SII Focus 20th September 2016

TUE inequality: Sloan Teeple’s testosterone story

Thanks to Fancy Bears, athlete use of Therapeutic Use Exemptions (TUEs) has been a bit of a hot topic recently. Documents relating to elite athlete use of TUEs have been illegally accessed from the World Anti-Doping Agency’s (WADA) Anti-Doping Administration and Management System (ADAMS). As such, the context in which they were issued is not fully explained. However, it does appear that a number of elite athletes have been granted TUEs for a number of drugs used to treat asthma and corticoids, which are used to treat inflammatory conditions.

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The Fancy Bears website has exposed elite athlete TUEs

This, in itself, does not suggest any wrongdoing. TUEs allow athletes with illnesses or conditions that require them to use a substance that features on WADA’s Prohibited List to apply for a TUE. Some of the leaked TUEs are backdated. Again, this is allowed under WADA rules, and is designed to cover situations where a prohibited substance has to be administered to an athlete due to a medical emergency, or situation where the athlete’s health may be at risk.

However, there does appear to be inequality regarding the speed and ease with which elite athletes acquired their TUEs. Many of the TUEs leaked by Fancy Bears were approved in one or two months. Sloan Teeple’s TUE took four years. And he is not the only athlete with a genuine medical need to be denied their medication by sport’s governing bodies. Most – but not all – of the athletes who have faced delays in their TUEs appear to be outside of the ‘elite’ category. It appears that TUEs requested by elite athletes are prioritised over those requested by amateur athletes who have a genuine medical need.

Sloan Teeple

Teeple is 45-years old and was diagnosed with testosterone deficiency (low T) at 33. However, he is also a doctor who is recognised as a specialist in low T, so is well informed about the harmful effects that depriving somebody with low T can have on their general health. In short, he has a valid claim to know more about his condition than the sporting federations and WADA, who are responsible for assessing his need for a TUE. He also has a genuine medical need.

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Teeple applied for a TUE when he started competing

“I am 45-years old currently, and at age 33 I was diagnosed with testosterone deficiency, otherwise known as ‘low T’”, he explains. “That was before I ever started doing triathlon, or any kind of racing. I didn’t really get serious about triathlon until the age of 40, when I wanted to do my first Iron Man. That’s when I decided I needed to apply for a TUE for testosterone.”

His TUE was turned down, which he describes as “frustrating”, since he was not taking it to enhance his performance. “Being a physician and something of an expert in the field at the time, I think I was still a little naive in terms of the regulations and how much the sporting  authorities were determined that nobody should use testosterone”, he continues. “So I applied for my TUE and when I was denied, I was a little bit shocked, then frustrated, then a little bit angry. Realisation set in almost immediately when I saw the documentation and the reasons why they denied my TUE. I realised that this was going to be a long battle, but one worth fighting and one I have to do for all other men out there suffering from similar conditions to myself, as well as the patient athletes that I treat. I knew I had to be patient, and it was going to be a long, slow process.”

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Teeple and his wife wrote a book about Low T

However, he was not prepared for just how long a battle it would turn out to be. “That process took four years”, he states. “When I was denied, I went ahead and continued racing because in my mind, I knew that the rules were not up to date with current medical practice. In my mind, I felt like I wasn’t doing anything ethically or morally wrong. The regulations just needed to be updated, so I kept racing and kept using my medication.”

“Later on, I decided that I needed to make it obvious to all my friends and everybody around me that I was using testosterone”, continues Teeple. “I didn’t want to hide anything, so I ran in a testosterone jersey, marketing a book that my wife and I wrote. I made myself a target for USADA [US Anti-Doping Agency] to come and find me, and sure enough they did. They tested me and I was honest with the questionnaire and told them that I was using my medication and they gave me a reduced sanction.”

That sanction, issued in June 2013, kept him out of sport for another 18 months. He says that had he probably could have reduced that sanction down further, however the process was still new to him at that time. “It motivated me to get all the resources I needed to fight to get everything overturned and pave the way for other guys to have things done the right way. Luckily, we were successful.”

Teeple’s recreational TUE

That success came in June 2015, when Teeple was successful in getting USADA to change its policies. In effect, USASA now allows a ‘non-national athlete’ who has had their application denied a second bite at the cherry, if they can show that they qualify as a ‘recreational competitor’ as defined by the USADA TUE Policy.

As might be expected, the criteria for meeting that threshold are quite narrow. To qualify as a ‘recreational competitor’, an applicant has to be a ‘non-national athlete’, who: ‘within the last 25 years (1) has not been in the USADA Registered Testing Pool or the Registered Testing Pool of an International Federation; (2) has not represented the United States in an International Event; (3) has not won a national or regional level Competition in any sport; (4) has not finished first, second or third in an age group category of any Event sanctioned by an NGB in which fifty (50) or more competitors have been entered in that category in the sport in which they are presently competing; (5) has not won more than five hundred dollars (500.00 USD) in prize money in an Event in the sport in which they are presently competing; and (6) is not classified as a professional Athlete.’

