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

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.   

 

Why Physicians and Clinics Are At Least As Important as Randomized Clinical Trials

Year (month)	Medication	Key milestone	Dosing interval
1968	Fluphenazine decanoate (Prolixin Decanoate)	First FDA-approved LAI antipsychotic (oral fluphenazine approved 1959)	q2–4+ wk, IM/SC
1986	Haloperidol decanoate (Haldol Decanoate)	Only other first-generation LAI approved in the US; one source cites 1984, likely reflecting non-US availability	q4 wk, IM
Oct 2003	Risperidone microspheres (Risperdal Consta)	First second-generation LAI; bipolar I added May 2009	q2 wk, IM
Aug 2009	Paliperidone palmitate 1-month (Invega Sustenna)	First monthly second-generation LAI; schizoaffective disorder added Nov 2014	q4 wk, IM
Dec 2009	Olanzapine pamoate (Zyprexa Relprevv)	REMS required for post-injection delirium/sedation syndrome	q2–4 wk, IM
Feb 2013	Aripiprazole monohydrate (Abilify Maintena)	Bipolar I maintenance added Jul 2017	q4 wk, IM
May 2015	Paliperidone palmitate 3-month (Invega Trinza)	First LAI dosed beyond monthly	q3 mo, IM
Oct 2015	Aripiprazole lauroxil (Aristada)	Prodrug; 6- and 8-week regimens available	q4–8 wk, IM
2018	Aripiprazole lauroxil (Aristada Initio)	Single-day initiation regimen	Initiation only
Jul 2018	Risperidone ER SC (Perseris)	First subcutaneous LAI antipsychotic	Monthly, SC
2021	Paliperidone palmitate 6-month (Invega Hafyera)	Longest dosing interval of any LAI	q6 mo, IM
2023	Risperidone ER IM (Rykindo)	Additional IM risperidone LAI	q2 wk, IM
Apr 2023	Risperidone ER SC (Uzedy)	Schizophrenia; bipolar I added Oct 2025	q1 or q2 mo, SC
2023	Aripiprazole 2-month (Abilify Asimtufii)	Schizophrenia and bipolar I maintenance	q2 mo, IM
2024 (available Apr 2025)	Paliperidone palmitate (Erzofri)	Single 351 mg initiation injection; no day-8 dose	Monthly, IM
References Rowland D. Should we be prescribing fluphenazine long-acting injectable formulation? Curr Psychiatry Rep. 2025. Jann MW, Penzak SR. Long-acting injectable second-generation antipsychotics: an update and comparison between agents. CNS Drugs. 2018. Abbas F, Rajab T, Alsamarrai O, et al. Fluphenazine decanoate (timing of administration) for people with schizophrenia. Cochrane Database Syst Rev. 2017. Food and Drug Administration. Fluphenazine decanoate [package insert]. 2025. Kane JM, McEvoy JP, Correll CU, Llorca PM. Controversies surrounding the use of long-acting injectable antipsychotic medications for the treatment of patients with schizophrenia. CNS Drugs. 2021. Benarous X, Cottin G, Lahaye H, et al. Efficacy, tolerability, and acceptance of long-lasting antipsychotics in children and adolescents: a systematic review. J Child Adolesc Psychopharmacol. 2022. Food and Drug Administration. Haloperidol decanoate [package insert]. 2026. Rauch AS, Fleischhacker WW. Long-acting injectable formulations of new-generation antipsychotics: a review from a clinical perspective. CNS Drugs. 2013. García-Carmona JA, Simal-Aguado J, Campos-Navarro MP, Valdivia-Muñoz F, Galindo-Tovar A. Long-acting injectable antipsychotics: analysis of prescription patterns and patient characteristics in mental health from a Spanish real-world study. Clin Drug Investig. 2020. Mauri MC, Paletta S, Di Pace C, et al. Clinical pharmacokinetics of atypical antipsychotics: an update. Clin Pharmacokinet. 2018. Edinoff AN, Doppalapudi PK, Orellana C, et al. Paliperidone 3-month injection for treatment of schizophrenia: a narrative review. Front Psychiatry. 2021. U.S. Food and Drug Administration. Orange Book: approved drug products with therapeutic equivalence evaluations. Silver Spring (MD): U.S. Department of Health and Human Services. Pahwa M, Sleem A, Elsayed OH, Good ME, El-Mallakh RS. New antipsychotic medications in the last decade. Curr Psychiatry Rep. 2021. Food and Drug Administration. Invega Hafyera (paliperidone palmitate) [package insert]. 2025. Merenlender Wagner A, Perlstein I, Farkas P, et al. A phase 1 open-label study assessing the safety and pharmacokinetics of TV-46000, an extended-release injectable suspension of risperidone for subcutaneous use. CNS Drugs. 2026. Food and Drug Administration. Abilify Asimtufii (aripiprazole) [package insert]. 2025. Chen Y, Hu L, Meyer JM, et al. Population pharmacokinetics and dosing simulations for paliperidone palmitate 351 mg as alternative maintenance doses in patients with schizophrenia or schizoaffective disorder. J Clin Psychiatry. 2026. Food and Drug Administration. Erzofri (paliperidone palmitate) extended-release injectable suspension [package insert]. 2026.

