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As an expert on andrology and sexual dysfunctions, urologist Andrew Y. Sun, M.D., sees plenty of patients who’re struggling with low libido. And most are pretty sure they already know why: They must have low testosterone levels. Even if it turns out they don’t, “most of them still strongly believe that increasing their testosterone levels will improve their libido,” says Sun, who practices at Urology Partners of North Texas.
Sun’s experience is hardly unique. About dozen endocrinologists, urologists, sex therapists, and other experts told us that many of their patients echo these sentiments. But this conviction wasn’t always so widespread. According to several practitioners and researchers, it’s actually the result of over a decade of effective direct-to-consumer advertising by the makers of testosterone gels and creams, pills and patches, injections and under-the-skin implant pellets. Their ads suggest that men who often feel fatigued, or like their sex drive has taken a dip in recent years, may actually be suffering from “low T,” and may benefit from testosterone therapy.
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But contrary to all the popular hype and conviction, recent research suggests that testosterone treatments won’t do as much for many men’s libido issues as they might hope. In fact, several medical experts told us that most guys with low sex drive won’t see any benefits from T, thanks in large part to the incredible—and often idiosyncratic—complexity of our libidos. And while testosterone proponents often paint the hormone as overwhelmingly safe, doctors still caution that it’s not always harmless.
“It’s like with erectile dysfunction,” says Roger Libby, Ph.D., a sex therapist in Seattle who generally supports improving access to T, “Viagra is not the first and final solution.”
The Complicated Relationship Between T and Libido
“It is true that testosterone is related to libido in many men,” says Sun. People gleaned that long before we knew what hormones were, by observing things like the effects of castration or testicle injuries on men’s sexual lives. (Men produce testosterone in their testes—hence the name.)
But our longstanding focus on this relationship has arguably blinded many people to a simple fact: This hormone isn’t the only biological factor with clear, substantial power over our libidos.
Notably, estrogen, although often characterized as the female sex hormone, plays a major role in maintaining male libido. (Sun sees plenty of men who assume that estrogen will counteract their testosterone, so they take pills to suppress it. But estrogen and testosterone actually balance and support each other in any body. “Complete suppression of estrogen is a surefire way to destroy a man’s libido,” Sun adds.)
“Dopamine, serotonin, and oxytocin all play a role in libido, too,” explains Justin Houman, M.D., a urologist in Los Angeles who specializes in men’s sexual and reproductive health.
Psychological factors like stress and anxiety can lower a person’s libido, no matter how robust their levels of testosterone, estrogen, or any other biological element may be. So can social factors, like relationship troubles. If you’re not jazzed about your partner, or how things are going between the two of you, then even if you’re biologically pristine you may not have as much desire for sex as you used to. Even personal beliefs or values about sex and relationships can have a top-down effect on our bodies. If, say, you believe sex outside of marriage is a dire sin and you’ll be damned to hell if you pursue it, your raging hormones may not matter all that much.
The effect of any of these factors, much less the interplay between them, within any unique body and mind is hard to calculate. Stress and anxiety are big libido killers for many people, for example, but for others they lead to a spike in sexual desire—and we’re not entirely sure why.
“Libido is very complex, and definitely poorly understood,” stresses Sun. So it’s often far harder to treat sex drive issues than banner ads for testosterone treatments often seem to suggest.
The Magic Bullet Fallacy
It is tempting to reach for a dose of T rather than grapple with this complexity, acknowledges sex counselor and educator Eric Garrison, as it seems like a quick fix: No matter what’s going on in a person’s body or life, surely adding enough raw hormonal fuel will get their libido revved up.
But that’s not how T works. In realty, explains Petar Bajic, M.D., a urologist and men’s sexual health specialist affiliated with the Cleveland Clinic, “testosterone is a threshold hormone. Our bodies need a certain amount for normal functions, but beyond that, there is not necessarily any additional benefit.”
Even among people with consistently, verifiably low T—everyone’s levels fluctuate quite a bit day by day, and even hour by hour—the effects of testosterone on libido are incredibly mixed and complicated.
If your body produces exceptionally little testosterone, you’ll definitely have issues with your sex drive, which will improve once you start taking T. But most people with clinically low T aren’t anywhere near that level of lack. Most with mild to moderate low T levels don’t actually show signs of low libido—or any other low T symptoms. (Beyond fatigue and low sex drive, low T can also cause mood and concentration issues, losses of muscle and bone strength, increases in body fat levels, and mild anemia.) And those who do have low T levels and low libidos, according to a review paper in PLOS One journal, may only get a modest boost in their sex drives after they start taking testosterone. Some won’t see any improvement at all.
Some of this variation likely comes down to the fact that each of our bodies react to testosterone a little differently. Some of it just reaffirms the fact that testosterone may not be as key to libido as many of us believe it is. “In cases where men who have low T don’t have improved low libido symptoms from testosterone treatments, it means the problem is not testosterone,” stresses Bajic.
The Potential Pitfalls of Taking T to Boost Your Libido
Hardcore testosterone proponents often don’t present the potential downsides to taking T. This may make it seem easy to just test whether it works for you, or take it long-term even for marginal gains. But while testosterone is “overall pretty safe” when properly prescribed and monitored by an expert, explains Jesse Mills, M.D., a urologist, male sexual health expert, and director of the Men’s Clinic at UCLA, it’s not risk free.
