A few years ago, I went to my doctor complaining of excessive sleepiness. I’ve always been a champion “let me just lay down for 20 mins” kind of guy, but this was really different. My days had taken on a bizarre schedule where I’d sneak home after lunch for a “meeting” and lay down for a nap because I was exhausted. After waking up, I didn’t feel any better, and after a few months of this I decided to seek medical advice.
“Ok Gabe, there are two possible reasons this could be happening,” said my doctor, a gruff but knowledgeable gay man whose otherwise great skills were marred by the persistent dramatics of his office administrator — slash — husband.
“You either have diabetes or low testosterone.”
This hit close to home because I love sex almost as much as I love pastry. I knew a Sophie’s Choice when I heard one.
“Does it have to be just those two things? Are there no other possible reasons?” I pleaded. I didn’t quite make a wish for cancer in that moment, but I got awfully close.
“No, we’ve run every other test but these two and nothing else is out of the ordinary.”
“Ok doc, I just need this to get better. Let’s figure it out.”
To get a proper blood sugar and testosterone reading you need to have blood drawn early in the morning and ideally fasted. The only times I enjoy waking up early are when I’ve got a plane to catch (I love the smell of jet fuel in the morning), I’m getting paid to give a speech, or I need to wake up last night’s guest so he can make it to work on time. I was very emotionally ambivalent about the whole thing, beyond the schedule. I put off the test for weeks hoping for a miracle recovery. But it didn’t come, and I finally mustered the nerve to go to the lab.
A week later, back in my doctor’s office, he was ready to give me my results.
“Ok, Gabe. Your blood sugar is high but not pre-diabetic. Your testosterone however is 75.”
“What does that mean, doc?” I asked. 75 was good, right? That’s a solid B, maybe a B+ graded on a curve.
“Well,” he said, “normal testosterone is measured from 200–800, so that’s really low.”
I was floored. I’m a balding, hairy beast who’s been sexually active since my teens. I have never had my testosterone checked, nor have I ever had cause to question whether it was functioning correctly. Despite knowing a lot about menopause, I had no idea that men could experience something similar. And no, it’s not called man-o-pause. The technical term, as I would learn, is Andropause.
But here I was. Only 42 years old and with a diagnosis that is either grossly underreported or doesn’t appear until you’re in your 50s. The symptoms of Andropause, as I was told, mirror those we normally associate with aging in men, such as: increased irritability and emotionality (get off my lawn!), lethargy, weight gain, reduced libido and sexual function.
Testosterone, just in case you’re as many years out of Biology class as I am, is the chemical responsible for many male characteristics. These include body hair (check!) and being bald (check check!). Oh the sweet, hirsuite irony. Scientists know you need it during puberty if you want to fully develop male sexual characteristics, but the specific things it does when you’re older — and how those affect you — is significantly less well understood.
I hit puberty around the age of 10 or 11. I remember this specifically because my parents used to bathe my sister (4 years younger) and I together when we were kids. Lest you think they were just being cheap — they were, hot water costs money — they were also trying to be efficient. One bath time, 2 kids, shift workers, presto. We were thrilled to be cleaned in the bathtub, because it was a major upgrade from the previous bathing process. Until we moved into our first proper home, bathing involved the kitchen sink and a contortionist-level process of washing, rinsing and drying body parts on the counter. If you complained, my parents gently reminded you that when they were kids growing up in Eastern Europe, there were many fewer baths and they often didn’t have hot water. I would later understand this to be hyperbole: they were never really just kids.
Like many young boys I hated taking a bath. My parents got me the Sesame Street album to try and persuade me to get clean. I can still remember the bathing song’s chorus:
“Rubber Ducky, you’re the one
You make bath time lots of fun
Rubber Ducky I’m awfully fond of you”
Those Sesame Street folks were masters at persuading kids. Now, I understand that a focus on toys and a good beat are useful when pushing yourself into uncomfortable territory, regardless of age. So, thanks Jim Henson!
