PEDs aren’t likely to lead to deaths in MMA, but these things might

A year or so ago, Georges St-Pierre claimed an opponent being on PEDs was like allowing them to bring a knife into the cage. In a recent interview with Ariel Helwani, Mark Hunt compared it to having a gun in the cage. Esteemed sports journalist Kevin Iole, claimed a fighter facing someone on performance enhancing drugs is "a fatality waiting to happen."

This idea that performance enhancing drugs are turning fighters into potential killers is widespread, but it's just not backed up by the evidence. The claim seems to be that taking steroids will allow fighters to be stronger and hit harder, to the point they could kill someone.

If this is a serious concern, why is there no outrage over the fact that some men will naturally have over 3x more testosterone than others? In most labs a "normal" result for total testosterone is between 300 ng/dL and 1,000ng/dL. Why isn't a fighter who naturally has three times the testosterone of his opponent also seen as having an advantage equivalent to bringing a knife or gun to the Octagon?

Several fighters have shown testosterone levels below 300 ng/dL, and qualified for testosterone replacement therapy (TRT). From what I can tell, USADA do not give therapeutic use exemptions for TRT to UFC fighters. Nor do some of the major commissions. This means fighters with testosterone levels below, for instance, 100ng/dL will fight men with 10x more testosterone than them. That's well above and beyond the difference between the average fighter and one taking steroids.  Why is there no outcry over the safety of those fighters with low testosterone?

Let's examine it from a perspective of pure biology; performance enhancing drugs, even the most powerful steroids, do not magically allow you to have your muscles be capable of more, pound for pound, than another person's muscles. What this means is if two fighters have to compete at roughly the same weight, which everyone outside of heavyweight does, PEDs won't make one fighter stronger than another.

PEDs can make it easier to gain and retain muscle, or train for longer, or even compete at a high pace for longer, but if two guys weigh 170lbs with the same amount of lean muscle mass, steroids won't make one guy stronger. It also won't make them able to hit hard enough to kill their opponent if they weren't already capable of doing so.

The evidence shows that PED use only has a small effect on a combatant's success in the cage. In fact, it showed that fighters taking performance enhancing drugs, excluding marijuana, actually lost more often than they won in the fight they were caught using PEDs.

The analysis examined 41 fights which a fighter failed a drug test immediately after. Of those 41 fights, the record for the PED user was 13-27-1. That means the fighter taking performance enhancing drugs actually lost 65.9% of the time.

It's hard to make broad assumptions on data like this due to the sheer number of confounding factors in MMA. Everything from fighters being more likely to go on a losing streak as they get older, to facing different levels of competition, to the effect a suspension has on their abilities when they return.

All of that being said, the data shows in the five fights prior to being busted for non-marijuana PED use, the average win-rate was 69%. Afterwards the win-rate was around 52%. Making the assumption that fighters were on PEDs for 5 fights before being caught, this suggests that a PED user will win roughly 1 fight in 7 more than they would have without PEDs. 17% more likely to win. If PEDs can't even guarantee a win, why do we think they are uniquely dangerous to opponents' health?

If fighter safety is something you are genuinely concerned about, and I am, you quickly realize there are much more dangerous aspects to the sport. I'm not referring to the fact that being punched in the head is inherently dangerous, I mean facets of MMA which could be changed to make the sport safer.

Erik Magraken compiled a list of the 14 deaths in MMA immediately surrounding a bout. Of those, four deaths appear to be directly related to weight-cutting and seven were caused by brain trauma. All of the fighters who died following brain trauma had also, apparently, cut weight before the bout. From what I can tell, none of the fighters involved failed a test for performance enhancing drugs. In fact, I am unaware of a single fatality or major brain injury in MMA being caused by a fighter who has subsequently failed a PED test at any point.

