In our continuing coverage of Testosterone Replacement Therapy (TRT) and its associated issues in MMA and combat sports, FightMedicine.Net interviewed Keith Kizer, Executive Director of the Nevada State Athletic Commission (NSAC). Since there is no federal oversight of athletic commissions, each state has their own. With a large majority of fights taking place in Las Vegas, most other commissions look to the NSAC to set the standard for other commissions. In the first part of our interview, Keith discusses how the NSAC tests for TRT and how a fighter is allowed a Therapuetic Use Exemption (TUE). He also discusses other organizations out there such as the World Anti-Doping Agency (WADA) which tests on an international level such as cycling and the Olympics. If you missed our primer on TRT basics, you can see it here.
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FightMedicine.Net: A lot of people have been talking to you about testosterone replacement therapy (TRT). What are your thoughts? Do you see TRT as a performance enhancing supplement or drug?
Keith Kizer: Oh, it could be. It certainly could be. I don’t know anyone that could argue that it couldn’t be if it’s abused. The general idea, of course, on all this is therapeutic use. If a contestant, be it a fighter or be it another athlete, has a legitimate medical condition and there’s a way to treat that condition in such a way that it doesn’t put the fighter in undue risk or give the athlete an unfair advantage, they should have that right. Just like you and I would, if we had similar condition or the same condition, that we have the right to get medical treatment. And it does bother me a lot of people almost act like these fighters shouldn’t have basic rights to medical treatment or would have to choose. And there might be some situations, there might be some medical conditions, where they do have to choose between fighting or getting treatment.
Or maybe it’s a situation that you don’t get a choice, you can’t fight anymore. If you know you have this serious medical condition and there’s just no way to treat it in such a way to make it safe for you to keep competing then you need to retire. And that’s happened with a lot of athletes, of course, over the years – not just fighters, but especially fighters, because it is such an inherently dangerous sport.
So with all that in mind, you want to have a situation where you have some therapeutic use exemptions, when applicable. And as you probably know, it doesn’t mean that you get the drug of your choice or you can take as much of it as you want. It’s very seriously regulated and monitored. I saw the interview with Bas Rutten on your website that you gave the other day and he said – and I don’t blame Bas for this, it’s not his fault he’s wrong because he’s got people out there saying this stuff; But he said “You need six times the normal amount,” or something, and it’s just not the truth by any means here.
These fighters who are entitled for TRT, for example, their testosterone levels need to be below normal. It can’t just be low normal, you have to be below normal. And then we look at things like cause and condition and treatment plan. And in the fighters who do get the exemption, we closely monitor them.
And sometimes even with the treatment, they’re still below normal or they’re on the lower half of normal. So it’s not like I can get TRT and I get to shoot up to 1100 or even 800 (Total Testosterone Level). And these fights, I know the last couple we’ve had, the fighters have been below 300. And we look at the total testosterone and the free testosterone. We look at the FSH, the LH, the hematocrit and the hemoglobin levels. These are the main six things that our personnel will look at.
So all that stuff comes into play in addition to other information they need to provide us. So yeah, it’s heavily regulated. You hear people say things like, “Oh, once you get a TRT TUE (Therapeutic Use Exemption), you can take as much as you want or you can get your levels to that of a 20-year-old; Or they can be like Bas commented, six times the amount or something, which is just not the case. We basically follow what WADA (World Anti-Doping Association) has set forth on these exemptions. And then add in some additional requirements on the athlete to prove their case. It’s a burden for them to make the case.
But modern medicine has grown by leaps and bounds in the last couple decades. And it’s a great thing for all of us, not just athletes. And it’s good that you have these treatments that you may not have had even ten years ago.
But if you’re involved with any type of regulated substance, you need to get clearance and you need to go through all the proper steps. And in some situations, including with TRT, we’ve had some situations where fighters have not met those requirements and they’ve not been able to compete.
It seems that most people worry about, not that a fighter needs it medically, but fighters or doctors abusing the prescription of TRT.
We’ve had some people apply for TRTs that perhaps follow that category and they were not granted. It’s a very high burden on us as well to do the homework and our doctor talks with the fighter’s doctor and reviews all the medicals. There’s a lot of medicals we get, and if there’s any issues, that’s definitely addressed, including up until the point of saying, “Sorry, you’re not competing.”
