Therapeutic use exemptions

What a TUE is, and what it is not

A therapeutic use exemption is a permission, granted in advance by a committee of physicians, allowing a named athlete to use a named substance or method from the Prohibited List to treat a diagnosed medical condition. Its legal effect comes from the Code rather than from the standard that governs it: presence, use, attempted use, possession or administration of a prohibited substance "shall not be considered an anti-doping rule violation if it is consistent with the provisions of a Therapeutic Use Exemption granted in accordance with the International Standard for Therapeutic Use Exemptions".^[3] [4]

Everything turns on the word consistent. A TUE authorises a substance at a stated dose, frequency, route and duration and nothing else; where use departs from those terms, "the fact that the Athlete has the TUE will not prevent the finding of an anti-doping rule violation".^[1] Nor is the committee acting as the athlete's doctor. The standard says so expressly: a grant "is based solely on consideration of the criteria set out in Article 4.2. It does not consider whether the Prohibited Substance or Prohibited Method is the most clinically appropriate or safe, or whether its Use is legal in all jurisdictions."^[1]

Four things are routinely collapsed into one and should be held apart on any reading of this subject. A TUE granted. A TUE refused. An anti-doping rule violation. And a threshold substance — inhaled salbutamol and formoterol among them — where the exception sits on the Prohibited List itself and no exemption, committee or certificate is involved at all. The last of these is the source of most public confusion and is dealt with in its own section below.^[32]

The mechanism predates the World Anti-Doping Agency. It was run at the Olympic Games from Barcelona 1992 by the IOC's medications advisory committee, and WADA later adopted both the machinery and the name.^[25]

The four criteria — and the changeover on 1 January 2027

The International Standard for Therapeutic Use Exemptions is a mandatory standard within the World Anti-Doping Program. It was first adopted in 2004, took effect on 1 January 2005 and has been amended eight times. The 2023 edition is in force to 31 December 2026; a ninth version, approved by the WADA Executive Committee on 5 December 2025 at the sixth World Conference on Doping in Sport in Busan, takes effect on 1 January 2027. Any citation to an ISTUE article is meaningless without its edition, and this page dates every one.^{[1] [2] [6]}

Under the 2023 standard, Article 4.2, an athlete may be granted a TUE "if (and only if) they can show, on the balance of probabilities, that each of the following conditions is met":^[2]

(a) the substance or method "is needed to treat a diagnosed medical condition supported by relevant clinical evidence"; (b) its therapeutic use "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"; (c) it "is an indicated treatment for the medical condition, and there is no reasonable permitted Therapeutic alternative"; and (d) the necessity for its use "is not a consequence, wholly or in part, of the prior Use (without a TUE) of a substance or method which was prohibited at the time of such Use".

From 2027 the four are reordered and reworded — the diagnosis criterion comes first and standing alone, the indicated-treatment criterion second, the no-enhancement criterion third, and (d) is unchanged — but they remain cumulative and the standard of proof remains the balance of probabilities.^[1] [5] Criterion (b) is the one that carries the argument: the test is not whether the treatment helps, but whether it does more than restore normal health.

A numbering trap worth knowing. In the 2019 standard the criteria sat at Article 4.1 and were materially stricter — the substance had to be needed "to treat an acute or chronic medical condition, such that the Athlete would experience a significant impairment to health" if it were withheld, and enhancement had only to be "highly unlikely". The 2021 edition moved the criteria to Article 4.2, replaced the significant-impairment test with a diagnosed-condition test, and tightened the enhancement limb to the balance of probabilities. A reference to "ISTUE Article 4.1" therefore means something different depending on the year it was written.^[1] [2]

Three further 2027 changes matter. A TUE acquires a maximum duration of ten years, where the 2023 standard sets no cap at all. A new Article 6.12(b) allows withdrawal before expiry where, on a change of circumstances, the criteria are no longer met. And the data-protection standard the process runs under is renamed and replaced: the International Standard for the Protection of Privacy and Personal Information becomes the International Standard for Data Protection.^[1] [5]

Who grants one, and who sits on the committee

There are three levels and an athlete deals with exactly one of them. Athletes below international level apply to their national anti-doping organisation. International-level athletes apply to their international federation — unless they already hold a national TUE, in which case they should not re-apply but seek recognition instead. Major event organisers may require their own application for use at the event, and a TUE they grant "is effective for its Event only". Athletes never apply to WADA, which as its own guidance puts it "outlines the rules and the process, hears appeals, and audits TUE applications".^{[1] [3] [7]}

