Dr. John Pierce, a Las Vegas-based anti-aging doctor, has heard from several fighters who say they’d rather go to the black market for performance-enhancing drugs than get a therapeutic-use exemption (TUE) for testosterone.

But now that the Nevada State Athletic Commission has closed the TUE program for testosterone-replacement therapy (TRT), he believes everyone will go the illicit route.

“What they’ve in essence done is taken people that were forthright about their usage of testosterone for a medical purpose and punished them for it,” Pierce told MMAjunkie. “That makes no sense because, bottom line, it’s going to happen.

“Instead of having a physician involved in the care of a patient – monitoring their levels, where you’re getting a test all the time, much more so than you would a normal patient because of the nature of their work – you’re going to get people doing it underground, using black market steroids, not bio-identical hormones that have not been tested. They could potentially get themselves sick injecting themselves with whatever.

“And then, at that juncture, they’re cheating because they’re not being forthright about it.”

Among thousands seeking a license to fight in the state, the NSAC has issued a total of six exemptions to MMA fighters over the past seven years until its decision this past month to ban them outright. The regulatory body also turned away several fighters who sought a TUE as the exemption process became more public – and more controversial. There was, however, widespread belief in the MMA community that prior to the ban, the NSAC was helping to legitimize the use of a performance-enhancing drug.

NSAC’s TRT ban sets off dominoes

NSAC representatives repeatedly defended the practice of granting exemptions in the past, citing safeguards to avoid abuse, but they starkly reversed course in the recent meeting that produced the ban.

Asked whether the NSAC’s now-shuttered exemption process had steered athletes from the black market to above-board medical professionals, Pierce, an emergency medicine doctor who heads Las Vegas’ Ageless Forever clinic, initially said, “It had the potential to do that, and in my experience, it did do that.” He then clarified that he hadn’t explicitly treated any fighters in such a situation, but he had spoken casually about it among Las Vegas’ large fight community.

“I actually have had people tell me that doing it the illicit way was much easier,” he said. “They wouldn’t even consider doing it the legal way, because it would be much easier to do it the illicit way. They wouldn’t be under as much scrutiny.”

In the wake of the NSAC’s bold move, prominent athletic commissions have pushed to decide where they stand on TRT. California’s athletic commission recently placed a temporary ban on exemptions with the aim of revising their policy to make exemptions more difficult to acquire. The Brazilian MMA Athletic Commission, the country’s regulatory body and whose medical director has worked as an advisor to the UFC, said it will shut down the process after TRT user Dan Henderson fights Mauricio “Shogun” Rua at UFC Fight Night 38 on March 23. The New Jersey State Athletic Control Board and Association of Boxing Commissions have expressed confidence that the existing protocols are sound.

Industry-leading MMA promotions UFC and Bellator have backed the ban. UFC President Dana White openly celebrated the decision, saying that TRT “needed to go away.” Meanwhile, for at least two fighters, including one linked to Pierce, the decision has presented a crossroad as they decide whether they’ll continue their careers without the controversial treatment, and how.

The focus on Belfort

Shortly after Nevada moved against TRT, another public user of the treatment, Vitor Belfort (24-10 MMA, 13-6 UFC), was removed from a UFC 173 title fight against middleweight champion Chris Weidman (11-0 MMA, 7-0 UFC) and replaced by Lyoto Machida (21-4 MMA, 13-4 UFC). Belfort asserted he will fight the winner of the bout.

Pierce’s name came to light in a story on therapeutic exemptions for ESPN’s “Outside the Lines” when Belfort referred to him on questions about his testosterone use. Pierce told MMAjunkie he could not confirm he treated Belfort due to medical privacy laws and said he merely spoke in general to ESPN about treating a patient who was hypogonadal, or lacking the ability to naturally produce testosterone.

“I said ‘if I had a patient that’s hypogonadal, than that’s what they’re being treated for: hypogonadism.’ What the reasoning is, sometimes, you can’t figure that out,” Pierce said.

The doctor’s stance on TRT nonetheless has placed him at odds with the Nevada commission, whose medical consultant, Timothy Trainor, advised a previous TUE applicant to see another doctor and informed the UFC that he didn’t trust Pierce.

In the ESPN story, Trainor said Pierce failed to submit proper paperwork when UFC heavyweight Frank Mir applied for a TUE for UFC 146. In a previous interview with MMAjunkie, former NSAC Executive Director Keith Kizer said the doctor pushed back after the NSAC recommended the fighter maintain a more conservative level of testosterone in his system. Pierce disputed Kizer’s recollection and said he generally only recommends that his patients stay within the ranges recommended by drug-testing laboratories.

