Wednesday, November 11, 2026

Stoner – A Personal Review

 



Several months ago, I read a review of the 1965 Pulitzer Prize winning novel – Stoner by John Williams.  The plot was described as life story of a man who goes from farm life to college to get an agricultural degree but gets sidetracked and ends up being a college English professor instead.  That seemed very similar to what happened to me so I was interested in two things – were there any parallels – psychological or otherwise and were there any examples of stream of consciousness prose?  Stream of consciousness is one of my literary and psychiatric interests.  I was not disappointed. 

For comparison, I went to college because I had a football scholarship. I did not apply to several colleges – I only went to one because of the scholarship and my vague goals of teaching physical education and possibly coaching.  I developed a serious case of appendicitis and sepsis so football was not a possibility. A series of events followed that involved many of the faculty of that college that resulted in me graduating as a chemistry biology major and eventually going on to medical school.  None of that was planned by me and in retrospect it seems like I was swept along by the enthusiasm and concerns of my professors.  I don’t think that would have been possible at any other place than the small liberal arts college that I attended. I know several others who had similar experiences there and went on to highly successful professional careers. Ironically, when our small college closed two years ago, it left behind a tragic void—all the unrealized potential of the students who will never get to attend.

William Stoner was born as an only child and raised on a farm in late 19th century Missouri.  As the story begins, we hear about the rigors of farm life and the stoic approach taken in his family of origin. His father talks with him about a new agriculture degree available at the College of Agriculture at the University of Missouri in Columbia.  He explains the crop yields are low and more scientific methods may improve the yield and sustainability of their farm.  Stoner accepts his father’s suggestion and arrangements to live on his mother’s cousins farm where he can work for room and board while paying for tuition. He expects to complete his degree and return to the farm.

From the outset he is described as tall, thin, awkward, and having a stooped posture from all of the hard physical labor on the farm. Williams describes him as an unremarkable and not memorable man.  His physical labor is only slightly diminished with his initial living arrangements.  His first year in school was routine.  In the second year he had a life changing event. 

He was taking a required survey of English literature from Prof. Archer Sloan.  Sloan was described as being disliked by most of his students because of his detached teaching style as if he knew he was unable to convey all that he knew about literature to the students.  Stoner notices he was getting frequent images of Sloan and his speech patterns away from the classroom and engaged in other activities.  He had initial difficulty with the class.  One day in class Sloan asks about Shakespeare’s Seventy-Third Sonnet – specifically what does it mean?  He calls on two students and after giving an elaborate introduction of the poem calls on Stoner.  Stoner is unable to answer and the class is dismissed.  With no explanation we learn in the next semester that he dropped his science courses and added history, philosophy, and English literature.  The process suggested to me that he identified with Prof. Sloan at some level. 

The next two years he was immersed in study and experienced a change in his experience of reality. In his fourth year, he has a more cordial meeting with Sloan who asks him about his plans and then announces that he is going to be a teacher. They outline a plan to get him on a path to his master’s degree and then his PhD. At this critical point, Sloan possesses a clearer vision of Stoner's path than Stoner himself does.  When Stoner asks for clarification of his certainty, Sloan replies “You are in love, it’s as simple as that.” Referring to Stoner’s love of the subject material.

All of this happens in the first chapter that ends with Stoner explaining to his parents that he will not be returning home after graduation.  They are shocked but deal with it in the expected quiet desperation of deeply disappointed parents who never express much emotion. Williams describes these scenes perfectly in third person narrative.     

The next chapters follow the course of Stoner’s life and relationships.  His erratic marriage to Edith and his personal relationship to their daughter Grace.  Edith is described as a thin attractive women shaped by her privileged upbringing to expect that she will be taken care of.  She has no interest in academics and her attachment to Stoner fluctuates significantly over the course of the book. At times Stoner had to care for the home and their young daughter when Edith was withdrawn and isolated.  They eventually come to an equilibrium where she is concerned but at a considerable distance. 

He has two close friends that are described more as acquaintances.  One of them eventually becomes a Dean at the University and offers him some cover from the department head who is his arch enemy and would fire him if possible. There is an affair with a younger instructor that eventually leads to scrutiny and pressure that causes her to leave and move to another college. The effects of two world wars and various health crises are described.  One of his two friends is killed in WWII almost immediately. As time passes, Stoner is becoming more of an academic and a better teacher.

Stoner’s relationship to his daughter Grace becomes a central part of the book. During the time when he is caring for the home while Edith is isolated and seemingly ill, he is also responsible for taking care of Grace.  He alters his work and preparation schedule so that he can do more of it at home and watches her at the same time. He sets up his study to accommodate her and she draws while he is working on his courses. Edith eventually takes a more active role in Grace’s life, bans her from Stoner’s study and fills her schedule with social activities.  She becomes a frail and anxious person like Edith, hardly talking with Stoner.  She ultimately becomes a more tragic figure after losing her husband in the war.  She returns home to visit him at one point and although she has developed a problem with alcohol – Stoner thinks he is glad that she has alcohol to comfort herself.

The main characters outside the family in this novel include Katherine Driscoll – a young instructor in Stoner’s department and Hollis Lomax the head of the department.  We see Lomax become Stoner’s arch nemesis early in the plot when they disagree on the promotion of a graduate student.  During an oral examination, Stoner demonstrates that the student lacks the basic knowledge base to continue in the graduate program but Lomax disagrees.  After Stoner refuses to compromise, Lomax increases his teaching burden of lower-level courses, refuses to promote him even though Stoner has tenure and is a well-liked and productive teacher.  The conflict becomes more heated when the affair between Stoner and Katherine Driscoll becomes widely known and Lomax threatens to fire her. Both Lomax and Stoner are communicating through surrogates at that point.

