Concussions are a common yet debilitating occurrence in athletics. While previously considered mild injuries, evidence of the long-term impacts of repeated head injury in the athletic context has emerged, and public attention has subsequently been directed towards the issue. As a result, sporting organizations for traditionally high concussion-risk sports have made systematic changes that reflect a shift towards risk management and long-term athlete care.
However, the issue of gender is critically overlooked when examining the issue of concussions in sports. Despite growing evidence that concussions impact women differently (and often more severely) than men, concussion protocols and recovery programs often don’t take these gender differences into account. This is because concussion research overall lacks female participants. Concussions cannot be treated properly if we don’t involve female athletes in concussion research and incorporate gender-specific differences into recovery plans. All athletes deserve to receive care that is tailored to their needs, and sporting organizations need to consider these factors when developing concussion protocols to promote athlete well-being.
Concussions
Concussions are a form of traumatic brain injury (TBI) that, while often considered a minor or mild injury, can have serious short- and long-term consequences. Concussions are often caused by direct hits to the head or whiplash that results in a temporary loss of brain function.
Common symptoms include headache, confusion, dizziness, nausea, memory loss, and sensory disturbances (for example, being overly sensitive to light and sound or loss of smell) 1. A common misconception is that all concussions result in loss of consciousness. Other physical signs of concussion – reflexively shaking the head after sustaining a head injury 2, confused appearance, or clumsy movements – should be looked out for as well 3. There is no such thing as a “minor” concussion, and any signs of concussion after a head injury should be taken extremely seriously.
Concussions are an unfortunately frequent occurrence in youth athletics; 7 out of 10 sports-related concussions reported to emergency rooms are sustained by children under 17 4. While concussions can result in any sport, certain sports are considered to have a higher risk than others.
Sports that are considered high-risk for concussions include football, soccer, rugby, hockey, and combat sports 4. In sports like football and combat sports, the concussion risk is sourced from the contact element – hits sustained to the head from blows or tackles. In soccer, concussions arise from techniques like “heading” (when a soccer player uses their head to direct the ball). Other sports where concussions may occur include sports involving fast movement (such as cycling) and sports with additional environmental factors (for example, whitewater rafting and equestrian).
Concussion Prevention Efforts
While at one point concussions were considered to be mild injuries that are “just part of sport,” the public and athletic conception of concussions as “normal” has been changing. Technological advancements allow us to view the serious neurochemical changes caused by concussions – inflammation in the brain 5, excessive neurotransmitter release, increased need for glucose 6 – and to more accurately screen for brain injury. We have also seen increased research on the long-term consequences of concussions, including post-concussion syndrome 7 and chronic traumatic encephalopathy (CTE) 8, particularly among athletes.
In 2011, multiple players from the National Football League (NFL) sued the NFL, alleging that the league was aware of health risks related to enduring hits to the head but intentionally hid them from players 9. In 2017, the NFL began providing baseline neurological exams to players and compensation to those who later developed CTE, a degenerative brain disease caused by repeated concussions. The NFL has since devoted time and resources to concussion prevention and reduction 10, including promoting helmets like the Guardian Cap (seen to reduce concussions by 50% in players who utilize them 11) and prohibiting dangerous tackles that contribute to concussion risk 12.
Similarly, over 300 former National Hockey League (NHL) players have sued the NHL since 2013 for failing to warn players about head trauma and for promoting violence in the sporting context that led to further injuries 13. The NHL has never acknowledged the connection between head injuries in hockey and CTE 14, has stated on record that players have sole responsibility to be educated on head trauma 15, and has appealed caveats in the player settlement that would provide compensation to all retired NHL players 16. The NHL has since begun providing an accessible online concussion protocol.
Ten years after German soccer player Christoph Kramer reported having no memory of playing in the 2014 World Cup Final after sustaining a concussion 17, FIFA teamed up with the World Health Organization to create the Suspect and Protect campaign. This campaign is designed to raise awareness of concussion risk and long-term effects across all of FIFA’s national federations.
It is demonstrably a good thing that we are treating concussions as serious brain injuries – which is what they are. It is a great sign that sporting organizations acknowledge this by making top-down changes that positively impact athletes. Sporting organizations actively mitigating head injury risk reflects a much-needed shift towards prioritizing athlete wellbeing.
