Testosterone Dreams: Sex, doctors, and the male hormone 

Testosterone dreams are the fantasies of hormonal rejuvenation, sexual excitement, and supernormal athletic performances that have been inspired by testosterone drugs since the “male hormone” testosterone was first synthesized in 1935. Shortly after testosterone was produced in a European laboratory, following a competition among three pharmaceutical companies, Time magazine reported that: “German and Swiss chemical laboratories are already prepared … to manufacture from sheep’s wool all the testosterone the world needs to cure homosexuals (and) revitalize old men.” Imaginative interpretations of the power of hormones—a word that was invented in 1905—proliferated for decades even before the eventual synthesis of testosterone. “Attempts have been made to explain even psychic processes such as emotions and states of mind through the increase or diminution or alterations of this or that gland,” as one scientist noted in Endocrinology in 1919. In short, hormonal substances were granted a power to shape personality and produce euphoric states that they have retained to this day.

Over the past seven decades, the growing use of testosterone and its derivatives, the anabolic-androgenic steroids, have demonstrated that many people around the world are interested in using testosterone products for a variety of purposes. These practices run the gamut from legal procedures such as “anti-aging” therapies, which employ these androgenic drugs with synthetic human growth hormone, to the illegal use of anabolic steroids by many bodybuilders, athletes, and some policemen, who view physical strength and aggression as requirements for performing on stage, in the stadium, or on the street. The use of synthetic testosterone as a sexual stimulant is also becoming increasingly common among older people who belong to a generation that increasingly regards sexual fulfillment as a lifelong entitlement.

Sexuality in conservative times
Testosterone became a charismatic drug during the 1940s because it promised sexual stimulation and renewed energy. Physicians described the optimal effect of testosterone drugs as a feeling of “well-being,” a term that has been used many times since the 1940s to characterize their positive effect on mood. In the early 1940s testosterone was hailed in pharmaceutical advertising as a mood-altering drug whose primary purpose was the sexual restoration and reenergizing of aging males. It appeared at that time that an inexpensive supply, widespread demand, and favorable medical opinion would soon produce a major market for testosterone products.

The first public advocate of testosterone therapy for aging men was the popular science journalist Paul de Kruif, whose manifesto The Male Hormone was published with some fanfare in 1945. Excerpted in Reader’s Digest and promoted by a full-page review in Newsweek (“Hormones for He-Men”), The Male Hormone was in some respects a prophetic book. The potential market for a rejuvenating male hormone seemed to be enormous: “How many millions of American males, not the men they used to be, would flock to the physicians and the druggist, a bit shame-faced and surreptitious, maybe, but hopeful, murmuring: ‘Doc, how about some of this new male hormone?’”

Testosterone did not become a mass market drug in the 1940s due to the sexual conservatism of most American physicians and the society they served. The belief that testosterone was a stimulating drug made it a potential threat to sexual morality as well as a promising therapy. Sensational coverage had given the male hormone a quasi-pornographic image that its female counterpart estrogen had never acquired. Commenting on testosterone’s unsavory reputation in 1946, Science Digest reported that “the uninformed continue to believe that the sole use of this innocent chemical is to turn sexual weaklings into wolves, and octogenarians into sexual athletes.”

The 1940s also saw the use of testosterone therapy as an experimental “cure” for homosexuality. The medical view of homosexuality as a type of endocrine deficiency made the use of testosterone propionate to reverse homosexual orientation virtually predictable. As one physician in 1940 put it: “If homosexuality is merely the result of an endocrine disturbance, the prospect for its cure must be excellent today.”

The idea that the bodies of homosexuals contained less male hormone and more female hormone than those of heterosexuals first appeared in 1935. By 1940 a number of investigators were confident enough in their ability to assay hormone levels to claim that homosexuality was rooted in abnormal sex hormone ratios rather than the psychological complexes hypothesized by Freud and others. “It seems,” one research team wrote, “that the constitutional homosexual has a different sex hormone chemistry than the normal male.” The fallacy of this therapeutic rationale became evident soon enough. Testosterone propionate combined with chorionic gonadotropin was not curing homosexuals, even in studies that encouraged belief in the drug and did not compare its effects with those of a placebo. In fact, it was becoming increasingly clear that androgens did not reverse but actually intensified homosexual libido, so that “sometimes instead of helping one gets a worsening of the condition.”

Prescription for women?
Testosterone drugs were also the favored pharmacological technique of the 1940s for treating sexual “frigidity” in women. Testosterone propionate ointment could be applied to the vulva or clitoris to increase genital sensitivity. Testosterone could be injected or pellets implanted under the skin to intensify libido. By 1943 testosterone propionate was reported to be in widespread use to treat women with sexual and other endocrine disorders. In 1947 a team of authors noted that over the previous decade “the effect of androgens in increasing libido in women has been an almost universal observation.” It appeared that androgens influenced libido in three ways, “causing a) a heightened susceptibility to psychic stimulations; b) increased sensitivity of the external genitalia, particularly of the clitoris and c) greater intensity of sexual gratification.” Perhaps the most interesting point about these scientifically primitive observations is that they have been repeatedly confirmed by later investigators.

