If you are in the mood, check out my discussion with Dr. Rassman on Reddit about PFS. I am user ngc800. My comments in the tressless sub-reddit may get deleted as has happened in the past, so I repost them below. There are other users’ comments as well, which I omit here.
Warning: Don’t read this if you get triggered by such kind of discussions. I don’t mince words when I describe the reality of PFS. If you want to focus on positive or hopeful messages, you are better off not reading this.
Also, don’t accept your current state as a life-sentence as you may improve.
Rassman: Sometimes it takes a few months for things to calm down and your sexual side effects to go away. Wait at least 3 months off of the drug. As far as breast lumps, that may not go away and you should see your family doctor about it if its doesn’t disappear. What your doctor told you is totally unprofessional and if he didn’t know what to do he should have sent you to someone who could help you. I hope that this posting gives you hope.
ngc800: And sometimes sexual side effects never go away. Correct, doctor? No doubt of course this would just be in the victim’s head. After all, you have never seen it in your entire career…
Rassman: I believe that there is a condition call post-finasteride syndrome which means that the sexual side effects continue after stopping the drug. I have never seen it in thousands of patients because, I believe, I recommend stopping the drug when persistent sexual side effects occur.
William Rassman, M.D.
ngc800: I and hundreds of thousands of young men like me got PFS from a single pill, doctor - from the first pill. How would your self-rationalization deal with that inconveninient truth? Oh, I know how:
Denial.
Rassman: If that is true, I can’t understand the physiology of it. If there were hundreds of thousands of men suffering from PFS from a single pill, I would have seen it in my practice. A single pill? What is the mechanism for it? I am a clinical scientist and I look to science for answers to questions.
A physician wrote: “I have personally been taking finasteride for 14 years and will be taking it for the rest of my life. I have never had a patient in my practice have long term side effects from finasteride [he has prescribed it to thousands of men]. I have only seen a positive psychological influence on my patients’ lives since they realize they are slowing a progressive aging process. I would bet my retirement that there is a lowering depression/suicide rate for patients on finasteride compared to their peer group not on finasteride with similar Norwood pattern hair loss (if this study could ever be performed since there are so many confounding variables).”
All the doctors in my field are struggling with the PFS problem as you told us here. In my practice I have not seen PFS in my patients except one man who reported impotence within 2 hours of taking the first dose and I told him to stop it. Like the doctor I quoted above, I too have been taking finasteride for years with no ED or libido problems.
William Rassman, M.D.
ngc800: I see that you continue to deny PFS, as you have been for 20 years, although the nature of the denial has evolved to keep up with accumulating incontrovertible evidence. I understand that you have no choice but keep up some form of denial. The opposite would be to admit to the world and to yourself that you are responsible for the utter annihilation of thousands of young men, which is what PFS does. But the truth about what you must have done in your practice to countless innocent souls over the years will come out, hopefully within your lifetime.
That you haven’t seen a single case of PFS in your practice is a statistical impossibility. The only way to explain not seeing something that 100% must be there is if you are not looking. Also, very few patients go back to the doctors who prescribed them drugs that injured them, as they are usually faced with denial, dismissal or minimization of their condition.
Prof. Traish’s latest paper estimates that there would be between 900,000 and 1.6 million men with PFS only from finasteride and dutasteride prescribed for hair loss. The numbers for benign prostate hyperplasia would be much higher. https://www.sciencedirect.com/science/article/pii/S0015028219325993
Of these cases, no doubt a sizeable fraction were caused by the first pill of finasteride. This is how I got PFS - from a single pill. This is the tragic story of many others as well that I have been in contact with over the years. Many people don’t realize something is wrong for a while or just wait for it go away, as usually advised by doctors, but the damage was already done by the fist pill.
You claim you do not understand the mechanism behind PFS form a single pill. Do you understand the mechanism behind PFS from 10 pills or 100 pills? Your ignorance and willful blindness are the same either way, but your financial interest is not. If you can claim that people can avoid getting PFS if they stop taking finasteride when they have side effects, then you can continue to prescribe it and your conscience would be clear.
This is a really smart deception tactic indeed, even though it is based on neither theory nor evidence. You are lying to patients that they can avoid PFS if they stop the drug, which is not true, but also you are putting the responsibility on them to decide how bad their side effects are. If it turned out they got PFS then it must have been their fault for not catching it on the first day rather than on the third.
The reality of PFS is that the risk for the condition cannot be mitigated against. Small doses don’t cut it because the drug has a flat dose response curve and is almost equally effective at reducing DHT at 0.05 mg as at 1mg or at 5mg. I know people who got PFS from a quarter of 1 mg pill.
This is all very bad news for you because it means this drug should never be prescribed to anyone. A 1-4 % risk of PFS, which is a death sentence to a young man, cannot be rationally justified for a cosmetic indication. The only way to justify it is by employing deception tactics: minimizing the severity of the condition, expressing doubt or uncertainty about its existence, minimizing the odds of getting it, or coming up with a fake risk mitigation strategy.
You appear to employ all four of these deception strategies and this is how you convince your patients it is safe to take the drug. It should be absolutely clear however that your patients make no informed consent to take this drug, as they have not received accurate and complete information, including information that you yourself have or should have. In fact, no informed consent can ever be made about taking this drug, because it is simply impossible for a healthy person to imagine what it is like to live with PFS.
Many diseases don’t have clear etiologies but that does not make them any less real. Your apparent insistence that we understand exactly how Finasteride causes PFS before we accept it as real is particularly hypocritical considering that virtually no-one is doing research in this area because there is no profit to be made from it but only profit to be lost.
If you want to understand the etiology of PFS, how much have you donated to the PFS Foundation? Currently, the only people who are funding PFS research are the victims themselves, even though they can barely support themselves - not the doctors (you) or companies (Merck, Hims) that are profiting from their suffering.
