The truth about TRT therapeutic use exemptions

Robert Cianflone

What you need to know about how TRT therapeutic use exemptions are controlled to prevent cheating

This piece was written before the Nevada Athletic Commission voted to ban testosterone replacement therapy. Here's my thoughts on that; The NAC said themselves that a factor in them choosing to ban TRT was the cost associated with properly testing users as per the ABC guidelines (which are attached). Testosterone replacement therapy users are the most tested athletes in the sport, and anything that leads to less testing is a negative in my books. This article covers what commissions should be doing if they are following the guidelines, and why TRT TUEs don't lead to an unfair advantage when these guidelines are followed.

Testosterone Replacement Therapy is getting a lot of attention just now, including in an ESPN OTL piece recently published by Mike Fish and Josh Gross, both of whom do great work. It's definitely worth a read.

That being said, I felt like it didn't do a great job of educating the reader about how TRT therapeutic use exemptions are actually supposed to be handled by competent commissions. Whether or not all commissions do everything they should is certainly up for debate, but understanding fully what commissions are supposed to be doing, and what the best commissions are doing, is vital when forming an educated opinion on the matter.

I have written extensively on the subject, including original research, and have interviewed people from Keith Kizer to Nick Lembo and ABC doctor Sherry Wulkan in the past while trying to get the best and most accurate information on TRT use in MMA possible.

I have presented, in a Q&A format, the issues I most often hear raised about TRT and the answers are based on the information I have been provided from people who actually set policies and handle the testing for this issue in commissions.

Q: Isn't TRT the same as doing steroids?

A: Testosterone itself is a steroid. You could even call it the steroid. That's where this statement of "TRT is legalized steroid use" comes from. It differs from what you would consider traditional steroid use in two ways, though. Qualification for receiving treatment, and the ‘advantage' from the treatment.

Q: How does a fighter qualify for TRT? They just have a doctor say they need it and the commission gives them an exemption, right?

A: Nope. To qualify your natural levels must be below 300ng/dL. You have to show three separate baseline levels below this number. The number can vary slightly depending on the lab, but in all cases the result has to be at around that level. Having "low-normal" levels of testosterone does not qualify you, even if a doctor claims it does.

Having "low-normal" levels of testosterone does not qualify you, even if a doctor claims it does.

To quote the guidelines: "Results should demonstrate T levels consistently below the low normal value for the reference laboratory" (emphasis mine).

Keith Kizer informed me he had denied several TRT TUE applications because the recipient had baseline levels considered low-normal. While an anti-ageing doctor might feel that's enough to prescribe you TRT, it's not enough to get a TUE. Dr Sherry Wulkan of the ABC informs me that all commissions are given the same guideline to follow on this.

Dr Wulkan spells out the ABC's policy on "low-normal" results in no uncertain terms:

Low normal is still normal. Each individual has a biological passport and different normal levels of testosterone. Such is why there is a range of normal levels. Thus, a candidate must consistently test shy of normal range; not low normal to be eligible for a TUE.

Nick Lembo points out that New Jersey has only ever given one initial TRT therapeutic exemption, to Nate Marquardt, which was subsequently revoked when he failed one of the conditional tests. They have also given exemptions to Chael Sonnen and Frank Mir, based on exemptions originally granted in Nevada/Illinois/Texas and Nevada/Wisconsin, after additional testing and endocrinologist documentation.

In jurisdictions like New Jersey, where the ABC guidelines written by Dr. Wulkan are properly followed, over a dozen fighters have been refused exemptions, compared to just one fighter granted an initial exemption (which was then revoked). A doctor saying you need TRT is not enough to get you a TUE from a commission properly following the guidelines.

Q: But once you qualify you can just take a bunch of it and cycle off before your fight, can't you?

A: Nope. Competent commissions will test you several times, both your blood and your urine, leading up to a fight if you receive a TRT TUE. In addition, in at least New Jersey, your dosage has to be set by an endocrinologist, not your general physician.

Competent commissions will test you several times, both your blood and your urine, leading up to a fight if you receive a TRT TUE.

On top of this, your levels have to be below 700ng/dL even during treatment. For reference, the range considered "normal" by the national institute of health is 300ng/dL to 1000ng/dL. Even while you're receiving treatment your levels can't reach the high end of normal, let alone give you an abnormal boost. Basically as soon as a patient is injected with testosterone, their levels begin dropping back to their baseline level. This means even if a fighter gets the perfect dosage and gets to 700ng/dL, they will spend the next week, or longer (depending on the frequency of their dosing) with levels below that and dropping.

Q: So fighters on TRT get tested more often and in more effective ways than other fighters?

A: Yes. A fighter on TRT in a competent jurisdiction like New Jersey will be tested at least three times leading up to and on the night of the fight while on TRT, including both blood and urine tests. A fighter not on TRT will typically be tested once, on fight night, via urine.