Do you think more of the abuse is on the medical side or on the fighter and his camp’s side?
Well, I don’t know if that’s mutually exclusive. I gave an interview awhile back and I was actually on the phone with a medical facility to get some information that had nothing to do with drugs, but they had an infomercial, or whatever you want to call it, on hold. And it was like, “Check with your doctor. See if you might have low testosterone. There’s new treatment plans available to help you with that.”
So it’s obviously being pushed pretty hard, and not just for athletes, but for all type of men– especially in the 30 plus age bracket. And there’s probably a lot of doctors out there taking advantage of this. You got a 45-year-old recently divorced man who wants to get back on the dating scene, and he goes to his doctor and his doctor says, “Hey, look, I can make you look a little younger here and give you a little more energy here.” And that’s abuse by the doctor, and hopefully the medical boards handle situations like that.
So I think it’s a situation where there’s probably a lot of non-athletes out there who either want to look better or they want to do better on their softball team on the weekends or something like that. And it’s unfortunate. I think it is a situation where doctors see a lot of dollar signs and some of them are going to act improperly. Other doctors, though, they have legitimate patients who have legitimate concerns with low testosterone and they’re going to be able to treat them and get them the help they need. That, again, probably wasn’t available ten years ago.
But the flipside, though, is that the athlete is the ultimately responsible party here. And I’ve told other athletes who’ve been on this, “Look, you talk with your doctor. You’re entitled to this exemption, but you better play it conservative with your treatment plan. I’m not going to tell you how much to take or how much not to take. That’s up to your doctor talking with our doctor on this“. I think there’s always going to be a feeling in a lot of these athletes, “If I take this much, I’ll get to be healthier and good and it won’t give me any kind of advantage or anything, but it’ll give me the medical treatment I need, so why not take twice as much? Why not take three times as much?”
I think that’s probably true with other drugs too; probably with pain medication. Your doctor tells you, “Hey, look, I’m going to give you some pain medication for your injury. You should take no more than two a day.” There’s people who take four a day, six a day, eight a day. Because why not? Why not take four? If two’s great, four is going to be doubly great.
I think it’s always important to recognize that situation. Part of that is human nature, I guess. It’s very important to let these athletes choose for themselves – but we monitor them. We test them a lot before the fight. We test them at the fight night. We test them the morning after the fight. And if they’re at a level that they shouldn’t be at with their approved treatment plan, they’re subject to discipline as if they had no therapeutic use exemption whatsoever.
When you do review TUEs, who’s on the board that reviews these exemptions? Are there ringside doctors or endocrinologists (hormone specialists) on the committee?We have a consulting physician who does all of our medical information. Timothy Trainor’s his name. So he does all that stuff, and he’s the consulting physician for the Commission. What he does is he’ll go out and review the information. He’ll talk to experts in the field if it’s something beyond his basic level of practice or knowledge. And so he’ll have his consultants and specialists he’ll talk to, in this case endocrinologists or something along those lines, that helps him in these issues.
There’s also a broader policy type issue. We have a medical advisory board or medical advisory panel, which we have doctors with various different specialties that come onboard and, again, if it’s something that doesn’t fall within one of their specialties, we’ll invite other experts in the field – specialists in the field – to come and testify before the panel.
You mentioned you follow the WADA (World Anti-Doping Association) rules. Dr. Margaret Goodman is promoting VADA (Voluntary Anti-Doping Association) as a voluntary alternative. Is there a need that she’s trying to fill or do you think that it’s something that you guys are doing fine on your own? Or is it something that you guys could do together? What are your thoughts on that?
Well, my basic view on drug testing is the more the better. So if fighters or promoters want to sign up for additional drug testing, supplemental drug testing is probably the best way to word it, in addition to the primary testing done by the Commission, I’m for all that. Obviously, there’s a price issue there with athletes or the promoter whether they’re willing to spend it or not, but we basically test almost everybody. Most fight cards we test every athlete. Some, if they’re out of the way or somewhere, we might test only 70% of the athletes, or something along those lines. I think in the Olympics they test about half, so we test a hell of a lot more than that and we’ll continue to do so.
