Aging Athletes Should Be Allowed to Take Testosterone
Last year, Kim Ciolli, a longtime fixture in Texas cycling, got busted for doping. Her case is evidence of the fact that maybe the anti-doping system for older athletes—and especially for women—is broken.
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On a steamy Saturday morning in June 2016, 48-year-old road racer Kim Ciolli lined up for the Women’s Master 40+ event at the St. Francis Tulsa Tough. Ciolli’s race was one in a series of prestigious criterium races held annually over a three-day weekend in the northern Oklahoma city. As she looked over the competition, Ciolli thought one thing. “I’m going to win the race,” she told me months later.
Ciolli, a former national and many-time state amateur champion who had already raced in Tulsa on Friday night, says she entered the relatively benign masters event for fun and exercise. Her race consisted of only five women—two of them teammates—and would run combined with a men’s masters race with 64 entrants. Ciolli, a one-time nurse who now works in Austin, Texas, as a residential developer, and who has been competing in cycling for well over a decade, guided her Specialized bike with the main pack for as long as she could over the short-circuit course. At the finish line, she saw only men, and quickly discovered that she was the first woman across—a victory she found unremarkable.
But USADA took note. The Colorado Springs, Colorado-based United States Anti-Doping Agency, the nation’s cop when it comes to the battle over performance-enhancing drugs, was running doping controls at the Tulsa Tough. For the first time in her racing career, Ciolli was summoned by its officials to pee into a cup.
A little over two months after Ciolli’s Oklahoma race, USADA announced that she had tested positive for testosterone and a stimulant called propylhexedrine, and would be banned from all sanctioned competition for two years. What followed for Ciolli, a longtime fixture and leader in Texas women’s cycling, has been shame, sadness, frustration, anger, and finally the epiphany that maybe the anti-doping system, at least in its treatment of older athletes, is broken.
When it comes to doping, there are basically three kinds of amateur masters athlete. The people in the first group resign themselves, chemically speaking, to aging. They run, ride, climb, kayak, and so on, albeit a little more slowly, courtesy of factors like hormonal changes, greater concern for injury, reduced aerobic capacity, and diminished power.
Then there are the gonzo citizen dopers—age-grouper jocks who acquire performance-enhancing drugs specifically to beat their fellow gray-haired athletes. USADA says that it doesn’t keep score, but according to the list of sanctioned athletes on the agency’s website, these calculating cheaters are outliers: 13 percent of athletes sanctioned by USADA over the last 12 months were over age 40, and even some of those “guilty” dopers received no or reduced punishments for their infractions. For more than a few aging cheats, however, a steroid like testosterone represents but a beginning. Citizen dopers have been found taking everything that pro athletes use, including amphetamine, ephedrine, erythropoietin (EPO), and human growth hormone.
Testosterone serves women as it does men—helping fuel libido and build bone strength and muscle mass. But, as they age, women start producing less of their own testosterone, and when that happens, they don’t have a standardized option for testosterone replacement.
“As an athlete, when you start losing your edge you can go through an identity crisis,” says Brendan Parent, a bioethics professor at New York University’s School of Professional Studies, and director of the NYU Sports & Society Program think tank. “For some people, it’s very sad to watch those abilities go away.”
Ciolli—who admits to her use of banned substances and also insists that she did not take them to boost performance—represents a potential third group of older competitive athletes. For most of their adult lives, these athletes have lived in largely healthy bodies that delivered on most requests to go harder and faster. Then, after what can feel like a very brief transition, those bodies do noticeably less, and not just athletically.
Daily life—sleep, appetite, attitude, energy levels—changes. The jocks don’t want to abandon the very sports that they love, even if they’re somewhat less competitive. They don’t want to break rules in order to participate, either. But what such aging athletes often want most of all? To feel whole again. Trouble is, the potential relief for these ills, at least from USADA’s perch, can turn such masters athletes into inadvertent dopers.
Ciolli, like anywhere from 25 to 80 percent of America’s entire aging population, experiences hormone imbalances that some doctors seek to treat with supplements. Her physicians tell her that to feel normal, she needs supplemental estrogen, progesterone, dehydroepiandrosterone (DHEA), and testosterone. Those last two are staples on the World Anti-Doping Agency’s annually published guide to illegal substances, known as the Prohibited List.