Which level an athlete falls into is not fixed globally. Each national body publishes its own definition of a national-level athlete and each federation its own definition of an international-level athlete and its list of international events — which is why the same person's obligations differ between sports. A national TUE is nonetheless "valid at national level on a global basis" without formal recognition elsewhere, so an athlete tested by a foreign national agency while training abroad is covered; the granting body must warn them in writing that it will not carry into international competition unless recognised.^[1]

Every national body, federation and applicable event organiser must establish a TUE Committee. Its composition is set out at Article 5.3(c), and the drafting repays attention: a committee considering an application "should include at least three (3) physicians" with experience in athlete care and a sound knowledge of clinical, sports and exercise medicine, while one physician member "shall act as chair". The standard defines "shall" as mandatory and "should" as a recommendation. The three-physician panel is therefore a recommendation, not a requirement — a softness in the standard that is rarely reported, and one that matters because the single-reviewer arrangement that preceded 2015 is the specific thing the system's critics attacked.^[1] [30]

Independence is thinner than the word suggests. The whole of the formal requirement is that every member has signed a conflict-of-interest and confidentiality declaration on WADA's template; there is no bar on a federation's own medical staff sitting and no term limit. Decisions should ideally be reached by consensus and otherwise by majority, and should be taken "usually within no more than twenty-one (21) days of receipt of a complete application".^[1] In practice the larger committees are specialist pools rather than standing panels: the International Testing Agency's international TUE committee, which acts for many federations, describes roughly twenty declared clinical specialities — adult and paediatric endocrinology, asthma, cardiology, clinical pharmacology, psychiatry, para-sports medicine, transgender healthcare, sports pharmacy among them — and convenes a bespoke sub-committee for each application, aiming to decide within 48 hours.^[8]

Applying: prospective, retroactive, and the escape hatch

Prospective application is the rule. An athlete needing a prohibited substance therapeutically "shall apply for and obtain a TUE prior to Using or Possessing" it, and a grant takes effect "at the earliest, the date of the TUEC's decision" — a TUE does not backdate itself. What must be filed is substantial: a comprehensive medical history including documentation from the original diagnosing physician where possible, and the results of all relevant examinations, laboratory investigations and imaging studies, signed by a physician. Incomplete applications are returned unassessed. And the athlete pays — Article 6.9 puts the cost of making and supplementing an application on the applicant, which is a real equity point in a system whose evidentiary bar is high.^[1]

An athlete may not hold or seek more than one TUE for the same substance and condition from more than one body, though multiple TUEs for different conditions are permitted. Where a regime fluctuates — insulin-dependent diabetes is the standard example — the committee may approve a dosage range or an upper limit rather than a fixed dose.^[1]

Retroactive application is available on five narrow grounds only (2027 Article 4.3): emergency or urgent treatment; insufficient time, opportunity or exceptional circumstances preventing the athlete obtaining a TUE before use; a national policy that did not permit or require a prospective application; testing of an athlete who is neither international- nor national-level and was using the substance therapeutically, where the body "shall permit" a retroactive application; and out-of-competition use, for therapeutic reasons, of a substance prohibited in competition only. The comment is emphatic that clearing the gate is not the same as winning: meeting a retroactive exception "does not mean that a TUE will necessarily be granted; it means that the Athlete's application may be evaluated under Article 4.2." Note also who decides what — the medical criteria go to a TUE committee, but grounds (b) to (e) are assessed by the anti-doping organisation alone, which may consult an expert at its discretion. Most retroactivity decisions are administrative rather than medical.^[1]

Behind those five sits an escape hatch, and it is the only corner of the system with no appeal at all. Where "it would be manifestly unfair not to grant" a retroactive TUE, one may be granted "even if the criteria in Article 4.2 are not met" — for international- and national-level athletes only with WADA's prior approval, which WADA may give or refuse "in its absolute discretion". The provision then closes the door: any decision under it "may not be challenged either as a defense to proceedings for an anti-doping rule violation, or by way of appeal, or otherwise." Relevant factors include why the athlete did not apply in advance, their experience and education, whether they declared the substance on the doping control form, and the recent expiry of an existing TUE.^[1]

