The Art of Manliness - #399： The Vast Influence of Testosterone on Our Bodies, Minds, and the World We Live In

00:00:00.000 Brett McKay here. Welcome to another edition of the Art of Manliness podcast. Testosterone.

00:00:19.080 It's what makes men, well, men. My guest today argues that this hormone is a paradox. On the

00:00:24.300 one hand, it makes men physically strong, courageous, and ambitious. But on the other

00:00:28.120 hand, testosterone can contribute to prostate cancer and asocial aggression. My guest's

00:00:32.520 name is Charles Ryan. He's an oncologist that specializes in prostate cancer. And in his

00:00:36.720 book, The Virility Paradox, he walks readers through the upsides and the downsides of testosterone.

00:00:41.540 We begin our conversation discussing testosterone's role in prostate cancer growth and how Charles

00:00:45.480 artificially lowers T levels in cancer patients to prevent its growth. Charles then walks us

00:00:49.720 through how our exposure to testosterone in the womb, yes, when you were a fetus, has a huge role

00:00:54.260 in how we respond to testosterone later on in life. We then delve into the positives and

00:00:58.220 negatives of testosterone, including the way it decreases the risk of Alzheimer's but increases

00:01:02.480 your chance of balding. We end our conversation discussing whether TRT is the fountain of youth

00:01:06.200 for older men or can turn young guys into beasts. After the show's over, check out the show notes

00:01:10.440 at aom.is slash virility. And Charles joins me now via clearcast.io.

00:01:26.580 All right, Charles Ryan, welcome to the show.

00:01:29.460 Thank you. Happy to be here.

00:01:30.660 So you published a book called The Virility Paradox. Tell us about your background. What got you

00:01:35.760 thinking about testosterone? It's all about testosterone. What got you thinking about testosterone

00:01:39.760 and wanting to write a book about it? Yeah, so I'm a medical oncologist and I focus on the

00:01:44.540 management of prostate cancer. Actually, I focus on two diseases, prostate cancer and testicular

00:01:49.360 cancer. And so both of them tend to involve testosterone. But most importantly, prostate

00:01:54.540 cancer is a disease that is driven by testosterone and the management of it for many patients, if not

00:02:01.460 most ultimately, is the depletion of testosterone in a way to sort of cut off the fuel supply to the

00:02:07.140 cancer. And ultimately, this disease, in those who die of it, it becomes resistant to these effects and it

00:02:13.520 figures out a way that cancer does to make its own testosterone, to be really sensitive to

00:02:18.940 testosterone. So testosterone is all around prostate cancer and it's really the central

00:02:23.580 foundation or the foundation of how we think about it and manage it.

00:02:27.740 So I imagine as you've reduced testosterone in patients, you've seen, you know, effects of that,

00:02:32.560 like in their personality, things like that. Yeah, absolutely. And that's one of the really

00:02:37.860 interesting things as an oncologist in the management of cancer. This is really the only

00:02:42.240 cancer. I guess ovarian and breast would be the others potentially, but more so prostate. This is the

00:02:47.980 only cancer where to treat the cancer, we have to deplete a chemical that is so fundamentally important

00:02:54.880 to identity as testosterone is to the identity of a male. And that's something that we've done,

00:03:01.440 you know, for a generation now, since the 1940s, when it was first discovered that you could do this.

00:03:06.980 And interestingly, as I've been practicing medicine for many years now, I've had many,

00:03:12.380 many people who've sort of worked in my clinic or met my patients, reflected almost jokingly,

00:03:20.320 you know, your patients seem so nice in a way. And I used to sort of joke back with them and say,

00:03:25.580 of course, they're nice. Of course, these men are nice. They have no testosterone,

00:03:28.840 which is not always the case, of course. But that sort of joke in a way, or that observation

00:03:35.360 percolated within me over the course of many years. And I actually began to think maybe there's

00:03:40.760 actually something to this. And so I started researching it. And I started, you know, gaining

00:03:46.180 an appreciation for all of the other factors, things that testosterone does to our bodies and

00:03:52.840 our brains and ultimately to our society. And that was the genesis of starting to write the book.

