. Yeah. That's, that's a decent
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way to put it. Okay. So let's talk about, I mean, I think we all intuitively know what happens if you
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have high testosterone. We've probably met those guys. They're, they're, they're just, I don't know,
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they're just, they're manly. Right. But what, what happens, we've talked about this a bit, like
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what happens when you artificially decrease their testosterone with prostate cancer treatment? Do
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they just become these big teddy bears? What happens, what goes on there? Well, some do, you know,
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and this is what's, this is why I got interested in this topic, which is that, you know, and this is
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basically what I do in my, in my clinic. You know, I have the patients I'm treating, many of them have
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had suppressed testosterone for many, many years and they do that because it controls the cancer.
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Now, there are some individuals who will, who will say to me, you know, when I have this conversation
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with them, look, I need to use hormonal therapy, which is what we call it against your prostate cancer.
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They will refuse at first. And many, some of them will refuse the whole time because they will fear
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so much the loss of their testosterone or they will hear that it's so awful that they will do everything
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they can to avoid it. And for some of them, they're right to think that way because when they undergo
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this depletion, they really suffer. Others, not so much. And that's what I find to be interesting
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is that others actually either don't have much in the way of side effects. Other phenomenon, which I find
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really fascinating and I write about in the book, is there are others who feel like it's actually
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helpful to them when their testosterone goes away? And, and, you know, for example, I'll have
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some people who will say, I used to think about sex all the time. It was, it was part of my daily
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stream of thought, you know, every minute on some level. And all of a sudden that's not there anymore.
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And I don't mind that because it's almost like I've freed up more mental space for other things.
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And I think that, you know, this, this, this is an issue that some people face. I mean, a healthy libido
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is a great thing, but I think there are some people who have, maybe have a little too much and that they
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appreciate it when it comes down. And I have this quote in the book from Plato's Republic, you know,
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a book written, you know, over 2000 years ago in which they talk about this phenomenon of as you get
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older and you lose your, you know, your libido or your desire to be with a woman, it actually opens
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up other parts of your psyche. It opens up other parts of your mind. And as Plato puts it, it allows
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for the emergence of character. And once I saw that quote, I thought, wow, you know, this is something
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that is so fundamental to sort of human philosophy and psychology that Plato was writing about it,
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you know? So I see this whole spectrum in, in my patients and it's not a one size fits all treatment.
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With all of that said, you know, I, I would never say to a patient, you're going to feel better after
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we take away your testosterone because you're not going to have a libido. That's not what I'm saying
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because it's really troubling for a lot of people. From a physical perspective, just incidentally,
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you know, the signs and symptoms of low testosterone in, in my patients are also what you might see in
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patients who are not getting their testosterone depleted, but it's just going down naturally.
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Fatigue, loss of energy, loss of muscle mass, hot flashes can occur.
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And of course, loss of libido. So getting back to your, your, your teddy bear comment,
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I would have to say that I actually do think that some people do kind of become big teddy bears. And
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that's, what's part of the fun of, I think, or the joy of, of treating these patients is sometimes
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they kind of realize that, Hey, you know, I'm in my late sixties and my testosterone is gone and
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it kind of changes them a little bit away. And, and many of them are wonderful people to begin with
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and, and become maybe softer and more empathetic as time goes on. And, um, you know, I try to write
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about that in some cases in my, in my book as well. So again, this is not one size fits all people
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are going to respond differently. Right. Absolutely. Right. Yeah. That thing about, you know, you don't
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think about sex all the time and it opens up a new life to you. It reminds me of that Seinfeld
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episode where George Costanza stops having sex and, and he like becomes really like a genius.
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Yes. I wish I'd had that idea. It would have been a good anecdote for the book, but yes.
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Right. So when you, when you reduce testosterone artificially in your patients, is this like a
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permanent thing or is it temporary? It's temporary. We have shots that we give, we can give it for,
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to last for one month, for three months, that kind of thing. Rarely. And historically what was done is,
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if you remove the testicles, obviously that's permanent, but we do it temporary for some
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patients. There might be somebody, for example, who's going to get, let's say radiation treatment
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for their prostate. And they might take the hormone therapy for a year or two years.