That's not to say a fighter taking PEDs poses absolutely no more danger at all than a fighter who is on performance enhancers. It depends on what kind of PED being taken, of course, but PEDs can allow fighters to hit harder, move faster and fight at a high pace for a longer time, as well as train more often. That combines to make a fighter taking PEDs a little more dangerous than they otherwise would be. In terms of increasing the likelihood of a fatality, though, PED usage pales in comparison to these issues:

Weight Cutting

Weight cuts gone wrong lead to hospitalization for fighters far too often. Daniel Cormier damaged his kidneys trying to make weight for the Olympics. The NCAA overhauled their weight cutting regulations when three wrestlers died in a six week period, due to weight cutting complications. Johny Hendricks, Ulysses Gomez, Dhafir "Dada 500" Harris and Zoila Frausto are just some of the well-known names in MMA to end up in hospital because of complications related to weight cutting.

It's very likely that cutting weight also makes a fighter more vulnerable to brain damage. Dehydration not only shrinks the brain itself, it also leads to ventricular expansion which moves more cerebrospinal fluid into the skull and may increase the mobility of the brain. In MMA traumatic brain injuries are typically caused when a blow causes the brain to strike the inside of the skull. Dehydration can lead to the brain being more mobile, and less able to absorb the shock when it does hit something, which is not a good combination.

The danger weight cutting poses to the brain is becoming more apparent, and rule and regulation changes to help mitigate those dangers are being implemented. New Jersey has been consulting neurologists on the issue. Some commissions, along with the UFC, are having weigh-ins take place earlier in the day to allow for more time to re-hydrate. A fighter competing with even mild dehydration will almost certainly be risking more, and worse, concussions.

Prior Concussions

One of the best predictors of future concussions, both in terms of volume and severity, is the number of past concussions. Studies have found that an athlete who sustains a concussion is three times more likely to sustain a future concussion than an athlete with no history of concussions. Even when concussions were suffered months or years prior, there was still a strong correlation between number of concussions suffered, and the chance of suffering another concussion compared to someone with no history of concussions.

Research suggests that each concussion has long term or permanent effects on the brain. The damage sustained by each concussion is cumulative, and adds onto the damage suffered previously. The brain does not fully recover after a concussion, and is left more vulnerable to severe injury in future.

The more times a fighter is knocked out, the higher the risk of them suffering severe traumatic brain injuries in future. This risk is much more significant than the risk presented by an opponent using performance enhancing drugs.

Bad Matchmaking

The primary determining factor in whether or not a fighter will hurt another fighter is their relative skill. Two fighters who are evenly matched will be able, to some extent, to negate the offensive of each other. A fighter who is badly outclassed will be unable to effectively defend himself from his opponent.

If a fighter is able to land strikes at will, or is able to load up and land extremely powerful blows on an opponent who is unable to block them, they will do significantly more damage than a fighter on PEDs could do to a competitor who is able to at least partially block their strikes.

We often see fighters who have suffered several concussions in the past, sometimes the recent past, be placed in bouts against opponents who are younger, faster and more skilled than them. This drastically increases the odds of a fighter getting hurt.

It's also not uncommon for fighters to pad their records by competing against opponents who are drastically outclassed. For instance, recent UFC competitor Dmitry Smoliakov entered the Octagon with a record of eight wins and zero losses as a professional. His opponents in those eight bouts had a combined record of 20 wins and 26 losses. At the time he fought them, only two had a winning record. Two of his opponents have never won a professional MMA bout.

This kind of matchmaking is common at the regional level of MMA, and it is a significantly larger danger to fighters than PED using opponents. Strength and speed are only a part of being able to hit hard, a much larger part is technique. A trained fighter can hit harder than an untrained man with twice his strength. Two fighters with drastically different skill levels competing against each other is much more likely to end in a fatality than two evenly matched fighters where one happens to be on PEDs.

Poor Officiating & Cornering

We see fighters get knocked unconscious and then woken up by another punch all of the time. Good referees will step in the second a fighter falls unconscious, but a poor official might allow that fighter to continue. Fighting immediately after suffering a concussion is almost a guarantee that you will receive further traumatic brain injury.

