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By Zach Arnold | February 4, 2014

I’ve had the opportunity to work with several different young writers, some in high school and some in college, on suggestions and interviews for term papers on the topic of anabolic steroid usage in combat sports. The universal conclusion amongst these young writers is that the permission slips for fighters to use anabolic steroids is a scam.

One writer in particular, Joshua Rothstein (e-mail here to contact) in New York City, recently finished a term paper on this very topic and I think it deserves a read from everyone.

Why Testosterone Replacement Therapy Should Be Banned In Mixed Martial Arts

By Joshua Rothstein

It is shocking that in the sport that is considered by many to be the toughest in the world, the same sport that was once advertised as “having no rules” and is defined by masculinity, fighters have begun to request additional testosterone to help them fight. The sport that I am talking about is Mixed Martial Arts (MMA). Like in most sports, MMA competitors are always trying to gain an advantage over their opponents, and Testosterone Replacement Therapy (TRT), is the newest legal medication fighters are using to bolster their performance.

In the beginning of the Ultimate Fighting Championship (UFC), events were advertised as having no rules and were very unsafe. In fact Senator John McCain once led a campaign to ban MMA nationwide and called it human cockfighting. This forced the UFC to adapt and create a safer sport, and for the most part they have succeeded in this regard, as modern MMA is safer than it has ever been. Head butts, hair pulling, eye poking, and groin attacks are all banned, there are significant medical requirements competitors must fulfill to be able to compete, and doctors can ends fights whenever they feel it is appropriate. While it is true that MMA is a lot safer than it once was, the reality is that MMA is a brutal contact sport that causes significant damage to fighters. In order to survive the sport needs to constantly evolve and change to protect the safety of all competitors, and the next step in creating a safer sport is banning TRT. TRT should be banned due to the health risks associated with the treatment and because it puts fighters in a very vulnerable position to sustain significant brain damage.

Introduction to Testosterone and Low Testosterone: Testosterone is a hormone produced by the testicles that is responsible for the proper development of male sexual characteristics. Testosterone maintains muscle bulk, adequate levels of red blood cells, bone growth, and bone density, and it naturally decreases with age. Low testosterone is known as hypogonadism and is caused by many things, such as injury or infection to the testicles, obesity, stress, alcoholism, dysfunction of the pituitary gland, and steroid usage. Symptoms of low testosterone include decreased muscle mass and sex drive, depressed mood, difficulties with concentration and memory, and erectile dysfunction. Testosterone replacement therapy can treat hypogonadism, and people can get this therapy in a number of ways, including intramuscular injections, testosterone gel, and testosterone patches. TRT has been considered to be relatively safe for a long time, with minor side effects such as acne or oily skin, decreased stream or frequency of urination, breast enlargement, decreased testicular size, aggression, and increased mood swings.

Why do Fighters Want TRT? The three main reasons fighters want TRT are declining performance as a result of testosterone decreasing in the body, brain damage, and previous steroid usage. As previously stated, low testosterone causes a decrease in muscle mass and bulk, and one of the responsibilities of testosterone is creating red blood cells, which transport oxygen and carbon dioxide in the body. Nucleated red blood cells increase the workload of the heart by about twenty percent. When people have a low red blood cell count, the symptoms include tiredness, shortness of breath, and dizziness. Since testosterone decreases with age, as fighters get older they are unable to perform like they used to. Current UFC fighter Nate Marquardt wanted TRT because he was feeling “tired and moody” and felt that this was hurting his fighting ability. Low testosterone occurs when there is a signaling problem between the brain and the testes. In fact Ben Rothwell, a UFC fighter with hypogonadism, started using TRT after doctors diagnosed with him hypogonadism that was caused by a car crash that left him with severe head trauma and in a coma; because doctors told him TRT was something that could stop the disease from degrading his body. As mentioned above one of the causes of low testosterone is previous steroid usage, and there have been many cases of fighters requesting to use TRT after previous failed drug tests.



How do fighters get permission to use TRT? When fighters compete in sanctioned MMA events they are required to receive a license from the state athletic commission overseeing the event. To receive permission to use TRT, fighters must also apply for a Therapeutic Use Exemption from the same commission. The first step in this process is general informational paperwork. Next, the fighter’s doctor performs tests to determine if he needs TRT. Following this, the doctor makes a recommendation to the Executive Director of the athletic commission, who then chooses whether or not to grant the exemption. The Commissioners almost always follows the doctor’s recommendation. (While it is not a certainty that the Director will follow the doctor’s recommendation, there has never been a case in which a commission did not follow a doctor’s recommendation.)

