This is the second part of Bridging the Concussion Gap, discussing the systemic disparity between female and male athletes when examining multiple aspects of concussion risk and recovery. Athletic spaces that have primarily female athletes cannot often appropriately protect their athletes from concussions, despite growing evidence indicating that these environments could be high-risk contexts for concussion. One such athletic space is aesthetic sports.
Aesthetic sports, like dance and gymnastics, have a similarly high concussion risk and prevalence rate to traditionally high concussion-risk sports but are chronically overlooked when examining sport-related concussions. The heightened risk of concussion among aesthetic sport athletes is correlated with multiple aesthetic sport-specific factors: subjective scoring and its associated perfectionism, a culture of silent suffering, and artistic elements that do not allow for the use of safeguarding apparel.
Some sporting organizations governing aesthetic sports have implemented policies to prevent concussions among their athletes. However, the substantial underrepresentation of female athletes in concussion research – even as evidence emerges that gender impacts concussion predisposition and severity – means that the predominantly female athletes participating in aesthetic sports may not be receiving adequate treatment or protection. The pervasive narrative surrounding aesthetic sports as “not really sports,” despite requiring intense training and premier athleticism, means that public awareness is not directed towards this issue, and subsequently aesthetic sports do not have the same resources as other sports to implement concussion protections. Aesthetic sports athletes deserve to have concussion protections that consider and integrate their sport and gender-specific risk factors.
What is an aesthetic sport?
Aesthetic sports are routine-oriented sports that are scored subjectively based on artistry and technique. Sports included in the aesthetic sport class are artistic and rhythmic gymnastics, artistic swimming, diving, figure skating, cheerleading, and all forms of dance.
Significantly more women than men participate in aesthetic sports. 75.4% of professional dancers are women 1, and there are about three and a half times the number of female artistic gymnasts versus male artistic gymnasts 2. Male artistic swimming was only introduced to the Olympics in 2024 3. Rhythmic gymnastics is not approved as a male discipline by the International Gymnastics Federation but is still competed in some places 4.
The notable gender imbalance is likely due to aesthetic sports’ perceived femininity. Sports are subject to the same gender norms that everything else in society is subject to, and elements like grace, balance, and artistry (all of which are critical to aesthetic sports) contribute to labeling the sport class as traditionally feminine.
Risk and Rates
Concussion risk and rate in aesthetic sports is similar to, if not higher than, sports associated with elevated concussion risk.
In cheerleading, ⅓ of all injuries are concussions 5. Concussions primarily occur during stunts and affect all positions equally – flyers are at risk of hitting the ground, and bases and backspots are at risk of being hit by a flyer 6. In response to increased concussions and the devastating impacts felt by cheerleaders, USA Cheer in 2011 removed certain moves from cheerleading that are linked to higher injury risk – for example, “double down” baskets were removed from high school cheerleading 7. Despite this, as of 2022, concussion rates among cheerleaders have been increasing substantially, even as the overall injury rate has reduced 8.
23.5% of dancers report experiencing concussions in the dance environment 9, with 10% of concussions resulting in loss of consciousness 10. This is higher than the NFL, where 9% of players lose consciousness after concussions 11. There are a variety of ways dancers suffer head injury – falling, drops during partnering, and whiplash from “spotting” – a technique used when turning where a dancer whips their head around while focused on a fixed point to reduce dizziness12.
Women’s artistic gymnastics has the highest rate of concussion occurrence during the NCAA preseason across all sports 13. This rate (9 per 10,000 athlete participations) is hypothesized to be so high during the preseason due to the attempting of new or unfamiliar skills. In youth gymnastics, the rate of concussion occurrence was 7 per 10,000 athlete participations 14. Comparatively, the sport with what is currently considered the highest concussion risk in sport – women’s soccer – has a concussion rate of 6.7 per 10,000 athlete participations 14. (An athlete participation is defined as when an athlete steps into a practice or competition.) Concussions in artistic gymnastics can be caused by direct contact with equipment (apparatuses and safety mats), whiplash effects, or rotational forces on the head and neck when “twisting” 15.
There is a lack of research regarding the prevalence of concussions among female rhythmic gymnasts; however, the concussion rate among male rhythmic gymnasts is 14% 16. Head injuries are largely due to head contact with an apparatus 17. The catching of an apparatus contributes to a major component of scoring known as the “apparatus difficulty,” but, especially with heavier items like clubs, can be a source of concussion.