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And Aaron, the character or the patient who I profile in the book, he is, he gets a year of
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hormone therapy because we want to slow down the rise of his PSA. And so, you know, his story is
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really his one year on hormone therapy and his adjustment to sort of life as a trial attorney and
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thinking, you know, how's this going to, this going to take away my edge and what it does to
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him and things like that. So that's a pretty typical scenario. Now in, in, in men with more
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aggressive prostate cancers or, or more advanced disease, many of them will ultimately need to
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have permanent hormonal depletion. Gotcha. So let's get into some of these, these like fun,
00:23:38.520
I don't know, explorations of testosterone and how they affect us personally. So you talk about
00:23:44.020
testosterone levels when men and women fall in love, what happens there? And is there a difference
00:23:50.400
between the two? Yeah. So I try to make a distinction between falling in love and, and,
00:23:55.440
and libido and sex, right? Cause they're kind of different things and libido and sex is driven
00:24:00.320
a lot by testosterone. It's that, it's that drive to perform sex, if you will. Falling in love is,
00:24:06.300
is different insofar as it's more of a settling in. And there's a chemical known as oxytocin,
00:24:11.240
which is really the opposite of testosterone. And you'll sometimes hear, hear oxytocin called the
00:24:17.360
cuddle chemical. And if you, if you give oxytocin to a man, it'll, you know, it'll make him more
00:24:23.120
physically affectionate, but not necessarily in a sexual way. And so when, when falling in love
00:24:28.600
occurs, you know, testosterone may in fact sort of go down a little bit and oxytocin may, may sort of
00:24:34.580
drive it. That's also what happens, for example, when your partner has a child and you're, you're getting
00:24:40.060
more into sort of parenting mode or nurturing mode is what I call it. And that's not a testosterone
00:24:45.460
driven thing. What's really interesting is I write a little bit and there's a lot of science and sort
00:24:51.360
of controversy around autism, because there's a link, or I should say an association between higher
00:24:57.400
levels of this fetal testosterone that we were talking about before and traits that we might think
00:25:01.980
of as autistic traits, behavioral traits that, you know, that again, a little bit of a generalization,
00:25:08.060
but not expressing empathy, not expressing emotion, focusing on, you know, detailed things,
00:25:14.180
as opposed to understanding the emotions of people around you, et cetera. And that has been linked to
00:25:19.560
high prenatal testosterone. But what's interesting is that, you know, there's sort of this theory that
00:25:24.660
autism is kind of excessive male brain. It's called the excessive male brain theory, EMB. And, and in the
00:25:31.280
treatment of autism now they're studying, giving oxytocin. So they're studying, giving the opposite of
00:25:37.240
testosterone in a way to see if they can improve affection and empathy and those types of things.
00:25:42.700
So these two chemicals kind of go yin and yang. In the book, I write about a patient of mine who,
00:25:48.940
a very dear patient who was widowed, had to go on hormonal therapy, was trying to meet women and date
00:25:55.520
women and, and ultimately decided that he wanted to come off of all of his treatment because he,
00:26:00.500
he wanted to be able to, to meet women, a woman. And ultimately what we discovered or he discovered
00:26:07.680
is that falling in love can happen even when testosterone is low. And, and I think that that's,
00:26:14.200
that's the key thing is that I wouldn't want people to think that libido and testosterone and
00:26:19.600
virility and falling in love are all wrapped up in the same thing because they're kind of different.
00:26:23.900
Yeah. That extreme male brain theory, Borat's cousin is the guy that came up with that.
00:26:30.620
Yeah. Yeah. I'm sure he would love to hear you call him that, but yeah, he's actually very well
00:26:36.360
respected. He's a genius. Yeah. He's really smart. Yeah. He's very well respected. Yeah. I mean,
00:26:39.540
he's a, he's a professor at Cambridge university and, and he, he's doing a lot of really important
00:26:45.420
work, not only in autism, but just in sort of the acceptance of, of autistic people and inclusion
00:26:51.620
and things like that. And he seems like a fascinating person. I communicated with him by
00:26:55.360
email about, about my book and things. And I told him about some of my observations and I actually
00:27:00.840
wondered out loud to him why nobody has really looked at using the kinds of drugs that we use
00:27:07.720
for prostate cancer in people with autism, right? Cause we block testosterone. If, if autism is an
00:27:13.320
extreme male brain, maybe there would be some benefits. Who knows? Right. So let's talk about,
00:27:18.300
I thought this, this chapter was interesting about testosterone's connection to Alzheimer's
00:27:21.880
disease. What, what is that connection? Yeah. So it's, it's a, it, this is, this science is still
00:27:27.800
evolving, but there have been observations that men who have prostate cancer, who live a long time
00:27:33.540
with low testosterone have a higher, potentially higher risk of Alzheimer's disease. And we clearly know
00:27:40.800
that there are cognitive effects, even in the short run from the hormone therapy that we give.
