Does testosterone make you mean?

The risk-taking male hormone is blamed for everything from sexual violence to the financial crisis, but some researchers are starting to question the supposed links

Charles Ryan has a clinic in San Francisco at which he regularly relieves men of their testosterone. This chemical castration, as it is sometimes known, is not a punishment, but a common treatment for prostate cancer. Testosterone doesnt cause the disease (currently the third most deadly cancer in the UK), but it fuels it, so oncologists use drugs to reduce the amount produced by the testicles.

Ryan gets to know his patients well over the years, listening to their concerns and observing changes in them as their testosterone levels fall. Because it involves the so-called male hormone, the therapy poses existential challenges to many of those he treats. They know that every day, millions of people from bodybuilders and cheating athletes to menopausal women enhance their natural levels of testosterone with the aim of boosting their libido, muscle mass, confidence and energy. So what happens when production is suppressed? Might they lose their sex drive? Their strength? Their will to win?

The fears are not always groundless. Side-effects can also include fatigue and weight gain. But Ryan has witnessed positives, too. As professor of medicine and urology at the University of California, he has noticed that the medical students who have passed through his clinic in the 18 years that he has been treating prostate cancer invariably comment: Dr Ryan, your patients are so nice. He replies, jokingly: Its because they dont have any testosterone. They cant be mean.

Could there be some truth in that glib reply? Ryan knew his patients hadnt always been so kind. Before being robbed of their testosterone, they might have been personable and adept at small talk, but they werent nearly as interested in other people. He could feel a hypothesis coming on: that as mens testosterone levels lower, their capacity for empathy will rise. In his new book, The Virility Paradox, he argues that the fact that reducing testosterone in these ageing men may lead to increased empathy, more emotional engagement in relationships and a softening of aggression could be something of a silver lining.

Ryan started measuring his patients empathy quotients, using a survey developed for studying autism. Its too early to release detailed results, he says, but we do see increases in the empathy scores in many patients on the treatment.

He also dived into the literature on testosterone, attempting to understand what exactly was happening to them. Try as he might, however, he found little conclusive evidence for many of the claims made about testosterone, such as a link between hormone levels and risk-taking or sexual violence. Theres so much ambiguity in the science, he says. Many of the studies had been carried out on disappointingly small numbers of people.

Ryan is one of several researchers who are questioning the accepted wisdom about testosterone. It is often wheeled out as an excuse for patriarchal society, in arguments along the lines of: women, with their lower testosterone levels, have evolved to nurture and multitask in the domestic sphere, while men are hardwired to take risks, compete and furnish as many women as possible with sperm, thus ensuring the future of the species. But, as Ryan points out, obviously behaviour and cognition are extraordinarily complex and dont pivot on one molecule.

The psychologist Cordelia Fine makes a compelling case that it is our culture rather than our hormones that most influences gendered behaviours. As she writes in Testosterone Rex (winner of the Royal Societys science book prize for 2017) testosterone has been blamed for the financial crash of 2007-08, yet studies show that, although women have lower levels than men, they can have a higher appetite for risk even when it comes to financial decisions. She uncovered similar stories when it came to the evolutionary need for more sexual partners (more babies get made if women sleep around, too) and competition for status.

Fines pluck in challenging the scientific status quo could itself be viewed as classic testosterone-fuelled behaviour. She has cojones, you might say. She asserts that many typically female behaviours, such as deciding to have babies, are riddled with risk, only womens risks dont seem to count when it comes to testosterone mythology.

While Ryan comes at the subject from a different angle, both authors highlight how little research there is into testosterone in women. And yet we know it is vital to them (for example, oral contraception reduces testosterone levels, which can lead to low mood and libido). It can also influence sexual orientation, Ryan writes, with studies showing that self-described lesbians are likely to have [indications of] higher foetal testosterone levels than women who identify as heterosexual.

The lack of research, meanwhile, hasnt prevented a fierce debate about testosterones role in womens sports, with high levels seen as conferring an unfair advantage. The athlete Caster Semenya, who won a gold medal in the womens 800m at the 2016 Olympics, has extremely high natural testosterone levels for a woman. She had to prove her gender, and medically suppress the hormone before competing (although this ruling is currently suspended). Meanwhile, in 2016, the International Olympic Committee ruled that transgender women could compete without having had surgery, on condition that their testosterone levels were no higher than cisgender womens.