Ciolli believes that she was in her early 30s when her reproductive-system issues—perhaps as a result of hormonal imbalances—first became apparent. Her periods were irregular to the point that she didn’t have them. Instead, she experienced menstrual bleeding almost daily, as well as intermittent, intense abdominal cramping. By the early 2000s, while in her mid-30s, Ciolli transitioned from running to cycling, and soon afterwards began to compete on the bike. She loved the sport’s speed, and how it taught her to focus and persevere through pain. “I trained, I raced, I bled,” says Ciolli. She kept riding, and in Louisville, Kentucky, in 2008, she won a USA Cycling Masters National Road title in the women’s 40-44 criterium race.
The jocks don’t want to abandon the very sports that they love, even if they’re somewhat less competitive. They don’t want to break rules in order to participate, either. But what such aging athletes often want most of all? To feel whole again.
Finally, in late 2012 and after repeated assessments of Ciolli’s condition proved inconclusive, she decided to have a hysterectomy. “I wasn’t going to have children,” she says. “I thought, ‘I want this thing out of me.’” The procedure helped for a couple years, during which Ciolli entered nearly 50 races. But then, in early 2015, she began to experience hot flashes, sleeplessness, bloating, and night sweats—likely the early stages of menopause. By the beginning of 2016, lab work confirmed that she again had hormone-related imbalances.
“Menopause can be harsh,” says Sara Gottfried, a Berkeley, California-based gynecologist who has authored three bestselling books, including Younger and The Hormone Cure. “It’s not always a gradual slide.”
Ciolli wanted to race like she had in 2013 and 2014. But even more importantly, she wanted to feel healthy. Her gynecologist offered help: a rice-grain-size, boutique “hormone-replacement therapy” (HRT) pellet made, Ciolli recalls, of crystallized progesterone, estrogen, and testosterone. “My doctor said he could put one in,” says Ciolli, remembering her January 2016 appointment. “He made an incision into my backside. It took like 15 minutes.”
As with men, women naturally produce the hormone testosterone, although in much smaller quantities: women’s levels of natural testosterone are about one-tenth or less than those of men’s. Testosterone serves women as it does men—helping fuel libido and build bone strength and muscle mass. But, as they age, women may produce less of their own testosterone. When that happens, they don’t have a standardized option for testosterone replacement.
Men who have low or virtually no testosterone as a result of certain medical conditions can turn to U.S. Food & Drug Administration-approved therapies like AndroGel testosterone gel, and Testopel testosterone pellets. Women have no medical equivalent.
“I had done so much to promote the sport in the right way, then to be the one that screws it up so badly?”
Some of women’s HRT meds are unrecognized or unapproved by the FDA—or they’re being employed via “off-label”—unapproved—use. Ciolli’s pellet lacked FDA approval, yet such prescriptions aren’t necessarily uncommon or medically irresponsible. The allergy medication Benadryl, for example, is often used off-label as a sleep aid. Millions of women enter menopause annually, and significant numbers of them will likely try and perhaps regularly use some form of HRT, including testosterone.
“I do hope we will stop carrying the flag of ‘disease mongering’ or of ‘the battle of the sexes,’ as far as FSD [female sexual dysfunction] are [sic] concerned,” Rossella Nappi, an associate professor of obstetrics and gynecology at Italy’s University of Pavia, wrote earlier this month in an op-ed piece for the journal Expert Opinion on Pharmacotherapy. Nappa lobbies for women to have greater access to testosterone. “My wish is that we will all stand at women’s [sic] side… in order to finally get an FDA-approved treatment in the near future.”
Ciolli was told that the pellet she carried would release a steady stream of hormones over a period of three to four months, at which time she’d receive her next dose. All Ciolli cared about was her state of being, and within about a month following its insertion under her skin, the pellet made an impact. “I didn’t exactly feel like Wonder Woman, but the hot flashes stopped. I got off the Ambien,” she says. “I felt normal.”
While Ciolli’s daily dosage of supplemental testosterone was but a mere trace of what a testosterone-depleted man might receive, was it enough to boost her performance at the Tulsa race? “Where’s the line between restoring normal physiology as one ages, and performance enhancement?” asks Gottfried, the gynecologist who has been prescribing various forms of hormone-replacement therapies for over 20 years. “It’s an interesting question.”
Ciolli vows that when she arrived in Tulsa in June 2016, she felt nothing other than ordinary. Scientifically, it’s impossible to know for certain how much, if any, of Ciolli’s effort was chemically aided. Claims around the timing and impact of testosterone in terms of enhancing human performance in various sports are all over the map—from the benefits being possible to unavoidable.