00:27:47.560
So we, we hypothesize that there's sort of a spectrum, right? So maybe there are men who are
00:27:54.020
at risk for cognitive problems in the short run from hormone therapy, and maybe that's going to lead
00:27:58.840
to an increased risk of Alzheimer's disease for them. But, but the reality is what's really interesting
00:28:03.820
is that forget about prostate cancer for a second is that the brain cells are happier in sort of in
00:28:11.060
the dish. If you grow them in a lab, for example, they're happier if there's testosterone in the mix.
00:28:15.380
And if you take testosterone away, they get thinner, they get less protected, and they're more likely
00:28:20.860
to become damaged. And so that's, that's one component of it. And so, and then, and then also
00:28:26.400
research has shown that if you look at testosterone levels in the brain between the ages of 50 and 80,
00:28:33.580
testosterone levels in the brain go way down, like by 80%. And so there's some theory that, that,
00:28:40.720
when we lose this, as we naturally lose this protection of, of brain testosterone, the neurons
00:28:47.520
may in fact become damaged and, and that may lead to some impairments. Now, Alzheimer's disease is a
00:28:53.760
pretty specific entity where there's an accumulation of proteins in the brain called amyloid plaques and
00:29:00.180
neurofibrillary tangles. These are things that accumulate. And you can, if you do an autopsy on
00:29:04.820
somebody who had Alzheimer's disease, you can actually see these sort of actual plaques in the
00:29:09.320
brain. And there is a way that our, the plaques are really the accumulation of kind of a protein
00:29:16.040
garbage in our brain and testosterone will stimulate the breakdown of some of this garbage. So it's
00:29:22.620
almost like, if you will, testosterone helps our brain cells take out their garbage. And when
00:29:28.180
testosterone is low, the garbage accumulates and it forms these plaques. And that's what
00:29:32.300
Alzheimer's disease is. Now that's a gross oversimplification of course, but, but there
00:29:37.220
is a connection. Well, so let's go out, let's move outside the brain to the cranium thing that
00:29:42.400
encases our head. So testosterone has been connected with balding. Why is that? Cause like, you know,
00:29:47.540
testosterone stimulates facial hair growth. So you think it would stimulate growth on the hair in your
00:29:52.360
head, but it doesn't. What, what's going on there? And there's a paradox, right? It, it stimulates
00:29:57.800
growth of the beard and stimulates loss of hair on, uh, hair on top of the head. Exactly. So
00:30:03.320
baldness is really interesting, not only for its connection to testosterone, but, but it is connected
00:30:07.740
to some other, uh, health phenomena. So long story is that chronic exposure to testosterone is,
00:30:17.140
which is by the way, converted into a chemical called DHT, which many people may know, have heard
00:30:22.340
of dihydrotestosterone and DHT stimulation in the follicles of the hair on the scalp will cause a
00:30:29.340
thickening of the follicle. And, and it'll basically, if you think about the tunnel that the hair grows
00:30:34.240
out of that tunnel thickens, so the hair thins and ultimately, you know, that, that thinning hair
00:30:41.240
goes away. And so that's, uh, again, the sign of chronic testosterone exposure and the, the health
00:30:48.020
issues that it's linked to, for example, uh, baldness is a sign of chronic testosterone exposure
00:30:52.980
as is, you know, potentially heart disease and prostate cancer, as I mentioned. And so a couple
00:30:58.460
of years ago, there was an observation made that men who are losing their hair at 45 on the top of
00:31:03.540
their head, not a receding hairline, but the middle back of the head, they were at higher risk for prostate
00:31:07.920
cancer, for high risk prostate cancer. So, so this is a sign of sort of the testosterone role in our
00:31:14.040
bodies. And, and on the beard, it's totally, it's totally the opposite, which is that, uh, it
00:31:20.160
stimulates hair growth and it doesn't stimulate the thinning out of those follicles.