Katherine Driscoll and Stoner have an intense intimate relationship. Stoner is fulfilled by the relationship and it causes his to examine his thoughts about love over the course of his lifetime.  When the relationship becomes more known – it leads to the inevitable ultimatum from Lomax and societal pressure to end it.  In Katherine Driscoll’s interest she decides to move to another school and is eventually successful there and published a book that Stoner reads.  He notices that it is dedicated anonymously to him.

I will not discuss the ending except to say that it continues the main themes of the book.  Many reviewers suggest this book is about an average man living an average life.  They suggest it is a celebration of that averageness.  I see it somewhat differently.  Just living anywhere requires a tremendous sustained effort.  Many force that thought out of their awareness every day as they go to work and either do a job they do not like or as in Stoner’s case – work a job they like but suffer because their manager is not a reasonable person.  In those cases, most people do not rebel and lash out but put their shoulder to the wheel and keep pushing ahead no matter what.  Stoner’s life was permanently altered by his love of literature.  He becomes a devoted teacher protecting the integrity of his discipline.  When pressured he retreats into this work with stoic discipline and dedication.

I had the random thought last week that nearly all of the professors who taught me in college and medical school are dead.  They were all dedicated scholars but none of them were famous.  I was profoundly saddened by that thought. All of that work and dedication – to be celebrated by a few grateful students in relative anonymity. Getting back to the questions posed at the outset of this post – yes - I think this story reflects some of my experience in college and how it changed my life.  And – yes - there is some stream-of-consciousness writing – but not much. Williams writes a precise and almost perfect third person narrative about William Stoner.  He describes an episode of delirium near the end of the book that is very good and relies on elements of stream of consciousness.  The Shakespeare Sonnet epiphany in class that changed Stoner’s life trajectory was another brief example:

“…He looked away from Sloane about the room. Light slanted from the windows and settled upon the faces of his fellow students, so that the illumination seemed to come from within them and go out against a dimness; a student blinked, and a thin shadow fell upon a cheek whose down had caught the sunlight. Stoner became aware that his fingers were unclenching their hard grip on his desk-top. He turned his hands about under his gaze, marveling at their brownness, at the intricate way the nails fit into his blunt finger-ends; he thought he could feel the blood flowing invisibly through the tiny veins and arteries, throbbing delicately and precariously from his fingertips through his body.” (p. 13)

Many critics write about Stoner as an existentialist novel.  Whenever I think of existentialism I reflect on Yalom’s dimensions of death anxiety, freedom, isolation, and meaninglessness. Those themes apply not only to Stoner but several other characters in the plot line.   In Stoner’s case his isolation within his own marriage is an extension of the emotional isolation he had growing up with distant parents.  He carves out an existence within his home as Edith isolates herself and removes Grace from his influence.  Although Stoner seems to live a life of tolerance and passive acceptance of his predicament – his life trajectory is altered by radical freedom of choice when he chooses to abandon farm life in favor of academia, refuses to pass an incompetent student over his department head’s strong objection, and elects to end his affair with Katherine Driscoll rather than ruin her career.  Although more implicit at no point did, he consider divorcing his emotionally estranged wife. 

In terms of meaningfulness, Stoner treats scholarship and teaching as an intrinsic good and an organizing factor in his life. He recognizes that his contributions to his field are modest.  His only book was a monograph from his doctoral thesis that was not widely read and did not bring him any fame.  In the final analysis, it was proof he had lived a life faithful to his goal of scholarship. 

Stoner’s sophomore epiphany can also be seen in psychodynamic terms.  Identification occurs when an individual unconsciously adopts the traits, values, or posture of an admired figure, incorporating them into their own ego ideal.  He does not want to just learn from Stone – he wants to be like him.  He introjects Sloan’s love of literature, institutionalized approach to university life, and self-discipline.  Any identification with his father and farm life are gone at that point.  In this type of identification, it does not stop with introjection it also requires generativity consistent with the identification and Stoner does that throughout his teaching career.

In reading a book like Stoner, it may be temping to think “I am Stoner.” Or “We are all Stoner” because of some of the common elements.  As I mentioned at the outset, my trajectory was very similar to Stoner and as an old man who teaches psychodynamics – I have attributed it to identifying with many of my undergraduate and medical school professors.  In most of those cases I worked with them intensely for 3 or 4 months and never saw them again.  The identification in my case opened up a world of possibilities that I could not have imagined.  But Williams’ novel points out all of the nuances in a life beyond what you do or do not imagine for yourself and who you identify with.  The interactions between Stoner and all of the important people in his life – especially the emotional tone cannot be predicted and there are rarely any good resolutions. There are too many permutations of what can happen in any life to say you would probably react like Stoner.  In the end, Stoner achieves hard-won satisfaction with his life despite multiple failures because he can claim it as his own.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Even though I did not come right out and say it – I highly recommend this book.  Reading it is without a doubt more enjoyable than reading my obsessive review.  I have not encountered a novel written like this before and it is very unique.  All of Stoner’s 60+ years are packed into 278 pages and Williams keeps it moving right along.  The description of characters who are emotionally unexpressive or unpredictable expressive is first rate.  Anyone involved in academic or medical administration politics will relate immediately to the type of conflict Stoner has with his department head.

Supplementary 2:   Physicians may find this novel particularly interesting.  Stoner’s monastic academic career resembles the career of most physicians. Lifelong study without acclaim and the only reward being the knowledge that you are doing an adequate job.  The field has to be approached with the same level of integrity that Stoner approaches English literature.  The impact on the family is high even though in Stoner’s case – his wife had a large role in that.     

 

 

 

Sunday, November 8, 2026

A Thought On the 2026 Midterm Elections

 


I am not going to obsess over the details. There are plenty polls, pundits, and demographics out there for anyone interested. The election was clearly a mandate against an authoritarian Trump style government. I know the Vice President has come out and said it was due to the war against Iran (is it a war now?) – but it is far deeper than that. It is also far deeper than politics as usual.