That day in 1985, my sister and I got into the tub as usual. The bath had been run, it was half-full and warm enough to qualify as comfortable without breaking the bank. This was the standard protocol when my dad was the bather. My sister was already sitting in the tub, playing with her toys (we had our own, of course) and making her usual fart jokes, when I got undressed and hopped in. I cleaned myself while my dad washed her up. After we finished and got out of the tub, my dad looked at me and said:
“Ok, from now on you get your own private bath time.”
“But why dad,” I whined. I had just become especially fond of torturing my sister’s favorite Cabbage Patch Kid-related bath toys, and didn’t want the fun to end. But also, bathing was chill time I could spend with my dad without the two of us fighting.
“Because it looks like you’re becoming a man soon and that means taking your own baths.”
I had only the vaguest idea of what he was talking about. I knew that at 13, like all Jewish boys, I would be called to do my bar mitzvah. Roughly translated from Hebrew, bar mitzvah means “rented tux, cash gifts”, so I was already expecting it to be major. Perhaps, I thought, he meant something different?
As I stood there in the mirror, bewildered, I started drying off with my favorite green towel. I looked down at my body. And there, sure enough, was some hair around my crotch. Today you’d have trouble finding any spot on my body that’s hairless, save for my non-unibrow (I promise, I’ve never plucked) and my palms (not for lack of trying). But at that time, body hair definitely stood out, and this hair was different. It was small, and black, and definitely out of place.
Many kids get their puberty education from teachers and peers in gym class. I wasn’t much of an athlete, and I was chubby, so I tried to avoid any showering or exertion during Physical Education. Now, with the addition of this pubic hair, I became even more self-conscious. Though I had a good system for avoiding nudity around my peers, it didn’t extend to swim practice. At swim practice, all dicks had to eventually come out. And they did, all meanings.
“Look guys, Gabe has hair on his junk,” one of the boys said one day after swim practice, pointing at me.
I had successfully hidden the hair for nearly a year and now my cover was blown.
“That’s so gross,” one of the other kids chimed in, and everyone laughed.
I was mortified. But it did give me a chance to look around at my classmates, who were a sea of short, smooth, hairless and thin white Jewish boys. I was bigger in every way, the tallest kid in my class by far. This was the first time I remember being ashamed of my body, but certainly not the last. It was also the last time I’d swim with classmates.
This embarrassment about my body persisted into my early 40s. Until then, I never took my shirt off in public, and often demurred even with sexual partners. Nudity with friends? That was completely out of the question. I had somehow decided in that 12 year old moment that only hairless, lithe bodies were worthy of being seen by others. It took 3 decades to finally see myself clearly and to embrace the reflection in the mirror.
My parents didn’t add any additional context to puberty or help me adjust to my changing body until I was 16. This was woefully late for a kid who started maturing at 10 or 11. Everyone’s “sex talk with parents” is awkward, but in retrospect mine was truly in a league of its own.
My mom and dad had divorced because he was gay, and 3 years later apu (as we call him in Hungarian) was summoned back to do the birds and the bees at my mom’s behest. He and I barely spoke at this point beyond the absolute minimum, so we knew almost nothing about each other. He came over and we sat in our family room. It was bright and sunny, but strangely cold inside. My dad kept his coat on, which I assumed was a subtle “let’s get this over with” statement.
“So, your mom wants me to talk to you about some stuff,” my dad said joylessly.
“Yes, I know.” I replied, the adrenaline already rising, as I braced for embarrassment and conflict.
“You know about masturbating?”
“Yes dad, I’m 16. I know about masturbation,” I said with my best valley girl “duh” accent.
“Ok,” he said, relieved. “You know how sex works?”
“Yes dad, I know how sex works,” I replied.
“Ok. Don’t get a girl pregnant. Always use a condom.”
“I promise to always use a condom,” I replied, making my own personal contribution to the greatest lie told by men.
And that was it. Three statements. I was relieved at the time but now I wonder how things might have been different. What if we were able to communicate honestly as two burgeoning gay men? There are so many things he could have taught me that would have changed the next few years of my adolescence. But of course, there was too much shame and fear and not enough mutual understanding to enable such a conversation. Even now, beyond that awkward time I had to clean his computer of malware (ahem), I’ve had no visibility into his sex or romantic life, and neither he into mine.