00:31:24.340
And I think the same goes for nose and ear hair as well, right? It stimulates, it keeps
00:31:28.380
stimulating that growth. That's why when you get older, you get these bushes growing out of your
00:31:33.200
Yeah. I hadn't really delved into the science of nose hair that much. Maybe that'll be in the second
00:31:37.760
book, but, uh, but because I'm sure we'd all like to see that chapter. Uh, but, um,
00:31:44.020
right. Uh, yeah. I mean, basically you're right. Facial hair, whether it's on the ear or the nose.
00:31:48.760
Yeah. So in the past few years, there's been this uptick I've seen, maybe just this past year,
00:31:53.660
this uptick in companies selling pharmaceuticals that can reduce balding. So they take these drugs.
00:32:01.700
It's not supposed to like grow your hair back. It's just supposed to slow it down. Do you know,
00:32:07.300
do you know what's going on there? Um, what those pharmaceuticals do and are there any dangers to those?
00:32:11.640
Yeah. So a lot of those pharmaceuticals try to block the very effective testosterone on the
00:32:17.740
hair follicle, right? So there's one that I highlight in the book called Propecia,
00:32:22.060
which is very commonly used. And Propecia is a drug. It's the same drug that we use to,
00:32:28.800
to slow the enlargement of the prostate and except at a lower dose. And it blocks the conversion of
00:32:35.520
testosterone to dihydrotestosterone. And therefore reduces the amount of testosterone that's
00:32:40.880
stimulating the hair follicle basically. Now getting back to this issue of the sensitivity
00:32:45.640
to testosterone that we talked about before, you know, there are many men there's, in fact,
00:32:49.760
there's a foundation out there following men who took Propecia for hair loss, who experienced in
00:32:55.540
some cases, irreversible loss of libido, irreversible sexual dysfunction, erectile dysfunction,
00:33:02.020
and things like that, indicating that some young men, these are all men in their twenties and
00:33:07.240
early thirties. Some young men are extremely sensitive to these types of pharmaceuticals.
00:33:12.100
So there's definitely a danger to them. And then there's other, there's more benign things like
00:33:16.860
there are shampoos that are designed to basically wash the testosterone out of the hair. And I've
00:33:21.940
actually used one of those for years. And I think it actually works, but it doesn't penetrate into
00:33:26.380
the systems, right? So it's not getting into the blood and causing behavioral effects, at least as far
00:33:30.840
as an L. So let's get into sort of like how testosterone affects us individually, but which
00:33:36.820
ends up affecting us socially. The connection between testosterone and social aggression. I mean,
00:33:42.760
this is kind of, this is kind of a paradox because there are some men who have high levels of T and I
00:33:48.780
think they've done studies where they show criminals typically have higher levels of testosterone
00:33:52.840
than non-criminals. But there are some men with high levels of testosterone and they're, you know,
00:33:57.920
functioning pro-social members of society. So why, why is that paradox there?
00:34:03.380
Yeah. So I would say that the science of criminality, if you will, like that's trying to link testosterone
00:34:10.300
and criminal behavior is, is kind of dangerous territory, to be honest with you. It's, there's
00:34:16.680
probably an association, but so this is a great example to use the phrase association is not causation.
00:34:23.300
So for example, and we haven't talked about this much, the androgen receptor, which is basically,
00:34:28.920
if you think of testosterone as the key, the androgen receptor is the lock into which the key
00:34:34.620
goes. And so any of our body tissues that respond to testosterone, whether it's our muscles or our
00:34:39.800
brains or our prostates or whatever, have lots of androgen receptors in them. And your androgen receptors
00:34:45.940
are not a monolith either. You can have an individual genetically may have fast androgen receptors
00:34:52.380
or may have slow androgen receptors. And in fact, there's a, there's a condition of very,
00:34:58.580
very slow androgen receptors called, called Kennedy's disease, where they don't develop muscles and they
00:35:03.820
don't develop secondary sex characteristics, et cetera. So anyway, I give this introduction to say
00:35:09.220
that there was a study that I cite in the book that was done in India, where they looked at individuals
00:35:14.020
in prisons in India. They looked at controls who were not in prisons. They looked at people who had
00:35:19.080
committed rape. They looked at people who had committed murder. And they looked at people who
00:35:23.620
had committed rape and murder together, like violent rapists. I should say, I guess all rapists
00:35:28.400
are violent, but I should say rapists who murdered their victims. And what they found was that as they
00:35:34.100
looked at this, this number, it's called the CAG repeat. It's a molecular number. And the shorter than,
00:35:40.000
the lower the number, the faster the androgen receptor. And as they looked at the more violent the
00:35:45.640
crimes were, they found that the androgen receptors were more active in those, in those subjects,
00:35:51.600
in those prisoners compared to controls. And they found a statistical significant association between
00:35:57.000
that. Now that does not mean that having a fast androgen receptor is going to make you a rapist or
00:36:02.200
a murderer. It just is probably one ingredient in a very complex sociological and biological mixture
00:36:10.520
that led to a violent act occurring. Now, having a fast androgen receptor might make you a better
00:36:17.020
athlete. It might make you stronger, be able to jump higher or do something else, or it might make
00:36:21.880
you a better architect. So, you know, there's all kinds of ways that these things could have a
00:36:28.440
beneficial effect. And the science of criminology based on hormone levels is, as I looked at it, I said,
00:36:35.540
wow, this is kind of weak science, but it's also just kind of interesting too. But I really try to
00:36:40.980
make the point that this is association and not causation.
