Therapeutic Use Exemption (TUE)—a right with obligations
It is a lovely sunny morning. Hannah, a 17-year-old sprinter, is getting ready for training. As she leaves the house, she quickly checks the mailbox. There is a very official-looking letter from her national anti-doping agency (NADO). She immediately knows that this is significant. Two weeks before, she had been tested for the first time in her career at a regional athletics meeting.
She rips the envelope open and unfolds the pages inside. There is a large watermark “confidential” across the pages. The letter signed by the NADO’s General Manager tells her that the substance methylphenidate had been found in her sample. Since there was no Therapeutic Use Exemption (TUE) for her on record, the NADO would take the case further as an “adverse analytical finding” and “charge” her accordingly. Hannah is stunned. She feels dizzy and has to sit down on the entrance stairs.
Staring at the signature underneath the letter, she tries to make sense of this. She has been taking Ritalin ever since she was diagnosed with attention deficit hyperactivity disorder (ADHD) at the age of seven. It is a medical condition, and her doctor prescribed the tablets to her. They help her to stay focussed. So, why is there a problem?
What is a TUE? Why should I care?
As an athlete, you may suffer from a disease or sustain an injury, whether related to your sport or not. At times, your doctor has to treat you with a medication that contains substances that are on the World Anti-Doping Agency (WADA)’s Prohibited List (“List”). In that case, you will have to apply for a Therapeutic Use Exemption or ‘TUE’.
The TUE system is meant to protect athletes’ right to appropriate medical care. The principle of this use by exemption goes back to 1986, when the IOC Medical Commission decided to ban certain substances at the Olympic Games. The ultimate goal is to create a level playing field for all athlete patients worldwide.
The principles underlying TUEs are by no means uncontested. TUE criticism has seen an upsurge ever since the ‘Fancy Bears’ group gained access to and published the TUE certificates of some athletes during the Rio Olympic Games. You will find fractions in the anti-doping community that believe TUEs are granted much too easily. Some even argue that athletes with diabetes or asthma should not compete at all.
What you need to know about TUEs
Remember that substances are on the List for a reason. An athlete may theoretically use a disease or condition as a pretence to use a prohibited substance to increase their performance. This is where the TUE system needs to balance your right for medical care with the potential of the medication to enhance your performance.
Hence, your right comes with obligations for you as an athlete. First of all, the World Anti-Doping Code (the Code) article 21.1 requires you to tell your doctor and any medical personnel treating you that you are not allowed to use prohibited substances or methods. Essentially, the approach to and documentation of your history, symptoms, diagnosis, and treatment have to meet certain requirements that are defined by the International Standard for TUE applications. This is no different from other patients in occupations that demand a unique medical approach, such as airline pilots or professional SCUBA divers.
The next obligation is that you are ultimately responsible for your TUE. This can become quite daunting because, on the one hand, you most likely do not have medical knowledge. On the other hand, the official rules are written in medico-legal language that is not easy to understand.
Knowing when and how to apply
Hannah should have applied for a TUE once she became a national level athlete in the definition of her NADO three months ago. She received a whole pack of information back then, but did not take the time to go through it. In general, as an athlete, the first thing you need to establish is whether you actually need a TUE and to whom you need to apply. This depends on your competition level and also differs from country to country and between sports. Many anti-doping organisations require only elite athletes to apply in advance, which means before using the substance. Other athletes may only need to apply once they have been tested and the substance has been found in their sample.
Your NADO or international sports federation define which athletes have to apply for a TUE, and should have clearly described processes when and how exactly to do so on their website. They will also provide a TUE application form that you have to download. A fully completed TUE application form is a standard part of any application.
Susan just made it to the regional swimming team. She is very excited but also extremely nervous. She has diabetes, and injecting herself with insulin is part of her daily life. Her friend Hannah has just been sanctioned. She is not allowed to compete because she took medication for her ADHD without having permission from their NADO. Susan has checked the List and found that insulin is prohibited. Her coach tells her not to worry but sign up for the Anti-doping e-learning platform (ADeL) where she would learn everything about how to apply for a TUE.
Your medical documents
Even though you are responsible for your TUE, you will need the support of a physician to apply for it. Importantly, any doctor who accepts to treat you as an athlete becomes bound by the Code, too. This entails several professional obligations such as providing a complete medical file to support your TUE application.
This might be very clear for your team doctor or other sports medicine physician with experience in anti-doping. However, it may become a challenge for a general practitioner or specialist who is not familiar with these rules. We will get back to this in a future blog and explain how you can support your doctor.
As a rule, remember that the completed TUE application form itself is never enough. There always needs to be a detailed medical report from your doctor.
The report has to describe the history of your symptoms and the findings when they examined you. They should include copies of the results of investigations (blood tests, urine tests, X-rays, computed tomography or magnetic resonance imaging as needed), or maybe surgery reports. Your doctor also needs to describe how they arrived at your diagnosis.
Susan’s family doctor writes a note for her on the application form: “I herewith confirm that Susan has diabetes type I. She is treated with insulin and will die without it. There is no alternative treatment.”
Susan is relieved. She signs the application form and sends it off to the NADO. She thinks, “So, that was that.”
TUE review and decision
You will have to sign on the TUE application form that you agree with your medical information being shared with your anti-doping organisation’s TUE Committee. This body consists of at least three physicians who will assess whether your application meets the criteria defined in the Code and WADA’s International Standard for TUEs. They may ask for further information from your doctor before they accept your application.
Once your anti-doping organisations has accepted your application as complete, they have, in general, 21 days to decide whether to grant or deny your application for a TUE. If approved, you will be notified of the conditions. Only after that are you allowed to start taking the substance (the exception is a “retroactive” application, which we will explain in a future article).
Was that really it?
A few days after Susan had submitted her application, the NADO sends her an email. The administrator writes that Susan’s medical file was incomplete and attaches the WADA Checklist for TUE applications for diabetes. She takes that back to her doctor and asks him to provide the information described there.
This means that, even if you take a life-saving medication, your doctor still needs to explain and sufficiently document how they made the diagnosis. Simply saying that you need it is not enough.
Susan’s TUE was eventually granted after she had included a full medical report. A TUE allows you to use a prohibited substance at a defined dosage and frequency and always for a limited amount of time. This means you need to create reminders that alert you when your TUE is about to expire so that you can re-apply. Your anti-doping agency will not necessarily inform you about the upcoming expiry.
TUE denials
If your TUE is denied, your anti-doping organisation needs to explain their reasons to you in writing. This means they have to explain where exactly your application does not meet the criteria defined in WADA’s International Standard for TUEs. The consequences of such a denial may differ considerably, for example, when the rules do not require you to apply in advance, but only retroactively, and we will talk about that in a future blog.
One important reason to apply retroactively is an emergency. For example, if you suffer a life-threatening allergic reaction, your well-being and health come first and must never be compromised. Urgent treatment should never be delayed because of TUE considerations. These can be dealt with afterwards—with a retroactive application.
Although the process can feel intimidating, TUEs are a critical part of inclusive and fair sport. ShePower Sport aims to assist you in navigating the complex anti-doping world and make it easier to understand.
Author Profile
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I am a surgeon with over 15-year leadership experience in international sports, anti-doping, medicine, and research organizations. Currently, I am chairing the South African Institute for Drug-Free Sport TUE Committee and am a member of the UEFA TUE Committee and the WADA TUE Expert Group.
My professional and personal ambitions are driven by the belief that confident female athletes will transform sports and make it more powerful, inspiring, diverse, and convincing. That is the reason why I co-founded ShePower Sport with Yoko.
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