Quiet Professionals and Low-T

Enlisting in the military had always been a dream of mine since I was a young boy. I left for Basic Training at Fort Benning, Georgia after graduating from high school in the summer of 1986. I was fortunate enough to have had the opportunity of serving in the 1st and 2nd Infantry Divisions and later reenlisted for the 10th Mountain Division at Fort Drum, New York. My service was during the Cold War and the incidence of depression and suicide among service-members seemed rare, almost nonexistent. I began a career as a firefighter/paramedic after completing my six years of service in the Infantry, but always remained close to my military roots. One of my first service-related exposures to mental illness was during a psychology rotation at the Providence VA Medical Center while I was attending paramedic school. I soon began to take notice that a large percentage of the medical emergencies I responded to as a firefighter/paramedic would stem from mental health issues.

I had just completed a 24-hour shift at the firehouse and was slouched over my coffee table eating breakfast when I saw Flight 11 out of Boston strike the North Tower of the World Trade Center. Like most Americans, I was in shock as I watched the events of that day unfold in real-time on television. America responded swiftly to the attacks on 9-11-2001, and the Army’s 5th Special Forces Group was among the first boots on the ground in Afghanistan. This type of conflict required elite groups of warriors and America’s Special Forces “A-Teams” because their specialized training made them ideal for the task at hand. In fact, Special Forces not only played a major role in the War on Terror, but their important and impactful role inspired many patriotic Americans to attempt the Special Forces' rigorous selection process. Special Forces Assessment and Selection is designed to test survival skills and places an even stronger emphasis on intense physical and mental training over a period of 24 days. If selected, candidates will then begin the Special Forces Qualification Course, which consists of several phases, and lasts approximately 54-56 weeks. “Special Forces are elite teams consisting of mature, intense, highly-trained operators. SF Operators receive specialized training in advanced weapons, language, demolitions, combat medicine, military free-fall, and advanced combat tactics. Today’s quiet professional operates in autonomous environments as the most trusted force in America’s Army” (Special Forces, 2019). Many of these Special Forces Operators leave the military and suffer bouts of depression. Some individuals have suggested that depression is all too often misdiagnosed as PTSD otherwise known as Post Traumatic Stress Disorder. Kevin Lacz had his article, “The “Signature Injury” of the War on Terror Is Not PTSD. It’s Low-T, appear in the Havok Journal on 6 August 2019. In his article, Lacz suggests that:

It’s important that our communities understand the prevalence of hormone imbalance among veterans because of symptom overlap with TBI/PTSD. This overlap of symptoms could lead to an exacerbation of symptoms or even misdiagnosis. Veterans presenting with mood swings, weight gain, irritability, apathy, sleeplessness, depression, or low sex drive should have hormone levels checked to ensure that an imbalance is not masquerading as a brain injury or mental health disorder, or simply making symptoms of TBI/PTSD worse. (Lacz, 2019)

Author Kevin Lacz is a former Navy SEAL who served on two deployments in Iraq as a team sniper and medic. His article inspired me to dig deeper into the issue of Low-T and its direct impact on the Quiet Professional. The need to take a closer look stems from the tendency of both the Armed Forces and the medical community taking the plain approach of painting all service members with the same broad brush of PTSD. However, there may be something more complex at the core, which is what this investigation intends to explore. I have had the opportunity and privilege to work with many Quiet Professionals in the private sector, forging great relationships. Exploration of the issue through research, will be achieved by a purposive sample of interviews, as well as through critical analysis of the various components revealed feelings of depression associated with low testosterone levels. A few of these Quiet Professionals interviewed admitted to having themselves tested for low levels of testosterone after leaving the military on their own dime. One Quiet Professional interviewed explains, “Most of us paid out of pocket at BIO station in Florida. Covered by Tricare in the day. Not anymore” (Quiet Professional #6). These interviews also exposed a stigma that exists within our society and the medical profession about the use of testosterone replacement therapy (TRT) for America’s warriors even when indicated through laboratory testing. According to the Urology Care Foundation, depression is a major symptom of low testosterone (Low Testosterone, 2019). The average age of the Quiet Professionals first deployed to Afghanistan after 9-11 was thirty-two (King, 2018), and studies indicate that testosterone begins to decline in males after age thirty (Hirsch, 2019). The exploration at hand is important because twenty-two Quiet Professionals took their own lives in 2018 (Birkenbuel, 2019), and the relationship between Low-T and grave depression suggests that the connection between these two variables among Quiet Professionals is worthy of exploration more thoroughly in military settings.