The wake-up call for all Americans is that we do not have a perfect democracy.  Historians are all well aware of that and know that what happened in 1776 is not the way the current government should be run because it ignores what happened in 1863.  The so-called Founding Fathers had documents that outlined a rough sketch of the Republic in theory but it took another 100-200 years to approach the theory that “all men are created equal.”  Like most people my age – I lived through overt racism even in areas where there were only white people.

Apart from the appeal to history, the other requirements are that everyone involved stay law abiding and cooperative, and live in the real world.  The first two years of the Trump government saw unprecedented levels of corruption in the form of quid pro quo pardons of convicted financial criminals, mass pardons of insurrectionists including those involved in injuring police officers, self-enrichment of the President and his family in situations where they were supposed to be representing the interests of the American people, and failure to investigate or prosecute masked federal agents who shot and killed two Minnesotans.  These incidents just scratch the surface.  At the same time, the complete report by Special Prosecutor Jack Smith and most of the files related to the Epstein scandal were suppressed.  

To a psychiatrist all of this can be regarded as sociopathic behavior.  By that I mean, any person or group who has the ability to take what they want from you or force you what to do what they want in spite of your preferences.  That can range from somebody pointing a gun at you in an alley to take your money to someone getting access to your bank accounts on the Internet without your knowledge.  The power exerted over you can be overt or covert, but the common factor is the person exercising that power is not bothered by what they are doing.  When asked about it they may suggest their victim was “just in the wrong place”, “should have known better” or they did something to “deserve it.”  There is no conscience, moral code, or accountability.

In modern society, there is nuance in the form of conflict of interest.  Conflict of interest laws and policies were developed to prevent the silent exploitation made possible by elected and public positions.  These polices exist and are codified in the federal government.  We have just seen an administration that chose to completely ignore them as well as the Emoluments Clause in the Constitution. It can be argued that this was facilitated by a pro-Trump Supreme Court.  The message to Congress is that the law in this area needs to be tightened up.  The Republic can no longer depend that an elected President will avoid what are potential massive conflicts of interest and the associated compromises.  Although historical precedent worked until Trump, there can be no doubt that the President is focused on the interests of the Republic.  There is already a move to apply a no stock trading rule to Congress and the same considerations apply there. 

The level of corruption was a top issue for voters in this election after it was apparently ignored for the first two years of the Trump presidency. There was a long list of issues ignored where Trump supporters apparently gave him and his version of the Republican party a complete pass.  To name a few others – incompetent cabinet choices, a complete lack of decorum when it came to Presidential behavior, alienating most of our allies and trading partners, destroying American competitiveness by shutting down scientific research and turning space research over to private industry, killing, detaining, and deporting US citizens without an investigation, turning public health over to a health and wellness influencer with no expertise in public health, withholding funds from American universities based on political biases, attempting to interfere with state midterm elections at least 30 times, defunding the largest insurer of maternal, substance use, and mental health treatment in the US; defaming top America scientists and other distinguished members of the civil service, firing 10-12% of the civilian civil service without cause; weakening the US military by arbitrarily removing staff at the highest levels of command for political reasons and then proceeding to demonstrate that the US could not win a war against Iran or keep the Strait of Hormuz open.   That is just a partial list of what comes to my mind as I type the essay.  When it comes to specifics – the list gets much longer.    

In the post-election spectacle so far, I have seen the following themes: What does it mean for the Democrats?  What does it mean for the Republicans?  What does it mean for the Supreme Court?  What does it mean for the stock market?  The Vice President is blaming the loss on the War in Iran, etc.

None of the analyses looks at the real problem and that is - American voters.  The voters typically get a pass by just saying: “It is a free country and I get to vote for whoever I want.”  That is true – but why would you not want to avoid the misery and national embarrassment of the last 2 years?  How can Americans be so blind that they elected a President like Trump in the first place?  That is the only critical question that needs to be asked and here is why.  We cannot afford to be fooled twice.  In fact, we are not out of the woods yet – we might not even be able to be fooled once.  Trump is still President for 2 more years and if the dynamics are still in place that elected him – the Republic is not out of danger. 

The first crucial observation is that many people are not able to see reality as it exists.  Based on facts alone, Trump was the worst possible candidate for the Republican party. His only positive resume point was his reality TV show, apart from that he had multiple real-life business failures, a history of not treating contractors and employees poorly, criminal convictions, civil lawsuits, charges of racism and misogyny, and charges of sexual abuse.  He made public statements that would have immediately disqualified any other candidate.  For many entry level jobs, he would not have passed the background check.  Despite all of these factors, tens of millions voted for him on the premise that he was going to “drain the swamp (of corruption)”, restore jobs that were being lost to modernization, lower taxes, and avoid wars.  That disconnect should have been the first clue.

Even though Trump brags about his ostentatious lifestyle and seeks to names buildings and institutions that he encounters after himself - working class voters suddenly believed he was going to help them.  Why would anyone believe him as opposed to anyone else with that background?     

Much has been made of Trump’s charisma. The type of charisma he has is often overlooked.   Real charisma is affiliative and pro-social.  It is optimistic, hopeful, and genuinely interested in inclusion and one’s fellow man.  Empathy is present and used to support the emotional states and well being of others.  Any displays of anger are directed at tasks and unfairness.  People like to be around charismatic people.

Dark charisma is pseudo affiliative with rapid shifts to non-affiliative distancing if there is disagreement or criticism.  Positive emotions are largely performative. Any observation of a Trump rally shows him pandering to and entertaining his audiences who seem to regard him as a benign and somewhat humorous older relative. There is the predictable progression to name-calling and personal attacks on individuals, discussion of non-existent conspiracies (Deep State, election fraud), false promises and more general prevarication.  The crowd keeps chuckling no matter how dark he gets. 

