The pharmaceuticalization of ‘healthy’ ageing: Testosterone enhancement for longevity

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Abstract

The United Nations estimates that the world’s population will reach 8.5 billion by 2030, and the populations of most countries are expected to grow older. This is the case for many developed countries, including Australia, the United Kingdom, Canada, the United States of America, and member states of the European Union. Older cohorts will comprise a larger proportion of overall populations, driven in part by our increases in life expectancy. An aging population poses challenges for governments; notably, older people tend to have multiple, chronic health conditions which can place a burden on health budgets. At the same time, we are witnessing a shift in how we respond to the health needs of our populations, with global drug policy acknowledging that some substances are contributing to increased morbidity and mortality (e.g. opioids) while others may have beneficial therapeutic effects (e.g. psilocybin, cannabis). There is general agreement that as men age their levels of testosterone decrease, and there is some evidence to suggest that there have been population-level declines in testosterone which are not associated with age. Anecdotally, testosterone is accessed by men seeking to self-medicate in the belief that they are experiencing low testosterone levels. There has also been a rise in anti-aging clinics in the United States, providing access to testosterone replacement therapy (TRT). The non-medical use of testosterone can result in a number of adverse health events, including complications from the use of the black market or underground products. Placing testosterone under a new prescribing regime may address some of these concerns, but is society ready for this change, and if so, what would this regime look like? This paper will explore the issue of how society responds to enhancement for longevity, or how we increasingly use pharmaceuticals to address and prevent illness, with a specific focus on testosterone and testosterone deficiency.




The United Nations estimates that the world’s population will reach 8.5 billion by 2030, an increase from 7.7 billion people in 2019 (United Nations Department of Economic and Social Affairs Population Division, 2019). This population growth is accompanied by the aging of populations in most countries largely due to advances in medicine and public health that reduces mortality, especially in children, but also due to declining fertility (United Nations Department of Economic and Social Affairs Population Division, 2019). Governments in many developed parts of the world, including Australia, the United Kingdom, the United States, Canada and the European Union member states will have populations with a larger median age and higher proportions aged 65 years and over. Already in 2015, the median age for Australia, the US, and the UK was 37.2, 37.6, and 40.2 years, respectively (United Nations Department of Economic and Social Affairs Population Division, 2017), an increase from 35.4, 35.2, and 37.6 years in 2000, respectively (Ritchie, 2019). In 2015, it was estimated that 8.5% of the world’s population was aged 65 years and over, and this is expected to increase to 12% in 2030 and 16.7% in 2050 (He, Goodkind, & Kowal, 2016). The demographic shift is good news for longevity and overall population health, but it signals the need to revisit social and health infrastructure that was designed for a younger population with a shorter lifespan.

The aging population presents significant policy challenges. First, given lower fertility rates, some countries do not have enough people entering the workforce to replace the older generation and fund their retirement. Second, existing social support systems may experience financial stress if older generations do not have sufficient personal funds to support their own retirement. Third, as people age, they tend to have multiple, chronic conditions, which require support from government health budgets. Thus, continuously increasing life expectancy and stable healthy, or disability-free periods highlight the emergence of a “longevity trap” (von Zglinicki et al., 2016). Indeed, while we are expanding the lifespan, we are not only expanding the healthy lifespan but also the length of chronic disease. The World Health Organisation estimates that 71% of global deaths in 2016 were due to non-communicable diseases, with cardiovascular diseases the leading cause (World Health Organisation, 2018). Subsequently, there is a growing focus on ensuring good quality of life later in life (Sinclair, 2019). As Blackburn and Epel (2017) write: “Ageing and death are immutable facts of life, but how we live until our last day is not.” Over the last three decades, a number of possible solutions regarding how to deal with the aging population have been proposed. These include the emergence of commercial and clinical anti-aging movements aimed at extending the time customers and patients can live without or delay the common morbidities of aging (e.g. wrinkling of the skin, hardening of the arteries, memory loss, muscle loss, and visual impairment) (Robert H. Binstock, Fishman, & Johnson, 2006). In this commentary, we focus on the use of testosterone to repair, reverse, or slow the undesirable signs and conditions of aging, with a particular focus on men. It will explore the issue of how society responds to enhancement for longevity, or how we increasingly use pharmaceuticals to address and prevent illness, with a specific focus on testosterone and testosterone deficiency.




*The case of testosterone

*The rise of anti-aging

*Can regulation accommodate the various uses of testosterone?

*A cautionary note about ‘anti-aging quackery’




Conclusion


Over the next decades, nations will be adapting funding and infrastructure to support the health and flourishing of their aging populations. This commentary intended to initiate a dialogue about including the adaptation of regulation of substances that could help sustain health later in life. Many of these, like testosterone, are existing substances with established safety and efficacy profiles, strict medical indications, yet documented uses outside of traditional medicine (often labeled enhancement). It is imperative that the regulatory legacy of such substances as ‘medical’ not be used to preclude an honest examination of whether their current regulation is fit for purpose amidst major demographic and conceptual changes around aging (Dunn, McKay, & van de Ven, 2019).

In the case of testosterone, two mammoth tasks lay ahead in rethinking its regulation for anti-aging. First, the enthusiasm for using substances like testosterone for anti-aging purposes will need empirical support. Part of that evidence will be studies of the groups using testosterone and their motives. The other part will be producing rigorous scientific evidence of their efficacy. This evidence will provide the basis for considering whether the benefit conferred by testosterone warrants the difficult ethical discussions and red tape involved in reforming regulation. Second is the exploration of options for reforming the regulation of testosterone. This commentary presented the advantages and challenges of prescription and OTC models of regulation, but, as we have seen with policy changes with other substances such as cannabis, there are other options (Caulkins et al., 2015). Liberal options will have to ethically justify any potential harm, small as it may be and the potential for inequalities in access. Options that are more restrictive will have to ethically justify the restriction of access to substances that could promote health in the aging population. The willingness of scientists, both medical and social, as well as regulators to discuss the fraught topic of substance regulation will signal a first and necessary step to considering how we might better support those at the top of the population pyramid
 

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