We have been discussing the diagnostic process used to determine whether or not one suffers from testosterone deficiency. That process initially begins with the collection of symptoms that may be associated with low testosterone.
- Do you have a decrease in libido (sex drive)?
- Do you have a lack of energy?
- Do you have a decrease in strength and/or endurance?
- Have you lost height?
- Have you noticed a decrease in your enjoyment of life?
- Are you sad and/or grumpy?
- Are your erections less strong?
- Have you noticed a recent deterioration in your ability to play sports?
- Are you falling asleep after dinner?
- Has there been a recent deterioration in your work performance?
Although the Androgel website does not cite the source of this quiz, it is, in fact, the Androgen Deficiency in Aging Males (ADAM) questionnaire developed by Morley and his colleagues and published in the journal Metabolism in 2000. In this scale, probable evidence for androgen or testosterone deficiency is based on a positive response to either question 1 (decrease in sex drive) or 7 (less strong erections) or positive responses to three other items. Needless to say, the ADAM questionnaire is weighted heavily toward reduced sexual functioning as a key sign of testosterone deficiency.
In the study behind the development of this questionnaire the authors’ affiliations are listed as the St. Louis Veterans Affairs Medical Center, the St. Louis University Medical School, and Organon Canada. Organon was (it has since been merged with Merck) a multinational Dutch pharmaceutical company whose mainstay had traditionally been the production of synthetic hormones, notably insulin, estrogen, and cortisone.
Although somewhat brief in length at under four pages, the goals of this study were quite ambitious. The authors begin by querying whether a disorder analogous to menopause might be present in men as they reached middle age. If so, this male change-of-life – or androgen deficiency in aging males (ADAM) – would be defined by a decrease in production of androgens or, more simply, testosterone. Such as change would be marked by reduced libido, fatigue, and lower stamina and strength.
After providing no real strong evidence for the existence of ADAM as a disorder, beyond noting that aging men show a steady drop in testosterone levels and that older men tend to be tired and low on energy, the authors then describe what they believe to be common symptoms that are displayed by older men with low levels of testosterone. These symptoms are based on the authors’ own clinical experience and they become the ten items contained in the ADAM questionnaire listed above.
Despite the suggestion that ADAM is defined by ten symptoms shown by older men who are suffering from low testosterone, the authors then proceed to create a scoring method in their questionnaire that disregards the majority of those same symptoms that define the ADAM construct. That is, at a minimum, one needs only to endorse reduced sexual interest or performance to be a candidate for ADAM. What happened to all the other symptoms? Where did they go?
It is certainly puzzling to argue that a disorder exists but that same disorder is highly individualistic and does not need to follow any consistent pattern.
You will often see the ADAM questionnaire and its items when you review the literature or peruse websites attempting to sell testosterone products to men. This short questionnaire is often presented as a somewhat inoffensive and unobtrusive method of assessing symptoms of testosterone deficiency among older men. It is assumed that testosterone deficiency, as a disorder, exists and that this questionnaire was developed to assess this disorder in an economical fashion.
But that is incorrect. The ADAM disorder and the ADAM questionnaire were created simultaneously. In Marshall McLuhan terms, the questionnaire is the disorder.
Next, I will review how the ADAM study validated its questionnaire.
- Morales, A., Bella, A. J., Chun, S., Assimakopoulos, P., Bebb, R., Gottesman, I., . . . Elliott, S. (2010). A practical guide to diagnosis, management and treatment of testosterone deficiency for Canadian physicians. Canadian Urological Association Journal, 4, 269-275.
- Morley, J. E., Charlton, E., Patrick, P., Kaiser, F. E., Cadeau, P., & Perry III, H. M. (2000). Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism, 49, 1239-1242.