One provision deserves to be better known because it saves athletes who did everything right. Where an adverse analytical finding is issued after a TUE has expired, been withdrawn or been reversed, the reviewing body "shall consider whether the finding is consistent with Use of the Prohibited Substance prior to the expiry" — and if it is, that use, and any resulting presence, "is not an anti-doping rule violation."^[1]

What changes in 2027, and it is the largest practical softening of the cycle. A new Code Article 10.2.4 provides that where an athlete can establish that their use met each of the ISTUE criteria — setting aside the requirement to show no permitted alternative — at the time it occurred, "the period of Ineligibility shall be two (2) months", not subject to further reduction. An athlete who would have qualified for a TUE but never held one currently faces a fault-based sanction of up to four years; from 2027 they face a fixed two months. That is the answer to the long-standing criticism that the system punished a paperwork failure as though it were doping.^[3] [4]

Recognition, review and appeal

A TUE that works in one place does not automatically work in another, and the 2027 standard reverses the default. Under Article 7.2(a), TUE decisions reported through the anti-doping database "will be automatically recognized by the International Federation or Major Event Organization" unless WADA has granted that body an exception — and a body granted one must publish which categories of decision it will accept and which it will review. The 2023 text frames automatic recognition as something federations choose to offer; the 2027 text makes non-recognition the thing that requires permission.^[1] [2]

Where recognition is refused the athlete lands in a split state that is the clearest thing on this page to picture. A national TUE that a federation declines to recognise "may not be relied upon" against that federation, while — pending WADA's review — it "remains valid for national-level Competition and Out-of-Competition Testing (but is not valid for international-level Competition)". The mirror image applies where a federation grants and the national body objects. The same athlete can be simultaneously covered and uncovered depending on who is testing them. Twenty-one-day clocks run on both referrals, and every grant, denial, recognition and refusal must be reported through ADAMS "as soon as possible and in any event within twenty-one (21) days", in English or French.^[1]

WADA's review power has two mandatory limbs and one discretionary. It shall review a federation's refusal to recognise a national TUE when the athlete or the national body refers it, and a federation's grant when the athlete's national body refers it; it may review any other TUE decision at any time, on request or on its own initiative. The reversal powers are mandatory in both directions: WADA "shall reverse any grant of a TUE that does not comply" with the criteria, and "shall reverse any denial of a TUE where the TUE application met the criteria, i.e., it will grant the TUE." A refusal to conduct a discretionary review is itself final and unappealable, though the underlying decision may still be appealable. And silence counts against the deciding body: a failure to decide a properly submitted application within a reasonable time is treated as a denial, which triggers the review and appeal rights.^[1] [3]

One asymmetry in the reversal rule is almost never reported. Reversing a prospective TUE takes effect no earlier than notification, "will not apply retroactively and the Athlete's results prior to such notification will not be Disqualified". Reversing a retroactive TUE is itself retroactive, and results management continues or restarts.^[1]

The appeal routes are collected in one article from 2027. A national body's denial is appealed exclusively to the national-level appeal body, not to the Court of Arbitration for Sport in the first instance. Any federation TUE decision that WADA has not reviewed, or has reviewed and not reversed, is appealable by the athlete or their national body exclusively to CAS; so is a WADA reversal, by the athlete, the national body or the federation. A major event organiser's refusal is appealed to an independent body the organiser establishes, and if that fails the athlete may not use the substance at that event — but any national or federation TUE "remains valid outside of that Event". The manifestly-unfair power alone is unappealable.^[1] [3] No published CAS award from 2024 to 2026 turning on a TUE grant, refusal or reversal was located on the arbitration court's own database, which is not the same as saying none exists.

Confidentiality, and the 2016 breach

The standard is emphatic about medical confidentiality and states it as a rule rather than a reassurance. Applications "shall be dealt with in accordance with the principles of strict medical confidentiality"; committee members, consulted experts and relevant staff "shall sign appropriate confidentiality agreements" and must keep confidential all medical information provided and "All details of the application, including the name of the physician(s) involved in the process." Processing must comply with WADA's data-protection standard, and the body must have a valid legal basis for it. Access to the clinical file is tiered: the application form and clinical information are "for access only by WADA, the Athlete's National Anti-Doping Organization and International Federation, and the Major Event Organization organizing an Event in which the Athlete wishes to compete." An athlete may revoke the body's authority to obtain health information on their behalf, but the application is then "deemed withdrawn without approval".^[1]