Not that testosterone levels are consistent in anyone. They rise and fall all the time, according to season, health, relationship and parental status, age, time of day (higher in the mornings) and emotional responses. When a man hears a woman cry, his testosterone goes down. When a person cares for their child, the bonding or love hormone oxytocin rises, while testosterone falls. If a threat to status or territory is perceived, testosterone rises again. Its the situations, the culture even, that seem to pull the hormones strings. Testosterone, in both men and women, also works in a feed-forward system: when you win at something, you get a spike in testosterone that as well as making you feel dominant and confident, increases your sensitivity to the hormone encouraging further swagger and quests to win.

Another of the hazards when studying testosterone is that there are three significant measures of how strong its force is in you. You can check levels in the bloodstream, but we already know how they fluctuate. The second measure is the number and sensitivity of androgen receptors, which vary significantly from person to person. (Testosterone is one of three hormones known as androgens, and receptors are what allow them to act on the cells in our bodies.) Third is the amount of testosterone to which we were exposed in the womb, most of which is produced by the foetus itself. This exposure is harder to gauge, although the difference between the lengths of the index and ring fingers is often used as a marker. The smaller the difference, the theory goes, the greater that foetal exposure.

This complex web, says Ryan, means that responses to hormonal suppression therapy are highly variable, based on [individuals] intrinsic biology. I have patients whose testosterone I take away and they dont have any [unwanted] side-effects. In fact, they say: I feel better. My brain is less clouded with intrusive thoughts about sex and things like that.

In a sort of mirror-image experiment, the writer Ann Mallen recently told how she accidentally rubbed testosterone cream into her skin every day for a month due to a mixup at the pharmacy. She wrote in the Washington Post that her sexual appetite became a constant distraction, as did her new persistent bouts of irrational anger. She concluded that underneath the high-pitched whine of our sex hormones, we are neither [male nor female].

Because women are more responsive than men to supplemental testosterone, they were used in one of the key studies into how testosterone essentially removes the burden of empathy from moral decision-making. Its known as the trolley car experiment. Picture a runaway tram hurtling down the tracks towards five unsuspecting workers. Theres a lever that would divert the tram to another track, but theres someone working on that track, too. You have to kill somebody to save five others, says Ryan, and you have to act fast.

The researchers at Utrecht University gave some of the subjects a shot of testosterone the night before presenting them with the dilemma. The number of respondents who were willing to kill in order to save people, and their confidence in carrying out the act were enhanced, says Ryan. And the equivocation they demonstrated was significantly reduced.

This isnt to say that empathetic people cant make tough decisions. Hormones are a bit-part in a complex cognitive picture. Aaron, a high-flying lawyer treated by Ryan, was adept at suppressing his empathy in order to win a case. But as his testosterone dissipated, he grew more caring and started asking Ryan about his family. At one appointment he asked whether getting emotional was a side-effect of his treatment, after he had wept at the end of a long-distance visit to his elderly mother. Like many patients, writes Ryan, Aaron regards these developments with a measure of surprise. Hormonal therapy hasnt been as bad as he expected, and he admits he has actually come to appreciate some of the effects it has had on him.

However, this outcome posed one worry for Ryan. A major case is heading to trial and Aaron is the lead attorney. Will having a testosterone level at 10% of normal affect his performance? he writes. The answer, it turns out, is no: Aaron had not lost his killer instinct in the courtroom.

You get the sense that Ryan sees toning down testosterone as a force for social good. Take his patient Marcus, an octogenarian who is still a keen runner. When his cancer risk was sufficiently low, he came off hormone suppression therapy and started taking supplemental testosterone to counter its effects. He would come in and talk about his half-marathon, weightlifting, his younger girlfriend, says Ryan. He never talked about anybody but himself. Eventually, he had to quit the supplements because his markers for cancer rose again. He disappears for more than a year, and comes back and is now taking care of his daughter, picking up his grandkids and being a nice grandpa. I think it is misguided for ageing men to think they should necessarily want to have high testosterone levels, because they may pay a price for that in terms of their relationships. They may be more self-centred, lack empathy.