00:03:57.880 And once it hit me, I started digging into the research on it outside of the world of prostate

00:04:02.800 cancer and really began to realize that this chemical, this hormone has lots of roles in our

00:04:09.640 world.

00:04:10.560 So before we get into those roles testosterone plays, and not only in the individual, but into

00:04:14.680 society, I mean, I'm curious about this link between testosterone and prostate cancer. I guess

00:04:19.560 without getting too technical and complex, like why is it that testosterone drives prostate cancer?

00:04:26.040 Sure. It's actually pretty simple. You know, the prostate is an organ that is involved in

00:04:31.120 reproduction. It's a reproductive organ. It doesn't really develop until puberty. And it develops during

00:04:37.200 puberty because of the rise of testosterone. And the prostate's normal function in life is to create

00:04:44.360 some of the fluids that are in semen that protect sperm and allow us to reproduce. So it's every bit

00:04:50.580 linked to our fertility and to reproduction. And it comes to life, so to speak, at puberty and is driven

00:04:58.880 by testosterone. And so, you know, a lot of people, a lot of men over as they age get enlargement of the

00:05:05.340 prostate, but not prostate cancer. And that in a way is also driven by long-term stimulation from

00:05:13.020 testosterone. So it makes sense then, if you think about cancer, that a cancer that arises from this organ

00:05:20.060 that is driven by testosterone would itself be driven by testosterone. And that is in fact the

00:05:26.560 case and has been known for 80 years. So yeah, the enlargement of the prostate, that's something if

00:05:31.520 you have to get up a lot to go to the bathroom, that's one of the signs your prostate might be

00:05:35.920 enlarged. Right. So a lot of men, as they age, their prostate gets big. And so what happens is

00:05:41.200 it, the prostate sits, by the way, right at the base of the bladder. And so when the bladder is

00:05:46.920 emptying, when you're urinating, if the prostate's big, that process stops early. And so the bladder

00:05:52.740 doesn't empty. And so you have to go to the bathroom more often. And so that's what's a

00:05:58.340 common condition called benign prostatic hypertrophy or BPH. But it's a really common reason why men have

00:06:03.980 to get up at night to pee. And that begins, you know, at different ages in men, but frequently as

00:06:09.020 early as age 35 or 40, then people start to have that phenomenon. Right. I've heard, I don't know if this

00:06:13.820 is true, but like if, if a man lives long enough, you're probably going to get prostate cancer. I

00:06:18.380 mean, it's like a disease that of old age, basically that it's almost inevitable.

00:06:22.800 Yeah, it is. And it is an age related disease. Now there's a couple of points there. I think that

00:06:28.040 your statement is largely true. I've heard that ever since I started studying medicine as well.

00:06:32.560 The epidemiologic data say that about one in six American men will get prostate cancer. A lot of men

00:06:38.500 will get prostate cancer that is not that aggressive. And it's, it's a cancer, interestingly,

00:06:42.180 that doesn't always need treatment. So that's, that's interesting. But the other thing about it is

00:06:46.220 getting back to the testosterone idea is that this is a cancer that is, again, being driven by

00:06:53.760 sort of the chronic persistent stimulation from testosterone. And so the longer we get, if we have

00:06:59.280 testosterone in our bodies, that may increase the likelihood of this occurring. Okay. And we'll talk

00:07:03.820 about that later on when we talk about TRT, because we'll discuss, I want to discuss that a bit.

00:07:08.220 So let's talk about, let's move away from prostates and just sort of, you know, what are some of the

00:07:12.800 attributes that we know that testosterone drives in men, but also women too?

