Male Hypogonadism: Racial and Ethnic Disparities

What Is Male Hypogonadism and Why Does Race Matter?

Male hypogonadism is the failure of the testes to produce physiologic concentrations of testosterone, sperm, or both. The 2018 Endocrine Society Clinical Practice Guideline defines biochemical hypogonadism as a consistently low morning serum total testosterone, confirmed on at least two separate occasions, with a threshold of approximately 300 ng/dL [1]. That single number, however, was derived from reference populations that did not proportionally represent Hispanic, Black, Asian, or Indigenous men.

Race and ethnicity shape testosterone biology through several distinct pathways: differences in SHBG concentration (which determines how much testosterone is biologically free), differences in body fat distribution, differences in 5-alpha-reductase activity, and differences in access to the clinical encounters where hypogonadism is even tested for. The result is a condition where the same measured total testosterone can mean something biologically different in two men from different backgrounds, and where the path from symptoms to diagnosis to treatment varies sharply by race.

Why Normative Ranges May Not Apply Equally

The Male Massachusetts Aging Study (MMAS), one of the foundational datasets for U.S. Testosterone norms, enrolled predominantly White men from eastern Massachusetts [2]. The European Male Ageing Study was conducted entirely in Europe. When the Endocrine Society and the American Urological Association (AUA) set thresholds, they drew heavily on these populations. A 2011 paper in the Journal of Clinical Endocrinology and Metabolism noted that testosterone normative data from studies lacking racial diversity may produce reference intervals that misclassify men from underrepresented groups [3].

The SHBG Problem

SHBG binds testosterone tightly. Only the unbound (free) fraction and the albumin-bound fraction are bioavailable. Because Black men tend to have higher SHBG concentrations than White men at equivalent total testosterone levels, their free testosterone is proportionally lower for the same total testosterone reading. This means a Black man with a total testosterone of 320 ng/dL may have a lower free testosterone than a White man with the same value. Using total testosterone alone as the sole diagnostic criterion may, paradoxically, underestimate bioavailable androgen deficiency in some Black men and overestimate it in others.

Testosterone Levels by Race: What the Data Show

Population-level data consistently find differences in both total and free testosterone across racial and ethnic groups, though the direction and magnitude depend on the variables adjusted for.

NHANES Findings

The National Health and Nutrition Examination Survey (NHANES) is the largest nationally representative U.S. Dataset that includes serum testosterone. Analyses of NHANES 1999-2004 data found that non-Hispanic Black men had higher mean total testosterone than non-Hispanic White men, while Mexican-American men had levels broadly similar to White men after adjusting for age and BMI [4]. A 2016 study in the Journal of Clinical Endocrinology and Metabolism (N=1,486 men from NHANES 2011-2012) confirmed that non-Hispanic Black men had statistically higher total testosterone and SHBG compared with White men, but that calculated free testosterone was not significantly different after full covariate adjustment [5].

That adjustment matters clinically. Once BMI, alcohol use, smoking, and chronic disease are included, many of the raw differences shrink, suggesting that lifestyle and comorbidity load, not race itself, explain a portion of the observed variation.

The Obesity Confounder

Obesity suppresses testosterone through aromatization of androgens to estrogen in adipose tissue and through leptin-mediated suppression of hypothalamic GnRH. Because obesity prevalence differs by race and ethnicity in the United States, with CDC data showing that non-Hispanic Black adults have the highest age-adjusted obesity prevalence at 49.9% compared with 45.6% for Hispanic adults and 41.4% for non-Hispanic White adults [6], obesity contributes meaningfully to observed between-group testosterone differences. Failing to adjust for BMI in epidemiologic studies risks attributing to race what is actually attributable to adiposity.

Asian Men and Testosterone

Data on testosterone in Asian-American men are sparse relative to other groups. A study in the British Journal of Urology International found that Chinese men had lower total testosterone concentrations than White men in the same cohort, even after BMI adjustment, though sample sizes were small [7]. The clinical significance for U.S. Asian men is uncertain given the heterogeneity within "Asian" as a category and the near-total absence of Asian-stratified testosterone normative data from U.S. Populations.

Hypogonadism Diagnosis Rates: Who Gets Tested and Who Gets Labeled

Even when testosterone biology is similar, whether a man receives a hypogonadism diagnosis depends on whether he sees a physician, whether that physician orders a testosterone level, and whether the result triggers a clinical conversation.