Side Effects of TRT: There have been two recent studies that suggest that there may be serious health dangers in TRT. In 2010, Dr. Shalender Bhasin stopped a study that found that older men have a higher rate of adverse cardiovascular events, such as elevated blood pressure and strokes when receiving testosterone gel instead of placebo. This information was reported online in the New England Journal of Medicine. New research in the Journal of the American Medical Association found that among 8,709 older men who were assessed for the possibility of blocked arteries, those taking testosterone were 30% more likely to suffer a stroke, heart attack or death. The study concluded that its “findings raise some uncertainty regarding the potential safety of testosterone use in men…long-term risks are unknown and there is a possibility that testosterone therapy might be harmful.” While it is true that these results happened in older men and not young fighters, and that there is a lot of scientific uncertainty, there is serious concern that side effects of TRT could potentially harm all men.

Brain Damage in MMA: TRT allows fighters to continue their careers as they get older, and while TRT does not directly affect the brain, it puts fighters’ brains in extremely vulnerable situations. Dr. Sarah Banks of the Cleveland Clinic’s Lou Ruvo Center for Brain Health in Las Vegas is leading a study that has found that the volumes of important regions of the brain and the functional connections between them were decreased in fighters with the most experience, and MRI scans are being used to show this. At the clinic they scan the size of various areas of the brains of fighters. They know what the normal size range should be for brains, and Dr. Charles Bernick (one of the lead doctors in the study) said that “the thought about that is as volumes decrease that’s probably due to loss of brain cells, damage to brain cells and the brain fibers. It’s in some sense a measurement of damage.” They can also track these sizes over time, to see if brains will continue to worsen as competitors get older and/or continue fighting. Dr. Bernick also noted “the areas in the brain that appear to be affected from fighting are the areas deep in the brain that involve motor control and movement and speed of processing.” 104 boxers and 135 MMA fighters have taken part in the study so far, but the team hopes that more competitors will participate. The study has found that the number of years of fighting as well as the number of fights correlated significantly with reduced volume in the caudate, amygdala, thalamus, and putamen. These parts of the brain are very important to the body; here are their functions:

Caduate : Responsible for voluntary movement

: Responsible for voluntary movement Amygdala : Plays a major role in the processing of memory and emotional reactions

: Plays a major role in the processing of memory and emotional reactions Thalamus : Relays sensory and motor signals to the cerebral cortex and regulates sleep, alertness, and consciousness

: Relays sensory and motor signals to the cerebral cortex and regulates sleep, alertness, and consciousness Putamen: Regulates movements and influence various types of learning

The researchers have not noticed any major variations in the brains of individuals with six years of fighting experience, however in fighters with more than six years of fighting experience these results quickly changed. These fighters had significantly higher brain volume loss, which could cause diminished brain function and is normally caused by aging, trauma, or disease.

For example, in competitors with fifteen years of experience, the brain volume was ten percent lower in the caudate when compared with fighters with five years of experience. Additionally, brain volume was five percent lower in the amygdala and the putamen. Dr. Bernick also said “there are detectable changes in the brain even before symptoms appear, such as memory loss or other changes in cognitive function resulting from repeated blows to the head.”

The group has also seen a reduction in the size of the hippocampus in fighters, which plays key roles in the consolidation of long and short- term memory and special navigation. The team concluded that the lag between detectability and physical symptoms probably occurs sometime between the sixth and twelfth year of a fighter’s career. The issue with TRT is not that it hurts a persons’ brain- it doesn’t. The issue with TRT is that most fighters use it when they get older because it helps them extend their careers. This is a problem because the longer competitors fight, the more at risk they are of suffering from brain damage.

Chronic Traumatic Encephalopathy in MMA: While there have not been studies linking MMA to Chronic Traumatic Encephalopathy (CTE), there is evidence that MMA fighters could be at risk of getting CTE later on in their lives. The Center for the Study of CTE defines it as a “progressive degenerative disease of the brain found in people with a history of repetitive brain trauma.” The disease can affect people at any time after the last traumatic brain injury. For example a football player can be diagnosed with CTE forty years after his last game. Symptoms of CTE include impaired judgment, confusion, memory loss, aggression, depression, and progressive dementia. Concussions are a proven cause of CTE and multiple NFL players have been diagnosed with CTE after having careers in which they sustained concussions.

Concussions exist in MMA; current UFC fighters TJ Grant and Wanderlei Silva, and former UFC/K-1/PRIDE fighter Gary Goodridge prove this. In fact, Goodridge has already been diagnosed with early onset CTE. One of the problems with MMA is that injuries don’t just happen during fights, as training is sometimes just as dangerous, if not more dangerous, than the fights themselves. Grant suffered his concussion in training and Silva has gone on record saying said that he spars at full force and has been knocked out more times than any MMA fan has seen. It is also possible that Silva has had many undiagnosed concussions.

