The sport of mixed martial arts is, by nature, controversial. In today’s “civil society,” the very idea of two men fighting each other with few holds barred in a cage on pay-per-view television is nothing short of repulsive to a great many people. As I watched UFC 153 this past Saturday night, I could very easily understand how a lot of folks, even a lot of sports fans, would be turned off by the sort of brutality unleashed during the Glover Teixeira/Fabio Maldonado fight.

Still, there is a large and growing market of people who regularly shell out their $50 for the UFC’s pay-per-view events. These are the people who can get past the gore of Teixeira/Maldonado because they know the main event will feature the sort of artistry in motion that one only sees in someone like Anderson Silva—who put away Stephan Bonnar in jaw-dropping fashion to close out Saturday’s card.

These fans’ acceptance of (and in some cases, lust for) sanctioned violence does not, however, mean that the sport is free of controversy in their minds. For those people who have truly invested themselves in the goings-on in MMA, whether they are fans, journalists, fighters or promoters, there have been two issues in the last year or so that have stirred the pot more than the rest: Testosterone Replacement Therapy (TRT) and the plague of injuries that has forced significant alterations to a number of fight cards.

Let’s quickly address the latter issue first.

As I wrote in September, injuries to the UFC and Strikeforce’s best fighters are no longer simply forcing matchmakers to find new opponents for undercard fighters. In 2012, six of the UFC’s pay-per-view co-main or main event fights were altered due to injuries suffered by their original participants, alterations which included the cancellation of UFC 151 altogether. This cancellation seemed to start an unsettling trend, as fans more recently saw two consecutive Strikeforce cards scrapped due to injuries to fighters.

I’m not going to waste your time by re-hashing the many, many pieces that have been written this year bemoaning the rash of injuries and grasping at straws in attempts to find a solution to minimize the number of fighters hurt during their training camps. It’s a reality of the sport, and there’s probably not a ton of preventative measures that can be put in place to ensure a combat athlete can adequately prepare for a fight while simultaneously minimizing the risk of injury.

This fact dovetails well into a discussion of TRT—perhaps the most controversial aspect of MMA among its fans and participants outside of the sport’s inherent violence.

Most fans likely only became aware of the practice of fighters using TRT after UFC middleweight title contender Chael Sonnen was suspended after his testosterone to epitestosterone ratio was measured at a rate not commensurate with the California State Athletic Commission’s (CSAC) regulations. This was in late 2010. Just two years later, fans now hear about TRT before or after every other card.

This increase in exposure TRT has received is no doubt due to the somewhat dubious circumstances under which fighters take advantage of the supplement. When Sonnen was brought before the CSAC to explain his off-kilter T/E ratio, he claimed that he suffered from a condition known as hypogonadism and was thus instructed to undergo TRT to counteract the disorder’s effects. The explanation Sonnen provided seemed a stretch to many, but apparently it was enough to convince an athletic commission to allow the middleweight to use TRT in his subsequent fights.

Seizing upon this new supplemental loophole, a number of other fighters have since applied for and been granted similar TRT use exemptions by the Nevada State Athletic Commission (NSAC), thus shining the spotlight even brighter on the controversial practice.

According to this article published by the National Institutes of Health, the main symptoms of hypogonadism (the only disorder for which TRT is recommended and, thus, the disorder MMA fighters repeatedly claim to have so they can gain the use exemption) are “low libido…erectile dysfunction, decreased muscle mass and strength, increased body fat, decreased bone mineral density and osteoporosis, mild anemia, breast discomfort and gynecomastia, hot flushes, sleep disturbance, body hair and skin alterations, decreased vitality, and decreased intellectual capacity (poor concentration, depression, fatigue).”

In other words, conditions one typically observes in men reaching middle age.

TRT is purported to counteract these symptoms. Specifically, “[t]estosterone is well known to help in libido, bone density, muscle mass, body composition, mood, erythropoiesis, and cognition,” according to that NIH article. Simply put, TRT is supposed to make older men feel younger.

Assuming that Chael Sonnen and Forrest Griffin haven’t quite reached the age where their erectile function is in question, they and the other fighters taking advantage of the TRT loophole are presumably doing so for its other youth-rejuvenating properties. In their mid-30’s, their capacity for training at 90 or 95 percent is almost certainly diminished from what it was ten years ago, and TRT probably provides the sort of energy boost they need to get back to that place. In a similar light, TRT’s muscle-retention function slows the natural aging process these fighters are experiencing as they reach the latter parts of their careers and allows them to more easily maintain the physiques that elevated them to the top of the sport all those years ago.

