When Normal Isn’t Good Enough
Earlier this week, I read Jamie Waters’ essay in The Wall Street Journal about his brief fantasy of being a “high-T alpha male.” It struck a chord because I’ve been thinking a lot about testosterone replacement therapy (TRT) lately, and I recognized the impulse that sent him to his doctor: he was overtired and social media made him curious whether his testosterone could explain why.
If you read last week’s newsletter, you might recognize that impulse too. I wrote about going to my annual physical secretly hoping my bloodwork would reveal something that could explain why I’m always tired. I mentioned my thyroid, but low testosterone has crossed my mind plenty of times as well.
I had my blood checked at my wellness visit in May. My testosterone level was 562.0 ng/dL, comfortably within the normal range. I was relieved, of course. But part of me would have welcomed a result that came with an explanation and a prescription to restore my energy. It’s a strange feeling to look at perfectly normal bloodwork and wish it had given you something to work with.
Truthfully, the appeal goes beyond being less tired. Who wouldn’t mind building muscle more easily and recovering faster? The men selling testosterone online seem to have an abundance of everything I would happily accept more of. I dispense the drug regularly at my pharmacy, C.O. Bigelow, and understand enough to question those promises. Apparently, that does not make me immune to wanting them to be true.
The “manosphere” is a loose network of online personalities and communities organized around men and masculinity. It includes explicitly misogynistic influencers such as Andrew Tate, who promote a hierarchy of dominant “alpha” men and inferior men who need to improve themselves. But it also includes well-respected scientists like Andrew Huberman, and the number one podcaster on Earth, Joe Rogan. Its boundaries overlap with fitness, dating advice, and self-improvement content, which can make the ideology harder to distinguish from an ordinary interest in getting in shape or becoming more confident.
You can enter that world with a perfectly reasonable question about your health and encounter a much larger theory about what is wrong with you. Being tired becomes evidence of weakness. Difficulty building muscle becomes a failure to fulfill your potential. A hormone level becomes a way to rank yourself against other men.
The audience extends well beyond the people we might imagine inhabiting the darkest corners of the internet. In a Movember survey of more than 3,000 young men across the United States, United Kingdom, and Australia, nearly two-thirds regularly engaged with masculinity influencers. Many described the content as motivating. That category is broader than the manosphere, but it shows how much appetite there is for someone offering guidance on being a man.
I think that appetite deserves to be taken seriously. A man who feels lonely, physically exhausted, or unsure of his place in the world is looking for something understandable. He may want someone to acknowledge that he is struggling without treating the admission as embarrassing. A confident person who appears to understand his problems can have enormous appeal.
What bothers me is how easily that need gets exploited. The version of masculinity being sold leaves very little room for being an ordinary person. You are supposed to feel driven, look exceptional, and remain in control. Once you accept that standard, almost any difficult day can feel like evidence that something is wrong with you.
Testosterone gives that feeling a medical vocabulary and something to buy.
“Low T” is particularly effective because it can serve as both a diagnosis and an insult. In the world described in the WSJ essay, the term carries a judgment about the kind of man you are. A person already worried about falling short now has a biological explanation for the anxiety, and the promise that he can correct it.
Women reading this no doubt will recognize a business model built around making ordinary bodies feel inadequate. The male version comes with a lot more talk about independence, which is an interesting way to sell people the idea that they need your product to become themselves.
This is where the resemblance to the wellness peptide pitch I often criticize becomes difficult to ignore. I hear the same promise of an improved self waiting to be unlocked, accompanied by the suggestion that conventional medicine is keeping people from feeling as good as they could. An unsatisfying answer from a doctor becomes an opportunity for someone willing to offer certainty.
Testosterone adds something that makes this pitch especially persuasive: a legitimate medical reputation.
To be clear, testosterone deficiency is real, and appropriate treatment can help. There are FDA-approved testosterone products with an established place in medicine. Clinical guidelines require symptoms and consistently low levels. That is a substantial distinction from the experimental wellness products I have criticized.
But the credibility earned by treating a deficiency can be carried into a much broader promise about how men should feel and who they should become. A consumer hears “FDA-approved” and reasonably assumes there is evidence behind what he is being offered. The approval belongs to a product for particular uses. The sales pitch can travel considerably further. Evidence that testosterone helps men with a deficiency does not establish that raising an already normal level will improve energy, well-being, or long-term health. Those claims require evidence of their own.
That is the sense in which I find this marketing even more troubling. An established medicine makes the overreach easier to miss. The drug’s legitimacy becomes a substitute for demonstrating that the person being sold it needs it.
And yes, testosterone can produce effects in men whose levels are normal. At sufficiently high doses, it can increase muscle size and strength. Those effects have been demonstrated in a randomized trial; they do not establish that raising my normal level will resolve my fatigue. A drug can do something real while being sold through a story that goes far beyond what has been demonstrated.
There is a revealing example of how this works in practice. In a 2022 study, a secret shopper approached seven online testosterone platforms as a 34-year-old man with low energy and low libido. His total testosterone was 675 ng/dL, and both his total and free testosterone were within the laboratory’s normal ranges.
Six of the seven platforms still offered him testosterone. Three of those six described treatment goals of at least 1,000 ng/dL. It was a small study using one patient scenario, so it cannot describe every clinic. But it does show how readily a reassuring test result can become the starting point for selling treatment.
I keep coming back to what that means for the patient. He arrives feeling unwell, gets tested, and learns that his level is normal. That ought to help guide the next question. Instead, he can be encouraged to question whether normal is good enough.
Once “optimal” replaces a defined medical need, the person selling treatment has a great deal of freedom to decide how far away you are from it. There is always a higher number or a more impressive physique, especially on social media. A business built around closing that distance has little incentive to tell you when to stop.
My objection is to how a medical decision gets shaped before the patient ever has a serious conversation about it. Someone who has spent months being told that his hormone level determines his value as a man is bringing more than a symptom to the appointment. He is bringing an expectation that the prescription will give him something back.
I believe people should have a meaningful say in their treatment. That requires an honest understanding of the benefits, risks, and uncertainties, with a clinician who is responsible for helping them make the decision. Testosterone can impair fertility, for example. That deserves a real conversation with a young man considering treatment.
A clinician also has to be willing to say that the requested drug is unlikely to help, while continuing to care about the problem that brought the patient in. Normal bloodwork should guide further care. It should never be an excuse to dismiss someone who still feels lousy. That dismissal leaves a space for the person (or podcaster) promising to finally take him seriously.
The men on the receiving end of this pitch deserve more than a warning to do their own research. Wanting help for persistent fatigue or a diminished sex life does not make someone foolish. And when a licensed clinician offers an FDA-approved medication, it is reasonable for a patient to assume that somebody has done the work of determining whether it is appropriate.
That is why the responsibility cannot rest entirely with the consumer. An influencer can create the anxiety and point toward a product. A clinician who reinforces that anxiety and supplies the prescription gives the sales pitch medical authority. The patient may have agreed to treatment, but that agreement is compromised if the supposed need for it has been manufactured.
Men looking for answers deserve to have their problems taken seriously. A clinician who uses their trust to sell an unnecessary treatment is participating in the exploitation. The fact that the drug is FDA-approved makes that abuse of trust easier to conceal.
The more you know… Giddy up!
Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy
