Robert Qualls deserves a retroactive therapeutic use exemption

If gender affirming care qualifies for a therapeutic use exemption for testosterone, why not anti-aging treatment?

Against the backdrop of USA Track & Field Olympic Trials, the United States Anti-Doping Agency (USADA) sanctioned one of America's most dominant runners for using performance enhancing drugs.

Robert Qualls tested positive for amphetamine and a metabolite of nandrolone and related steroids. This ends Qualls' medal streak that includes gold in cross country, silver in the 10k road race and 4 x 400m, and bronze in the 1500m and 5000m at the 2022 World Masters Athletics Championships; and silver in the 6 km cross country race, plus bronze medals in the 1500m and 3000m at the 2023 World Masters Athletics Indoor Championships, all in the men's 70-74 age group. Back home, Qualls won the last six USATF Masters 5K Championships for his age group, and was USATF's 2023 Male Masters Road Runner of the Year.

Nandrolone is a synthetic version of testosterone and an anabolic steroid. It most recently came up in track & field circles when Shelby Houlihan blamed a positive drug test indicating nandrolone usage on a pork carnitas burrito.

Medical doctors are prescribing nandrolone with increasing frequency. Not to women in their 20s, like Houlihan, but to men in their, shall we say, Masters age groups.

The American Urological Association sets 300 ng/dL as the threshold for low testosterone. Clinically, "a lack of androgens or their action" is known as hypogonadism. When it occurs in men over 50, the diagnosis may be late-onset hypogonadism, a condition "characterised by loss of vitality, fatigue, loss of libido, erectile dysfunction, somnolence, depression and poor concentration," potentially resulting in "significant detriment in the quality of life."

Males' testosterone levels decline by up to 2% a year starting in their 50s. By the time we reach Qualls' 70-74 age group, about 70% of men are hypogonadal under the Free T Index criterion, and about 35% by the serum testosterone criterion (i.e., <300 ng/dL).

On top of the decreased sexual everything that most people associate with age-related declines in testosterone, comorbidites of hypogonadism include osteoporosis, Alzheimer's disease, diabetes, hypterension, cardiac failure and ischemic heart disease. A 2008 review in Clinical Interventions in Aging caveats "[t]he extent to which testosterone deficiency is involved in the pathogenesis of these conditions, or to which testosterone supplementation could be useful in their treatment is an area of great interest with many unanswered questions." Correlation? Causation? Unsure, but hey, feel free to FAFO.

Nandrolone is "potentially beneficial in the treatment of male health alone, or as an adjunct to [testosterone supplementation therapy] for hypogonadal men," a 2016 review concluded.

Little wonder, then, that anti-aging clinics around the country not only provide testosterone replacement therapy, but complement it as necessary and appropriate with nandrolone prescription. The New England Center for Functional Medicine cites the above review almost verbatim. Innovative Men's Health near Seattle says "the systemic administration of nandrolone could improve body composition and augment testosterone’s effects in preventing and reversing metabolic syndrome and the risk of type 2 diabetes in hypogonadal men."

I first heard of anti-aging medicine about 10 years ago. My friend's husband was a trauma doctor working towards his board certification in anti-aging medicine. I likely said something about making money off the Boomers, and he quickly corrected me. The target market, he said, was the 40- and 50-something Patagonia fleece vest crowd in the Westlake and Lake Travis areas of Austin, TX, who were willing to do anything - anything - to qualify for Kona and crush their PRs on the triathlon scene. They would never be competing for the podium, so they had no fear of drug testing. Their only fear was having a slower time or putting out fewer watts than that MBA at their rival tech incubator.

The motivations for anti-aging hormonal (steroid and otherwise) treatments have expanded as anti-aging medicine has gone more mainstream.

While a segment of social media spent the first few weeks of June wondering what PEDs would get Joe Biden through the first debate (now joined by nearly the entirety of social media wondering what PEDs failed that night), the third presidential candidate is open about his use of anti-aging treatments.

Robert F. Kennedy, Jr., was on The Lex Fridman Podcast last year and said "I'm on an anti-aging protocol from my doctor that includes testosterone replacement... I don't take any anabolic steroids or anything like that and the TRT I use is bioidentical to what my body produced." Could a man his age look like the multiply reheated beefcake bro benching on Venice Beach last year with the assistance of "only" bioidentical testosterone replacement and no anabolic steroids? Maybe? Might just depend on how willing you are to take (a) a political candidate, (b) a lawyer, (c) a Kennedy, (d) all of the above at his word.

Teaser: I know of a fun connection between RFK, Jr., and elite running. Hopefully, at some point, we'll be able to share it.

The other dons of long form podcasting have also increased the demand for and acceptance of testosterone replacement therapy and anti-aging protocols. Anti-aging researchers-evangelists David Sinclair and Peter Attia have multiple appearances each on The Huberman Lab and The Joe Rogan Experience; and Rogan is openly all in.

"Testosterone replacement therapy, hormone replacement therapy, I started doing all that when I was 40... It makes a big difference. F--k yeah!" said Joe Rogan in 2018.

Rogan's guest, Joey Diaz, growled "I gotta get USADA on this motherf--ker." "I'm gonna fail all those tests," Rogan responded.

"There's a stigma attached to it. 'Where do you get your testosterone from? <whiny voice> I get it from my balls!'" Rogan cracked at the expense of non-users. "Hormone replacement therapy exists for a reason. It makes you feel way better. It makes your body work better. You can avoid a host of ailments and conditions related to your body breaking down due to age. The key to doing it, though, is doing it correctly," he said, before outlining a process that starts with going to your doctor.