In recent years the campaign against female “frigidity” has taken on a new form, as pharmaceutical companies have attempted to launch the marketing of synthetic testosterone to a potential population of millions of women supposedly afflicted by a disorder known as “female sexual dysfunction.”

In December 2004 a U.S. Food and Drug Administration (FDA) Advisory Committee for Reproductive Health Drugs refused to recommend Procter & Gamble’s Intrinsa testosterone patch for female sexual dysfunction (FSD) in surgically menopausal women whose ovaries had been removed. The FDA panel found that administering testosterone to these patients would produce an average of one extra sexual encounter a month, a benefit that in the panel’s view did not justify exposing women to the risk of heart attacks and strokes.

This decision surprised executives at both Procter & Gamble and at BioSante Pharmaceuticals, Inc., its principal rival in the race to develop a mass marketed male hormone sex stimulant for women. BioSante had been rooting for P&G’s application because it believed its own testosterone delivery systems—gels, creams, nasal sprays, and pills—would outperform the Intrinsa transdermal testosterone patch as drug delivery vehicles and as products in the marketplace.

The decision to bar the use of sexually therapeutic testosterone in the absence of long term safety studies did not demoralize the leadership at either company. On the contrary, Proctor & Gamble announced that it would eventually resubmit the Intrinsa application once it had carried out studies on naturally menopausal women, a much larger potential market than the estimated 10 million women who have had their ovaries removed. The president and CEO of BioSante, Stephen M. Simes, emphasized the positive by saying that he was “gratified that the panel agreed that FSD is an indication worthy of treatment with testosterone.”

He added that he looked forward to getting “the FDA’s advice on what additional safety data will be required.” Sidney Wolfe, director of Public Citizen’s Health Research Group, had already told the panel that P&G’s skin patches could increase testosterone levels by a factor of four and thereby double the risk of breast cancer. Given the current momentum that is driving public interest in the use of androgenic drugs to boost libido, it is unlikely that this sort of medical caution will prevail against the further expansion of the testosterone market that is targeting the sexual needs of both men and women.

Sciencing sexuality
The current campaign to market testosterone devices such as the Intrinsa patch and LibiGel ointment for the treatment of “female sexual dysfunction” should be examined in its larger historical context. Given the short memory spans of our major media, it is not surprising that the history of this hormone therapy has been absent from virtually all of the coverage it has received. But knowing something about the history of testosterone for women is essential to assessing the potential benefits and hazards that today’s physicians and drug companies claim to understand. What is more, a familiarity with the history of attitudes toward giving male hormones to “frigid” women offers important lessons in how and why we came to evaluate intimate sexual experiences in ostensibly scientific ways.

The more recent context for the promotion of “female sexual dysfunction” as a treatable disorder takes us back to the introduction of Viagra for “erectile dysfunction” (ED) in 1998. The spectacular success of Viagra raised a gender equity issue: If aging men were entitled to a sex drug, then aging women were entitled to nothing less than an equivalent therapy. The subsequent clinical trials that administered Viagra to women proved disappointing, thereby confronting researchers and patients alike with the stubborn (yet also reassuring) fact that female sexual response was more complicated than the essentially hydraulic process that produces an erection. (The fact that male sexual response is also more complex than erectile functioning appears to have been lost on many consumers of the famous blue pills.) The beckoning market for a female sex stimulant prompted doctors and scientists to acknowledge how little they knew about the anatomy of the female sex organs and how these organs reacted to various forms of stimulation. This encounter with the complexity of human sexual response did little, however, to discredit the idea that a pharmacological fix for low libido was waiting to be found.

The topic of female sexual disorders received additional publicity less than a year after the launching of the Viagra boom when an article titled “Sexual Dysfunction in the United States” appeared in the Journal of the American Medical Association (JAMA). This widely publicized study reported that “sexual dysfunctions are highly prevalent in both sexes, ranging from 10% to 52% of men and 25% to 63% of women.” The fact that these authors never mentioned drug therapies for sexual dysfunction, and that they emphasized the importance of “health-related and psychosocial factors,” was not what registered among drug company executives looking for new markets. What did resonate throughout the media was the finding that “ 43% of American women” had sexual problems that needed fixing. It seemed as though American society had suddenly found itself burdened with yet another public health crisis that required a medical solution. But how novel was this diagnosis? And why were women assigned the principal role in a problem that clearly involved an equal number of men?

The idea that women are the principal cause of sexual problems in marriage has been a staple of medical folklore for more than a century. Men were assumed to have a stronger sexual impulse than women. Over the many years the term was in circulation, the medical literature always assigned sexual “frigidity” exclusively to women. The disorder once known as male “impotence,” and that was eventually rechristened “erectile dysfunction,” never carried the same stigma of emotional deficiency and personal inadequacy. Impotence was an unfortunate physiological problem, while “frigidity” signaled a defective personality and a failure to live up to a wife’s marital obligations. Some (male) doctors knew perfectly well that a great deal of the “frigidity” displayed by wives was the direct result of sexually ignorant or indifferent husbands. A 1931 JAMA editorial, for example, argues that most female “frigidity” is caused by the emotional disinterest of husbands who had “obtained their premarital knowledge of the sexual act from intercourse with prostitutes” whose sexual gratification was of no interest to the paying customer.