But again, its complicated and depends on the individual. Many men, as they age, feel sluggish and lose muscle mass, lose their self-esteem, so I dont say we shouldnt ever use supplemental testosterone.

Its estimated that one in 10 men aged over 40 in the UK have low testosterone levels, which is in a large part related to obesity. Fat tissues will produce an excess of oestrogen, says Ryan, which leads to reductions in testosterone. Artificially boosting the latter could help them lose the weight, but any other benefits, Ryan warns, could be transient. A study published in the New England Journal of Medicine found that while [their participants on supplemental testosterone] felt good at first and their libidos went up, there werent long-term beneficial effects.

And, of course, they may end up impairing their capacity for empathetic relationships. But there are non-medical ways to boost empathy. In Testosterone Rex, Fine cites a 10-year US study targeting boys at high risk of behaving antisocially later in their lives. Some of them were given coaching to improve their emotional resilience, relationships and educational performance, while their parents were trained to manage their childrens behaviour. The goal was to enable the boys to respond more calmly and less vociferously to provocation. Years later, when the participants had reached their mid-20s, about 70 were deliberately provoked by someone stealing points from them in a game. Not only were the group who had been given coaching as boys less likely to retaliate; their testosterone levels rose less.

Another way, according to Ryan, is to do more childcare. Testosterone levels are 33% lower in fathers of newborns than in non-fathers, making way for a good 25% more oxytocin. This hormone, says Ryan, induces men to spend more time with their children and respond more quickly to their needs. It enables fathers to play more closely with their children, and get less rattled if they cry. (One of Ryans patients started getting down on the floor to play with his grandkids for the first time during hormone suppression therapy.) Romantic love, friendship and pet ownership open the floodgates to oxytocin, too (even a dogs oxytocin rises when it stares into its humans eyes). Less testosterone, more oxytocin, more bonding, says Ryan. Thats another, perhaps more fulfilling, feed-forward system.

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Ultra-processed foods may be linked to cancer, says study

Findings suggest increased consumption of ultra-processed foods tied to rise in cancers, but scientists say more research is needed

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Cancer I could deal with. Losing my breast I could not

When Joanna Moorhead found out she had breast cancer, a mastectomy seemed the best option. So why did she pull out of the operation at the last minute?

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How the hardest year of my life ended my catastrophic thinking

Worst-case scenario has always been my default setting but complications during pregnancy and an ill mother and partner meant I had to get my anxiety under control

It is March and I am Googling meningitis again. My partner has caught our sons chicken pox and her symptoms are frightening me. Vice-like headache. Aversion to light. Brain fog. Also, I am pregnant and my habit of catastrophising has sprouted horns, and, pumped up on hormones, my heart is working twice as hard as usual. Nausea is now approaching something more cataclysmic. My phone starts autocorrecting morning to meningitis. I become convinced that my partner has developed brain swelling, a rare complication of chicken pox. From here, it is a short step to picturing her dying and me giving birth alone, letting the worst case scenario in like an old friend.

The thing is, this time I am right. Sort of. She does have meningitis. The GP takes one look at her and sends her up to the infectious diseases ward in a taxi. I feel a tiny bit triumphant in the way only catastrophisers can. See? I told you. The worst has happened! But Im also wrong: a tiny wad of catastrophe may have been fired at us, but my partner does not die and I do not give birth alone. She recovers. The baby is born. We are lucky again.

Time and again during the hardest year of my life (to date, the catastrophiser in me would like to qualify), my habit of fearing that the worst will happen got, well, worse. I dont know when it began, so peculiarly subtle is the feeling that the most likely outcome is the really bad one. But last year some of my most calamitous predictionscame true, at least in part. The realisation that I needed to do something about it came when my partner, who is a psychotherapist, arrived home with a book. I saw this and thought of you, she said. It was called Why Does Everything Always Go Wrong?. I laughed a bit too hard. The truth is, there was a lot to catastrophise about last year, on a global, national and personal level.

