Ana Megawati
A quiet revolution is sweeping through men’s health, driven by a powerful hormone and the aggressive marketing tactics of direct-to-consumer companies. Testosterone Replacement Therapy (TRT), once reserved for severe medical conditions, is now being positioned as a panacea for a host of modern male ailments, from fatigue and weight gain to anxiety and low libido. This surge in demand, particularly among younger men, has ignited a fierce debate between traditional medical practitioners, who warn of overdiagnosis and potential health risks, and a burgeoning industry that claims to be addressing a widely underserved need.
The Personal Stories: From "Shell of Himself" to "Second Puberty"
The human face of this trend is often compelling. Nick Dooley, a train driver, never considered his hormones in his youth, describing himself as "outgoing, confident, chatty." However, as he approached 30, a gradual decline set in: weight gain, anxiety, and a profound loss of motivation left him feeling like "a shell of my former self." By 38, weighing 22 stone and grappling with various health issues, he instinctively knew "something wasn’t right."
In 2024, a private medical exam revealed two significant findings: fatty liver disease and low testosterone levels, measuring 11.2 nmol/L. While this level falls within the NHS’s broad "normal" range (typically 8 to 30 nmol/L), Dooley felt dismissed when an NHS doctor offered antidepressants instead of investigating his hormonal concerns. Unconvinced, he turned to the internet, falling down a "Reddit rabbit hole" that led him to Manual, an online men’s health company, since rebranded as Voy. After two quick blood tests and a virtual consultation, Dooley began TRT, injecting testosterone cypionate three times a week. The results, he claims, were transformative. He has lost 45kg, his anxiety and depression have vanished, and he feels "back to being myself." So profound was the change that Dooley now leverages social media to advocate for TRT, becoming an influencer for the very company that he credits with changing his life. "Testosterone," he states, "changed my life."
Dooley’s experience is echoed by others. George, a social care worker from Manchester, suspected a hormone deficiency since his teenage years, struggling with overweight and an "extremely low" sex drive. Despite a previous flag for potential hypogonadism as a teenager that was never communicated to him, his attempts to get a diagnosis through conventional channels were met with skepticism, even laughter from one doctor. It was an online TRT ad that prompted him to take an at-home blood test, leading him to a private clinic. He describes a "skyrocketing" confidence and renewed energy after starting TRT. Similarly, Will, in his late 20s, suffered from depression and erectile dysfunction, initially attributing it to aging. A surgical report revealed an atrophied testicle, yet his GP deemed his testosterone levels "above the threshold" for treatment and offered antidepressants. Will, too, sought out a private TRT clinic, describing the impact as "like I was wearing a pair of glasses with the wrong prescription; suddenly, all the blurriness lifted." These narratives highlight a perceived gap in mainstream healthcare, where men feel their symptoms are not adequately addressed, pushing them towards private solutions.
The Cultural Phenomenon: "T-Maxxing" and the "Masculinity Crisis"
The conversation around testosterone has transcended medical clinics, infiltrating popular culture and social discourse. On platforms like TikTok, fitness influencers promote "T-maxxing," a practice aimed at maximizing testosterone levels through both natural methods (sleep, diet, exercise) and artificial means (steroids). Celebrities such as Robbie Williams and Joe Rogan openly discuss their TRT experiences, further normalizing the therapy. Advertisements for companies like Voy are ubiquitous, even appearing on the London Underground with slogans like "Feeling irritable? It might be low testosterone."
This cultural shift has taken on an almost existential dimension. In certain online "manosphere" circles, "low T" has become a pejorative, synonymous with terms like "beta" or "simp," reflecting a deep-seated anxiety about modern masculinity. High-profile figures contribute to the narrative; Robert F. Kennedy Jr., at 72, openly uses testosterone as part of his "anti-ageing regimen" and, without providing evidence, controversially claimed that American teenagers today possess "50% of the testosterone of a 65-year-old man." This climate fosters a perception that testosterone is central to a broader "masculinity crisis," driving men to seek solutions, often outside traditional medical pathways.
A Medical Divide: NHS Guidelines vs. Private Practice
The dramatic increase in TRT prescriptions underscores the growing tension. According to NHS data, prescriptions for testosterone in the UK surged by 135% between 2021 and 2024. A similar sharp rise has been observed in the US, with the largest increases noted among younger men. This trend is a significant concern for medical professionals. Channa Jayasena, an NHS endocrinologist and clinical professor of reproductive endocrinology at Imperial College London, notes the "crescendo" of demand, recalling how at a national endocrinology conference, every group reported clinics being "clogged up" with men seeking TRT, prompting the question: "What do we do?"
The core of the medical debate lies in diagnostic criteria. The medical term for male testosterone deficiency is hypogonadism, which describes a clinical condition where the testes cannot produce enough testosterone due to a physical problem or a disruption in hormonal signaling from the pituitary gland or hypothalamus. Crucially, a diagnosis of true hypogonadism requires not only low testosterone levels but also specific, key symptoms, such as erectile dysfunction (especially absence of morning erections), low libido, infertility, unexplained weight gain, osteoporosis, and depression. NHS England generally considers total testosterone levels between 8 and 30 nmol/L as normal, while the British Society for Sexual Medicine (BSSM) typically uses 12 nmol/L as a treatment threshold for symptomatic men.
