Discordance Between Online Information and Male Hypogonadism Clinical Guidelines: A Global Multilingual Content Analysis

253 testosterone clinic websites worldwide: 1 in 4 promote off-guideline treatments, 1 in 5 falsely claim cardiovascular benefits

Journal: The Journal of Clinical Endocrinology & Metabolism | Published: 2026-05-19 | Type: Content analysis | PMID: 41489427 Authors: Grant B, de Silva NL, Gumssani M, Quinton O, Kayali F, Gamage IL, Dhillo WS, Grossmann M, Jayasena CN — Imperial College London and Austin Health (Melbourne) Funding/COI: NIHR Senior Investigator Award, NIHR Post-Doctoral Fellowship, NIHR/Imperial CRF, NIHR Biomedical Research Centre. No COI listed.

Summary

Testosterone prescriptions have risen up to 12-fold globally over two decades, and this paper set out to quantify how much online clinic advertising is driving that trend with false or off-guideline claims. Researchers audited 253 publicly accessible websites offering testosterone prescriptions, using VPN searches across seven regions and four languages to minimize geographic bias. They found widespread violation of advertising law and clinical guidelines, with US-based clinics the worst offenders by a significant margin.

Claims

• 24.4% (61/253) of websites promote non-testosterone androgens or testosterone secretagogues (e.g., gonadotrophins) as routine treatment for symptomatic low testosterone — not supported by international guidelines
• 20.6% (52/253) claim testosterone treatment reduces cardiovascular risk — no guideline consensus supports this
• 11.9% (30/253) promote "microdosing" (lower, more frequent dosing than guideline or manufacturer recommendations)
• 9.9% (25/253) advertise testosterone prescriptions for men with normal serum testosterone (>12 nmol/L)
• 9.9% (25/253) claim testosterone has anti-aging effects
• 54.9% (139/253) of included sites were US-based; US clinics made non-guideline claims at significantly higher rates than other regions
• 45.8% of sites advertised as "men's health clinics"; 17.4% as "TRT clinics"; 9.5% as "wellness, aesthetic, or anti-aging clinics"

Study Quality

This is a content analysis, not a clinical trial, and it is well-suited to the research question. The methodology is unusually rigorous for this type of study: the team used VPN searches from seven geographically distinct IP addresses, conducted searches in four languages (English, Hindi, Spanish, Arabic) with native-speaker translation, cleared browser history and cookies before each search, and archived pages via the Wayback Machine. Three researchers coded independently with a fourth resolving disputes; intercoder reliability was Cohen's kappa = 0.83, which is strong. Guidelines used as the reference standard were cross-checked against five major international bodies (Endocrine Society, AUA, ISSM, Endocrine Society of Australia, Society for Endocrinology), reducing the risk that any single guideline quirk drives the findings.

The coding frame combined concept-driven categories (from existing literature) with data-driven categories (from pilot review of five random sites), then was tested in a 10-site pilot before full deployment. That's a more defensible frame than most content analyses produce.

Red Flags

• Search period spanned November 2023 to November 2024 — results are algorithm- and time-dependent; the sample is a snapshot, not a census
• Not all languages or regions were covered; Chinese, Russian, and Portuguese are conspicuous absences given global testosterone market share
• Country IP over-representation: despite VPN mitigation, the researchers acknowledge the browser's home IP (UK) influenced baseline results
• Website content is not a direct proxy for clinical practice — a clinic may advertise one thing and prescribe another
• Visual content (images, diagrams, infographics) was not coded, potentially underestimating promotional messaging
• No assessment of whether the advertised claims were accompanied by any supporting citations or disclaimers

Strengths

• Multilingual, multi-engine, multi-region methodology reduces the US-centric bias that dominates prior work in this area
• Strong intercoder reliability (κ = 0.83)
• Large sample: 1,138 sites screened, 253 included — the largest global audit of TRT clinic websites to date
• Reference standard drawn from five independent international guidelines, not one
• Wayback Machine archiving ensures the evidence base is preserved and auditable
• Funded by NIHR with no industry involvement; no declared conflicts of interest

Verdict

This is a methodologically serious audit of a genuine public health problem. The finding that one in five testosterone clinic websites falsely attributes cardiovascular benefits to testosterone — when guidelines contain no such claim and the cardiovascular safety of TRT has been actively debated — is newsworthy and concerning. The US-concentration of non-guideline claims is notable and the authors are appropriately blunt about it. The paper's limitations are real but honestly acknowledged, and they don't undermine the central finding. What it cannot tell you is whether any of this actually changes what doctors prescribe; that's a different study. What it does establish is that the information environment men encounter before walking into a consultation is systematically skewed by advertising that violates existing law in the EU and UK. Worth reading if you cover testosterone prescribing trends, men's health marketing, or regulatory enforcement gaps.