The Quiet Professional is not easily defined because of being shrouded by a mysterious history that can be traced back to the early days of WWII at Fort Bragg’s Camp Mackall (Special Forces, 2019). Lara Logan reports on the process of readying Afghans to fight on their own in her 60 Minutes article, Green Berets: The Quiet Professionals: “Few people realize that the Green Berets traditional role is to train foreign armies - the only arm of the military designed especially for this purpose. These operators are known as the "quiet professionals" because they work mostly in secret, unnoticed and unrecognized, among the best soldiers America has. For the most part, these "quiet professionals" are camera shy Joes who let their expertise do their talking” (Logan, 2010). According to U.S. Army Special Forces Recruiting site:

The simple, but time-tested, phrase "Quiet Professionals" best describes our SOF ethic and culture - the principles we live by and the behaviors and beliefs we exhibit every day. We are a values-based organization - always mindful that our personal and professional conduct reflects not only on ourselves but on our Nation. We are focused on contributing to the mission at hand and being a well-integrated part of the team - unconcerned with who gets the credit and recognizing that much of what we do will remain in the shadows. We support the Geographic Combatant Commanders (GCCs) - if they are successful, we are successful; if they fail, we fail. (Special Forces, 2019)

One Quiet Professional interviewed best describes by self-reflection: “The Quiet Professional is the guy that actually does the deeds, does the hard jobs without asking or seeking fame, fortune or recognition. He does it because he believes in what he is doing, and his sense of selfless service overrides his need for the acknowledgement of others” (Quiet Professional #5).

In communications with RN Sarah McNary the former Lead TBI Nurse Case Manager attached to the USSOCOM Warrior Care Coalition at Landstuhl Regional Medical Center (2012-2017) McNary asserts, “I 100% support your idea that routine neuroendocrine monitoring (and lead levels while we’re at it!), similar to optometry, audiology and dental requirements would be a very smart preventative measure to institute.” If such screening were to be implemented, it stands to reason that the incidence of Low-T could be more fully addressed, conceivably lowering the incidence of grave depression that precedes attempts of suicide among Quiet Professionals. Thus, many lives could potentially be saved by a simple and routine screening for Low-T.

To the outsider, the Quiet Professional is regarded as a fierce warrior and a strong individual who is capable of tremendous feats. Emotion is kept at bay in order to accomplish their given missions. Therefore, so many of them have difficulty expressing what they are truly feeling when they leave military service and transition to a normal civilian lifestyle. For years they have trained to endure pain and other stressors in extreme austere conditions. These Quiet Professionals with such high self-standards and intense work ethic live by a code and find it almost impossible to openly admit their weaknesses, therefore they suffer in silence instead of getting the help they need, which may be remedied by something as simple as a blood test to check testosterone levels. One of the questions I asked off all my respondents was their thoughts about the possibility of a connection between Low-T, depression and suicide and all agreed a likelihood does exists. One was very candid about his feelings:

Depression, anxiety, irritability and other mood changes are common in men with Low-T. However, from what I’ve read, researchers aren’t sure what causes the correlation. Think of an Operator, type A warrior and then you have these problems with Low-T: irritability, anxiety, sadness, low sex drive, memory problems, trouble concentrating and sleep problems. These are all things that we view as weakness. So sure, Low-T in Operators can cause depression. We see ourselves as less then what we have been trained and told we are and what we believe we are. We believe we aren’t men anymore, we’re weak, aren’t what the movies, memes and what our brothers think we are. So, we suffer in silence and that increases our depression. Feelings of inadequacy, failure and why we see so many SOF dudes struggle with alcoholism, suicide, etc. (Quiet Professional #3)