Just before the meningitis episode I discovered that the baby I was carrying was high risk for Downs syndrome. While we awaited more results, my pregnancy was reduced to a series of statistics one-in-58 chance of Downs, one-in-100 risk of miscarriage with amniocentesis and I grappled with the fact that someone has to be the one. In fact, I already knew what it was to be the one, because my son is autistic and, actually, we are all coping brilliantly; being the one is not a catastrophe once you are living it.

But catastrophising does not give a damn about hard evidence and I remained terrified. A fortnight later, the results came in: the chance of the baby having Downs was vastly reduced, to one in 10,000. It occurred to me that catastrophising is more than just a destructive habit: sometimes it is a reasonable response to what is happening, a kind of mental preparation.

In April, my mother, who is incurably ill with breast cancer, got pneumonia and ended up in A&E. She asked to see my sister and I, so I rushed to London from Edinburgh, five months pregnant, with a daughter (and dread) somersaulting in my belly. I feared the distress would make me lose the baby and I thought my mother was going to die. Catastrophisers have a habit of thinking a person is dead if they are half an hour late, so a situation like this suits our sense of drama perfectly. My mother recovered. We continued to live with the deep uncertainty that comes with scans every three months and the neverending wait for results. Each time, I prepared myself for the worst. Maybe this is not a habit to be broken, but a coping mechanism.

By June, I had to make a major decision that provided an opportunity to see whether I could nix the catastrophising: how to have my baby. My son, who is four, was born by emergency C-section and so I was offered an elective caesarean. I saw a consultant who ran through the risks I faced if I attempted a natural birth without constant foetal monitoring and a cannula in my hand. I decided to laugh or, at least, get off my head on laughing gas in the face of potential catastrophe and attempted a natural birth on my own terms. I hired a doula to support me in hospital and here is a first hoped for the best.

In August, my daughter was born 45 minutes after I arrived in hospital. It was a short, fierce and mind-blowing natural labour. It was not perfect I had an episiotomy and there was a minor Strep B scare that meant we ended up in A&E twice in the first week after her birth but it was one of the best days of my life (to date, the optimist in me would like to qualify).

How am I trying to break my habit of catastrophising? Not by deep breathing, yoga, therapy, drugs or imagining all the catastrophes I fear floating away down a river. Talking and thinking have helped in the daily maintenance of perspective, which is catastrophisings greatest enemy. Has this year been about the worst happening (and I write this a week after my beloved dog has had four tumours removed from her powerful, young body) or about a series of narrow escapes? Is it about bad luck or survival? After all, my partner recovered. The baby is perfect. My mother is still here. The dog is walking off the lead again. We are lucky.

Catastrophising is dependent on you never being in the moment: it constantly shoves you up against an unknowable, uncontrollable future. Once you go there, you are lost. Parenting, so often a source of anxiety, has been the best antidote to this. The hard graft and small, pure joys of looking after a baby and a little boy with autism anchor me to the present. The baby keeps me healthy, makes me feel lucky and gives me a constant dose of perspective. She is also exhausting: I am too tired and busy to catastrophise with as much fervour as the habit demands.

Then there is my brilliantly singular, loving and brave son. Before he was diagnosed with autism (that happened this year, too) I feared this moment: how will we manage? What will we do about school? How will he develop? Is everything going to be OK? The mystery and idiosyncrasy of autism can be frustrating, but it is also a visceral reminder that none of us knows what lies ahead and that compassion is the most powerful weapon against anxiety. So, here I am, living and thriving in the future over which I once catastrophised. And you know what? It is not so scary after all.

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HRT and vaginal moisturisers? Here’s what really helps menopausal women

Products claiming to fix the menopause are now a multibillion-dollar global industry. We asked the experts for their advice on what works and what doesnt

Even though 80% of women going through the menopause will get symptoms, such as hot flushes and night sweats (and in 25% of cases they will be severe enough to affect quality of life), few are confident talking about it. A global industry worth about US$4bn (3.4bn) flogs books and products, but reliable information is hard to come by. So how can women distinguish fact from marketing hype and what helps?