That machinery was tested in public in September 2016. WADA confirmed on 13 September that a group it identified as Tsar Team (APT28), also known as Fancy Bear, had obtained access to its anti-doping database "via an International Olympic Committee (IOC)-created account for the Rio 2016 Games", credentials having been taken by spear-phishing. Its forensic account of 5 October recorded unlawful access to that single Rio account between 25 August and 12 September 2016, and stated plainly that "the broader ADAMS was not compromised in the attack" — and, separately, that not all the data the group released accurately reflected what the database held. Rio accounts were deactivated the same day, the self-service password reset was disabled, dormant accounts were closed and logging was expanded.^[26] [27]

Seven officers of the Russian military intelligence service were later indicted in the Western District of Pennsylvania. The indictment describes the stolen material as including "information regarding therapeutic use exemptions (TUEs), which allow athletes to use otherwise prohibited substances", released "in many cases in a manner that did not accurately reflect their original form", and ultimately covering the private or medical information of approximately 250 athletes from almost thirty countries. It repeats the same parenthesis about the broader database.^[28]

The load-bearing point is a negative one: neither WADA nor the United States Department of Justice has described any leaked TUE as improper, and no anti-doping rule violation arose from any of them. This is a data-breach story and an influence operation, not a doping story. WADA's own position on what followed is worth quoting, because it frames the transparency argument in the next section: "It is very unfortunate that athletes' TUEs are being debated publically on the basis of partial, confidential, medical information. Athletes should not be required to publically justify their TUEs."^[29] No athlete is named here for that reason.

The numbers — and where there are none

Two verified absences frame everything that follows. WADA's Anti-Doping Testing Figures Report contains no TUE statistics at all — the 2024 edition, 345 pages, mentions TUEs only in a boilerplate caveat — and WADA's statistics hub publishes two series, testing figures and rule violations, neither of which is a TUE series. The global numbers exist only as prose inside WADA's digital annual reports, and they are a flow: newly approved TUEs per year. No body publishes a count of TUEs in force worldwide at any moment. The absence is itself a finding, and a stock figure should not be inferred from the flow.^{[10] [11] [12]}

On WADA's own account, newly approved TUEs recorded in the database ran 3,744 in 2023, 3,975 in 2024 and 4,254 in 2025, granted overwhelmingly by national agencies — 81, 77 and 79 per cent respectively, with federations taking most of the rest and major event organisers under 1 per cent rising to 2. The leading substance classes flipped over the period: glucocorticoids led in 2023 at 32 per cent, and stimulants led in 2024 and 2025, rising from 31 to 32 to 38 per cent. WADA attributes part of the 2024 rise to the expanded Paris 2024 calendar, and records that federations and event organisers collectively recognised about 15 per cent of the TUEs approved in 2024.^{[10] [11] [12]}

WADA's own review committee convened 10 times in 2023 (7 TUEs not granted), 15 times in 2024 (13 reversed and denied) and 13 times in 2025 (13 reversed and denied). Against 4,254 approvals, thirteen reviews is roughly three in a thousand; WADA says it screens all TUEs on risk prioritisation but does not publish the screening denominator, so no reversal rate can honestly be computed from these figures.^[10]

The International Testing Agency, acting for partner federations, published its underlying dataset in March 2026 — 3,528 applications from 2019 to 2025 — and no comparable release by any other anti-doping body was located. Applications rose from 329 in 2019 to 852 in 2025; roughly two-thirds are approved or recognised, about a quarter withdrawn or found unnecessary, and about 2 per cent refused, with the agency reporting 10 to 15 per cent pending on incomplete documentation — a category that exists in its data only for the most recent years and cannot be read back across the series. The agency attributes the growth to more federations delegating their programmes to it rather than to more athletes needing exemptions, and states that only around 1 to 3 per cent of athletes require a TUE at all. Its own class shares for 2025 were stimulants 43.3 per cent, glucocorticoids 15.5, hormone and metabolic modulators 9.5 and diuretics 7.4; anabolic agents were under 2 per cent and erythropoietin under 0.1.^[13] [14]