Gottfried says that women are very sensitive to the effects of supplemental testosterone and that HRT pellets can deliver spiked dosages. In Tulsa, says Gottfried, Ciolli may have been enjoying the effects of a “supraphysiological” level of testosterone. However, while USADA doesn’t release any metrics associated with the levels of prohibited substances found in the athletes it busts, the agency’s August 22, 2016 announcement regarding Ciolli’s sanctioning was gentle in tone. The release stated that the exogenous (originating from outside Ciolli’s body) and therefore unquestionably illegal “…substances were contained within a prescription medication and an over-the-counter product she was taking in a therapeutic dose under the care of a qualified physician without the intent to enhance her athletic performance.”
Ciolli claims that three physicians agreed that her natural testosterone levels were extremely low. Which squares with this undeniable fact: Ciolli’s (testosterone-making) ovaries remained intact, but their ability to produce the hormone was compromised once her uterus was removed. Furthermore, an April 2011 paper from The American College of Obstetricians and Gynecologists, titled “Performance Enhancing Anabolic Steroid Abuse in Women,” states that serum testosterone of “10-100 times the normal level are required to have the desired cosmetic and athletic effect.”
Relatively speaking, that sounds like a lot of supplemental testosterone. More, perhaps, than a certain menopausal road racer from Texas had inside of her last June.
When Ciolli carried along that subcutaneous pellet to the start line of her 2016 Tulsa Tough crit, USADA, along with USA Cycling and its RaceClean program, was in the midst of ramping up efforts to police age-groupers and non-elite amateurs. “Our strategy for testing at the amateur level has changed quite dramatically,” wrote Matt Fedoruk, USADA’s senior managing director of science & research, in response to my emailed questions. “Prior to 2012, USADA didn’t conduct a lot of testing at the amateur level, but around that time, we started hearing from athletes—as well as national sports bodies—who were genuinely concerned that amateur competition was not occurring on a level playing field.” With RaceClean “revamped in 2016,” wrote Fedoruk, there was even more testing planned for USA Cycling events.
USADA claims to have a straightforward, 8.5 x 11-inch equalizer for older athletes to take needed meds without getting flagged by doping controllers. It’s called a “therapeutic use exemption” (TUE), and to qualify, older (and of course, other permission-seeking) athletes must complete a laundry list of items that can include probing and comprehensive TUE forms, medical histories, documentation from pertinent lab tests, and proper doctors’ correspondence.
USADA then reviews the information. A TUE, which often requires ongoing verification and never comes with a lifetime grant, can permit the use of medications for conditions including asthma, renal disease, diabetes, or growth-hormone deficiency. You can also receive, after your doctor successfully tackles an especially rigorous, 13-page USADA worksheet, permission to take testosterone.
Maybe. If you’re a man, that is, suffering from true hypogonadism (insufficient testosterone production) as a result of genetics, injury, or infection. USADA constantly shoos away male TUE applicants who claim testosterone deficiencies but who are at best borderline “low” in testosterone. That perhaps earns them a prescription for voguish, supplemental “T” from their doctors, but not a hall pass to enter races. As VeloNews recently reported, USADA has even granted a special Recreational Competitor Therapeutic Use Exemption (RCTUE) for supplemental testosterone to a couple of aging male athletes. The unusual TUE is in effect so long as those guys don’t win.
“Where’s the line between restoring normal physiology as one ages, and performance enhancement?”
For women petitioning for testosterone supplementation, USADA offers no such gray area. “Except for very limited circumstances,” USADA’s Fedoruk wrote me, “there are no diagnoses in females where androgen [like testosterone] replacement therapy is considered the best medical practice.” USADA later informed me, through its media relations representative, that it has never granted a TUE for testosterone to a woman for treating post-menopausal symptoms.
In his written responses to me, Fedoruk accurately states scientific truths: normal testosterone levels vary greatly between individuals, and that factors including sleep, stress, nutrition, training, and genetics contribute to its variability. Plus, USADA’s decision to keep supplemental testosterone out of virtually every older, competing female athlete is in part informed by the thinking of the century-old Endocrine Society, which recommends against testosterone supplementation for women. The group claims it’s both difficult to characterize a low-testosterone condition as well as to know the long-term effects of such supplementation. (However, one can find similarly critical thinking from the medical community over the potential dangers for men who take supplemental testosterone.)