Let’s be clear: These fighters are not doing anything against the rules. They’ve been approved to undergo TRT by their physicians and then by state athletic commissions, and therefore are 100 percent in the right from a regulatory standpoint. Of course, there are the ethical issues that are inextricably linked to athletes’ use of performance-enhancing supplements, particularly in sports where the goal is to beat your opponent to the point of incapacitation, but that’s another discussion for another time.

Putting aside questions of legality, though, there’s another issue surrounding TRT that many people are overlooking. TRT might provide the extra oomph aging fighters need to continue in the cage. It might enable those fighters to train longer and with more intensity. It might help them retain the lean muscle mass that’s so critical to their occupational success. But what it won’t do is protect those fighters against injuries.

Dan Henderson was supposed to fight Jon Jones for the light heavyweight title at UFC 151 back in September. At age 42, Henderson’s admitted use of TRT was perhaps slightly more understandable than it would be for, say, a fighter in his early-to-mid 30’s. Henderson has been a fixture atop the middleweight and light heavyweight divisions for several years and was riding a four-fight winning streak heading into his bout with Jones. Clearly, the combination of Hendo’s natural athletic talents and the TRT supplements were still making for a successful career, even as he reached an age where the vast majority of professional athletes, let alone cage fighters, have been retired for several years.

Alas, however, Henderson’s desire to fight was not matched by his body’s ability to absorb punishment in preparation, and he was forced to withdraw from the bout with Jones after injuring his knee. As a result, UFC 151 was canceled altogether and, well, you know the rest.

Frank Mir is another example of a TRT user who has recently been hampered by injuries. After losing a title fight with Junior dos Santos, Mir was asked to migrate to Strikeforce to take on its heavyweight titlist, Daniel Cormier. The fight was scheduled to headline the promotion’s planned Nov. 3 event in Oklahoma City. Once again, TRT might have helped Mir get into fighting shape more easily, but it didn’t stop his knee from giving out, thus nixing his participation. Mir’s withdrawal was the first among fighters on the Nov. 3 Strikeforce card, but it would not be the last to damage the eventually canceled event.

This is certainly not to say that TRT is a direct source of these fighters’ injuries. One could, however, reasonably extrapolate that older fighters using TRT are training harder than their bodies would otherwise allow. These aging fighters might have the energy and musculature of their younger counterparts, but their joints and ligaments (those fragile connective areas that so often are the cause of a fighter’s pain) are no less susceptible to injury just because they’re using TRT. In other words, they’re pushing their bodies past their natural limits because they have the energy to do so. TRT or not, everyone has a breaking point.

Let’s also not forget that TRT use does not necessarily translate to victory in the cage. Mir was taking TRT in his loss to the clean dos Santos. We all saw happened to Sonnen in his rematch with Anderson Silva, when Sonnen had permission to use TRT. Outside of Henderson’s continued relevance as he reaches an age where he could, mathematically speaking, be the father of some of the other UFC fighters, really the only success we’ve seen in the UFC that could conceivably be attributed to a fighter’s admitted TRT use was Forrest Griffin’s win over Tito Ortiz. Or that could be due to the fact that Ortiz is being held together by a virtual toolbox of bolts and screws and plates.

There are no doubt countless other instances that are not widely known where fighters have taken other, far more dangerous and/or effective, performance-enhancing drugs and saw tremendous success as a result. There’s a particular heavyweight who recently tested positive for an elevated T/E ratio who immediately springs to mind. And who knows what prescription cocktails some of those guys in Pride were taking. All I’m saying is that we haven’t seen any UFC titles won by a fighter who has admitted to using TRT. Not yet, anyway.

What we have seen are TRT users being just as susceptible to injury as supposedly “clean” fighters. Perhaps the energy boost that TRT provides these fighters is an indirect cause of their injuries. After all, a 35-year-old is not necessarily meant to train the same way as a 22-year-old, no matter what supplements might enable that sort of intensity.

Until the UFC or the various athletic commissions around the country are willing to get serious about cracking down on the use of TRT among MMA fighters, not just paying lip service to the desire to have all fighters be clean fighters, TRT is going to continue to be a part of the sport. Perhaps its prevalence will even increase as more fighters discover how easy it is to legally use.

But injuries are a part of MMA too, and no matter how fighters are enhancing their training regimens, they’re just a punch, kick, twist or tweak away from having to call UFC President Dana White and tell him they’re off the card.

Photo: Chael Sonnen (Dave Mandel/Sherdog)