The others are the others : perceptions of male users about the adverse effects of testosterone 1 Os outros são os outros : percepções de homens usuários sobre os efeitos adversos da testosterona

This article analyzes the perception of male users of testosterone about the adverse effects of the hormone, aiming to challenge the effectiveness and scope of health actions for this practice. Empirical data were obtained in 2016, mostly in Rio de Janeiro, from life history interviews with 21 male users of testosterone, with or without medical monitoring, from different backgrounds. In the light of gender and masculinity studies, it discusses how men interpret the impacts of testosterone use from a social valuation of certain traits associated with a normalizing manhood ideal. Results indicate an invisibilization or re-signification of potentially negative effects of the hormone, culminating in a widespread perception that it causes little or no harm. The problems associated with testosterone use acquire stereotyped characters, through a process of denying self-responsibility and reaffirming attributes of an ideal type of masculinity. This study is expected to contribute to the development of more adequate and thus more effective health actions to users’ daily lives.


Introduction
Testosterone is a steroid hormone produced primarily by the gonads in both men and women, and associated with a wide range of effects, ranging from anatomical to behavioral. It is directly associated to the development of secondary sexual traits in men and, unlike other hormones, enjoys a prominent place in people's imagination. Testosterone is still described, even by science, as the male sex hormone par excellence, although this classification has been challenged in many fields -from biochemistry to anthropology -since the early days of scientific research on the molecule (Rohden, 2011;Tramontano, 2017b). Common sense still associates testosterone with masculinity, using one as a synonym for the other.
Among several issues surrounding such a meaning-laden molecule, this article focuses on the perceived undesirable effects in the use of the hormone, either prescribed or otherwise. Testosterone (like the other sex hormones) may be seen as a paradigmatic case in that it is a substance synthesized by the body, yet supplemented or replenished, blurring the boundaries between natural and artificial.
However, it is often used on its own, widely distributed by the illegal market, and often used for aesthetic purposes. Even medical use, such as hormone replacement, is questioned as it is considered by critics and some doctors to be more of a tonic than a medication. Its therapeutic value is many times treated as an enhancement, as shown by Russo, Faro, and Montezuma (2019). Another use involves gender transit. In this specific possibility, the boundaries of body naturalness are further blurred. The concept of what would be natural or not is crossed by political positions in face of conceptions of sex and gender that will be supported by scientific knowledge, and not considered as genuine and irrefutable proof. The very physiological action of the hormone makes its effects multiple, diffuse, and difficult to predict. This characteristic is deepened by the symbolic character, and the generification of sex hormones, as pointed out by Nelly Oudshoorn (1994).
For Nikolas Rose (2013), the 21st century is witnessing a new stage in the process of regulating bodies. It would be a deepening of Michel Foucault's biopolitics (2006), through the advance of a "technological biomedicine", increasingly dependent on machines and equipment, which sustains and is sustained by a molecular vision of the body and its functioning. Such a technological biomedicine shall favor the pharmacological resource whenever it is available, which is also perceived by Adele Clarke et al. (2003). The intensive production of new diagnoses, packaged by the pharmaceutical industry's need to make its products marketable, leads to a "pharmacologization of the everyday life", which creates a looser and more intimate relationship with the medication (Bell;Figert, 2012;Fox;Ward, 2008). This is the position adopted by the article to locate the users' perception about the negative effects, aiming to problematize the dichotomy between the natural and the artificial in light of testosterone use. The discussion starts with excerpts from interviews with users about adverse effects. Next, it advances on strategies for coping with the problems. In the conclusion, it addresses how characteristics of the ideal of hegemonic masculinity emerge from the reports. It ends with a reflection on the potential for health response in face of the risk caused by indiscriminate use of testosterone.
