Why eliminating TUEs is wrong

There is an old saying – don’t throw out the baby with the bath water. Unfortunately, that is exactly what some are calling for in response to the abuse of Therapeutic Use Exemptions (TUEs). Namely, a total ban. While that reaction may seem like “common sense” to other racers that feel cheated by the abuse of TUEs in the pro peloton, it actually impacts others in an unintended way. In fact, there is one entire team that relies on valid, legitimate Therapeutic Use Exemptions to even compete. TUEs were made for a reason – and we must not let that reason be forgotten.

There is a need for TUEs and that is for someone to treat an illness or a
sickness. They are not intended and should never be used to improve

Phil Southerland. CEO and Co-Founder of Team Novo Nordisk

First – a little history

Almost all of the substances routinely (and illegally) used as performance enhancing drugs were designed to treat real medical conditions. As anti[doping controls covered more and more substances over the years, it was inevitable that would overlap with professional athletes using these substances for purely medical reasons – without the desire or intent to gain a competitive advantage.

Because of the desire to open the sport to as many legitimate athletes as possible, as well as help ensure the health of the athletes, a mechanism has been enacted to allow exceptions to standard doping rules for those that demonstrate a medical need and will not receive a performance gain from use.

Athletes may have illnesses or conditions that require them to take particular medications.

If the medication an athlete is required to take to treat an illness or condition happens to fall under the Prohibited List, a Therapeutic Use Exemption (TUE) may give that athlete the authorization to take the needed medicine.

The purpose of the International Standard for Therapeutic Use Exemptions (ISTUE) is to ensure that the process of granting TUEs is harmonized across sports and countries.

World Anti-Doping Agency

There are, unfortunately, possibilities for abuse. And one can definitely understand the anger felt by clean athletes when TUEs are abused in events. A recent publication in the academic news outlet The Conversation even went as far as suggest that TUEs are harmful to athletes by masking symptoms when they should instead be recovering.

If an athlete is ill or in pain, they should rest. Drugs which mask a health problem in order to allow athletes to push themselves for the sake of sport could have an impact in the short and longer term.

Elite sport: time to scrap the therapeutic exemption system of banned medicines

However, this argument falls very much short by refusing to acknowledge that not all TUEs are simply about managing symptoms. The most glaring example of this is the treatment of type 1 diabetes. Diabetics are forced to take insulin – not only to compete, but to stay alive. In is not an optional medication, and it is not something that is used simply to mask symptoms. Instead, in is necessary to use via daily injections in order to replace a vital hormone that is absent in type 1 diabetics. And there just happens to be an entire pro cycling team rostered exclusively by type 1 diabetics.

Team Novo Nordisk

Team Novo Nordisk (formerly Team Type 1) was co-founded by Phil Southerland and Joe Eldridge. The team has become an inspiration for athletes with diabetes world wide. And given that the team is made up entirely of athletes that live with diabetes, each and every one of them has to have a therapeutic use exemption to compete. Ban TUEs, and you ban an entire team.

Team Novo Nordisk is a global all-diabetes sports team of cyclists, triathletes and runners, spearheaded by the world’s first all-diabetes professional cycling team.

Comprised of nearly 100 athletes from over 20 countries, Team Novo Nordisk competes in more than 500 international events each year.

I had a chance to talk with Phil Southerland, as well as Team Novo Nordisk rider Sam Brand, about cycling with diabetes, TUEs, and their reactions to the call for the elimination of legitimate therapeutic use exemptions. Below are their words:

Phil Southerland – CEO and Co-Founder of Team Novo Nordisk

JustAnotherCyclist: Therapeutic Use Exemptions (TUEs) have been in the news quite a bit lately. While researching them for this story, I was somewhat surprised to learn that insulin itself is on the banned substances [list]. Does that mean that every athlete on Team Novo Nordisk has a TUE?

Phil Southerland: Yes, all riders at Team Novo Nordisk race with a TUE. Since the team’s inception in December 2012, we have always been very public and extremely proud that we race with type 1 diabetes. Additionally, we have always been open that we race with TUEs. WADA included the use of TUEs so that an athlete who has a legitimate medical condition can continue to compete. The UCI and the anti-doping organizations recognize that diabetes is a legitimate medical condition and grants all Team Novo Nordisk athletes TUEs to use insulin.

JAC: How many total athletes on Team Novo Nordisk have existing TUEs related to diabetes?

PS: As of January 1, 2018, 28 athletes on Team Novo Nordisk race with TUEs. There are16 riders on the men’s professional team, 11 riders on the development team and one professional female track cyclist, Mandy Marquardt.

JAC: What is the process for an athlete with a legitimate medical need – such as diabetes – to be able to compete while taking insulin?

PS: Our medical staff handles all TUEs, and the process with the UCI includes submitting medical records that show the date of diagnosis, place of diagnosis and the doctor who diagnosed the athlete. All this information is verified to show that our riders are racing with type 1 diabetes and need insulin injections to survive.