Non-concussive Brain Injuries and CTE: While concussions are a problem, non-concussive blows to the head can be just as bad, if not worse, then concussions because you can get CTE without ever having a concussion. Chris Henry, formerly of the Cincinnati Bengals football team, had CTE when he died and had zero diagnosed concussions in his college and professional career. While it is possible that Henry had undiagnosed concussions like Silva, doctors believe that non-concussive blows to the head can also cause CTE. Dr. Bernick said that “repeated blows to the head are not good for you…we may not need to focus so much on concussions…it could be that sustaining thousands of blows that don’t knock you out could be more important to the long-term health of your brain.” When asked about the dangers of CTE for MMA fighters he said that “no matter how you’re getting hit, you’re going to have damage…I don’t think MMA people are immune to it. Whether you look at them separately or together (with boxers), you still get these findings.”

CTE exists in sports like boxing and football, and there is no reason to assume that CTE won’t eventually be known to exist in MMA as well. Dr. Matt Pitt wrote that:

Even blows to the head that don’t cause a knockout…cause cumulative permanent damage…For any competitor in fight sports the number of blows to the head is incalculable: the hours of sparring, amateur fights, professional fights—even a short career entails tens of thousands of minor traumatic brain injuries.

Additionally, the New Jersey Star-Ledger recently published an article on brain damage in MMA. They profiled George Sullivan, a fighter, who was thirty years old at the time of the article and was a seven-year veteran of MMA with 17 career fights. Even though he had only been fighting for seven years there is allegedly evidence that he could already be suffering from severe brain damage and CTE. He supposedly slurs/slurred his speech for up to 36 hours after sparring sessions and was once found wandering through a Target after a practice session, oblivious to how he got there.

The article claimed Sullivan does not remember this and says that he was brain-dead.

Industry Opinions: TRT is the most controversial issue in MMA today. Some people think that TRT should be illegal due to the health risks, while others believe it should be allowed to due positive effects on fighting ability. Zach Arnold is the founder of Fight Opinion and has been writing about MMA for a long time. He strongly believes that TRT should be banned due to the health risks associated with the treatment, and he has lost multiple friends as a result of heart attacks due to steroid abuse. He believes that:

There is no legitimate reason for fighters in…MMA to be asking for permission to use [TRT]. If you’ve damaged your body because of previous steroid usage, concussive brain trauma…or abuse of painkillers then you should retire…Either MMA is such a dangerous sport to the health & safety of fighters that it needs to be shut down or fighters are the ones who are making excuses to use TRT in order to increase punching power to inflict more damage upon opponents.

Sam Genovese is a writer for Fightline.com who believes that TRT should be allowed because it helps fighters perform, even though he acknowledges its health risks. He said: “It’s hard to argue against the results…TRT obviously allows fighters to fight harder for longer periods of time…If TRT wasn’t causing such drastic and exciting changes in fighters; it would be much harder to be apathetic about its use.” Keith Kizer, the former head of the Nevada State Athletic Commission, is in favor of TRT and has never considered banning it due to health risks because he thinks that logic could apply to “any medical aid given to a fighter (e.g., a fighter who breaks an arm should not get it fixed as it will help him get back to competition where he will then get hit in the head…)”

Ethical Arguments: To evaluate this issue I used two ethical frameworks: utilitarianism and John Rawl’s “veil of ignorance.” Utilitarianism is a theory that states that the proper course of action is the action that creates or maximizes the most happiness. The veil of ignorance is based off the idea that the people determining the original position know nothing about their individual abilities, position within society, etc. and in this situation everyone involved in the original position would make the morally correct decision. To use utilitarianism I came up with the pros and cons associated with TRT use:

Pros:

1. TRT allows fighters to perform and train as if they were younger. This enables them to train and perform better

2. Thus they would not need to retire, which means that TRT helps extend careers

3. You can possibly earn more money fighting, which would help you and your family

4. TRT could allow fighters to have more fun doing what they love

Cons:

1. 30 percent greater chance of having a heart attack/ stroke when using TRT

2. The longer someone fights, the greater chance they have of developing brain damage and possibly CTE

3. TRT allows fighters with brain damage to continue fighting

4. TRT helps previous cheaters and steroid users

5. While it is true that TRT can allow a fighter to earn more money, it can also cause strife to families due to the health risks associated with TRT.