Hegemonic masculinity is understood as the ideal of masculinity imposed on men by the gender norms. George Mosse (1996) describes how the construction of modern masculinity in the West is reflected in the exaltation of an ideal image of man. This image both shapes and is shaped by the standards of morality and behavior of the European bourgeoisie. It is also marked by attributes such as power, physical strength, courage, competitiveness, willpower, resilience and self-control. For Miguel Vale de Almeida (2000, p. 150), "the culturally exalted form of masculinity only corresponds to the characteristics of a small number of men," turning 2 It is worth noting that a "myth of invulnerability" is often associated with hegemonic masculinity, even underpinning menoriented health policies as, for example, in the Brazilian Ministry of Health's National Policy for Integral Attention to Men's Health (BRAZIL, 2008 hegemonic masculinity into a virtually unattainable ideal. These attributes will not be exhibited by all men at all times, and the resulting contradictions are resolved once they depend on interpretations and negotiations. Interpretations will depend on other markers of difference such as class, race/ethnicity, age group, and regionality. In other words, the meanings of "being a man" are multiple, but not individual, as advocated by Raewyn Connell (2005). For the author, there is no single model of hegemonic masculinity, and the same man may embody different models in different contexts. Michael Kimmel (1998) agrees and emphasizes how hegemonic masculinity is constituted simultaneously and oppositely to questionable or devalued ways of being a man -as observed in this article -when problems associated with testosterone are solved through an artifice present in the ideal model, i.e., competitiveness. The article shows that men displace the adverse effects of testosterone from themselves to the others, who would be those who truly suffer from the hormone. Both Vale de Almeida (2000) and Mosse (1996) argue how men build their masculinity through the minimization or denial of the other's masculinity, treated as a "countertype", and that reinforces the (own) hegemonic values. Men, therefore, present themselves as "more masculine" through two movements, represented in the two sections of discussion herein: (1) claiming resistance or invulnerability to the damaging effects of testosterone 2 ; and (2) accusing other men of not exhibiting the attributes required for safe use of the hormone.

Method
Data were extracted from the author's doctoral research 3 , which worked with life history accounts of 21 men, among cisgender (14) and transgender (7). Regarding age, the sample ranged from 26 to 66 years, converging on the 30-40 age group (9). Regarding race/color, there was a concentration of white men (15) as opposed to black men (4 brown and 2 black), according to self-identification criteria. The marker sexual orientation reported more parity, with 10 heterosexual and 9 homosexual men, besides 1 pansexual, and 1 bisexual. As for location, there was a large concentration in the Rio-São Paulo axis 4 . The search for interlocutors was based on the snowball scheme, which led to some homogeneity among interviewees: white, middle-class, and with university degree. For the analysis, it is relevant the categorization based on the purposes of use, which may be roughly divide into: professional bodybuilding; amateur bodybuilding; and gender transition. This division, however, is not hermetic, and the same man may be in more than one group at the same time.
The choice for life history accounts was based on the concept of social life of things, by Igor Kopytoff (2008) and Arjun Appadurai (2008), and on the biography of pharmaceuticals, according to Geest, Whyte, and Hardon (1996). The tool aimed not only to listen to the respondents' biographical reconstruction of their use of a chemical substance, but to run a strategy for understanding the intersection between two biographies: that of the men interviewed, and that of testosterone (in their lives). It is, therefore, a double biography, constructed in the relationship between respondents and the hormone. Interviews were conducted by the author during 2016, upon signing of the Informed Consent Form (ICF), and using a tape recorder as a backup, and lasted 1h15 on average. Data analysis followed the discourse analysis method, understanding that the socio-historical and ideological context, as well as nonverbal language enabled by the elections of interview as a data collection tool, are relevant for the broad understanding of the meaning of production, and enunciation of the interviewees' discourse.
"Nothing, nothing, nothing, nothing!": denial and displacement The accounts make clear that testosterone may cause problems, even if men tended to discredit or minimize them. There is some hesitancy with the idea of a free, unmediated use of testosterone, which suggests there is something dangerous about the use of the hormone. However, what exactly would be this "harm"? When asked directly, the answer tended to be negative: "I had no side effects" (João Pedro); "No, I always had blood tests, followed up and there was no significant change" (Silvio); "No, [...] apparently nothing. Nothing, nothing, nothing, nothing!" (Otávio); "No, I think...not that I can remember [...] nothing that causes a...that displeases" (Flávio) 5 .
