Participants complete a team-based casualty evacuation exercise during the annual 22Mohawks Performance Mohawk Medevac, combining physical challenge, teamwork, and shared purpose. Photo courtesy of 22Mohawks.
The Pentagon’s new screening initiative raises an important question: What happens when we stop separating physical health, mental health, and suicide prevention?
By David M. Campisano
I want to start with something that could easily get lost in this discussion: I support testosterone replacement therapy.
If a veteran or service member has a clinically diagnosed testosterone deficiency and TRT can improve his health, functioning, and quality of life, I don’t think we should be afraid of that treatment. In fact, I think hormonal and metabolic health have probably been overlooked for too long in the broader conversation about veteran wellness.
Where I become more cautious is when that argument gets extended into something much larger.
Recently, I have heard versions of the claim that if there were one thing we could do to prevent veteran suicide, it would be addressing testosterone deficiency through hormone replacement therapy.
I understand why that idea gets people’s attention.
Low testosterone can be associated with fatigue, reduced libido, sexual dysfunction, changes in body composition, diminished physical capacity, and mood-related symptoms. For someone who has spent much of his adult life connecting physical capability to identity, confidence, and purpose, those changes aren’t insignificant.
There is also evidence that testosterone treatment can improve depressive symptoms in some men. A systematic review and meta-analysis of 27 randomized placebo-controlled trials involving 1,890 men found a statistically significant, although modest, reduction in depressive symptoms among men receiving testosterone treatment.
Those are legitimate reasons to take testosterone deficiency seriously.
But suicide is where I think we need to be much more careful.
There is an important difference between evidence that an intervention can improve depressive symptoms and evidence that the intervention prevents suicide. At this point, we do not have evidence establishing TRT as a suicide-prevention intervention.
More importantly, after spending years working in veteran suicide prevention, I have a hard time accepting the premise that there is going to be one answer.
The problem simply doesn’t behave that way.
The Pentagon Is Asking an Important Question
That is why the Department of Defense’s recent move on testosterone screening caught my attention.
In September 2026, the Defense Health Agency issued new clinical guidance addressing testosterone deficiency among male service members. The development is significant, but perhaps not for the reason receiving the most attention.
I don’t see it simply as an argument for putting more service members on TRT. I see it as another acknowledgment that physiology belongs in our conversations about readiness, performance, and mental health.
That’s important.
At the same time, testosterone deficiency has to be diagnosed correctly. Major endocrine guidance recommends diagnosing hypogonadism when a man has symptoms consistent with testosterone deficiency together with unequivocally and consistently low testosterone concentrations. The diagnosis should be confirmed with repeat morning fasting measurements, followed by evaluation of the underlying cause.
That distinction matters because one low testosterone measurement isn’t necessarily the same thing as having clinical hypogonadism.
And having hypogonadism isn’t the same thing as saying TRT will prevent suicide.
There is, however, enough evidence around testosterone and psychological functioning that I don’t think suicide-prevention researchers should dismiss the subject either.
That leads me to what I think is the more interesting question:
What if testosterone isn’t the answer, but is instead one part of a much larger physiological system that we have not adequately incorporated into suicide prevention?
The Veteran Is a System
Think about a veteran who hasn’t been doing well for a couple of years.
He’s sleeping four or five hours a night. His back and knees hurt. He stopped working out and has gained 30 pounds. He doesn’t have the energy he used to have. His sex drive is down and that is beginning to affect his relationship.
Maybe he’s drinking more than he used to.
He doesn’t see the guys he served with very often anymore. His job doesn’t provide anything close to the sense of mission he had while serving.
Physically, he doesn’t feel like himself.
Mentally, he doesn’t feel like himself.
Socially, he’s becoming increasingly isolated.
Now let’s say we test his testosterone and discover that he’s clinically deficient.
Which one of those things is the suicide risk?
That’s the problem.
They are interacting.
Poor sleep affects energy and recovery. Fatigue makes exercise harder. Reduced activity can contribute to weight gain and metabolic dysfunction. Chronic pain makes sleep worse. Physical changes can affect confidence and identity. Sexual dysfunction can create relationship strain. Alcohol may temporarily help someone disconnect while making several of the underlying problems worse.
Somewhere inside that system there may also be hormonal dysfunction.
That doesn’t mean low testosterone caused the veteran to become suicidal.
It means the veteran’s physiology, psychology, environment, relationships, and identity are interacting with one another.
That distinction is important because we have spent a lot of time trying to divide these things into separate categories.
Mental health over here.
Physical health over there.
Social connection somewhere else.
Suicide prevention becomes another category entirely.
But the veteran doesn’t experience his life in categories.
He experiences all of it at once.