At the NSAC meeting that led to the TRT ban, Trainor told the commission that legitimate cases for the treatment were rare and there was a potential to abuse the exemption process. He said it was medically proven that prior steroid abuse could cause low testosterone, and he expressed doubt that repeated head trauma caused a deficiency, as Pierce asserted in the ESPN story.

Pierce disputed Trainor’s statements, saying the link between previous steroid use and low testosterone was “the biggest crock of nonsense I’ve ever heard.” While he backed the work of a colleague whom he said is working on a National Institute of Health-backed study that links head trauma to low testosterone, he said it was only one possible cause.

He openly questioned why Trainor, an orthopedic surgeon by trade, had such a central role in the testosterone policies of the NSAC and disputed the notion that prior steroid use set fighters up for TRT. He also reacted strongly to reports that the ban was put in place, in part, because exemptions were a drain on the NSAC’s resources.

“If that’s the case, boy, that’s terrible because that’s what the commission is there for,” Pierce said. “If they’re saying, well, what the hell are you doing? Maybe bring Keith Kizer back because he wasn’t afraid of that work.”

NSAC chair Francisco Aguilar and Trainor did not immediately respond to MMAjunkie’s request for comment.

Pierce on misconceptions about TRT

Pierce said there are widespread misconceptions about the process and effects of hormone-replacement therapy and called the NSAC’s ban a “shortsighted” decision based on a lack of understanding. He particularly took umbrage to the idea that fighters needed the treatment because of prior steroid use.

“If any of these people that are saying they have any experience dealing with people who’ve done steroids in the past, you can get their systems turned back on, unless they’ve done high dosages for years,” he said. “Then, I’ve had very difficult times getting their system back on. But for the majority of people, they can be on testosterone, and you can take them off and get their natural system producing right back to normal within six weeks.

“So it’s laughable when I read some of the stuff that you guys write. People that are naysayers go, ‘If he did steroids, then that’s why he has a low level.’ Well, no, because No. 1, you guys don’t know how to read the labs. I do. And you can see the other hormones that are being sent from the brain down to the testicles to get them to work, and they’re not working. It has nothing to do with steroid use in the past.”

As to whether the commission should approve testosterone use for someone whose deficiencies may have been caused by fighting, he said regulatory bodies can and should make sure that a combatant is healthy enough to compete.

“They get cleared by the commission,” he said. “If the the commission wants a CT scan, then that’s what they should require. I’m treating an aspect of it. Just like if a guy broke his hand, he would go see an orthopedic surgeon. What if he has something else? [The doctor] is just treating the broken hand. I can’t comment on something. If head-trauma causes [testosterone deficiency], I’m treating the [testosterone deficiency], not the head trauma.”

Belfort recently posted a statement from an unnamed doctor that said the fighter would need 90 days to adapt his “treatment and nutrition in order to support his extremely hard training routine.” Pierce, however, estimated the process would take between six and seven weeks.

“After that, in his unique situation, he’ll be left with whatever amount that he can produce,” he said. “Testosterone isn’t the only thing in the world to make a fighter a fighter. There are women fighting, and they don’t have a lot of testosterone. He’s a well-rounded and experienced fighter, so I’m sure he can compete.”

The UFC, meanwhile, is taking a hands-off approach to the issue. White said the question of whether Belfort can continue to compete or needs to hang up his gloves is not his problem.

“Is [Belfort’s] level of performance going to drop? I don’t know,” Pierce said. “That all depends on his training. Does testosterone help? Absolutely. Can he still function and perform? Absolutely. Will his testosterone levels be where they were when he was on testosterone therapy? Who knows. The idea is that if he’s truly hypogonadal and incapable of producing that on his own, and he needs exogenous testosterone to maintain a decent level, then he won’t be able to get to those levels. So there’s going to be some adjustment. But as with anybody in the world, we have the ability to adapt.”

Pressed on whether Belfort should compete, however, he added that if the fighter’s levels were below those accepted by endocrinology experts, “he or anybody is at a marked disadvantage, in my opinion.

“Everybody who likes NASCAR, it would be like when you start with NASCAR, this is car that you can get, and you can’t change it. So 10 years down the road, the new rookie comes in, and he’s got a car that’s brand new, and you can’t beat him. Why? I’m a better driver, I’m better than everybody. He’s got a better machine. To me, athletes are machines. You’re asking for a high level of performance from them at all times. It makes it more difficult for them, but it doesn’t make it impossible.

“I truly hope for [Belfort’s] sake that he can compete at the same level, and then all the naysayers can just button their lips and say no more. Because it seems to me that everybody’s trying to take away from this particular individual’s accomplishments, and all the time and effort that he’s put into his career.”