America has been fighting the War on Terror for nearly two decades and the incidence of veteran suicide has been increasing exponentially. Hard but valuable lessons come from “combat” whether they be new advances in battlefield medicine, tactics such as the use of Special Forces force multipliers or the more recent focus on mental health and the early indications of depression. The Merriam-Webster dictionary defines depression as a mood disorder marked especially by sadness, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal tendencies (depression, 2019). A man’s serum total testosterone levels decline by 1 to 2% annually beginning at about age 30. In addition, sex hormone-binding globulin (SHBG) levels increase with aging, causing an even greater decline in serum free and bioavailable testosterone. These age-related changes are referred to as the andropause, although there are no abrupt changes in hormone levels and corresponding symptoms as occur in the menopause. The decline in testosterone may contribute to a combination of symptoms that has been termed androgen deficiency of the aging male (ADAM), which includes age-related muscle loss, increased fat deposition, osteopenia, loss of libido, erectile dysfunction and cognitive decline. Men are diagnosed with hypogonadism if they have these symptoms along with low serum testosterone and are eligible for treatment with supplemental testosterone. Testosterone supplementation in men with low-normal levels of testosterone is controversial (Hirsch, 2019). According to Wolters Kluwer Clinical Drug Information, Inc., free testosterone should be measured in patients with conditions associated with increased or decreased SHBG, or in patients with total testosterone concentrations in the borderline zone around the lower limit of the normal range (e.g. 200 to 400 ng/dL). For the treatment of hypogonadism, a total testosterone goal in the mid-normal therapeutic range (e.g. 450 to 600 ng/dL for most laboratories) is reasonable for most patients to prevent over- or under-treatment. For injectable formulations (IM, SubQ), a range of 350 to 600 ng/dL may be reasonable. Dose titration is not necessary if complete symptom resolution occurs with testosterone levels below the suggested target range (Hirsch, 2019). Quiet Professional #8 states, “I’ve had them check it once. They said it was on the low side but not enough for them to give me supplemental T. I think It was over 300 but not by much.” It is concerning that physicians generally wait for one’s testosterone levels to drop well below “the lower limit of the normal range (e.g. 200 to 400 ng/dL)” before beginning testosterone replacement therapy (TRT) while “a total testosterone goal in the mid-normal therapeutic range (e.g. 450 to 600 ng/dL for most laboratories) is reasonable.” High stress is also associated with low testosterone. Both acute and chronic stress have physiologic effects on the body. Deployed soldiers (particularly those outside the wire such as Special Operations) have acute and chronic stress. These men function at very high physical and mentally demanding levels for hours on end. In a discussion with one Special Forces Operator, he remarked: “Being and growing on an A team is a huge responsibility and requires enormous personal sacrifice both to the mission and home life, i.e. family. Particularly in a time of war with an unrelenting operational tempo, better known as op tempo. With this thesis in mind, I suppose Low-T, stress of declining performance and depression would absolutely affect an Operator’s mental wellness” (Quiet Professional #1).

“Warriors, bravery, and change, and the one. I have been fortunate to know many warriors, have observed much bravery, and witnessed many positive changes. I have also met a very few of “the one” (Donner, 2017). The Greek philosopher Heraclitus had written, “Out of every one hundred men, ten shouldn't even be there, eighty are just targets, nine are the real fighters, and we are lucky to have them, for they make the battle. Ah, but the one, one is a warrior, and he will bring the others back” (Donner, 2017). Parallels can be drawn from the ancient quote with this verse from the Ballad of the Green Berets written by Special Forces Medic SSG Barry Sadler during the Vietnam War. “Silver Wings upon their chest -These are men America's best - 100 men will test today - But only 3 win the Green Beret” (Moore & Sadler, 1966). The verse references the Army’s rigorous selection process for Special Forces Green Berets. My grandfather was a WWII veteran and we would always watch war movies together when I visited. One of the most memorable we had watched was, The Green Berets starring John Wayne (Kellogg & Wayne, 1968) and it opened with Barry Sadler’s Ballad of the Green Berets. The first scene takes place at the United States Army, John F. Kennedy Center for Special Warfare, Fort Bragg, North Carolina. There a Special Forces A-Team conducts an orientation of its capabilities as Green Berets to a group of civilians and reporters. These men appear larger than life, displaying professionalism as each informs the crowd of their individual skill sets and abilities. In a true Quiet Professional manner, lead character Master Sergeant Muldoon informed the crowd that he and Sergeant First Class McGee had been “ordered to volunteer to answer questions” they may have. The two answered all questions with wit, character and expertise. I was inspired by the scene and it influenced me to select the Infantry when enlisting.