But they have the supplemental testing, whether it’s done by USADA (United States Anti-doping Association, a branch of WADA) or VADA or somebody else, that’s something for the contracting parties to decide. But I definitely would be in favor of any additional drug testing that the applicable parties want to do. But I’m not endorsing anybody. I know USADA and VADA have had their war of words with each other because they both want that dollar from the promoters. And they both have their PR people masquerading as journalists in the press or in the blogs pushing for them. I make it easy. You want to do a fight here in Nevada? You have to come through the Commission and we’re going to do any test we want to do. If you don’t like it, you’re not fighting here. It’s very easy. There, they have to fight it out, a peer battle and put each other down and put other people down and try to get that buck, that ever important buck. We don’t have to do that. So I just want to make it clear that we’re not endorsing anybody.
You mentioned Bas talked about six times the testosterone limit. He was probably talking about the T to E ratio. Where did that range come from? Some commissions allow six to one, others allow four to one. Why is there a discrepancy in that?
I think that it is just a matter of what standard deviation you want to go. I think four to one is two standard deviations and six to one is three standard deviations from the average. As you know, not all doctors out there realize this. One guy gave his interview not too long ago saying, “You can’t be two to one naturally.” And, of course, you can. You can be five and a half to one naturally. I don’t think he ever publicly corrected that. And that’s unfortunate, but that’s who he is.
But you can be two to one naturally. You can be three to one naturally. You can be five to one naturally. So the average is, of course, one to one. I think that’s funny because I think one of the people who was complaining about the six to one that we have, and New York has, and the NCAA has, said, “We use four to one.” And I think the reporter asked him, “Well, why don’t you go to two to one then?” And he had no good answer for them. And then it was a pair of question, “Well, why don’t you guys go three to one or two to one?” “Well, uh, uh, uh…” It was kind of strange, but I think a telling response.
And the six to one, of course, came from what? That’s what WADA has used for most of its existence. Most of the time they’ve been doing T/E ratios, they have used six to one. You don’t want to brand someone as a cheater. You don’t want these false positives. To me, a false positive is a lot worse than a false negative. It’s the whole thing about sending an innocent man to jail or a guilty man going free.
And here in Nevada, these are public records. We don’t have the luxury that some of these semiprivate or semipublic groups have of keeping these things private. So you’ve got to be very, very concerned about that. So it’s very important. But yeah, it’s a good debate. I’m by no means saying six to one is definitely the answer or four to one is definitely the answer; but there’s arguments for both. It was only about five or six years ago that WADA went to four to one. I think this is only the second Olympics, actually, that they used the four to one ratio.
I know I talked with the California Commission. They went from six to one to four to one about two years ago. When I checked with their recently departed executive officer a couple of months ago, I said, “How many guys did you get – that you test – that fell between four to one and six to one on their T/E ratio?” And he said, “Keith, absolutely nobody. Of the hundreds we tested, nobody.”
And I think other states I’ve only heard of one situation where the person was between four and six to one. Again, that doesn’t mean that four to one is not the better ratio to have. But there are definitely some pros and cons of both. Obviously, you probably want to be as close to that one to one as you can be with the ability to make sure you’re not unfairly accusing somebody of a violation that they did not commit.
It seems most people now in the media are talking about TRT. Do you think steroids are less of a problem now or do you think it’s just being overshadowed by TRT?
I don’t think it’s been overshadowed by TRT. I don’t know. I hope so. I give a lot of credit to Congress on this. I remember when I started out here, still, there were a lot of people, it was a small but vocal minority who would say, when people get caught, “The only real crime is that they didn’t cycle correctly.” They didn’t really see it as cheating. They didn’t see it like jumping on a subway during the Boston Marathon. They were more so, “Oh boy, next time hopefully I’ll cycle better.”
And again, it wasn’t most people. Most people did say, “It’s cheating.” But you didn’t hear much about that. And then I came out and did what I needed to do to push this stuff, and I think we’ve had dozens and dozens of people we’ve caught. And we started with a leniency and now it’s been ratcheted up to some pretty serious penalties for these fighters. But your ultimate goal is always deterrence and education. And I hope that came out. But Congress, I think, when they had their hearings on baseball, I think more and more people started seeing this as, “Hey, this is straight up cheating. This is nothing about, ‘Can you sneak by,’ or the old saying from pro wrestling, ‘Oh, if you’re not cheating, you’re not trying hard enough,’ ” which people laughed about it when it came to steroids.