Granted, there’s a ton of active debate among medical experts about exactly what risks testosterone might pose, and in what contexts it may be risky. It’s pretty clear, for example, that serious testosterone abuse may lead to heart and liver issues. But are those risks only relevant to ‘roided-up bodybuilders? Or should people with normal levels of T who just pump a little more into their bodies than they actually need be worried about them as well? If there are risks, are they outweighed for some folks by potential health benefits? Researchers who have reviewed the available evidence recently noted the need for more long-term, robust studies on all of this. (Results of a big trial on testosterone’s effect on health are due to come out this summer, and it may answer some of these questions.)
But one thing is absolutely sure: Going on testosterone can rapidly and drastically reduce male fertility. Ariel Moradzadeh, M.D., a urologist who specializes in infertility treatment at Cedars-Sinai, says that at least once a week he sees a patient who got their hands on testosterone—sometimes off the grid—because they heard it was a good tool for addressing libido issues, but “were unaware of the potential fertility implications.”
There is no set timeline, but if you take testosterone long enough then your body also basically forgets how to produce its own as well, becoming dependent on this external source of ample hormones. This means going off of T sometimes involves an uncomfortable withdrawal period.
“Testosterone is a phenomenal therapy for the right man,” Mills stresses. But given all of these caveats to its libido-boosting potential, and the situational risks associated with it, none of the experts we spoke to were in rush to direct people struggling with their sex drive to it.
Even Libby, who believes everyone who needs testosterone should have easy access to it, maintains that “people should deal with other potential issues first.” Because doing so not only means potentially finding a solution to their libido issues without resorting to an external hormone they could become dependent on. It also means getting their health house in order such that, if they do determine that testosterone is right for them, they’ll get the most out of it.
What to Tackle First
While our libidos are incredibly complex, the first step to resolving any issues we have with them is surprisingly simple, saysMadelyn Esposito-Smith, a sex therapist and mental health clinician at UW Health Behavioral Health and Recovery: “See a physician for that yearly physical you’ve rescheduled four times, to rule out underlying medical conditions.”
Any number of chronic or acute health issues can affect libido, directly or indirectly. Notably, conditions including diabetes, kidney and liver diseases, recent weight increases, thyroid disorders, and even sleep apnea can all cause a decrease in testosterone, and thus libido, and that decrease can often be reversed by treating this underlying health issue.
It may be hard for a doctor to nail down exactly what’s causing your sex drive issues, but identifying and tackling any latent health issues is a good in its own right, even if doing so doesn’t end up helping your libido. Just make sure to talk to your doctors about how to mitigate the sexual side effects of any meds they prescribe. Many common drugs, from antidepressants to anticonvulsants, cancer treatments to contraceptives, and more, can all lower libido themselves.
Whether or not you rule out clear physical-medical issues, you should also take a fearless inventory of your sex life. Reflect on when your libido started to drop and whether that coincided with any issues in your health or relationship. Adriane Fugh-Berman, M.D., a professor of pharmacology and physiology at Georgetown University who has studied testosterone marketing and usage, specifically suggests asking yourself: “Am I depressed or anxious? Does my relationship need work? Does my level of libido actually bother me or my partner? Is the issue really about a libido mismatch between me and my partner?”
“Most men need insight,” stresses Dr. Fugh-Berman, “not drugs.”
“If you can’t figure out exactly what mental, physical, or social issue is messing with your sex drive, then the experts Men’s Health spoke to suggest taking the following steps before turning to T:
• Talk to a mental health professional who specializes in sex and relationship issues, a sex therapist, or a male sexual health-focused endocrinologist. These specialized experts might be able to help you figure out something you, or your general practitioner, is missing.
• If you think multiple issues are, or could be, affecting your sex drive, face them one at a time rather than all at once. “It’s like tackling credit card debt,” explains Garrison. “You address what’s going to have the biggest impact—and what you’re most likely to succeed in addressing.”
• When in doubt, focus on improving your exercise regimen, hydration, and sleep hygiene. These are low-hanging fruit of libido health. Many people neglect or struggle with them. But we know that even simple tweaks to any of them can have major positive effects on libido directly, or on conditions that indirectly affect our sex drives.
If you go through this checklist and still find yourself struggling with clinically low T levels and a low libido, that’s when you would finally consider testosterone treatments, the experts we consulted explained.
This doesn’t necessarily mean reaching for testosterone injections, pills, topicals, or other options, though. As Houman points out, “there are ways we can boost testosterone production” before turning to an external source. Some doctors prescribe meds that help your body boost its production, although there’s not always consensus among medical professionals about which meds and how much. But if those aren’t what you need, then exogenous T may be in order.
Going through all this rigmarole before turning to T may seem frustrating or pointless, given the wide availability of the hormone. However the wait may be worth it, even if other approaches aren’t effective for you. Because the more additional factors dragging down on your libido you take care of beforehand, the more of an impact testosterone may end up having. As Garrison put it, “the hormone works best for people who have the rest of their health in order.”
Mark Hay is a Brooklyn-based reporter who writes frequently about health, medicine, and sex for publications like Men’s Health, Men’s Journal, VICE, Aeon, Slate, and more.
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