You might think we’re heading into a low time of year for suicides because they peak during the cold, dark months of winter. But, in fact, suicide peaks during the spring and early summer.

This is just one example of the popular beliefs around suicide that turn out to be myths. Here to unpack more of these myths, as well as the truths around this poorly understood subject, is Rory O’Connor, the leader of the Suicidal Behaviour Research Laboratory and the author of When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It. Today on the show, Rory discusses possible reasons for why suicides go up in the warmer months and why men die by suicide more often than women. He explains that suicide doesn’t happen without some warning signs and why someone’s improved mood might be one of them. In the second half of the show, Rory walks us through the real reasons people move from having suicidal thoughts to acting on them, and what works to prevent suicide.

Resources Related to the Podcast

• The Suicide and Crisis Lifeline
• The Suicidal Behaviour Research Laboratory
• Atlantic article: “The Troubling Link Between Springtime Allergies and Suicide”
• AoM Podcast #585: Inflammation, Saunas, and the New Science of Depression
• AoM Podcast #886: What the World of Psychology Gets Wrong About Men
• AoM Podcast #756: How the Desire for Status Explains (Pretty Much) Everything
• “Why Men Kill Themselves” by Will Storr

Connect With Rory O’Connor

• Rory’s faculty page

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Read the Transcript

Brett McKay: Brett McKay here, and welcome to another edition of the Art of Manliness podcast. You might think we are heading into a low time of year for suicides because they peak during the cold, dark months of winter but in fact, suicide peaks during the spring and early summer, this is just one example of the popular beliefs around suicide that turn out to be myths. Here to unpack more of these myths, as well as the truths around this poorly understood subject is Rory O’Connor, the leader of the Suicidal Behavior Research Laboratory and the author of When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It. Today in the show, Rory discusses possible reasons for why suicides go up in the warmer months and why men die by suicide more often than women. He explains that suicide doesn’t happen without some warning signs and why someone’s improved mood might be one of them. In the second half of the show, Rory walks us through the real reasons people move from having suicidal thoughts to acting on them and what works to prevent suicide. After the show’s over, check out the show notes at aom.is/suicide.

Alright, Rory O’Connor, welcome to the show.

Rory O’Connor: Thank you, I’m delighted to be here, Brett.

Brett McKay: You are a professor of psychology who researches suicide and suicide prevention. I’m curious, what led you down this career path?

Rory O’Connor: Well, that’s an interesting question. Like many things in life, this path was serendipitous. As an undergraduate student in Belfast in Northern Ireland, I’d been studying depression, and I thought I was going to continue my undergraduate work into looking at depression rather than suicide itself. But then as things happen, I got a call in the summer of… I think it must have been the summer of 1994, so quite a while ago, and the person who turned out to be my PhD supervisor told me that there was an opportunity for a funded scholarship PhD program on suicide, and so that’s where it all began, just that phone call and I decided that that’s the direction I would go. And I suppose what’s quite interesting to my point of view is that, well, clearly suicide is the most devastating of outcomes from depression and other mental health problems. But I suppose I didn’t quite envisage where that journey would take me, and in particular, that man, that phone call, my PhD supervisor, the person without whom I wouldn’t have done the research on suicide, sadly, some years later, he took his own life. And I often think back to that phone call and really, I often wonder what was in his mind at that time, why did he ask me? He wasn’t a suicide researcher. So it’s just funny how these things happen. But I’m incredibly grateful to him because it genuinely was like a sliding doors moment which changed my life.

Brett McKay: What did your family think when you told them, “I’m gonna do my PhD in suicide?”

Rory O’Connor: Well, my mother in particular, she was quite concerned because she knows me as a person and she just knew that everything I would do, I would put me heart and soul into, and so her big concern was the impact on me, on my own mental health. And yeah, one of the first questions she asked me was, “My God, you’re not gonna kill yourself. Are you?” That was her genuine fear that if I was so immersed in this… And I suppose that question was really an important question to ask and something I remind myself of daily, of reminding myself to look after my own mental health, as well as now the mental health of the people I work with here in my team in Glasgow.

Brett McKay: You’ve written a book called When It Is Darkest: Why People Die by Suicide, and What We can do to Prevent It, which is a book where you’ve taken the research you’ve done on suicide and suicide prevention and presented it for a lay audience. We’re gonna talk about this book but before we do, I think it’s important to talk about how to talk about suicide. I’m sure a lot of people have noticed maybe in the past decade or so, when we talk about suicide or someone who has taken their own life, you hear people say, “He died by suicide,” instead of, “He committed suicide,” why that shift?

Rory O’Connor: Yeah, it really has been a marked shift I would say in the last 20 years, and the reason for the shift is because the term “committing suicide,” it harks back to a time in many countries where suicide was illegal. And so it harks back to that criminal undertone, that it was seen as a criminal offense. And indeed in the United States and in the UK, thankfully, suicide is no longer a criminal offense but there are still many countries in the world in which it is a criminal offense. And I just know from speaking to countless people who are bereaved by suicide or people who’ve been suicidal themselves, they often are quite upset about that criminal over undertone. So for that reason, I think we shifted and been much more careful in our language because to my mind, we can talk about people dying by suicide, it conveys the same message and it’s not going to cause distress to those who are bereaved. So in all the work that I do, I avoid the term “committing suicide” for that reason.

Brett McKay: What’s the state of suicide in the West today? Are rates increasing or decreasing?

Rory O’Connor: In some sense, there’s no simple answer to that question, so maybe I’ll try and answer it in a couple of ways. If I look at the suicide rates, say, over the last 40 years… Now, if I take a global perspective first. So on a global perspective, the suicide rates have decreased by about 30% or thereabouts over the last 40 years or so. However, if you try and disentangle then where the decreases have happened, you see that much of the decline in suicides happened in Asian countries, in India and in China and other Asian countries, largely in China. And so that tells you a pattern, yes, on a global context, in those lower, middle income countries historically, the suicide rates have been decreasing. Now, if I take then the last 20 years and focus in on, say, the United States or the United Kingdom, you see a different pattern. Indeed in the United States, you’ve seen this upward trend in suicides. And then if I look in the UK, say over three or four years before the pandemic hit, similar to the United States, the suicide rates were increasing. And in Australia, New Zealand, other western countries, in those recent years, suicide rates have been on the increase.

Now, when the pandemic hit, many of us working in the field of suicide research and suicide prevention were really, really concerned about the potential impact of Covid 19 on the suicide rates. Now, thankfully, our concerns were not realized because the suicide rates broadly speaking did not increase basically in a global context. And indeed with a colleague, Jane Pirkis from Melbourne University, she led this big international initiative of 33 countries across the globe, and it covered the first, I think it was 15 months of the pandemic, and within those first 15 months, broadly speaking, the suicide rates did not increase. Now, there were some exceptions. For example, Japan, there are some signals now that the suicide rates might be increasing in Japan but the broad picture is that the pandemic did not see the increase that we feared. But now my concern is, and we’re starting to see this in the United States, in the UK, and in other countries, is now with the cost of living crisis and the potential economic turmoil and the Ukraine crisis and other things going on in the world, our concern is that suicide rates are starting to go up again. So we had this period when they didn’t increase during the pandemic, we need to be really, really vigilant moving forward.

Brett McKay: Are there demographics, groups that are more susceptible to suicide, say, by age or sex?

Rory O’Connor: Yes, well, if we just focus on Western countries or high-income countries, suicide rates are significantly higher in men than a women. In the United States and in the UK, about three quarters of all suicides are by men, but then if you look to other countries to lower middle income countries, you see less of a disparity between males and females. But I think in every single country in the world, men outnumber women in suicide. Now, if you look down at age profiles, again, you have the nuances, there’s slightly different patterns in different countries but broadly speaking, suicide is rare before puberty, and then when puberty hits and those periods through from puberty right up to your mid-20s, you see this increase in suicidal thoughts, behaviors, and deaths by suicide. And again, there are slight differences in countries, but in the UK, for example, the leading middle-aged men are the group most at risk of suicide.

And in other countries, older-age men are at increased risk or the highest risk group but the concern many of us have is that we are starting to see this increase in young or youth suicides again. And that really reminds me of when I first started researching this field in the 1990s, the biggest risk group were young men. And if we think back to the 1990s, we had just all emerged from a recession or real economic turmoil. And my concern now here is we’ve a similar pattern, we’ve gone through a recession a few years ago, we now have this cost of living crisis and the broader uncertainty in the world, and my concern is that young people are being maybe even more at risk and that their suicide rates may start to increase faster. So we need to be so, so careful and protect our young people.

Brett McKay: Speaking to the sex breakdown, something that I’ve read, and I want to see if this is true. Is it true that women attempt suicide more often than men but men are more likely to actually take their lives because they use more lethal means?

Rory O’Connor: Yes, broadly speaking, that’s a correct statement, I agree with that, is that yes, women are more likely to engage in nonfatal suicidal behavior. However, the explanation for that differential isn’t as straightforward as saying it’s all down to the method that has been used. That’s certainly part of it, we know that men are more likely to use more lethal methods and obviously therefore more likely to die, say, on a first attempt but it is more complicated than that. And I think we need to look at issues around masculinity, what it means to be a man in today’s society, issues around the way we structure and tailor treatment. So the question I often ask is, “We know there are effective treatments, psychological treatments, which reduce risk of suicidal behavior but the question is, do they work for men, and are they tailored for men?” And that is linked to the fact that the way men help-seek is perhaps different from women.

And we know that men are less likely to seek help for mental health problems. And so what we should be asking is… Instead of blaming men for not seeking help, which sometimes is part of the narrative, we should be saying, “Actually, perhaps the treatments and support coupled with the stigma around help-seeking, mental health, masculinity, these are all contributing to a situation, and like a perfect storm of factors, together with the increased use of more lethal methods of suicide. And that’s really, the complexity, is the answer to the question of why there are more male suicides than female suicides.

Brett McKay: What are some of the biggest myths around suicide, and how can those myths get in the way of helping people who are susceptible to suicide?

Rory O’Connor: To my mind, probably the single most common myth that I have come across is that if you ask somebody whether they’re suicidal, it will plant the idea in their head, and it’s really important that we squash that myth because there is no evidence at all that by asking somebody whether they’re suicidal that it actually will make them suicidal, there’s just no evidence. However, there’s now quite a bit of evidence showing the opposite, showing that actually if you ask somebody that question, and I agree it’s a difficult question to ask, but if you ask that question, ask somebody directly whether they’re suicidal, there’s evidence showing that actually it can get them the help that they need. And I often describe that question as being potentially the start of a life-saving conversation. So that would be myth number one.

Then another myth I often think is important to highlight, Brett, and that is this idea that… And it comes from a place of real sadness and heartbreak, is that the number of people that I have encountered over the years, both loved ones as well as health professionals, who have come up and told me the story that the person who they’ve lost to suicide had seemed okay, had seemed well in the days and weeks before they died. And so the myth is that if there’s this improvement in mood that’s associated with reduced risk, that’s a myth because it’s the opposite in too many cases. And I suppose to clarify it, I’ll make it clear what I mean in a second. What the work or the research and evidence suggest is that if there is an unexplained improvement in mood, it could mean that the person has resolved to end their life, and because they’ve resolved to end their life as a way of dealing with their pain, their mood lifts because they found a solution to their pain, a solution to their problems.

And the reason it’s concerning is, as a person’s mood lifts, their cognitive capacity, their motivation, their ability to plan and carry out the suicidal act increases. So the message on that myth is, if there is any unexplained improvement in mood, if somebody has been in a depressive episode, please check in with them to try and understand why their mood is lifted. Now, of course it could be their mood has lifted because their treatment has kicked in, either their medication or their psychosocial treatment has kicked in or their crisis has abated but the concern is if somebody seemingly improves in mood, in emotional wellbeing and you don’t know why, always, always check in to ensure they’re doing okay.

Brett McKay: Okay. So if someone’s mood improves, it can actually be a danger sign because they may just be feeling relieved that they’ve made the decision to stop struggling and take their own life. And another related myth is that someone will always be depressed before they die by suicide. Mental illness is correlated with suicide but sometimes someone hasn’t been depressed, and we’re gonna talk more about this later, but they haven’t been depressed but then they experienced some sort of a big setback or humiliation that leads them into this spiral of suicidal thoughts. And these things relate to another myth, which is that there aren’t any warning signs before a suicide. A lot of times, when someone takes their own life, their friends and family, they’re shocked and they say they didn’t see any signs it was coming, but your research shows that there are typically signs, they can just be hard to recognize.

Rory O’Connor: The sad reality is that warning signs for suicide are difficult to spot, but there are warning signs. And so the things I would often highlight are changes in behavior, that could be changes in eating, sleeping, drinking. Like sleeping in particular, because we know that disrupted sleep, sleep problems are associated with suicide risk because obviously if your sleep is interrupted, that’s a basic… In biological terms, we would describe it as a basic homeostatic function. You don’t sleep well, your problem-solving is affected, your mood is affected, your self-regulation is affected. So changes in these basic processes are important to look out for. But other things like… And this certainly only probably applies to some cases, people who are starting to get their life in order, their life affairs in order, that would be another warning sign that the person may have resolved to die by suicide.

And then obviously if somebody has been bereaved by suicide themselves or they’ve experienced a marked loss either in status or in relationships, things like that, those marked changes can have an impact. So again, I would be checking in with somebody as well. Also, people who are talking about feeling trapped and hopeless and feeling a burden on those around them because we know that sense of burdensomeness is at the heart of the suicidal thinking. The person feels, “Actually, if I end my life, the people around me would be better off if I was dead.” And so those are the sorts of things I would highlight as warning signs, but the reality sadly is our ability to predict suicide is no better than chance, it’s no better than the toss of a coin, it’s really difficult to predict who will die by suicide, but we should be still checking in with people if we are concerned, of course.

Brett McKay: Is there a seasonality to suicide? Because I think maybe there’s a common belief out there that a lot of suicides happen in the winter because it’s dark and cold, maybe the holidays make people feel sad. Is that true?

Rory O’Connor: Well, the holidays bit is probably true but not necessarily the winter bit. Again, the best evidence… If you try and bring together all the evidence from across the world, the best evidence suggests that suicides actually peak in spring, summertime, so the increase in that period… And actually in December, they’re actually lowest on Christmas day, but then they peak on new year’s day. And so the question is, Well, why do you see this seasonal effect? And the short answer is, we don’t know for certain. Part of it could be due with, as we move seasons, there’s a change in our sleeping patterns and our physical activity, it could be maybe linked to… If we look at occupations at risk of suicide, as you move into spring, perhaps there’s increased work-related stress, say, if you’re working in the agricultural sector, if you’re a farmer or whatever it may be, so you can see increased stress and risk there. But it could also be the fact that as we move into spring and summer and the brightness and vitality of spring and summer, if you’re struggling with your mood, there’s that mismatch or that dissonance between your internal world and your external world, and perhaps that’s part of the explanation as well. So yes, there are seasonality effects but we need to do more research to understand why they persist.

Brett McKay: I saw this article in the Atlantic, this is speculative, but a factor that might contribute that seasonality is… In the spring, there’s allergies, and inflammation can potentially contribute to depression and mental illness. Again, this is speculative but I thought that was interesting, I saw that a couple months ago.

Rory O’Connor: No, absolutely. And I may have read that same article in the Atlantic actually. No, I think we need to look at the allergens and the role of allergens because, as you say, there’s growing evidence that the impact on how they can activate some of the obviously biological systems which are associated with mental health problems like depression. So I think that’s an area we need to look at in much more detail because remember, one of the things certainly I’ve recognized more and more as I’ve studied suicide and suicide prevention is… And I often describe it as, historically, we’ve either been too focused on the individual or too focused on the context in which an individual lives without bringing those together. Those people who do work on brain imaging and biology, that’s all great. And those people who do work on social contexts and cultural factors, that’s brilliant as well. But ultimately, as John Donne said… That idea of “no man is an island,” we need to recognize it each… If we’re to understand suicide risk, we have to understand the individual in their context, and that context includes these wider environmental factors that you’ve mentioned, as well as of course things closer to home, like obviously relationship crises, mental health problems, bullying, unemployment and on. We need to look at the environmental context as well.

Brett McKay: And we’ll talk about some of these factors ’cause you’ve developed this model, the integrated motivational volitional model of suicide behavior. Maybe we can talk about some of those factors in that model but just broadly speaking, big picture, why do most people decide to take their own life?

Rory O’Connor: Well, the answer to that question I often give is, people end their life as a way of managing unbearable pain. And so for whatever it is, 703,000 people who die by suicide each year, there’s a whole complex set of reasons which will lead to each one of those individuals dying by suicide. But I think the common thread is that those people feel trapped by unbearable pain, which can be caused by a whole range of factors, it could be caused by the fact that your relationship ended or the fact that you had experienced trauma as a child or the fact that your mental health problems are really, really unbearable, but the key driver is seeing suicide as the ultimate solution to your pain. And for Edwin Shneidman, who’s a founding father of suicide prevention from the United States, often talked about this idea of seeing suicide as a permanent solution to our often temporary problems. And so for me to answer the question of why people die by suicide, the answer to that question is, we need to understand, What are the drivers to the mental pain by which an individual feels trapped by? And they see no alternative, no way to end their pain, no solution to that pain, and the only solution is the ultimate solution, that is, to take their own life. So it’s like the person in essence doesn’t want to die, they just want the pain to stop, they just can’t bear the pain.

And maybe we’re gonna go on to talk about my model of suicide, that’s at the heart of my model, that sense of entrapment. And then just say the key premise of the model is that suicidal thoughts emerge, they come out of this sense of entrapment but that sense of entrapment is triggered by feelings of defeat and humiliation. And those feelings of defeat and humiliation are often triggered by loss, by shame, or by rejection. And although that’s the common spine to understand the emergence of suicidal thoughts, then the question goes, For every one of us who become suicidal, the pathways to defeat, the pathways to entrapment are unique.

Brett McKay: We’re gonna take a quick break for a word from our sponsors.

And now back to the show. Let’s dig into the integrated motivational volitional model of suicide behavior that you developed that can help practitioners but also other people, loved ones or even individuals who might be experiencing suicidal ideation, help them figure out where they are in that path towards suicidal behavior. And the first part of the model is the premotivational phase. What are the factors there that can influence whether someone decides to take their own life?

Rory O’Connor: Yeah, the premotivational phase is part one. There are three parts to the model: The premotivational phase, the motivational phase, and the volitional phase. The premotivational phase is like the background context in which suicidal thoughts or behaviors may emerge, the motivational phase is a central… The middle bit of the model, and that’s really trying to understand the emergence of suicidal thoughts, and then the third bit of the model is called the volitional phase, and that’s trying to understand who is more likely to cross a precipice, from thinking about suicide to acting on their thoughts. Going back then to the premotivational phase, the premotivational phase is really trying to understand, What vulnerabilities do we all carry? For example, we all have different vulnerabilities, they could be biological vulnerabilities, for example, there’s evidence that people with low levels of serotonin and other metabolites. And [0:26:14.8] ____ metabolites and other neurotransmitters are associated with suicide risk, that’s a potential vulnerability factor but it’s never an inevitability, it is just a vulnerability factor.

Another vulnerability factor we’ve done quite a lot of work on is on different types of perfectionism, and there’s one type of perfectionism which is described as socially prescribed or just simply social perfectionism. And what that is is if you’re high on social perfectionism, and I speak as somebody who is also high on social perfectionism, is that we’re overly concerned about the expectations of others such that we continually live our life thinking that we’re letting others, important people in our lives down. And I describe it in the book When It’s Darkest, I describe people who have this high social perfectionism as basically having thin psychological skin such that when the bows and arrows of life come at us, when negative events occur, our skin is much more likely to be pierced metaphorically. And so let’s say it’s our premotivational phase because the concern is that people who are high in social perfectionism are much more likely to feel defeated or humiliated when stuff happens to them.

Brett McKay: The social perfectionism is interesting. Will Store, we had him on the podcast talk about his book about social status. He wrote an article about male suicide and he talked a lot about this social perfectionism and the role that plays, as well as status defeat in men can play in a man susceptibility to suicide.

Rory O’Connor: Yeah, no, absolutely, I know Will, Will’s a good guy, and actually Will Store interviewed me as part of that article, and then obviously initially, it was an article in the book or one of his books. And he’s exactly right, which is, that social perfectionism is a really useful framework for us to try and understand as Will has done, understand male suicide. But the way I’ve tried to conceptualize it is, try to understand, Well, how does it increase risk, in my case from a psychological perspective? And I think that idea of the thin skin-ness is a useful way to think about that. So we’ve got that vulnerability aspect, and then the other two bits are environmental influences and negative life events, they’re the last two parts of that premotivational phase. And the environmental influences are really recognizing that this idea that we know that there’s a socioeconomic gradient to suicide and that basically people from more socially disadvantaged backgrounds are much more likely to die by suicide. Some estimates are you’re three times more likely to die by suicide if you’re from a socially disadvantaged background compared to a more affluent background. And now, that’s not to say that people from more affluent backgrounds don’t take their own lives, because they do, but the risk is higher when there’s more social disadvantage.

And then the last bit on the premotivational phase is we know that people who die by suicide or attempt suicide have experienced a disproportionate number of negative life events, and that’s both in childhood as well as across their lifespan. And actually, when you look at the psychophysiology of suicide risk, we also know that people who attempt suicide or die by suicide, their stress system, their cortisol system… Remember cortisol is like the fight or flight hormone we need to help us either defend ourselves or flee a threatening situation. The people who are suicidal, their cortisol system is dysregulated, it’s not working as well, so it adds to the vulnerability.

Brett McKay: Okay. So the premotivational face, these are just the background factors that are already in place in someone’s life that could make them more vulnerable to suicidal thoughts, they won’t necessarily lead to suicide but they’re potential vulnerabilities. You move into the motivational phase of this, this is when ideation and intention formulation occurs. And I think you said what usually kickstarts the ideation is some sort of defeat, whether you lose a relationship, you lose a job, etcetera.

Rory O’Connor: Yeah, absolutely. I’ve touched on the motivational phase when I was answering one of the previous questions, that central idea that suicidal thinking is driven by or it grows out of feelings of defeat and humiliation from which you cannot escape. And it’s that sense of mental pain and entrapment which drives the emergence of suicidal thoughts. And again, when we think about what then drives or causes defeat or humiliation, that’ll be unique for all of us, it’ll be different for every one of us. And defeat and humiliation, again, are often also driven by loss, rejection, or shame. So I think when we’re trying to understand risk at an individual level, that’s a really helpful way to think about it, is asking ourselves, Well, what are the potential drivers to somebody feeling defeated or humiliated? And ultimately, what are the drivers to them feeling trapped? And then if we can identify those drivers, the causes of defeat, the causes of humiliation, we can hopefully intervene either to change the thing that’s leading to the defeat or humiliation. Or if we can’t change that, thinking of ways to support the individual through that crisis time.

Brett McKay: Well, in this part of the model, you have this idea of, I think it’s a threat to self-moderators and motivational moderators. What are those?

Rory O’Connor: Yeah, they are psychological factors. We’re trying to understand… If we think about the model as a horizontal line going from… On the left-hand side, you’ve got defeat and humiliation, and then if you move from left to right, you move from feeling defeated to feeling trapped. And then you move from feeling trapped to suicidal. The threat to self moderators and motivational moderators are psychological factors which we hypothesize facilitate or impede the movement from left to right. That includes things like if you’re a really good problem solver, social problem solver, and you’re feeling defeated… Well, actually if I’m feeling defeated and I can solve the problem, I’m less likely to feel trapped. So let’s take an example of where good problem solving will arrest or stop the movement from left, from defeat to entrapment. Or for example, if you’re feeling trapped, what increases the likelihood that you might become suicidal? Well, if I’m feeling trapped and I’m really socially isolated or I feel that I’m a burden on those around me or if I feel disconnected, I’m much more likely to feel suicidal.

And so that sense of being a burden, that sense of support or isolation, they are these motivational moderators which help us understand who is more likely to move from feeling trapped to suicidal. And although often in the model, we frame it as risk, the presence of all these factors lead to risk, the motivational moderators and the threat to self-moderators help us identify what we describe in psychological terms as targets that we could focus on which will hopefully protect somebody from moving from defeat to entrapment to suicidal thinking.

Brett McKay: There’s the motivational phase, you have the defeat or humiliation which leads to entrapment, which then could lead to suicidal ideation and intent. What causes someone to start shifting over from just ideation to, “I’m actually gonna do something?” We’re moving to the volitional part of this.

Rory O’Connor: Yeah, the volitional phase is the third part of the model, and it’s our attempt to try to identify what we think is about 30% of people who have thoughts about suicide, we think about 30% move from thoughts to suicidal acts, and that includes fatal as well as nonfatal suicidal behaviour. According to the model, there are eight key factors, which I call “volitional moderators” or “volitional factors” which increase the likelihood that you make that transition, you act on your thoughts. And they include things like having access to the means of suicide.

It stands to reason, if I’m suicidal and I’ve ready access to the means of suicide, well, I’m more likely then to act on my thoughts because if it’s ready access, it means that the environmental constraints on you accessing that method are reduced or low, then anything which leads to reduced constraints on access to means increases the likelihood that you’ll engage in that behaviour. And indeed, if you look at the evidence for what works at a public health level to prevent suicide, it is interventions which are focused on restricting access to the means of suicide. That’s like for example having barriers in places of concern, not having ready access to medication and so on. That’s one of the volitional factors.

Others include exposure to suicide. What we mean by “exposure” is that if you know somebody else who’s died by suicide. And again, it stands to reason that if I have having thoughts of suicide and I know somebody who’s died by suicide, I’m more likely to act on my thoughts. And that’s because the mechanism could be that if somebody close to you has died by suicide, that method of death is potentially more cognitively accessible. Or it could be that if that person is like you, you’re modeling their behavior or it could be that it legitimizes the behavior for you because if a loved one uses that method of coping with a distressing situation, well, maybe that’s something you would consider. That’s one of the volitional moderators.