Papers have been written about this dark personality style and the elements (psychopathy, Machiavellianism, narcissism, etc) – but like the application of all psychiatric concepts to Trump it is not necessary.  A psychiatric diagnosis or formulation is not necessary to notice the disconnect of a constellation of behaviors from reality or their historical precedents. 

The second clue or disconnect is how much of what he says is factually incorrect or plainly rhetorical. The rhetorical statements often violate social norms.  The third clue is how much is just self-aggrandizement like unsubstantiated claims that everything he does is “the best” and that he is generally superior in every way.  Expect no apologies or acknowledgements that mistakes were ever made.  He has to come across as the strong man no matter what has happened. If he feels slighted in any way – he is on the attack with lawsuits, investigations, law enforcement, and the military.

For observers who do not identify with the behaviors – these rallies are bizarre – like newsreels from the 1940s.  They appear to be from another era.  People have not seen Presidents act like this at any point in their memory.  Since Trump never talks about policy or a clear vision for where the country is headed and what the hope is for the future - watching him perform is profoundly alienating.  How can this guy really be President of the United States?  What does it say about this country?

Historical comparisons were just beginning at the time of this post. There are the comparisons to Nixon and the Watergate scandal.  That resulted in the same mandate for Democrats after Nixon resigned in 1974.  Of course, that was at a time when Gerald Ford was blamed for pardoning Nixon.  In the current era, Trump pardoned all of the January 6 insurrectionists including those accused of violent crimes along with 70 financial criminals while excusing their restitution payments of $1.5B.  Many of those pardons appear to be in exchange for significant payments or donations.  As the linked article points out – Trump has made corruption the rule rather than the exception. At the same time Trump and made Minnesota a target of fraud allegations while ignoring the fact that the state has some of the lowest fraud statistics in the country.  

There is a more accurate historical precedent for the Trump strategies that reaches back to the 1950s.  The table that follows provides a direct comparison of tactics used by Trump to those used by Senator Joseph McCarthy.  The conventional wisdom of McCarthyism today is influenced primarily by Hollywood portrayals of the effect on the entertainment industry.   McCarthyism is synonymous with unsubstantiated claims and attacks on people for alleged communist activity by using a number of political, social, and legal tactics. McCarthy was a US Senator from Wisconsin from 1947 to 1957 but in 1950 he gave a speech saying the US State Department had been infiltrated by communists.  The Army McCarthy hearings in 1954 resulted in discrediting both McCarthy and his attorney Roy Cohn, effectively ending the attacks and investigations.  Roy Cohn is a direct line to Donald Trump who taught him these techniques when he was his attorney.     


Tactic / Dimension Joseph McCarthy And The Second Red Scare (1940s–1950s) Donald Trump And Administration Tactics
1. Unsubstantiated And Sweeping Accusations
  • Claimed to hold lists of "known Communists" within the U.S. State Department with constantly shifting numbers.
  • Relied on dramatic press conferences right before print deadlines to make unverified charges of subversion and treason.
  • Regularly alleges broad, unevidenced conspiracies (e.g., claiming the "Deep State," "weaponized DOJ," or "rigged" systems actively target him and his allies).
  • Employs high-profile social media statements and rally speeches to make sweeping allegations of treason or corruption against critics before formal evidence or investigation.
2. Presumption of Guilt And Erosion of Due Process
  • Applied "guilt by association"—labeling individuals subversives simply for attending progressive events or reading certain literature.
  • Framed invoking the 5th Amendment as an implicit admission of treason ("Fifth Amendment Communists").
  • Frequently pressures law enforcement and investigative bodies to open probes into political opponents regardless of formal evidence.
  • Asserts that federal investigations targeting his actions or inner circle are inherently corrupt "witch hunts" while demanding immediate legal action against political rivals.
3. Blacklisting and Institutional Ruin
  • Stripped security clearances and enforced job terminations across government, academia, and entertainment (the Hollywood Blacklist).
  • Required compulsory loyalty oaths for teachers, civil servants, and university professors as a condition of employment.
  • Revoked or threatened top-secret security clearances for former intelligence officials, military leaders, and civil servants who criticized White House policy.
  • Weaponized executive orders, tax-exempt status threats, and funding cuts against university administrations, non-profits, media groups, and law firms that permit critical viewpoints or protests.
4. Bureaucratic Investigation and Informing
  • Staged televised Congressional hearings (via HUAC and Senate committees) designed to publicly humiliate, intimidate, and interrogate targets.
  • Coerced individuals into naming friends and colleagues to prove their own political loyalty.
  • Utilizes executive oversight bodies, presidential commissions, and partisan congressional investigations to subpoena, publicly rebuke, and pressure critics.
  • Imposes strict loyalty tests across federal agencies (e.g., Schedule F civil service reclassification) to fire non-partisan bureaucrats and replace them with loyalists.
5. Exploitation of National Fear And Moral Panic
  • Capitalized on Cold War anxieties—such as the Soviet nuclear threat, the Fall of China, and the Korean War—to frame all left-leaning political dissent as an existential threat to the nation.
  • Capitalizes on border security concerns, cultural polarization, and economic fears—framing political opponents, protestors, and mainstream media outlets as "enemies of the people" or threats to national survival.
6. Negative Effects on Science and Public Health
  • Purging Top Scientists: Revoked security clearances and denied passports to world-class scientists (e.g., J. Robert Oppenheimer, Linus Pauling) over political views, delaying critical research like the structure of DNA.
  • Depoliticizing and Halting Health Initiatives: Targeted progressive medical groups (e.g., Association of Internes and Medical Students), effectively crushing early advocacy for universal health coverage and community medicine.
  • Institutional Censorship: Forced researchers and universities to abandon socially oriented public health studies in favor of "safe," non-controversial defense projects to retain federal funding.
  • Institutional Purges & Ideological Oversight: Replaced career agency leadership, installed political appointees over scientific advisory boards (e.g., CDC, FDA), and terminated or reclassified thousands of career scientists.
  • Suppression & Censorship of Public Health Data: Altered or delayed official scientific reports (such as CDC morbidity reports), purged federal health databases, and restricted communications on vaccines, disease modeling, and environmental health.
  • Defunding Targeted Research: Suspended or cancelled federal grants for long-term clinical trials, public health programs, and international scientific collaborations deemed politically objectionable.