Between the start of puberty and the end of my testosterone production, I got 30 mostly good years. I’m not sure how this compares to others, because most of the guys I know who have been treated for low T are in their 50s. Many of them opt to treat in more subtle or minimal ways, but I’ve found that unless my testosterone levels are on the high side of normal, I don’t feel good. So I had to be more aggressive about my health.
In the gay bear community, there are many guys who like much older men and fetishize the trappings of their golden years. Chasers — as these people are known colloquially — often joke that the sound of CPAP machines or the smell of the testosterone patch gets them going. In my experience, they are only half-lying.
But I’m not quite at full daddy level yet. I don’t need a CPAP, I’m only 250 lbs and I’m still in my 40s. The worst thing you can be in gay sexual circles is caught between stereotypes: just ask any Asian top or Black bottom. People graft their pre-conceived fantasies on each other, and size-discordant pairings are no exception.
To top it off, I had to work through my feelings about getting older about a decade earlier than I had planned. My 30s were a roaring high of sexual conquests and adventures, and now — between my andropause and depression (likely related) — I was facing a much different future.
Over time I’ve learned that a lot of people have low testosterone. They just don’t talk about it openly. People are fine with telling you they are celiac, have lupus or any other non-communicable condition, like veganism or a degree from Harvard. But low testosterone for a man? Nyet. Consider this: have you ever heard a comedian make an andropause joke? What about a man expressing gratitude for the end of his fertility? Probably not, because andropause is considered shameful and highly embarrassing, especially for men that derive a lot of their identity from their sexuality.
←Raises hand. Slowly.
So once I had a diagnosis, my doctor insisted I go on TRT: Testosterone Replacement Therapy. In TRT you give yourself an injection of Testosterone every few days or once a week. The downsides are smaller testes, greater risk of cancer and runaway anger. The upside is not feeling like crap all the time. Additionally, you have to travel with a refrigerated vial of a tightly-controlled hormone and a bunch of needles. I worried that I’d get stopped by some braindead customs agent and have to explain that I was not a Russian Olympian “training” for Tokyo 2020.
This association with illicit steroid use is one of the two reasons that Endocrinologists — those specialized in hormonal medicine — generally will not see low testosterone patients. The other is the lack of reimbursement from insurance. As I found out quickly, despite having the best insurance available in California and living in the second largest city in the country, no endocrinologist would take me on unless I paid cash. After a ton of deep Googling, I found a guy who would see me. I forked over the $500 via paypal for an appointment a month in advance.
The doctor saw patients only 1 evening per week at his “office” on the seedier side of Beverly Hills. When I arrived, I noticed his name was not in the building’s directory. Once upstairs, it became clear that he was actually using someone else’s office after the practice there closed for the night. He brought his own nurse and admin and had setup shop for the marathon of patients he’d be seeing. It all felt like going for a back-alley abortion in the 1950s (or 2020s if you live in the American south).
The doctor’s last name was Mandelbaum. I’ve seen plenty of Jewish doctors in my life, and that itself was no surprise. What caught me off guard was that he was orthodox, resplendent in his black wool suit, big hat set carefully on the table, long curly hair framing his face and prayer fringe hanging out of his shirt. He looked and smelled like my Rabbi from childhood. This was not comforting. I needed to talk about my sex life with this guy and all I could hear was Rabbi Schwartz intoning against gays and other sexual perversions from the bimah. I was not a religious kid, but I spent a lot of time at synagogue faking it with my family. It left a mark.
I was snapped back from my sabbath reverie when the doctor spoke.
“Hi Gabe. I’m Doctor Mandelbaum,” he said, with a half smile forming on his face. “What can I do for you?”
I explained my situation, and shared my medical history with him. He listened closely and had clearly been down this road before.
“Most of the patients who are here to see me today have seriously bizarre hormonal cases, many of whom fly in to LA for a consult with me. Your situation is very straightforward. Yes, you’re kind of young for this, but it’s not unheard of.”
And then he added the kicker I had been dreading: “You should just take the TRT injections. I’ll come up with a plan for you, and your regular doctor can administer it over time. You’ll be fine. You don’t need my help.”