The medical literature offered various cures for female “frigidity.” During the 1930s and 1940s these included the use of electricity to sensitize the vaginal mucous membrane: “The treatment consists in inserting a large vaginal electrode into the vagina, connecting it with the negative pole, while the positive pole is connected with a wet abdominal electrode, the galvanic current is allowed to pass for about ten minutes. Without disturbing the electrodes, we now give the sinusoidal-galvanic current for another ten minutes. No pain must be caused by the treatment.” Other commentators, as noted, recommended sexual education for the many husbands who appeared to know nothing about female sexual anatomy or psychology. It was during the 1930s that proposals to use hormonal substances to boost female sex drive began to appear with increasing frequency in the medical literature.

By the end of that decade synthetic testosterone propionate and methyltestosterone had become, in effect, experimental drugs that were being used for various (and, in retrospect, usually mistaken) clinical purposes. Megadoses sometimes amounting to thousands of milligrams that were intended to neutralize estrogen-driven breast cancers were one application. One of the unofficial dogmas of this early period was that the male hormone would sexually stimulate men and that estrogens would have a similar effect on women. Androgens were sometimes applied to the penis, while estrogens were applied to the clitoris. The discovery that testosterone sexually stimulated females thus came as a shock to the physicians who observed this effect. A 1941 paper reports the author’s reaction to this phenomenon in both young and old women: “My attention was first drawn to it by several elderly women who found the resurgence of libido distressing. The phenomenon is equally as striking among young women. A number of married women, who had considered themselves frigid, stated that after receiving the testosterone propionate injections they experienced a marked increase in coital gratification, culminating in an orgasm.”

Another physician later recalled the discovery of inadvertent androgenic stimulation of women during this early period in the case of a patient being treated for uterine bleeding: “Her physicians were amazed that testosterone, the so-called male hormone, could accentuate libido in the female to the degree experienced.” Just as significant were the measures taken by these male doctors to keep this newly intensified sexual appetite under control: “When the patient returned for further evaluation, it was decided that, despite the benefit the treatment had had on her uterine bleeding, it would be better to discontinue it in order to reverse her libidinous tendency. Testosterone was discontinued, and therapy with progesterone was instituted. Within a short time her libido decreased markedly.” Such regulation of female libido by male doctors was deeply embedded in the mores of 20th century medicine. At the same time, there was no doubt about the stimulating effect of these androgens: When female patients being treated for gynecological disorders report intensified sex drive, he says, “we have unbiased evidence on the effect of androgens in increasing libido in the female.” Yet the fact is that, over the next half century, the use of testosterone for this purpose fell off the medical agenda and did not reappear until the testosterone boom that began during the mid-1990s.

The promotion of testosterone as a female aphrodisiac was delayed for 50 years because the social conservatism of American physicians and of the society as a whole during the 1940s and 1950s could not accommodate public encouragement of sexual fulfillment as a therapeutic goal for all adults. It is seldom noted that the work of the pioneering sexologists of the first half of the 20th century, including that of the controversial Alfred Kinsey, was intended to save marriages that were imperiled by sexual frustration.

Over the half century that followed these successful experiments, the discussion in the medical literature of androgens for sexual stimulation fell off sharply. Androgen therapy for “frigidity,” one author writes in 1962, “is usually of little or no avail.” “There is no treatment for frigidity as such,” a (female) British doctor writes in 1967. “A good meal, a bottle of wine, and a good film of her choice, are often excellent aphrodisiacs,” says a South African physician who, writing in 1976, mentions not a word about androgens. A 1978 report in the British Journal of Psychiatry offers androgens a qualified role in sex therapy, but a 1989 report in the British Journal of Clinical Psychology concludes that “testosterone has very limited value and offers no obvious advantage when combined with sexual counseling.”

The socially sanctioned return of testosterone for women has occurred in the context of the growing acceptance of hormone replacement as an “anti-aging” therapy for that segment of the adult population that is willing to pay for it and accept the risks of what amounts to an uncontrolled experiment. The lifestyle demands of the aging Baby Boomer generation include a presumed entitlement to lifelong sexual fulfillment. In the absence of cultural restraints that might oppose this ambition, testosterone therapy for “female sexual dysfunction”—a questionable diagnostic category at best—awaits only that crucial meeting between the drug companies and the FDA that will put to rest the medical safety issue once and for all.

John Hoberman’s most recent book is Testosterone Dreams: Rejuvenation, Aphrodisia, Doping (University of California Press, 2005). He is Professor and Chair of Germanic Studies at the University of Texas at Austin.