However, direct-to-consumer companies often adopt broader definitions. Voy, for instance, despite claiming to follow BSSM guidelines, uses a threshold of 15 nmol/L for low T diagnosis, significantly higher than established medical consensus. This wider net allows them to identify a larger pool of potential patients. These companies, including Voy (formerly Manual), Hims, and Numan, strategically leverage social media advertising and a regulatory "loophole" in the UK: while they cannot legally advertise prescription drugs like testosterone, they can advertise diagnostic tests. This enables them to funnel men into their services, often for a fee, and then offer treatment based on their own, often less stringent, criteria.
The Science of Testosterone: Function and Deficiency
Testosterone is undeniably a foundational hormone for male biology. As Professor Jayasena explains, "It literally turns boys into men." Primarily produced in the testes, it plays a vital role in the development of male anatomy in the womb and triggers the dramatic changes of puberty, including the growth of facial hair, deepening of the voice, increased red blood cell production, bone density, and muscle growth. Geoff Hackett, a consultant urologist and author of BSSM’s guidance on testosterone, elaborates that it is "why men tend to be stronger and run faster." It is also an anabolic steroid, which is why it is banned by the World Anti-Doping Association and famously used by bodybuilders for extreme muscle development.
While primarily associated with men, women also produce testosterone in their adrenal glands and ovaries, albeit at much lower levels. Prescriptions for testosterone in women in the UK have also risen significantly, tenfold in seven years, partly fueled by celebrity endorsements from figures like Davina McCall, Kate Winslet, and Halle Berry, who have spoken about its use for menopause symptoms. Testosterone also plays a crucial role in trans healthcare for masculinizing hormone therapy.
TRT vs. Anabolic Steroids: A Blurred Line
A critical distinction, often blurred in online discourse, lies between legitimate TRT and the abuse of anabolic steroids. TRT aims to restore testosterone levels to a normal, physiological range to alleviate symptoms of deficiency. Steroid abuse, or "juicing," involves injecting testosterone at doses vastly exceeding natural levels, often in combination with other drugs, to achieve extreme muscle growth and performance enhancement. Historical figures like Arnold Schwarzenegger have openly admitted to using testosterone and other steroids to achieve their physiques.
The health consequences of steroid abuse are severe, including a significantly increased risk of heart attacks and permanent damage to sperm and natural testosterone production, often leading to a lifelong need for TRT once use is discontinued. Worryingly, online communities for TRT and steroid users often overlap, with advice on side effects, fertility maintenance, and injection practices ("pinning") being shared indiscriminately. This convergence, as George notes, is "dangerous, because it can cause a rabbit-hole effect for people," potentially leading individuals seeking genuine medical help towards unregulated and harmful practices. The difficulty in obtaining an NHS diagnosis and the cost of private TRT also drive some men to self-medicate using substances from "underground" labs, exacerbating the risks. Matthew, a 60-year-old travel agent who buys his T from an "underground" pharmacy and previously used steroids, exemplifies this path.
Investigative Insights: The Author’s Experience with Voy
To gain firsthand insight, the author undertook an at-home testosterone test with Voy. After a broad questionnaire and a £27.50 payment, an email arrived a week later: "Your free testosterone levels are low." This was surprising, as the author had only recently blamed fatigue and weight gain on Christmas indulgence. However, a closer look at the results revealed a total testosterone level of 16.4 nmol/L, well above the NHS (8 nmol/L) and BSSM (12 nmol/L) thresholds for hypogonadism. The "low" free testosterone was also above Voy’s own stated cutoff levels. Despite this, Voy urged a further £79.95 "enhanced blood test."
Professor Jayasena, upon reviewing the author’s initial results, was "stunned," asserting, "That is just wrong. That – 16! – is amazing. Your levels are fine. That’s absolutely shocking." This stark contrast highlights the differing interpretations of what constitutes "low T."
Voy’s parent company, Menwell Ltd., founded by tech entrepreneurs Michalis Gkontas and George Pallis, has grown rapidly since 2018, expanding from hair loss and erectile dysfunction to weight-loss jabs, menopause treatments, and TRT. With over $150m raised and 1.5 million patients across multiple countries, their aggressive marketing and expansive diagnostic approach are clearly effective.
