Testosterone, Informed Consent, and the Military Masculinity Complex

In July, U.S. Secretary of Defense Pete Hegseth announced, in a video titled “The High T Department of War,” that every service member 30 and older will now be screened annually for testosterone deficiency. Those who test low will be offered testosterone replacement therapy (TRT). Service members under 30 can request a screening on a voluntary basis. This policy applies to both male and female service members.

Hegseth was careful to frame the treatment as optional, stating: “If treatment is recommended, it’s entirely your choice to receive testosterone replacement therapy.” That single word — choice — is doing a lot of work it may not actually support.

As a bioethics and health law scholar, I’ve spent the past few weeks considering this policy. My conclusion: The testing may be mandatory, but the “voluntary” label on the treatment offer is close to meaningless once you understand how the military actually functions, and how Secretary Hegseth talks about testosterone.

Start with what Hegseth actually said. He didn’t just call this a routine health screening. He called testosterone the “biological foundation” of the warfighter and the military’s “most decisive tactical advantage.” He framed the goal of the new policy as helping troops “operate at their absolute best.” That’s not neutral medical language. It tells every service member, in plain terms, that a low number on this test marks him as something less than optimal — by the very yardstick the Secretary has just publicly endorsed.

There’s a reason this messaging lands the way it does. Culturally, testosterone has never just been a hormone — it’s shorthand for manhood itself, for the idea that a “real man” is strong, dominant, sexually virile. Hegseth isn’t drawing on medical consensus when he calls testosterone the military’s “most decisive tactical advantage”; he’s drawing on a much older cultural script that equates low testosterone with being less of a man and, more specifically, less of a warfighter. Dressing that script up in the language of “readiness” doesn’t neutralize it. It just gives an old anxiety a uniform and a chain of command to enforce it through.

Now place that message inside a strict hierarchy where physical performance already determines promotions, assignments, and reputation. In that environment, “voluntary” stops meaning what it means in your doctor’s office. A soldier can decline treatment without anyone issuing an order against him and still pay a price for it; in how peers see him, in how a command quietly weighs his “readiness,” in whether he starts to wonder if his peer who said yes to TRT will out-perform him at the next fitness test. Bioethicists have a name for this: structural coercion. It doesn’t require a threat or official order. It only requires a hierarchy, a stake, and an institution that has just announced a correlation between a biological marker and professional worth. This policy has all three.

There’s a second problem, and it’s just as serious: The test itself isn’t ethically neutral, even before anyone talks about treatment. Unlike a vision check or a blood-pressure reading, a testosterone panel produces a stigmatizing diagnosis — “low T” — inside a force that has just spent a public messaging campaign tying testosterone to lethality and combat effectiveness. That diagnosis becomes part of a medical record other people can see: superiors, evaluators, anyone assessing deployability. A service member who is told he’s “deficient” and then declines treatment has no guarantee that the label itself won’t shape how he’s perceived, whatever he decides to do about it. The Department’s framing — that testing is a harmless administrative add-on and treatment is the only meaningful choice — simply isn’t accurate. The compelled test result carries stakes of its own.

Then there’s the group Hegseth’s framing conveniently leaves out of the “mandatory” conversation: troops under 30 who can request testing on their own initiative. This is where the fertility risk comes in, and it’s substantial. TRTsuppresses the body’s own testosterone production and can significantly reduce sperm count. This is a well-documented, sometimes prolonged, occasionally permanent effect. Major medical societies, including the American Urological Association, specifically recommend that anyone of reproductive age discuss fertility plans before starting treatment. Yet roughly a quarter of men are unaware TRT affects fertility at all, and a similar share of urologists mistakenly believe it can actually improve fertility.

Ask yourself whether an 18-year-old service member, freshly told by the Secretary of Defense that testosterone is his “most decisive tactical advantage,” is in a good position to weigh a distant, probabilistic risk to a family he may not be thinking about yet against an immediate, publicly celebrated performance boost. Decision-making research has a term for exactly this bias: “present bias,” whereby people systematically underweight costs that are delayed and uncertain against benefits that are immediate. This isn’t a hypothetical problem, either. Unauthorized use of performance enhancing supplements is already a documented issue in the military.  An official, celebrated pathway to the same substance doesn’t remove that pressure. It removes the deterrent.

… Calling a program “voluntary” doesn’t make it so, and a policy built on the rhetoric of individual choice needs safeguards sturdy enough to make that choice real.

None of this means low testosterone isn’t a real, treatable condition, or that the Department of Defense has no legitimate interest in troop readiness. It does mean that calling a program “voluntary” doesn’t make it so, and that a policy built on the rhetoric of individual choice needs safeguards sturdy enough to make that choice real.

Those safeguards aren’t complicated: 

• Route the treatment decision through a clinician outside the chain of command, with real confidentiality. 
• Require an explicit, documented conversation about fertility risk before anyone starts treatment, with a referral to fertility preservation for those who want it. 
• Keep a low-testosterone diagnosis out of fitness reports and deployability files, so declining treatment costs nothing beyond the medical condition itself. 
• And if hormonal health is genuinely about readiness rather than a particular vision of manhood, don’t just limit it to testosterone; extend the same attention to servicewomen with diagnosable hormonal conditions of their own.

Should the Department of Defense keep the policy, it should also take its own rhetoric about choice seriously enough to build the protections that would make it true.