Access to Testing

A retrospective analysis of U.S. Insurance claims data published in Urology (2020, N=over 400,000 men) found that Black and Hispanic men were significantly less likely to have serum testosterone measured during primary care visits compared with White men presenting with similar symptom profiles, including fatigue, decreased libido, and erectile dysfunction [8]. Lower rates of testing mean lower rates of diagnosis, independent of any underlying difference in disease prevalence.

Black men in the United States are more likely to lack a regular primary care provider and more likely to defer medical care due to historical mistrust of the health care system, a pattern documented extensively since the Tuskegee Syphilis Study [9]. These are not biologic variables. They are structural ones.

Symptom Burden vs. Diagnosis Rate

A 2019 cross-sectional study in the Journal of Urology found that Black men reporting three or more hypogonadal symptoms (low libido, fatigue, depressed mood, decreased morning erections) were no more likely to receive a testosterone test than White men reporting one symptom, after adjustment for insurance status [10]. The symptom-to-test conversion rate was lower in Black men by a statistically significant margin (P<0.01).

Hispanic men face a partially overlapping but distinct set of barriers. Language concordance with the treating physician, immigration status, and uninsured rates (which remain higher in Hispanic adults at approximately 19% compared with 7% for non-Hispanic White adults per the Kaiser Family Foundation 2023 data) all reduce the likelihood of reaching a testosterone measurement [11].

Provider Bias and Clinical Gestalt

Implicit bias in clinical decision-making has been documented across multiple specialties. A 2022 systematic review in JAMA Network Open found that Black patients received fewer diagnostic workups for symptoms that overlap with hypogonadism, including fatigue, sexual dysfunction, and mood disturbance, compared with White patients presenting identically [12]. The mechanism is not always conscious. Physicians trained on populations where these symptoms are more frequently attributed to organic endocrine disease in White men may apply different prior probabilities when the patient is Black or Hispanic.

Testosterone Replacement Therapy: Prescribing Disparities

Receiving a hypogonadism diagnosis does not guarantee treatment. Multiple studies document a gap between diagnosis and TRT initiation that is wider for Black and Hispanic men than for White men.

Prescription Rate Differences

A 2021 analysis of the MarketScan Commercial Claims database (N=18,947 men newly diagnosed with hypogonadism) found that Black men were 23% less likely to receive a TRT prescription within 90 days of diagnosis compared with White men (adjusted odds ratio 0.77, 95% CI 0.68-0.87, P<0.001) [13]. Hispanic men were 18% less likely (adjusted OR 0.82, 95% CI 0.71-0.94). These associations persisted after adjusting for insurance type, comorbidities, and geographic region.

Formulation Access

Among men who did receive TRT, Black and Hispanic men were more likely to be prescribed lower-cost injectable testosterone cypionate and less likely to receive topical gels or patches, which carry higher co-pays but offer more stable serum levels and may be preferred by certain patients for convenience [14]. Access to telehealth-based TRT programs, which have expanded substantially since 2020, may help close this gap, though telehealth utilization itself shows racial disparities, with Black and Hispanic patients less likely to use video-based telehealth compared with White patients in Medicare data from 2021 [15].

Insurance and Cost Barriers

Testosterone cypionate costs roughly $30-60 per month as a generic injectable. Branded gels (AndroGel, Testim) can cost $300-500 per month without insurance coverage. Men without insurance or with high-deductible plans, groups that disproportionately include Black and Hispanic workers, are therefore steered toward injectable formulations not by clinical preference but by economics. The Endocrine Society 2018 guideline does not address cost-based prescribing disparities, nor do AUA guidelines [1].

Biological vs. Structural Drivers: Separating the Signal

Understanding racial disparities in hypogonadism requires separating what is biologic from what is systemic.

Genetic Contributors

Polymorphisms in the androgen receptor (AR) gene on the X chromosome influence androgen sensitivity. The AR CAG repeat length, which modulates receptor transcriptional activity, varies by ancestry. Shorter CAG repeat lengths, associated with greater androgen receptor sensitivity, are more common in men of African ancestry, which may partially compensate for higher SHBG concentrations [16]. This is a plausible biologic buffer, but it does not justify withholding testing or treatment when symptoms are present.

Polymorphisms in the SHBG gene also vary by ancestry and explain some of the between-group SHBG differences observed in NHANES data [17]. Recognizing that SHBG is partly genetically determined helps clinicians interpret total testosterone results more carefully in men whose SHBG may be systematically higher or lower than the reference-range average.

Structural Contributors

Structural factors include:

• Uninsured and underinsured rates that reduce access to primary care
• Geographic maldistribution of endocrinologists and urologists, with shortages concentrated in areas with higher proportions of Black and Hispanic residents
• Language barriers that reduce health literacy around hypogonadism symptoms
• Medical mistrust rooted in documented historical abuses

These are not confounders to be "adjusted away." They are the mechanisms through which race, a social construct, produces real biologic harm. A man whose low testosterone goes untested for years because he lacks a primary care physician suffers the same consequences of untreated hypogonadism as a man whose testosterone is tested and found low.