Dr. Jeff Foster, Voy’s director of men’s health, defended the company’s approach, arguing that the NHS often fails men with hormone conditions, leading them to private clinics. While acknowledging concerns about blurring lines with steroid use, Foster claims Voy spends time "trying to weed out those who just need to lose a bit of weight, or be a bit healthier." However, when pressed on the actual prevalence of low testosterone, Foster admitted, "The honest answer, if anyone tells you they know the prevalence of low testosterone, is they don’t, because the numbers have changed and are changing so rapidly." This statement contrasts sharply with Manual’s (and Voy’s) website claim that "one in four men suffer from low testosterone after age 30." This statistic, derived from a nearly 20-year-old study of 1,475 US men, found that while 24.3% had testosterone levels below 10.4 nmol/L, only 5.6% actually exhibited symptoms of hypogonadism, predominantly among men over 70. More recent studies consistently place the prevalence of symptomatic hypogonadism between 2% and 8% of men, with risk increasing with age.
Further investigation into Voy’s practices revealed more inconsistencies. An employee, "Ali, 34," featured in a video testimonial on Manual’s website, was confirmed to be a Voy employee and a paying TRT patient, a practice that the Advertising Standards Authority considers misleading if it "falsely claim[s] or impl[ies]" that employees are consumers. Voy has been penalized by the ASA three times for breaches of advertising standards. The company also previously used the term "suboptimal" for total T results as high as 17 nmol/L, a term with no clear clinical definition, which Foster admits he "got rid of because I don’t like the idea; either it’s low or it’s not." Despite this, his forthcoming book is titled "Optimal."
Commercial Imperatives and Ethical Concerns
The approach taken by some direct-to-consumer TRT providers has drawn strong criticism from within the medical community. Dr. Richard Quinton, a consultant endocrinologist and co-author of the Society for Endocrinology’s guidelines on testosterone replacement, contends that these companies have "invented a spurious pseudo-disease called ‘low testosterone’ from which vast numbers of men are said to suffer." He suggests that this broadens the market for testosterone sales, aligning with the commercial interests of private equity firms that have "dumped a vast amount of money into testosterone clinics around the UK."
The pro-TRT camp counters by highlighting the stories of men like Nick, George, and Will, who felt neglected by the NHS and found significant improvement through private treatment. Richie Gibbs, founder of the TRT clinic Origin, states, "I’ve spoken to at least 200 patients who have gone through the NHS, and when they contact us some of them are on the brink of tears because they’re not getting the help they need."
While recent studies have downplayed previous concerns linking TRT to higher risks of prostate cancer and heart attacks in men with diagnosed hypogonadism, Quinton emphasizes that these studies do not apply to men injecting testosterone beyond natural levels. He warns that "if you’re taking excessive amounts of testosterone, your risk of heart disease and heart events is significantly increased." Other side effects of testosterone abuse include suppression of natural testosterone production and fertility (though often reversible), blood thickening, testicular atrophy, acne, and hair loss. Psychologically, very high doses have been linked to severe mental health conditions, including psychosis and "roid rage." Research suggests testosterone encourages "status-seeking behaviour" and can make men more reactive to perceived challenges.
Broader Societal Implications: The "Medicalisation of Masculinity"
The author’s personal experience of feeling "emasculated" by a "low T" result, despite having normal levels by medical standards, underscores a broader societal anxiety. This feeling of shame and the notion that one might not have "enough of the only chemical that defines me as a man" highlight what a recent paper in Social Science & Medicine termed the "medicalisation of masculinity" fueled by social media.
This anxiety occurs against a backdrop of debated declines in average testosterone levels across populations, which some experts link to more sedentary lifestyles, exposure to endocrine-disrupting chemicals, and, most notably, obesity. Adipose fat is known to aromatize testosterone into estradiol, a form of estrogen, creating a vicious cycle of weight gain and reduced testosterone. Numerous studies have demonstrated that significant weight loss can naturally raise testosterone levels, and even weight-loss jabs have shown efficacy in increasing T among obese men, often negating the need for TRT.
For men like Nick Dooley, who was diagnosed with fatty liver disease concurrently with low T, the question of cause and effect remains a "chicken and egg question." Most men who start TRT will likely require it for life, incurring a significant monthly expense. Yet, for those who experience genuine relief, like Nick, who describes "a second puberty" and a return to the "libido of a 20-year-old," the cost is considered worthwhile.
The author’s journey concluded with a Medichecks test confirming "within normal range" testosterone levels. However, the experience of being drawn into the "funnel" of private testing and the subsequent exposure to an online world of "ripped young men hawking T" left a lasting impression. Dr. Foster conceded that advertising is a "blunt instrument" that will inevitably attract men who are not eligible for treatment. While he believes such individuals "won’t be falsely treated," they will likely pay for tests and consultations. The conversion rate, he notes, is less than 20% after the initial test, but "usually, about 70% to 80% will start treatment if you get them to consultation" after a second, more expensive test. This language, characteristic of marketing rather than medical consultation, leaves a lingering concern about patients being viewed more as customers moving through a sales pipeline.
The debate over testosterone therapy reflects a complex interplay of genuine medical need, evolving scientific understanding, cultural anxieties about masculinity, and powerful commercial interests. As prescriptions continue to rise, the challenge remains for healthcare systems to distinguish between legitimate hypogonadism and the over-medicalization of normal variations, while ensuring patient safety and ethical practice in a rapidly expanding market.
