The Struggle to Obtain Medicinal Testosterone in Canada

This article originally appeared on VICE Canada.

You wake up groggy-eyed and tired, with a back full of tight muscles and a shiver down your spine. You've been feeling depressed for as long as you can remember and you haven't had sex in months. In fact, it seems like you haven't had a proper erection in months either. But you are only in your twenties. You know something is wrong with you.

This is the sentiment I've heard from over a half-dozen young men suffering from a condition called hypogonadism, otherwise known as low testosterone or low T.

Sharing symptoms that are very similar to depression, hypogonadism often goes untreated for a long time due to misdiagnosis or an unwillingness on the part of the patient to seek treatment. This is especially a problem among young men, who are generally expected to have testosterone levels that are through the roof.

In America, the use of testosterone as a medicine has increased significantly over the past few years, with drugs like AndroGel (a topical cream containing the hormone) and testosterone injections becoming commonplace among men in their 30s or older who are experiencing issues with libido, strength, and energy.

Toronto Life reported last year that IMS Health found the testosterone industry to be worth over $2 billion USD globally, with an estimated 47 percent increase in Canadian sales of the drug over the previous five years. However, even with those projections, there hasn't been a normalization of the drug in Canada quite yet like there has been in the US.

According to doctors and patients that I spoke to, this has been less of an issue for older men trying to obtain treatment (as they're generally seen as the target audience for the variety of male performance enhancers out there) than it has for younger sufferers of hypogonadism.

The actual treatment method, dubbed TRT (testosterone replacement therapy), involves the controlled administration of the hormone in an effort to replace one's natural production of testosterone which may be out of whack can be for a variety of reasons.

Genetic defects, such as a dysfunctional pituitary gland (responsible for the production of luteinizing hormone—the signal that tells your testicles to get to work), to incidents involving an adverse reaction to medicine or drugs, are just some of the ways in which a male can become hypogonadal.

The upsides of getting treated are numerous: increased sex drive, virility, muscle mass, confidence, happiness, etc. The downside? Once you start administering synthetic testosterone, the person's natural production shuts off, their testicles shrink, and they become fundamentally dependent on the drug to stay functioning.

According to Dr. Larry Komer, a Canadian gynecologist and obstetrician turned hormone doc, those under 30 who come into clinics with testosterone on the mind are often viewed skeptically as either misinformed kids that are unwilling to admit they're depressed, or malicious adults trying to get their hands on steroids for athletic performance. Komer says that this oftentimes is far from the reality.

"If you believe the ranges of testosterone most doctors will give to patients, you will get absolutely nowhere with your health," he said, referring to the standardized ranges that most blood clinics have listed as "healthy" levels of testosterone. Komer notes these ranges are not controlled and include the entire clinic's populace (including everyone from teenagers to seniors).

For example, a man who gets his blood tested might register with a total testosterone level of 310 ng/dL on a scale of 300-1200 ng/dL and still be considered within normal ranges. The issue here, in Komer's words, is "the assumption is that men should be functioning rather than thriving."

"These ranges are so wide that it's ridiculous. No one should have to be 'OK' or 'average.' You don't go to a mechanic with two cylinders firing and ask him to bump you up to four. You want all eight cylinders firing, and there is a complacency in this sense when it comes to men and testosterone."

Undoubtedly an advocate of the hormone's use as a medicine for a wide variety of symptoms he attributes to testosterone deficiency, Komer describes testosterone as a highly-underrated drug when compared to alternative treatments such as long-term antidepressants.

"Doctors are constantly pushing antidepressants onto these guys when the real problem, most of the time, lies in low testosterone. Depression is just a symptom [of low T], an anomaly that is one in many [symptoms]," he said.

"Doctors are afraid of hormones because it's a tricky medicine and I see a lot people end up on antidepressants because [the doctors] don't want to get into it. These are just symptoms of the large problem, which is a hormone deficiency."

Dr. Keith Jarvi, the head of urology at Mount Sinai Hospital in Toronto, says that while he acknowledges the great success testosterone has produced in his patients with legitimate hormonal issues, he also notes that there are a number symptoms a patient must present before being considered for treatment.

"You have to be very careful and diligent when prescribing this medicine, to young men especially," he said. "Even when guys tell us they aren't planning on having kids, we still have to consider the fact that once they are on this drug, they will most likely never come off and that infertility will be a genuine issue. Before I, as a doctor, am willing to consider that, I need to cover every base."

Over the past month, I spoke to three hypogonadal men through an online bodybuilding forum who were willing to get in-depth with their issues. While the men lift weights regularly, none of them were actual bodybuilders. Interestingly, the forum, despite generally being a very bad place to get medical advice, is the only space in which they felt they could have their voices heard after their concerns were shot down by multiple family doctors.