00:07:18.320 Yeah. So we can think about this in sort of both the positive and the negative way, which is that,

00:07:23.980 you know, I attribute, I credit testosterone with a lot of really great things in life, such as our

00:07:31.280 ability to be strong, our ability to, to navigate space, to defend ourselves, to, and I'm going way

00:07:38.980 back now, even in our evolution, to hunt, to fight off aggressors, to be aggressors, insofar as that can

00:07:45.780 be a good thing, and to explore the world. I mean, I think that that's pretty well, you know, sort of

00:07:51.660 known anthropologic phenomenon that, that this, that this chemical and other processes, you know,

00:07:58.140 have helped create our, our ability to, to build the beautiful world that we have and survive the

00:08:03.660 aggressors that we face. So that's a, a sort of a positive way to look at it. Testosterone can keep

00:08:09.620 our bodies fit, not only muscular, lean by reducing fat in our bodies. It can also help with certain

00:08:17.300 aspects of cognition, even memory and other aspects of our, of how we think. There's a lot of evidence

00:08:24.440 to show, and we know this from treating prostate cancer by, by taking testosterone away, that

00:08:29.320 testosterone may help prevent things like diabetes and muscle loss, or sorry, bone loss, bone thinning

00:08:35.640 rather, and, and other aspects like that. So it's no question in my mind that testosterone is an

00:08:41.600 important part of health, both for men and women, mostly for men, because the quantities in men are

00:08:48.640 about 10 times higher than they are in women. But that's, you know, and that's a topic of, of 0.75

00:08:54.140 conversation in the book. The other, you know, issue around testosterone and, and what it does to

00:08:59.880 health is, of course, it drives reproduction, drives libido, drives, like I said, the prostate and

00:09:05.300 keeps it, keeps the reproductive organs going. It's really sort of one of the, one of the fuels of the

00:09:11.120 reproductive system. So without testosterone world, as I say in the book somewhere, I think the world

00:09:16.120 would be a lot less exciting place. And in fact, we probably wouldn't have evolved to the point where

00:09:19.980 we are today. And what about the negatives? So the negatives are things that a lot of it comes from

00:09:27.420 some experimental psychology and other aspects. And some of this might be intuitive to the listeners.

00:09:32.740 Too much testosterone, too much aggression could be a problem. And I write a chapter and mention

00:09:38.700 very frequently, empathy, for example, and, and lack of ability to sense the emotions in others,

00:09:45.800 giving testosterone to research subjects has been shown to reduce their sensitivity to the emotions

00:09:53.400 of others. It's been shown to sort of reduce moral ambiguity, like people are willing and able to make

00:10:00.380 decisions that may be difficult decisions, like hurting others or killing others, even

00:10:04.560 in experimental models. And in part of, in the book, I also talk, I try to bring it into sort of the

00:10:09.820 modern world and talk about how, you know, we're not out there all hunting for our food and fighting

00:10:15.140 wars every day, but things like higher testosterone levels in men whose partner has recently given birth

00:10:22.060 is associated with a decreased level of attentiveness to the newborn. There has been studies that I cite,

00:10:28.300 one of them in the book, responsiveness to a crying infant. You can actually measure

00:10:31.920 brain activity when a crying infant is in your midst. And they, and the researchers have shown that

00:10:38.160 higher testosterone activity reduces or delays the responsiveness of this. And so this gets in a

00:10:45.220 little bit to the empathy idea and our ability to connect with the emotional state of others,

00:10:50.760 but also as I think is important and it's fairly consistent research, you know, shows that our

00:10:56.840 parenting and our parental involvement is, is related to testosterone. So men with higher

00:11:03.580 testosterone levels even have been shown to spend less time with their kids. There is a higher rate

00:11:09.400 of divorce and marital strife and relationship problems in men with higher testosterone. And so

00:11:15.400 those are behavioral things related to higher levels of testosterone. In terms of physical health

00:11:20.640 related to higher levels of testosterone, you know, there, what, what we get on that level has to do

00:11:26.300 mostly with what we learn from people who, who are taking anabolic steroids, which is not exactly

00:11:32.380 taking testosterone, but it's taking chemicals with a testosterone like activity. And we know that there

00:11:37.520 can be problems associated with the heart problems associated with potentially even affecting bone health

00:11:44.080 in a negative way in certain circumstances. And so that's something that is slightly related to the

00:11:50.480 natural levels of testosterone, but really comes at the extremes. So yeah, that's the virility paradox.

