How the Low T Industry Is Cashing in on Dubious, and Perhaps Dangerous, Science

While Sisk owns his customers outside the examining room, his national medical director, Dr. William Reilly, owns them inside. He's a small, lithe, white-haired man. A joint surgeon for 22 years in Midland before he joined the center's staff, Reilly had grown weary of replacing old men's knees and hips. "With traditional medicine," he says, "you can talk your head off, give the guy a prescription: 'Here's your blood pressure medicine.' He doesn't get it filled, comes back six months later and he's worse. [I'm thinking,] Why did I talk to this guy?"

Reilly wanted to change his version of medicine. Instead of treating ailments, he thought, why couldn't he prevent them? This realization happened to coincide with a decline in his active lifestyle. "I've always played sports. I've always worked out," he says. "Then, when I turned 63, I started to hit a brick wall. I noticed my energy level was going down. My ability to concentrate was affected. I'm lifting weights, and I'm losing muscle."

He attended a meeting hosted by Cenegenics, another player in the low T industry. With the company's training, he opened a testosterone therapy clinic -- an "age-management" clinic in his parlance -- in Midland, "and before I knew it, I had 55 patients." He also began injecting himself with testosterone.

"I went from 23 percent body fat to 16 percent body fat in six weeks," he says. "I'm down to 9 percent body fat right now. I just turned 67. I bench over 200 pounds. I work out with the trainer three days a week. My energy level's like it was in college."

As a salesman, Reilly is as good as, if not better than, Sisk. His low T story, even if he hit the proverbial wall later in life, echoes those of many other men. They all fit the pattern of the industry's commercials to a T.

Reilly began working part-time at the Low T Center, and Sisk must have realized his potential: "Mike said what would it take to have you come full-time, and I put a number on the table. He said can you start tomorrow." That was more than a year ago, and it's been his job to maintain the clinics' medical standards for the men who walk through the door.

But what gets them to the door? For many, it starts with a simple quiz. It was designed to determine whether a man should talk to his doctor. The quiz, available on isitlowt.com, surely describes the life experiences of many middle-aged to older men: "Do you have a lack of energy?" "Have you noticed a decrease in your enjoyment of life?" "Have you noticed a recent deterioration in your ability to play sports?" "Are you falling asleep after dinner?" Most of these questions, or their variants, are recycled in industry commercials.

Though the quiz is widely used, it's hardly a foolproof indication of a low testosterone level. In 2013, The New York Times revealed that Dr. John Morley of the St. Louis University School of Medicine had drafted the low T quiz on toilet paper in about 20 minutes in a bathroom. He was paid by a company that produced testosterone. "I have no problem calling it a crappy questionnaire," Morley told the Times.

But that hasn't stopped men nationwide from seeking out testosterone therapy based on a vague set of questions. And according to the industry, the number of eligible men keeps climbing. When it first petitioned the FDA in 1999, Unimed estimated the market for AndroGel at one million men. But by 2000, when the drug was available, the number of men with low T, according to Unimed, was four or five million. Two years later, Unimed revised its numbers again: The market had grown to about 20 million. More recently, Dr. Joseph Perkinson, who used to be Low T Center's medical director, went on "Good Morning Texas" and said, "An estimated 30 percent of men between the ages of 40 and 79 have low testosterone. That's almost one in three." The FDA estimated that about 1.3 million men took testosterone in 2010; three years later, that number had increased by a million.

It's all a show, write doctors Lisa Schwartz and Steven Woloshin, medical professors at Dartmouth, in a 2013 article in the internal medicine edition of The Journal of the American Medical Association. "The Low T campaign," they write, "uses three basic strategies: lower the bar for diagnosis (turning ordinary life experiences into conditions that require medical diagnosis), raise the stakes so that people want to get tested, and spin the evidence about drug benefits and harms."

It's not clear what exactly constitutes a low level of testosterone. The consensus seems to be that, for a man 18 or older, a normal level is between 300 and 800 ng/dl. Some put the low end of normal at 200; others put the high end of normal at 1,000. One man's normal is another man's high or low. Schwartz and Woloshin note that for a clinic to use a low level of 230 means only 7 percent of men 50 or older nationwide would be eligible for treatment; using 350, as most providers including the Low T Center do, increases the number to 26 percent.

"Ideally," Schwartz and Woloshin write, "lines would be drawn to maximize benefit and minimize harm. Unfortunately, lines are often drawn not because of evidence but to expand the market. Whether the campaign is motivated by a sincere desire to help men or simply by greed, we should recognize it for what it is: a mass, uncontrolled experiment that invites men to expose themselves to the harms of treatment unlikely to fix problems that may be wholly unrelated to testosterone levels."