JAC: UCI rule 13.3.052 seems to imply that the injection of any substance via syringe in banned. However, the rule does specifically call out diabetes as an example of a permissible situation for athletes to self-inject. Is it a separate TUE for the insulin, and the administration method?

PS: There is an extensive process that we go through with the UCI to prove our riders’ need for insulin. It comes down to life or death for these athletes. The UCI grants all Team Novo Nordisk athletes long-term TUEs for insulin use. As an American-registered team, USADA serves as our anti-doping organization and recognizes and explicitly list on its website that athletes who are insulin-dependent (athletes with type 1 diabetes) are allowed to race under a TUE
while using insulin.

Currently, the only method for type 1 diabetics is subcutaneous injections. Our athletes are not choosing an injection over an alternative.

JAC: Have riders or team staff ever experienced any negative interactions from other riders or officials as a result of the possession and usage of insulin to treat diabetes during a race?

PS: Early on, we had people see the riders injecting at races and report it to officials. The officials are well versed in our situation and all our riders have documentation that they carry that proves their TUEs.

In general, we receive positive feedback from riders, organizers and officials. To be honest, seeing a rider inject typically opens up a conversation. People often use it as an opportunity to ask questions, which we always welcome.

JAC: What was your reaction when Froome’s test results turned out to be a
substance he had a TUE for?

PS: What concerns me about the Froome situation and anyone else using a TUE for marginal gains or to push the limits into the grey area is that it creates a huge negative perception around the sport and can damage the reputation of the athletes who have a vital need for long-term TUEs. There is a need for TUEs and that is for someone to treat an illness or a sickness. They are not intended and should never be used to improve performance.

We are happy to be a part of this conversation and want to set the record straight by showing the valid and positive side of TUE usage. We are proud and thankful that we have the opportunity to race with a TUE. It is a great concept, and one that we believe needs to be ethically respected. Thanks to TUEs, all Team Novo Nordisk athletes can inspire, educate and empower people around the world affected by diabetes.

Sam Brand – Rider, Team Novo Nordisk

JAC: Can you describe the experience the first time you had to acquire a TUE?

Sam Brand: First, let me thank you for taking the time to talk about TUEs and the valid side of the conversation. As a diabetic and even more so, an athlete for Team Novo Nordisk, I am passionate to speak about this topic and to try and further educate and raise awareness about diabetes.

My first experience acquiring a TUE took a long time. I moved up to Team Novo Nordisk’s professional team as a stagiaire mid-season, so I needed to have it in place before then. It required a lot of paperwork, emails and calls with the various organisations (British Cycling and UKAD) in order to process the application and finally have it granted to me. It wasn’t the easiest task and certainly not as straightforward as people may think.

JAC: There are numerous stories of cheating teams and athletes going to great length to hide syringes used for illegal PEDs. As a diabetic myself I know that keeping syringes on hand wherever I go is just part of diabetes management. Do the team athletes have to jump through any hoops in regards to the handling of their insulin pumps, syringes, or insulin as a result of a UCI license?

SB: As a fellow type 1 diabetic, you understand that all diabetics need insulin to survive. Currently, the only way to get insulin as a type 1 diabetic is through injections. We don’t actually have to jump through any hoops because we aren’t hiding anything. For us, the process is applying and being granted a TUE, and then we can use insulin. If we need to inject during a race, that is fine and we do not feel we have anything to hide. 

JAC: Since the findings against Froome, some have started to question the validity of TUEs at all. Do you have any concerns that regulation changes in response may make it more difficult – or even impossible – for diabetic athletes to compete in sanctioned events? Do you feel that riders abusing TUEs for performance gains impact you in other ways besides performance in the peloton?

SB: I definitely have concerns. There are more and more high-profile athletes calling for bans on TUEs. Additionally, people are claiming that if you need one, then you aren’t fit to race or be a professional athlete. To me, all of that is quite offensive.

This current conversation is about athletes using TUEs to enhance performance, and I completely understand this concern. As an athlete with a long-term TUE, I agree wholeheartedly with the need to sort out the current system, but I adamantly don’t agree with an outright ban on all TUEs. It isn’t the answer and takes a very shortsighted viewpoint.

JAC: Have you ever had any conversations with other riders about your use of insulin at an event? If so, what were some reactions?

SB: In my experience, there are many people around the world, not just riders, who are not well educated in diabetes.  This is why the team’s mission is to inspire, educate and empower everyone affected by diabetes. I greatly enjoy that part of my job because it allows me to have conversations with people about diabetes and help educate them on the condition. In general though, fellow cyclists tend to be genuinely interested in knowing more.

JAC: Have you had to change the way you manage your diabetes to comply with the anti-doping rules?

No, not at all. While everyone’s management is different, it’s relatively straightforward how I manage my diabetes.