Testosterone Therapy's Effects on Empathy and Aggression
Current evidence does not strongly support that testosterone therapy significantly impairs empathy or increases aggression in men, though some research suggests potential minor effects that vary by individual factors.
Effects on Aggression
Evidence Summary
- Meta-analytic data shows only a weak association between baseline testosterone and aggression in men (r = 0.071), with no significant association in women 1
- When examining testosterone changes, there is a slightly stronger correlation with aggression in men (r = 0.162), but still relatively weak 1
- Importantly, causal effects of testosterone administration on human aggression were not statistically significant (r = 0.046) 1
- High-quality clinical research demonstrates that even supraphysiological doses of testosterone (600 mg/week) did not increase angry behavior in healthy eugonadal men in a controlled setting 2
Clinical Implications
- The American Urological Association (AUA) guidelines do not list increased aggression as a significant side effect requiring monitoring during testosterone therapy 3
- Testosterone therapy should target the middle tertile of the normal reference range (450-600 ng/dL) to minimize potential side effects while achieving clinical benefits 3
- The weak association between testosterone and aggression suggests that concerns about "roid rage" may be overstated for therapeutic testosterone use at recommended doses
Effects on Empathy
Evidence Summary
- Research on testosterone's effects on cognitive empathy shows mixed results:
- A 2011 study found that testosterone administration impaired cognitive empathy in women 4
- However, two large-scale randomized controlled trials (n=243 and n=400) found no evidence that testosterone administration impairs cognitive empathy in men 5
- A 2020 study showed that lower digit ratio and higher endogenous testosterone were associated with lower empathic accuracy, independent of gender 6
Clinical Implications
- The American College of Physicians' evidence report notes that testosterone treatment was associated with small improvements in mood and depressive symptoms (SMD, −0.19) 3
- This suggests that rather than impairing emotional function, testosterone therapy may slightly improve mood in men with testosterone deficiency
Monitoring Recommendations
When initiating testosterone therapy, focus monitoring on established risks:
- Erythrocytosis (occurring in 3-18% with transdermal administration and up to 44% with injections) 7
- Fluid retention (particularly problematic in patients with heart failure or renal insufficiency) 7
- Cardiovascular events (though evidence is of low certainty) 3, 7
- Sleep apnea (may worsen with testosterone therapy) 7
Follow-up schedule:
- First follow-up at 1-2 months after initiation
- Subsequent visits every 3-6 months for the first year, then yearly
- Monitor symptomatic response, including mood changes 7
Key Considerations
- Individual factors may influence response to testosterone therapy
- Target mid-normal testosterone range rather than upper-normal to minimize potential adverse effects 7
- Discontinue therapy if no symptom improvement after 12 months 7
- The highest quality evidence does not support significant concerns about increased aggression or decreased empathy with therapeutic testosterone use
While anecdotal reports of "roid rage" exist, clinical evidence does not support significant concerns about aggression or empathy impairment when testosterone is used at therapeutic doses in appropriate patients with testosterone deficiency.