Earlier this year my MMA Sentinel co-host, Iain Kidd and I had a conversation with NSAC executive director, Keith Kizer who detailed the difficulty in getting approved for a TRT TUE, and the increased testing an athlete is subjected to after receiving one.
With the recent news that Antonio ‘Bigfoot' Silva failed his post-fight drug test at UFC Fight Night 33, despite having a therapeutic use exemption for testosterone replacement therapy, this seems like a good time to post the transcript of that conversation.
While the statements below apply specifically to the guidelines for Nevada, Marc Ratner informed us recently that the UFC looks to use the NSAC guidelines when regulating their testing policies and exemption policies, so some parallels can be drawn.
MMA Sentinel: Theoretically speaking, if a fighter has previously failed a drug test, would he still be eligible for a therapeutic use exemption if his blood work didn't indicate that his current low testosterone was due to prior steroid use?
Keith Kizer: Anyone can apply for an exemption. Whether they'll be granted one is, of course, a different story. The issue isn't so much failing a drug test previously, the issue is why do you now have low testosterone? If someone has failed a drug test for a drug that could cause a testosterone deficiency, they would have a much heavier burden, and I think it would be very difficult for that athlete to be granted an exemption.
As with all matters before us, we would give the athlete a fair and full opportunity to explain themselves and try to prove their burden. It's just that in this case, it would be a very heavy burden.
MMA Sentinel: Under normal circumstances I believe if the FSH or LH levels are low, then that's regarded as suspicious and you would dig a little deeper. Is there a heavier burden than that on an athlete who has failed a test?
Keith Kizer: All the people who apply have to turn in various blood tests showing their diagnosis. If we do grant a provisional approval, they then have to do various blood and urine tests on an ongoing basis before the fight, as well as after the fight. The night of the fight we give a urine test, and the morning after the fight a blood test.
We look at the LH and FSH levels, the hematocrit, the hemoglobin, the total testosterone and the free testosterone. The LH and FSH give you some clues, but unfortunately it's not definitive one way or the other. If someone had an FSH or LH level that indicated that perhaps the deficiency is related to prior PED usage, it definitely does increase their burden. If you combine that with a failed test in the past for PEDs, it makes it really, really difficult.
MMA Sentinel: Do you happen to know the cutoff limit for total testosterone in terms of ng/dL?
Keith Kizer: The cutoff is under 300ng/dL. One of the misconceptions is where can you be with treatment. The average, normal amount is somewhere between 300 and 1100, or 350 and 1050, depending on the lab; there's some dispute about how low should low be and how high should high be. We expect, with treatment, at best you should be somewhere in the 600's. Most of the time they're still in the 400's or 500's, or even 300's. We've had athletes who compete here on TRT and their blood levels don't get any higher than the 300's, but that's better than being in the 100's.
I don't think people understand that not being on TRT if you need it can lead to serious health problems. It's not a matter of, as I see from some people in the media, these guys are doing this TRT to get an advantage. Well, no. They're doing TRT because without it they could get very, very ill, regardless of whether they're an athlete or not. There is a concern obviously that if they do too much of it, they could get an advantage. So, even with the TRT, they're going to still be, at best, on the low end of normal. They're not going to be able to get to the high end of normal. If they do, they're not going to be competing.
It helps to have the levels before treatment showing they're below 300, but also to have the levels after treatment showing they're going to be on the low end of normal for their age group.
MMA Sentinel: How many tests would an athlete generally have to take, if they're on TRT to have a TUE.
Keith Kizer: Usually for pre-treatment, when they're in the diagnostics stage, we want to see at least two tests. Most of the time we get several tests, but we want to see at least two tests done in the morning showing the deficiency. Again, we're looking at all those things; Total test, free test, LH, FSH, hematocrit and hemoglobin. We look at those same things during the treatment, and we also take a urine sample every time to see if they're taking any type of PEDs, so they're actually doing urine samples as well as the blood test when they get tested during treatment, including being tested both fight night and the day after.
That's multiple times. We haven't had any fighters with a TRT exemption for over a year, but I can tell you when we had a gentleman last July, I think in that case it was Sonnen and Griffin, and we had Mir a couple of months earlier, they did three or four different tests leading into their fight.
MMA Sentinel: Under USADA guidelines, there is a very specific list of organic etyologies, or reasons, they will accept for low testosterone. From browsing the ABC documents, that doesn't seem to be a requirement. It seemed that as long as the levels are low and the doctor can say "it's probably because of this" it doesn't require supporting evidence of a physical cause. Do Nevada require proof of a physical cause?