6. The brain damage affects people for their rest of their lives.

7. While it’s true that fighters can earn more money fighting and can compete for longer with TRT, many fighters have other career options within MMA, let alone other unrelated jobs

I believe the cons would cause more pain and suffering than the pros would cause happiness, and therefore I believe that utilitarianism would not be in favor of allowing TRT. For many of the same reasons listed above I believe that in the veil of ignorance people would choose to reject TRT because of the health risks associated with the treatment, and because it puts fighters in a vulnerable position to sustain serious brain damage. In addition, there are always other ways for fighters to make money, support their families, and have fun.

The most important reasons in both frameworks are the health concerns of TRT. I find the fact that TRT allows people that have already suffered significant brain damage to continue to fight to be especially important under the veil of ignorance. For example people would never want someone that had already been in coma to be a professional fighter. The only way I could imagine people under the veil of ignorance accepting TRT is that some athletes claim that it “evens the playing field.” However my counter argument to this is that many of the fighters that argue this point have been caught taking steroids in the past and are simply looking to minimize the consequences of their actions. Additionally it seems crazy to me that in a contact sport, it would be fair for competitors to take a substance that artificially enhances their abilities, especially when this treatment is not available to all fighters with declining abilities due to age. As previously mentioned, testosterone naturally decreases with age. As fighters get older they will naturally feel the effects of lowering testosterone counts, however not all of them could qualify to be diagnosed with hypogonadism. Furthermore it would be crazy (and illegal) for older athletes in other sports to use drugs that would help them perform as if they were in their prime because it is a huge risk to their health, and it is insane that this has actually been allowed in MMA.

I also want to address Keith Kizer’s argument from above that which with I disagree. First, when a fighter breaks an arm, it will eventually heal and be just as strong and functional as before. Second, data shows that MMA does not affect fighters early on in their career, so while it is true that a fighter who breaks a bone could heal up only to take more punishment to the head, it is not clear that in the first six years of a fighters’ career that this punishment will cause brain damage. The main issue with TRT is that it allows athletes to keep fighting when their brains are already very susceptible to damage. Therefore I believe that testosterone replacement therapy should be banned in MMA.

Solution: In order to solve this problem athletic commissions need to ban fighters from applying for Therapeutic Use Exemptions to get TRT. While this will solve the problem of fighters legally using TRT, there will still be a problem of illegal doping, as there is in most sports. However, I believe that VADA testing can help solve this problem. The Voluntary Anti-Doping Association is an organization that provides and encourages effective anti-doping techniques and programs in MMA. In the VADA program fighters volunteer to be subjected to unannounced testing at any time eight weeks prior to a fight. Fighters are required to inform the organization of their daily whereabouts and training schedule to allow for this testing. The UFC and other MMA organizations should require that their fighters take part in this program. Additionally organizations should require fighters to get their brains scanned with MRIs at least once a year. While I do not think that organizations can force fighters to retire, they should require fighters to be informed about their own health. If a solution cannot be reached and the sport does not become safer, then maybe it is time to shut down mixed martial arts for good.

It will be interesting to see what happens with TRT in MMA considering a number of things. Firstly the Association of Ringside Physicians (ARP) recently released a statement showing their support for the “general elimination of therapeutic use exemptions for testosterone replacement therapy.” The ARP is a non- profit and international organization that aims to promote the health and safety of mixed martial artists and boxers, and they are in favor of banning TRT because it “significantly increases the safety and health risk to combat sports athletes and their opponents.” Additionally they believe that “TRT in a combat sports athlete may also create an unfair advantage contradictory to the integrity of sport.” Dana White was thrilled to hear the ARP’s statement because he believes that TRT provides unfair advantages to fighters.

Even though Dana White and the ARP support banning TRT, in the end the athletic commissions are the only ones with the power to eliminate TRT from MMA, and unfortunately sometimes there are external circumstances that play a part in their decisions. The UFC’s Middleweight Champion Chris Weidman is scheduled to defend his title against Vitor Belfort, a TRT user, in May. Belfort failed a drug test in 2006, and people suspect that his low testosterone is caused by past steroid usage. Belfort used TRT for his last three fights, all of which have taken place in Brazil. There has been concern in the past that Belfort would not be able to receive a TUE for TRT in Las Vegas due to his failed drug test, however Francisco Aguilar, (the chairman of the Nevada State Athletic Commission) recently mentioned that Belfort’s failed drug test will not automatically disqualify him from receiving a TUE. In fact he said that the decision to allow Belfort to use TRT could be influenced by money. Aguilar said that he would be “cognizant” of the title fight’s economic impact on the state of Nevada. It makes sense for the commission to understand the economic impact they have on the state, however it is inexcusable for them to be influenced by money when every decision they make seriously impacts the health and safety of fighters. It will be especially interesting to see how the commission rules now that Keith Kizer has stepped down as the executive director of the commission.

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