However, concussion research, resources, and safety measures have all been primarily focused on male-dominated sports. Female athletes are largely underrepresented in concussion research. The safety measures and athlete resources developed using current research as an evidence base therefore do not adequately represent or provide accurate care for female athletes.
Concussions Among Female Athletes
The rate of concussion among female athletes has tripled in the past two decades18. There are a variety of factors as to why this could be occurring - such as increased awareness of concussions or increased involvement of women in sports - but even when examining male and female athletes competing in the same sport, the concussion rate among female athletes is significantly higher. Female athletes playing soccer, lacrosse, and basketball at an NCAA level all experience significantly higher rates of concussion than their male counterparts 19.
As the incidence of concussions increases among female athletes, the gender-specific impact of concussions has become more evident. Women, on average, take twice as long to recover from concussions as men, and women report experiencing more severe concussion symptoms than men 20. Certain biological factors contribute to this. For example, women have thinner skulls and smaller neck muscles than men, which may increase concussion predisposition 21. The menstrual cycle also affects the availability of certain neuroprotective factors in the brain, namely progesterone – if a concussion occurs during certain phases of the cycle when progesterone is low, concussion recovery is often worsened 22.
The symptoms experienced post-concussion are also often different between men and women. Female athletes often report negative mental health symptoms after experiencing a concussion at a rate higher than male athletes. Neurocognitive decline post-concussion is significantly worse for female athletes as compared to male athletes, resulting in decreased reaction time, concentration problems, and worsened verbal and visual memory 23.
The Gender Gap
Concussion research continues to overlook the growing health issue of concussions among female athletes. Prominent public health organizations have stated that there is a dearth of research focused on female athlete concussions 24, and 80.1% of research on sport-related concussions is entirely male-focused25.
The NIH was not obligated to include women and minorities in research until 1993 25, which has created a systemic issue of under-researching issues specific to these marginalized communities. This has unfortunately extended to injuries as severe as concussions - even today, 40% of 171 studies done on sport-related concussions did not have a single female participant 26.
When scientific studies don’t include female athletes, we are not able to adequately treat them since we are not taking biological differences into account. Sporting organizations are using science to create policies and protocols to protect these athletes, but that science isn’t representative of the majority of their athletes. With the amount of female athletes participating in and dominating cultural conversations on sports, not appropriately engaging in proactive prevention, awareness and education efforts, and not appropriately caring for them after sustaining a traumatic brain injury (like a concussion) by formulating policies on an inadequate evidence base, is neglectful and dangerous.
In turn, athletic spaces that cater primarily to female athletes often do not have the capacity to implement safety measures seen in male-dominated sports. For example, the NCAA mandates male lacrosse players wear helmets, but does not ascribe this to female players as the sport is considered “non-contact”. This could explain why concussions occur more frequently in games and in practice among female athletes19. Access to care is also lower for female athletes than male athletes, with 32% of female athletes receiving trainer-administered on-field evaluations post-concussion in comparison to 40% of male athletes27.
Sustainable Sport
When sporting organizations set the standard of valuing their athletes’ long-term careers and health over short-term achievements, it shifts the needle towards prioritizing athlete safety. Ensuring a sport’s longevity requires treating athletes as people who require care rather than dispensable objects.
This should be echoed in concussion care. The needle has shifted towards treating concussions seriously, but it needs to be taken seriously among all athletic communities. Concussion research, prevention, and recovery plans need to incorporate gender-specific differences in order to appropriately treat all athletes and promote the best outcomes. Sporting organizations need to mitigate the real risk of concussions among female athletes by implementing safety measures to prevent concussions.
We understand, now more than ever, the danger and harm concussions present to athletes. Athletes deserve safe sporting environments where education on response and management is tailored to their athletic experience. To achieve the protection of athletes, demographic vulnerabilities like gender and sex must be taken into account. Female athletes should be equally represented in research discussing concussions and athletics, and coaches have a responsibility to stay educated on best practices regarding concussions.
Click here to continue reading Part 2 - Bridging the Concussion Gap: A Case Study on Aesthetic Sports
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For additional information regarding sport-related concussions, the Concussion Legacy Foundation is an excellent resource, linked here.
Annelise Ware, MHS
Program Manager at #WeRideTogether