I’ll just say there’s eight of them but I won’t go through all eight, I’ll do a couple more. Impulsivity is one of the volitional moderators. Again, the idea that if you’re having thoughts of suicide and you’re impulsive, it stands to reason you’re more likely to act on your thoughts. And then just maybe two last ones. Second last one in the list, if you read the model, is basically this idea that having mental imagery around dying or death. What we think happens is, if somebody is having thoughts of suicide and they’re picturing themselves either dying or dead, that’s perhaps like a rehearsal mechanism or it could act as a habituation of making death less scary. So then the presence of both thinking about suicide and imagery around death increase the likelihood that you’ll act on your thoughts.

And then one very last one is past behavior. The single best predictor of any future behaviour is whether you’ve engaged in that behaviour in the past, it’s exactly the same for suicidal behaviour. The evidence shows that if you’ve engaged in suicidal behaviour in the past, you’re statistically more likely to engage in suicidal behaviour in the future or sadly die by suicide. It’s important to put that in context because although past behaviour is one of the strongest predictors of future suicidal behaviour, the majority of people who say are suicidal or have attempted suicide in the past won’t do again in the future and will never die by suicide.

Brett McKay: Okay. So that’s the integrated motivational volitional model of suicide behaviour. And what this allows you to do as a practitioner or anybody, there’s points where you can see where you can start doing some preventative things. I’m going to start working here in the motivational part… Or I’m going to start working here in the volitional part. So based on your research, not only do you research suicide, but you research suicide prevention. What’s the best thing that works in suicide prevention?

Rory O’Connor: I’ll answer that in two ways. Large-scale public health interventions have been shown to be effective, that’s things, as I mentioned earlier on the restricting access to the means of suicide, anything which restricts access to the means of suicide has been shown to be effective in reducing suicide. So that’s good news, that’s really good news. Now, that’s challenging, for example, in the United States, that’s challenging when we think about firearms, that’s a really complicated topic to address, given the constitutional implications and so on. That’s a big public health-type example. But if I focus in on the individual level, over the last 20 years, there’s been growing evidence that psychosocial interventions, these are like talking therapies, things like cognitive behavior therapy have been shown to be effective in reducing suicidal behavior over time. So that’s good news. There’s a growth in the evidence base for those sorts of talking therapies.

There also has been a lot of interest and focus on brief interventions, things like safety planning. And safety planning is an intervention that we’ve done some work with ourselves over here in the UK, but safety planning was developed by Barbara Stanley and Greg Brown in the United States. It’s an effective intervention, but it’s a simple intervention, and it really focuses in on the volitional phase. If you think about cognitive behavioral therapy or CBT, it’s more focused on the motivational phase, it’s trying to understand the complex factors that lead to defeat and entrapment and suicidal thinking and so on. But a volitional phase intervention like safety planning is trying to interrupt suicidal thoughts so that somebody doesn’t cross the precipice from suicidal thoughts to suicidal acts.

And it’s very, very simple, the intervention basically has six steps. Step one is you work collaboratively with somebody who’s suicidal to try to identify the warning signs that a suicidal crisis might be escalating. So hopefully, if you can identify in advance, you can intervene and do something to keep yourself safe. And then in steps two, three, four, and five, it helps the individual identify people or places or organizations that they can go to either to distract themselves as the suicidal thoughts might be escalating, or if they feel they cannot keep themselves safe, somewhere to go in crisis or somebody to contact in crisis.

And then step six is the last step of this intervention, and it’s working again collaboratively with the person to help them keep their environment safe, and by keeping their environment safe, what we mean is basically to increase the distance between them and a method of suicide. If they thought about how they might end their life, what can we do to ensure that when that crisis escalates again, they do not have ready access to the means of suicide. So something like that I would really focus in on, that safety planning, it’s only one example as a brief intervention, but a really important one because it’s something which intuitively makes sense, Brett, but something we can all be thinking about.

Brett McKay: And then also on an individual level, if you know someone who you’re worried about, we talked about this earlier, don’t be afraid to ask them if they thought about taking their own life because it’s not going to implant that idea in their head to do it, it’s just that could actually be the thing that could kickstart them getting the help they need.

Rory O’Connor: Yeah, absolutely. And really, we cannot emphasise that enough, if you are concerned, please ask somebody directly whether they’re suicidal. But I appreciate that that’s a difficult thing to do, and again, I describe some tips in the book. But in essence, if the person answers “yes,” that I am suicidal, in many respects, that’s your biggest fear… If you ask that question, and somebody says, “Well, yes, I am suicidal.” Your biggest fear is, “Well, what do I do next?” What you do next is you just validate how they’re feeling and say, “That must be really difficult for you.” That’s all we mean by “validation.” “That must be really difficult for you.”

It’s not about trying to solve their problems, it’s trying to acknowledge, be alongside them in their distress and then encourage them to think about how they might be able to get support if they think they cannot keep themselves safe. And that sense of common humanity, that sense of connection and treating an individual as worthwhile, as somebody who’s valued in this world, because many people who are suicidal don’t think that they have a role in society anymore and feel that they are a burden. So anything which promotes connectedness and then encourages them to maybe reach out, speak to their physician, their general practitioner, somebody else in their life who can help keep themselves safe. I would really encourage people to do that. Please, please reach out.

Brett McKay: Let’s talk a little bit… You talk about this in the book, about those who are bereaved by suicide, so family members who had a loved one that took their own life. How does their grief differ from someone who might have just experienced someone who died by other causes? And any advice for them on how they can navigate that? And I guess the other question there too would be, What can people do to help those who are bereaved by suicide?

Rory O’Connor: Yeah, again, really important questions. The grief associated with a suicide is complicated because, of course, any sudden death is devastating, but on top of the sudden death, there’s often shame and guilt and, “What could I have done differently?” And again, I speak as somebody who’s twice bereaved by suicide, and in particular, with a close friend of mine who took her own life. I still ask myself today what I could have done differently and I felt in part responsible for not being able to save her life. And many people bereaved by suicide feel the same. So part of it is trying to be more self-compassionate. No one of us should ever be held or can ever be held responsible for the actions of another person. Recognizing that the prediction of suicide is so, so difficult, and as I said earlier, it’s no better than chance, our ability to predict suicide. And so recognize that every day is different, every day is different and it’s the pain, anger, the steps of bereavement, that people go through them differently. And probably the only certainty about bereavement by suicide is its uncertainty, is its unpredictability, some days you might feel okay and other days not, and it can come on such unpredictably obviously.

And I suppose it’s also recognizing that although as days become weeks and weeks become months, it’s all about moving forward, it’s not forgetting, it’s just you’re moving, step forward, step forward, step forward. You’re changed as an individual, of course, you are, and it’s just trying to recognize that, and things do become a bit easier.

In terms of advice for those who are around those who have been bereaved, again, it’s just recognizing that the person is going through unbearable pain. Don’t be frightened because one of the big fears, again, is, “I’ll say the wrong thing.” And again, the advice that I would certainly give, and I know from speaking to countless others who have been bereaved, is as long as somebody treats you with humanity and compassion, you’re unlikely to say the wrong thing. And don’t judge. It’s nonjudgmental. Don’t try and tell the person how they’re feeling, just be alongside the person and let them know that you’ll be with them, you’re there if they need them at any stage. And please don’t cross the road because that still happens, that idea of people who are bereaved by suicide and people cross the road instead of speaking to them, and that’s often out of fear of saying the wrong thing. Please, please support each other.

Brett McKay: Well, Rory, this has been a great conversation. Where can people go to learn more about your work in the book?

Rory O’Connor: To find out more about our work, we have a website, the website is www.suicideresearch.info that’s suicideresearch.info, and the book is available I think everywhere, so wherever you tend to get your books, in Amazon or wherever, or other obviously booksellers, the book’s widely available.

Brett McKay: Well, Rory O’Connor, thanks for your time, it’s been a pleasure.

Rory O’Connor: Thanks so much, Brett, I really enjoyed our conversation.

Brett McKay: My guest today was Rory O’Connor. He’s the author of the book, When It Is Darkest: Why People Die by Suicide, and What We Can Do to Prevent It, it’s available on amazon.com and bookstores everywhere. Check out our show notes at aom.is/suicide, where you can find links to resources, we delve deeper into this topic.

Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofmanliness.com, where you’ll find our podcast archives, as well as thousands of articles that we’ve written over the years about pretty much anything you think of. And you’d like to enjoy ad-free episodes of the AOM podcast, you do so on Stitcher premium. Head over to stitcherpremium.com, sign up, use code “manliness” to check out for a free month trial. Once you’re signed up, download the Stitcher app on Android or iOS and you can start enjoying ad-free episodes of the AOM podcast. And if you haven’t done so already, I’d appreciate it if you take one minute to give us a review on Apple Podcasts or Spotify, it helps out a lot. If you’ve done that already, thank you. Please consider sharing the show with a friend or family member who you think would get something out of it. As always, thank you for the continued support. Until next time, this is Brett McKay reminding you to not only listen to the AOM podcast, but put what you’ve heard into action.

The post Podcast #900: The Myths and Truths Around Suicide appeared first on The Art of Manliness.

An important part of manhood has always been about having the competence to be effective in the world — having the breadth of skills, the savoir-faire, to handle any situation you find yourself in. With that in mind, each Sunday we’ll be republishing one of the illustrated guides from our archives, so you can hone your manly know-how week by week.

Tourniquets exist in a class of medical techniques associated with wilderness survival and military medicine primarily because they are only used in drastic, uncontrollable circumstances. Whether on the battlefield or some distant peak, a tourniquet is often the only way to stop excessive bleeding to severely injured limbs. Using a strip of fabric, belt, or other material, tourniquets constrict blood flow until the wound can be attended to by medical professionals.

During World War II, tourniquets were used heavily in the field, but because soldiers often had to wait hours on end to be seen by surgeons and medics, their constricted limbs suffered nerve and tissue damage that forced amputations. The perceived relationship between tourniquets and amputation caused them to fall out of use for decades, but research that emerged from the battlefields of Iraq and Afghanistan showed that, when used correctly, the benefits of tourniquets far outweigh the risks, especially in circumstances where patients can receive proper medical care within a few hours of their application.

The bottom line is that when blood loss from a limb injury risks death, a tourniquet is a lifesaving technique that cannot be ignored.

Like this illustrated guide? Then you’re going to love our book The Illustrated Art of Manliness! Pick up a copy on Amazon.

The post Skill of the Week: Apply a Tourniquet appeared first on The Art of Manliness.

When men think about optimizing their hormones, they tend only to think about raising their testosterone. But while increasing T can be important, an ideal health profile also means having testosterone that’s in balance with your other hormones as well.

Today on the show, Dr. Kyle Gillett joins me to discuss both of those prongs of all-around hormone optimization. We start with a quick overview of the different hormones that affect male health. We then get into what qualifies as low testosterone and how to accurately test yours. We also discuss what causes low testosterone in individual men, and how its decline in the general male population may be linked to both birth control and the world wars. In the second half of our conversation, we discuss how to both raise testosterone and get rid of excess estrogen, including the use of some effective supplements you may never have heard of. We then get into the risks and benefits of taking TRT, before ending our discussion with what young men can do to prepare for a lifetime of optimal T and hormonal health.

Resources Related to the Podcast

• AoM series on testosterone, including How I Doubled My Testosterone Levels Naturally
• AoM Podcast #761: How Testosterone Makes Men, Men
• AoM Podcast #878: The Fitness Supplements That Actually Work 

Connect With Dr. Kyle Gillett

• Kyle on IG
• Gillett Health Podcast on Spotify and Apple
• Gillett Health on YouTube
• Gillett Health website

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Read the Transcript

Brett McKay: Brett McKay here and welcome to another edition of The Art of Manliness Podcast. When men think about optimizing their hormones, they tend only to think about raising their testosterone, but while increasing T can be important, an ideal health profile also means having testosterone that’s in balance with your other hormones as well. Today in the show, Dr. Kyle Gillette joins me to discuss both of those prongs of all around hormone optimization. We start with a quick overview of the different hormones that affect male health. We then get into what qualifies as low testosterone and how to accurately test yours. We also discuss what causes low testosterone in individual men and how it’s decline in the general male population may be linked to both birth control and the world wars. In the second half of our conversation, we discuss how to both raise testosterone and get rid of excess estrogen, including the use of some effective supplements you may never heard of. We then get into the risk and benefits of taking TRT before ending our discussion with what young men can do to prepare for a lifetime of optimal T in hormonal health. After the show is over checkout our show notes at aom.is/optimalt.

All right, Dr. Kyle Gillette, welcome to the show.

Dr. Kyle Gillette: Thank you. My pleasure.

Brett McKay: So you are a medical doctor. You do family practice, you specialize in obesity but also hormone optimization, helping people have healthy hormones so they live a flourishing life. And today I’d like to talk about hormones, particularly male hormones. I think when most people think about male hormone optimization, they think about testosterone and which is obvious why you do that. And we’re gonna dig deep into testosterone today. But are there other hormones that affect male health that people often overlook?

Dr. Kyle Gillette: There certainly are. So even testosterone in and of itself, there’s nothing unique about it compared to other androgens. There’s just one androgen receptor. Testosterone just happens to be the most well-known androgen. So there’s DHEA, which is a very weak androgen. It’s produced by the adrenal glands, which are small glands above the kidney. There’s DHT, which is dihydrotestosterone. This is a very strong androgen. You don’t have as much of it as testosterone, but it’s vitally important for what’s called secondary sexual characteristic development, like the deepening of the voice, growing facial hair, those secondary sexual characteristics which are vital.

Brett McKay: And also I think people often overlook estrogen plays a role in male health.

Dr. Kyle Gillette: Certainly, testosterone aromatizes and directly converts to estrogen. So the way to think about estrogen is the more estrogen the better for your health because it prevents things like heart attacks at a correct ratio to where you feel good.

Brett McKay: Okay, so we gotta have some estrogen in there at the right balance. And then there’s another hormone called SHBG. What does that do?

Dr. Kyle Gillette: So SHBG is also known as androgen binding globulin. It’s a protein, it’s made in many places, the liver makes most of it, but the testes also make some of it. And SHBG stands for sex hormone binding globulin, it most strongly binds DHT and then it binds testosterone, relatively strongly, DHEA weaker than that. And then estradiol, which is your main estrogen, even weaker than that. So think of this as regulating all of the hormones and keeping them more stable. The higher the SHBG, the more stable the level will be. Men produce a lot of testosterone during sleep. So the level is generally much higher in the morning. But if you have a very low SHBG you’ll crash and you can actually have deficient levels of testosterone in the evening routinely. But normal levels in the morning if you don’t have enough SHBG, the most common cause of an SHBG deficiency is insulin resistance, which is often due to too many calories or too many carbohydrates and sugar.

Brett McKay: So what’s interesting about all those hormones is they interact with each other. It’s a complex system so if you raise the level on one, one might go down or up. So I think a lot of guys they get too focused on, well I gotta increase this one thing or reduce this one thing. Well, if you do that you’re gonna have these cascading effects that might not be optimal.

Dr. Kyle Gillette: Correct. I actually heard an advertisement from a TRT clinic this morning and it said new studies shows that men with low testosterone are more prone to cardiovascular disease and early death and diseases of aging. And I thought to myself, this is odd because they are implying that you need testosterone replacement to prevent this. But of course that is a logical fallacy because just replacing the testosterone without figuring out what’s actually causing it in the first place, not that TRT is wrong, but you need to figure out what the cause of it is and then address it.

Brett McKay: Okay. And I hope we can talk about TRT ’cause I know a lot of guys are thinking about doing it or maybe they are doing it and they might have questions about that. Let’s talk about testosterone. So there’s two ways to measure testosterone or two measurements of testosterone that I read about. One is total testosterone and free testosterone. So first, what’s the difference between the two and as a clinician is there a particular number you focus on?

Dr. Kyle Gillette: Yeah, so total testosterone is a total amount of testosterone, whether it’s bound or unbound, when testosterones bound it in general does not bind the androgen receptor, which is on the X chromosome. And total testosterone includes a testosterone bound to albumin, which is the main protein in the blood and also SHBG which we talked about earlier. But free testosterone or any free androgen is what is going to be what is actually binding to the receptor. And then it takes it into the nucleus of the cell and then it binds to DNA to cause what’s called gene transcription. So the androgen receptor gene that’s on the X chromosome is then mostly activated by free testosterone. Oddly enough, sometimes I make the analogy of plumbing. So you have a pipe that’s your bloodstream that takes testosterone everywhere and then you have different types of cells. For example, a muscle cell or a brain cell or a germ cell in the testicle or a somatic cell in the testicle, which we don’t have to get into. But anyway, the free testosterone level can be very different in the bloodstream, which is where we measure it on a blood test versus inside the cell. So it is possible to have symptoms of low testosterone because you don’t have enough androgen in the cell but have a normal level in the blood. It’s rare but it’s possible.

And the opposite is possible, to have a low level in the blood but still have enough inside the cell that’s free to be causing normal gene transcription.

Brett McKay: Okay. So just to recap there, total testosterone is made up of bound and unbound testosterone. Bound testosterone could be bound to albumin or SHBG. And then when it’s bound to those things it can’t attach to the antigen receptor in the cell and so it can’t be… Can’t effect have those changes on the cell. Free testosterone, unbound testosterone is free testosterone. So as a clinician, when you do a blood test on a patient, what number is more important to you? Which one are you gonna be focusing on more? Is it the free or the total?

Dr. Kyle Gillette: I think both are equally important. For athletic purposes, for muscle building purposes. Usually that’s more correlated with free testosterone level. However, symptoms and how you feel is usually correlated more with total. Insurance companies and academic societies usually put more weight into total testosterone, partly because free testosterones are often measured inaccurately so often it’s more accurate to calculate your free testosterone using your total testosterone and your SHBG and then you estimate what your free testosterone is. Some societies say low testosterone is often best treated if you one, have symptoms. And then two, also have a testosterone below about 400. That’s what the urologists say. Most other societies go by 300 and I tend to agree with the level of 400 with a caveat if you have significant symptoms and with a second caveat, if you cannot improve that naturally in any way after identifying the root cause.

Brett McKay: Okay. I wanna dig more into diagnosing low testosterone because there’s lots of commercials out there. You just mentioned one or these businesses popping up where you can just go in, get a blood test and like, hey, you got low T, here’s testosterone and maybe they don’t. So you mentioned two things you look at to diagnose low testosterone, you’re gonna do blood work and if it’s below 400, coupled with if the patient is reporting symptoms of low testosterone, we’ll talk about the symptoms of low testosterone here in a bit, but let’s talk about blood work. ‘Cause I think a lot of guys out there, they think it’s a panacea, if you just take a test, you take the test and it says, oh well, your T is at 400. They’re like, well I got low T. Why isn’t one blood test alone sufficient to diagnose low testosterone?

Dr. Kyle Gillette: Yeah, in general testosterone levels can have what’s called outliers. It’s the statistical phenomenon. But it’s especially true of testosterone where you could check it one time and your testosterone that morning could be low because the last two nights you’ve had poor sleep and poor diet and other lifestyle factors. Males that are generally seeking a TRT prescription know those very well because there’s various things that you can do to artificially make your testosterone level look low that morning. So in general, the recommendation is to recheck it two to three times after a good night of sleep and normal diet and whatever you’re doing normally not after you’ve dieted down to 7% body fat to do an ultramarathon or body building show, then your testosterone is certainly going to be low. But when you’re at a healthy body fat and there’s not an artificial something else that is going to make your testosterone look low. There’s a runner, his name is Nick Bare and he also is doing a body building show and I saw that he got his total testosterone checked and he’s a healthy guy. I’m not sure what his baseline testosterone is and his total testosterone was right at 100 before his body building show.

So that was obviously secondary to the caloric deficit. That wouldn’t necessarily count as a testosterone reading that you could put stock in assessing TRT or not. But for most people they probably won’t be in a scenario like that. But it is important to get at least two readings. If you’ve been sick before, then maybe just postpone the blood test by a week. That way you get an accurate reading.

Brett McKay: Let’s move on to the symptoms. So you do the blood test, what symptoms are you looking for to diagnose low testosterone?

Dr. Kyle Gillette: Yeah, could be through any system. So it could be anything from depression, anxiety to low libido is certainly classic. Low muscle mass is not really one that we look for. Testosterone levels that are naturally produced are not as correlated as people would think with body composition and muscle mass and athletic performance. So it’s not uncommon to see a pretty high level athlete have a total testosterone of let’s say 450 and let’s say someone that has very low muscle mass and maybe even 20%, 22% body fats have a total testosterone of 1000 and there’s not as much correlation. But other things that you would look for seriously is, for example, erectile dysfunction, sexual health in general, sperm production. So if there’s a patient that is having even sub-fertility, just a little bit of trouble getting pregnant, that individual should certainly have a test of his testosterone as well.

Brett McKay: So with low libido, how does a guy know if he has low libido? Because that seems like it’d be pretty subjective.

Dr. Kyle Gillette: Yeah, libido obviously has a lot of psychosocial factors as well. It’s usually taken at a patient’s word and a lot of times when you’re testing these patients, you’ve known the patients for a while, sometimes you haven’t. But if they’re telling you that it’s low relative to what it usually is and no other factors have changed, for example, you know they’ve been married to the same person for five years, they’re not actively going through problems in the marriage, there’s not something else that would be affecting the libido. So that would usually come up in the social history. When you do a history and physical on a patient, it is important to dig into the social history to make sure there’s not something else that is affecting the libido.

Brett McKay: So besides the low libido, maybe the lack of drive, what are the consequences of suboptimal male hormone levels like chronically? Is it gonna affect your cardiovascular system? Is it gonna affect cancer? Does it affect things like that?

Dr. Kyle Gillette: It will. If someone is significantly hypogonadal for a long time, they’re at much higher risk of osteoporosis, which leads to bone fractures and even mortality as well. They’re at higher risk of neurodegenerative disease, likely largely due to low estrogen. If you don’t have a lot of testosterone, you’re probably not converting a lot of it to estrogen and if you’re not doing that then you’re also at risk of cardiovascular disease. Estrogen is very cardioprotective and helps with the production of good cholesterol to help take cholesterol out of the plaque. So they’ve done studies and you look at one group of people that have true hypogonadism, which is generally two levels under 264 or so, and then one group you give TRT and then one group you don’t give TRT, you would think that the group that you give TRT would’ve a shorter lifespan ’cause androgens do cause excess production of “bad cholesterol.” They do increase a particle called ApoB, which is the most important one to watch for cardiovascular risk. But the group that you give TRT actually has less heart attacks and strokes.

Brett McKay: Right, because what you were saying before, the testosterone creates estrogen and then the estrogen protects the heart. So let’s talk about the causes of low testosterone. What can be behind low T?

Dr. Kyle Gillette: Most commonly, metabolic syndrome. So excess calories, excess carbs, insulin resistance, high fasting insulin leads to the liver not producing SHBG. So you might be producing a decent amount of testosterone but it’s being metabolized so fast that it’s difficult to use. That’s most common. The second most common I think is sleep apnea or obstructive sleep apnea. Obviously that kind of goes hand in hand with metabolic syndrome but often it goes hand in hand with PTSD. I saw a study on young men that had just gotten out of the military and they had been diagnosed with PTSD and they tested them all for sleep apnea and something like 80% of them had sleep apnea and they were all under under a BMI of 25. So there’s certainly a lot of stress component as well. The limbic system includes places like the hypothalamus and the amygdala and downstream to that is the hippocampus and the amygdala, downstream of those is the hypothalamus and that’s some of the places of the brain that are involved in sleep regulation and breathing.

So the theory is that apneic episodes don’t just come from having a huge neck and excess body fat, but there are other factors like trauma at play. And when you have a patient with severe sleep apnea, they have a score called a AHI score and if that score is very high, like 100 or 200, you almost always see deficient testosterone levels.

Brett McKay: Okay, so having metabolic syndrome, being overweight, sleep apnea, any other causes of low testosterone?

Dr. Kyle Gillette: Yeah, so theoretically xenoestrogens could be a cause of low testosterone. These are things like phthalates. These are also things like bisphenol A, also known as BPA, you might see BPA free on water bottles from time to time. These do bind various estrogen receptors and are likely suppressive. By suppressive, I just mean they shut down the production of the hormones that lead to testosterone production to some degree. Heat damage is also kind of an honorable mention. Some people might be familiar with what varicose veins are. Varicocele is where there’s varicose veins in the scrotum and some people with varicocele can have venous cooling very well. The testes wanna be about 91 to 92 degrees where the body is 98.6 degrees. So if you can’t keep your testes at 91 or 92, then you’re going to have less testosterone production and less sperm production. And in the more severe cases you’ll have atrophy, which is shrinking because, think about them as factories. If you’re not using the factory, they start to shut down.

Brett McKay: And besides these lifestyle factors and environmental factors, you could also have just an issue with your pituitary system, right? You might have a tumor or something in pituitary gland that’s dysregulating the release of hormones.

Dr. Kyle Gillette: Correct. I suppose that would be likely one of the more common less modifiable risk factors. There’s not a lot that you can do about that. You can take supplements like vitamin B6 or like vitamin E, but a lot of times pituitary microadenomas or even macroadenomas, basically it’s a small tumor in the brainstem. The pituitary gland is where you make a lot of different hormones like growth hormone and like LH and FSH. But LH is the main hormone that’s produced there that leads to testosterone release. So there’s two different types of hypogonadism. There’s primary and secondary. So primary is where the testes are not functioning. And then secondary, think about it, it’s two steps instead of one step. So the LH can be low in secondary hypogonadism and if your LH is very low and a hormone like prolactin or IGF-1 is very high, then that might be a sign of a pituitary micro adenoma. In which case you need MRI.

Brett McKay: And LH, that’s Luteinizing Hormone, correct?

Dr. Kyle Gillette: Correct. LH is Luteinizing Hormone. FSH is follicle stimulating hormone. They do crosstalk to some degree, but LH mostly helps with testosterone production and mostly binds to the Leydig cell in the testicle. And FSH mostly binds in the seminiferous tubules and helps with spermatogenesis.