Two of the three said that they had been on a waitlist at Komer's clinic for over six months and had been searching for an endocrinologist specializing in male hormones for years. Komer himself acknowledged this, pointing out that the average wait time for someone at his clinic is around a year and that most of his patients visit at least four to six different doctors before finding somebody who won't laugh them out of the office.

One of the men I spoke to, Ken, described his experience of being shut down by numerous doctors as "an insane asylum."

"You start to doubt yourself a lot. It can be very discouraging to be told time and time again that you're simply depressed and that they aren't willing to take a second look," Ken told me, noting that his family doctor had him on an increasing dose of antidepressants for two years until he was no longer responding to the pills. It was at this point he began visiting other doctors until he got the blood tests confirming that he was clinically deficient in testosterone.

Ken, 23, who is now being treated on the hormone after paying to get into a private clinic in the US, believes that the struggle he had to go through to get treatment was mainly due to being in his 20s and being involved in swimming, which he says gave doctors the impression that he was trying to improve his athletic performance.

"I was convinced I was either crazy, or stupid, or making these problems up in my head," he said. "You would just think to yourself, 'Do I need this or do I want this?' [Doctors] kept telling me that I was fine and that I was normal, so I kept rationalizing until I just couldn't do it anymore. Now that I'm being treated [with testosterone], I've realized just how bad I used to be."

While it's impossible to narrow down exactly how many men are suffering from hypogonadism in Canada due to lack of hard statistics, IMS Health's 2013 report on the drug showed 550,000 retail prescriptions were filed for medicines containing testosterone in Canada. That compares to a US study of the same year that examined prescriptions filed under a large health insurer and found that 11 million men received treatment for testosterone-related issues. Canada, at least based on those two studies, has a significantly lower prescription rate per capita.

Debate around the safety of testosterone as a medical treatment has been ongoing for a long time. There is hard evidence that shows synthetic testosterone use causes infertility in men, as well as side effects like hair loss and increased blood pressure.

While all of these things can be controlled—usually with a combination of other drugs and lifestyle changes—some studies have attempted to create a connection between diseases such as prostate cancer and heart failure with testosterone usage. Despite research that has found the drug to be dangerous, such as this 2014 paper from Harvard, overall consensus on the hormone's efficacy is still pretty murky.

Komer, who claims to have seen over 5,000 patients during his 13 years running his Master Men's Clinic in Burlington, says that his inspiration to go from delivering babies to helping men feel healthy came from when he saw how female hormones such as estrogen were able to not only stop the negative side-effects of menopause, but actually improve their lifespan and decrease risk of things such as heart disease. He believes that, based off research and his own observations, male menopause (otherwise known as andropause) can be counteracted in the same way with testosterone.

"I would not be stupid enough to keep prescribing this drug if I didn't know it worked. I've seen over 5,000 guys with low testosterone now, so I know there are real issues here that have a clear and evidence-based solution. I hear about changes in people. Stories like, 'Thank you for giving my life back,' or somebody's wife telling me 'This is the guy I was ready to bury. Thank you for saving our marriage.' These are the things that affirm [the drug's] effectiveness for me."

While both Jarvi and Komer agreed that the medical community hasn't realized the full potential of testosterone and its benefits just yet, they differ in their methodologies to prescribing it. Komer checks for signs and symptoms based off how the patient describes their life and asks them to fill out a detailed questionnaire. Jarvi, on the other hand, says that he tries to figure out whether a patient is exhibiting signs of depression, stress disorders, or other mental ailments before proceeding to testing for a testosterone deficiency.

Both doctors perform extensive blood tests, but the divider between Komer and Jarvi seems to lie in the premise of whether testosterone is a drug that should be used liberally or one that needs to be carefully and rigorously controlled.

"We can control the negative side effects of testosterone if we know what we're doing, and there are experts that do. We should not be afraid of using this drug when there are so many benefits that can literally change men's lives," Komer says, noting that he believes if any adult male is feeling the signs and symptoms of low testosterone, they're most likely in need of treatment and that the medical system shouldn't limit their access to the medicine.

"Look at how women were prescribed estrogen 20 years ago—it was for the symptoms [of menopause]. Now, they give the same drug to combat fatal diseases such as heart disease, cancer, fertility issues. Teenage girls use it when taking birth control. It is completely common now." Komer says.

In Komer's opinion, testosterone could one day be considered as valuable as female hormones of the same class.

"It's the same thing playing out with testosterone, but because there's this negative connotation that goes along with it, we're moving very slowly toward progress. If this was a non-hormonal drug, you would have a blockbuster."

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