Managing the symptoms

Kathy Abernethy, chair of the British Menopause Society, says: Hormone replacement therapy (HRT) is absolutely the best treatment for hot flushes and sweats that affect daily life. It can also help sleep disturbance caused by night sweats and is one of several strategies to keep bones strong. Dr Mark Vanderpump, an endocrinologist (hormone specialist), agrees: If men got hot flushes, theyd be screaming for HRT, he says. Other options include the non-hormonal drugs clonidine, venlafaxine and gabapentin, or lifestyle measures such as avoiding spicy foods, alcohol and hot places.

HRT and cancer risks

The risk of cancer from HRT is overstated, says Vanderpump. Cancer Research UK puts it in perspective; if 1,000 women start HRT at the age of 50 and take it for five years, there will be two extra cases of breast cancer and one extra case of ovarian cancer compared with among non-HRT users. There will also be some extra cases of heart attack and stroke, but the overall negative effects are small. Avoiding HRT could prevent 1,700 cancer cases a year, but staying a healthy weight could prevent 18,000 cancer cases and not smoking would prevent 64,500 in a year. Women need to be given information and choices, says Vanderpump. Abernethy recommends the Womens Health Concern factsheets and the website Manage My Menopause, which offers tailored advice.

Natural supplements

Campaigner and author Maryon Stewart advocates a diet rich in plants such as soy that contain oestrogen-like chemicals called phytoestrogens. But Abernethy says we dont know how much soy you need to eat to get the same effect as HRT. And if phytoestrogens have similar benefits to synthetic oestrogens in HRT, they may share the risks: an increased chance of blood clots and a possible increase in breast cancer.

Dietary supplements containing isoflavones (the active chemicals in phytoestrogens), herbal remedies such as black cohosh and vitamin E are all available over the counter, but there is little evidence about their effectiveness or otherwise, according to the North American Menopause Society.

Eating a varied, Mediterranean-style diet, avoiding obesity, and doing regular weight-bearing exercise will help to minimise the risk of osteoporosis, heart disease, depression and osteoarthritis. Most women dont need calcium supplements, but those at particular risk of osteoporosis should get specialist advice.

Preventing heart disease and strokes

June Davison of the British Heart Foundation says women need to be aware that their risk of heart disease and stroke increases dramatically after the menopause. Oestrogen, which has a protective effect on artery linings, falls and other factors, such as high blood pressure, raised cholesterol and the ageing process kick in. Davison says: Heart disease kills three times as many women as breast cancer does; its common and certainly not a male disease. The best approach is to get a health check at your GP, optimise blood pressure, cholesterol and weight, dont smoke, eat well and exercise. We dont advise HRT to protect against heart disease; it may increase the risk of thrombosis (blood clots) if you are at increased risk and there is some evidence that heart disease is increased in the first year of HRT use. Women who want to take HRT for other reasons, such as hot flushes, and are at low risk of heart disease, can be reassured that the increased risk will be very low.

Sex drive and dry vagina

Loss of sex drive is common around the time of the menopause. Low mood, tiredness, hormonal changes and relationship problems may all play a part. It doesnt help that sex can be painful as the fall in oestrogen levels makes the vagina dry and sore. Non-hormonal vaginal moisturisers such as Replens, lubricants, and oestrogen pessaries (on prescription only) can restore vaginal moistness; the other factors may be more complex to fix.

Supplements for skin and hair

Vanderpump says women and men in midlife often experience thinning hair, rougher skin and various other age-related changes to their looks. But these are more likely to be due to genetics and environmental factors, such as sun exposure and smoking. If you eat a normal, varied diet, there is no reason to think that nutritional supplements will help hair, nails or skin. HRT doesnt turn the clock back and isnt recommended for these factors.

How can my employer help?

A government review examined 104 studies and found that the years around the menopause can have a big, usually negative, impact on womens working lives. Study co-author Professor Jo Brewis of the University of Leicester school of business says: We need to talk about the nitty gritty of menopause without embarrassment or fear being judged. Brewis says the analogy is with pregnancy 20 years ago when women feared telling employers that they were pregnant and needed certain reasonable adjustments in the workplace. For menopausal symptoms such as hot flushes, that might include fans, open windows, adjustable air conditioning, non-synthetic uniforms and flexible working hours.