Brett McKay: So I mean listeners have probably heard reports that T levels in men have been declining in the past few decades. Do we know what’s causing this sort of general decline? Is it just all these lifestyle, like people are getting fatter, there’s not sleeping, they’re stressed, and the stuff in the environment is that kind of what we’ve decided is the cause of the lower T levels?

Dr. Kyle Gillette: The various causes that we’ve already discussed are likely the primary causes of what is causing declining testosterone levels. But I think there is another factor, and a lot of that has to do with what I’d call epigenetic drift. Some people might call it natural selection, I might call it unnatural selection, where individuals with higher testosterone levels are no longer being selected for as early. And also a lot of individuals are having kids later on in life, for example, in their 30s or even 40s, when you might have very different maternal and paternal hormone profiles. That’s one of the reasons why I recommend if men are taking medications like Finasteride or Dutasteride, that they stop their Finasteride 90 days before attempting conception and they stop Dutasteride, depending on what dose they are, usually six months before conception. By the way, spermatogenesis takes about 60 days or two months. That way they have enough time to wash out before they start producing the sperm in the germ cells so that they wouldn’t pass down any epigenetic changes to potential offspring.

Brett McKay: Okay, so maybe this is… The idea is that… Again, this is theoretical, right? The testosterone increases aggression and risk taking behaviors and that’s not as adaptive in our safe high tech modern landscape. So men with lower testosterone might be more successful these days and women choose those men for their partners and then when they have children, the men pass down his genes and then his children have lower testosterone too. And that just perpetuates, just lower testosterone in the male population overall. Also, this idea of selection, I’ve heard that, I read this somewhere, correct me if I’m wrong on this, that women on birth control, they’re not attracted to higher testosterone men. Is that true?

Dr. Kyle Gillette: Yeah, that is one of the major players of what I would call unnatural selection. Another interesting unnatural selection, I suppose, if you look at, not very recently, but the World Wars, certainly in World War I and World War II or in the Korean War or Vietnam War, but especially wars that… Even if a war has a draft, the individual that has higher testosterone and also more sensitive androgen receptors, so this is probably true throughout all of human history, you would… And this obviously cannot be proven scientifically, but theoretically that individual would be more likely to volunteer to go to the front line or to very risky positions. And if that male passes away at age 18 or age 19, then that is likely a fecundity rate of zero. So no offspring from that individual and then you start to have genetic drift.

Brett McKay: Okay, so again, this is theoretical, what you’re saying is that men with very high testosterone, they’re gonna take more risk and in doing so, that may take them out of the gene pool by taking those risks. And there’s more opportunity for that sort of risk taking during big global conflicts like the world wars, right? More high T men die, they lose the chance to reproduce and pass on their genes. And then that just contributes to the declining testosterone in men in general. And that’s gonna have echoes through the generations. And on top of that, we have selection factors going on in the mating market as well.

Dr. Kyle Gillette: Yes. And it’s not like it’s an be all end all. All or nothing. You select for high testosterone or you select for low testosterone. There’s a lot more psychosocial factors at play, but we are certainly seeing that there’s likely a decline in testosterone even a bit more than could be accounted for by just metabolic syndrome and sleep apnea. Maybe things like heat damage to the testicle, maybe things like xenoestrogens are playing some part in this, but we’ll probably never know. But it’s very fun to speculate about it.

Brett McKay: Well, the heat damage to the testicle, what would… Causes like keeping your laptop on your lap, sitting down a lot, would that cause heat damage?

Dr. Kyle Gillette: Probably not significantly enough, but if you already had a Varicocele and you already spent an hour in the jacuzzi, keeping your really hot laptop and phone directly over your scrotum is certainly not gonna help. I suppose someone could prove this at some point. They’ve actually done a lot of studies where they look at the scrotal temperature and they’ve randomized two groups of usually, college students and one group they have wear basically like a sock around their scrotum that has something really warm in it. So they warm up the scrotum artificially to 98 degrees instead of 91 or 92 degrees. And in the individuals that don’t have varicocele, they can still overcome that heat damage because their venous pooling mechanism is so good at buffering that heat damage. So that did not affect their testosterone production and it did not affect their spermatogenesis. However, in individuals that already have impaired venous cooling, for example, with varicocele or varicose veins then it did.

Brett McKay: We’re gonna take a quick break for a word from our sponsors. And now back to the show. Let’s talk about optimal levels of testosterone. So below 400, and if you’re experiencing low testosterone symptoms, that’s not good. Is there an optimal level, as like a level that guys should reach for or is it gonna differ from man to man?

Dr. Kyle Gillette: It certainly differs, but that’s kind of an easy answer. So I’ll get into it more than that. A lot of times people have told me that I say individualized, I say that word a lot because health is individualized. We are all unique, we have different genetics, we have different epigenetics and we have different growth and development past that as well. But for most men, an optimal testosterone level is between about 500 and as high as you can go naturally. So there is some individuals with a total testosterone of 1500, they almost always have really high SHBG. So a lot of times their free testosterones only 20 or 25, between about 550 and whatever you can produce top in endogenously naturally without medication.

Brett McKay: But you also said it could be lower. I mean you mentioned there are athletes who are at 450 and they’re healthy. So if you get a blood test and it’s below 500 a little bit, you probably… I mean, I guess you shouldn’t worry too much about it if you’re not experiencing any symptoms.

Dr. Kyle Gillette: Correct.

Brett McKay: Okay, that’s good to know. So let’s say a patient comes to you reporting symptoms of low T, you do a series of blood tests that show yeah, that your T levels are low, they’re below 400. What’s your first line of attack in helping this patient get his T levels up?

Dr. Kyle Gillette: First thing to look at would be LH and FSH. If those are really low, then I’m worried about the pituitary or the brain. If those are really high, then I’m worried about the health of the testicles. If they’re in between, then I look for another pathology like diabetes, metabolic syndrome, insulin resistance, sleep apnea, etcetera. I also look at prolactin and IGF-1, make sure you assess their tumor risk. And then I also look at estradiol. If it’s a very high estradiol, then estradiol is likely what is suppressing the production of LH from the pituitary. So you have estradiol, which is your main estrogen, which is causing less testosterone production. And in that case, I look at things like alcohol consumption that can up-regulate aromatase or consumption of excess calories or fat that can up-regulate aromatase, which converts testosterone to estrogen by the way. So those are the first things.

Brett McKay: Beyond that, what are you looking at?

Dr. Kyle Gillette: Beyond that, I’d like to, if pertinent, do an exam, make sure, especially if this individual is developing, if they’re an adolescent or whatnot, you need to make sure that they’re through all the tanner stages. Basically tanner stages one to five, five is done, when you’re essentially adult growth and development to make sure that they don’t have some unusual or unlikely syndrome. And then after that I’d like to look at their fasting insulin, their A1C, see if there’s something that I can correct. I look at their cortisol. If their cortisol is high, then there’s a lot of lifestyle factors and also supplements that can help control cortisol like Ashwagandha or Emodin. I look at their prolactin. So if their prolactin is just a little bit high, then maybe I do start them on some Vitamin B6 or some Vitamin E. If their estrogen is high, maybe I start them on some Calcium D-glucarate that helps with estrogen glucuronidation and metabolism. It basically helps you excrete it through your stool and then repeat labs in one, two, maybe even three months and see if we can improve those things along with, as always, diet and exercise.

Brett McKay: Okay. So it sounds like the first line of attack, if it’s not a pituitary problem, you’re gonna be primarily doing lifestyle changes, right? Quitting drinking, getting better sleep, diet, exercise to help get that insulin sensitivity back online. So yeah, lifestyle stuff would be the first line of attack and then will it take maybe one to two months before you start seeing results from that?

Dr. Kyle Gillette: Yeah, often it does. A lot of times you feel better the first week and a lot of times your testosterone production recovers very quickly. But occasionally, I use medications as well. So some people utilize a short course of HCG, which essentially binds the LH receptor, takes the place of LH and occasionally, I’ll utilize very short courses. By very short, I mean, a week or maybe two weeks of selective estrogen receptor modifiers or sometimes longer in the right patient, especially very young patients that you’re trying to stimulate endogenous production, these are often patients that desire fertility within the near to mid near future.

Brett McKay: Besides diet, exercise, sleep, managing stress, you mentioned a few supplements that you recommend men taking to optimize male hormones. Are there ones that you recommend for just any guy who… Maybe they don’t have any problems with testosterone but they just want to feel good? Are there ones that you like and that are safe?

Dr. Kyle Gillette: Creatine 5g-10g a day would be a great start. L-carnitine would be a consideration, especially if they’re interested in athletic performance optimization or body composition optimization, L-carnitine would be reasonable. Consider checking a TMAO to make sure that it doesn’t convert to that in too high of a rate. Another reasonable addition if someone has high estradiol would be Calcium D-glucarate to make sure that they’re binding up extra estrogen and excreting it.

Brett McKay: I’ve heard that Boron can impact testosterone. How does boron increase T levels?

Dr. Kyle Gillette: Boron works okay for people with really high SHBGs. It increases free testosterone by decreasing SHBG. The effect wears off to some degree if you take Boron for a very long period of time. If you have very low levels or you’re insufficient or deficient in Boron, it works extremely well and a lot of people consume Dates or Raisins because they tend to be relatively high in Boron.

Brett McKay: There’s another something I’ve been hearing about lately, Tongkat ali, I think that’s how you pronounce it. What’s going on with that one?

Dr. Kyle Gillette: Tongkat ali is also known as Longjack. So Tongkat’s active ingredients are Eurypeptides, one of which is Eurycomanone. And Tongkat is helpful because it upregulates a couple different enzymes in the steroidogenesis pathway. There’s been plenty of human study on it, with mixed results and it looks like the cause of the mixed results is, sometimes people have great activity of those enzymes. So that’s not the rate limiting step in testosterone production. So think of it as a signal, think of your testicles as a factory. Tongkat is a signal to that factory to ramp up production, but if your factory is already operating at maximum capacity or it’s limited by something else, then that’s not going to improve your testosterone level. Tongkat works on very similar enzymes that are also upregulated by insulin and IGF-1. So in general, if you’re in a caloric deficit or if you’re trying to lose weight or body fat, Tongkat will work better. If you have a low fasting insulin or a lower end IGF-1, Tongkat will also likely work better. And I’ve seen this anecdotally as well.

Brett McKay: A couple years ago, I remember ZMA was a big supplement that was pushed for increasing testosterone levels. Anything to that?

Dr. Kyle Gillette: ZMA is very reasonable to add if you have a low alk phos. So if you look at your CMP, which is your metabolic panel, there’ll be an enzyme called alkaline phosphatase. Alkaline phosphatase along with GGT are two intracellular enzymes. And the lower these two are the more likely you are to have insufficient levels of Zinc and magnesium. That’s why when I have input to various companies designing a supplement to optimize testosterone, I almost always put in Zinc, Magnesium and Vitamin D. You just wanna make sure these aren’t the right limiting step. Think about trying to optimize your testosterone is like trying to get into a fraternity. You’re not just making best friends with one of the people and then just hoping that nobody else will blackball you. You wanna make sure that you address each individual because if you… Let’s say you forget your Vitamin D and forget your Zinc, you’re deficient in Zinc, you’re deficient in Vitamin D, those two things will hold you back.

Brett McKay: Once you start down this path of increasing your testosterone or getting them optimized, is there any benefit to getting them higher? So let’s say you started off at 400, you had low T symptoms and then through lifestyle changes and maybe taking some supplements, you bump it up to like a 700. Are you gonna get any more benefit from testosterone by getting it up to 800 or 900?

Dr. Kyle Gillette: Past about 600, there’s little to no benefit, other than bragging rights.

Brett McKay: At what point would you have a patient go on testosterone replacement therapy?

Dr. Kyle Gillette: At any point when the risks outweigh the benefits and they understand both the risks and the benefits in their own terms.

Brett McKay: So what are the risk of TRT?

Dr. Kyle Gillette: Yeah, one of the risks is it causes more fluid retention and swelling. One of the risks is if you hyper convert to estrogen, estrogen will then bind to the liver and cause more SHBG and platelet production. And if your platelets go very high past a certain point, we know that people on oral estrogen, the blood clot risk is associated with how high their platelets and SHBG go. It’s likely the same for TRT. So if you go on TRT and you go into a huge bulk and you start consuming a bunch of alcohol and your platelets skyrocket, then it is gonna increase your blood clot risk. So TRT is not in and of itself going to improve health, it’s just going to be a tool to help you achieve a lot of your goals. Another risk of testosterone is if people have heard of medications called statins. Those work by decreasing the activity of an enzyme called HMG-CoA reductase. Any androgen including testosterone increases the activity of this enzyme. So often people’s cholesterol and it’s not actually cholesterol, they are lipoproteins, but people’s “bad cholesterol” gets worse. That’s why we watch that ApoB number very closely because we know that ApoB is the particle that is going to lead to plaque formation in areas like the coronary artery.

Brett McKay: And I guess the benefits of TRT is that you’ll mitigate those symptoms of low testosterone?

Dr. Kyle Gillette: Correct. And there’s of course other benefits as well like the benefits of estrogen, that we discussed earlier, being it’s cardioprotective benefit. And one of the main benefits of testosterone in a lot of individuals that I see start is they might have a… Let’s say they have an A1C of 5.7 or 5.8, which is technically pre-diabetes. You’re very unlikely to get diabetes on testosterone compared to if you are not on TRT. So a lot of individuals, perhaps they’re, I wouldn’t say doomed, but very likely to get diabetes and TRT can make a huge difference, especially when combined with other insulin sensitizing medications to prevent that.

Brett McKay: Do you keep people on TRT indefinitely? Is it like once you start to keep doing it or are there periods where you’re like, “Well, we’re gonna take you off and see what happens” or well how does that work?

Dr. Kyle Gillette: Most individuals are on indefinitely, but not everyone. Occasionally there’ll be a patient that is profoundly hypogonadal and the benefit of testosterone at that time is just huge. Let’s say it’s a patient who has a BMI of 40 and they weigh 400 pounds and they also don’t have a huge amount of lean body mass to lose in proportion. Everybody who weighs 400 pounds is gonna have a lot of lean body mass, but just less relative to your average person and they wanna maintain as much of that as possible. They need that tool in order to exercise, even if it’s somewhat of a placebo tool, that still helps. So if it gets them having a very healthy lifestyle, they go on that medication, perhaps they go on another medication like a GLP-1 for a short period of time and then they don’t really know what their baseline testosterone is. So maybe after two years they’ve learned those lifestyle interventions. They very slowly are ready to come off of every medication and then you can use a medication like HCG to help restore natural production. Perhaps one week of a medication like Enclomiphene or Novedex or even Raloxifene. And then you see what their natural production capability is. You give them a few weeks and perhaps they restore to a total testosterone of 600s, which is likely quite good in that situation or perhaps they go down to 100s again.

But a lot of people would want that chance to go back to producing their testosterone naturally. And in some cases it does work. I would say 90% of people that start on testosterone are going to remain on it indefinitely. But I would also say that 90% of people that go on testosterone can very likely regain at least their previous level of testosterone if they were to want to come off.

Brett McKay: Well, here’s a question. With female hormone therapy, you might start taking it during menopause to help with symptoms, but at a certain point, once menopause is over, I think you’re supposed to get off those hormones. Does something like that happen for men? I mean, you might do TRT throughout your 50s and 60s and then at a certain point you’re in your 70s and you’re like, Well I don’t need to do this anymore. Or are there 80-year-old or 90-year-old guys taking TRT?

Dr. Kyle Gillette: There are 80 or 90-year-old guys taking TRT. Occasionally, you’ll do a dose adjustment. It just kind of depends on the situation, but a lot of times when males reach that age, they are less likely to have as much benefit and they are more likely to have slightly more harm. So it’s a moving target over time where you get out the scale and you’re weighing the risks and the benefits and at that point when a patient’s already on TRT, you also weigh the risks of how difficult it would be to come off, which is not extremely difficult. But it is difficult because there’s medication regimens that you have to go with and even with those medications often there is a short period of time when you don’t feel great.

Brett McKay: So we’ve been talking about optimizing male hormones in grown men, but let’s say we got some dads and moms out there listening and they’ve got boys who are about to start or are in the middle of puberty. What can they do for their sons? What can young guys do to make sure they set themselves up for a lifetime of male hormone optimization?

Dr. Kyle Gillette: First and foremost, no huge dirty bulk in early adolescence. What I mean by that is, I mean, let’s say there’s somebody that’s trying to put on weight for football or whatever other reason, can’t think of any reasons where it would be worth it, but they’re putting on weight and also putting on fat. Adipose tissue in fat, adipose tissue is fat, that is going to increase the conversion to estrogen and estrogen is gonna close the growth plates of the bone. So that’s gonna prevent you from reaching full stature, both in height and other areas of your skeletal developments as well. So that’s a great initial recommendation. Thinking about gut health and fiber consumption is also very important. That’s gonna prevent, again from over, it’s called intrahepatic circulation of estrogen. Estrogen is not necessarily the enemy. In fact, a little bit of estrogen is neat to what’s called priming the pituitary in order to fully kickstart adolescence.

And that’s one of the reasons why boys with very high body masses have higher estrogens. The pituitary gets primed too early and something called precocious puberty is happening, which is too early of puberty. So that’s another thing to consider. In addition to that, you wanna have a reasonable balance between cardiovascular exercise and resistance training. You certainly want to do both because adolescents can be thought of as your free endogenous steroids of, I’ll say cycle, just because people understand it. But your free endogenous steroid boost where you know you are going to be one, super sensitive to all the androgens that are released, probably most people remember puberty and you’ll also be having a lot of androgen around, regardless of what you do, even if your health hasn’t been great. So when that endogenous steroid burst happens, that is the perfect time to take advantage of those lifestyle tools to build up very high bone mineral density and very high lean body mass without putting on excess body fat.

Brett McKay: I imagine young people getting plenty of sleep is important too.

Dr. Kyle Gillette: Yes, extremely important. And that might be one of the most common causes of suboptimal hormone profiles in adolescents.

Brett McKay: What about supplementation? Is supplementation something you encourage in young people to optimize their hormones or is you just focus on the diet and exercise?

Dr. Kyle Gillette: With the oversight of a doctor, I do encourage supplementation, if it makes sense. For example, let’s say there’s a young person and they get a stool test and the beta-glucuronidase enzyme is very high. We know that that individual is just recycling their estrogen over and over again, that makes something like a Calcium D-glucarate or with the oversight of the doctor maybe even a very low dose of an aromatase inhibitor, a very reasonable addition. And then if you get blood tests, you can actually check the hormones to make sure that they’re increasing at the correct rates, that your DHT is optimal, your testosterone’s optimal, your estradiol is optimal, your IGF-1 is optimal, and then you can tweak a supplement. Supplements are just like medications, they have pharmacologic effects so they have an effect on the body and the body metabolizes them.

So things like Creatine can be very reasonable. Creatine does not affect the development of the kidneys. I did a podcast with my good friend James O’Hara recently. We get a lot of questions from pediatricians because the AAP, which is a society of pediatricians, still recommends no Creatine supplementation whatsoever up to the age of 18. So not even, not even a 17-year-old. So I just kind of thought that was… And it’s been 15 years. So they’re gonna update their recommendation within the next couple years whenever they have a joint meeting. But that’s definitely a vestige of times past when we thought that Creatine was harmful to healthy kidneys. You just check a Cystatin C because Creatine makes your creatinine blood marker look abnormally high. Falsely high. So Creatine can make sense in a lot of kids as well. And then if there is a kid that has really low insulin IGF-1, sometimes Tongkat makes sense in that individual.

And then in some kids that do have optimal hormone profiles, let’s say there’s an athlete and he’s developing or she’s developing and they have very high testosterone, very high IGF-1, that’s great, you know that Myostatin levels are gonna be really high after you have that burst of androgen during adolescence. Myostatin is gonna stop the muscle from developing and cause you to start putting more fat into the tissue. I think that Myostatin inhibitors, week ones like Fortetropin, which comes from fertilized egg yolks or Epicatechin. CocoaVia is a good source of Epicatechin. Different cocoa powders have a lot of Epicatechin. Green tea has EGCG, which is another Epicatechin. Basically, those take down the levels of Myostatin. Those are also very reasonable to take for the right patient.

Brett McKay: What about, should parents be sweating about xenoestrogens in their kids? Like, make sure they get certain types of deodorants or cosmetic products and avoiding plastics?

Dr. Kyle Gillette: Bisphenol A and phthalates. Yes. That’s kind of where I personally draw the line, where if you are worried about every single thing, we live in an unnatural environment, more so than ever. So those are usually the ones that I say to avoid. If you live in an area that more likely has contaminants and microplastics, a lot of times I do recommend testing your water. There are a lot of services that do this. I personally used MyTapScore to test both the water, from the tap and the water through my Berkey filter. If you have young children. And that seems like a very reasonable time to use a water filter if you don’t know what the contents of your water is. And then as far as foods, of course, avoiding ultra processed foods, I think, it was ultra processed mac and cheese that got a bad name for having high phthalates. I assume they fixed that by now, but I actually don’t know. So a lot of times it’s the same recommendations as any other whole food diet. And then know your sources, try to avoid contaminants at very high levels and use the Pareto principle, try to do right most of the time and you’ll get most the benefit even if you’re just doing it some of the time.

Brett McKay: Well Kyle, this has been a great conversation. Where can people go to learn more about your work?

Dr. Kyle Gillette: My hub is on Instagram, kylegillettmd, and it’s Gillett Health on all other platforms. I do have a podcast that we fairly recently have, I guess, gotten pretty good audio and video of, but that’s on YouTube, Spotify and Apple Podcasts. We have a clinically, I guess, a clinical grade podcast. And then we have a layman’s podcast that we’re gonna call After Hours, which should provide good entertainment.

Brett McKay: Fantastic. Well, Dr. Kyle Gillett, thanks for your time. It’s been a pleasure.

Dr. Kyle Gillette: Thank you.

Brett McKay: My guest today was Dr. Kyle Gillett. You can find more information about his work at his website, gilletthealth.com. Also, check out his podcast, Gillett Health podcast and check out our show notes at aom.is/optimalt where you’ll find links to resources where we delve deeper into this topic.

Well, that wraps up another edition of The AOM podcast. Make sure to check out our website at artofmanliness.com, where you can find our podcast archives as well as thousands of articles that we’ve written over the years about pretty much anything you think of. And if you’d like to enjoy ad-free episodes of the AOM podcast, you can do so on Stitcher Premium. Head over to stitcherpremium.com, sign up, use code MANLINESS at checkout for a free month trial. Once you’re signed up, download the Stitcher app on Android or iOS and you can start enjoying ad-free episodes of the AOM podcast. And if you haven’t done so already, I’d appreciate if you take one minute to give us a review on Apple podcast or Spotify, it helps out a lot, and if you’ve done already, thank you. Please consider sharing the show with a friend or family member who you think could get something out of it. As always, thank you for the continued support. And until next time, it’s Brett McKay, reminding you to not only listen to the AOM podcast, but put what you’ve heard into action.

The post Podcast #893: Optimize Your Testosterone appeared first on The Art of Manliness.

One of my favorite things about my recent interview with Kelly Starrett about essential health practices was that he reintroduced me to the concept of “sleep pressure.” I know I had heard the phrase before, but I hadn’t thought about it in years. Since our conversation, it’s been regularly on my mind and given me a great rubric for making decisions around my daily routine.

Sleep pressure, as the name implies, is the drive towards sleep that accumulates during the day. Interestingly, scientists aren’t entirely sure what creates sleep pressure, but it’s believed to be related to the creation of adenosine. This makes sense: adenosine is a chemical that helps regulate the sleep-wake cycle, and just like sleep pressure, it rises during the day and falls while you slumber. Adenosine is produced when cells consume energy. The more physical and mental activity you engage in during the day, the more adenosine is created, and the more tired you become.

You certainly don’t need a biology degree to understand the dynamics of sleep pressure; it’s a phenomenon you’ve experienced firsthand. Think back to times you hiked all day or spent hours swimming in the ocean; how did you sleep that night? Probably amazingly well because of the huge sleep pressure you’d built up. As I mentioned in my conversation with Kelly, I still remember the sleep I got while visiting Italy as the very best sleep of my life. Kate and I walked miles and miles and miles around Rome during the day, under the bright hot sun. When we’d get back to the hotel at night, we’d both fall asleep the instant our heads touched the pillow and stay in an utterly dead-to-the-world state of profound unconsciousness until morning. That’s the power of sleep pressure.

People often complain of trouble falling and staying asleep and seem uncertain as to why they experience these issues. But it’s usually not a great mystery: they spend most of their day indoors, sitting and sedentary. Little activity = little sleep pressure = poor sleep.

While few of us have schedules that will allow for doing hours of activity every day, all of us can incorporate a little more effort, sweat, and sunlight (fresh air and sun both seem to increase sleep pressure for some reason) into our daily routines. Move more. Spend more time walking. With the clients he’s worked with, Kelly has noticed that improvement in sleep begins to kick in once you start hitting just 6,000-8,000 steps a day. When he had special operators in the Army’s Delta Force add 12,000-15,000 steps on top of their usual day-to-day training, it effectively squashed their insomnia problems altogether. 

What’s great about sleep pressure is that building it requires doing the kinds of practices that contribute to overall health but can be tempting to skip because the benefits are longer-term and less tangible. Better sleep is a visceral, short-term reward that’s easier to get motivated to work towards. 

Sleep pressure is a simple concept, and once you absorb it, you’ll start looking for ways to increase it as you go about your day. We created the visual guide above to help get it ingrained in your head so that throughout your daily routine, you’ll be thinking about where your sleep pressure dial is sitting, make choices that move the needle in the right direction, and enjoy deep, restful sleep every night as a result. 

For more tips on the health practices that will enhance your everyday vitality, listen to our podcast with Kelly Starrett:

The post The Importance of Building Your Daily Sleep Pressure appeared first on The Art of Manliness.

There’s plenty of advice out there about how to have a better daily routine. But what’s just bunk and what actually works to improve the quality of your day and your overall life?