In effect, this only includes people who have taken up sport later in life and excludes elite athletes who may have problems with low T in later life. Teeple doesn’t feel entirely vindicated by USADA’s policy change. “I feel it was a success in that we were able to ensure that things were going the right way”, he explains. “However, deep down, I am a little bit sad because I realise that there are still a lot of things that need to change – especially for professional athletes. In my professional opinion, any man who has low testosterone is at a big disadvantage not only in sports, but also in maintaining overall health.”

Scientifically contradictory

USADA’s decision to prohibit elite athletes from competing whilst allowing recreational athletes with the same medical condition to compete does appear contradictory. Testosterone is the main male androgenic hormone and scientists have found that when the body loses its ability to produce androgens, it loses its ability to maintain itself, as androgens have over 200 daily functions in the human body. Why should only elite athletes be denied a medical need?

“Testosterone provides the overall foundation for male health”, explains Teeple. “It affects many different organ systems. The most famous or notorious has to do with sexual function and libido. The other area is the physical aspect, comprising bone strength, muscle strength – all of that relies on testosterone. Also, metabolism – i.e. the body’s ability to continue to burn fat. It keeps the metabolism going.”

“Then there is the mental aspect”, he continues. “A man’s energy level and sense of well-being is tied to testosterone. A lot of the symptoms that men present to me in my office are either low libido, poor erections, poor sexual function, or they are terribly fatigued, low energy, lack of motivation. Other things people notice are poor sleep, and it can even effect urination – how they empty their bladder. As I am a urologist, I see that a lot. Irritable mood is also common – it can make men kind of grumpy. All of these are typical symptoms of low testosterone.”

“Studies have been done in the US where they have used the VA [veterans] hospital population involving over 50,000 men that have low testosterone”, explains Teeple. “They found out that men with low testosterone are at greater risk from heart attacks and strokes. Mortality rates go up.”

Scientifically, as shown above, men competing with low T are significantly disadvantaged. By taking away their right to use medication to maintain that health, sport is medically handicapping them not only on the field of play, but in their daily lives.

“If professional athletes are not able to use their medication and compete on a level playing field, like everyone else who has normal testosterone, those guys are disadvantaged”, explains Teeple. “There is still some work that needs to be done on that level. Unfortunately, I think that USADA and WADA have set themselves up for potential lawsuits to get things changed, because low testosterone could be considered a true disability, and I think that there’s lots of ways in which you could fight that battle, especially if you are an elite athlete.”

The effects of stopping treatment on Teeple

In order to force USADA to take a second look at its policies, Teeple stopped taking testosterone supplements for a short period, in his words, “to prove some things to USADA”. The effects were dramatic.

“I gained a lot of weight, I was tired and it made my worst day more difficult”, he states. “I didn’t try and compete in that time – I just did some workouts and tried to stay in shape the best I could. I didn’t have any grand plans of racing during that time – I knew it would just be a hard time for me. However I had to deal with it and get through it, to prove a point. My motivation to exercise in the first place also went down.”

Other amateur athletes

In contrast to the elite athletes whose TUEs have been exposed by Fancy Bears, Teeple is not alone in facing significant delay in receiving a medically-required TUE. Amateur cyclist Jeff Hammond’s story was picked up by the newspapers after he was denied a TUE by USADA for testosterone prescribed in 2012 to combat a bone-weakening condition. After almost four years, Hammond received a recreational TUE in September last year. “I started crying,” Hammond told the Wall Street Journal. “It had broken my heart to stop racing.” Hammond received that TUE thanks to Teeple’s efforts.

Roger Wenzel was not so lucky. He died of liver cancer last year shortly after a two-year USADA sanction medication taken to combat Parkinson’s disease had expired. The USADA statement neglected to mention this fact. Anti-doping efforts had taken away his last chances of competing.

To add insult to injury, just last month USADA sanctioned 62-year old Greg Pizza for taking a testosterone supplement for erectile disfunction, fatigue and depression, which resulted in an AAF. Pizza only declared six multivitamin tablets on his doping control form at the USA Track & Field Masters Championships, but following his AAF he submitted a retroactive therapeutic use exemption (TUE) for the testosterone supplement. The arbitration panel accepted his claim that he was only taking the supplement for heath reasons, not to gain a competitive advantage, and he didn’t know that it would cause him to fail a doping test. His applicable ban was reduced from two years to 20 months.

USADA sanctioned Mary Verrando-Higgins, 54, with a one-year ban after she informed them about a medication she had been prescribed. ‘USADA responded that the product she was using for medical purposes was prohibited and required a Therapeutic Use Exemption (TUE), which she was unlikely to obtain’, explains a statement. ‘Verrando-Higgins applied for a TUE, and after review of the supporting medical evidence by USADA’s independent TUE Committee of endocrinology physician experts, USADA denied her application with detailed rationale, including a reference to the existence of permitted therapeutic alternatives to treat her diagnosed medical condition’.

Medical harm to elite athletes

With the exception of Verrando-Higgins, all of the above sanctions involve testosterone and perhaps herein lies the problem. Testosterone is the ‘bogeyman’ of elite sport due to its reputation as the drug of choice for athletes during the 1980s and early 1990s. Due to its reputation as potentially performance-enhancing, sport is unwilling to grant TUEs for fear of encouraging false applications for testosterone use.

