Unmasking Masculinity: Biological, Behavioral, and Social Determinants of Testosterone Deficiency in U.S. Men, 2011-2023.

Abstract

Testosterone deficiency in men is often attributed to aging or biology, yet hormone levels also reflect social determinants of health (SoDH) and masculinity-related stressors. This study applied the Healthy People 2030 SoDH framework to examine biological, behavioral, and social predictors of testosterone deficiency in U.S. men. Data were analyzed from four National Health and Nutrition Examination Survey (NHANES) cycles (2011-2016 and 2021-2023), including 10,357 men aged ≥18 years with valid total testosterone measurements. Men reporting exogenous testosterone therapy were excluded. Testosterone deficiency was defined as total serum testosterone <300 ng/dL. Survey-weighted, age-adjusted multivariable logistic regression models examined biological, behavioral, and SoDH domains. Testosterone deficiency prevalence was 25.7%, declining from 28.1% in 2011-2012% to 20.3% in 2021-2023 (P-trend < .01). Independent predictors included obesity (AOR = 2.69, 95% CI [2.36-3.06]), impaired fasting glucose (AOR = 1.55, 95% CI [1.27-1.90]), diabetes-range glucose (AOR = 2.92, 95% CI [2.03-4.21]), and prolonged sedentary time ≥ 8 h/day (AOR = 1.39, 95% CI [1.14-1.70]). Men without a usual source of care had higher odds (AOR = 1.27, P < .05). Current smokers (AOR = .79, P < .05) and never-married men (AOR = .70, P < .001) had lower odds. Testosterone deficiency is shaped by metabolic, behavioral, and relational factors rather than socioeconomic markers alone. These findings support framing testosterone deficiency as a biopsychosocial condition and highlight the value of integrating endocrine and social-contextual perspectives in men's health research and clinical care.