One of the more interesting aspects of the above comparison is how McCarthyism was much more far-reaching than the entertainment industry.  Medicine, science, and public health were all affected in service of the false narrative that communists were everywhere.  As a chemistry major – I had no idea that Linus Pauling was refused a passport to the UK by this group because of his pacifist activity during this era.  That resulted in him not having access to high resolution x-ray diffraction photos that led Watson and Crick to determine the double-helical structure of DNA.  At the time Pauling had a competing triple-helix model.  J. Robert Oppenheimer who oversaw the development of the first US nuclear weapons was affected as well as medical research.  The parallels between these political initiatives are more than coincidence. 

The bottom line for me is that we may have avoided an ongoing nightmare.  The assumptions of 10 generations of Americans that we have an inherently stable system of government that has the interests of all of us in mind has been proven wrong by the Trump government. At one time or another we have all seen the paraphrase: “...democracy is the worst form of Government except for all those other forms that have been tried from time to time.”  We may have seen a glimmer of that with the judicial branch in holding the line against Trump’s voter interference and malicious and politically motivated prosecutions.  Beyond that there is a good reason why the average American has been anxious over Trump’s attacks on just about everyone including allies while taking a benign approach with dictators and autocrats.     

The Trump supporters don’t get a pass.  I don’t care if they were average voters, members of Congress, or working for right wing media companies.  They were the proximate cause of this near catastrophe.  They have to work a lot harder the next time and as I tried to point out in this post – you don’t have to be a psychiatrist to figure it out.  You don’t have to use psychiatric diagnoses or jargon to figure it out. You just have to look at what does not make sense.  

All of the clues are right out there in the open.  You have to figure out why you are ignoring them.

 

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Single issue voters. Immediately after the election results came in I started to see posts about abortion and how abortion supporters were evil.  I expect there will be similar posts about guns, climate change, and foreign policy.  If you think a national election should be determined by these issues especially the extremist positions – you are just plain wrong.  The MAGA defeat is proof of that.  Clearly, they got all of the anti-abortion, pro-gun, and anti-climate change vote and that was not nearly enough.  I heard several voters interviewed that they did not like how some state anti-abortion laws made them accomplices if they failed to report any abortions, they knew about or assisted women seeking abortions.  Single issue votes will not save the economy, keep us out of unnecessary wars, or improve the security of Americans against cyberattacks from other countries. I would argue that the current administration is clear proof of that.  

Supplementary 2:  Even though I have an interest in rhetoric and have many posts here that seek to simplify it – I avoided it for the most part in this post.  I will add at this point that the three most common rhetorical devices used by this administration are fomenting anger leading to emotional reasoning, misdirection, and false equivalencies.  I can produce many examples of each upon request. You can also see them satirized on the Comedy Channel and that might be easier to digest.  

Supplementary 3:  In the post election analysis, the number of clips I saw with Republicans claiming that communism, socialism, and Sharia law were on the ballot were striking.  Of course none of those statements are remotely true and yet they were some of the most vehement claims. Those claims are right out of the McCarthy-Cohn playbook from the 1950s.  


Graphics Credit:  US Capitol by Martin Falbisoner, CC BY-SA 3.0, via Wikimedia Commons



Monday, November 2, 2026

Testosterone Replacement Therapy Takes More Than A Blood Test...

 


Organization (Year)

Testing Requirement

Diagnostic Threshold and Notes

Endocrine Society (2018)

Fasting total testosterone measured on 2 separate mornings, both unequivocally low, plus consistent symptoms or signs

Lower limit 264 ng/dL (CDC-standardized assays). Measure free testosterone if SHBG may be altered (obesity, diabetes) or total testosterone is borderline

American Urological Association (2018)

Total testosterone measured on 2 separate early mornings, both low (Strong Recommendation, Grade A)

Consistently <300 ng/dL. Ideally the same lab and method for both samples

Society for Endocrinology and Association for Clinical Biochemistry and Laboratory Medicine, UK (2024)

Total testosterone measured on 2 consecutive fasting mornings, both low

Action threshold <8 nmol/L (~230 ng/dL). 8–12 nmol/L is a gray zone that needs careful clinical correlation

References:

 

1:  Sargis RM, Davis AM. Evaluation and Treatment of Male Hypogonadism. JAMA. 2018;319(13):1375–1376. doi:10.1001/jama.2018.3182

2:  Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, Snyder PJ, Swerdloff RS, Wu FC, Yialamas MA. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018 May 1;103(5):1715-1744. doi: 10.1210/jc.2018-00229. PMID: 29562364.

3:  Mulhall JP, Trost LW, Brannigan RE, Kurtz EG, Redmon JB, Chiles KA, Lightner DJ, Miner MM, Murad MH,       Nelson CJ, Platz EA, Ramanathan LV, Lewis RW. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018 Aug;200(2):423-432. doi: 10.1016/j.juro.2018.03.115. Epub 2018 Mar 28. PMID: 29601923.

4:  Zucker IJ, Masterson TA. Comparison of American Urological Association and Endocrine Society guidelines on testosterone replacement. Int J Impot Res. 2022 Nov;34(7):626-629. doi: 10.1038/s41443-021-00477-w. Epub 2021 Oct 18. PMID: 34663926.