Not everyone believes that taking testosterone is so positive. Evandro, very critical, decided to discontinue use because he presented diffuse organic problems, and what he defines as "psychological": "I think it's the imbalance of your hormonal rates and your metabolism, because it messes up so much, even your psychological". Frederico also describes non-physical changes with use, although when asked directly about unpleasant effects, the answer was categorical: "Gee, none!" I was a more multipurpose person. When I opened the computer to study a certain subject, [ Another issue was reported by Samuel, a common complication to the use of injectable drugs, mainly when administered under questionable conditions: local redness and swelling. Similar reports appeared in the field; however, I emphasize this was a problem in the route of administration, and not an effect of the testosterone itself. There were common reports of bruising, and various bodybuilding injuries associated with testosterone. However, this is a consequence of the increase in physical strength, which leads the user to even double the load lifted beyond the limits of the muscle. Therefore it cannot be considered a direct effect of testosterone.
A problem that my interviewees considered more serious involved atrophy, accompanied by a lot of pain, which ended up taking Sérgio to the emergency room: "I had a problem like this...on my balls, I had a problem of incredible pain [...] after I started taking testosterone, [...] I was working out and, like this, I didn't have an erection, I had nothing, and this pain started." Paulo developed the same effect, which he described more graphically: "I started feeling pain in my testicle, and when I went to check my testicle had the size of an olive!" When I asked Sergio if he had noticed any reduction, he denied it, saying he only felt pain. Testicular atrophy is an expected effect of testosterone overdose, due to the physiological negative feedback mechanism 6 , which virtually stops testicular production. Claudio explains further: Atrophy was not a problem only for cis men, trans men also report an atrophy of the vaginal canal, very uncomfortable for those who have in vaginal penetration a sexual practice. For others, the atrophy led to concern about possible health problems, notably cancer. Among the trans men, Leandro and Renato told me about this problem, which they face in very different ways depending on their sexual practices. For Renato, it was a major inconvenience. This idea of "killing the vagina" is repeated among trans men, and seems to be associated with a perception of the genital organ as eminently (and exclusively) female. Let's look at it from Leandro's perspective: Well, there was a process of gradually killing my vagina. At first, for affirmation of gender expression, then it became more and more painful, because it experiences atrophy, so it becomes an unpleasant experience. I already had a deviation in the vaginal canal. That got considerably worse.
It is worth noting that one of the historical criteria for the diagnosis of transsexuality (in its many nomenclatures) would be the repulsion for genitals. Nowadays, however, with the visibility that different expressions of gender gained in society, more plural discourses arise regarding the use or not of genitals by trans people 7 . That is what Ivan, the oldest man in the field, who is 66 years old, observes with excitement: "there's everything! There are trans people that use the vagina now, they don't mind being passive, there's everything!" Regarding possible other bad effects, Leandro mentions many things, but all have another explanation. I emphasize how the issues mentioned are somewhat typical to aging, not necessarily related to testosterone, and are relatively common in people in Leandro's age group (43 years  It was a common habit to attribute the perceived adverse effects to an issue other than the hormone directly, which takes the sting out of testosterone (and its user). The argument involves the notion of "correct use" which, according to them, only the man who already has experience with testosterone would be able to use it properly. Claudio is one of them: 7 In their latest editions, both the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) have undergone reformulations in their approach to transsexuality and transvestility. The current diagnosis in the DSM-5 is "gender dysphoria", focusing on the aspect of suffering resulting from the incongruence between identity and body (and not on the incongruence itself). In ICD-11, on the other hand, "gender incongruence" appears in the chapter on health-related, non-pathological conditions, such as pregnancy. The actual effectiveness of these transformations in health practices is something that will only be observed over the next few years. For a specific discussion on the Brazilian reality, see Almeida and Murta (2013). It is interesting how Claudio claims the "naturalness" of testosterone. This claim also appears in a less explicit way in other accounts. Another relevant point in this speech is that the assertiveness he conveys that "nothing can go wrong" is softened by "theoretically". This is an ambiguity of testosterone: it is natural and does no harm, but only "theoretically". There will always be some other factor that will justify the cases that go wrong. This posture is explicit in the speech of Antônio, who says he does not have any side effects; however, he describes several side effects, but quickly justifies them in another way. So, aggressiveness is not aggressiveness, but everyone gets impatient; erectile dysfunction, he has heard, but has not had; liver damage, blamed on the wrong diet, as well as acne. However, he claims that he "knows it is bad for him." Therefore, the hormone is definitely harmful. Jorge, very cautious and responsible during the whole interview, also believes that "if you do it right, there is no problem". In this speech, Jorge claims his "good genetic" protects him from the risk of gynecomastia. Claudio also makes several references to alleged predispositions, either to develop health conditions (notably cancer), or to favor testosterone gains. This argument irritates Otávio a lot, who accuses people of repeating it just "to say that they are Super Man, so, that they are Mega, Top, Blaster and that, you know, mega good genetics". Unfortunately, Roberto doesn't seem to be as lucky: "I think I felt I had gynecomastia, yeah". However, his gynecomastia was not exactly an effect of testosterone either; it was because he took testosterone along with DHEA 8 , intensifying the effects. Upon noticing the 8 It refers to dehydroepiandrosterone, an androgen with a more discrete action than testosterone. difference in his breast, he sought a doctor and asked to discontinue the DHEA, keeping the testosterone and stating that the symptoms of gynecomastia "are reversing".

