As a therapist, you become comfortable with the uncomfortable and not in the physical ways many of us are used to. To do what we do requires a stretching of emotional and psychological capacity, a push to be more open, present and understanding.

You quickly learn to lean into areas that might give some pause and explore topics that most people shy away from. Over time and after enough exposure, you no longer possess a barometer for the unusual, the taboo and the unexpected.

This is as it should be, as therapy should be the one place you can be carefree and selfish about what you say, believe and feel without fear of reprisal or rejection. It takes time and trust to establish but once it happens, being “in session” is more of a vibe than it is a place.

It was in one of those sessions when a former Special Operator with multiple deployments and all the badges quietly wondered if his lack of motivation for life, low sex drive, and brain fog he was experiencing might be a result of low testosterone.

We both sat in silence for a moment, him out of shame and me out of shock. To be frank, it was something I hadn’t considered.

That was four years and a lifetime ago. Back then, low testosterone and its relation to military service was barely a blip. While it still remains something most clinicians fail to inquire about during intake, it has received more attention in recent years.

Thankfully, the stigma of having low testosterone has begun to wane as better science emerges about its cause. In fact, it seems more people are willing to accept a low-t diagnosis than that of depression or PTSD.

In many ways, this makes sense because low-t is tangible in ways that most psychological disorders are not. Simply, there’s a blood test for it which makes it a physical problem rather than an “emotional one.”

Yet, their manifestations can be remarkably similar, as the overlap of symptoms for depression and low-t include decreased sex drive, a decline in physical energy and stamina, memory problems, and low mood. Moreover, the same professional hazards that make you at risk for low-t can also lead to emotional distress. The result can be a murky clinical picture.

Further complicating the matter is the wide range of what constitutes a normal t level for men usually considered to be between 300 to 1,000 nanograms per deciliter (ng/dL). What may be low for one person may not be for another. The issue is generally more about departure or significant decrease from an individual’s baseline than the number itself.

Though decreases in testosterone are to be expected (it peaks at around age eighteen or nineteen then declines throughout the rest of adulthood), the declination can be impacted or exacerbated by a number of things.

For starters, a recent study showed that men’s baseline testosterone levels are determined by environmental conditions experienced in childhood rather than genetics or race as previously thought. Accordingly, men who grew up in more challenging environments are more likely to have lower testosterone levels than men who grew up in emotionally and physically healthier environments.

This is worth noting because men who enlisted in the military over the last four decades are more than twice as likely as those in the general population to have been sexually abused as children and to have grown up around domestic violence and substance abuse.

Outside of environmental factors or occupational conditions can impact t-levels. A massive one is sleep. Yes, poor or fragmented sleep is associated with reduced testosterone levels. In a study of young men who experienced laboratory-induced restricted sleep, testosterone levels were lower after experiencing sleep restriction and lowered more over time. Read: one night of bad sleep will cause a temporary dip in t-levels, continuous poor sleep will make it worse and possibly permanent without intervention.

This is of particular importance for those in professions that prize themselves on the idea that “sleep is a crutch” or “I’ll sleep when I’m dead.” Sleep is the foundation of physical and psychological health and practicing good sleep hygiene is essential.

In addition, such professions typically require prolonged exposure to high-stress situations which can similarly result in decreased levels of testosterone. Unfortunately, there’s less you can do to mitigate those effects outside of prioritizing sleep, practicing mindfulness and investing in a solid exercise and nutrition plan. Additionally, lay off the alcohol as heavy drinking or regular drinking over long periods cause a decrease of testosterone in men.

Moreover, in the occupational hazard category, head or blast trauma can cause low-t. For those who’ve been banging around the GWOT block for a period of time, traumatic brain injury (TBI) is often cited as one of the hallmark injuries of these conflicts. Studies suggest that head trauma, even the mild ones, may be associated with low testosterone and sexual dysfunction.

Finally, no discussion of low-t would be complete without addressing performance-enhancing drugs (PEDs) aka steroids. The bottom line is unregulated use without completing a proper post cycle therapy runs the risk of impacting t-levels. Full stop.

Low-t is more than the sum of its symptomatic parts, it has serious long-term side effects but so does testosterone therapy, the treatment for low-t. Both, in their own ways, lead to increased risks of cancer and cardiovascular disease.

The bottom line is that too low or too high is bad but getting it just right can be tricky. The difficulty is interpreting the results. Levels do vary over the course of the day and one low test may be meaningless if there are no associated symptoms.

If you’re concerned about your t-levels, have an open and honest conversation with your primary health care provider which can either lead to a blood test or a referral to an endocrinologist. If you’re in therapy, it’s also worth having a discussion with your therapist who, at the very least, can assist with the crafting of a solid sleep hygiene plan and mindfulness. The most important thing you can do is advocate for yourself and arm yourself with information.

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