TRT Can Be Good Medicine Without Becoming a Cure-All
This is where I think we can hold two ideas at the same time.
TRT can be beneficial for appropriately diagnosed men.
And TRT does not need to become the explanation for veteran suicide.
Those positions aren’t contradictory.
Clinical guidelines support treating appropriately selected men with symptomatic, confirmed testosterone deficiency. At the same time, TRT requires proper evaluation and monitoring and has real considerations, including effects on fertility and the need to monitor hematocrit and other clinical measures.
The goal shouldn’t simply be getting everyone’s testosterone number higher.
The goal should be figuring out what is happening with the person.
Sometimes TRT may be part of that answer.
Sometimes something else may be driving the hormonal problem.
And often several things may be happening simultaneously.
Testosterone doesn’t exist independently from the rest of the body.
Obesity and metabolic dysfunction can influence hormonal health. So can certain medications and illnesses. Sleep disorders, energy availability, chronic disease, and other endocrine conditions may need to be considered.
Weight loss is a good example. A meta-analysis involving 44 studies and more than 1,700 men with obesity found that weight reduction was associated with increases in both total and free testosterone.
Exercise is more nuanced. We should be careful with the social-media version of the argument that lifting weights simply “boosts testosterone” permanently. But that almost misses the point.
Exercise can improve body composition, metabolic health, cardiovascular health, physical capacity, sleep, mood, and self-efficacy.
So even if my only concern were testosterone, I would still end up talking about the rest of the person.
And once we begin talking about the rest of the person, we are back to suicide prevention.
We Keep Looking for the One Thing
I think suicide prevention has a reductionism problem.
We keep looking for the variable that will finally explain why someone dies by suicide.
For years, much of the conversation centered on mental illness.
Then PTSD.
Traumatic brain injury.
Moral injury.
Alcohol.
Firearms.
Loneliness.
Sleep.
Financial stress.
Relationship problems.
Transition from military service.
Now testosterone is entering that conversation.
Every one of those things may matter.
None of them adequately explains suicide by itself.
There are veterans with severe PTSD who never experience suicidal ideation. There are veterans who experience suicidal crises without having PTSD.
There are veterans with low testosterone who aren’t depressed.
There are veterans with completely normal testosterone levels who feel profoundly hopeless and alone.
The same problem occurs when we look at protective factors.
A service dog isn’t the answer. Peer support isn’t the answer. Exercise isn’t the answer. Therapy isn’t the answer. A firearm lock isn’t the answer. TRT isn’t the answer.
That doesn’t make any of them unimportant.
It means we need to understand where each intervention fits within the larger system.
Instead of asking what single intervention prevents veteran suicide, perhaps we should be asking:
What is happening within this person’s system, and where can we intervene to make that system stronger?
For one veteran, identifying and treating testosterone deficiency could produce a meaningful change in quality of life.
Another may desperately need treatment for sleep apnea.
Another may need trauma treatment.
Another may need to address alcohol use.
Another may need metabolic intervention, physical rehabilitation, or chronic-pain treatment.
Another may have every clinical resource available to him and still desperately need something medicine can’t prescribe: purpose, connection, identity, and a reason to get out of bed tomorrow morning.
Most probably don’t fit neatly into one of those categories.
They may need several.
What This Means for Suicide Prevention
This is where I think the Pentagon’s decision creates an opportunity much larger than testosterone.
If more service members begin having conversations with clinicians about hormonal health, we have an opportunity to learn.
What happens to psychological health when genuine testosterone deficiency is identified and appropriately treated?
What happens to sleep, physical activity, sexual functioning, relationships, alcohol use, depressive symptoms, and perceived quality of life?
Does improving physiological functioning strengthen someone’s sense of self-efficacy?
Does feeling physically capable again affect identity?
Does that change someone’s willingness to reconnect socially?
Those questions interest me much more than whether we can simply raise someone’s testosterone level.
And I think we should eventually study suicide-related outcomes as well.
Maybe testosterone deficiency has been underappreciated in veteran health. I think there is a reasonable case that it has been.
Maybe appropriate TRT will eventually prove to have downstream effects relevant to suicide prevention. That possibility deserves serious research.
But I don’t think the lesson is that we have finally found the answer.
I think the lesson may be almost the opposite.
The more closely we look at testosterone, the more we are forced to look at sleep, metabolic health, injury, chronic pain, physical activity, sexual health, relationships, mood, identity, purpose, and belonging.
And once we do that, the artificial lines between physical health, mental health, and suicide prevention begin to disappear.
That’s where I think this conversation becomes genuinely important.
We keep looking for the variable that explains the veteran. Maybe we need to get better at studying the veteran as a system.