00:11:56.040 And there's both this, these positives and negatives that come with it. Right. Right. Okay. Well, let's talk

00:12:01.100 about this sort of get into starting from the beginning, right? From when you're a fetus and how

00:12:05.940 testosterone affects you. Well, let's talk about this testosterone sensitivity. A lot of people think if you just

00:12:10.740 jack up your testosterone levels, it's going to have all these, you know, amazing effects on you. But

00:12:15.760 as you talk about in the book, some people are more sensitive to testosterone. Why is that?

00:12:21.980 I think this is probably the most important teachable moment, teachable issue I'd like to get across

00:12:28.380 with related to testosterone, which is it's not a one size fits all thing. And there are, there are

00:12:33.760 really three components that I term the virility triad that have to do with how sensitive we are to

00:12:39.700 testosterone. We talk about testosterone levels as if that's all that really matters. But the other

00:12:44.100 thing is fetal testosterone, which is how much you're exposed to before you're born. And, and then

00:12:51.240 the other thing, and I'll come back to that. And the other thing is the androgen receptor, which is

00:12:55.180 the sensitivity of this receptor in all of these cells to the testosterone that's there. It's like a,

00:13:00.060 it's like a trigger, right? It's got a certain level of sensitivity. But with regards to the fetal

00:13:04.540 testosterone, I found this to be really fascinating. And frankly, this is not something I knew in my line of

00:13:09.220 work that when we are in about our week 15 of gestation. So I guess that's towards the end of

00:13:16.460 the first trimester and middle trimester where testosterone levels spike in, in a fetus in both

00:13:23.780 male and female fetuses, but it does so kind of across a whole spectrum. And so when this occurs,

00:13:30.640 the brain is undergoing obviously a ton of development during fetal life. And the, the higher,

00:13:36.620 the fetal testosterone, the more there may be traits related to what we might assert would be

00:13:43.380 related to testosterone later on in life. And this has been studied by both looking at levels of

00:13:50.000 testosterone in the amniotic fluid, and then traits in the babies that were subsequently born from those

00:13:55.920 women, which is really interesting. And then also there's a phenomenon where you're, there's this 1.00

00:14:03.060 thing called a 2D to 4D ratio. So if you look at your second digit, which is 2D, 2D, your, is your

00:14:09.220 index finger. And your fourth digit is your ring finger. And if you hold up your right hand and you

00:14:14.660 look at the ratio of how long your ring finger is to your index finger, that ratio is roughly

00:14:20.220 proportional to the amount of testosterone that you were exposed to as a fetus. And that's because

00:14:24.940 there are androgen receptors in our fingertips, crazily enough. And so if your ring finger is a lot longer

00:14:31.000 than your index finger, that's actually a low ratio, like 0.75 or 0.8 or something like that,

00:14:37.180 as opposed to 0.99. And that's higher testosterone in fetal life. And, and that, you know, that simple

00:14:45.100 observation launched a lot of interesting research in behavioral science, if you will. One that I cite in

00:14:53.000 the paper is really interesting. A researcher named Coates in the UK looked at this factor, 2D to 4D ratio

00:14:59.420 in day traders in the London Stock Exchange and found that the income, the bonus of these day

00:15:06.440 traders was directly proportional after correcting for a lot of other factors to their 2D to 4D ratio.

00:15:13.940 And the implication was that day trading is a gamble in a way. It's a risk taking behavior.

00:15:20.900 And it requires, you know, sort of setting aside doubt, moving forward and sort of, you know,

00:15:26.520 making these kinds of snap decisions. And I love this paper. It was in a very respected journal,

00:15:32.280 the Proceedings of the National Academy of Science, where they showed that the yearly bonus of those

00:15:37.120 with the highest fourth, the highest quartile of the 2D to 4D ratio was like 10 times that of the yearly

00:15:44.240 bonus of those in the lowest, even after they corrected for the years of trading experience.

00:15:48.860 And so what this says is that, you know, testosterone may have affected the brains of

00:15:54.000 these individuals most well before they were born. And this says nothing of their actual

00:15:59.920 testosterone levels in their blood. So a fascinating area. And this has been studied

00:16:04.280 with respect. Women have the same effect and it drives the sensitivity to testosterone. So if you give 0.94

00:16:11.220 testosterone to somebody, then you measure their behavior or whatever after that. People who have

00:16:17.540 different levels of this prenatal testosterone will respond differently to the testosterone that

00:16:22.980 you give them. So that's kind of the idea that there's this altered, that there's this spectrum

00:16:27.900 of sensitivity to what the levels of our blood testosterone do to our body.