My guest, medical-doctor-turned-science-educator Stuart Farrimond, took a deep dive into the research to find the authoritative answers to that question, and he shares them in his book Live Your Best Life: 219 Science-Based Reasons to Rethink Your Daily Routine. Today on the show, we walk through a daily routine, from morning to night, and Dr. Farrimond shares some best practices to make the most of it. We discuss why waking up to an alarm clock feels so terrible, why you shouldn’t drink coffee first thing in the morning, the ideal length for an afternoon nap, how to improve your commute, the best time of day to exercise, and more.

Resources Related to the Podcast

• AoM Article: What Every Man Should Know About Sleep
• AoM Article: The Digestive Power of an After-Dinner Walk
• “It’s Not Just What You Eat, but the Time of Day You Eat It”
• AoM Article: How to Stop Your Snoring
• AoM Article: Unleash the Power of the Nap
• Sunday Firesides: Your Routine Needs Rites of Passage

Connect With Stuart Farrimond

• Stuart on IG
• Stuart on Twitter

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Read the Transcript

Brett McKay: Brett McKay here and welcome to another edition of the Art of Manliness podcast. There’s plenty of advice out there about how to have a better daily routine, but what’s just bunk and what actually works improve the quality of your day and your overall life? My guest, medical doctor turned science educator, Stuart Farrimond, took a deep dive into the research to find the authoritative answers to that question, and he shares them in his book, Live Your Best Life: 219 Science-Based Reasons to Rethink Your Daily Routine. Today on the show, we walk through a daily routine from morning to night, and Dr. Farrimond shares some best practices to make the most of it. We discuss why waking up to an alarm clock feels so terrible, why you shouldn’t drink coffee first thing in the morning, the ideal length of an afternoon nap, how to improve your commute, the best time of day to exercise and more. After the show’s over, check out our show notes at aom.is/dailyroutine.

Alright, Dr. Stuart Farrimond, welcome to the show.

Stuart Farrimond: Thanks for having me.

Brett McKay: So you started off your career in medicine, but then you made the jump to science writing, particularly you writing about health and science for a lay audience. Why did you make that jump?

Stuart Farrimond: Yeah, so originally I was a medical doctor. I was working in a UK hospital, so I’m based in the UK and we’re talking about 15 or so years ago, I was diagnosed with a brain tumor, so it was just kind of completely out the blue, unexpected. I was having some tests for some other stuff. It was discovered and I actually had the scan and the result whilst I was at work one day and essentially it was a cancerous and malignant brain tumor that I had to have surgery on pretty much straight away. So I guess what was I was 25 or so, yeah, about 25 when I was diagnosed with it. So I had the surgery, it went well, but it left me with epilepsy afterwards. And because of the epilepsy, it basically meant that I couldn’t carry on with medicine because part of the, as I’m sure you appreciate part of the job of being a hospital doctor is that you gotta do hours of hours on calls, night shifts, things like that.

And basically I couldn’t really do that and not risk having a seizure in my profession. So that led to me having to step down from medicine, sort of take basically long-term sick or they always sort of say, well, keep the job that you can always come back at any point. But basically I don’t really… How can… My epilepsy is never gonna go away. My brain tumor’s never gonna go away. So I’ve never been able to go back. To be fair though, I don’t miss it because after I left medicine, I got a job in teaching and I taught for three years in a further education college in the UK and further education colleges, they’re like a halfway house between school and university. And I ended up teaching science themed topics to young people who were interested in going to some kind of health profession.

And I just really fell in love with teaching and then busting people’s ideas of what science is, because I don’t know about you, but at school for many of us, science was this really dull and dry subject. And actually for me now, I find that science is a thing that helps us understand the world and actually makes me more amazed about the world around me, how my body works and I wanna share that with other people. And I discovered the joy of doing that when I was doing this teaching job. And then it kind of evolved into doing things more broadly. And I realized that actually these 16, 17, 18 year olds, they don’t really appreciate the science of the every day and they reflect pretty much what the average Joe on the street appreciates. And so I realized actually if I can reach more people, then I can touch their lives in ways that help them actually appreciate the world more and appreciate how science can inform pretty much every area of your life. And that’s where I am now. So I write books about lots of different themes. I do quite a bit on the science of food and cooking, as well as this book that we’re gonna talk about today, which is about health and wellbeing, about pretty much every area of your life.

Brett McKay: And what’s the state of your brain cancer today?

Stuart Farrimond: So my brain tumor is that it was a low-grade glioma. A glioma is basically the name for these tumors. Probably the most common types of these malignant brain cancers, although that said all brain cancers are quite rare. It regrew a few years ago, it came back and it’s now more aggressive than it was. It’s gone from what’s called a grade 2 to a grade 3. So it’s more aggressive than it was before. And I’ve had to have more surgery and chemotherapy and radiotherapy, which happened, I guess about three or so years ago. And I finished off my chemotherapy during the COVID lockdown. So the first lockdown, so we’re talking 2020 February time, that’s when I sort of, I finished the treatment of most recently and I just have three monthly scans for the tumor. And thus far since then, it’s not been growing, which is pretty good.

I think that’s sort of, it’s unexpected. So I’m doing pretty well things considered. So that’s where I’m at. So every three months I go through the mill of, is it growing back? Is my life gonna just turn upside down with one day, one results? So just sort of always living under that cloud. But it does make you really appreciate every day. And so when I write my books, when I do talking, when I’m on this podcast with you, it matters because I may or not be here for, well, nobody’s gonna be here forever, but I appreciate that life is very, very temporary and very fleeting. So you wanna make everything count.

Brett McKay: Yeah. And you mentioned in the forward of this book we’re gonna talk about, Live Your Best Life, you were finishing this while it was during COVID and you were doing your treatments and you said that… You know, the questions you ask, you answer or seek the answer in this book. Things like how to get the best sleep, what’s the best breakfast, what’s the best way to not be stressed out at work? A lot of people will think, “Well, that’s kind of mundane and straight” but for you, you mentioned like, “Well, no, actually this stuff’s really important.” ever since your diagnosis, like you said, you have an appreciation for these really small things. These little small things add up to make a life well lived. So your book, Live Your Best Life, it’s organized around questions, but then you organize these questions about our daily routines. So you start off in the morning, work your way to the afternoon and then to the night. So let’s start off with the morning and take a look at some of these questions you answered, one question I think some people might have had is why is it that sometimes when we wake up we feel refreshed, ready to take on the day, you just feel awesome, but other mornings you just feel super groggy and it takes like an hour to fully awaken? What’s going on there?

Stuart Farrimond: Yeah, so that groggy sensation that you get in the morning when you sort of feel half drunk, almost kind of zombie-like we have a name for that and that’s called sleep inertia. And basically what’s going on in your brain is it’s not fully switched on yet because waking up in the morning, you’re going from this comatose unconscious state into the land of the living and it takes a while for your brain to switch on for all those cogs to get going, like getting a car start on a cold morning, that sort of thing. And that’s called sleep inertia. Whether you get sleep inertia varies on how well rested you are and also interestingly how you woke up. So when we sleep, we go through different stages of sleep, we cycle between going through deep sleep and light sleep. During deep sleep is when we’re snoring and that’s when all the restorative work goes on, in light sleep that is when we’re dreaming.

That’s when if you were to lift some of these eyelids up, you’d see their eyes darting left and right. And sometimes that’s when we speak, when words sort of escape from our dreams. And if you wake up from the deepest sleep, from the deep sleep, then you will wake up quite groggy. Whereas if you wake up from the light sleep, from the dreaming sleep, which is the natural way for you to do, in the early hours, you dream more and then you naturally come out of that into waking. But if you wake up from the deep sleep, you will generally wake up with that grogginess. So several factors, one of which is if you are poorly rested, you’re more likely to have it. If you are stressed, you’re more likely to have disturbed sleep and you are more likely to have this sleep inertia.

A lot of us though, do just get sleep inertia in the morning. And so I would always say, and part of what I put in the book is that don’t check your smartphone first in the morning because regardless of how well you slept that first 30 minutes, you will be experiencing some sleep inertia. When you look at people’s brain scans during that time, your brain actually looks like you are slipping back into sleep again. So you are only actually half awake, which is why you shouldn’t really make any decisions first in the morning. You should just get yourself up, get yourself going, get yourself in the shower, whatever your morning routine is, and then hold off checking emails, all the other stuff, all the Jesus of the day, up to later on and interesting I think that is why, because we can’t make decisions very well first thing in the morning.

Why I think we tend to have the same thing for breakfast everyday because we can’t cope with making difficult decisions first thing in the morning. So sleep inertia lasts about half an hour can last up to 2 or 3 hours depending on all those different factors that I’ve mentioned. There’s no solution for it. You’ve just gotta ride it out. But just be aware of it. So let yourself ride out. You guys be very wary about jumping in the car straight after waking up because you will be suffering from this and so you will be at higher risk of making mistakes when you’re in the car during that time.

Brett McKay: Well, another thing you point out too is the sleep inertia that’s caused by waking up during a deep sleep is one of the reasons why you don’t wannna hit the snooze button on your alarm because you’ll fall back to sleep and you might fall back into that deep sleep and then you wake up and you’re all groggy.

Stuart Farrimond: Yeah, absolutely. So alarms, ideally, in an ideal world you would wake up naturally and that is when your body is naturally used to waking up. You’ll find this out is that if when you’re on vacation and there’s no pressure, you’ll find out what your natural waking time is and that will give you a good gauge. And if you have a job that lets you, and if you can have any capacity to change your job so that you can have it so that you wake up at your natural waking time, that is the ideal. Unfortunately, many of us have to have alarms ’cause alarms aren’t very good ways of waking up because they basically stimulate our primitive vital flight response. We wake up as if a panther has just, or a tiger just walked into our room. It’s that there’s this part of our brain called the amygdala, which is alert to threats all the time, even when we’re asleep.

And so when you have a loud noise, it fires off the amygdala, gets adrenaline going, gets you fired up, you wake up with a jolt basically because your primal brain thinks there’s a threat. So you’re not in a great place when you wake up. You’re not waking up relaxed, calm, ready for the day. You hit the snooze button and you’re quite right, 10 minutes or so on the snooze button is just about the right time to start slipping into the deep sleep. You then can wake up back into a jolt again. And so actually you feel increasingly groggy And actually all those sort of rude awakenings, they kind of add up. And so they all increase your stress levels in the morning. And furthermore, if you wake up naturally or you just wake up, you just get up. When you wake up naturally you’ve got a natural chemical boost from a hormone called cortisol, which is a stress hormone that is released when you wake up. It’s been building up slowly in the early hours, getting you ready for waking up. When you wake up you get this surge like a jab in the arm of this hormone called cortisol. It’s the stress hormone. That’s what gets you going. If you stay in bed, if you keep hitting the snooze button and that will fade away and so you’ll lose your natural get up and go hormone.

Brett McKay: Okay, so we wake up, we might be having that sleep inertia, feeling groggy, I think the first thing that a lot of people do to counteract that is like, “Well, I’ll just have my morning caffeine.” Whether that’s coffee or tea or some other type of caffeinated beverage. But you’ve found research that suggests drinking coffee or caffeine first thing in the morning, you’re actually not doing anything. Why shouldn’t you drink your caffeine right when you get out of bed?

Stuart Farrimond: Yeah. Answering this question, if I’m gonna give an answer to the best time to drink coffee, if it’s different to what you do, most people don’t like to hear it ’cause everybody thinks their way of drinking coffee is the right way of doing it because they find that helps them. In reality, when you look at the science, if you find out how caffeine works, then you can understand when the best time should be to have coffee. Caffeine works by blocking a naturally sedative relaxing chemical in the brain called adenosine. And this is a substance that is produced naturally throughout the day. When you wake up in the morning, it’s very low.

Throughout the day, it builds up and it builds up. It’s sort of like a waste product of your brain throughout the day. When you sleep at night, your brain gets rid of it all and it’s adenosine that makes you sleepy. Not the sleep hormone called melatonin that people so often know about when people… People take melatonin supplements because they think it’s gonna help them sleep, most of the time it doesn’t do anything at all. The thing that makes you sleepy is this brain hormone called adenosine and caffeine works by blocking that substance, that adenosine. And that’s great because in an evening or if you are driving in an evening and you need to sort of a pick me up to keep yourself going, then having some coffee, that will keep you going, that will keep you on the road because it knocks the edge of this adenosine that is making you feel sleepy and wanting to make you to go to sleep.

But first thing in the morning, that is the time when you have your lowest levels of adenosine. So you have your coffee first thing in the morning and actually it’s not gonna be doing much. It’s like you’ve already got this get up and go hormone called cortisol, getting you going first in the morning. Having coffee on top of that is basically like throwing a couple of matches onto an already raging bonfire. It’s not gonna do very much. And actually first in the morning, strong coffee is more likely to make you jittery and give you the side effects of caffeine, make you more uptight, make you a bit more anxious rather than when actually if you’re gonna have coffee, you’re gonna have caffeine and you want to have it so that it picks you up and it gets you going. So a sort of a nice way of doing it is to wait an hour, hour and a half, maybe a couple of hours into the morning. So the cortisol shot in the arm has started to fade and Adenosine has started to come up, so that mid-morning when you’re starting to feel a bit sluggish, and that will be a time when to have your coffee that it will actually… You get much more bang for your buck if you have your coffee then.

Brett McKay: Okay, so shift to two hours, or wait an hour to two hours.

Stuart Farrimond: Yeah.

Brett McKay: Let’s talk about breakfast. Is there an ideal breakfast that will help us get going in the morning?

Stuart Farrimond: Now breakfast is interesting one ’cause that’s, it’s a meal for which we have breakfast foods for, and we don’t really have lunch foods or evening meal foods, but we have breakfast foods, which is kind of a curious thing, across the world there will be breakfast foods. And you tend to find that if you take a step back and you look across cultures that breakfast tend to be based on starches, on carbohydrates or what you call carbs. They’re the things that provide the… And I know that they’re sort of, they’re seen as a bad thing these days, carbs are, but actually they’re the main fuel for your brain. They’re the main fuel for your muscles. So if, especially if you’ve got an active job, if you’re a kid, then breakfast is really important and ideally it should be based on carbohydrates ’cause they’re the main fuel that your body and your brain likes to use.

You can get by without it. And interestingly, if your body, if you’re not a morning lark, if you wake up in the morning and actually you don’t want breakfast, it doesn’t feel right for you, your body isn’t asking for it, then there is no benefit in forcing yourself to have a breakfast. Skipping breakfast does not make you put on weight. There is no evidence for that. And actually when they’ve done the studies and they’ve got people to skip breakfast, they actually lost weight compared to putting it on. So it’s a myth that the breakfast is the most important meal of the day. Many people will need a breakfast because of their lifestyle, because of their body clock, but it’s not the thing that it’s made out to be.

Brett McKay: It’s interesting your observation about there being special breakfast foods across cultures and that they’re usually carby foods. There’s been some research coming out that our bodies metabolize carbohydrates and just food in general better in the morning and we get less efficient at it as the day wears on. And so maybe there’s like some wisdom into how people used to schedule their meals, right? Like today, our biggest meal for most people in the west, it’s dinner and we eat that late. But a couple centuries back, the biggest meal of the day was, well they called it dinner but it was like at midday, right? So they had a really big, what we would call lunch and then they just have a very light supper in the evening. So it might be better for you to eat more of your carbs and calories earlier in the day.

Stuart Farrimond: And there is some evidence for that. And I think eating big and late at night that that is linked with poor sleep. There is definitely evidence for that because at nighttime everything shuts down. The whole intestinal system goes into sleep much like the rest of you. So if you have a big meal at night, it’ll just be sitting there largely overnight and actually that’s not very good for you really because it’s gonna more likely to give you indigestion, it’s gonna disturb your sleep, as you process the food your intestines generate quite a lot of heat in that process of digesting the food. So especially protein, that’s something that generates a lot of heat. Your body has to work quite hard to process that, to digest it, which is why you’ll get meat sweats at nighttime if you had a big meal in an evening.

So whether it’s bad for putting on weights, that’s a controversial thing, but generally speaking you’re probably best avoiding a large meal on the evening. That said in the Mediterranean they eat really late and people only sit down for the evening meal about 8 o’clock in the evening oftentimes. And I don’t know how they do it, typically you’d have it like a pastry and a coffee first in the morning as your breakfast, then you’d have have a lunch and then you’d have a big thing in the evening meal. And that’s the way they’ve always done it. And I don’t know how they do it because generally, the evidence would say that’s not the ideal way of doing things. So yeah, you’re quite right is that a big meal in the evening is probably not ideal for most people.

Brett McKay: Okay, so you’re eating breakfast in the morning, maybe. You don’t have to eat breakfast necessarily, but you’re probably, hopefully definitely brushing your teeth. So what’s the best time to brush your teeth? Is it before you eat breakfast or after?

Stuart Farrimond: It depends what you have for your breakfast. If you have anything citrus for breakfast. There’s pros and cons of each of them. If you have anything with citrus for breakfast, then avoid brushing afterwards because citrus and indeed carbonated drinks are quite acidic and if you have something acidic, then you brush your teeth, there is a risk that you start to brush off the enamel, which is the super hard, very white protective coating that’s on the covering of your teeth. So I would say typically it’s better before because it means that you can get rid of the detritus from overnight. We often wake up with very bad breath in the morning and that’s because there’s been an overgrowth of bacteria in the night because we produced less saliva over the night and saliva has antibacterial properties in it. And so overnight we’ve had this overgrowth of bacteria. So it’s good to… You could brush before and afterwards that would even be better providing that you haven’t had anything citrus for breakfast.

Brett McKay: We’re gonna take a quick break for a word from our sponsors.

And now back to the show. So let’s move on to our commute. A lot of people commute’s like the worst part of their day. Why does our commute make us so miserable? And then anything we can do to improve it.

Stuart Farrimond: Yeah, yeah. And research shows that an extra 20 minutes onto your morning commute can impact job satisfaction as much as a 20% pay cut. And what happens is that we associate our commute with our job. Psychologically we see it as one and the same thing. So if we don’t enjoy our commutes, it means that our job satisfaction overall will be lessened. So likewise, if you can improve your commute, then you can improve the quality of your job experience. 90 minutes of total commuting time a day seems to be the turning point for when it starts to impact our health. So if you are commuting 45 minutes each way, then that’s a point at which you gotta be very careful that it may be impacting your health. Because if people have a total commute of more than 90 minutes every day they tend to be… They weigh more, they’re more likely to have diabetes, more likely to have higher blood pressure. All the things that we associate with the ills of the day, they are linked with longer commutes.

And that’s largely if you… Because most people commute, they do it sedentary, they’re doing it in a car or they do it on some kind of public transport. To improve your commute, in any way you can, make it as active as possible. So walking, cycling, anything that moves your legs and that will improve your commute or make you healthier and also put you in a better place when you get to work. So that’s one thing that you can do. If you’ve got a journey that has multiple stops, try and simplify your morning commute because a lot of the thing that makes the commute bad and stressful is stress on the journey. It’s holdups in the traffic, it’s delays, it’s somebody cutting you off in the traffic. It’s something getting in your way. It’s roadworks. These are things that… And if you add to that, if you’ve gotta drop the kids off at school and you’ve got to do another errand on the way to work, that makes it all the more stressful. And so that will negatively impact your commute. So make your journeys as simple as possible, try and make them active. And yeah, I guess the thing is to try and see if there are ways in which you can make it less stressful and possibly shorter, especially if you have a sedentary form of commute.

Brett McKay: And what’s counterintuitive though is you found the research that suggests that some people, like they need a commute for their job to make that transition. Right? The commute itself can act as a transition from home life to work life and work life to home life.

Stuart Farrimond: Oh, absolutely. Yeah. And we discovered this now. We’re working from home and some people’s mental health has worsened as a result of this. And because we have commuted since Neanderthal times, since stone age, there’s good evidence to show that we’ve always moved away from where we live and where we sleep to go and do our daily work. And there’s something really important in that, and it seems to be the ideal commute is about 15 minutes. And that gives you just enough time to mentally move yourself away from home life and into work life. And conversely, when you’re coming back, it’s really important that we switch off from work and that we reengage to what’s going on at home. We start thinking about our family, our spouse, so that when we get home we’re interested in them and we’re not preoccupied by our work. And so having that physical distance helps mentally with having that mental distance. And so it is good for our mental health to have a commute, and 15 minutes, research points to being the optimal length of time.

Brett McKay: Let’s take a look at our work life. We’re at the office. Is there anything to the idea that there’s certain types of work we should do in the morning or the afternoon?

Stuart Farrimond: Yeah. And this comes back to your body clock and what you find is that there are differences because obviously night owls is flipped a little bit and they work better in the evening. But for most of us, something like 75% of us, the first 2 or 3 hours of our working day, and when I say our working day, that’s from 9 o’clock in the morning, I’m assuming that that’s the sort of the standard time of the working day. Those first, that morning is our brains primetime. That is when we need to prioritize the most important tasks. So I don’t know about you, Brett, but sometimes I sit down at my workstation first thing and I start work and I go, “All right, I’m gonna clear out my emails or I’m gonna do something on social media.” But in reality, that’s probably not the… You really shouldn’t be doing that because those first 2 or 3 hours, until you get to about 11:00 midday, that is when your brain is, the computing and the thinking powers of your brain are at their maximum.

So you should first thing prioritize that thing that you’ve been putting off, that project, that assignment, whatever it is that work, sort of bite the bullet and get on with it. Because after that time, after those first 2 or 3 hours after lunchtime, whatever you do, no matter how much coffee you have, you are not getting that back again. It’s a one hit deal. You’ve gotta make the best of it the first thing in the morning. Some people say they work especially in stateside. I know people like to boast about how many hours they work and how they got up so early in the morning and they stayed at work till gone dark. But actually people who do that, they’re not productive as they think they are. And it’s about understanding how your body works and you can actually work smarter and not harder. So that is one way of doing it is realizing my most productive time, my mentally my most productive time is gonna be in the morning before 11 or 12 o’clock when things will naturally start to slow down. So yeah, that would be what the science would point towards.

Brett McKay: Well, let’s talk about just being at the office this day. Most people have jobs where they’re sitting down, it’s sedentary. Anything we can do to alleviate some of the, I don’t know, it hurts like, it doesn’t feel good to sit down all day. And then also I think it’s a mental stressor. Anything we can do throughout the day to maintain our health and mental sharpness?

Stuart Farrimond: Yeah, it was once fashionable to have Standing work stations, which some people get on with and they’ve not really taken off in the way that it was once imagined. It’s often said that sitting is the new smoking. It’s nothing as bad as smoking. But yeah, there are high correlation between sitting a long time and poor health, weight gain and all the things associated with Western lifestyle. So a good way to do it is to try to make yourself stand up and do something. If you work from home, then make yourself a cup of tea every, or whatever it is, or a cup of coffee, maybe not coffee, but get yourself a glass of water or something regularly. You may even set yourself a timer just to get up, walk around and…

Yeah, and that will help. The thing is that you can’t concentrate for very long periods of time anyway. Between 60 and 90 minutes is the maximum capacity in which you can focus on a task with complete concentration, and actually be performing well. So, when your concentration starts to fade on any given task, swapping to something else is good. Taking a break is even better, and using that as an opportunity to stand up and walk around. Another thing that I heard, which I thought was quite a smart thing, is get yourself some dumbbells or a dumbbell, and put it somewhere maybe by your kettle or by your fridge somewhere that you’ll often go to in the daytime. It’s maybe a little bit more difficult to do in office space at work, but you could do it. You could put a little dumbbell somewhere, and whenever you go there, you can do a few sort of arm curls with it.

And you’re not gonna become really masculine or become Arnold Schwarzenegger from it, but it will just help. Any kind of physical exercise will help combat the overall fatigue, because fatigue will worsen as we’re lots of times sedentary. So, any of these things, take the stairs if you can, anything that you can. And it’ll be specific for you, be it for your working environment. You’ll know things that you can do, if it involves setting a timer on your phone every 45 minutes from now saying, “Stand up now.” That will help.

Brett McKay: Oh, let’s shift to the afternoon and evening. Some people get sleepy, naturally sleepy, like 1 o’clock, 2 o’clock. Is it okay to take a nap in the afternoon? And if so, how can you do in a way so it doesn’t disrupt your sleep in the evening?

Stuart Farrimond: Yeah. Again, something that’s become quite trendy is having an afternoon nap, having this… And the siesta is, as you probably appreciate, is very much ingrained in Mediterranean culture and in Chinese culture. There used to be a law in China that meant that workers were entitled to an afternoon nap. It was a right that they could have their, I think 90 minutes or something like that in the early afternoon where they could have a sleep. And actually having an early afternoon nap is something that seems to be a part of our biology, because we evolved in the Savannah. And if you’ve ever been to equatorial regions, you will know that the middle of the day after about 1 or 2 o’clock in the afternoon, it’s absolute… I did my medical elective in West Africa, and those hours of the day, you had to retreat inside, you couldn’t do anything. It’s utterly, utterly stifling.

People in the states who live in the southern regions, as you all know this very well, that you can’t do very much. And so our body is geared to actually taking… Is just lying down and resting during that time. S, even now it’s in our genes that during that time we naturally get sluggish. We have the post lunch slump that isn’t actually entirely to do with the lunch itself. It just happens to be our body clock is geared towards slowing down, actually having a nap at that time. So, yeah it’s a difficult thing to get your head around because we have this whole thing, “I’ve got to work 9:00 to 5:00, having a sleep is lazy.” But I know a lot of the tech companies are now getting onto this ideal, they have been in recent years of having your sleep pods where you can go and have a nap.

And if you can work that into your day, you may well find that energy, mood, learning and productivity are boosted by a 10 to 20 minute nap in the early afternoon. If you go longer than that, if you go to about 60 minutes, then that’s the time where you will… Over more than about 20 minutes to 60 minutes, you may well find that when you wake up, you have that groggy thing again, that sleep inertia. So, you wake when you feel worse than before and you think, “I’m never gonna… Why do people do this nap thing? I just feel wasted for the rest of the day.” And that’s because you’ve gone into deep sleep. If you gonna do longer than half an hour, then you should do 90 minutes, ’cause 90 minutes is enough time to go into deep sleep and out again, and you’ll come out feeling refreshed.