I think in great part because of the Congressional hearings, a lot more people not only see this as cheating, but they see it as very serious cheating. Especially in a sport like MMA and boxing and kickboxing, where you can seriously harm your opponent, I think that comes into play.
I can tell you we’re testing more people than we ever have. I think when I took over for Marc (Marc Ratner, former NSAC executive and now VP for UFC) back in 2006 we probably were testing about 25% or so of the fighters. I immediately jumped it up to over 50%, and now it’s close to 100%. It’s very rare we don’t. Like if we have a fight in the middle of nowhere, which we occasionally do, we might have only testing of the winners. That’s still 50% of the people we’re testing – a lot more than any other commission. But for most fights, we’re testing 100% of the people on the cards.
And I think that’s very important to do that. But it took time. It takes a lot of different aspects to it and we’re able to finally get some help with some independent drug testing collectors who come out to the fights and collect the urine on fight nights for some of the fights, the earlier fights, which have a been big help. Because our inspectors were doing it, of course, they had to also worry about hand wraps and gloving and being in the corner and checking on the fighters after the fight in the back to make sure no one’s having an episode 20 minutes after their fight ends – which unfortunately has happened at times.
So having independent specimen collectors has really helped. That got us the pushed from the just above 50% to basically 100%, where we’re at now. We have that luxury that other commissions may not have, so we definitely are appreciative of that. But I think at the end of the day, you don’t know. You’ll never know who’s using and who’s not. It does bother me when people want to use blanket statements that 90% of the people are using, and it’s just so disrespectful to the athletes. To the clean athletes, it’s too bad.
But people are still getting caught, so obviously people are still using. We’re doing more testing than we ever did, and in some cases testing 100% of the athletes, and very few are failing for steroids. We’re actually having more of an issue with diuretics than anything else. But nothing makes me happier than when we test everything, the labs are done and everybody comes back clean. It’s a good feeling to get, and I think the message is out there and I think the promoters are pushing it in-house on their athletes. Obviously, the press is very hard on these guys when they fail. In the past sometimes they’d make excuses for the guys, but not anymore.
So I think all in all, it’s a very important thing. And I think the education aspect, including your site and other sites like yours where the athletes can learn the dangers and the consequences and feel comfortable knowing that hey, the odds are very good that my opponent’s fighting clean as well. So I think that all goes in the whole thing about deterrence and education being the main aspects.
Do you think that there should be a national standard? Some states don’t require mandatory testing. Do you think it should be mandatory?
I only can tell you about the WADA model, which I think is the best model or I’d change it. So I think it works based on our budget. But some commissions have less of a budget than we do. So it’s hard to blame them if they’re not doing as much testing as we can. Other states where they have the money and they’re not doing it, I think they are apt to criticism. But I think most states that I know, that I deal with, see this as a very important issue and are doing what they can in that regard. And you see fighters getting caught in other states, and in fact, some very high profile fighters getting caught in other states and having to face the consequences for that.
So I think most of the commissions, if not all, would like to do more than they are, but because of different constraints, including budgetary constraints, they have issues there. And it’s easy for an outsider to say, “Oh, come on, money’s no excuse. Don’t use the money excuse.” What do you mean don’t use the money excuse? You don’t have the money, you don’t have the money.
It’s funny, if you ask the people making the argument to test everyone why they don’t do it themselves, they won’t answer you because their answer is, they don’t have the resources to do that. I don’t know any drug testing group that tests every athlete in their jurisdiction every week. You can’t. You can’t. And if you could, it wouldn’t be fair to the athletes to do that. But you do what you can with your resources, and obviously, we do very a good job with ours.
We would like to thank Keith Kizer for taking the time to discuss these very important issues in mixed martial arts and combats sports. TRT is a very controversial issue and the first step in having it discussed in an open and productive manner is educating the fighters and fans. FightMedicine.Net will also be posting an upcoming interview with Dr. Margaret Goodman on the new Voluntary Anti-Doping Agency (VADA).
FightMedicine.Net would also like to thank Sandra for her transcription services. She can be reached at firstname.lastname@example.org
Jonathan Gelber, M.D. is licensed to practice medicine in the State of California
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