5:  Jayasena CN, de Silva NL, O'Reilly MW, MacKenzie F, Marrington R, Jones H, Livingston M, Downie P, Hackett G, Ramachandran S, Tomlinson J, David J, Boot C, Patel M, Tarling J, Wu F, Quinton R. Standardising the biochemical confirmation of adult male hypogonadism: A joint position statement by the Society for Endocrinology and Association of Clinical Biochemistry and Laboratory Medicine. Clin Endocrinol (Oxf). 2024 Nov;101(5):531-534. doi: 10.1111/cen.14929. Epub 2023 Jul 1. PMID: 37393195.  (UK)

6:  Grossmann M, Jayasena CN, Anawalt BD. Approach to the Patient: The Evaluation and Management of Men ≥50 Years With Low Serum Testosterone Concentration. J Clin Endocrinol Metab. 2023 Aug 18;108(9):e871-e884. doi: 10.1210/clinem/dgad180. PMID: 36995891; PMCID: PMC10438885.

 

We are living in the age of testosterone – for the second or third time.  Some are taking it to caricature levels. I started writing about it on this blog 13 years ago – as a form of cheating in sports and health and wellness hype.  I have written about a study that carefully screened men for hypogonadism and demonstrated moderate benefit on sexual functioning and some benefit with mood and depressive symptoms but no effect on physical functioning or vitality.  Since then, testosterone prescribing has continued unabated and expanded with the growth of telemedicine and advertising to the target audience. As a psychiatrist working during that time, I saw men who were clearly taking supraphysiological doses of testosterone for the anabolic effects.  I did not have to speculate about that use when I saw men with obvious muscular hypertrophy who told me they were taking testosterone because they liked the interpersonal effects when people noticed they had muscle. 

 

The major guidelines for testosterone replacement therapy are produced in the above table. The indication for replacement is hypogonadism by clinical evaluation and laboratory determination.  The laboratory guidelines vary slightly between organizations but they are generally consistent.  The current guideline in UpToDate uses a determination of two morning determinations of testosterone and a diagnosis of hypogonadism that considers the many causes of primary and secondary hyopgonadism.  The indications for therapy are more concrete than many medications that are purportedly overprescribed.  Cultural factors are more prominent than ever with the current administration mandating testosterone screening (2) for active and reserve military to optimize human performance and address Operator Syndrome.  Interestingly the Operator Syndrome is a collection of physical and psychological injuries – some of which may have been pre-existing conditions.  The endocrine aspect of this syndrome is secondary hypogonadism from blast injuries.  There is a significant differential diagnosis of both secondary and primary hypogonadism that include functional etiologies like acute and chronic illnesses, malnutrition, other endocrinopathies, various drugs, infections, and various toxins. The  value of including this as a feature of a non-specific syndrome seems questionable to me.  The best approach to this problem is a comprehensive assessment by an endocrinologist – not a testosterone level. 

 

What about the mass screening aspects?  The pie diagram is from the EMAS study (4) of 3,369 men ages 40-79.  The interesting finding is that only 2% of that population has symptomatic hypogonadism that would be treated with testosterone.  5% had low testosterone that normalized on repeat.  10% had persistently low testosterone but no symptoms of hypogonadism. 83% had normal testosterone on the first test.            

 

 

After the DOD release, Hennigar, et al did a retrospective study of pre-existing health data on military personnel with a focus on testosterone (5).  The analysis was based on a sample of 479 men with an average age 29.9 years.  Weighted mean morning total testosterone, sex hormone–binding globulin, and free testosterone concentrations were determined.  Using 2 cutoff levels of <300 ng/dL and < 264 ng/dL – weighted prevalences of the sample were calculated for < 30 yrs old and ≥ 30 yrs old.  A separate non-obese group was estimated using the 264 ng/dL cutoff.  Extrapolating those prevalence figures to the active-duty US Army personnel gives a range of 57,788 to 100,691 service men.  Using the EMAS study estimate for symptomatic hypogonadism that number is 7,862.

 

The authors of this study qualify their results by saying that this is only one morning fasting testosterone level. 30% of the low levels are expected to normalize on repeat, but that would still leave about 20% of this sample in the low range. The sample was not screened for specific symptoms of low testosterone or moderate to severe head injury that has been associated with blast injuries and post-traumatic hypopituitarism (7).  Obesity and body composition contributes and they note the normal weight cohort has a lower prevalence of low testosterone.  The stress of some military conditions can also suppress testosterone.  Army Ranger training can reversibly suppress testosterone levels by 50% (8).  That is attributed to energy deficit, sleep restriction, heavy physical work, and psychological stress effects on gonadotropin-releasing hormone and luteinizing hormone pulsatility.  This is a critical observation that appears to be omitted from both the formulation of Operator Syndrome and the rationale for screening.  Treatment in this case would be removal from the stressful military conditions rather than testosterone replacement.  It would also seem to be a factor in determining the optimal time and status for diagnosing post-traumatic hypopituitarism.

 

All the factors mentioned so far suggest that testosterone is over prescribed in the US population. Since the US has no comprehensive pharmacosurveillance indirect estimates are made using other samples. In 2013 an estimated 2.3M men were using testosterone.  That dropped to about 1.15M men after an FDA warning about cardiovascular effects (9). From 2018-2022 the number of men being treated increased 27% from 1.22M to 1.66M.  The data in that study was from 25 state prescription data monitoring programs (PDMPs).  Remaining states were prohibited from sharing that information and the authors suggest that more populous states need to be included (10).      

 

The current population of men between the ages of 40 and 79 is estimated to be about 72 million and they make up 21.5% of the total population. Using the EMAS estimate for true hypogonadism (low total and free testosterone and 3 sexual symptoms of 2.1% yields a total of 1.53M men with true hypogonadism.  That number is lower than the estimate of 1.66M  from 25 states (10).  In that study the fastest growing testosterone use groups were 35–44 (+58%) and 45–54 (+35%) – groups that according to the EMAS study have the lowest prevalence of hypogonadism.  This age mismatch combined with missing or normal baseline testosterone levels, non-specific symptoms (fatigue, low energy), and low treatment rates in the target population of men ≥ 60 with the highest rates of hypogonadism suggests overprescribing.