The only side effect I feel is that I can't sleep. I get insomnia straight up when
Analyzing all the speeches, one notices a tendency to excuse testosterone for its disorders, sometimes claiming greater knowledge about the hormone, sometimes of an organic advantage that protects the user from adverse effects. The ideal of hegemonic masculinity comprises a superiority to cope with adversity, whether innate or acquired. Except for atrophies, which are hard to ignore, other negative effects are relativized, melt in factors unrelated to testosterone. However, no one ignores the fact that there are cases of people who experienced serious, even fatal issues, as a result of steroid use. How to deal with this apparent contradiction and not give margin for a vulnerability of the self?

"That's too much!": others and male competitiveness
The interlocutors shift the adverse effects of testosterone to an "other" who will concentrate all problems related to the use; this other will be the target of all the stigmas they described as unfair and hypocritical when applied on themselves. Even when they perceive (or it becomes impossible to disguise) negative consequences of the use, men organized some justification that differentiated them from other users. I observe, therefore, the same as Azize and Araújo (2003, p. 144) about Viagra users: "When it comes to the construction of masculinity in the discursive field, the use of comparisons with other men is recurrent. There is an 'other' that appears in the discourse of the interviewees, sometimes as a positive reference [...] sometimes as a negative reference." Three major "others" may be outlined: the athlete, professional bodybuilder; the amateur bodybuilder; and the macho trans man. The first two "types" are reciprocal accusations: the anabolic user is the "other" of the professional bodybuilder, while the bodybuilding athlete is the "other" of strength trainers. There is a clear displacement of the insults received to someone who is close in the eyes of society, but is described as diametrically opposed. I often had the feeling that the other was actually a hyperbole of the self: there was a fear of becoming the other, which would require vigilance, surveillance of the self. Pointing out the mistakes of other users would serve as a reminder of what not to do. In some cases, these men do not consider the body of the bodybuilder athlete something so repulsive, and have even thought, at some point in their lives, about the possibility of becoming an equal. This is very clear in the story of Mateus, who grew up fascinated with bodybuilding, but for whom today's bodybuilders do not have the glamor he used to admire: The rhetoric of excess is also triggered by Fernando, for whom the main victims of testosterone would be those who take it on their own, "who have gone too far", and with no medical follow-up, the opposite of their choices. For Sérgio, "it is usually bodybuilders who die because of it", despite the fact that, among the interviewees, bodybuilders do not report serious adverse effects.
Evidencing the reciprocity of accusation, for the athletes the ones who will suffer with the adverse effects are those who "don't know how to take it". "They don't know the right dosage; they don't know when to stop" (Antonio). Following a difference that marked these two groups, athletes will expose the "mistakes" of amateurs with a wealth of detail, proving their vast knowledge on the use, while disqualifying the knowledge of others. Jorge even gets aggressive in pointing out the mistakes of these "laymen": The criticism that testosterone does not work magically has less to do with actual effects of testosterone than with an assumption that transformation would be easy and quick. There is a contradiction here with a perception of the effects considered positive, which are described as quick and incisive, molecularly reproducing characteristics of masculinity in a process of hormonal generification (Oudshoorn, 1994). However, the denial of a rapid action of testosterone in this specific context is useful in two interconnected respects: (1) it values the effort and dedication these men have with testosterone; and (2) it serves to denounce the forums and websites that give the impression that one only has to want (and take testosterone) to grow.