There is no doubt that taking on exogenous (external) testosterone is performance-enhancing. Just ask Ben Johnson. However for people that cannot produce enough endogenous (internal) testosterone, taking away their medication can be medically harmful. This is where sport is likely to face lawsuits.

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Kristen Worley’s TUE took almost four years

This medical harm is not confined to amateur masters athletes. Canadian cyclist Kristen Worley’s application for a TUE to take synthetic androgens took three years, plus an additional ten and a half months to process. Even after it was approved, the androgen limits mandated by the TUE were so low that they induced ‘complete hormonal deprivation’, making her ill and unable to compete in elite sport.

Like Teeple, she is fighting a battle to get sport’s rules – which place upper limits on the amount of endogenous (internally produced) androgens a woman is permitted – changed. In July last year, the Court of Arbitration for Sport (CAS) gave sport two years to present scientific evidence that endogenous testosterone levels have a significant performance-enhancing effect in women and so far, it has failed to do so. Yet the myth that endogenous testosterone is performance-enhancing persists, and the battle has got dirty.

In a disgraceful episode, sport carried out unnecessary surgery on four young athletes who were told that it would allow them to compete at the London 2012 Olympics. The surgery medically damaged the young women, who must now take synthetic testosterone for the rest of their lives or suffer ‘complete hormonal deprivation’.

In 2013, a study was published which found that surgery was performed on the four athletes, who were found to have a mix of male and female anatomical features. The athletes, aged 18-21, were told that the surgery would lower their endogenous testosterone levels, which were deemed to be too high by sport’s hyperandrogegism regulations (the same regulations struck out by the CAS), and therefore allow them to compete at London 2012.

However, all the athletes had medical procedures that had nothing to do with this: reductions to the size of their clitorises, ‘feminine’ remodelling surgery and oestrogen replacement therapy. This surgery was entirely unnecessary. It was not due to any gender identity issues, had no basis in relation to sport or physical performance, and was based purely on cosmetic ideals put forward by sport.

Even worse, as these young women had no ovaries and had surgery to remove undescended testicles, they have had their ability to naturally produce testosterone removed. No investigation has been carried out into who is culpable for medically harming these athletes.

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Ranges for endogenous testosterone differ

Teeple, a medical professional, is unequivocal on how this issue should be approached. “If they were male and that is what their genetic make up is, then they should use the male ranges to keep that person healthy”, he states. “If they are female, then they should use the female ranges to keep that person healthy. Typically, women have one tenth of the amount of testosterone that a man will have. There are averages, as testosterone fluctuates during the daytime as well. If you do a blood test in the morning then the result might be different than if you do the test in the afternoon.”

Teeple helped guide USADA on what the appropriate parameters might be for his TUE. “There are going to be some individuals that fall into the extremes either way”, he continues. “I have some men that are doing great and have no symptoms, however their testosterone is much lower than the average man. I also have the opposite – men that are not doing well and their testosterone level needs to be higher than the average man.”

“I do know of a professional mountain biker who has quit his sport because he had low testosterone and did not want to go through the process of obtaining a TUE”, says Teeple. “He knew how hard it would be and so decided to stop racing as a professional and just race on a non-professional level in order to avoid that. He was not a world class athlete, but he was a regional elite athlete. He contacted me to get my opinion and help. I know that there have been some golfers that have faced this issue, but I don’t think the golfers have been successful in getting a TUE for testosterone at this time.”

Conclusion

It appears that a review of the TUE system is needed. Teeple has succeeded in getting USADA to allow the use of medically-required testosterone, but only in amateur sport. Elite athletes suffering low T must continue to suffer. Such an approach appears inequitable.

An explanation is also needed as to why elite athletes are able to obtain a TUE in under a month, yet for amateur athletes the process can take four years. It appears that the connections between those that govern the TUE process (WADA) and elite sport are enabling some spurious TUEs to be fast-tracked, while TUEs based on a genuine medical need are placed on the back burner. To athletes that have been denied a TUE based on a medical need, this appears unfair and discriminatory, hence the widespread anger at the TUEs revealed on the Fancy Bears website.

Once again, such a confused and conflicted process plays into the hands of those who wish to make the regulation of anti-doping entirely separate from sport. Such a discussion is planned for an Extraordinary World Conference on Doping in Sport in 2017, and the International Olympic Committee (IOC) has already stated its support for such a move.

At present, the entire anti-doping movement is based around the concept of ‘zero tolerance’, which does not lend itself well to the concept of TUE rules that are sympathetic towards athletes. Teeple would like to see that change.

“In medicine, there are no hard and fast lines that can be drawn because although every individual is basically the same anatomy wise, physiologically there are always differences, and you have to take that into consideration”, he argues. “I think that with regulations in medicine, you have to treat the whole patient using science, however there is also an art to it. You have to look at the whole picture to decide what is going to be best for that person, or athlete. I think having lines drawn in the sand using certain numbers that have to be adhered to is not necessarily the right way to approach this area.” Perhaps sport ought to invite him…

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