Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Atul Dhingra  ( Department of Endocrinology, Gangaram Bansal Hospital,Sri Ganganagar )
Rakesh Sahay  ( Department of Endocrinology, Osmania Medical College, Hyderabad, India )
Ashish Sehgal  ( Department of Endocrinology, Cygnus Hospital, Karnal, India. )

Testosterone levels are known to decline with advancing age. However, there are frequent reports of inappropriate social behaviour involving middle-aged men, suggestive of hyperandrogenic state. The andro-accelerator hypothesis seeks to explain this phenomenon. This states that external stimuli, both asexual and sexual in nature, can increase or accelerate testosterone production, by stimulating the hypothalamo-pituitary-testicular axis, and resetting this axis at a higher level. This article discusses the concepts of andro-conditioning due to endocrine disruptor stimuli or endocrine disruptor social content, explores the clinical and public health relevance of the andro-accelerator hypothesis, and calls for a focus on addressing androgen imbalance, achieving “androequanimity”, rather than treating andropause as a disease.

Keywords: ADAM, Andropause, Hypogonadism, Hypergonadism, Sexual offenders, #MeToo, Testosterone.

 

Andropause

 

Numerous observational, cross sectional and longitudinal studies testify to the fact that testosterone levels decline with increasing age in men. So clear cut is this decline that it has been given the name ADAM (androgen deficiency in the ageing male).¹ ADAM, also called andropause or male menopause, is accompanied by a spectrum of physical, psychological and sexual symptoms and signs, all of which reflect androgen deficiency. Sexual drive and libido are mediated by testosterone. Though the difference in mean testosterone levels between subjects with low libido and those without is small, it is significant; there is a 3.4 ng/dl increase in total testosterone per unit increase in libido.²

 

Paradoxical Behaviour in Mid-life

 

There is no consensus as to the relationship between testosterone levels with sexual or aggressive or violent behaviour.^3-6 Such behaviour may include sharing and use of pornographic material, sharing sexually explicit messages through social media and sexually-replete verbal and physical actions. Hypersexual behaviour may range from sexually lewd comments or suggestions, to inappropriate touching and feeling and penetrative sex. Anecdotal reports, unleashed by the #MeToo campaign, highlight the frequency of sexually offensive behavior by men. Published literature reports an upsurge in such behaviour among men aged 40–50 years.⁷ This is surprising, as testosterone should actually begin falling at this age, and result in a lower rate of sexual offences.⁸ The surge in hyperandrogenic behaviour may be a defence mechanism, utilised as a camouflage to hide lack of testosterone. An actual, or perceived, lack of testosterone, or a sudden drop in its concentration, may lead to both physical and psychological symptoms. In a bid to maintain, or improve one’s testosterone and one’s self-esteem, the ageing male may try to demonstrate his ‘masculinity’ by indulging in sexual behaviour. We suggest the term ‘andro-camouflage’ to describe this. A phenomenon similar to that of operant conditioning or Pavlovian conditioning may be seen in sexual offenders.⁹ A particular behaviour will continue to be performed if it has initially elicited a described response. This can be termed andro-conditioning. Abuse of complementary/alternative medicine of unknown composition, taken to prevent or manage symptoms of hypoandrogenism, or endocrine doping, may lead to factitious increase in serum androgen levels. Discontinuation of therapy which is known to reduce serum testosterone, e.g., statins, spironolactone, flutamide, may lead to a rebound in testosterone.^10,11 This too, may present as biochemical hyperandrogenism. However, these aetiologies do not explain the vast majority of hyperandrogenic behavior in middle-aged men.

 

Historical Perspectives

 

Advances in communication, both digital and otherwise, have increased exposure to sexually explicit stimuli. Prior to the development of written language, the only way to access sexual stimuli was person-to-person contact. The development of written language allowed concepts of sexuality to be spread through books.