However, even if criticism is made keenly, it may be completely ignored by those who use it "wrongly," who may exhibit total indifference, or even debauchery, regarding the risks. Let's see how Paul responds to this:  this, this, this, this, and this," and then I say, "guys, that's absurd! I'm old hands in this, I don't take all that stuff! The adverse effects become consequences of three situations: (1) resorting to broscience, the jocular way in which the athlete refers to the prescriptions and explanations about the use in Internet forums, a kind of parallel science "of the brothers"; (2) a medical error, since it is common among users the argument that medicine is hypocritical and biased with the use, repeating incomplete or even false information; and (3) the lack of discipline, a requirement for obtaining favorable results. Thus, Jorge deconstructs effect by effect. Acne? "backyard-made drugs"; "bum supplement"; "eat crap". Other men present the difference in relation to the "other" in the form of a moral or intellectual advantage, like Silvio: You'll find people who really do an excessive body cult, and get completely sucked into it, and other people who were, like in my case, it was more of a self-esteem thing, of overcoming oneself, even more for self-acceptance, [...] but you also have those who, in fact, are there for other reasons.
That is, for Silvio, the people who are there for these "other reasons" are the problem. Silvio claims the discourse of "overcoming the self", the others do it for the "excessive body cult", which is negatively appraised. In fact, it seems that men find different ways to dispute masculinity. Among trans men, for example, something that was repeated in all the interviews was the report of the uncritical reproduction of a stereotype of masculinity, considered negative.
I think they are wanting to be cis men, really. They want to use other things from the masculine universe [...] to show that they are the bad guy, the alpha male, you know? [...] there are also guys who say that he only starts to be a man after he takes testosterone, because then he will be a man because he has testosterone in his body (Augusto).
By presenting themselves as "alpha males," these men would not only be reproducing a sexist masculinity, but also making a "misuse" of it. He adds: It turns out that you have the guys who use testosterone irregularly, and not every organism is ready to that. [...] What happens is that people don't always use it the way the doctor tells them to, they take it in a different way and end up causing problems [...] then they have strokes, they have a lot of things.
So, also among trans people, the one who dies is the one who "doesn't know how to take it". The most interesting thing in this comparison is to notice how this trans "other" is who reproduces the hegemonic masculinity represented, in Flavio's words, by the "straight white cis man". Regardless of occasional differences, the conclusion that we can draw is that the "other" is usually a hypermasculine figure, in the sense that some of the attributes of masculinity are hyperbolized in this experience. The "other" represents the excess, the exaggeration, what is over the top. In short, the "other" lacks the most essential characteristic of the modern man pointed out by Mosse (1996): self-control.

Final Remarks
It is interesting to note how the description of this other (exaggerated, inexperienced and/or undisciplined) stems from a relative position of men in front of different images of masculinity. George Mosse (1996) describes how, in order to establish itself as a norm, masculinity depends on comparison with countertypes that concentrate those characteristics considered negative. Following Raewyn Connell (2005), attributes will be considered hegemonic or subordinate based on the relative location of men at an intersection between different social markers of difference. Features that were noted as very positive in one context, for a certain type of man, were precisely those described as undesired by others. What did not meet the desired was what belonged to the "other".
The discussion proposed herein is a contribution to health promotion, and prevention of health conditions regarding the use of testosterone. In line with Farias, Cecchetto, and Silva (2014), a taboo on frankly addressing this use, based on a fear of "apologia for drug use", leads to a difficulty of dialogue with users, and a weakness in the formulation of health policies and actions. "If ANVISA has banned it, it's good," said a meme that circulated among some users. This explains the distance between the official discourse of science and health and the user's daily life. Therefore, an effective response should consider the lived experience of users who consider themselves able to manage the health risk of their practices. It is possible to design health actions that seem less stereotyped and biased, as the speeches of health professionals were many times qualified during the research.