Vitor Belfort was 33 years old when an Ultimate Fighting Championship doctor in Las Vegas -- whose name has faded from his memory -- diagnosed low testosterone as the cause for his feeling "tired and lethargic." The fix for the two-time champion was a testosterone-replacement therapy regimen that continues to this day.
Now 36, as he basks in a career rebirth that has him set for a spring UFC title fight, Belfort has emerged as the poster child for a practice anti-doping experts portray as, at worst, outright cheating and, at best, an unfair exploitation of a performance-enhancing-drug testing loophole: athletes competing while treated with synthetic testosterone.
Exemptions for testosterone use -- a substance banned in sports as a performance enhancer -- are being handed out at exceedingly high rates in the ever-popular combat sport of mixed martial arts, with state athletic commissions routinely granting allowances based solely on low lab values and diagnoses of hypogonadism, an "Outside the Lines" investigation has found. A major known cause of acquired hypogonadism: prior use of anabolic steroids.
In the past five years, at least 15 mixed martial artists have been issued exemptions to use testosterone, the vast majority revealed or confirmed through public records requests filed by "Outside the Lines" with the major state commissions or athletic bodies overseeing the sport. The sport itself has had more than 20,000 pro fighters over the past five years, according to record keeper mixedmartialarts.com, although fewer than 1,800 MMA combatants are under contract to the sport's dominant promoters -- Zuffa (UFC) and Bellator, which account for 11 of the fighters on TRT. Although only a small fraction, the number of exemptions still dwarfs what can be found in other sports:
• The International Olympic Committee did not issue a single testosterone exemption for the 2012 London Olympics, which featured 5,892 male athletes.
• The U.S. Anti-Doping Agency issued one testosterone exemption last year among the thousands of elite-level athletes under its jurisdiction.
• Major League Baseball has issued six exemptions to athletes over the past six seasons -- an average of 1,200 players populate its rosters each season.
• National Football League officials say testosterone exemptions are "very rare" and only a "handful" have been issued since 1990. Nearly 2,000 players circulate through rosters each season.
• No pro boxer is known to have had an exemption issued through a state athletic commission, and Nevada officials said they have never even received an application.
"It's a huge number," said Dr. Don Catlin, the country's leading anti-doping expert, of the MMA testosterone exemptions. "I am on the IOC committee that reviews [therapeutic-use exemptions for testosterone] requests. We essentially grant none. But in boxing and MMA there is no central control. There is no set of rules that everybody has to follow.
"There is a set of rules for each [state athletic commission], but they are kind of Mickey Mouse rules. So the route to being able to take testosterone is wide open. ... You go in and say 'I have these symptoms.' The doc says, 'Oh yeah, you got low testosterone.' You get a TUE."
Along with exemptions, several MMA fighters and officials also described to "Outside the Lines" widespread use of performance-enhancing substances in the sport. One top contender labeled PED use in the sport "rampant," and a prominent state athletic commission chairman matter-of-factly acknowledged: "We got some doping going on in MMA."
A few state commissions where MMA fights occur less frequently acknowledged they don't test for PEDs or don't require fighters to reveal whether they are being treated with testosterone. Nor, apparently, does any state -- including Nevada, arguably the most influential commission and a model for other regulators -- require notice in a bout agreement of an individual having an exemption to use testosterone, so an opponent is left to learn through the rumor mill, if at all.
Drug testing in MMA is confined to postfight by the state athletic commissions that test for performance-enhancing substances, with Nevada believed to be the only commission attempting out-of-competition testing. The UFC also does some of its own testing, although officials declined comment and little is known about the program. By comparison, major pro leagues such as the NFL and MLB -- in part as a result of urging from Congress -- engage in far more rigorous programs that include testing at the start of camp or spring training as well as year-round, random testing.
"Outside the Lines" found the average age of the MMA fighters when granted their first testosterone exemption was 32 -- the youngest 24. The majority enjoyed exemptions from multiple states, and, in some instances, fighters were found to have simply informed a commission they were on TRT rather than filing a formal application to compete while being treated with testosterone.
