By Dr. Alfie Suarez-Sarmiento, Jr., MD, MBA | Men’s Health Expert
Last week, The Guardian published a long feature asking why so many men are being told they have low testosterone. The headline was borrowed from a TRT skeptic: “They’ve invented a spurious pseudo-disease.”
It’s a provocative line, and the piece raises some valid concerns. But somewhere between the opening anecdote and the closing paragraph, it takes a wrong turn that has consequences for real patients.
Where the Article Gets It Right
Reporter Oliver Franklin-Wallis described the testing process of a popular UK men’s health app. His total testosterone came back at 473 ng/dL; a number the app flagged as low, then used to funnel him toward $225 worth of follow-up testing.
Here’s the problem: Total testosterone alone is just one data point, which for a qualified andrologist or sexual medicine specialist, is a starting point, not a conclusion. A complete picture requires free testosterone, the fraction of testosterone that is bioavailable to your tissues, along with SHBG (sex hormone-binding globulin), which determines how much of your total testosterone is bound and therefore inactive. A man can have a “normal” total T of 473 ng/dL and still experience genuine hypogonadal symptoms if his SHBG is elevated and his free testosterone is suppressed.
The inverse is also true; a lower total T with favorable SHBG may be entirely adequate. None of those numbers mean much without the clinical conversation: How are you sleeping? What’s happened to your morning erections? How has your energy, mood, and body composition been over the last two years?
These questions require a consultation, not a questionnaire. The diagnosis needs to be done by a physician who has dedicated their training to understanding the male hormonal axis rather than an algorithm designed to move you down a sales funnel.
Every serious clinician in this space should be equally troubled by what that app did, because reducing a complex hormonal picture to a single flagged number and then charging for the privilege is exactly what gives ammunition to critics who want to dismiss testosterone medicine entirely.
The article is also right that the “1 in 4 men over 30 have low T” statistic plastered across men’s health marketing is a distortion. The study it references did find that roughly 24% of men had testosterone levels below 300 ng/dL, but only 5.6% had both low levels and actual symptoms, well below the combination required for an accurate diagnosis of hypogonadism.
The majority of the men studied were over 70. Prevalence studies across Europe, the US, and Asia consistently put clinically significant hypogonadism at 2–8% of men, rising with age. Those numbers deserve to be quoted accurately, not inflated to build a market.
So far, so good. But here is where the piece goes off the rails.
Hypogonadism Is Not a Pseudo-Disease
Male testosterone deficiency, or hypogonadism, is a recognized, ICD-10 coded, guideline-endorsed medical condition. It presents with a well-characterized clinical picture: absent or diminished morning erections, loss of libido, unexplained fatigue, loss of lean muscle mass, depressed mood, bone loss. In men with primary testicular failure from prior chemotherapy, radiation, trauma, or Klinefelter’s syndrome, it is not a gray area. These patients need treatment, and withholding it causes measurable harm.
The problem the article is actually describing — and conflating with the diagnosis itself — is overdiagnosis by platforms that aren’t doing clinical medicine. Those are different things. Critiquing a telehealth company’s marketing funnel is legitimate. Calling the underlying condition fictitious is not.
“Critiquing a telehealth company’s marketing funnel is legitimate. Calling the underlying condition fictitious is not.”
The distinction matters most to the patients who fall through the cracks. The men quoted in the article itself, who were flagged for potential hypogonadism as teenagers and never told, or found to have atrophied testes on a surgical report but still turned away, are not victims of overdiagnosis. They are victims of underdiagnosis, managed by a system that sets diagnostic thresholds based on healthcare budgets rather than biology. They deserved treatment from a specialist instead of an app.
The Cardiovascular Question: Settled by the Best Evidence We Have
The article gestures at heart risk, and blurs the line between therapeutic TRT and supraphysiologic steroid abuse. This is worth addressing directly, because the science has advanced significantly.
Cardiovascular concerns around TRT trace back largely to two studies that generated enormous headlines: a 2010 trial in frail elderly men that was stopped early, and a 2013 Veterans Administration database analysis by Vigen et al. Both were widely cited as evidence that testosterone therapy increases heart attack risk.
Both studies are problematic.