Keith Kizer: The problem with low T issues, is it's almost impossible in some cases to determine what the actual cause is for that actual athlete. There's obviously a lot of things out there that could cause low testosterone. One of the big things is weight cutting. I know a lot of people like to compare and contrast with the NFL; first off, the NFLs records aren't public, so I don't think they're obligated or up front about all those people being treated with TUEs. Secondly, they don't have the issue of weight cutting, which my understanding from speaking to the experts, is one of the big causes.
Some people say, ‘if the body won't allow it, then the athlete should just hang them up.' Well, would you say the same thing to a kid in little league who is a diabetic? That he shouldn't be able to play baseball because he needs to take insulin? It's just not a well thought out argument or position to have.
On the flipside, make no mistake that we all know that if it's abused, it could give the fighter an unfair advantage and put him at undue risk of certain conditions including cancer and heart disease, so it's something that we take very seriously. We've only had, I think, six cases in our history. You're talking six cases out of over 6,000 athletes, so you're talking less than one tenth of one percent, which is much lower than the incidence rate in the general population for men of the same age. It's very rare, and I'm surprised we've only seen that many. Six men in the last 10 or so years since this stuff has been around have been granted an exemption.
We've had some athletes come before us whose non-treated T level is above 300, and I tell them, ‘hey, good news for you, you don't qualify!' but they have a doctor telling them, ‘oh you have to get on this stuff, just pay me a bunch of money every month.' The doctors have their hand out, just looking out for their own pocket book, and it's unfortunate. I don't think the athlete is trying to do anything wrong; he's been told by his doctor that he needs it, and he is on the low end of normal, but he's not abnormally low. You see some of that come into play, and I don't blame the athlete for coming to me and asking if it's something I can get. I tell them, ‘no, it's good news. It's a positive thing. You're not below normal.' If they're in the 400's or 500's, that's where these guys in the 100's or 200's would be after treatment. It's not like with treatment I could be at 1000, but without it I'll be at 500. No. You're going to be at 500 either way.
MMA Sentinel: When you're talking about the guys having at least two tests, preferably several, coming in with a diagnosis of low T, are those tests specifically done by their own physicians, or do you require your own physicians to do a test?
Keith Kizer: Those tests are done by their physicians. Their physician has to send the documentation confirming the diagnosis, as well as provide us with information regarding the proposed treatment plan; the diagnosis, the dosage, all of that. Our doctor talks to their doctor. If our doctor requires additional tests pre-treatment, we order those as well. Then we control the tests after treatment.
MMA Sentinel: Are you able to give a rough number of MMA athletes who have approached you for a TUE, or applied for a TUE, and have been rejected?
Keith Kizer: Since about 2007 or 2008 when we started dealing with this issue, you're probably talking maybe a couple of dozen. We've not had any athletes in the last year who have competed under a TRT TUE. In those 12 or 14 months, I've probably had two or three athletes even approach me. In some cases, when fighters fight elsewhere, such as when Sonnen fought in New Jersey, they will contact us and say, ‘can we get what he has done so far?' and vice-versa, so it helps to have that line of communication with the different commissions.
MMA Sentinel: Do the commissions typically accept results or exemptions from other athletic commissions, such as from Brazil?
Keith Kizer: Well, the exemptions are from us. The exemptions between commissions aren't transferrable. I would expect to get all of the information that they have that is relevant for us to look at, with an onus on the athlete to get that information. That is one of the questions we ask, even more so than WADA asks, we ask not just whether they have applied and been granted an exemption elsewhere, we also ask if you've ever failed a drug test for PEDs, and whether you've ever taken PEDs regardless of whether or not you've ever failed a drug test.
That information is submitted to us under oath in an affidavit. As you know, Marion Jones didn't go to jail because she failed a drug test; she never failed a drug test. She went to jail because she lied to the government. In the last four or five cases we have these affidavits on file, and if something ever changes with these guys I'll be sending them to the district attorney's office. So, there are other components to it than just the medical, but the medical is by far the most important part of the process.
MMA Sentinel: Has there ever been a situation where you have asked a fighter to undergo additional blood tests because the information they have is old, or from a source you may consider unreliable?
Keith Kizer: Yeah, there have been times when they've done their blood tests in the late afternoon or something, and it's like, ‘no, you need to do that in the morning before 9am,' or whenever the cut off is. So there have been situations like that, or when there's maybe only one test and we want more than one test to make sure it wasn't just a low day for the athlete, especially if they're close to the 300 mark. Sometimes they're in the 100s, and then, of course, when they do get an exemption we do several blood and urine tests leading up to the fight to ensure that even if they're entitled to the exemptions, they're not super-dosing.