Whether you're reading the scientific and medical literatures or listening to your favorite podcaster, one thing you should notice is that they all talk about using anti-aging testosterone treatments to bring their levels back to where they once were. The target levels are the normal range for men. In the case of men with clinical hypogonadism, it's just getting back into the bottom end of the range - clearing that low threshold of 300 ng/dL.

So if a male masters athlete uses testosterone, is it performance enhancing, performance restoring, or performance correcting? Is the baseline against which we judge the physiological and athletic enhancement their personal lifetime highest level of testosterone, presumably set in their 20s? Or are we gauging against what their testosterone would be in the absence of supplementation as they progress through their 50s, 60s, or - like Robert Qualls - 70s?

These are not faculty lounge questions.

The World Anti-Doping Agency's International Standard for Therapeutic Use Exemptions states "The Therapeutic Use of the Prohibited Substance or Prohibited Method will not, on the balance of probabilities, produce any additional enhancement of performance beyond what might be anticipated by a return to the Athlete’s normal state of health following the treatment of the medical condition."

Is the "normal state of health" the naturally reduced levels of testosterone that progessively accompany each decade of life past middle age? Or is the "normal state of health" the levels of testosterone during a man's physiological (and athletic) prime years, before the onset of the senescence processes associated with aging? And how does this conversation shift if medical associations, academics, and government agencies classify aging itself as a disease?

Robert Qualls almost certainly had serum testosterone concentration over 300 ng/dl at some point in his life. Given his age, there is a good chance his serum testosterone concentration would be below 300 ng/dl right now if not for his pharmaceutical interventions, although his active and presumably healthy lifestyle would mitigate the drop in testosterone. Even without the nandrolone, he might still be above 300 ng/dL.

Last year, USADA granted a therapeutic use exemption to an athlete who had never had testosterone levels above 300 ng/dl without the use of exogenous testosterone. As readers of my work here and elsewhere, building upon Sarah's ground breaking reporting here, know, USADA granted the first ever TUE for testosterone to a female runner, Cal Calamia, to run in the male and non-binary categories in October. The TUE was retroactive, covering several races Calamia had run despite being admonished by USADA not to do so while under investigation, and extending 10 years into the future.

USADA pretends there are sexless runners

The Washington Post first reported the TUE, and said that exogenous testosterone supplementation brought Calamia's levels into "the lower end of the 'normal' range" for men - that 300 ng/dL we're all familiar with at this point. However, we haven't yet mentioned the normal range for women: 15 - 70 ng/dL.

Unlike Qualls, Calamia never experienced her current levels of testosterone absent supplementation. Given the effects of testosterone supplementation on nearly every measure of athletic performance, there is no way Calamia's new testosterone levels do not "on the balance of probabilities, produce any additional enhancement of performance." USADA could only rationalize their decision by the last clause of the ISTUE standard - "the Athlete’s normal state of health following the treatment of the medical condition" - which requires a complete acceptance of the transgenderist ideology regarding "normal state of health" and "medical condition."

Robert Qualls could be a trailblazer for anti-aging medication patients. Granted, we don't know if he was prescribed nandrolone by an actual doctor for anti-aging purposes, or if he just binged a bit too gluttonously at his local burrito truck. And he's on his own with that amphetamine usage.

But if gender affirming care, why not anti-aging medicine? And as an avatar for anti-aging patients, why not him?

Qualls will face some difficulties following Calamia's path to relief in front of USADA.

Calamia garnered her TUE on the back of pro bono legal representation by David Feher, head of the Sports Litigation Practice at Winston & Strawn. Feher has deep experience breaking down Chesterton's fences in sport, having worked on one of Caster Semenya's legal proceedings. Feher started representing Calamia at the intercession of New York Road Runners CEO Rob Simmelkjaer, who boasted in November and again in January on NYRR's podcast about his machinations on behalf of the genderwang community to loosen USADA's policies.

Simmelkjaer gave "a shout out to David Feher," during his conversation on the podcast with Calamia. Feher is "a friend of mine who I know worked with you, a great lawyer who's done a lot of great work in this area. I was happy to be able to connect you with David and help you get this TUE... He was instrumental in this whole process." Two months later, Simmelkjaer's co-host and NYRR SVP Christine Burke spread the credit around the organization: "We've worked really closely with USADA... to encourage the inclusion of non-binary gender option on USADA forms and applications, as well as advocating for therapeutic use exemptions for gender affirming care for trans athletes."

Qualls does not appear to check any priority boxes for diversity, equity, nor inclusion. He lives in Reno, NV, and has never run a NYRR race. Now that he has received an anti-doping sanction, Qualls is ineligible to participate in any New York Road Runners race. Unless he is selected as the Chair of the Board of the Directors.

The deck is stacked against him, and - I'll just say it - time is not on his side.

Therefore, on behalf of middle aged, Joe Rogan-listening, Jonathan Swift-reading, RFK Jr.-curious, adult human male runners who believe in The Science, I call on track & field's and road running's most influential individuals and institutions to mobilize behind a retroactive therapeutic use exemption for Robert Qualls.

What say you, Rob Simmelkjaer, Christine Burke, and Nnenna Lynch? Will you #LetRobertRun? Because unless you're ageist, you should have #NoQualmsAboutQualls.

I will accept your response in podcast form.

From L to R: Athlete; Athlete; Athlete; Athlete; Athlete; One man’s doper is another man’s trailblazer, martyr, and all-around legend.