Problem is that if it goes much longer than an hour and a half, it obviously eats into your day and it can affect your nighttime sleep. So, ideally 10 to 20 minutes. And another way that I’ve heard people do is to have a coffee before you have your nap, and it takes about 15, 20 minutes for the full effect of the caffeine to kick in. So, that will… When you wake up again, you’ll have the combination of the feeling refreshed from the nap, and the sort of the extra boost from the caffeine. Personally, I don’t do that one because I find that the caffeine will affect me before I get to sleep, but that’s a tried and tested thing that many people do.

Brett McKay: Alright, let’s talk about exercise. When’s the best time to exercise or it doesn’t matter?

Stuart Farrimond: Any exercise is good, but when you look at people’s physical performance, you find that it is best eight to nine hours after waking. So, that we’re talking early, mid-afternoon for most people. It’s geared towards your body clock as well, so you tend to find that people who are in their early 20s and teens, ’cause their body clock is shifted forward by a couple of hours. They will tend to be in their prime in the early evening time, which I’ve… My theory behind this is that most world records are broken in the early evening time. Some of that is gonna be because things are televised in the evening time that’s when they put on events, but I think that large part of that is that world records are broken in that time. Olympic world records are broken that time, is because people who are athletes, they’re generally in their early 20s, so they have a body clock that peaks later in the day. And so their prime physical time for exercise is in that early evening time when they’re performing at their best.

But it’s the same for you and me, Brett is the best exercise time will be in the mid-early to mid-afternoon. You can try this, I don’t know if you do much exercise, Brett, but if you go for a run first in the morning and then you do another run at 5:00 or 6:00 in the evening, you will find that the one in the afternoon, evening time will be easier. And you’ll probably find that you can do better times than you did first in the morning. And that’s just a nature of the fact that our body takes awhile to warm up, it’s like a locomotive. It just sort of takes away everything, all our muscles, all the chemical processes and the enzymes that power our muscles, which are just the chemicals that work within our muscles to get them going. They take a while to get going throughout the day. I think they warm up throughout the day. But that said, any kinda exercise is good and morning exercise is still good for you, but generally speaking, it’s better to do the most vigorous exercise later in the day because going at it too hard in the morning, you’re much more likely to have a risk injury.

Brett McKay: Yeah, I’ve noticed that. So I do power lifting and when I first started, I trained first thing in the morning, so I had like the sleep inertia thing going on, I was really groggy so I didn’t perform as well. I think the other issue too was I didn’t have time to eat before I trained. So I was training in a fasted state and that’s not good if you’re doing explosive strength stuff. And then when I shifted to training later in the afternoon, things got better and my performance started improving. And I still notice the difference today, right? Like sometimes I can’t train in the afternoon for whatever reason. So I have to train in the morning, and there’s a big difference between afternoon training and morning training. And it’s interesting that given people perform better or do better later in the day that competitions, things like 5K races, I’ve done weightlifting competitions, amateur ones, they’re usually in the morning, and my wife, she’s a runner and I think she’d do more running races if they were later in the day because she likes to run but she doesn’t like to run at 7:00 or 8:00 o’clock in the morning. She’d much prefer to run late in the afternoon or early evening.

I think it’s interesting. We need more competitions later in the day, I think. Okay, so we’ve covered waking up, commuting, working, exercise, and then comes nighttime, right? It’s time to sleep, and in the book you suggest, the kind of sleep hygiene tips that I think most people are familiar with if you want to get better sleep, but what about snoring? Snoring can disrupt your sleep and possibly other people’s sleep. So what can we do to stop snoring?

Stuart Farrimond: Yeah, four in 10 blokes snore. It’s one of those things like you never know you do it until somebody tells you, but yeah, it is a problem. I know a couple that they can’t sleep in the same bedroom anymore because he snores so loudly and he doesn’t like being woken up to be told. I mean I snore sometimes when I roll onto my back, but yeah it can be really problematic. How can we stop it? The reason why we snore, you can either have nasal snoring which is because of the configuration of your nasal cavity or you can have mouth snoring or throat snoring, which is probably the most common type of snoring. And that is because at nighttime when we go into this deepest sleep, the deep restorative stage of sleep, we become very floppy. Every… The tone of the muscles drops a lot so everything becomes relaxed.

And of course that means that the muscles at the back of the throat that keep our windpipe open, they can relax so much that it starts to close our airways and it becomes like a flapping door in a breeze as it vibrates and you have this snoring sound, it’s more likely to happen in people who are bigger, people who are overweight. So people often find if you lose some weight then the snoring will stop. Lying on your back is also more likely to cause snoring. Something that people have done with great success is in their night wearing their pajama top. They’ll sew in a tennis ball into the middle of the back so that it’s impossible for them to lie on their back. And they find that is quite a drastic thing to do. But they find that that is enough to stop them snoring ’cause it stops them rolling into the back. There’s lots of different things, lots of different aids that you can buy.

There’s like nasal strips, things that you can put into your nose. There’s chin straps, there’s pillows, there’s some evidence that pillows, antis-snoring pillows can help because they align your neck in a certain way so that you keep the airways open more and you’re much less likely to snore. The thing is that if you snore and you are very, very sleepy in the daytime, then you could be experiencing, could be suffering from what we call obstructive sleep apnea or OSA. That’s very, very common, more common than I think we appreciate, and that is actually very harmful for your health, not least because your sleep is so unrestorative that you will drift off in the daytime and your risk of having a car accident while driving are very, very… Are magnified hugely because you’re not getting restorative sleep. What happens with people with OSA is they’re snoring and as the muscles relax even more and more, eventually it blocks off their airways.

So you start to suffocate, you then wake up with a jolt but it’s so brief that you don’t realize that you’re awake. ‘Cause interestingly in those very lightest layers of sleep between awake and being asleep, you have no memory of it. You may have noticed this Brett, you’re sat on the sofa, you’re watching a movie or something, your partner drifts off, falls asleep and you wake them up and say, you fell asleep, they will swear blind, “I was not asleep.” And that is because in those periods of very light stages of sleep, you have no memory of it. So when people wake up with a start very briefly, they’ll have no memory that they’ve had a very disturbed sleep. Every time they go into that deep restorative sleep, they’re being woken up at the very deepest part of it.

So they’re not getting the benefits of sleep. So throughout the daytime they’re constantly fatigued and that has long-term impacts, much like doing night shifts, actually unfortunately no matter what we do seems to… When you’re working against your body clock, it has negative effects, causes your arteries more likely defer process called atherosclerosis, increases likelihood of having diabetes and other such conditions by having long-term disturbances to sleep. And this is also the case with OSA, obstructive sleep apnea. So if you feel exhausted, if you find yourself falling asleep when you’re waiting for the lights to go from red to green, or you’re woken up because somebody’s sounding the horn behind you and especially if your partner says that you snore, then it’s worthwhile getting an assessment for that because it’s something that’s very treatable.

Brett McKay: Well Stuart, this has been a great conversation. Where can people go to learn more about the book and your work?

Stuart Farrimond: Yeah, sure. The book is called Live Your Best Life. If you are outside of North America, it’s called the Science of Living. So the Science of Living or Live Your Best Life. You can find out more about me on all the socials. My name is Dr. Stuart Farrimond or Dr. Stu Farrimond. My handle is realdoctorstu, all one word. R-E-A-L-D-O-C-T-O-R-S-T-U. And that’s what I’m on, on Twitter and Instagram and all those things. I’m not a big social media user, but I will do updates of books and things. I’ve got a book out recently, which is all about gardening believe it or not. So it’s a completely left field thing for me. But that’s selling very well as well. It’s just another one of my missions of using science in the everyday in ways in which you wouldn’t have thought.

Brett McKay: All right, well, Dr. Stuart Farrimond, thanks for your time. It’s been a pleasure.

Stuart Farrimond: Awesome. Thanks Brett.

Brett McKay: My guest today was Dr. Stuart Farrimond. He’s the author of the book Live Your Best Life. It’s available on amazon.com. You can find more information about his work at his website, stuartfarrimond.com. Also, check out our show notes at aom.is/dailyroutine. Where you can find links to resources where we delve deeper into this topic.

Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofmanliness.com. Where you can find our podcast archives as well as thousands of articles that we’ve written over the years about pretty much anything you’d think of. And if you’d like to enjoy ad free episodes of the AOM podcast, you can do so on Stitcher premium, head over to stitcherpremium.com. Sign up, use code manliness at checkout for a free month trial. Once you’re signed up, download the Stitcher app on Android or iOS and you can start enjoying ad free episodes of the AOM podcast. And if you haven’t done so, I’d appreciate if you take one minute to give us a review on Apple podcast or Spotify. It helps out a lot. And if you’ve done that already, thank you. Please consider sharing this show with a friend or family member who you think will get something out of it. As always, thank you for the continued support. Till next time, this is Brett McKay reminding you to not only listen to AOM Podcast but put what you’ve heard into action.

The post Podcast #888: The Science of a Better Daily Routine appeared first on The Art of Manliness.

For centuries, when someone referred to “dinner,” they meant a meal, the largest of the day, which was eaten around noon. A lighter “supper” was then consumed in the evening. 

Starting in the 18th century and accelerating in the 19th and 20th, the hour at which dinner was eaten moved later and later in the day. This shift occurred for various reasons: later dinners became fashionable; electric lights facilitated dining after dark; and with more men working away from home and not returning until after 5 p.m., an evening dinner allowed the entire family to reconvene for a meal together. 

Today, dinner remains the largest meal of the day but is typically eaten around 6:00-7:00 p.m. in America, and often even later in Europe.

While these large evening meals may be convenient in our modern, industrialized societies, emerging research has shown that this schedule doesn’t align very well with our innate human biology. 

As AoM podcast guest Steve Hendricks shared in our episode about fasting:

our circadian rhythms have hardwired us to process food most efficiently in the morning and early afternoon, and we get worse and worse at it as the day goes on. By nighttime, we’re frankly pretty terrible at processing nutrients. So when we eat later in the day or at night, nutrients linger in places where they shouldn’t, and our overnight repairs become interrupted. And there seems to be just nothing we can do to change this circadian rhythm that governs all of these processes.

Because the efficiency of our metabolism peaks in the morning and then declines throughout the day, people who eat the bulk of their calories early on improve their blood sugar and insulin sensitivity. They’re also less hungry and burn more fat than people who eat their biggest meals later in the day, and this is true even when people are eating the same amount of calories overall and doing the same amount of physical activity; meal timing alone can make a significant difference in overall metabolic health. 

It turns out there’s much wisdom in the old saying: “Eat breakfast like a king, lunch like a prince, and dinner like a pauper.”

While it may be beneficial to eat a bigger breakfast/lunch and keep one’s dinner small (or non-existent — according to Hendricks’ research, the ideal daily eating window is something like 8:00 a.m. to 2:00 p.m.), most people won’t find this idea very appetizing for reasons both practical and psychological. There is something very satisfying about sitting down with loved ones for a big meal after the stress of the day is through.

If you’re understandably not willing to mix up the timing and “weight” of your meals, there is something you can do to blunt the negative effect of eating the bulk of your calories late in the day: an after-dinner walk.

The Digestive Power of an After-Dinner Walk

Whenever we eat, glucose hits our blood, and insulin rises to shuttle it into our cells. In the morning hours, our cells are more insulin sensitive, so that when insulin metaphorically knocks on their doors, the cells are more receptive to opening up and letting glucose in. 

As the morning wears into evening, our cells become less insulin sensitive, meaning they start ignoring insulin’s “knocks,” leaving glucose in our blood. 

What’s more, as the day progresses, our pancreas starts getting sluggish and produces less insulin, meaning our cells will become less responsive to sugar spikes because the knocks from insulin are less loud.

This combo — less insulin sensitivity + less insulin — means that our blood sugar tends to be higher after meals eaten later in the day. This effect is, of course, only compounded when we eat a large meal later in the day. Thus, big dinners are not optimal for our metabolic health. 

Fortunately, our body has another powerful way to clear glucose from our blood that doesn’t rely on insulin: movement. 

Muscle is the primary tissue in our body, and it also happens to be one of the main consumers of glucose. In fact, as Dr. Benjamin Bikman noted in our podcast about metabolic health, “Roughly 80% of the glucose that gets cleared from our blood goes into the muscle.” 

He goes on to explain: “the moment the muscle starts moving — contracting and relaxing — it opens [its] glucose doors even though insulin isn’t there knocking on them. . . . And so if we just get up and start moving . . . [our muscles] begin greedily consuming all of that glucose.”

Bikman imagines your muscles as having tons of hungry little mouths that open up and gobble your glucose as you get going, and I find this metaphor really motivating!

By getting your muscles to soak up glucose in the absence of insulin, an after-dinner walk blunts blood sugar’s rise and allows it to come down quicker.

In a study done on people with diabetes, participants who were asked to walk for 10 minutes after each main meal improved their blood sugar curve more than those who were told to walk for 30 consecutive minutes at a random time, and this “improvement was particularly striking after the evening meal.”

That an after-dinner walk also effectively blunts glucose for people without diabetes is something to which I can personally attest. I used a continuous glucose monitor a few months ago (while I don’t have diabetes, I was interested in tracking my blood sugar), and it was interesting to see the effect post-dinner movement had on my glucose. My blood sugar would usually start rising around 45 minutes after eating. If I did nothing, it would continue to rise and take two hours to return to normal. But if I took a walk after dinner, my glucose levels wouldn’t rise as high, and they’d get back to normal in just 45 minutes — less than half the typical time.

Walking is also an aid to digestion in other ways. Because the intestinal system slows down when you sleep, a big evening meal can sit heavy in your stomach, disrupting your sleep. Research shows that a post-dinner walk stimulates the stomach and intestines, causing food to pass through them more quickly and giving your digestion a head start before you hit the hay. Walking after a meal can also diminish gas, heartburn, and bloating.

How to Take an Effective Post-Meal Stroll

Length/intensity. The faster and longer you walk, the more of movement’s post-meal glucose-sucking benefit you’ll get. (Though walking too fast might upset your full stomach a bit, so don’t ramp the intensity up too high.) But while a 10-minute walk is a good minimum to aim for, a recent meta-analysis showed that taking even a two to five minute walk after eating significantly moderated blood sugar. Any movement helps!

Timing. When I wore a continuous glucose monitor, I noticed that when I took my walk immediately after dinner, the walk didn’t blunt the spike in my blood sugar; instead, it just postponed the spike. When the delayed spike occurred, it had the same magnitude as if I hadn’t taken a walk.

A research study backs my personal results. It seems like if you want to reduce blood glucose, you should wait 30-45 minutes after eating to begin your activity. Happily, this gives you ample time to engage in post-dinner conversation before you get up from the table and take your stroll. 

An after-dinner walk won’t reverse the effect of eating a big meal at a time that runs contrary to your metabolism’s optimal clock. But it will help a little. Hey, it beats eating dinner like a pauper!

The post The Digestive Power of an After-Dinner Walk appeared first on The Art of Manliness.

Among people who experience some sort of trauma, what percentage do you think go on to develop post-traumatic stress disorder? A third? A Half? More?

Actually, the answer is 10%. An overestimation of how common it is to develop PTSD after trauma is one of the misconceptions my guest thinks are leading to its overdiagnosis and an underestimation of human resilience.

Dr. Joel Paris is a professor emeritus of psychiatry and the author of Myths of Trauma: Why Adversity Does Not Necessarily Make Us Sick. Today on the show, Joel explains what some of those myths of trauma are, including the idea that it’s trauma itself which causes PTSD. Joel argues that PTSD is instead created when exposure to trauma meets an individual’s susceptibility to it, and he explains what psychological, biological, and even social factors contribute to this susceptibility. We also get into how the methods used to prevent the triggering of trauma can backfire and how the treatment for PTSD will be ineffective if it only focuses on processing an adverse experience.

Resources Related to the Episode

• AoM Podcast #788: The Dangers of “Concept Creep”
• AoM Podcast #555: Dandelion Children vs. Orchid Children
• From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era by Edward Shorter
• AoM Podcast #440: The 3 Great Untruths That Are Setting Up a Generation for Failure
• Jay Belsky’s research on differential sensitivity 
• Video demonstration of EMDR
• Radical Acceptance 
• Interview with Bruce Wampold as to what makes for a good therapist
• Joel’s other books

Connect With Joel Paris

• Joel’s faculty page

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Read the Transcript

Brett McKay: Brett McKay here and welcome to another edition of the Art of Manliness Podcast. Among people who experience some sort of trauma, what percentage do you think go on to develop post-traumatic stress disorder? A third? A half? Four? Actually, the answer is 10% and overestimation of how common it is to develop PTSD after trauma is one of the misconceptions my guest thinks are leading to its overdiagnosis and an underestimation of human resilience. Dr. Joel Paris is a professor emeritus of psychiatry and the author of Myths of Trauma, why adversity does not necessarily make us sick. Today on the show, Joel explains what some of those myths of trauma are, including the idea that it’s trauma itself which causes PTSD. Joel argues that PTSD is instead created when exposure to trauma meets an individual susceptibility to it. And he explains what psychological, biological, and even social factors contribute to the susceptibility.

We also get into how the methods used to prevent the triggering of trauma can backfire, and how the treatment for PTSD will be ineffective if it only focuses on processing an adverse experience. After the show’s over check out our show notes at aom.is/mythsoftrauma.

Alright. Dr. Joel Paris, welcome to the show.

Joel Paris: Thank you very much for asking me.

Brett McKay: So you are a psychiatrist who specializes in working with individuals with borderline personality disorder. You also do a lot of research on borderline personality disorder, but you’ve recently published a book called The Myths of Trauma, where you take readers on a tour of the history and oft-overlooked research of post-traumatic stress disorder. So why did a researcher and clinician of BPD decide to write a book about PTSD?

Joel Paris: People think that BPD is caused by trauma and that you must have had trauma and that’s the main reason that you have that disorder. And it’s simply not true. It’s an aggravating factor and it’s one of the risk factors of several that lead to BPD, but people have… Some people have wanted to actually redefine BPD as a post-traumatic disorder. And also since I do a less specialized practice consulting for colleagues about various cases, I find that both patients and doctors are all too ready to diagnose anyone with PTSD if they have something bad has happened to them in their lives and this really doesn’t make any sense. It’s an attempt to explain very simply something which is complex, interactive, and multi-dimensional.

Brett McKay: Well, we’ll dig into these ideas more in our conversation, but your book’s called The Myths of Trauma. You’re not saying that trauma itself, this idea is a myth, but there are myths around this idea. So what are the biggest ones? And maybe throughout the conversation we can flesh this out some more.

Joel Paris: Okay. Well, definitely I’m not dismissing trauma. It is important. About 25-30% of the borderline patients that I see have histories like this, but a lot of them don’t. And so the problems are many, first of all, the way the trauma is defined, the DSM is too broad, and then there’s a big discrepancy between exposure to trauma, which is almost universal, somewhere between 75 and 90%, versus the frequency of PTSD after exposure to trauma, which is like 10%. So 90% of people who are exposed to a traumatic event don’t develop PTSD. And PTSD is most clear in a more narrow definition, such as a threat of violence or threat to your life or threat of rape, these are the things which are more likely to cause PTSD, but when people say, “Well, I was emotionally abused in my family,” I mean, that’s a real thing, but it’s not the same thing as the other types of trauma in PTSD. So I think too broad a definition of a traumatic event and a gap between exposure to trauma and actually developing post-traumatic symptoms are some main myths that I discussed in my book.

Brett McKay: Well, let’s talk about this definition of trauma. So you said it’s broad. You’re arguing that it’s too broad. How is it defined clinically and how has that definition changed over the past few decades?

Joel Paris: PTSD got into the diagnostic manual in 1980 with the DSM-III, and that was the first time it appeared. And at that time it had a narrower definition and it got broader over subsequent additions. For example, it’s mentioned that sometimes just hearing about trauma from somebody else without being directly exposed to it or witnessing it, or indirect exposure in the course of your job, that these things could be causes of PTSD makes less sense than as a direct threat against yourself. And I think this is where the beginning of the trouble begins.

Brett McKay: Why did they make it more broad? Okay. So originally it was if you experienced violence, rape, etcetera, that was considered trauma. It’s gotten broader and broader. Like why, why would they do that? What’s the reasoning behind it?

Joel Paris: There’s something called concept creep which a psychologist described a few years ago. When you have a concept in psychology or a construct or a diagnosis, it tends to be increasingly used with time. Now then the second question is, why do the writers of the manual agreed to expand it? Well, they have expanded many of their diagnoses. This is not the only example, that’s a whole other talk in itself, know about the problems with DSM. There may be clinical reasons in that therapists like to make this diagnosis, and there may also be political reasons because people have talked about whether we live in a kind of a post-traumatic society or a traumatic narrative, and that people talk about their traumas and these days I’m hearing from patients they use this language even if they haven’t read the manual. It’s out there and it’s popular because I think people would rather be victims of something else than feel this is something inside them which made them more vulnerable to trauma. One of the main points in my book is that PTSD is not only a result of the exposure, but reflects a vulnerability, a susceptibility to trauma of which there are many, many causes.

Brett McKay: Okay. So one of the arguments you make, one of the myths of trauma is that we’ve broadened the definition too much possibly to make it a useful idea. And this idea of concept creep, we’ve actually had, it was Nick Haslam.

Joel Paris: That’s who I was quoting. Yes.

Brett McKay: Yeah, we had him on the podcast.

Joel Paris: Oh, good.

Brett McKay: That’s episode number 788 for those who wanna listen to that.

Joel Paris: I will look that up.

Brett McKay: But you also, so you mentioned one of the other myths of trauma I think it’s kind of been embedded in our popular culture, psyche, consciousness, whatever you want to call it, is that if someone experiences a traumatic event, I think the assumption is, oh, well that person’s gonna have some sort of PTSD, it’s gonna harm them. But you highlighted numbers like, actually it’s very, very few people who actually experienced a traumatic event go on. So what were those numbers again?

Joel Paris: Well, in general, about 10% of people who are exposed directly to trauma and will develop PTSD later on. And the numbers are somewhat higher for certain things like rape is the worst one, and that gives you a 20% level, although that still means that 80% of people after rape don’t develop PTSD.

Brett McKay: And why do you think this gets overlooked? ‘Cause I think people automatically assume if someone experiences a really severe hardship, they’re gonna have some kind of problem. They need to go get professional help. But you’re showing the numbers actually. I mean, 10%, I mean, it’s terrible for the people who do experience it, but it’s most people, they’re gonna be okay, sounds like.

Joel Paris: Well, yes, this is called resilience and it’s a very central concept in psychology and psychiatry. And resilience is the rule after trauma. And I always say if we weren’t resilient, we would have gone extinct 100,000 years ago. I mean, life was much more traumatic in the past than it is today, in fact. I would refer your listeners to Steven Pinker on that subject. And so I think from an evolutionary point of view, we need to be resilient.

Brett McKay: So I think one of the arguments you make in the book is that this sort of tight coupling between trauma and PTSD that we have in our… Not only amongst the public, but also amongst a lot of clinicians, that it might be increasing the diagnoses of PTSD because someone thinks, “Well, this person had a traumatic event, they automatically have PTSD.” And you’re saying, maybe not.

Joel Paris: Well, I see this all the time because I’m evaluating patients. I do hundreds of consultations a year so I have a lot of experience with this. And if there’s almost anything of this sort in the patient’s past, even just an adverse situation like a dysfunctional family, people write in… After the first diagnosis, they stick in PTSD as a second diagnosis. And some people, and this goes into the latter part of my book where I talk about treatment, some people will prescribe various kinds of what are called trauma focused therapies, even in people who haven’t had the kind of trauma which is most likely to produce PTSD.

Brett McKay: And this is an issue. I’ve heard other clinicians raise concerns about this idea of diagnosing people who probably shouldn’t receive a diagnosis. ‘Cause what it does, people begin to take that identity, “Well, the shrink said I had PTSD, so I must have PTSD,” and they start thinking, “Well, I have PTSD.” But then if they would have gone to another psychiatrist, they probably wouldn’t have gotten that diagnoses and they wouldn’t have been thinking themselves as someone with PTSD.

Joel Paris: Probably not if they’ve seen… Probably less likely if they see somebody like me. It doesn’t even need a shrink to convince people that they have PTSD. People are self-diagnosing all the time. And then they talk about, “Oh, that’s my PTSD acting up,” or, “That’s my ADHD acting up,” and all these diagnoses which are sort of fuzzy and uncertain become a part of your identity. Like you’ve said, it’s a really important point.

Brett McKay: Well, so, okay, so most people don’t get PTSD. Let’s say someone comes to you saying, “Well, I think I got PTSD.” How do you, as a clinician, how are you defining PTSD? If you look at a patient like, yeah, you’ve got something here. We need to help you out. What’s that look like for you?

Joel Paris: Well, I’m following the DSM criteria because they’re most precise. If you look at it, it’s basically exposure to trauma followed by certain characteristic symptoms, most particularly flashbacks, avoiding things that remind you of what happened to you, the so-called triggers, a kind of state of expecting bad things to happen. I mean, there are all kinds of symptoms which are listed in the manual which are required for the diagnosis above and beyond the exposure and people who have PTSD will probably have them and people who don’t will probably not.

Brett McKay: So the research shows that most people who experience a traumatic event, they’re likely not gonna have PTSD, about 10%, 20% in cases of rape. So it sounds like if trauma itself doesn’t cause PTSD, if that’s the case…

Joel Paris: Well, that’s my whole point.

Brett McKay: Yeah. Okay. The trauma itself doesn’t cause PTSD but you say there are other factors that can contribute to it. So what are those other factors?

Joel Paris: Well, first of all, it was noted many years ago, it was a study of Australian firefighters. They were fighting bush fires which is pretty dangerous work. And the nice thing about this study and other similar studies have been conducted since then, but this was was the first study, what they did was they measured some of their personality traits when they started working as firefighters before anything had actually happened to them all, before they’d been in the fire. And they found that people who have what is called very high trait neuroticism, were more likely to develop PTSD after something bad happened in firefighting. So trait neuroticism basically is a central concept in personality theory which describes how easily you’ll get upset and how hard it is to calm down and it could be called being thin-skinned or extremely sensitive. So people who had more of this, were more likely to develop PTSD after exposure. And they’ve done studies like this with policemen and health workers and all kinds of people exposed to trauma. So personality is certainly one of them.