 

There is additional indirect evidence available.  Every viewing of streaming channels on the Internet generally produces an advertisement about the easy availability of testosterone prescriptions by telemedicine.  A recent secret shopper study (17, 18) of online platforms offering testosterone therapy found that none of the assessments were done by a physician and despite normal total and free testosterone levels and wanting to father a child - 7 of 8 platforms prescribed testosterone.  The associated commentary says this highlights a problem and this technique might be used by state medical boards.  An earlier study looked at the relationship between advertising and prescriptions and noted that each additional testosterone ad exposure was associated with 14 new tests, 5 new initiations, and 2 initiations without testing per million men. Unbranded "low T" ads had a stronger effect than branded ads.  Advertising was also specifically associated with starting testosterone without a prior blood test. (19, 20).

 

At this point it goes without saying that testosterone and other anabolic steroids are considered performance enhancing drugs with other magical properties.  There is a fountain of youth myth and some men claim to take them for anti-aging effects. Excessive use can also occur associated with body dysmorphia and an anabolic androgenic steroid (AAS) use disorder (22, 23).  There is both pre-clinical data to support the use disorder diagnosis but it is not directly recognized in either the DSM or ICD.  Some studies suggest that 30% of casual users will go on to develop dependence on AAS.  It can also be recognized clinically because of the comorbidity with other substance use disorders most notably opioid use disorder.  In treatment settings, supraphysiological doses of testosterone can also be an indication.

 

To summarize, there is a clear indication for testosterone replacement therapy for hypogonadism that requires two fasting morning blood tests with specific cutoffs as noted in the table at the top of this post.  In reality, much more is required because of the causes of primary and secondary hypogonadism that can be both medical (like TBI) or functional (like the stressors of the military environment).  There is no indication for mass screening and no reason to believe that replacing testosterone in men with or without hypogonadism will enhance military effectiveness.  Testosterone has no anti-aging or vitality enhancing properties at physiological doses.  At supraphysiological doses, it is an androgenic anabolic steroid and cause muscle hypertrophy, irritability and aggression, and persistent hypogonadism when withdrawn.  In a study of quality of life in former AAS users abstinent for 2 years – the nonusing strength trainers had a quality of life score comparable to young adults with a previous ischemic stroke (16).

 

Any man considering testosterone replacement should adhere to the guidelines from the endocrine and urological societies.  For those members of the military that may not have a choice – I am hoping that you have access to a VA endocrinologist to make any treatment decisions.  They knew all about it in 1986 when I trained there and have been refining the guidelines for the past 40 years. 

 

George Dawson, MD, DFAPA

 

References:

 

1:  Hennigar SR, Heymsfield SB, Bukhari AS, Lieberman HR, Berryman CE. Testosterone Screening Thresholds in Active-Duty US Male Service Members. JAMA. Published online October 15, 2026. doi:10.1001/jama.2026.19794

 

2:  Health and human performance optimization to enhance military readiness.

Published July 15, 2026. Accessed 10/30/2026.  PDF

 

“Effective immediately, all Active Duty and Reserve Component personnel aged thirty

and older will be screened for testosterone deficiency as a mandatory element of their Periodic

Health Assessment (PHA). Service members under the age of thirty may also request this

screening during their PHA.

 

This enhanced screening protocol directly supports the Department's focus on Human

Performance Optimization while comprehensively addressing Operator Syndrome. Originally

identified among Special Forces in 2020 through collaborative research between the Department

of War (Do W) and leading academic institutions, Operator Syndrome represents a unique

convergence of health challenges that require proactive clinical intervention. Additionally,

applying lessons learned from treating Operator Syndrome across the Total Force including

targeted testosterone therapy directly optimizes Warfighter readiness….”

 

3:  Frueh BC, Madan A, Fowler JC, Stomberg S, Bradshaw M, Kelly K, Weinstein B, Luttrell M, Danner SG, Beidel DC. “Operator syndrome”: A unique constellation of medical and behavioral health-care needs of military special operation forces. The International Journal of Psychiatry in Medicine. 2020 Jul;55(4):281-95.

 

4:  Wu FC, Tajar A, Beynon JM, Pye SR, Silman AJ, Finn JD, O'Neill TW, Bartfai G, Casanueva FF, Forti G, Giwercman A, Han TS, Kula K, Lean ME, Pendleton N, Punab M, Boonen S, Vanderschueren D, Labrie F, Huhtaniemi IT; EMAS Group. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. 2010 Jul 8;363(2):123-35. doi: 10.1056/NEJMoa0911101. Epub 2010 Jun 16. PMID: 20554979.

 

5:  Hennigar SR, Heymsfield SB, Bukhari AS, Lieberman HR, Berryman CE. Testosterone Screening Thresholds in Active-Duty US Male Service Members. JAMA. 2026 Oct 15:e2619794. doi: 10.1001/jama.2026.19794. Epub ahead of print. PMID: 42879141; PMCID: PMC13673370.

 

7: Mubarak, M., Modgil, V. Routine testosterone screening in military personnel: an opportunity for evidence-based implementation in men’s health. Nat Rev Urol (2026). https://doi.org/10.1038/s41585-026-01181-4

 

8:  Friedl KE, Nindl BC, Potter AW. Stress-associated testosterone suppression: central adaptation or hypogonadism? J Clin Endocrinol Metab. 2026 Jul 15;111(8):e1951-e1960. doi: 10.1210/clinem/dgag181. PMID: 42044038; PMCID: PMC13368364.

 

9:  Walker RF, Zakai NA, MacLehose RF, et al. Association of Testosterone Therapy With Risk of Venous Thromboembolism Among Men With and Without Hypogonadism. JAMA Intern Med. 2020;180(2):190–197. doi:10.1001/jamainternmed.2019.5135

 

10:  Selinger S, Thallapureddy A. Cross-sectional analysis of national testosterone prescribing through prescription drug monitoring programs, 2018-2022. PLoS One. 2024 Aug 28;19(8):e0309160. doi: 10.1371/journal.pone.0309160. PMID: 39196907; PMCID: PMC11355536.