Q: I read that fighters don't even get informed if their opponent is taking TRT, is that true?

A: Generally, yes. When a fighter receives a therapeutic use exemption for any substance, it is treated as a confidential medical issue. Different states and commissions may have different procedures for how medical issues are handled.

Q: Way more mixed martial artists are taking TRT than should be, though. Right?

A: That's really, really hard to determine when the numbers involved are so small. The ESPN piece put the number at 15 mixed martial artists from 20,000. That's an incidence rate of 0.075%. That's not an alarmingly high number.

The ESPN piece put the number at 15 mixed martial artists from 20,000. That's an incidence rate of 0.075%

Nick Lembo of New Jersey informs me that since January 2008, New Jersey has given 3 therapeutic use exemptions, one of which was subsequently revoked. The other two exemptions were originally granted in other jurisdictions and were honoured by New Jersey after additional testing and endocrinologist documentation. In that time period, it has had 4,930 mixed martial artists compete. That's a 0.04% - 0.06% incidence rate. Or a 0% incidence rate in terms of fighters getting their first ever exemption from New Jersey. Again, it's hardly an epidemic, and when you're dealing with numbers in the single and double digits, it's almost impossible to separate statistical significance from the noise.

Q: So the TRT situation is fine, then?

A: Well, no. While I believe the way commissions such as New Jersey handle the issue is commendable, that doesn't mean all commissions are as thorough as they should be. It also doesn't mean international commissions are following the same rules and standards. The increased testing and the strict limits imposed by competent US commissions should be applied to all fighters.

There is a further issue with this. If a less than competent commission gives the initial TUE and handles the initial testing requirements imperfectly, it becomes more difficult for future commissions to properly determine whether or not a TUE is appropriate without requiring an athlete to stop treatment for several months. As a result, it appears that even competent commissions are more likely to give an exemption to an athlete with a pre-existing exemption than they would be to an athlete applying for the first time. Obviously, that's a problem, but it's one that can be solved via commissions being held to higher standards.


In addition, epidemiological studies need to be undertaken to help identify the underlying causes of "idiopathic" hypogonadism, in my opinion. At the moment there are several theoretical causes of low testosterone that are used to explain the relative prevalence in MMA; rapid weight loss and trauma to the back of the head, for instance.

Much like the way CTE was very poorly understood for decades until funding for better tests and studies was put in place, I feel like studies examining the effects of drastic weight cutting and the effects of trauma to the back of the head should be conducted to help determine the effect these issues have on the HPA axis, the endocrine system and the health of the athletes involved in general over long timescales.

TRT gets the headlines, but what gets overlooked when that happens is the standard of the testing most commissions have on the other fighters. The blood and urine testing fighters receiving TUEs undergo? In an ideal world, all fighters would undergo that. Out of competition testing is the direction the sport needs to move in if it's serious about countering PED use. The guys on TRT are already getting extensive testing to ensure they're playing by the rules and within normal limits. The guy superdosing on steroids isn't. That's insane.

Nick Lembo provided me with a quote expressing similar feelings:

If I was a manager of a fighter and concerned with PED abuse, I might prefer to fight Vitor Belfort on a TUE, if in a major jurisdiction, due to the amount of testing and scrutiny that Belfort will be subject to. Belfort is very likely to be drug tested far more and scrutinized much closer than any other fighter. The issue is to ensure adequate drug testing for all contestants along with rigorous requirements and adequate monitoring of those with TRT TUE's.

Here's the thing. Are there guys trying to cheat by doing TRT? Probably, but in the jurisdiction of a competent commission, he's running a huge risk of getting caught. A much higher risk than if he just cycled steroids without ever trying to get a TUE. Handled properly, there's no advantage for a guy taking TRT. There just isn't.

That's borne out by their record in the ring. To use the fighters who competed in New Jersey as an example, two of the three fighters given a TRT TUE (Mir and Sonnen) lost their bouts. Marquardt won his against a replacement opponent (though his exemption was later revoked.) The winning percentage of guys taking TRT is not impressive. If it's a form of cheating, it's an exceptionally ineffective one.

People talk about it being some sort of fountain of youth. The average guy in his mid-40's will have T levels of about 600ng/dL. If you're on TRT, your levels will be below that most of the time anyway. You're just not getting some huge advantage. You're not.

There you have it, my attempt to give you the facts about what getting a TRT TUE in MMA actually does. Hopefully it's all in a simple, easily digestible form that allows you to better form an educated opinion on the matter. The articles and interviews linked at the start are a great place to get more detailed information if you want to dig into it some more, and you should definitely read the ABC TRT Guidelines.

I want to give special thanks to Nick Lembo and Dr. Sherry Wulkan of the New Jersey Athletic Control Board for making themselves available to answer questions I had while putting this piece together.

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