And I should point out here also that trait neuroticism is partially heritable, like all personality traits. There’s about half of it which is you are born with and the other half is due to your life experience so it’s a little bit more complex than that. But it has to do with things about you and how you respond to stressful events and not just the trauma itself.

Brett McKay: Well, so it sounds like some people are just more susceptible. So if they experience a traumatic event and if they’re high on this neuroticism, which as you said, part of it is just genetic, just that’s the luck of the the draw for you. You’re more likely to possibly experience PTSD after that traumatic event.

Joel Paris: Absolutely.

Brett McKay: Okay. Anything else besides the… The personality, any other factors that contribute to a diagnose or more people being susceptible?

Joel Paris: Well, what I proposed in the book is what’s called a biopsychosocial theory, which is bid for many decades, a rather influential concept, and it’s not just for PTSD, it’s for everything in psychiatry. So that… Let me take a step back and say it’s easier for people to think that A causes B and that is one cause, it is one effect, and the world isn’t like that. The world is multivariate. Everything is interactional. Everything that happens to you is complicated. Every response you have to what happens to you in life is equally complicated. And so when we say biopsychosocial, we’re talking about hereditary propensity. And I’ll give you another example of the hereditary propensity while I’m at it.

There was a study of Vietnam vets and we did quite a lot of studies of Vietnam vets. But this one was a twin study of Vietnam vets where they were able to measure the concordance of various mental disorders, including PTSD, and they found for every feature of PTSD, there was a fairly strong heritable component which influenced whether you would get it. So what you’re born with is really quite important. Some people are just born very nervous, and it’s not always a bad thing because cautious people sometimes live longer than risk takers, but it’s still something to… Then there’s a psychological aspect of it and this relates to other aspects of eroticism and other personality traits and also your life experience. So people who’ve had previous mental disorders, particularly those related to anxiety and depression prior to PTSD are more likely to end up with PTSD or even if there’s just a family history. We saw that in the Australian study, that even though there’s just a family history, they’re more likely to develop PTSD. So there are all these psychological factors which affect, which increase the risk.

And then social factors, well, I do talk about this in the book, which is I think the culture of PTSD is part of a larger issue in which people are using psychiatry to validate their sense of victimization in life and people write memoirs about this, and some of them are bestsellers, and sometimes you see these on television. So there’s a whole social structure around it saying it’s not only okay to have PTSD in a way, it’s kind of like almost you should have it because it’s a tough world out there and we need to change the world. So this, some people believe so. But the point about the biopsychosocial model is it’s an interactive model, so one hit won’t give you a mental illness usually. It kind of takes two hits, three hits maybe more, and they all sort of add up and have a cumulative effect and affect each other. So that’s the model they’re proposing and it leads to a different kind of treatment because… I’m sure we’ll get to this. I don’t think that spending all the time discussing the traumatic event itself is always the best idea.

Brett McKay: Okay. So with this biopsychosocial model, it’s complex, it’s non-linear. I think a lot of people, I think particularly the public and just the lay individuals, they think, “Well, if X happened, then Y happened.” They’re very linear thinking and is…

Joel Paris: Well, they’re made that way to think linear.

Brett McKay: Yeah. So I wanna talk more about this social aspect. So we talked about the sort of the biopsycho part of this model. Some people are just born with a propensity to develop mental illnesses, including PTSD if they experience severe adversity in their life. There’s this social model, you call it like the culture of PTSD. You also talked about the culture of trauma. Have there been studies done? I think you particularly see this in the West, in America especially. Have there been studies done across cultures where they look at say a country in Africa or China, for example, where maybe this idea of trauma and PTSD isn’t in the popular psyche? Do they have about the same amount of PTSD diagnoses compared to the United States?

Joel Paris: Well, there are very few systematic or large scale studies of this kind. I mean, it’s expensive and difficult to find out the prevalence of mental disorders in Africa or other developing countries. Nevertheless, I think somewhat partly anecdotally but also based on some of the things I’ve read from anthropologists and cultural psychiatrists, people in other cultures, they have the stress but it comes out differently. For example, fatigue, people just take to their bed and they have no energy. We used to call that in the 19th century psychiatry, neurasthenia. So these kinds of symptoms tend to be more common in developing countries. And I don’t know of anybody who’s gone out to measure PTSD. I’ve been interested in even in the question as to whether or not there’s borderline personalities sort of outside the West. And what I’ve seem to have concluded is that yes, in the large, in very large cities, but no, not in places which haven’t changed in a thousand years.

And there’s something about, I think there’s something about the stresses of modern life, the pace of change. Maybe we could even put a little bit of blame on the internet and social media for spreading all kinds of ideas of how to frame your distress. I mean, the stress, psychological stress is universal, but how it comes out is not as universal. There’s a historian of psychiatry named Edward Shorter, who I think would be interesting for your program, he describes something called the symptom pool and he documented over the last couple of centuries how symptomatic presentations have changed even in the West, and PTSD is probably an example of that but I can’t prove it with hard data.

Brett McKay: You cite some research. Let’s see. Dückers and Brewin, they noted a vulnerability paradox in that PTSD is much more common in highly developed countries than in those afflicted by widespread poverty. And then McNally did a study, he said, he suggested that the paradox can be resolved if PTSD is more frequent in sub-populations within wealthier countries who are more vulnerable. So I guess the idea is that if you grew up in a very affluent life and you don’t have a lot of adversity your standard of what is considered diversity is probably lower than those who grew up in really trying circumstances.

Joel Paris: I think that’s very true. Thank you for the close reading of my book and those references because I did discuss them. Although they’re not based on extensive data, I think those ideas make a lot of sense.

Brett McKay: Okay. So the thing you’re saying again, it’s like, you’re not saying that PTSD doesn’t exist in these, maybe Africa or China or whatever?

Joel Paris: I’m sure it does, but I suspect at a lower, much lower rate.

Brett McKay: Lower rate. Or it might manifest itself differently than here in the United States?

Joel Paris: That’s right, that’s what I’m saying.

Brett McKay: Yeah.

Joel Paris: It may come out of something else which doesn’t look like PTSD, and maybe looks a little bit more like depression or anxiety.

Brett McKay: We’re gonna take a quick break for a word from our sponsors.

And now back to the show. Okay. So yeah this biosocial, psychosocial model shows how complex it is. There’s a lot of factors going on. Just the way you think about PTSD might influence whether you have, will be prone to get PTSD. If you think, well, if I had this traumatic experience, ’cause that’s what everyone’s saying then if you experience a traumatic experience, you think, “Oh, my gosh, I’m gonna get PTSD. I need to go get help.” Some other myths that you highlighted in the book is this idea of repressed memories when it comes to PTSD.

Joel Paris: Yes.

Brett McKay: What’s going on there?

Joel Paris: What’s going on is a fad, well, what I call a malignant fad within psychiatry, it’s not the only one but it was one of the worst. It was most prominent in the 1990s and it was promoted by one psychiatrist who wrote in her book, the usual response to trauma is to forget about it, which is totally untrue because the whole concept of PTSD is that you can’t get it out of your mind, you can’t put it behind you, and the treatment involves, often involves helping people to put it behind them and accept that that happened and then they have to move on. Now, but people are troubled by intense memories of bad things that happened to them and that’s a crucial element of PTSD.

Joel Paris: The idea that trauma is repressed, there’s really almost no evidence for this at all. It was an idea introduced by Sigmund Freud about 130 years ago, and it just has not, it has not been supported by research. But what the fad consists of was hypnotizing people or putting them into very intensive therapies and telling them, you must have been traumatized because look at your symptoms. I mean, I had a patient with borderline personality disorder. She told me her experience as a teenager in the pediatric hospital in Montreal, and she set out with some venom. “They tried to convince me that my father must have molested me and are they wasting my time?” [chuckle] So this idea that you…

There was this book, The Courage to Heal. It sold millions of copies ’cause it appeals to people, it said, “If you have these symptoms you probably were traumatized as a child, and if you can’t remember it that proves that you were traumatized because you repressed it.” It was completely wacko in this respect and yet it appealed to many people. It was only a minority of psychotherapists who embraced or psychiatrists, whoever embraced this idea. But it was out there in the public and there was a small number of people who were promoting it, and I think you’ll still see it. So these ideas of something terrible happened to me, I just have to work to remember it and then process it. This is a very appealing idea for many people.

Brett McKay: Then you also… Maybe you highlight so you’re saying this idea that you, if you experience a traumatic event, you’re likely to repress it. I mean, you go back to the historical record showing Civil War soldiers who… They weren’t diagnosed with PTSD but they basically in their journal entries and their letters they’re, obviously they were traumatized and their problem was they couldn’t forget it. They wanted to get it out of their head, but they’re…

Joel Paris: Exactly, exactly.

Brett McKay: They’re having flashbacks.

Joel Paris: And by the way, soldiers in war, also a majority of them never develop PTSD. But there’s another thing which is particularly relevant for the USA which is that the Veterans Administration offers you free treatments of all kinds if you say you have PTSD and, or if somebody tells you, you have PTSD. It’s an entry into treatments which tend to be not so easily available otherwise.

Brett McKay: So let’s talk about this, this idea you mentioned triggers warnings. You also, you often hear that like I experienced something that triggered my PTSD. There might be something that you hear about people, soldiers particularly, who they might hear some sort of loud noise and it might remind them of an intense memory.

Joel Paris: It is definitely a real phenomenon.

Brett McKay: But then you say there’s some myths around this idea of trigger warnings that have creeped in into our… How we talk about this stuff.

Joel Paris: Well, if you hear a loud noise or even a low flying bird or something like that and you wanna duck, that’s a good example of a trigger that can bring back certain traumatic events. I don’t disagree with that at all. But then it starts becoming like, I was rejected by my partner and that triggered me because of my unhappy childhood. I mean, it starts to spread in Haslam’s concept creep into something which becomes all the pathways to psychopathology can be seen in this model and it’s very tempting.

Brett McKay: Yeah. And it becomes so broad that it, like the idea of triggers becomes useless almost.

Joel Paris: It’s certainly overrated.

Brett McKay: Yeah. And I think that you’ve highlighted research too, this idea. You’re seeing this in college classrooms, this idea of trigger warnings. Oh, we’re gonna discuss something that’s potentially, you know, if you experience this it might trigger you, so if you want to get out, that’s fine. I think you highlight research in the book showing that those actually, they don’t do anything, like in…

Joel Paris: No. Well, in fact, this is the whole probable, and the whole culture in the university and the trigger warnings. I went to a lecture at my university from an expert in a rather controversial field which is gender identity. And at the beginning of the… And before I was being introduced the moderator announced that, “If you get too upset by anything this person says, we have people in the back ready to talk to you.” I think that Jonathan Haynes and others, Christakis, people, academics have talked about this as something which is really undermining free speech and diversity because somebody’s going to be triggered by it. And it’s kind of like a weird idea that young people could be so easily triggered that they have to be in the words of these academics coddled, rather than be in an environment where you can pose difficult questions and look for answers.

Brett McKay: Yeah. You highlight research from Bellet, he has had this to say, I thought it was really interesting. He says, “Trigger warnings may raise awareness of the difficulties of people suffering PTSD. However, they may also create the impression that the experience of trauma always renders survivors emotionally incapacitated.” And we talked about this. “In reality, most trauma survivors are resilient and show few symptoms of PTSD after initial period of adjustment. The perception of trauma survivors as dysregulated victims may contribute to negative stigma concerning the very individuals trigger warnings are intended to protect.”

Joel Paris: And it works somewhat against the idea of confidence mastery, getting a life, having an identity, feeling realistically optimistic about one’s options. All these things is infantilizing.

Brett McKay: Yeah. So we talked about what can cause people to get PTSD and some of the myths around that. Again, you highlight research, most people aren’t affected about 90 to 80%. If they experience a traumatic event, they’re gonna be okay. But then you also highlight research that some people actually become more emotionally and mentally robust after a traumatic event. What’s going on there?

Joel Paris: That’s called post-traumatic growth. And the people like to quote Nietzsche who said, “What doesn’t kill me makes me stronger.” But in terms of science, there’s a lot of research on resilience and people who’ve been through terrible things, you know, most of them will cope. There’s a whole enormous literature and psychology about resilience and it’s probably related to what’s been called positive psychology, whereas I think this trauma focus could be called negative psychology.

Brett McKay: On this idea of post-traumatic growth syndrome, are there some people who just have more of a propensity for that than others?

Joel Paris: Well, again, the highly neurotic people by nature are probably going to have more difficulty getting out of their traumas than people who could just… So there are some people who just bad things happen to them and they just shake them off and move on. They’re very low in neuroticism. So I think this is a very important factor in terms of how much people tend to get better without treatment and how much better they’ll get within treatment.

Brett McKay: And this idea that, okay, some people will experience growth, some people will have a hard time after they experience traumatic events. Others reminds me of a podcast we did a couple years ago about children, and there’s this idea that some children are born orchids and some are born dandelions.

Joel Paris: I love that, I love that.

Brett McKay: Yeah. The dandelion kids, like you could put them in any situation and they’ll be okay ’cause they’re like weeds or they’re like dandelions or robust. But then some kids, because of genetics and whatever, they’re more like orchids and they require a more… A better environment, they can’t handle a lot of stress. And I think it’s a interesting thing to keep in mind as you’re thinking about this stuff.

Joel Paris: Well, Jay Belsky has written about this too, he’s a well known psychologist, and he just calls a differential sensitivity to the environment and he suggests that actually these people who are easily upset are also more permeable to good things that happen to them. So they may actually do better than the average person if they’re in a very positive environment, but they do much worse if they’re in a negative one.

Brett McKay: So let’s talk about treatment. What are some of the biggest myths about the treatment of PTSD and other trauma related disorders?

Joel Paris: Well, I think the biggest one is that the treatment should only be about processing the trauma and this is the problem with several of the methods that I described in my book. I’m somewhat negative about EMDR, this eye movement thing where if you have ever seen a video of this being done, that it reminds me of Mesmer from the 18th century with a wand, waving and then the eye movements which has not been shown to make any difference. EMDR is no better than most standard therapies which are being offered to these patients. But it’s trendy, it was marketed very cleverly by this woman, Shapiro, who developed it, and some people come in asking for it and so… But in fact, I think we could live without it. There are variations of cognitive behavior therapy which have a traumatic focus, which make more sense. You do have to talk about the trauma. I’m not suggesting in any way we should avoid talking about it and it’s always worth going into it.

The question is whether or not healing happens because you’ve processed the trauma or whether healing happens because something larger like your sense of self-identity, direction, your relationship, your career, you’ve got things to protect you and guide you through recovery, which can be supported and reinforced in psychotherapy. And I think those broader aspects of therapy, which have sometimes been called the common factors in therapy, the ones that make you feel that somebody has understood you and you can get better and you don’t have to give in to all of these things. This is what works for most people in therapy. And not seeing that broader picture may be a negative in terms of what we offer for patients who do have PTSD.

Brett McKay: Okay, so what you’re saying is the bottom line therapy for PTSD is as long as you’re with a therapist who you feel like you’re understood, you have a good relationship with them, they give you a sense of hope that you can get over this and move on with your life and be robust, that’s probably the more important thing compared to the specific therapy you use.

Joel Paris: The research totally supports that. There’s a guy in Wisconsin called Bruce Wampold who’s been writing about this for decades, and the evidence overwhelmingly shows that techniques in therapy are much less important than the relationship. And that the ability to get people better is as much a talent, a personal talent to the person who provides a treatment as it is anything nuts and bolts specific that they do.

Brett McKay: And I think this could apply to other mental health things that you might, if you want [0:35:18.3] ____.

Joel Paris: Generally, it’s generally true in all the non-psychotic mental health conditions, anxiety, depression, personality disorders. We certainly do a bit of trauma work when we treat our patients with borderline personality disorder in the clinics that I run, but it’s part of a larger frame and we’re very influenced by Marsha Linehan’s DBT, which emphasizes something called a radical acceptance, which goes back to the stoics and philosophy in some ways. And that you encourage people to say whatever’s happened to you in the past, it’s in the past, the future is in your hands, you can make it better. I’ll coach you to get there, but you don’t have to be hobbled by the past. But before you… But in order to do that you have to accept that it’s happened and you can’t change it and… But not see that yourself is doomed to be marked by it for the rest of your life. So this is a… This crucial concept in dialectical behavior therapy of radical acceptance we use it a lot and I think it’s just as relevant to trauma as some of the other more trauma specific things that have been described.

Brett McKay: And one of the arguments you make and this is bolstered by other researchers you cite, is that the focusing on treatment where you just talk about the trauma over and over again, it’s not helpful and actually can backfire because it just ingrains in the person’s head that, “Well, I can’t do anything about this. This happened to me and there’s no hope and I just kinda had to muddle along through life.”

Joel Paris: They had these trauma counselors who were some at one point were being flown into various disasters to talk to people right away and they found that that definitely made people worse because they haven’t even gotten past the stage of being so-called shock yet. And I think you have to respect trauma, validate the person’s right to be upset about it but not indicate that somehow by going over and over the same thing, they can get better without doing something in their present life to make a difference.

Brett McKay: Yeah. I thought it was interesting that the studies about the trauma counselors, I remember hearing about that 10, 15 years ago when there would be a natural disaster or even at 9/11, they would fly in these trauma counselors so they could just talk to these people right away. And I think it was well intended. They thought, “Well, these people had a hard time. If we just talk to them right away, maybe you can diminish the amount of PTSD they might experience.” But it actually backfired because like, I guess the body or in the mind, they have… We have a natural way of processing traumatic events and if we, I don’t know, talk about it too much, it might disrupt that natural process.

Joel Paris: I totally agree with you.

Brett McKay: Yeah. And I think you still see it nowadays. I’ve seen it at schools where a teacher might die and they’ll have grief counselors right away. And it reminded me of the trauma counselors. I don’t… Maybe it’s helpful, maybe some students need that, but maybe, maybe not, maybe there’s just kids who just need to kind of get together and talk about it on their own and they’ll, I mean, maybe they’ll figure it out.

Joel Paris: Absolutely. And I think and of course that also relates to the situation of trigger warnings in universities, in classrooms is the same issue. They don’t know, the counselors, they hear something which is upsetting, you have to learn about things which are upsetting, that’s part of education.

Brett McKay: Okay. So when you treat someone with borderline personality disorder or PTSD, you’re gonna talk about the trauma, yet people need to feel they’re heard and understood, but then I guess you’re saying the better thing to do instead of focusing on that, continuing to focus on that, is to talk about what are some things I can do now to make things better? Like restore agency in people’s lives.

Joel Paris: Agency is a lovely word, and I totally agree with what you’ve just said. That’s my position.

Brett McKay: Okay. Well, this has been a great conversation. Is there any place people can go to learn more about the book and your work?

Joel Paris: Well, I am on the Author Center at Amazon. [laughter] I’ve written 25 books mostly on personality disorders but also on [0:39:29.0] ____ in general. This one is published by Oxford University Press, it came out in October, it’s in a paperback it’s not that expensive. So if people want to look for it, I think Amazon is the easiest place to go.

Brett McKay: Fantastic. Well, Joel Paris, thanks for your time, it’s been a pleasure.

Joel Paris: Thank you.

Brett McKay: My guest here is Dr. Joel Paris, he’s the author of the book the Myths of Trauma. It’s available on amazon.com. Check out our show notes at aom.is/mythsoftrauma where you’ll find links to resources, where you can delve deeper into this topic.

Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofmanliness.com where you find our podcast archives as well as thousands of articles written over the years about pretty much anything you can think of. And if you’d like to enjoy ad-free episodes of The AOM podcast, you can do so on Stitcher Premium. Head over to stitcherpremium.com, sign up, use code MANLINESS to checkout for a free month trial. Once you’re signed up, download the Stitcher App on Android, iOS and you start enjoying ad-free episodes of the AOM podcast. And if you haven’t done so already, I’d appreciate it if you’d take one minute to give us a review on Apple Podcast or Spotify, it helps out a lot. If you’ve done that already, thank you. Please consider sharing the show with a friend or family member who you think will get something out of it. As always thank you for the continued support. Until next time, this is Brett McKay, reminding you to not only listen to podcast, but put what you’ve heard into action.

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What creates the differences between the sexes? Many would point to culture, and my guest today would agree that culture certainly shapes us. But she’d also argue that at the core of the divergence of the sexes, and in particular, of how men think and behave, is one powerful hormone: testosterone.

Her name is Dr. Carole Hooven, and she’s a Harvard biologist and the author of T: The Story of Testosterone, the Hormone That Dominates and Divides Us. Today on the show, Carole explains the arguments that are made against testosterone’s influence on shaping men into men, and why she doesn’t think they hold water. She then unpacks the argument for how testosterone does function as the driving force in sex differences, and how it fundamentally shapes the bodies and minds of males. We delve into where T is made, how much of it men have compared to women, and what historical cases of castration tell us about the centrality of testosterone in male development. We then discuss how T shapes males, starting in the womb, and going into puberty and beyond, before turning to its influence in athletic performance. We end our conversation with Carole’s impassioned plea for celebrating what’s great about men.

Resources Related to the Podcast

• AoM Podcast #86: Demonic Males With Richard Wrangham
• AoM series on testosterone
• AoM Podcast #336: Master Your Testosterone
• AoM series on status
• AoM Podcast #756: How the Desire for Status Explains (Pretty Much) Everything
• AoM series on the origins and nature of manhood

Connect With Carole Hooven

• Carole’s Website
• Carole on Twitter
  
  

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Brett McKay:  Brett McKay here, and welcome to another edition of The Art of Manliness Podcast. What creates the differences between the sexes? Now, many would point to culture, and my guest today would agree that culture certainly shapes us, but she’d also argue that at the core of the divergence of the sexes, and in particular of how men think and behave, is one powerful hormone: Testosterone. Her name is Dr. Carole Hooven, she’s a Harvard biologist and the author of, “T: The Story of Testosterone, the Hormone that Dominates and Divides Us”. Today on the show, Carole explains the arguments that are made against testosterone’s influence on shaping men into men and why she doesn’t think they hold water. She then impacts the argument for how testosterone does function as the driving force in sex differences, and how it fundamentally shapes the bodies and minds of males. We delve into where T is made, how much of it men have compared to women, and what historical cases of castration tell us about the centrality of testosterone in male development. We then discuss how T shapes males starting in the womb and going into puberty and beyond, before turning to its influence in athletic performance. We end our conversation with Carole’s and passionately for celebrating what’s great about men. After the show is over, check out our show notes at aom.is/t.

Carole Hooven, welcome to the show.

Carole Hooven:  Thanks so much for having me, Brett.

Brett McKay:  So you got a book called “T: The Story of Testosterone, the Hormone that Dominates and Divides Us”. So, you have spent your career studying the physiological and psychological effects of testosterone on humans and other animals. How did that happen?

Carole Hooven: Okay. Wow, I don’t know where to start. I guess I could start… I’ll just start by saying, when I graduated from college, I had no idea what I wanted to do, I just sort of got a regular job, I did that for 10 years, and then I decided that I wanted to go work with Richard Wrangham, who I know you’ve had on the show before, and the reason I wanted to do that is because I had been taking classes, and reading books and just trying to… And traveling, and trying to figure out what I really wanted to do when I grew up. And I read this book by Richard Wrangham called, “Demonic Males”, and I had really been focusing in on understanding human behavior, and I’d gotten really interested in neurobiology, then I discovered genetics and evolution and got really interested in that. And then I read Richard’s book, which used research on non-human primates, primarily chimps, as a way to understand the evolutionary and genetic origins of human behavior, particularly aggression, and I thought that was fascinating, and I thought that was something that I might be able to actually do, especially ’cause Richard was at Harvard at the time. And so I applied, quit my job and applied to the Harvard Graduate Program, and got rejected because I had no relevant experience, and then I really bugged Richard and some other people in the department, and I was like, “Look, I already quit my job. [chuckle] This is what I wanna do.”

And eventually, because I was persistent and enthusiastic, not because I had any special expertise, I have to say, Richard gave me an opportunity to go out to Uganda and study chimps for a year. I ended up getting evacuated because there was a lot of really awful violence and political upheaval around Uganda, in that region of Africa at the time, so I only spent eight months out there. But long story short, it was spending eight months in the jungle with chimpanzees surrounded by a lot of actual human aggression and violence that got me really interested ultimately in testosterone, because the way… If you… Anyone who goes and spends time with chimps can see that the sex differences in the chimpanzees in so many ways mirror sex differences in humans, just in these very broad patterns of the status and hierarchy, obsession among the males, competing largely for food and the right to have sex with the females who are in estrus, who can get pregnant. So there’s a lot of aggression, there’s a lot of status obsession in the males. They’re also capable, like humans are, of being kind and nurturing, and warm, and family-oriented in a way.

And the females, on the other hand, I never saw, although it does happen, I never saw any instances of female physical aggression. I saw it every single day among the males. And so there was just this very pronounced sex difference where there’s a lot of nurturing and caregiving among the females, just much more peaceful overall on… All of this is on average. And they don’t have any human culture, so there was nobody who was gonna be able to convince me after that experience that these similar patterns of sex differences in humans are primarily due to human culture. They’re not. They’re molded by human culture, the way they’re expressed is heavily dependent on human culture, but the evolutionary and genetic origins are in us. We’re born that way. And so that’s why I got interested in testosterone ’cause there’s no more powerful way of explaining human sex differences, which are… Male behavior in particular is a really important aspect of our lives.

Brett McKay: Yeah, one of the goals of your book is to push back some of these popular arguments out there that testosterone really doesn’t influence differences between the sexes. There’s lots of them. Can you briefly summarize the arguments against T’s influences on sex differences? Like, if it’s not testosterone, what are they saying is causing the sex differences?