00:16:32.820 So if you have the longer ring finger, you respond better to testosterone?

00:16:37.180 Yeah, it's actually in some cases the opposite because you're not, you're more malleable by

00:16:42.740 the exogenous testosterone is one way to think about it. So the, and there's research kind of

00:16:48.460 going in a lot of different directions, but, but yeah, I think of the prenatal testosterone from what

00:16:53.060 I was able to gather from it as a driver of, of sort of how malleable we are by testosterone levels

00:17:01.500 throughout life. And one of the things we don't know, which is interesting is, so for example,

00:17:06.020 in my world of, of prostate cancer, it has been shown that the longer ring finger,

00:17:10.380 the longer ring to index finger ratio is associated with a higher risk of prostate cancer, which kind

00:17:16.220 of makes some sense maybe, right? But what we don't know is whether that matters in terms of

00:17:20.840 the survival of the people and whether the cancer is more aggressive or whatever based on that. So

00:17:26.720 we're studying that. Do they know why some fetuses are exposed to more testosterone than others?

00:17:32.080 It's genetic really has to do with the genetics of probably both parents. And it's not something

00:17:37.100 that's related too much to, to diet or health of the mother. Although, you know, one could imagine 0.97

00:17:42.560 a setting where the mother is in a health impaired situation that the testosterone level could be

00:17:47.520 lower. There have been some, some speculation about diurnal rhythms and seasons of the year,

00:17:54.480 for example, because testosterone does undergo a little bit of a, of a rhythm with daylight and

00:18:01.480 darkness, but that's not really been substantiated to the, to the point where I think that it's

00:18:06.080 completely known. Okay. So you talk about some of the attributes, if you're exposed to high,

00:18:11.000 to high levels of testosterone in the womb, you're probably going to show more what we call masculine 0.99

00:18:16.060 traits, risk-taking that sort of not lack of empathy, et cetera. Fair. Yeah. That's, that's a decent

00:18:22.720 way to put it. Okay. So let's talk about, I mean, I think we all intuitively know what happens if you

00:18:27.320 have high testosterone. We've probably met those guys. They're, they're, they're just, I don't know,

00:18:31.360 they're just, they're manly. Right. But what, what happens, we've talked about this a bit, like

00:18:36.900 what happens when you artificially decrease their testosterone with prostate cancer treatment? Do

00:18:42.740 they just become these big teddy bears? What happens, what goes on there? Well, some do, you know,

00:18:47.720 and this is what's, this is why I got interested in this topic, which is that, you know, and this is

00:18:52.980 basically what I do in my, in my clinic. You know, I have the patients I'm treating, many of them have

00:18:58.320 had suppressed testosterone for many, many years and they do that because it controls the cancer.

00:19:03.220 Now, there are some individuals who will, who will say to me, you know, when I have this conversation

00:19:08.520 with them, look, I need to use hormonal therapy, which is what we call it against your prostate cancer.

00:19:13.660 They will refuse at first. And many, some of them will refuse the whole time because they will fear

00:19:18.860 so much the loss of their testosterone or they will hear that it's so awful that they will do everything

00:19:24.560 they can to avoid it. And for some of them, they're right to think that way because when they undergo

00:19:29.660 this depletion, they really suffer. Others, not so much. And that's what I find to be interesting

00:19:34.160 is that others actually either don't have much in the way of side effects. Other phenomenon, which I find

00:19:40.420 really fascinating and I write about in the book, is there are others who feel like it's actually

00:19:45.060 helpful to them when their testosterone goes away? And, and, you know, for example, I'll have

00:19:51.000 some people who will say, I used to think about sex all the time. It was, it was part of my daily

00:19:56.060 stream of thought, you know, every minute on some level. And all of a sudden that's not there anymore.