00:36:45.220
Right. So I guess this is where environment would come in, right? On whether or not testosterone,
00:36:50.520
like high testosterone or high androgen receptor sensitivity is either going to be positive or
00:36:56.740
Yeah. And also, this is, I think, one of the overarching themes of the book, which is we've got this paradox,
00:37:02.480
which is that testosterone and this whole system of virility has gotten us to this point in our
00:37:08.780
evolution, right? We're good hunters. We're able to survive. We create cities and societies and maybe
00:37:17.260
testosterone helps that, but it doesn't always help it. And maybe this virility that got us to this point
00:37:23.600
in our evolution is not quite needed so much anymore. And I begin to ask the question of, you know,
00:37:29.400
knowing this and seeing this, are we in a position as men or as a species really to sort of temper this
00:37:36.960
biology? In other words, you know, we're not able to control our environment. We are able to control
00:37:42.900
so much, so much of the natural world. And we now have a recognition of this paradox of virility,
00:37:49.900
I think, but are we able to control it? And so, you know, when we think about empathy and we think
00:37:55.760
about behavior, and really more importantly, when we think about nurturing and parenting and
00:38:00.060
being just good people, and we think about how some of our impulses that are built into our biology
00:38:06.480
through our evolution may make us not so good people. And I wonder if understanding that,
00:38:14.820
understanding this paradox of virility might allow us to think about how we act and behave in certain
00:38:21.300
circumstances and actually ask ourselves from time to time, you know, is this the right thing to do?
00:38:27.260
Or is this my testosterone acting? You know, something like that. So I bring that up because
00:38:31.940
our society is changing so much. If you look at certainly American society right now, you know,
00:38:37.940
there's a lot of crazy stuff going on, but there's a lot of really great things going on. Fathers are
00:38:42.700
spending more time with their kids than ever before. Parenting is being split between a man and a woman
00:38:48.660
more than ever before. Our recognition and acceptance of transgender individuals is better
00:38:55.600
than ever before. And so we are at a point where we're beginning to see some of the benefits, I think,
00:39:02.220
of tempering virility. And I'm not a sociologist, I'm not a psychologist, but I've sort of put the
00:39:09.160
science out there and say, well, maybe this is something where understanding this can help us build a
00:39:14.780
better society. So let's, let's talk about TRT. So you've, I'm sure people are listening. They've
00:39:20.380
probably seen the commercials or the billboards, low, get, get my erection back.com, low libido.com,
00:39:26.640
whatever. So you have all these men who are in their fifties, late forties, fifties, sixties,
00:39:32.160
who naturally would have their testosterone levels would have gone down, but now they're starting
00:39:36.980
to take TRT. How, how is that changing your job as a oncologist? Yeah, it's not changing my job that
00:39:45.200
much. Although I do occasionally run into patients who were diagnosed with prostate cancer after they
00:39:50.160
started TRT. And that is probably because of carelessness on the part of their physician to
00:39:55.100
not screen them for prostate cancer before they started testosterone. But it's also just an inherent
00:39:59.800
risk of taking testosterone that you might wake up a sleeping cancer. But I think in the bigger
00:40:05.260
picture, just in terms of healthcare, there's a couple of points I look at it. I say, TRT is great
00:40:10.360
for some men. Some men really benefit from it. And, and I think it's good to have it there for some men.