Carole Hooven: Right. I’ve been asked this before, and I admit, I do find it challenging because… But it’s a really good exercise, and I try to do this in the book, which is to entertain the best argument from the opposition. So most critics, except for the most extreme ones, will acknowledge that the physical differences basically from the neck down are due to testosterone. So it really… You have to be kind of a nut job to deny that male size and strength overall, although there are nut jobs who are getting a lot of press, unfortunately, but that’s just really would be incredibly far-fetched to try to deny the science that testosterone at least explains the secondary sex differences in humans, so that’s high muscle mass, fat distribution, body hair, those kinds of things.

So most critics will acknowledge that testosterone is responsible for those physical differences. More reasonable critics, and I think this can play a really useful role in the science of testosterone and sex differences, most other critics deny that testosterone has any important effects on the brain, and thus, behaviour, and that it is not ultimately the most powerful driving force in those sex differences that I just talked about. So the largest sex differences that exist, and this is not my view, this is, in fact, I’m not talking about the cause, I’m just talking about the observation, are in sexual psychology and behavior and physical aggression.

So those are huge, consistent with non-human animals. We see them across ages, not the sex part, but across cultures. They’re just incredibly pervasive. And so those sex differences exist, but the question is, does testosterone influence the brain and behavior in ways that promote increased physical aggression in males and increased desire for variety and number of sexual partners. So those are the biggest sex differences, and those are the ones I really focus on in the book because there’s so much clear evidence that testosterone in the early developmental period around pre-natally and directly post-natally, and then in puberty and beyond, that those differences in exposure to that hormone and how it acts, coordinates the body, the physical adaptations of size and strength with psychological adaptations that enable male animals, including humans to take advantage of their larger body size, and the fact that they have sperm and a penis, that they have to be motivated to wanna get that sperm into the female reproductive tract, and to do that, especially over human evolutionary history, there had to be physical competition with other males for status or for the resources they need to acquire high status, which enable…

And that could be territory, now a lot of that is money and professional status. But doing all of that increases the chances that males will be able to have a higher number of sex partners ultimately. And there’s different strategies that males can use and we can get into that. So it might not be an increased number of sex partners, but it might be using one’s body and having the psychology to wanna use one’s body, or even just one’s sort of competitiveness and desire to elevate one’s status that could result in the acquisition of a high quality mate, where if you mate with that single female for life, you could do very well reproductively. It doesn’t mean that you have to have 10 kids, but it means you have to acquire that mate and have sex with her. So the adaptation is not the male desire necessarily for children, it’s the desire to either partner with one or a few mates and be a good partner, or play the field and have many different partners, there’s many different strategies. But… Sorry, this is a long answer, but the idea is that testosterone coordinates the psychological adaptations with the physical adaptations.

And I should just get back to the critics ’cause I’ve gotten off the topic here. But the critics are, to me, bizarrely denying that they’ll accept that testosterone acts on the body, but then are denying that it acts on the brain because they want to assert, and they do assert, that because we live in a gendered society, the default assumption should be that the sex differences that we observe are due to social and cultural influences. But this just doesn’t make sense from a scientific and evolutionary point of view. The default assumption is that we are like all of these other animals where testosterone does these very same things in males. It’s not a coincidence that it does the same thing in humans, it’s just that our culture can exacerbate those differences. They can minimize… The culture can minimize or kind of enlarge those differences or just budge the expression around. So it’s always gene, culture, interactions.

Brett McKay: Why do you think the critics are so reluctant to embrace the fact that T influences not just the body but the mind? What is the apprehension?

Carole Hooven: Yeah, I think it’s based on fear, which should not be playing a role in science and our efforts to understand reality. So even if the fear was true, if the fear was based in reality, so suppose the fear is that, well, if men are dominant to women and have power, commit rape, cheat on their wives, if that’s because of something in their genes, if that’s because their genes code for high levels of testosterone and testosterone promotes these behaviors, the fear might be, “Well, then there’s nothing we can do about it. Then we’re stuck with bad male behavior, and it justifies bad male behavior because it’s natural.” That’s called the naturalistic fallacy, by the way, the idea that what is found in nature is good. Anyone can see in two seconds that there’s plenty of things that are natural, like malaria, that are terrible. So that’s just a bad argument.

And there’s also plenty of evidence that we are definitely… That’s biological… The idea of biological determinism, that if something is in our genes, it’s immutable and we’re stuck with it and we have to accept it. Of course, that’s not true either. And all you have to do is look around the world at different cultures and different societies and see what the differences in, say, the rates of murderers, because males commit across the world about 95% to 98% of all murders, but in some cultures, the sex difference in the murder rate and the murder rate itself is incredibly low. And I always use Singapore as an example because it’s extremely safe, people, especially women can walk around feeling safe because the sexual assault is incredibly low, physical aggression committed by males in general is extremely low, and that’s because of their culture and harsh penalties for those crimes. So…

And that’s just one example, and we know that there are examples on the other end. I was just talking to a grad student in my department who is from India, and he was… And I know the data on India. But sexual assault is rampant because it hasn’t been taken seriously in India by the government there, and you can get away with it. And so men, if you can get away with it, men are going to do it, and they do. So the idea is that genes and testosterone sort of lower the bar for the expression of those behaviors in the right environmental circumstances, but that doesn’t mean that the environment can’t shape heavily the expression of those behaviors. So males are definitely more inclined to those behaviors, but we know that there’s all kinds of things we can do to tamp down the expression of those behaviors, and that’s clear from just even looking across cultures, or even across time, and how we’ve changed over time. Our genes haven’t changed, but the laws have, and the social norms have.

Brett McKay: Okay, let’s dig into the basics of testosterone. I think everyone has a general idea of what it is, it’s a male… All male and females have testosterone, but males…

Carole Hooven: That’s right.

Brett McKay: Males have more testosterone. Where is it made in the body and what are the difference in testosterone levels in men and women?

Carole Hooven: So testosterone… First of all, in adulthood, males have anywhere… In puberty, males can have 10 to 30 times the level of testosterone as women, but in western well-fed populations, it’s about 10… Males have about 10 to 20 times as much as females, adults, that is. And there’s no overlap in testosterone levels in healthy normal populations of men and women. And so in men, about 95% of testosterone comes from the testes, and the rest of it comes from, mostly from the adrenal gland, and there’s some other sources. Testosterone is actually made by many tissues, it’s even made in the brain, so it can… Most of it comes from the testes, and then can enter the brain, but it can also be made de novo in neurons, which is really interesting. And I should just… And so in females, about half is made in… These very, very low levels are made in the ovaries, and then the rest is made in the adrenal glands and in fat cells. So also, and I should just say, estrogen comes from testosterone. So testosterone is converted into estrogen in males and females, and males also make estrogen, and males who have more body fat are gonna have more of the enzyme, which is called aromatase, that converts testosterone into estrogen.

So men who have a high level of adiposity can start to develop some feminine features like gynecomastia, AKA man boobs, and that’s because the estrogen levels can really rise due to this high activity of this aromatase enzyme. So in females, estrogen can come from conversion of testosterone in various tissues and from precursors to testosterone that are produced in the adrenal gland, that can then also be converted to testosterone in other tissues. And I should just say that testosterone is an androgen, and there are different androgens and our body’s testosterone is the main one, but there were other ones like dihydrotestosterone, which is also a product of testosterone conversion, and all the androgens interact with what’s the androgen receptor and… Like a key in a lock, basically. And the androgen receptor is present in many, many tissues, again, also in our nervous system and our brain. And what’s interesting is that the sex steroids, which are estrogen, progesterone, testosterone, DHT, can all, because they’re steroids, because they’re fatty molecules, they’re lipophilic, they can go into any tissue in any cell. They can just cross the blood-brain barrier, they can get right through cell membranes, inside cells and they affect gene transcription once they’re inside cells. So they’re very, very powerful and they can go everywhere and have these long-term systemic effects on us.

Brett McKay: I think it’s interesting to note that our knowledge of testosterone is relatively new. It wasn’t until the 1920s that scientists were able to actually pin down testosterone, the hormone.

Carole Hooven: Right.

Brett McKay: But before that, they… Scientists, people, humanity had a hunch that the testicles were involved in masculinizing men. And there’s some interesting, I guess we can call them natural experiments that happened throughout human history where we were able to figure out there’s something going on with the testicles that cause men to be men, and one of them is this really interesting thing in Italy, church choirs would castrate young boys basically, and they called it Castrati. Can you tell us about that? What do we learn about testosterone from that?

Carole Hooven: Yeah, so this is disturbing. I do talk a lot about castration in the book, over the ages and in different cultures, and I learned a tremendous amount and it was all gross [chuckle] because I did get… It’s not funny, I did get into the procedure, and there’s also Unix in Imperial China, and the way that they were castrated was particularly horrific, but most of the history of castration. So if we just start with the Castrati in, say, 18th century Italy, these are… What happened was, there was a lot of poverty and there were opportunities for kids who were pre-pubertal who were singers, to gain fame and fortune by singing in church choirs, some of them could gain great fame and fortune, but even if they didn’t have great fame and fortune, they could have some fortune at least, and help out their families. And so every year, thousands of young boys were castrated in the hopes of sort of making it big and making it to a church choir, and this is before there was any anesthetic. So a lot of them died, and most of them did not make it and had to live lives of a eunuch.

So what happens is, if a kid, a boy is castrated prior to puberty. So most of the people listening are men who have gone through puberty, and you know exactly what happens when you go through puberty, to your body, to your psychology, to your voice, and sometimes to your hair. Some people start going bald fairly soon after puberty, but a eunuch never goes bald. And so what happens is, if you remove the testes prior to puberty, and again, yes, this is before anything was known about testosterone, but there were these predictable changes where the period of childhood growth continues for a long time, and the reason is that in puberty, it is actually rising testosterone that is converted primarily into estrogen even in boys, that causes the growth of the long bones, and that when it plateaus towards the end of puberty, that causes the growth plates in the long bones to seal, and that is why growth, the height spot stops at the end of puberty, it’s actually because of estrogen coming from testosterone even in boys.

But the point is, if you remove the testes, you never have that testosterone increase during puberty and that growth hormone generated childhood growth, like I have a 12-year-old boy, he’s still in that sort of growth hormone period, he’s transitioning now to… Testosterone is gonna be taking over and… But that period is extended, so you get this longer period of childhood growth, and the castrated men can end up to be very tall because they don’t have that testosterone peak where growth ends. So they can be very tall and they don’t get those secondary sex characteristics that most of your listeners will have developed during puberty. So they retain their head hair, their voice does not deepen, and that’s the big point, is that the voice doesn’t deepen, they retain sort of high… They retain a soprano singing voice, but they have a much larger body size. They have larger lungs, so they have a powerful soprano voice, more powerful than a female soprano voice. And females were not allowed in church choirs, so they needed men basically to fill those parts in the choirs, so that’s what castration did for them. But of course what happens is these men have almost no libido, and of course they have no ability to impregnate anybody.

So that is one of the ways, that’s one of the sources of information that castration, even in humans, lowers libido. So it’s something about the testicles is necessary for typical male libido. And this was also known because there was lots of castration experiments on animals and animals would be castrated to reduce aggression, to reduce libido for various reasons, to generate certain kinds of meat like from a chicken, a castrated chicken has a large body size and more tender meat, and that’s called The Capon. And so it’s been known for ages that castration of male animals reduces muscle mass, reduces and eliminates libido and aggression in some cases. Yeah, so there was a long, deep knowledge about the testicles and the necessity of the testicles for typical male behavior, but testosterone itself was not isolated until 1935. And so that took a long time because we’ve known about this since the fourth century BC, had this information and yeah, so it took until the early 20th century to really identify testosterone and start to try to manufacture it.

Brett McKay: Okay, so let’s talk about how testosterone makes boys boys and men men. And I think oftentimes we think, Oh, testosterone only has an effect on a male during puberty that’s when we have this huge spike, but you talk about the influence of testosterone starts in the womb prenatally. So walk us through that process, what happens to a fetus when it’s exposed to testosterone? What’s going on there?

Carole Hooven: Yeah, so that’s super important, that prenatal and directly postnatal period, we don’t know as much about what testosterone is doing in little boys, little boy babies when it goes up right after birth, but we can talk a little bit about that later, but we know a lot about what it’s doing in utero. And I should just say that the way that little humans or conceptuses, which are just that embryo, the very early embryo actually doesn’t become male or female because of testosterone, it takes on male and female characteristics because of testosterone, but the determination of male and female is dependent upon the presence of the Y chromosome and the gene on the Y chromosome, that is sex-determining region of the Y… Called sex-determining region of the Y-chromosome or SRY. So if you have the Y chromosome, and it has an intact SRY gene, which almost every male will have that. That is what causes the undifferentiated gonads to differentiate into testes. So before six weeks…

The embryo is not identifiable as male or female. You could look at the chromosomes, but there are no structures or physical differences yet, it’s when that gene is expressed, that it goes on to cause that tissue, those undifferentiated gonads to differentiate in the testes direction rather than the ovaries direction.

So once that happens, it just takes a couple of weeks for the testes to start pumping out testosterone. So, like, I was pregnant with a boy, and it was just bizarre to know that he was in there with his little testicles in my body, that his little balls are making testosterone, that and that testosterone is what was necessary for guiding his body and to promote the development of all the male reproductive structures and Physiology, so his scrotum, his penis, his prostate, his vas deferens… All that stuff is due to the actions of testosterone directly, and testosterone can do that because, like I said before, it acts on his genes that females share.

Females have the same genes, it’s just that they don’t have testosterone to cause the genes to be expressed in a way that grows and maintains the male reproductive structures. So the little fetus has testes that produce a lot of testosterone, and that’s what is responsible for the development of the male reproductive structures and male reproductive function that I just described, but at the same time, evolution has done this amazing thing where testosterone at the same time, prenatally, as it’s working on the body to masculinize it, it goes into the brain, because, I’m just gonna say it knows that this is an animal that needs to reproduce in a way that females don’t need to reproduce. Like this animal has to compete basically for female mating opportunities and it’s gonna be producing sperm, so this animal is going to, as a little kid, need to be do more rough and tumble play, for instance, and females might have to practice nurturing behavior, so females don’t have exposure to testosterone in utero, or they have very… Typically, very, very low exposure.

Males will have high levels of… Very high levels of testosterone in utero that masculinize the body and the brain, so that the brain can take advantage of the male body and shape that animal for male reproductive strategies, which are different than what females need, because females need to use their bodies to grow their offspring and feed their offspring… Sorry, offspring, and males don’t use their bodies to grow the offspring, they use their bodies to compete for the right to make… To have a female do the work for them basically, and that all starts in utero. And then there’s a small rise in testosterone… Sorry, it’s… Actually, it’s a short-term rise, it’s a three-month increase in testosterone shortly after birth that seems to be very important physically, again, and probably neurologically, but we don’t know a lot about it, but there are some hints that it might have to do… Might further masculinize behavior, and have something to do with penis development and could have something to do with ultimately penis size, but there’s not a huge amount of work on that yet…

Brett McKay: Right. So okay, basically, this is kinda like a mini puberty for boys right after they’re born.

Carole Hooven: That’s right. That’s right.

Brett McKay: We’re gonna take a quick break for words from our sponsors. And now back to the show. So basically, this prenatal exposure testosterone, is it kind of laying the ground work, like the wiring for later development in puberty?

Carole Hooven: That’s exactly right. So the framework that scientists use to talk about this is called the organizational activation effect or framework. So this is the idea, and this is actually really important because people think all you have to do is shoot up, and this happens obviously in, like trans men, or people who transition their gender, they will take the hormone, they’ll block their own hormones and take the hormones of the opposite sex. So for instance, if a female transitions to live as a male, and takes male levels of testosterone, that testosterone that she’s taking as an adult is acting on her brain, in a way that’s different from how it would act on a male brain, because a male brain has been… The neural structures are permanently masculinized, and these are very subtle effects, these aren’t huge differences in structures in the brain.

These are widespread small effects on, like cell death and synaptic, and connections between cells, so these are small effects that seem to have… Small changes that seem to have important effects in adulthood. So the brain is masculinized in boys pre-natally and then in adulthood when testosterone goes up in puberty, that testosterone is acting on those previously masculinized neural structures. So that if testosterone goes up in adulthood, say in a female whose brain has not been masculinized pre-natally, it’s going to have a different effect because it’s not acting on previously masculinized structures. And, this is hard to study, in humans, but it’s very clear in non-human animals, that you cannot activate typical male sexual and aggressive behavior in female animals whose brains have not been masculinized pre-natally, if that makes sense.

Brett McKay: Yeah.

Carole Hooven: Does that make sense?

Brett McKay: Yeah. That makes sense, that makes sense. And so okay, this prenatal exposure testosterone is what gives boys their boyish behavior, so like… While these others…

Carole Hooven: Yeah, yeah, before puberty, they’re like tackling each other.

Brett McKay: Before puberty, Yeah, so there’s a lot of rough and tumble play, I think I’ve heard boys, this is generally tend to be more object-oriented as opposed to person-oriented. And what’s interesting, like gender differences in toy preferences. You see this even in chimps, they’ll give Chimps a toy and the female girl chimps will play with maybe a doll, but the boys will somehow turn it into a weapon or some sword.

Carole Hooven: Yeah, the primate toy studies are less… They’re interesting, but I…

Brett McKay: Not robust. Sure.

Carole Hooven: They are less convincing to me than the rough and tumble play, we don’t even need the toy thing. We need… You can just…

Brett McKay: Okay, just the rough housing.

Carole Hooven: Yeah, you can look at all these. Just look at, take mammals, and it’s not even confined to mammals, but you could look at chimps, you can look at rats, you can look at a huge variety of animals, and you look at the juveniles and there are clear sex differences in play that are parallel in many ways to what we see in humans where the male, the little boys, say in chimps or in rats are tackling each other, they’re playing physically, they are… What they’re doing is practicing physical competition for status as adults, so they have to practice their reproductive skills, their survival and reproductive skills.

So that rough and tumble play is fun, it has to be fun, or else they wouldn’t do it and they wouldn’t get the practice, but they like that heavy physical play more than females do. Females are doing other things. And in humans, we see the exact same patterns. And in non-human animals, you can easily manipulate the expression of that behavior by simply suppressing testosterone exposure in boys, or increasing prenatal testosterone exposure in females and female juveniles in non-human animals, you can… It looks like it’s entirely due to prenatal testosterone exposure. And then in humans, first of all, we have a very large and cross-culturally consistent sex difference where boys like to play physically. Now, I’ve…

Again, I have a son, he has friends who are female, I know how they play. I don’t see girls getting together in groups and jumping all over each other for hours, like boys will tend… On average, not everyone does this, and there’s overlap in these complex behaviors, but these are broad patterns. And there’s a suggestion in humans that it’s also apparently, of course, the cultural influences, but that testosterone is the primary driver, because we know in girls who have different conditions, especially congenital adrenal hyperplasia, that result in their exposure prenatally to abnormally high levels of testosterone. So it’s not as high as boys, but even a slight elevation in girls can have a pronounced masculinizing effect.

And so girls that have this condition where their… It happens to be their adrenal gland is producing relatively high levels of testosterone, that condition is corrected at birth at least in places with good medical care, and those girls on average, end up far more than girls who don’t have that condition to want to engage in rough and tumble play, they wanna play with whatever toys the boys are playing with, they’re more likely to wanna play with boys, they’re more likely to grow up to be lesbians, they’re more likely, even though the rates are very low, to have a male gender identity than females who never had that condition. And the only difference there is that they had increased exposure to testosterone in utero, there’s no difference in the adult hormones.

So it’s clear that that sex differences in that early exposure to testosterone have a huge amount to do with who we become, because this is prior to puberty. So if boys are engaging more physically active basically, especially with each other, in childhood, that’s gonna set the stage for later behaviors, almost regardless of what happens in puberty. And this is not all boys, I should say that boys who grow up to be gay are much less likely to engage in rough and tumble play, but those boys… So that’s interesting, and that’s kind of a mystery, but those boys who grow up to be gay have the same pattern of sexual behavior of boys who grow up to be heterosexual. So being exposed to high levels of testosterone in utero seems to always shape male sexual behavior to be masculine, to shape the desire for a higher number of sex partners ultimately and a higher libido.

Brett McKay: Okay, so we’ve talked about childhood, so prenatal testosterone raise the ground work throughout childhood, T levels between males and females are pretty much the same, and then puberty happens and there’s this spike. And I think we all know what happens during puberty, the secondary sex characteristic just show up, you get taller, more muscle mass for men, body hair, facial hair, deeper voice. What’s going on though on the brain, how is that testosterone surge influencing the mind and behavior?

Carole Hooven: I’ve talked to a lot at this point, just in talking about the book, a lot of men and trans men, which is interesting, people who lived as women and then took high levels of testosterone about what it feels like. Most men say that they were preoccupied with sex, preoccupied with their position in the status hierarchy and social relationships among boys, and then young men. So again, I have this 12-year-old, and that’s what he talks about a lot, he’s… Not the sex part, but the who is popular, what they do, how they behave. And this is all fascinating because it seems all of them are really, really attuned to status hierarchies, and there’s a great evolutionary reason for that, and testosterone is promoting that.

Girls have their own hierarchies too, that’s also extremely important, but the way they navigate competition within those hierarchies is totally different. Girls don’t use this very direct form of aggression and physical aggression, they tend to use gossip and passive aggression and back-stabbing, I hate to say. And now social media, which I think that’s a horrible way to harm people’s reputations. Boys are more likely to go up into somebody’s face and call them an a-hole or something, and so they’re this… And they’re more likely to get into obviously physical aggressive… Physically aggressive interactions, and of course, that depends on culture around the world, and just within, say our United States, there’s obviously different norms around beating other guys up with different cultures.

Brett McKay: And I think there is a point…

Carole Hooven: So, Yeah. I think that’s what’s going on psychologically is sex and status competition.

Brett McKay: And I think a point to make is, there is a cultural… So we have this biological thing going on, but culture can help direct it, right? So in the west, it’s like, Well, how do you get status? It’s like, Well, you go maybe you play football, or you run for student council, or… This is if you were a teenage boy.

Carole Hooven: That’s right.

Brett McKay: You can get status that way. In another culture, it might be something different, but they’ll be a drive for status somehow.

Carole Hooven: Exactly.

Brett McKay: Because the idea is like, if you got status, the chicks will like you.

Carole Hooven: Yeah, but you might not even think of it that way at the time. You just seem driven to gain status over other boys or young men. And yeah, it seems like a benefit is that the girls start to pay attention to you. So, culture… People sort of miss this point about how incredibly important culture is. And nobody should resist the facts of biology about… And the role in all of these types of behaviors, they shouldn’t resist that because they think that culture is important or culture is more important. It’s incredibly important. But what’s interesting is how it interacts with our biology in these fascinating ways that have an important evolutionary explanation.

Brett McKay: Well, I think you made some guy, I forgot who is was, I think the guy that wrote, The Trouble With Testosterone. I forgot his tame.

Carole Hooven: Robert Sapolsky.

Brett McKay: Yeah, he said, like, if you… Talking about the influence of culture and biology, kind of the interplay they have. It’s like, if you gave testosterone to a bunch of monks, they would start competing… They wouldn’t start beating each other up, they would start trying to out compete each other, who can meditate the most or who can do niceness…

Carole Hooven: The niceness or something, yeah.

Brett McKay: But if you gave testosterone to a prison gang.

Carole Hooven: That’s right.

Brett McKay: You’d probably see just a bunch of shanks and things like that.

Carole Hooven: Yeah, that’s what’s fascinating is that, it seems to promote whatever is necessary for a man, and or an animal in a given environment to gain status or to avoid… Just to avoid losing status, say. So, it sort of increases your attention to those signals of status is how it seems to work. Your vigilance and your attention and your striving for status in whatever way is necessary. And in our deep history and still in many parts of the world, that was physical aggression. So that’s why males are larger than females and still are, so there’s still those cues and women are still attracted to big, tall, say, muscular, assertive men. Even if there isn’t any actual reproductive benefit. That’s how women are wired. So males are also still wired to, Yeah, really care about status and be responsive to those cues, in a way that women are responsive to different kinds of cues. And status just is not quite as important for female reproduction, of course, as it is for men. It still matters because females wanna compete for the high status males, and there aren’t that many of them, so.

Brett McKay: Let’s continue with this status-strain here. So I think it’s interesting, you talk about studies that testosterone can… Okay, influences this drive for status chronically, systemically, so, it just kind of wires you for that. But there’s these acute things going on. If a male experiences an increase in status or a decrease in status, there can be these sudden drops of testosterone or increases in testosterone. What causes such a rapid change? ‘Cause I mean, the production of testosterone takes a while. It has the pituitary gland sent a signal and…

Carole Hooven: Very good, very good.

Brett McKay: What causes that super fast? It’s so weird. A guy can watch his favorite sports team lose, and his T-levels will drop immediately. What’s going on there?

Carole Hooven: Yeah. So I don’t wanna overstate the prevalence of this phenomenon. And however, it does exist in humans and in non-human animals. And I think it’ll be helpful just to say what happens in non-human animals. And so the Syrian hamster has been studied heavily regarding these testosterone changes, which I think are very important in humans. And again, it’s not so much how much testosterone you have as a guy in general, as long as it’s within the normal range, your sort of baseline level seems not to be super predictive of much. What does, to me seem to be important is prenatal testosterone and these changes that you’re talking about in social… That are a product of social interactions. And this to me, is absolutely fascinating. So in Syrian hamsters, if a Syrian hamster has a fight with another male for territory… So territory is the equivalent of any kind of resource in humans, ’cause you need territory to get females, ’cause females will feed on the territory that a male can guard, basically. So high status males will have larger territories in the wild, anyway. And the outcome of… If you think about it from an evolutionary point of view, or even think about it from today.

So if you’re fighting physically with another guy, if you lose, you need to know on some level that you’re a loser. You can’t go… If you’re losing consistently against other males in physical competitions, you need to stop, you need to run away, basically. [chuckle] If somebody’s in your face, you need to run away, you shouldn’t be challenging them. ‘Cause you wanna survive to try to win some other competition in the future, so that you can mate, right? So how do animals make those decisions about… How do they know, “Well, I need to fight,” or, “I need to flee,” right? Those are decisions that animals have to make. So when you’re… When someone’s threatening you, it may trigger in you the feeling that they’re threatening you physically, even if it’s just a chess game or a tennis match, definitely in a football game or just some guy is in your face, there’s all kinds of situations where two males are competing for status in humans, in some way, right?