The first recorded story, the Epic of Gilgamesh, written in Sumerian, details the hero’s attempts to find the elixir of youth, which he hopes to try on an elderly male, to assess its rejuvenative properties.¹² The first known endocrine pharmaceutical or nutraceutical preparation, was also developed for its androgenic potential; Indian history relates that the Ashwin brothers, who were the Raja Vaidyas (royal physicians) created the aphrodisiac chyawanprash, for the elderly sage Chyawan.¹³ This ghee-based medicine rejuvenated Chyawan and helped him lead a happy conjugal life with his young bride.

 

The Andro-Accelerator Hypothesis

 

We propose the andro-accelerator hypothesis to explain the paradoxical increase in sexual behaviour exhibited by some men in midlife. This hypothesis states that “external stimuli, both asexual and sexual in nature, can increase or accelerate androgen or testosterone production, by stimulating the hypothalamo-pituitary-testicular axis, and resetting this axis at a higher level”.

External stimuli can modify testosterone secretion; this is a well-known fact. A positive feedback mechanism or virtuous cycle is set into motion, whereby increased testosterone levels encourage more sexual behaviour, which in turn stimulates the hypothalamus. Initially adaptive in nature, this mechanism helps in achieving and maintaining success in the personal and professional domains. If unchecked however, it may prove maladaptive, as in the case of sexual offenders.

 

Endocrine Disruptor Stimuli

 

Invention of the printing press played a great role in increasing access to written pornography. However, modern inventions such as mass media (television) and internet-based social media have ensured that the modern human being is bombarded with sexual stimuli through multiple manners. Similarly to endocrine disruptor chemicals,¹⁴ we term these as ‘endocrine disruptor stimuli or ‘endocrine disruptor social content’. It is not always the case that every endocrine disruptor chemical will reduce endocrine output: some endocrine disruptor stimuli may create a ‘gain-of-endocrine function’ situation. Repeated exposure to high degrees of sexual content may disrupt the hypothalamo-pituitary-testicular axis, by resetting it at a higher level. The resultant androacceleration may result in sociopathic thoughts, which may convert to socially undesirable behaviour, in susceptible men. It must be noted that ‘normal’ levels of testosterone can have greater than normal effects if selective androgen receptors are hypersensitive to the hormone’s action.⁵ Excessive exposure to pornography may result in paradoxically lower sexual function by altering dopamine action.¹¹

 

Relevance to Health

 

The andro-accelerator hypothesis has great clinical and public health relevance, and especially so in today’s world.

 

Clinical

 

The andro-accelerator hypothesis may be employed to deploy non-pharmacological interventions in the management of hypoandrogenic states such as sexual desire disorder. Person-specific or person-friendly exposure to sexual stimuli may enhance endogenous testosterone production and help achieve desired outcomes such as increase in libido or improvement in sexual function. This is an accepted part of male sexual counselling.¹⁵ Avoidance of such stimuli, on the other hand, may obviate the need for medical or surgical castration in habitual sex offenders.

 

Public health

 

An understanding of the factors which lead to undesirable andro-acceleration may help attenuate their magnitude, and their effect. Government regulations, societal pressure, and personal self-discipline should be utilised to reduce availability of, access and exposure to sexually explicit audio-visual, literary and other stimuli. Sustained and concerted public health education, focusing on correct and incorrect social behaviour, must be carried out.¹⁶ The message and methods of such public awareness campaigns, are similar to those employed for smoking or other substance abuse “Don’t start; do stop”. Avenues for recreation, such as physical exercise, games and sports, must be encouraged to facilitate a healthy lifestyle, and utilise endogenous androgens in production activity. The possible intake of exogenous testosterone or other androgenic preparations, as part of complementary/alternation medicine, or as over-thecounter medication, must be probed and addressed.

 

Andro-Equanimity – The Ideal Goal

 

Simultaneously, a social marketing campaign around the mores and values of masculinity, and the concept of andropause, may be in order. The alpha male phenotype need not be portrayed as being the only desirable male prototype, and andropause need not be disparaged as a disease that must be treated. A balanced and holistic approach towards sexuality, which encourages the male, or rather, the couple, to enjoy the various phases of life, is in order. Rather than andro-acceleration or andropause, the concept of “andro-equanimity”, i.e., stability or acceptance of lower androgen levels, should be encouraged. This will go a long way in improving both individual male, and societal, health.

 

References

 

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