Too often, we see fighters barely able to stand, wobbling around and moving just enough to convince a referee to allow the fight to continue. We saw this during a recent boxing bout between Chris Eubank Jr and Nick Blackwell, in which the latter took blow after blow because he never received a single punch powerful enough to render him unconscious. The result was him collapsing and being placed into a coma due to a bleed on his brain.

It's only a matter of time before we see something similar happen in a major MMA bout, especially with MMA corners being extremely reticent to throw in the towel, as a rule. This willingness to allow fighters to sustain many sub-concussive blows, each of which may be inflicting injury to the brain, is incredibly dangerous.

Referees failing to step in immediately after a fighter falls unconscious is a real problem. There is an infamous image of Dan Henderson landing a huge blow to an unconscious Michael Bisping. Blows like this, when a fighter's head is against the mat and they are completely unable to defend themselves, are uniquely dangerous, and referees must be vigilant and quick enough to stop fights as soon as one fighter is knocked out. Unfortunately, there are many poor referees, especially at the regional level, and a serious injury occurring or being worsened in a situation like this is an inevitability. It may have already happened in the case of fighters who have died following traumatic brain injury in MMA.

Bad Regulatory Policies

There is a standard set of rules governing mixed martial arts in the United States, called the unified rules of MMA. Basically every commission follows these rules with very few modifications. When it comes to regulating the medical requirements for mixed martial artists, though, there is no widely enforced minimum standard.

The medical requirements to be cleared to fight vary greatly by jurisdiction. New Jersey, which I consider to be perhaps the most competent commission in the country, requires:

Blood tests for HIV, Hep B & Hep C, valid for 6 months.
Fighters competing in NJ for the first time must also submit a blood panel of CBC and bleeding and coagulation.
A physical exam performed by a licensed M.D. or D.O. within the last six months
An dilated ophthalmological exam. Valid for 6 months.
An EKG, valid for 6 months
A CT or MRI of the brain from the last 3 years
Fighters over the age of 40 must also provide an MRI and MRA of the brain, a Stress ECho signed off by a cardiologist , and a Carotid Doppler.

By contrast, North Dakota requires the following:

Blood tests for HIV, Hep B and Hep C. Valid for 6 months.
A pre-fight physical.
No eye exam.
No EKG.
No radiological exam.
No neurological exam.
Fighters aged 35 and over "will be evaluated by the commission on a case-by-case basis."

As you can see, the potential for a fighter who should not be medically cleared to compete exists. Fighters who have brain injuries, or heart problems, or some other major health issue may be able to fight in jurisdictions which just choose not to bother checking for those things.

Lack of Medical Treatment at Events

In addition to there being no set minimum standard for what medicals must be passed in order to compete, there is also no enforced standard for what health and safety precautions promoters must take. Some jurisdictions require several ambulances on site, along with a set number of doctors and paramedics. Some commissions don't even require a commissioner on site.

In 2007 a fighter received a broken neck while competing in Iowa. There was no ambulance on site, and at the time Iowa did not even require an athletic commissioner be present. In any major medical emergency, the time it takes to receive treatment or reach the hospital is a major factor in the outcome. The risk of fighting is exponentially higher if trained medical personnel, and an ambulance, isn't available on site.

This non-exhaustive list of dangers to the health and safety of mixed martial artists is not intended to excuse the use of performance enhancing drugs. There are many valid reasons to campaign against the use of PEDs. I'm personally strongly against their use because no PEDs is the closest we can come to an even playing field, and I do not believe fighters should feel forced to take PEDs and take the health risks brought on by PED use, in order to ‘keep up' with opponents doing the same.

What this piece is intended to do, is highlight the huge discrepancy between the actual danger fighters on PEDs present, and the level of hysteria around that danger. There are many much more dangerous factors which don't get the attention PED use is getting, despite the fact they're objectively more likely to result in serious injury or fatality.

Hopefully, the attention and conversation on fighter safety can be steered away from the cause du jour of PEDs, and towards the more serious and dangerous issues of regulatory incompetence, promoter malfeasance and weight cutting risks.