00:40:15.380
Gives them a sense, it helps them to reduce body fat, for example, maybe have more energy and certainly
00:40:20.960
help boost libido. When, when, when one looks at the studies in which you have a control group and a TRT
00:40:27.780
group, the studies seem to suggest that there are benefits, but they tend to be early and they tend to not
00:40:34.160
persist beyond much of a year or so. And the, the, the, the major variable that I, I write about in the
00:40:41.500
book is a variable called vitality, which is a mixed outcome, if you will, from a, from a clinical
00:40:48.040
intervention that has to do with energy and sort of activity of daily living type of things and
00:40:56.100
enjoyment of these things. And vitality spikes a little bit when you start testosterone replacement
00:41:00.860
therapy, but by a year it's back down to essentially the same levels as on a placebo. But I would say
00:41:08.160
that, you know, that, that shouldn't dissuade somebody from considering it if they think it
00:41:12.920
may be a benefit to them and their doctor agrees because there's a spectrum and some will benefit
00:41:18.020
a lot and some will benefit not so much. And I guess I would just say that for those who don't benefit
00:41:23.780
so much, it's, it's because of other things or, or it may be because of just variability to which their
00:41:30.420
body responds to testosterone, which is really the subject of the book because of the antigen receptor
00:41:35.680
and because of fetal testosterone and things like that.
00:41:38.720
Yeah. And I think a lot of younger guys are interested in TRT because they're thinking, well,
00:41:43.000
you know, I don't, might not have clinically low testosterone, but it's on the lower end. And if I
00:41:47.820
can jack it up to over a thousand, right, I'll become the super beast. And that might not be the
00:41:54.740
case. Like at a certain point, you, you might have enough testosterone in your body. Just like,
00:41:58.820
well, we're not going to do anything extra with this extra testosterone you've given us.
00:42:02.820
Yeah. So actually, you know, good, good point by the way, because I, I was referring to older men
00:42:08.280
who have a declining testosterone, uh, who take TRT. And then there's the younger men, you know,
00:42:13.600
men in their twenties and thirties who are taking it because of, let's just call them cosmetic reasons
00:42:19.640
or other things. And there it's, it's not studied as much, uh, because what you have in those settings
00:42:25.680
is you have a selection bias because of the data that are published on the use of testosterone are
00:42:31.500
coming from gyms and places like that, where people are highly motivated. That's different
00:42:35.540
from being a 75 year old man with a declining testosterone and being on a placebo controlled
00:42:40.540
trial where you get data with a control arm. Right. So, but I guess the point remains the same.
00:42:46.680
The effect that it has on the subject of the man varies based on their individual biology.
00:42:53.380
And I think that that's a key point to make at any age. Well, Charles, this has been a great
00:42:58.060
conversation. Where can people go to learn more about the book and your work?
00:43:01.560
So the book is available online, uh, Amazon. It's actually published also by Ben Bella books,
00:43:07.180
and you can buy it directly from their website. It's also available on audible.com and hopefully your
00:43:13.300
local bookstore, which would be a good for you and the bookstore. My work focuses on prostate cancer.
00:43:19.780
That's my academic side and men interested in learning more about prostate cancer. I
00:43:24.820
would turn them to the prostate cancer foundation, which is a great website as well as your standard
00:43:32.100
websites like Medscape and those others that might have information for them on prostate cancer risk and
00:43:39.280
prevention strategies and detection. Awesome. Well, Charles Ryan, thank you for your time. It's been a
00:43:44.100
pleasure. Thank you. My guest is Charles Ryan. He's the author of the book,
00:43:47.180
The Virility Paradox. It's available on amazon.com and bookstores everywhere. Also check out our show
00:43:51.520
notes at aom.is slash virility, where you find links to resources where you can delve deeper into this
00:43:56.180
topic. Well, that wraps up another edition of the Art of Manliness podcast. For more manly tips and
00:44:12.540
advice, make sure to check out the Art of Manliness website at artofmanliness.com. And if you enjoy the
00:44:16.600
show, please give us a review on iTunes or Stitcher, it helps out a lot. As always, thank you for your
00:44:20.520
continued support. Until next time, this is Brett McKay telling you to stay madly.