 

11:  Pope HG Jr, Wood RI, Rogol A, Nyberg F, Bowers L, Bhasin S. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014 Jun;35(3):341-75. doi: 10.1210/er.2013-1058. Epub 2013 Dec 17. PMID: 24423981; PMCID: PMC4026349.

 

12:  Kanayama G, Hudson JI, DeLuca J, Isaacs S, Baggish A, Weiner R, Bhasin S, Pope HG Jr. Prolonged hypogonadism in males following withdrawal from anabolic-androgenic steroids: an under-recognized problem. Addiction. 2015 May;110(5):823-31. doi: 10.1111/add.12850. Epub 2015 Feb 25. PMID: 25598171; PMCID: PMC4398624.

 

13:  Baggish AL, Weiner RB, Kanayama G, Hudson JI, Lu MT, Hoffmann U, Pope HG Jr. Cardiovascular Toxicity of Illicit Anabolic-Androgenic Steroid Use. Circulation. 2017 May 23;135(21):1991-2002. doi: 10.1161/CIRCULATIONAHA.116.026945. PMID: 28533317; PMCID: PMC5614517.

 

14:  Pope HG Jr, Kanayama G. Body Image Disorders and Anabolic Steroid Withdrawal Hypogonadism in Men. Endocrinol Metab Clin North Am. 2022 Mar;51(1):205-216. doi: 10.1016/j.ecl.2021.11.007. Epub 2022 Feb 8. PMID: 35216717.

 

15:  Bhasin S, Seidman S, Travison TG, Pencina KM, Lincoff AM, Nissen SE, Miller MG, Flevaris P, Li X, Wannemuehler KA, Pope HG. Depressive Syndromes in Men With Hypogonadism in the TRAVERSE Trial: Response to Testosterone-Replacement Therapy. J Clin Endocrinol Metab. 2024 Jun 17;109(7):1814-1826. doi: 10.1210/clinem/dgae026. PMID: 38205962.

 

16:  Pope HG Jr, Kanayama G. Reduced Quality of Life in Former Androgen Users: An Evolving Public-Health Concern. J Clin Endocrinol Metab. 2024 Apr 19;109(5):e1400-e1401. doi: 10.1210/clinem/dgad661. PMID: 37955864.

 

17:  Dubin JM, Jesse E, Fantus RJ, et al. Guideline-Discordant Care Among Direct-to-Consumer Testosterone Therapy Platforms. JAMA Intern Med. 2022;182(12):1321–1323. doi:10.1001/jamainternmed.2022.4928

 

18:  Woloshin S, Gill LL. Direct-to-Consumer Low-Testosterone Clinics—Where Is the Federation of State Medical Boards? JAMA Intern Med. 2023;183(4):288–289. doi:10.1001/jamainternmed.2022.7008

 

19: Kravitz RL. Direct-to-Consumer Advertising of Androgen Replacement Therapy. JAMA. 2017;317(11):1124–1125. doi:10.1001/jama.2017.1364

 

20:  Layton JB, Kim Y, Alexander GC, Emery SL. Association Between Direct-to-Consumer Advertising and Testosterone Testing and Initiation in the United States, 2009-2013. JAMA. 2017;317(11):1159–1166. doi:10.1001/jama.2016.21041

 

21:  Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope Jr HG. Anabolic–androgenic steroid dependence: an emerging disorder. Addiction. 2009 Dec;104(12):1966-78.

 

22:  Kanayama G, Hudson JI, Pope Jr HG. Features of men with anabolic-androgenic steroid dependence: A comparison with nondependent AAS users and with AAS nonusers. Drug and alcohol dependence. 2009 Jun 1;102(1-3):130-7.

 

23:  Bhasin S, Storer TW, Berman N, Callegari C, Clevenger B, Phillips J, Bunnell TJ, Tricker R, Shirazi A, Casaburi R. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996 Jul 4;335(1):1-7. doi: 10.1056/NEJM199607043350101. PMID: 8637535.

 

 

Supplementary 1:  I was fortunate to train and work with many excellent endocrinologists at the Milwaukee VAMC and at St. Paul-Ramsey Medical Center/Regions Hospital.  I learned a lot in the process and ended up seeing many complex endocrine problems in clinical practice and serving on relevant committees with some of those same endocrinologists. Based on that experience I do not see any potential advantages to consider post TBI hypopituitarism as a feature of another syndrome. I personally saw it diagnosed and treated many times at the Milwaukee VAMC often associated with panhypopituitarism and recognized and treated several of those cases in clinical practice.  They were all secondary to TBI or neurosurgery complications.

 

Supplementary 2:  I was equally fortunate to train and work with many vets.  One of them described Jungle Warfare School to me. I will not attempt to recreate the scenarios he told me about -  and will only say it clearly puts members of the military at risk and places them under extreme physiological stress. The neuroendocrine system has always been an area of research in psychiatry. I was a research fellow in a program where we tested the HPA axis and adrenal responsiveness in patients stressed by depression.  A thorough characterization of some of these stressful training programs may be a batter place to start than just measuring testosterone levels and considering the patient to have hypogonadism.

 

The political atmosphere that these recommendations occur in cannot be ignored.  They are being made by a Department of War Secretary who has taken to lecturing experienced military personnel about fitness for duty and suggesting goals that are long on aggression and short on strategy.  Combined with the DOGE effects of reducing VAMC staffing and medical care I think it is reasonable to be concerned about whether members of the military will get adequate assessments for any abnormal tests rather than just a prescription. Congress should be watching this as an experiment if the guidelines for testosterone replacement are not met and if the effects of testosterone are not carefully followed.