Note: Abilify Maintena is listed by one review as February 2015, but other reviews give February 2013. Exact months for Aristada Initio (June 2018), Invega Hafyera (August 2021), Rykindo (January 2023), Abilify Asimtufii (April 2023), and Erzofri (July 2024) should be verified against Drugs@FDA. Fluphenazine enanthate (circa 1966–67, since withdrawn) and non-US depots (flupentixol, zuclopenthixol) are excluded.

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I finished a memoriam to a colleague today.  He was one of the best psychiatrists I have known and I know a lot of excellent psychiatrists.  He was able to integrate the technical and humanistic aspects of the field to provide very high-quality care and consultation to his colleagues.  We both worked in the same acute care setting for a period of about 11 years.  I was primarily an inpatient psychiatrist and he was outpatient.  We both ran clinical trials but he was much more active in that area.

 

I am mentioning him here because of his innovative practices that preceded widespread adoption by years if not decades.  The first innovation was a large clinic for long-acting injectable antipsychotic medications or LAIs.  The above table lists all of the current LAIs with their approval dates in the left column. My colleague worked at our hospital from 1981-2002, so his LAI clinic probably only had two available options fluphenazine decanoate and haloperidol decanoate.  The older LAIs had a more significant side effect burden.  For optimal use, careful dose adjustment and in some cases therapeutic drug monitoring was necessary. There was also a reluctance to prescribe these medications because of a bias that most people would not want intramuscular injections on a regular basis. He had a very large clinic of patients taking these medications and none of those factors were a problem. As an inpatient specialist at the time – his patients were rarely hospitalized.  We had monthly quality assurance (QA) meetings that seemed more like surgical morbidity and mortality conferences, but at no time did we discuss different outcomes by physician or clinic or the potential advantages of the LAI clinic.  The QA meetings were focused on criticizing care rather than optimizing it.

 

When clozapine came out in 1990, it was strictly regulated in the state of Minnesota.  The only indication was treatment resistant schizophrenia and a normal absolute neutrophil count (ANC).  For the first several years it also required approval by a PharmD at the state level. There had to be documentation that the patient failed on 2 antipsychotics before they were allowed to use clozapine.  Clozapine also had a Risk Evaluation and Mitigation Strategy (REMS) before they existed.  Clozapine had a risk of agranulocytosis and therefore every patient had to have a weekly blood draw and normal ANC before they could get the next week supply of clozapine.  Over the next decade, my colleague built up and maintained what was probably the largest clozapine clinic in the state.  He was adept at treating all of the side effects of this medication as well as administrative complications. I can recall calling him in a panic one day when I found out that a patient I had discharged on clozapine to another state missed the weekly ANC determination but was still given the next week supply of medication.

 

Both of these clinics were early innovations based on both current discussions and how LAIs are discussed in treatment guidelines.  Clozapine is now widely regarded as the most effective antipsychotic medication with secondary applications in movement disorders. The REMS strategy has been reduced to the point that it is done but is no longer mandatory and it is no longer for the entire period of time while using clozapine. Some guidelines have incorporated additional indications such as one failed antipsychotic or significant suicide risk.  Since better tolerated second generation LAIs have been developed the indications have expanded to include bipolar disorder.  I have personally seen patients with clear bipolar disorder who have been stabilized on newer LAIs when nothing else worked.   

 

My main point in discussing these two clinics is that they were in place and working 10-15 years before these modalities were being discussed as not being widely enough deployed or not being utilized early enough in treatment.  My colleague was focused on providing that level of care and establishing therapeutic relationships with his patients. He was always available for consultation and discussion.  We had humorous conversations about the personal embarrassment of polypharmacy but how some people seemed to need it.  We discussed the best ways to treat depression with comorbid schizophrenia.  We covered movement disorders that were barely discussed in the literature (tardive torticollis) and patients with hematological malignancies who needed clozapine.  Acute care psychiatry can become a series of desperate situations and it is always good to have a colleague who can reassure you that there is nothing else that can be done. 