So in the hamsters, if a male loses a physical fight and he submits, right? He ends up by getting on his back and submitting, his testosterone will tank. So first of all, when they’re facing off, they’re both of them have an increase in testosterone, the loser will have a pronounced decrease in testosterone. The winner will maintain high testosterone or it will get higher. And if you… And then the loser will fail to defend itself or defend it’s territory against a future threat, because he’s lost… That reduction in testosterone is somehow telling him, He should be scared and run away.

So if you block that reduction in testosterone after he loses, he’ll continue to defend his territory and challenge other males. And then he’ll get his ass kicked and he could die, right? So it seems like the testosterone drop is adaptive for losers. A testosterone rise is adaptive for winners. Because it’s a way of, signaling, shaping, the animal for future encounters. So if you’re a winner, you know in the face of threat that you’re a winner. You act like a winner, you don’t back down. You take on the challenge. If you have lost, you’re fearful and anxious and you retreat from confrontation. So we have all varieties in humans of those responses to competition, but it seems like testosterone changes in the moment in the face of competition are playing a role neurologically to set people up for reaction to future competitions and may help to account for different… Even in the ways that people engage in competition in general.

And just feeling like, they are fearful or feeling confident in the face of competition. So yes, there’s all kinds of examples in the human literature where either from sports, or again, from competitions that are not physical even. And then there’s all these competitions that we don’t measure, which are just males getting in each other’s faces in some way. Having subtle competitions where there are these testosterone changes. It’s tough to pin down experimentally, exactly when they happen, and who they happen in, and exactly what the function is. But from the literature on non-human animals, it seems clear that we do know that when testosterone rises in these social situations, it can increase dopamine, which is a hormone that is rewarding, and promotes the same behavior in the future, because… It increases motivation for the same behavior in the future because it felt good last time. And cortisol is a hormone that is associated with stress and anxiety and that can be paired with the testosterone drop and that can possibly motivate the animal more towards a retreat-strategy in the future.

Brett McKay: So, there’s like a Matthew effect going on, right? To he who has, will be given more, he who doesn’t have will be taken away from. So.

Carole Hooven: Yes.

Brett McKay: Yeah.

Carole Hooven: I think that’s right, but it’s adaptive for all basically based on… But it’s a way to… If you’re in a stressful situation, it’s possibly a way to condition males about how to respond very quickly, so they don’t have to stop and think about it. And I should just say you raise a really interesting question, how does testosterone change in these situations, because like you said, the signal to produce testosterone in the testes comes from the brain. It comes from the hypothalamus and pituitary in the form of luteinizing hormone, and it takes an hour for that hormone to get from the brain to the testicles and to result in a pulse of testosterone, essentially. Then that testosterone have to go through the blood and alter gene transcription, which theoretically should not have immediate effects on behavior. So the answer is we don’t know how social interactions can cause these testosterone rises. It may be that it’s not coming from the testes or it may be that it’s not coming from LH… Luteinizing Hormone. It may be that there’s an increase in adrenaline, and that somehow adrenaline acts on the testes to release testosterone that’s kind of hanging out there, but we don’t know.

Brett McKay: Right.

Carole Hooven: And this is something that I’ve been obsessed with a long time. What is the mechanism here?

Brett McKay: Okay, so testosterone makes a boy… Or teenage boys, young adults, young adult males preoccupied with sex, preoccupied with status. We also talked…

Carole Hooven: I wouldn’t say makes but heavily influence. Heavily influence, yeah.

Brett McKay: Heavily influence. [chuckle] Yeah. Right. But… And then also, we’ve talked about this a little bit, aggression. It makes or causes or influences males to be more aggressive. And what’s the advantage of… What’s the advantage of being aggressive, because that just helps you get access to mates and resources? Is that the idea?

Carole Hooven: So there’s actually not a big sex difference in aggression just broadly. It’s really physical aggression.

Brett McKay: Okay. Physical aggression.

Carole Hooven: So using… And what’s interesting is, if you think about these strategies over human evolutionary history that males and females would use to maximize their reproduction. And that’s what natural and sexual selection acts on, is the traits that animals possess that allow them to maximize reproduction. So for females, taking physical risks is a bad idea because you need your physical integrity. You need energy, you need safety, you need a long healthy life. That’s what… Because you don’t have to worry about fighting for mates, right? You have to worry about having the energy and health that you need to bear and feed your children, and you have to care for them.

So it doesn’t pay off for females to take physical risks. And they don’t have that need to compete physically for mates. Although they compete for mates, but in ways that don’t put their physical selves at risk, typically, right? So males are, relative to females, over evolutionary history have benefited from physical aggression, because that’s what their bodies are, in a sense, built to do, relative to females. That’s where they’re putting their reproductive energy budget. That’s why they have bigger bodies and more muscle. That’s the only reason, relative to females. So that muscle, that’s a history of using their bodies to compete physically for mates. So we retain that in a modern environment… And that’s… Again, that’s attractive to females. It’s not the case that they have to compete physically anymore. So in different cultures, women are gonna prefer men who have high status, whether it’s gained physically or not. I’m married to a philosophy professor and he’s definitely never gotten into a fight, but he’s super attractive to me, partly because, partly because of his status, but it’s not, he got that with his brain, not with his body, but it depends on the environment you’re in and what pays off. So we have this evolutionary history of physical aggression paying off, but it still plays out in the extremes.

Brett McKay: Yeah, you can see the propensity for physical aggression in males, just like looking at crime reports.

Carole Hooven: That’s right.

Brett McKay: If you look at murders, physical assault, sexual assault, it’s pretty much all dudes. There’s women there every now and then, but it’s mostly dudes, but then if you look at crimes like fraud, shoplifting, etcetera. There’s still more men, but women, that’s more of where they do their crime, if they’re gonna commit crimes.

Carole Hooven: Yeah, that’s where the sex difference is reduced, so women are gonna commit crimes, but they’re just much less likely to put themselves physically at risk to commit those crimes. Males are much more likely to put themselves physically at risk to commit crimes and to do everything else, to show off, to thrill-seeking, men are just far more likely to do that physically.

Brett McKay: Okay let’s, so we’ve talked about testosterone’s effect on behavior in males. Something that’s been getting a lot of press lately is the role of testosterone in athletic performance. What do we know what’s going on there?

Carole Hooven: So there’s a lot of controversy and confusion around this area, but I’ll just say that the science is clear. It’s not confusing, and people who try to make it seem confusing, from my point of view, have a political or ideological agenda. It’s totally clear that in the almost all sports, there are some exceptions, males, men, so if you’re looking at the elite level, if you’re looking at comparing highly trained people who are all taking care of themselves, all healthy, eating well, sleeping, training, etcetera, men blow women out of the water. There is no competition. There are, in many sports, even at the Olympic level, there will be thousands of men who will be better than the number one female, and that’s almost the case across the board. In some endurance sports, there are some exceptions to that.

The reason is testosterone. It is, again, this is abundantly clear that this is an effect, a consequence of males going through puberty, for all the reasons that… All the things we’ve been talking about physically, never mind what might be happening psychologically, which is a question, but the physical advantages are immense in terms of what happens that is irreversible, first of all, in puberty. So there is some aspects of pubertal changes that are reversible, but there’s others that are not.

So the ones that are permanent are obviously the bone growth, so the height, bone density to some extent is irreversible. Testosterone causes increase in bone density, and that happens because of the increased muscle during puberty that exerts forces on the developing bones that causes them to increase mineralization and density. So you have stronger, taller bones. So you have larger bodies, and on those larger bodies have much more muscle and testosterone causes stem cells during puberty to differentiate into muscle preferentially over fat. So those don’t reverse, so that in adulthood, if you suppress… If you’re a man, and a male and you suppress your testosterone, you will not lose all of that muscle advantage you would have over a typical female.

So there’s height, there’s bone density, there’s larger hearts and lungs, there’s increased hemoglobin. So males have significantly more hemoglobin. That’s a direct effect of testosterone and hemoglobin carries oxygen around the blood, so you’ll have more oxygen fueling the greater amount of muscle mass. You have massively higher upper body strength. Males, again, the upper body strength just blows away the upper body strength of females. You have greater throwing capacity. You have greater grip capacity. I could go on and on. And you have more power. So sports that emphasize power, like weight lifting.

Like Laurel Hubbard, for instance, is a trans woman who competed in weightlifting in the Olympics recently, and there was a lot of controversy and questions about whether she, because she was a person who was male who transitioned to living as a woman and had stopped her testosterone and taken estrogen and the question was would she have an advantage in weight-lifting over natal women? And the answer is yes. Because she went through male puberty, she’s going to have a huge advantage because all of her muscle mass that she gained as a result of male puberty doesn’t disappear even when testosterone has stopped for something like even five years. So there’s enormous advantages to going through male puberty and those do not disappear when testosterone is suppressed in trans women. And that’s just indisputable. There’s just no, it’s not that women, some people are saying women aren’t trying hard enough and that’s why they’re losing. That’s just a joke. That is a joke.

Brett McKay: So when people finish this book, what do you hope they walk away thinking?

Carole Hooven: Yeah, there’s a couple of things. Of course, I’m incredibly interested in testosterone and the power of testosterone and how it shapes who we are, but I think one of my overarching values in life is that science and knowledge is, it’s crucial for us to have clear views about reality and to not fear the truth, and to do whatever we can to find and communicate the truth. That’s what I see my job as a science educator, and that when you learn how things work, you have more power to make the world a better, safer, more equitable place. And so that is one thing I want people to come away with. I want them to see that it’s possible to be clear and honest and open, but also sensitive and compassionate.

And then the other point is of course about the hormone. There’s just so much evidence that this one molecule shapes our society in these really profound ways and that the more we understand about how it works, the more we can capitalize on the positive aspects of being a man, which we didn’t even talk about. We didn’t talk about toxic masculinity, which I really don’t like at all. I don’t like that term. I don’t want my boy…

Brett McKay: I don’t like the concept either.

Carole Hooven: I don’t want him to be exposed to that idea. He already is, and I don’t like that at all. I want him to be, I’m tearing up here. I want him to be proud. Sorry.

Brett McKay: No, it’s fine.

Carole Hooven: Sorry. I feel so deeply about this. Nobody should be ashamed to be a man, to be masculine, and we didn’t talk about heroism, and if you look at the news and who’s risking their lives to save the lives of others, it’s men, typically. There are really brave women who are doing that too, but over, I don’t know why I’m getting so upset. I’m sorry.

Brett McKay: No, you’re fine.

Carole Hooven: It’s men, and I think there are a lot of struggles that we need to acknowledge that men are facing, and I wish we could just be open, and some of those struggles are around puberty and adolescents and I wish that more people felt they could talk about their struggles and have support, and that this ultimately is the way to making the world a better place, and there’s so much positivity around masculinity and that should be celebrated and encouraged, and this whole narrative about toxic masculinity that seems to be increasing, I wish would end. I wish it would end.

Brett McKay: No, I think that’s a… I like how we ended on that ’cause I think it’s true. I’m tired of the toxic masculinity discourse. I don’t think it’s helpful. I don’t even know what it means anymore ’cause it gets banded around so much, but then we also forget about all the great things men do, and I think that’s, I think men need to hear that as well ’cause I think you’re just scolded all the time in the popular culture and it can get you down.

Carole Hooven: Yeah, and you’re… I assume working hard and being a great dad. To me, having that involvement in the family and having that kind of support and men bring something to the family that women just don’t. And I watch this in my own family, the way that I am with my son and the way my husband is with my son is very different and he needs that. I’m not saying that people won’t, that every family has to have a male and a female, or a mom and a dad, ’cause of course, they don’t, but there is something that is so important that dads are bringing to the family, and also I have, the people aren’t gonna like this, but to the world, there is a different way of being in the world that I’ll just say quickly.

That I asked my students at the end of class, I usually ask them, what would the world be like without men or something like that, and just a couple years ago a student said, “I don’t think we’d have tall buildings.” Or I think I said, “What would happen if we castrated men?” or some other student said, “We should castrate all men” or something ridiculous, and this other student spoke up, which was great. I don’t think he’d say that today. He said, “I don’t think we’d have tall buildings. I don’t think we’d have the kind of innovations that we have,” and that’s controversial, of course, but there is something to it. That competitiveness, that drive for status sometimes can be destructive, but can also be incredible motivation for innovation, and that’s something that remains to be explored. It’s too politically incorrect probably to study it seriously, but I wish we could.

Brett McKay: Well Carole, this has been a great conversation. Where can people go to learn more about the book and your work?

Carole Hooven: Okay, so I have a website, CaroleHooven.com. I’m on Twitter @Hoovlet, H-O-O-V-L-E-T, and my book is on Amazon and wherever you like to get your books, and if you do get it and like it, I never ask people to do this, I keep forgetting. Just if you could review it on Amazon, that really helps. And yeah, so I’d like to get more reviews.

Brett McKay: Fantastic. Well Carole Hooven, thanks for your time. It’s been a pleasure.

Carole Hooven: Thank you so much, Brett. I’ve enjoyed the conversation.

Brett McKay: My guest today was Carole Hooven. She’s the author of the book; T, The Story of Testosterone. It’s available at Amazon.com and book stores everywhere. You can find out more information about her work at her website, CaroleHooven.com. Also check out our show notes at AOM.IS/T where you can find links to resources, where you can delve deeper into this topic.

Well, that wraps up another edition of The AOM Podcast. Make sure to check out our website at ArtofManliness.com, where you can find our podcast archives as well as thousands of articles written over the years about pretty much anything you can think of, and if you’d like to enjoy ad free episodes of AOM Podcast, you can do so on Stitcher Premium. Head over to StitcherPremium.com. Sign up, use code Manliness at check out for a free month trial. Once you’re signed up, download this to your app on Android or iOS and you can start enjoying ad free episodes of The AOM podcast. And if you haven’t done so already, I’d appreciate it if you take one minute to give us a review on Apple Podcast or Stitcher. It helps out a lot. If you’ve done that already, thank you. Please consider sharing the show with a friend or family member who you’d think would get something out of it. As always, thank you for the continued support. Until next time this is Brett McKay reminding you to not only listen to AOM Podcast, but put what you’ve heard into action.

The post Podcast #761: How Testosterone Makes Men, Men appeared first on The Art of Manliness.

With our archives now 3,500+ articles deep, we’ve decided to republish a classic piece each Sunday to help our newer readers discover some of the best, evergreen gems from the past. This article was originally published in February 2021.

For a lowdown on the practicalities of sauna-ing, including how to choose the sauna that’s right for you, check out this article: How to Sauna: All the FAQs.

There was a particular moment when I finally decided to get myself a sauna.

Even though I have a garage gym, I had gotten a membership at a nearby 10GYM just so I could use its sauna. I had thought about buying a sauna for years, but before pulling the trigger on this relatively large purchase, I wanted to see if I would enjoy sauna-ing as much as I imagined I would, and I figured paying $10 a month to run this experiment would be worth it.

I found I did get something out of my sauna sessions, but that was the problem. I liked it, but I liked it so much that I found I wanted more from the experience than I could access at the gym. And this became crystal clear when I walked into the sauna on one particular evening.

The place was packed to the hilt. Perhaps a dozen dudes were crowded into a not-so-large space. Dudes were squished together on the benches; dudes were sprawled out on the floor; dudes were blasting music from their smartphones. Just as soon as I walked in, I walked right back out. I went home and started to earnestly research purchasing a sauna for my home. Not long after, I became the owner of a Finnish-style wooden barrel, which I put together in my backyard.

A year later, I can say the sauna has been one of the best purchases, nay investments, I’ve ever made, with one of the highest ROIs. I’ve enjoyed it even more than I thought I would. Indeed, my sauna has been helping save my body, mind, and spirit. 

When I got my sauna, male friends and family members often expressed their excitement for me and their own envy, sharing how they too had long wanted a sauna and had been thinking about getting one for years.

If you fall into that category, below we highlight the research-backed benefits of regular heat exposure that perhaps will persuade you too to pull the trigger on a lifelong sauna dream, or, at the least, to join a gym that has a sauna; nearly all the benefits we’ll outline apply equally well to the non-personal variety, and are still worth pursuing, even if you have to squish in next to some strangers.

The Many Benefits of Sitting in a Sauna

Sauna is one of the world’s many hot bathing traditions. It originated in Finland but has close relatives in the Russian banya, the Turkish hammam, and the sweat lodge traditions of Native American tribes. 

This kind of cultural ubiquity usually points to some veritable, time-tested benefits, and indeed, modern research has been confirming what many of the world’s peoples already knew for thousands of years: saunas can strengthen the body, calm the mind, and bolster the spirit.

Saunas Are De-Stressing & Meditative

Getting your sweat on in a sauna may not literally release toxins from the body, but it sure feels like it does. While mercury doesn’t drip out of your pores, your metaphorical stress does. It just feels dang cleansing.

Saunas offer a unique, almost paradoxical, sense of rejuvenation. They’re not relaxing in the traditional sense; in fact, the intense heat acts as a stressor on your body, and can get kind of uncomfortable. Yet it’s a discomfort that feels strangely pleasurable; the physical stress somehow alleviates your mental stress.

That’s partly because it releases a bunch of feel-good endorphins in your brain.

Sitting in a sauna also facilitates introspection and a sense of calming reset, especially if you’re by yourself. While you could bring your phone into the sauna, the heat isn’t good for it, making sauna sessions a great way to regularly disconnect from the anxiety-inducing distractions of your life. 

As you first start to warm up, your mind will wander, and it’s a great time to chew on ideas you’ve been mulling over. As your body starts really heating up, you start to lose the ability to do much real thinking. You get into a kind of meditative state, though it’s one you reach without effort; your mind involuntarily starts to go blank. By the end, you feel wrung out, but blissed out. 

Saunas May Boost Cardiovascular Health

Sitting in a sauna not only gives you the kind of “runner’s high” you get from moderate exercise, studies show it also provides you with similar benefits to your cardiovascular health — improved blood pressure and cholesterol counts, along with a reduction in your chances of heart disease.

Heat raises your heart rate. In moderate temperature sauna sessions, your heart rate can rise to 100 beats per minute; in hotter sessions, it can hit 150 beats per minute — as high as when you’re running. Along with that higher heart rate comes an increase in calorie burn.

It’s often been thought that blood pressure drops in a sauna because the heat dilates your blood vessels, but in fact, your blood pressure will climb while sitting in the sauna and then drop below baseline levels once you finish your session. Over time, sauna-ing has a healthy effect on your BP; one study found that men who hit the sauna 4-7 times a week were half as likely to have high blood pressure, and that was compared to those who already did one sauna session a week.

Saunas May Reduce Chronic Inflammation

Saunas have a kind of paradoxical effect on inflammation. While sauna-ing induces inflammation in the body in the same way as exercise does, this short-term increase in inflammation reduces inflammation in the long-term. It increases the body’s overall capacity to deal with the stress that produces inflammation.

When our bodies become injured or sick, inflammation occurs to help with the healing process. But too much inflammation for too long isn’t healthy. Chronic inflammation makes you feel crappy and can contribute to conditions like heart disease, diabetes, cancer, obesity, and (as we’ll see below) depression.

One way doctors detect chronic inflammation is by looking at your levels of c-reactive protein (CRP) in your blood. Elevated levels of CRP mean elevated levels of inflammation. 

One study of Finnish men found an association between increased sauna use and decreased CRP levels. What’s more, studies suggest that sauna use may increase levels of an anti-inflammatory protein called IL-10 as well.

Saunas May Help Alleviate Depression

In our podcast interview with psychiatrist Charles Raison, he laid out a theory that chronic inflammation in the body may be one (of the many) causes of depression. Besides damaging tissues, chronic inflammation makes us feel sad and down. Studies have shown that many people with severe depression also have high levels of chronic inflammation. It isn’t clear if the inflammation caused their depression, or if their depression caused the inflammation, but if you reduce the inflammation in these individuals, oftentimes their depression starts to alleviate, too. 

That may be why several studies have shown that regular sauna sessions, which, as we just discussed, reduce inflammation, also help boost mood.

In my interview with Raison, he was quick to note that saunas are not a panacea for curing depression. Many people with depression don’t have chronic inflammation, so working on the latter won’t address the former.

But even if sauna-ing doesn’t work on depression via the inflammation pathway, it may still enhance mood via the aforementioned release of endorphins, or simply by giving you a half hour of silence and solitude; many people with depression simply need more time-outs from the stress that besieges minds that are overly reactive to negativity. If you regularly battle the black dog, consider adding sauna sessions to your multifaceted approach to leashing it. 

Be sure to listen to our podcast interview with Charles Raison about depression, inflammation, and saunas:

Saunas May Help Boost Immune Function

When you get sick, your body becomes inflamed to help kill the bacteria or virus that’s causing the disease. One of the things that helps your body’s immune system destroy these bodily invaders is a fever. While fevers are uncomfortable, they kickstart cellular mechanisms that ensure our immune systems are running full steam ahead. White blood cells, T-cell antibodies, and phagocytes start increasing and perform best when our internal body temperature is between 100 and 104 degrees Fahrenheit.

When you sit in a hot sauna, you give yourself an artificial fever and get the immune-boosting benefits that come with it without actually getting sick. 

For example, one study showed that individuals who sat in a 204-degree sauna for 15 minutes, and then followed that session with a 2-minute cooldown shower, had a marked increase in white blood cells. 

The immune-boosting effects may (partly) explain why regular sauna users experience fewer colds and less severe pneumonia cases than non-sauna users. 

Saunas May Boost Human Growth Hormone

Human Growth Hormone (HGH) is what causes children to, well, grow.

As adults, we still need HGH for our bodies to stay in tip-top shape. Decreases in HGH result in declining muscle mass, increasing body fat, tiredness, problems sleeping, and diminished libido. 

In addition to regular strength training and eating a healthy diet, sitting in a sauna can help keep HGH levels optimized throughout adulthood. 

Research shows that people who sit in a moderately hot sauna experience an increase in this hormone afterward. For example, one study found that individuals who sat in a 176-degree sauna for two 20-minute sessions separated by a 30-minute break experienced a fivefold increase in HGH levels immediately afterward. 

Couple regular sauna sessions with regular strength training and you’ve got yourself a potent, healthy, and legal HGH cocktail. 

Saunas May Increase Insulin Sensitivity

If you struggle with pre-diabetes or type 2 diabetes, saunas may be another weapon in your arsenal to keep elevated blood sugars in check. 

The research here is pretty speculative and has only been done on mice. However, it does suggest that whole-body hyperthermia can help increase insulin sensitivity in your muscles. More research is needed to confirm this finding. 

Saunas Can Increase Athletic Endurance

If you’re an endurance athlete — a runner, biker, or swimmer — regular sauna sessions may increase your endurance. 

One study found that athletes who took part in 30-minute sauna sessions twice a week could run longer before reaching exhaustion compared to athletes who didn’t do the sauna sessions. 

This benefit may be particularly pronounced if you run in a location with hot weather (or plan to travel to and compete in an event in a hot climate). A few studies have shown that regular sauna sessions can boost your body’s heat tolerance and help you acclimate to exercising in hot conditions.

Saunas May Help in Maintaining and Increasing Muscle Mass

Several studies have shown that individuals who regularly use a sauna have less muscle loss and, in some cases, increased muscle growth compared to individuals who don’t use a sauna. Why would this be?

As noted above, saunas can boost HGH levels, which play a significant role in protein synthesis, which our bodies use to create and maintain muscle tissue. 

Another way sauna-ing can help maintain and increase muscle mass is by increasing heat shock protein (HSP) in our system. Breaking Muscle has a deep dive into how HSPs work. The TLDR version is that when our muscles experience stress, HSP helps reduce muscle loss by assisting muscle damage repair and protein folding during protein synthesis. 

Exercising can boost HSP levels, but so can sitting in a sauna. 

To be clear, sauna sessions won’t magically turn you into the Hulk. You still have to train hard and be disciplined with your nutrition, and you can get big and strong by simply doing those things alone. Think of the sauna as just another good supplement in your pursuit of the gainz. 

Saunas Provide a Retreat and a Third Space 

One of things I’ve appreciated the most about my sauna is the kind of external retreat it provides, that’s right outside my house. In a time when we’ve been cooped up at home a lot, doing a session in the sauna feels like I’ve gone somewhere, and done something, even though I haven’t left my property. It offers a change of scene and pace.

My sauna feels like a private sanctum sanctorum, and at the same time, also acts as a communal “third space.” A space outside the home and the office (which for me, like many, is the same!), where I can meet up with other people:

Saunas Offer Social Therapy

Most guys wouldn’t ever call up their dude friends and say, “Hey, who wants to come over and talk?” And most dude friends wouldn’t be too receptive to that invitation. 

But ask your buddies, “Who wants to come over and sauna?” and everybody jumps at the opportunity. Even though you pretty much just invited them to come over and talk.

Men like to socialize around some activity, and a sauna session, even if it’s not actually so active, provides a focal point to gather around. 

As soon as I got my sauna (which holds six grown men comfortably) built, I invited several good friends over for a session. We started off with a low temperature so we could talk and catch up and not be too distracted by the heat. As the evening progressed, we’d slowly ratchet up the heat, and we finished the session off by cranking things up to 215 degrees and splashing water on the hot rocks for a burst of steam.

We all slept like babies that night. 

The socializing probably did us more good than the heat, though. Getting stripped down (to our swimsuits; as prudish Americans, no, we don’t get naked) and sweating in a small space facilitates intimate bonding and discussion, and our conversation went all over the place. We talked about what’s happening in our lives, discussed philosophy, theology, and current events, and quoted movies from our teenage years. And interspersed between all of this, we shared what we were each struggling with and provided each other support. 

Subsequent sessions unfolded in the same way, and for me, this kind of social therapy has been perhaps the biggest and most enjoyable of the many benefits of getting a sauna.

The post How Saunas Can Help Save Your Body, Mind, and Spirit appeared first on The Art of Manliness.