National figures, each on its own body's published basis and not like-for-like: United States 436 applications reviewed in 2025 plus 20 retroactive, led by stimulants; Great Britain 151 received in 2024, 124 approved, 27 refused; Australia 188 approved and 1 rejected in 2024–25, with no appeals; Italy 830 examined in 2025, 431 granted, 25 denied, and 47 per cent of requests concerning glucocorticosteroids; France 283 received in 2025 of which 70 were admissible, 58 granted; the Netherlands 227 granted in 2025 against 150 in 2024, topped by methylphenidate at 43 per cent; China 160 applications in 2025, up 38 per cent, of which 53 were approved and 65 assessed as not needing a TUE at all; Germany 109 granted and 7 rejected in 2025; Norway 125 applications, 81 granted; Denmark 149 applications in 2024, 89 approved and 15 rejected; India 43 considered in 2023–24, 29 granted. Japan's agency publishes no TUE statistics at all.^{[15] [16] [17] [18] [19] [20] [21] [22] [44] [45] [46]}

The single best evidence on how common TUEs are at the top of sport is peer-reviewed. A 2024 cross-sectional analysis of database records across Rio 2016, PyeongChang 2018, Tokyo 2020 and Beijing 2022 found TUE prevalence of 0.90 per cent among 28,583 Olympic competitors and 2.76 per cent among 9,852 Paralympic competitors, concluding that "TUEs are not widespread in elite sport". A companion study across five Games found athletes competed with a TUE in 0.9 per cent of athlete-competitions and that 21 of 2,062 medals were won by an athlete holding one — a risk ratio for medalling of 1.13, and adjusted 1.07, neither statistically meaningful.^[23] [24]

Salbutamol, and the error it corrects

The most widespread public misunderstanding of this subject is that an asthmatic athlete needs a TUE for their inhaler. Usually they do not.

Beta-2 agonists are prohibited at all times, but the Prohibited List carries dose exceptions on its own face: inhaled salbutamol to a maximum of 1,600 micrograms over 24 hours in divided doses not exceeding 600 over eight hours; inhaled formoterol to 54 micrograms over 24 hours; inhaled salmeterol to 200; inhaled vilanterol to 25. Below those limits the substance is simply permitted — no application, no committee, no certificate. The List then sets a urinary threshold: salbutamol above 1,000 ng/mL, or formoterol above 40, "is not consistent with therapeutic use of the substance and will be considered as an Adverse Analytical Finding unless the Athlete proves, through a controlled pharmacokinetic study, that the abnormal result was the consequence of a therapeutic dose".^[32]

That is results management, not exemption. The exception lives on the List, not in the ISTUE; there is no TUE anywhere in the process. What does require a TUE is a different drug — a systemic glucocorticoid, or a beta-2 agonist outside the excepted four. Both halves of that sentence matter, and most accounts carry only one.

The mechanism ran its most public course in cycling. The UCI announced on 13 December 2017 that Christopher Froome had been notified of an adverse analytical finding for salbutamol above 1,000 ng/mL in a sample taken during the Vuelta a España on 7 September 2017, and noted that the presence of a specified substance carries no mandatory provisional suspension. The case was closed without an anti-doping rule violation: the UCI's own question-and-answer of 6 July 2018 records that it acted "primarily based on WADA's advice" and on "WADA's position that he did not commit an anti-doping rule violation", and that a controlled study was unnecessary before closing. WADA's account adds the pharmacology — salbutamol "is an effective therapeutic remedy for asthma with no known performance-enhancing properties when inhaled at a therapeutic dose", but at excessive doses or by systemic routes it can act as a stimulant or an anabolic agent, which is why it sits on the List with a threshold — and records that a permitted dose was shown capable of producing a concentration above the applicable decision limit.^{[33] [34] [35]} No TUE was involved at any stage.