U.S. and international anti-doping agencies insist therapeutic-use exemptions for testosterone should be rare and permitted only in dire medical cases such as testicular cancer and Hodgkin's disease, as is the norm in most major sports. The international standard for an exemption specifically states that "low-normal" levels of a hormone isn't justification for granting approval, also noting the same of isolated symptoms such as fatigue, slow recovery from exercise and decreased libido.
Dr. Richard Auchus, a leading endocrinologist and University of Michigan professor of internal medicine, described the incidence of low testosterone or what is known as hypogonadism in healthy 30-year-olds as "vanishingly small" -- or well less than 0.1 percent.
"What people have to understand is a [testosterone exemption] is granted for a disease, not for a [low] lab value," said Auchus, a consultant to USADA. "If you say idiopathic hypogonadotropic hypogonadism, meaning 'I don't know why you have it, but you have low testosterone production and there is nothing wrong with your testes' -- well, that can happen because you are taking exogenous androgen [steroids]. That doesn't cut it."
The issue, said Catlin, is that synthetic testosterone remains one of the favorite drugs to enhance performance. Anti-doping leaders thus fear testosterone exemptions might be used by athletes to dope under the disguise of legitimate medical need.
"It's just a farce that is perpetuated in MMA," said Catlin, who developed the test used to differentiate an individual's natural testosterone from the synthetic version. "It is doping. It is cheating. It is both."
Belfort, dubbed "The Phenom" from the early days of his pro career, says life has never been better, inside or outside the octagon. A sweaty, tightly muscled figure, he chugged from a Muscle Milk bottle and playfully fussed over his two young daughters -- Victoria, 6; and Kyara, 4 -- after a recent grueling gym workout with his Blackzilian fight team in Boca Raton, Fla.
"Eighteen years doing this, my friend," Belfort told a reporter. "Eighteen years -- combat sport. I think you will not find this in history, I believe."
When prodded, Belfort (24-10, winner of eight of his past 10 fights -- seven via KO or TKO) insists the synthetic testosterone regimen hasn't fueled his longevity or late-career revival, which he describes at one point as "devastating people" and "taking guys' heads off." He called the injections a legal, necessary treatment, not an enhancement -- much like insulin for a diabetic. The injections raise his hormone levels back to healthy, normal levels. Without them, he couldn't make a living.
Belfort, who tested positive for the anabolic steroid 4-Hydroxytestosterone in 2006, cast himself as the most transparent, drug-tested athlete in the sport. "I am telling you, many fighters [are] out there doing drugs, enhancement drugs," he said. "And they don't get tested for it. They don't get tested in camp. I do. ... Other people do TRT and they never go public. I am not ashamed. I am very loyal to my principles. And that is what I do."
"We have, like, tons of fighters with TRT," Belfort said. "It looks like just me. ... I feel condemned right now. And I am doing everything legal."
Yet Belfort, who is training for a late May title fight with middleweight champion Chris Weidman at UFC 173 in Las Vegas, looms ominously over a sport maneuvering through the TRT conundrum. Belfort is expected to appeal to the Nevada State Athletic Commission for an exemption to stay on testosterone therapy for the Weidman fight, which is complicated by the fact that the same commission suspended him in 2006 after a positive steroid test.
Belfort has been a lightning rod, even with his past five fights staged outside the country -- including four in his native Brazil, where he's been allowed to fight under TRT by a Brazilian commission loosely aligned with his UFC promoter. The medical director, Dr. Marcio Tannure, also has been retained independently at times by the UFC. According to Belfort, the Brazilian doctor also has a role in an unrelated DNA study the fighter is participating in.
Dr. Tannure and UFC officials refused multiple interview requests for this story, even after asking for and receiving written questions. When the fighters were receiving testosterone exemptions, 11 of 15 were promoted by Zuffa LLC, which encompasses UFC and Strikeforce. UFC President Dana White has been inconsistent in interviews about the exemptions, saying most recently that they should be banned. But that comment came only a few months after saying the opposite.
White's latest change of heart followed the Association of Ringside Physicians' call last month for the elimination of testosterone exemptions in combat sports -- a motion pushed by Las Vegas-based board member Dr. Margaret Goodman, founder of the Voluntary Anti-Doping Association.