Traish, Guay, and Morgentaler, writing in the Journal of Sexual Medicine, dissected the Vigen study in detail. The raw data actually showed 10.1% cardiovascular events in the testosterone-treated group versus 21.2% in the untreated group: The untreated men had double the event rate. That finding was statistically manipulated through adjustment for over 50 variables, reversing the raw result entirely. The authors were later required to issue a correction. Meanwhile, the study excluded 1,132 men who experienced heart attacks or strokes; and all of those events should have been counted in the no-treatment group, which would have further strengthened the case for TRT. As Morgentaler and colleagues noted: “The raw data strongly favored T [testosterone] therapy.”
The 2010 Basaria trial, similarly, was a six-month muscle strength study in frail elderly men — not a cardiovascular safety trial — and compiled a mixed bag of subjective adverse events alongside only four major cardiac events total.
Then came TRAVERSE: 5,246 men, double-blind, placebo-controlled, and the largest randomized controlled trial ever designed specifically to assess testosterone therapy and cardiovascular outcomes, which was published in the New England Journal of Medicine in 2023. The result: major adverse cardiovascular events occurred in 7.0% of the TRT group versus 7.3% in the placebo group: statistically noninferior. The trial also showed a 22.5% reduction in new-onset type 2 diabetes in men receiving testosterone, along with improvements in anemia, sexual function, and mood, with no increase in prostate cancer.
This is the highest level of clinical evidence we have. The cardiovascular scare narrative is not supported by it.
One important nuance the article does raise correctly: supraphysiologic dosing — the steroid abuse practiced by bodybuilders — does carry real cardiovascular risk. That is not TRT. That is a completely different pharmacological category. Conflating them is like warning patients off antihypertensives because cocaine also affects blood pressure.
What Good TRT Practice Actually Looks Like
What this article criticizes about “TRT clinics” is accurate, and something that the best clinicians in this field have been saying the same things for years. Testosterone therapy should not be initiated from a fingerprick test and a questionnaire about whether you’re tired. It requires:
- Two fasting, early-morning blood draws: Testosterone follows a diurnal rhythm; a single afternoon value is clinically meaningless.
- Gonadotropin levels: (LH and FSH) help distinguish primary from secondary hypogonadism and rule out pituitary pathology.
- Metabolic evaluation: Obesity, insulin resistance, and sleep apnea are major drivers of functional testosterone suppression that deserve their own treatment first.
- Symptom correlation: This must be identified using validated tools.
- An honest conversation about fertility: Exogenous testosterone suppresses endogenous production and sperm output, which is manageable but must be disclosed and addressed.
When diagnosed and prescribed properly, TRT is not a lifestyle product. It is precision medicine for a real condition.
“When diagnosed and prescribed properly, TRT is not a lifestyle product. It is precision medicine for a real condition.”
Dr. Paul Perito, one of the most experienced prosthetic urologists and men’s health physicians in the world, puts it simply: “Testosterone is the closest thing to a real fountain of youth that we have in medicine — but like any powerful tool, it has to be in the right hands.”
The right hands in this case are andrologists, urologists, and reproductive endocrinologists who trained in this discipline; not entrepreneurs who identified a lucrative market.
The Bottom Line
The real issue isn’t testosterone, but rather who is prescribing it and how.
When the evaluation is rigorous and the diagnosis is correct, the dose keeps a man in the physiologic range, and the follow-up is consistent: TRT is safe, effective, and for many men, genuinely life-changing.
“TRT is safe, effective, and for many men, genuinely life-changing.”
The body of evidence, including over two decades of longitudinal mortality data showing that low testosterone is independently associated with increased all-cause and cardiovascular mortality, supports treatment in appropriately diagnosed men.
The men’s health space needs specialists back at the center of this conversation. This isn’t because apps and telehealth platforms have no role, but because the clinical standard has to be set by people who trained for it; namely urologists, andrologists, and physicians who understand that a testosterone level doesn’t exist in isolation; it exists in the context of a man’s age, symptoms, comorbidities, fertility goals, and life.
That’s the standard we hold ourselves to at Perito Urology. That’s the standard every man being evaluated for testosterone deficiency deserves.
Dr. Alfie Suarez-Sarmiento, Jr., MD, MBA is a urologist and Chief Medical Officer of UroFill International, practicing within the Perito Urology and UroFill® Clinic ecosystem in Coral Gables, Florida. He specializes in prosthetic urology, sexual medicine, and men’s hormonal health.