“But I do, doctor. I am curious about the clomid + anastrozole treatment regimen.”
I had heard about this drug cocktail in an even more back-alley fashion. Just a few weeks earlier I found myself celebrating a friend’s birthday party in the valley. We capped off our delicious meal by driving to the Salt & Straw in Studio City. After we had all received our cones, our group of portly hairy dudes stood on the sidewalk as the traffic whizzed by on Ventura Blvd.
While standing there, licking my Bourbon and Chocolate or pig’s blood ice cream (it’s a real thing, look it up), I struck up a conversation with a friend.
“How are you doing?” James asked.
I really needed some support and felt vulnerable enough to share my recent news. I replied, “I’m ok but just got diagnosed with low testosterone and I don’t want to take the injections.”
He barely skipped a lick of his Salted Caramel or Carrot Top ice cream (it’s a real thing, look it up) and said “Oh yeah? Me too. My doctor prescribed me clomid and anastrozole, it’s been working great.”
I had to ask James to repeat the names, and I wrote them down in my phone. They were new to me and none of the doctors I’d seen had proposed them as a solution.
Clomid is a pill used to rev up people’s hormone production when they are trying to get pregnant or suffering from hypogonadism. Anastrozole is an estrogen blocking tablet usually given to women with breast cancer. Used together, the treatment can increase your body’s production of Testosterone while modulating its conversion into estrogen. This last step is crucial to avoid breast development and other high-estrogen symptoms. As I’d come to find out, it’s rather complex to get the dosing right, but once you do, it can be very effective.
Dr. Mandelbaum was not amused.
“Ok, you can try it,” he said dismissively, “and sometimes it works. But the TRT is pretty safe and we know it will work, so you should just do that.”
“But doctor, I don’t want to lose my body’s ability to produce it’s own T, and the needles are a huge hassle.”
“Insurance will generally pay for TRT but clomid + anastrozole are off label for use in men, and will not be covered,” he said, trying to appeal to my love of a good deal.
“That’s fine, I just feel like I should exhaust all my options before doing the injections.”
“Like I said, it’s up to you. But I’m confident you’ll be back here wanting to do TRT.”
It’s been nearly 3 years since my first diagnosis of low Testosterone. Things are mostly better now thanks to this drug cocktail and my persistence. Along the way, I’ve learned a few important things. First, estrogen really messes with my mood. If I don’t get the Testosterone-Estrogen balance right, I get really emotional, bitchy, tired and sick.
Second, doctors still don’t want to deal with low-T patients. Through force of will, I’ve been able to persuade and cajole various practitioners to write me the scripts that have saved my life. But unless you are a strong advocate for — and willing to experiment a bit on — yourself, you will get pushed into TRT right away and will receive much less ongoing care than folks with other chronic conditions. Alternatively, you may have your symptoms explained away as “getting older” and your issues dismissed entirely.
Moreover, there has been a proliferation of cash-only, low-T clinics popping up around the country. From nearly zero a few years ago, today there is a clinic in almost every city. They offer blood work, injections and drug scripts that should be covered by your insurance but aren’t. They seem shady, like the medical equivalent of accident lawyers putting billboards up on social media. This market effect demonstrates unequivocally that there is legitimate demand and suffering by aging men, but the system is ill-equipped to deal with it through regular channels.
Overall, I’ve realized that we’ve made almost no progress in getting men to open up about this condition. It’s happening to millions of us, and yet there are few conversations, even less pharmaceutical research and an appalling lack of doctors with the expertise to treat low T. I’m very fortunate to have caught the problem early, to have been insistent with my providers, and to have found a treatment that works for my body and my lifestyle.
But unless we talk about it openly, and advocate for men of all ages who are suffering with low Testosterone, not everyone will be so lucky.
My grandads both died before I turned 20, so I didn’t have a great sense of how their energy and vitality progressed through the end of their lives. But I am pretty sure that their generation would have just accepted this as a fait accompli, a symptom of aging, and left it at that.
I won’t. And I hope you won’t either.
If any of you want to talk about this issue and/or need referrals, I’m here to help.