In the wake of the recommendation as well as in anticipation of Belfort's application, the Nevada commission plans to review its TRT policy in a regularly scheduled meeting Thursday, raising the possibility it could decide to eliminate testosterone exemptions. UFC co-owner Lorenzo Fertitta responded, saying the promoter would continue to defer to the judgment of athletic commissions with regard to TRT.
But, although the state athletic commissions and not the UFC ultimately grant exemptions, the MMA promotional giant has at times played a role in leading fighters down a path to TRT. Belfort volunteered that it was a "UFC doctor" who started his testosterone regimen in 2011 -- similar to a 2012 claim by Quinton "Rampage" Jackson, who said a UFC doctor referred him to an age-management specialist. Sources also told "Outside the Lines" that the UFC encouraged heavyweight Roy "Big Country" Nelson to see a doctor about TRT, although he eventually opted not to after having lab work done in 2010. Nelson declined multiple interview requests for this story.
"Outside the Lines" also obtained a 2010 letter to Dr. Jeff Davidson, a UFC medical consultant and former Nevada commission ringside doctor, from a Las Vegas physician thanking him for his referral of MMA fighter Todd Duffee. The doctor prescribed Testosterone Cypionate for the then 24-year-old, whose "extreme fatigue" was diagnosed as caused by "secondary hypogonadism."
Also, a doctor for Chael Sonnen wrote Davidson regarding the middleweight's TRT regime in 2010 -- a year before there is a record of his having formally applied with a state regulator for an exemption. Dr. Mark Czarnecki apologized for the handwritten letter, noting "apparently Dana needs the information ASAP." "Dana" is presumed to be UFC president White, and the letter details Sonnen's use of testosterone since a 2008 diagnosis of hypogonadism.
In a later instance, anti-aging specialist Dr. John Pierce wrote in 2012 advising Davidson and Greg Hendrick, then director of event operations for UFC, that fighter Frank Mir had been diagnosed with hypogonadism and had already started on a regimen of Testosterone Cypionate. That was 10 weeks before Pierce wrote the Nevada commission about the diagnosis and start of care, according to commission records obtained by "Outside the Lines."
Belfort revealed that he also has been under the care of Pierce, although Belfort said Pierce is not the "UFC doctor" who offered his initial diagnosis. Records also identify Pierce as the doctor who referred and evaluated the lab work for Nelson in 2010.
Asked when he began testosterone-replacement therapy, Belfort initially told "Outside the Lines" it was before a loss in early 2011 to then middleweight champion Anderson Silva, then corrected himself and said it was after the fight. "It was one of the doctors from UFC," he said, speaking of his low testosterone diagnosis. "He asked me to do a bunch of tests. ... He said, 'Man, you don't have the energy.'
"I said, 'Yeah.'
"He said, 'Yeah, 'cause you are having an issue.' So then we started doing some treatment."
Belfort struggled in an interview to describe the cause of his low testosterone, other than to offer that he had felt rundown and tired. "It is like a dysfunction of the hormones, and it can cause your immune system to go down and it can cover a lot of things," he said. "If I don't do it [testosterone-replacement therapy], I am actually at a disadvantage. People don't know that."
Belfort referred questions regarding a more detailed explanation to medical professionals, including Pierce, medical director of the Ageless Forever clinic -- which sits five miles west of the Las Vegas Strip.
"Quite frankly, he has hypogonadism," Pierce said, hesitating initially. "Now why is that caused? I don't know. More than likely it is secondary to repetitive head trauma over the years."
Pierce issued a similar diagnosis about Mir on his TUE application to the Nevada commission, writing that he had a "history of head trauma ... inherent nature of his chosen career path is head trauma. Patient has had at least one loss of consciousness from head trauma."
Pierce said the most reasonable cause of low testosterone in a combat athlete, as well as a football player, is repetitive head injury resulting in damage to the hypothalamus or pituitary in the brain, which affects the release of natural testosterone. But "Outside the Lines" found no boxers having been granted a testosterone exemption -- in fact, Nevada officials said they had never received a request. And the NFL says it has granted a minuscule number over almost three decades.