 

In addition to the clinics my colleague was also an investigator in 80 clinical trials for Alzheimer’s Disease, Schizophrenia, Obsessive Compulsive Disorder, Major Depression, Tourette’s Syndrome, Post Traumatic Stress Disorder, and Generalized Anxiety Disorder. Although most were medication trials many involved psychotherapy and quality of life outcomes.  He was also a speaker and between 1991 and 2001 gave over 200 invited presentations for grand rounds, regional psychiatric and community meetings, and pharmaceutical presentations.

 

It was not until after I had finished writing my tribute that I thought of a piece written by Atul Gawande, MD about another Minnesota physician.  In that piece he describes how pediatrician Warren Warwick may have made the Minnesota Cystic Fibrosis Center at Fairview-University Children’s hospital – the top center in the country.  He had that discussion after a long introduction of how physicians were rated on outcomes, the need for transparency in those ratings, and how most physicians would either not want to see the results or be reluctant to accept the results. Evidence Based Medicine (EBM) is introduced as the standard, but it takes more than that.  All of the top cystic fibrosis centers used the same guidelines, procedures, and medicines. Why was it that Warwick had consistently better results in terms of much lower mortality rates?

 

Gawande observed a couple of Warwick’s sessions with patients. In the dialogue he is doing much more than a review of symptoms. He is actively exploring and confronting the patient about their CF care.  Gawande suggests that “more nebulous factors like aggressiveness and consistency and ingenuity can matter.”  As I read about the interaction it seemed like supportive psychotherapy to me. The only element missing was an explicit statement about the therapeutic alliance, but that was implied by Dr. Warwick’s: “What have you been doing to make us the best CF program in the country?’

 

I am sure that my colleague was much less direct.  He knew what his patients needed and he knew that it included more than medicine.  He was able to discuss anything with them. Years after he left, those same people would approach me in the hallways and ask: “Have you heard from him?  How is he doing?”  They all knew he wanted the best for them and that they could problem solve with him and get his support.

 

Gawande’s piece still contains important observations 22 years later.  It also has implications for psychiatry. Gawande was writing at that time about a country wide network of 117 CF centers.  Even before his essay these centers had reduced CF mortality significantly from an average life expectancy of 10 years in 1962 to 33 years in 2003.  At the best center - lifespan was 47 years.  The questions come down to: can the reasons for these differences be measured reliably, is it a question of a bell curve distribution of outcomes and how static is that curve, and how important are the intangibles?

Gawande seems to have been using the bell-shaped curve literally in this essay and that is problematic.  A normal or Gaussian distribution has to have certain characteristics that typically do not exist in medical outcomes data.  For example, in a normal distribution the data have to be continuous, symmetrical about the mean, and the mean, median, and mode all have to coincide. Counted outcomes based on medical interventions do not have that kind of distribution.  The distribution will generally be skewed in the direction of the intervention with a long tail of outliers. That has led to modeling outcomes like surgery and length of stay with the Poisson distribution or modifications of that distribution. It has also led to predictive analytics with machine learning being used to select the most relevant variables and use those to predict outcomes.  

 

I was in a managed care organization that attempted to measure process outcomes.  One of the criticisms of psychiatry is that there are no “hard outcomes.”  Having completed an extensive review of antidepressants and suicide risk I know that is not true.  Death and hospitalization are both hard outcomes in psychiatry. The paradox in current healthcare measurement-based care is that all care in the US is based on rationing.  No amount of rationalization will convince me that rationed care has quality or optimizing outcomes as a goal.  Care in many of these settings is observably bad - even compared with care I personally received in 1969.

 

But what would happen if we approached care like my late colleague?  What if we developed networked clinics based on LAIs or clozapine, or specific diagnostic groups?  What if the goal was cooperative elevation of the field and enhanced collegial consultation instead of avoiding difficult problems and rationing care?  What if it was possible to learn intangibles and psychotherapy that would enhance the treatment process instead of the continued silo based practices?

These are additional thoughts I had as I commemorated my colleague.  They are things I wished I had asked him when he was around.

 

     

George Dawson, MD, DFAPA

 

 

 Reference:

Gawande A.  The Bell Curve.  The New Yorker.  November 29, 2004:  https://www.newyorker.com/magazine/2004/12/06/the-bell-curve

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