In a way, Gottfried essentially supports Fedoruk and USADA: she often suggests that women try to elevate their testosterone via resistance training, dietary changes, and de-stressing via yoga before turning to supplementation. But she also says that prescribing supplemental hormones to aging women, including estrogen, progesterone, and even USADA-forbidden testosterone, has its place. “Some women are hypogonadal, too,” she says.
USADA apparently exists by a double-standard—what’s permissible for some aging men will not be considered for women. Last year, USADA bared its teeth when age-grouper Mary Verrando-Higgins sought a therapeutic use exemption for a prescribed derivative of testosterone. The application was denied, and the 54-year-old Verrando-Higgins, who went on to win her road race at the 2016 USA Cycling & Para Road Nationals, was subsequently disqualified and sanctioned.
“I think that the USADA policy probably needs to be revisited,” says Gottfried. “To me that smacks of misogyny.”
What upsets Ciolli most is knowing that she broke the rules. Her post-Tulsa Tough drug test resulted in USADA sanctioning Ciolli not just for one violation, but two. Her urine specimen taken at the 2016 race indicated the presence of an exogenous androgenic steroid, as well as the stimulant propylhexedrine, which came from Ciolli’s doctor-prescribed asthma medicine. She blames nobody but herself for what she claims is a lifelong lack of attention to detail—failing to ask her doctors exactly what they’re instructing her to take.
“To talk about how much I beat myself up would be an understatement,” says Ciolli. “I cried and cried. I had done so much to promote the sport in the right way, then to be the one that screws it up so badly? I didn’t care about the guy who doesn’t know me. But I did care about those who had believed in me.”
Many in the Texas cycling community have rallied around Ciolli, including the 19-woman, ATX HitSquad Team that she’s led and funded to the claimed tune of $30,000 over nearly the last three years. “Kim was doing what doctors and nurses told her to do to feel normal. Make no mistake—she did not know that she was taking a banned substance,” says Debra Bailey, an Austin cyclist who for years has raced both against and as a teammate of Ciolli’s. “Kim would never do anything that’s not above bar. I would bet my life on it.”
Ciolli thinks about the 100,000 lifetime miles she’s ridden, the countless bones she’s broken while cycling, and the nine state championships that she has won. They all seem like they’re part of some other athlete’s life.
Some people in her peer group, however, are as wary of Ciolli as they are sympathetic. Ciolli, at a certain point, sounds like so many doping cyclists who have rolled under the Klieg lights before her. The drug use, plenty of dopers say, was an accident. They weren’t doping to win. Ciolli, other bike racers whisper, was once an intensive-care-unit nurse. She’s been in the sport a long time. She knew to be mindful of everything that entered her body.
“People like Kim. I like Kim,” says Austinite and former pro cyclist Kat Hunter. “But because a person does good things, that doesn’t make everything they do good. You don’t know what’s going on in other people’s heads.”
In what is a very thorny doping case, finding absolute justice and exactly who is right seems nearly impossible. You have a female bike racer with a history of burdensome hormone issues, as well as enough competitive experience to know better than show up at a start line while on an illegal substance.
You have a small policing entity that, in addition to monitoring the behavior of a country’s elite athletes, must increasingly concern itself with amateur jocks, including the health and welfare of more and more never-say-die masters athletes. These participants don’t want to quit in competition, and won’t quit when it comes to the pursuit of feeling good, which means feeling like their old—young—selves.
“This is the stuff I lose sleep over,” says Brendan Parent, the NYU bioethics professor. “I think the answer to this whole dilemma is, ‘It’s complicated.’”
Ciolli twists and turns in bed over her case, too, and not only because she failed to apply for TUEs ahead of racing on banned substances like testosterone. She thinks about the 100,000 lifetime miles she’s ridden, the countless bones she’s broken while cycling, and the nine state championships that she has won. They all seem like they’re part of some other athlete’s life.
Ciolli also lies awake at night because, even though she’s not racing now and may never again, her hormones are thoroughly imbalanced. Despite her doctor’s pleadings, Ciolli refuses to take testosterone and DHEA, because at any time the USADA cops can now knock on her door and request a urine sample. To test positive again, says Ciolli, would be unbearable. “I’m choosing not to take my medications,” she says. “I don’t want to risk the chances of receiving a lifetime ban. I refuse to have another whirlwind crucifixion of my name and reputation.
“I have to decide whether I’ll race my bike or feel normal,” adds Ciolli, whose personal email address, computer screen saver, home-décor tchotchkes, and multiple bikes housed in her impeccable garage all speak to her huge passion for the sport. “Why keep me from being a normal human being?”