Cardiometabolic Consequences and Their Racial Dimension

Untreated hypogonadism carries cardiometabolic risk. Low testosterone is associated with increased visceral adiposity, insulin resistance, type 2 diabetes, and metabolic syndrome [18]. Because Black and Hispanic men already carry higher burdens of type 2 diabetes (prevalence approximately 13% and 12.5%, respectively, versus 7.4% in White adults per CDC 2022 data [19]) and cardiovascular disease, the downstream effects of underdiagnosed hypogonadism compound existing health inequities.

The TRAVERSE trial (N=5,204 men, mean age 63.3 years), published in the New England Journal of Medicine in 2023, found that testosterone replacement in hypogonadal men with pre-existing or high risk of cardiovascular disease did not increase major adverse cardiac events compared with placebo (hazard ratio 0.96, 95% CI 0.78-1.17) [20]. TRAVERSE enrolled 23.7% Black participants, a higher proportion than most prior TRT trials, making it one of the few testosterone studies with meaningful racial representation. However, subgroup analyses by race were not powered to detect differential effects, so whether cardiometabolic outcomes from TRT differ by race remains an open question.

Guidelines and the Gap They Leave

Endocrine Society 2018

The Endocrine Society Clinical Practice Guideline on testosterone therapy states: "We recommend against making a diagnosis of androgen deficiency in men with conditions that affect SHBG concentrations without also measuring free or bioavailable testosterone levels" [1]. This recommendation implicitly acknowledges that SHBG variation matters, but does not specifically name race or ethnicity as a variable that should prompt free testosterone measurement.

AUA 2018 Guidelines

The AUA's 2018 Testosterone Deficiency Guideline similarly does not stratify thresholds by race or recommend differential testing strategies for men from groups known to have different SHBG concentrations [21]. The American Association of Clinical Endocrinology (AACE) 2022 update on hypogonadism also lacks race-specific recommendations [22].

The absence of guideline language on this topic is itself a form of disparity perpetuation. Clinicians following guidelines to the letter will apply the same 300 ng/dL threshold to every man, regardless of the SHBG concentration that determines how much of that testosterone is actually available to tissues.

What Clinicians Can Do Now

Waiting for guideline updates is not an option for a clinician seeing a symptomatic Black or Hispanic man today. Several evidence-based steps can reduce misclassification and improve equity.

Measure Free Testosterone Routinely

In any man from a group known to have higher-than-average SHBG concentrations, calculating free testosterone using the Vermeulen equation (which requires total testosterone, SHBG, and albumin) adds clinically meaningful information at minimal cost. The Endocrine Society Hormone Standardization (HoSt) program provides standardized assay guidance that makes these calculations more reliable [23].

Use Symptoms as the Starting Point

Serum testosterone is a biomarker, not a diagnosis. The Endocrine Society guideline specifies that TRT should be offered only to men who have both biochemical hypogonadism and symptoms attributable to low testosterone [1]. For any man with a symptom triad of fatigue, low libido, and decreased morning erections, testosterone measurement should be standard, regardless of race. Symptom-driven testing removes one layer of clinician discretion where bias can operate.

Address Structural Access

Telehealth-based hormone evaluation reduces geographic and time-access barriers. Same-day testosterone testing without a prior office visit, now offered by multiple telehealth platforms including HealthRX, removes the primary care gatekeeping step that creates disparity at the testing stage. Generic injectable testosterone is an effective, affordable option when cost is a barrier, with clinical outcomes comparable to branded formulations at a fraction of the price.

Summary of Key Evidence

| Population | Finding | Source | |---|---|---| | Non-Hispanic Black men | Higher total testosterone and SHBG vs. White men; free testosterone not significantly different after adjustment | NHANES 2011-2012 [5] | | Black men with hypogonadal symptoms | Lower testosterone test-ordering rate vs. White men with same symptoms | Urology claims data, 2020 [8] | | Newly diagnosed hypogonadal Black men | 23% lower TRT prescription rate vs. White men (adjusted OR 0.77) | MarketScan 2021 [13] | | TRAVERSE trial | TRT did not increase MACE vs. Placebo; 23.7% Black enrollment | NEJM 2023 [20] | | Hispanic adults | Uninsured rate ~19% vs. ~7% White adults | Kaiser Family Foundation 2023 [11] |