Depression and suicide in the military as well as with our veterans are complex issues for mental health and medical professionals to combat. Alfred Adler (1870-1937), world-renowned philosopher and psychiatrist, stressed the need to understand individuals within their social context. Adler developed the first holistic theory of personality, psychopathology, and psychotherapy that was intimately connected to a humanistic philosophy of living. According to Adler, when we feel encouraged, we feel capable and appreciated and will generally act in a connected and cooperative way. When we are discouraged, we may act in unhealthy ways by competing, withdrawing, or giving up (Alfred Adler: Theory and Application, 2019). Suicide is considered to be the ultimate “giving up.” Adler began his career as a physician and received an invitation from Freud in 1902 to join a discussion group that would later start the psychoanalytic movement. Adler put off his psychology lectures and studies to serve as a military physician during World War I and he later disengaged from Freud’s circle. The two reportedly disliked each other because Adler held fast to his own ideas, which differed significantly from those of Freud. Alder believed people are motivated by striving for success, that it's largely responsible for whom they are, that a view of the future shapes present behavior, and that psychologically healthy people are consciously aware of what they are doing (Feist, Feist, & Roberts, 2013). I feel that Adler’s combat experiences serving as a physician for the Austrian Army on the Russian Front during WWI helped contribute to his later theories. These theories can easily be applied to the unique lifestyles of Quiet Professionals. Adlerian individual psychotherapy encourages clients to overcome their feelings of insecurity, develop deeper feelings of connectedness, and to redirect their striving for significance into more socially beneficial directions. Through a respectful Socratic dialogue, they are challenged to correct mistaken assumptions, attitudes, behaviors, and feelings about themselves and the world. Constant encouragement stimulates clients to attempt what was believed impossible. The growth of confidence, pride, and gratification leads to a greater desire and ability to cooperate. The objective of therapy is to replace exaggerated self-protection, self-enhancement, and self-indulgence with courageous social contribution (Alfred Adler: Theory and Application, 2019). I believe Adlerian individual psychotherapy combined with testosterone replacement therapy (TRT) for depression in conjunction with Low-T would be an effective treatment plan for our Quiet Professionals.

The Quiet Professionals have left their homes to live in a very different world known only to those of like mind and ability. They find the world as they knew it to be very different when redeploying stateside and ultimately returning to civilian life after discharge. Our society has evolved when it comes to personal wellness. There are wellness programs available now in the workplace to encourage better lifestyles such as weight loss and smoking cessation programs. With all the resources available to civilians to improve their mental health we have neglected the needs of these Special Force’s Operators; largely in part because society does not understand what these needs are. A wellness program, which includes low-testosterone screening and treatment, should be made readily available to them when they leave military service. They should be made to feel just as comfortable seeking assistance for depression and low testosterone as a civilian would feel seeking help for a weight loss program.

Part of the ARSOF vision is that:

We must recruit, train, and retain the very best talent available. ARSOF succeeds because of the excellence and determination of our Soldiers. We exemplify disciplined, independent, intelligent, adaptable, and combat fit Men and Women. We value, more than anything, being trusted and empowered teammates. ARSOF must produce Special Operations Forces with the skills, cultural expertise, and education to excel in all operational environments. We value the strength of our specialized and professional civilian work force and remain committed to the world-class care of Soldiers and families. (Army SOF Vision, 2018)

The exploration at hand is important because twenty-two Quiet Professionals took their own lives in 2018 (Birkenbuel, 2019) and the relationship between Low-T and grave depression suggests that the connection between these two variables among Quiet Professionals’ is worthy of exploration more thoroughly in military settings. “People tell us, we are in charge of our careers, and the same should be said about our health care. There is so much that we, as Green Beret’s don’t know. (Quiet Professional #8)

Sincere appreciation to all those in the Army’s Special Forces community for their continuous feedback and support. This project would not be possible without them. De Oppresso Liber.

Author Note This paper was prepared for PSY495: Senior Capstone, a directed study mentored by Dr. Laliberte.

References

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Lacz, K. (2019, August 6). Fitness. Retrieved from The Havok Journal: https://havokjournal.com/fitness/the-signature-injury-of-the-war-on-terror-might-not-be-ptsd-it-might-be-low-t/

Logan, L. (2010, January 28). 60 Minutes. Retrieved from CBS News: https://www.cbsnews.com/news/green-berets-the-quiet-professionals/

Low Testosterone. (2019). Retrieved from Urology Care Foundation: https://www.urologyhealth.org/urologic-conditions/low-testosterone

Moore, R., & Sadler, B. (1966). Ballad of the Green Berets [Recorded by B. Sadler].

Special Forces. (2019, September 30). Retrieved from U.S. Army Special Operations Recruiting: https://goarmysof.com/specialforces/sfrecruiting.html