One drafting note for anyone quoting the List: the frequently quoted phrase "presumed not to be an intended therapeutic use of the substance" is the 2017 wording. The current text reads "is not consistent with therapeutic use of the substance".^[32] [33]

The criticism, and four places the system bends

The best-documented institutional criticism is British and parliamentary. The Digital, Culture, Media and Sport Committee's report Combatting doping in sport, published on 5 March 2018, recorded that three TUEs for triamcinolone had been granted to Bradley Wiggins before the 2011 and 2012 Tours de France and the 2013 Giro d'Italia, and that "each of these applications was approved under the WADA rules at the time, by a single doctor at WADA". The Committee's conclusion was expressly its own belief and expressly not a finding of a rules breach: it believed the corticosteroid was used to prepare the rider for the Tour rather than to treat medical need, and said that this "does not constitute a violation of the WADA code, but it does cross the ethical line" the team's own principal had drawn. It also could not establish the central fact, recording that there remained "no documented evidence as to what was in the package" delivered in June 2011.^[30]

Two things in that report are more useful than the headline. Its systemic criticism is aimed at the pre-2015 arrangement — TUEs granted on a team doctor's assessment and a single WADA reviewer — and it welcomed the reforms since, which is precisely what the multi-physician committee requirement is for. And the real institutional failure it exposed was record-keeping: the anti-doping agency closed its investigation on 15 November 2017 unable to confirm or refute the account of the package, its chief executive stating that the investigation "was hampered by a lack of accurate medical records being available at British Cycling."^[30] [31]

The live argument is about publication. The International Testing Agency opened a public, anonymised TUE dashboard on 17 March 2026; in triathlon it recorded 78 applications between 2019 and 2025, of which 28 were approved and one denied, with no names attached. A professional triathlete then campaigned publicly for all TUEs to be made public, and the athlete whose application had been denied identified herself, in a video on her own account, in response. That sequence is the whole debate in miniature: anonymised aggregate publication satisfies almost none of the transparency demand, because the demand is really for names — and the moment a name appears, the athlete must justify a diagnosis in public, which is exactly what WADA said in 2016 that athletes should not be required to do.^{[13] [36] [29]}

Para sport. The standard contemplates impairment-specific expertise — where required, at least one committee member or expert "should" possess it — and the International Paralympic Committee wears two hats, acting as the major event organiser for the Games and as the international federation for five para sports. Impairment is not an excuse for non-compliance: the IPC's code says so in terms. The measured prevalence gap is real, at 2.76 per cent against 0.90, and the leading class at the Summer Paralympics was diuretics and masking agents rather than stimulants or glucocorticoids — the only dataset here in which that is so. No source attributes that finding to any particular impairment-related condition, and none of WADA's 22 published TUE physician guidelines is para-specific, so the number is reported and left there.^{[1] [23] [37] [9]}

Hormone therapy, and the sharpest structural point on this page. Testosterone is prohibited at all times and non-specified, so its therapeutic use needs a TUE; oestrogen is not prohibited; the substance most often requiring one for transgender female athletes is spironolactone. WADA's dedicated guidelines draw the boundary themselves: their purpose "is not… to define the criteria for the eligibility of these athletes to participate in competitive sport, which is entirely left to the different sporting federations", and they sequence the two — a TUE may be granted "only once their eligibility has been established with their sport federation." The clearest published proof that a valid TUE confers no eligibility is World Athletics Rule 3.5.2(b), effective 1 September 2025: biological females who have used testosterone under a validly granted TUE "may not compete in the female category" until a period of not less than four years has passed. Anti-doping permission to use a substance and federation permission to enter a category are different machinery run by different bodies. The IOC's female-category policy adopted on 26 March 2026 is an eligibility instrument and contains no TUE provisions; WADA's transgender guidelines remain at their October 2023 version, and the two have not been publicly reconciled.^{[38] [39] [32] [47]}

College sport in the United States runs a parallel regime that recognises none of this. The NCAA maintains its own banned-class list — on which caffeine appears and insulin does not — and splits approval into two tracks. Pre-approval is required only for anabolic agents, hormone and metabolic modulators and peptide hormones. For stimulants, including ADHD medication, there is no pre-approval at all: the institution holds the documentation on campus and submits it only after a positive test, within two business days of notifying intent, with the athlete withheld from competition if it is not filed before the B sample is reported. The ADHD documentation requirements are demanding — a DSM-5 diagnosis with the criteria listed, psychiatric and family history, documented comorbidities, mandatory collateral information from a secondary source, full medication history, and the non-banned alternatives tried or the rationale for not trying them. And the two systems are not interoperable: the United States Anti-Doping Agency states that it and the NCAA "do not recognize each other's medical exemptions/TUEs at this time", so a dual-status athlete needs both. Outside the United States, university sport runs on the WADA system — FISU automatically recognises a national TUE without reviewing the clinical file. The NCAA is the outlier here, not the model.^{[40] [41] [42] [43]}