To Pierce's point, researchers have documented pituitary dysfunction as result of head trauma in battered children, as well as victims of severe car accident and soldiers injured in war, but medical experts caution that in most cases individuals suffered an extreme injury, often accompanied by cerebral hemorrhage.
As for MMA fighters, medical experts question the logic of allowing someone diagnosed as suffering head trauma to step back in an MMA octagon. It would figure there'd also be some signs of cognitive problems. At the very least, a full CAT scan should be done to rule out permanent damage or anything catastrophic, they said.
Some experts further challenge the notion of head trauma triggering the shutdown or reduction of testosterone production in MMA fighters, noting that multiple hormones likely would be affected by damage to the hypothalamus or pituitary -- not just the production of testosterone.
Four endocrinologists and neuropathologists interviewed by "Outside the Lines" also said they were unaware of any controlled studies in which it had been shown head trauma in an athlete had shut down hormone production. The only definitive way to make such an observation is to autopsy brains after death, and an expert in the study of chronic traumatic encephalopathy in athletes indicated research to date had recorded no such hormone deficiencies.
"There doesn't appear to be any direct evidence from what I can see that that would be an answer for why they would have hypogonadism," said Dr. Ronald Hamilton, a Pittsburgh-based neuropathologist who has reviewed brain autopsies of former NFL players. "This kind of [hormonal] change has not been noted in autopsies of CTE patients."
Michael "The Count" Bisping probably knows best what a shot of testosterone can do, although by all accounts he hasn't dabbled in the stuff himself.
The British middleweight (24-5) has suffered the misfortune of having been in the octagon against three fighters benefiting from testosterone exemptions: Dan Henderson, Sonnen and Belfort, accomplished veterans in their mid to late 30s at the time. He lost to them all, done in twice by KO or TKO -- the first of his career.
"It is obviously advantageous if you are on it," said Bisping, dropped by a Belfort leg kick in January 2013. "Look at somebody like Vitor -- you know he failed a drug test [in 2006]. And one side effect of taking steroids is reduction of testosterone production. So now he is being rewarded for cheating in the past. You also have to understand that, as your body gets older, certain parts slow down a little. On the flip side of it, you also got more ring experience.
"These older guys have had 30 or 40 professional fights, so they have more experience, plus they got the scientific supplementation. It is ridiculous. Of course, we're also not trying to hit a ball with a bat or throw it in a hoop. We're trying to knock our opponents out. So somebody is going to get hurt one day."
Indeed, the safety issue is dicey in a combat sport in which the endgame is inflicting enough bodily harm to send an opponent into submission -- occasionally via a blow to the head.
But whether naive or merely oblivious to the rumor mill, 34-year-old Bisping claims he was ignorant of his past opponents' testosterone exemptions when he stepped in the octagon. His suspicions about Belfort perked up after their 2013 fight in Sao Paulo.
"With Vitor Belfort, there was a whole cloud of secrecy regarding his drug test," Bisping said. "A lot of people saying he failed it. So I was obviously very intrigued and I contacted the UFC and they said, 'No, he hasn't failed it, but he did have a TRT exemption certificate."'
Only a month after the fight, amid a firestorm of rumors, the UFC issued a statement revealing Belfort had been on a medically approved TRT regimen under the supervision of a Nevada physician. Coming two years after Belfort now acknowledges having begun TRT, the release said the regimen had been initiated after a diagnosis of "hypogonadism, or low testosterone."
Despite his current hardened stance, Bisping said he likely would not have balked at challenging Belfort even had he known of his testosterone supplementation. He said, though, that friends told him after the fight of having feared for his well-being because of the "sheer size" of Belfort.
"The guy was so heavily muscled," Bisping said. "At the time, you are a fighter and you believe you are going to win. So I never thought about it. Looking back, you can clearly see he was on something stronger than a frosty shake."
Nor is the fiery Brit the lone voice of suspicion in a sport in which doping has evolved through the years -- as in many others -- from hard-core steroids to growth hormone and designer drugs. Or what one UFC contender referred to collectively as "blue gasoline -- the extra fuel."
The twist is that no other sport appears to have so freely handed out passes to TRT.
Reporter Josh Gross contributed to this report. Mike Fish can be reached at firstname.lastname@example.org