00:20:02.760 And I don't mind that because it's almost like I've freed up more mental space for other things.

00:20:07.980 And I think that, you know, this, this, this is an issue that some people face. I mean, a healthy libido

00:20:15.200 is a great thing, but I think there are some people who have, maybe have a little too much and that they

00:20:20.100 appreciate it when it comes down. And I have this quote in the book from Plato's Republic, you know,

00:20:25.540 a book written, you know, over 2000 years ago in which they talk about this phenomenon of as you get

00:20:32.260 older and you lose your, you know, your libido or your desire to be with a woman, it actually opens

00:20:38.160 up other parts of your psyche. It opens up other parts of your mind. And as Plato puts it, it allows

00:20:44.140 for the emergence of character. And once I saw that quote, I thought, wow, you know, this is something

00:20:48.900 that is so fundamental to sort of human philosophy and psychology that Plato was writing about it,

00:20:56.720 you know? So I see this whole spectrum in, in my patients and it's not a one size fits all treatment.

00:21:02.300 With all of that said, you know, I, I would never say to a patient, you're going to feel better after

00:21:07.220 we take away your testosterone because you're not going to have a libido. That's not what I'm saying

00:21:10.860 because it's really troubling for a lot of people. From a physical perspective, just incidentally,

00:21:16.000 you know, the signs and symptoms of low testosterone in, in my patients are also what you might see in

00:21:22.580 patients who are not getting their testosterone depleted, but it's just going down naturally.

00:21:27.360 Fatigue, loss of energy, loss of muscle mass, hot flashes can occur.

00:21:31.820 And of course, loss of libido. So getting back to your, your, your teddy bear comment,

00:21:37.840 I would have to say that I actually do think that some people do kind of become big teddy bears. And

00:21:42.840 that's, what's part of the fun of, I think, or the joy of, of treating these patients is sometimes

00:21:47.400 they kind of realize that, Hey, you know, I'm in my late sixties and my testosterone is gone and

00:21:52.820 it kind of changes them a little bit away. And, and many of them are wonderful people to begin with

00:21:59.160 and, and become maybe softer and more empathetic as time goes on. And, um, you know, I try to write

00:22:05.020 about that in some cases in my, in my book as well. So again, this is not one size fits all people

00:22:10.340 are going to respond differently. Right. Absolutely. Right. Yeah. That thing about, you know, you don't

00:22:14.680 think about sex all the time and it opens up a new life to you. It reminds me of that Seinfeld

00:22:18.440 episode where George Costanza stops having sex and, and he like becomes really like a genius.

00:22:26.440 Yes. I wish I'd had that idea. It would have been a good anecdote for the book, but yes.

00:22:31.420 Right. So when you, when you reduce testosterone artificially in your patients, is this like a

00:22:37.040 permanent thing or is it temporary? It's temporary. We have shots that we give, we can give it for,

00:22:42.460 to last for one month, for three months, that kind of thing. Rarely. And historically what was done is,

00:22:48.060 if you remove the testicles, obviously that's permanent, but we do it temporary for some 0.84

00:22:53.060 patients. There might be somebody, for example, who's going to get, let's say radiation treatment

00:22:57.100 for their prostate. And they might take the hormone therapy for a year or two years.

00:23:01.220 And Aaron, the character or the patient who I profile in the book, he is, he gets a year of

00:23:06.700 hormone therapy because we want to slow down the rise of his PSA. And so, you know, his story is

00:23:12.380 really his one year on hormone therapy and his adjustment to sort of life as a trial attorney and

00:23:17.800 thinking, you know, how's this going to, this going to take away my edge and what it does to

00:23:22.100 him and things like that. So that's a pretty typical scenario. Now in, in, in men with more

00:23:28.000 aggressive prostate cancers or, or more advanced disease, many of them will ultimately need to

00:23:33.980 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, 0.72

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

00:31:32.700 ears.

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 0.97

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

00:36:55.340 negative.

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 1.00

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, 0.99

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.

The Art of Manliness - April 24, 2018

#399： The Vast Influence of Testosterone on Our Bodies, Minds, and the World We Live In

Episode Stats

Summary

Transcript