We need to normalise the menopause, understand that it affects women differently and that many of the problems are relatively short-lived, says Brewis.

What are bioidentical hormones?

This form of HRT marketed in the private sector claims to offer hormones derived from plants that are chemically closer to the ones that occur naturally in the body. But the US Food and Drug Administration (FDA) is clear that they are no safer or more effective than standard HRT. Vanderpump says that if you find HRT helps symptoms, the exact preparation can be tailored to your specific needs; adding low-dose testosterone (Testim) gel, for instance, may help libido even though it is only licensed for men.

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Guiding light: the scientist who first diagnosed Sad

When Norman Rosenthal moved from sunny South Africa to wintry New York, he put a name to a debilitating slump in energy and mood that millions of sufferers would come to recognise seasonal affective disorder

When psychiatrist Norman Rosenthal moved from South Africa to the US in the 70s, something changed. In the colder winters of New York he and his wife felt their energy levels slump and their mood drop. So when he met fellow scientist Alfred Lewy at a party, it was easy for the pair to begin chatting about Lewys research into melatonin, a hormone associated with sleep and how light and mood might be entwined. Which is how, more than 30 years ago, the pair became the first scientists to describe seasonal affective disorder and treat it with light therapy. Since then our understanding of the way light affects us, Rosenthal tells me, has skyrocketed.

Sad, which is characterised by cognitive problems, withdrawing from friends and family, weight gain and increased time spent sleeping, may affect one in 20 people in the UK to a disabling degree. But as many as one in five can suffer the effects of less severe winter blues, struggling through darker days being less productive and happy than normal.

Sad helped us recognise that light and dark are strong influences of mood and behaviour and many of us dont get enough light, says Rosenthal. But now we know a large percentage of the population has some lack of functionality in the winter.

His work opened up new fields for exploration. For instance, it is now understood that light therapy using light boxes to mimic the effects of the suns rays can help people with forms of depression that are not seasonal. Its useful for patients for whom medication is a tricky option, such as pregnant women and the elderly.

I didnt realise how important our work would be …
Norman Rosenthal. Photograph: Dimitrios Kambouris/WireImage

Lights mood-enhancing effect can be used in other ways too, says Rosenthal, now clinical professor of psychiatry at Georgetown University school of medicine. The most cutting edge is with people who have had cancer and are having chemotherapy. They are now getting light and it helps them feel better.

Light, he explains, has an effect on our serotonin levels, a hormone that can affect our mood and energy. In Australia there was a study where they measured and evaluated the factors that make serotonin concentration levels go up and down. One of the most important factors was light.

Then there is the research into the effect of light on our natural body clocks. It can shift it earlier or later, says Rosenthal. Brighter light is more potent in this. He thinks research in this field will be the next discovery on the horizon. I think we will find out a bit more about the biological pathways associated with Sad. What genes does light turn on and off?

They have discovered clock genes [in mice] which regulate their biological clocks. When they disrupt them in animals it disturbs their rhythms and behaviours. This may lead us to understand how variations in our genes may influence the way we respond to light.

But he also sounds a cautionary note. Light can help people in so many ways, but it is not a cure-all and it can be harmful. There is an association between light pollution and cancers. Breast cancer and other cancers are associated with areas where there is a lot of light outside street lights for instance.

This could be, he says, because darkness allows melatonin to be secreted, which has been hypothesised to help prevent cancer.

Rosenthal says there have also been leaps in the way Sad is treated from the different intensities of light, to the time of day that light has the most effect on our bodies (the morning). Cognitive behavioural therapy can be helpful too, he says, though not everyone is keeping up the National Institute for Health and Care Excellence (Nice) has steadfastly refused to offer lightboxes on the NHS: Frankly, I think that is ridiculous. Hundreds of thousands of people use light and depend on it. I think their position is very curious and hard to understand.

Most recently, he has researched the effect of botox injections between the eyebrows to help with depression and is now looking into whether this too, could have an effect on Sad sufferers. Its wild, he says. Thirty years ago, I didnt realise how important [our work] would be. Now we have helped people live a full life, all year round.

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