Based on all the available evidence, the most likely etiology of PFS is that the gene for 5a-reductase type 2, SRD5A2, is epigenetically silenced in key tissues responsible for sexual function, including in the brain, through DNA methylation. Gene methylation is a well-described process that is known to occur with many genes and with this particular gene as well. If the right conditions are met, methylation can happen in seconds in millions of cells throughout the body. A single pill of finasteride can definitely trigger such a reaction.
Rassman: I do believe that PFS is a real entity; however, since neither I nor many of my colleagues have seen it, the frequency seems less than the 1-4% that you have referenced. If you think about it, why would I continue to prescribe finasteride as I don’t make any money from doing it and if I didn’t more of my patients would become surgical candidates and I would make more money. The answer is obvious, that the drug works for many men with minimal or no side effects and I care about the patient’s welfare. Impotence is common in men without finasteride on-board, about 20% in men in their 20s, 30% of men in their 30s, 40% of men in the 40% and so on. I appreciate the time you took to write this post to me, but although I believe that PFS does occur, it may not be as prevalent as you state.
William Rassman, M.D.
ngc800: I thank you for your time responding to me as well.
You benefit directly from prescribing Finasteride for two reasons.
First, even without the option of offering additional services, a doctor’s practice benefits if they can convince patients they have a valuable treatment option for them. Fewer people will go to doctors if doctors have nothing to prescribe them for their problems. Examining patients and writing prescriptions by itself increases the value of a doctor’s practice.
Second, and more importantly, prescribing finasteride increases the value of your hair transplant services as transplanted hair is retained longer. If transplanted hair is going to fall off at a higher rate without finasteride, people are going to value this service less. In other words, many people will decide there is no point to transplant hair at a high cost if the hair is gong to fall off anyway.
By prescribing finasteride and increasing the value of your service, you are able to charge a higher price for your work. What essentially happens is that a percentage of your patients gets destroyed by finasteride but on the flip side, by denying the damage, you are able to charge a higher price and also get more business. Ultimately, you make more money at the expense of mens’ destroyed lives.
As I said earlier, it is statistically impossible that with tens of thousands of patients you have not encountered PFS in your practice. This must be because you have not systematically attempted to follow up on your patients and measure in a reliable way PFS-related symptoms.
The prevalence of PFS I cited earlier is not something I just “state” but what’s been found in the literature. Based on the literature, Prof. Traish estimated the prevalence of persistent side effects at 3-5 %:
“It is not surprising that almost all studies published to date do report increased sexual adverse effects. However, even when such sexual adverse events were reported, many argued that the numbers of subjects afflicted are small and propagated the falsehood that the adverse effects do resolve with continued treatment. This is unfortunately a willful blindness and a deceptive method to continue to prescribe these drugs to unsuspecting young men. The number of subjects experiencing adverse events is neither small nor irrelevant, given the persistent nature of adverse events in susceptible individuals. For those individuals afflicted, this constitutes a life sentence of sexual dysfunction, depression and/or anxiety. To put this in perspective, approximately 30 million young men, worldwide, would be prescribed finasteride or dutasteride to treat male pattern hair loss. Even if the incidence of persistent sexual adverse events is 3% to 5%, which may be viewed as a small number, approximately 900,000 to 1.5 million men would suffer persistent sexual and psychiatric adverse events. By no means this would be considered a small number and should not be dismissed or ignored.”
Prof. Traish emphasized the serious conflicts of interests present in most studies. It is noteworthy how Merck fraudulently misrepresented the data from clinical trails of finasteride, as described in detail in this Reuters article - simply by dropping people with side effects from the treatment sample, which allowed them to fraudulently claim that side effects diminished over time.
A study by Prof. Belknap shows that adverse effects reporting in clinical trials of finasteride was inadequate. Prof. Traish agrees saying that “level of harm is tampered down significantly”:
“It is imperative that we consider how safety reporting of adverse events due to finasteride and dutasteride have been inadequate in most clinical trials (83, 84). Indeed, this inaccurate reporting of harm makes the evidence regarding the adverse events to be limited and may appear of poor-quality. Given the level of bias due to conflict of interest, it is not surprising that the level of harm is tampered down significantly.”
Your argument that impotence is common in men without finasteride as well is another deception technique employed by PFS deniers. This is accomplished by artificially boosting the control group (non-finasteride) symptom prevalence by claiming (or measuring that) sexual dysfunction occurs at a high rate in non-finasteride treated patients as well as failing to differentiate the severity of dysfunction between control and treatment groups. There is a very big difference between lower libido and weaker erection that almost any healthy man experiences from time to time and the permanent, unchanging and complete absence of libido and erection in PFS patients.
Finally, PFS is a lot more than “impotence”. This is where your systematic and deliberate minimization of PFS is very evident. PFS is the complete eradication of sexuality as well as any feeling of romantic attraction or ability to feel romantic love. This is a catastrophe for the cognitive architecture of a young person’s mind. Everything a young person strives to achieve in life or what actually makes life worthwhile is contingent on their sexuality - not being alone in this world, finding a partner, starting a family, having kids, leaving a legacy. All of this is virtually impossible with PFS.
A complete collapse of all drive and motivation ensues, followed by paralyzing anhedonia and the extinction of all emotions. This is a death sentence to a young person. Many people commit suicide but even if they manage to stay alive they drag themselves though life barely able to survive - without a career or any meaningful purpose to live.
I don’t even have to mention the myriad of other highly debilitating symptoms PFS brings - excruciating joint pain, neuropathy, shrunken and deformed genitals, dry skin, inability to concentrate, brain fog, etc, etc, etc.