27% of figure skaters report experiencing concussions or concussion-like symptoms while on the ice 18. These concussions are primarily caused by falls, but spins are also a source of concern – spins like the layback subject a skater’s head to a level of g-force that can jostle the brain within the skull, creating a concussion 19.
Around 25% of artistic swimmers have suffered a diagnosed concussion in the sport context 20. The chief of USA Artistic Swimming once said that 100% of artistic swimmers will experience a concussion in the sport 21. The intense lifts and compact formations signature to the sport largely contribute to this rate 22. The water element creates additional risk – artistic swimmers swim “blind” with no goggles in chlorinated water, which limits an athlete’s ability to assess how close they are to others (and if they’re about to be hit in the head) 22. Suffering a concussion in the water is especially dangerous due to the risk of hypoxia, or loss of oxygen to the brain.
Another aesthetic sport where concussions occur in water is diving. 54.2% of female collegiate divers report experiencing a diving-related concussion, with the majority of divers stating they felt uncomfortable or unconfident in the dive before the concussion 23. 54.2% of divers experiencing a head injury is staggering – in comparison, 37% of football players report experiencing football-related concussions across their careers 24. The velocity of the head hitting the water can result in a concussion and loss of consciousness, which is problematic when considering the risk of hypoxia.
Nuances of Aesthetic Sports
Certain foundational characteristics of the aesthetic sport class contribute to heightened concussion rates and hinder traditional athlete safeguarding efforts.
Aesthetic sports are subjectively scored – skills are typically scored based on their adherence to technique and difficulty, with a baseline provided and deductions made for errors. Because of the extreme demand for athletes to follow their sport’s technique perfectly to win, aesthetic sport athletes report increased levels of perfectionism when compared to other athletes and non-athletes 25. Constant perfectionism to this level is linked to significant psychological consequences (depression, decreased self-worth, anxiety) as well as physical consequences (headaches, fatigue) 26. In dancers, perfectionism and the consequences associated with it have been linked to an elevated baseline score of concussion 9. The intense standard of performance placed on aesthetic sport athletes means that these athletes don’t just suffer more concussions, but their concussions may be more severe.
In aesthetic sports, the instilled toxic resilience reflected in the response to falling is important to consider. Toxic resilience refers to an unhealthy form of perseverance or toughness where individuals continuously push through adversity, pain, or hardship at the expense of their well-being, physical health, emotional health, or boundaries. Across aesthetic sports, athletes report that they have been conditioned to get back up immediately after falling and continue the routine. This is because falls count as deductions, and additional recovery time potentially subtracts additional points. It also means that if an athlete sustains a head injury as a result of falling, they may not receive adequate treatment or rest afterward. Female collegiate divers, on average, wait 12 hours before seeking medical attention for concussion symptoms 23. Almost half of figure skaters did not report their symptoms to a healthcare provider 18, and 15% of artistic swimmers 20 report not seeking medical attention at all.
Aesthetic sports athletes are at additional risk of concussion because of the artistic element. In cheerleading, showmanship is scored through facial expressions. Artistic swimming requires sustained eye contact with judges, otherwise you risk deductions. This is similarly seen in dance and figure skating, where artistry and performance quality is measured through acting via facial expressions. Traditional safeguarding efforts from concussions – helmets – therefore become almost impossible to implement in aesthetic sports, as an athlete in a helmet would have a direct disadvantage due to their obscured face.
Aesthetic Sport Concussion Prevention Efforts
Multiple national governing bodies (NGBs) for aesthetic sports have implemented protocols regarding concussion prevention and response. USA Cheer, USA Gymnastics, and USA Artistic Swimming have published concussion protocols on their websites, which all include signs and symptoms of concussion, recommendations on concussion prevention, and return-to-sport protocols. USA Gymnastics’s and USA Artistic Swimming’s protocols also includes recommendations on what to avoid after concussions. U.S. Figure Skating does not provide a return-to-play program, but does recommend that figure skater baseline neurocognitive functioning should be evaluated to assist in creating athlete concussion management plans. USA Diving requires all coaching staff to complete concussion training provided by the National Federation of State High School Associations (NFHS) or Center for Disease Control (CDC). USA Artistic Swimming has additionally partnered with TeachAids for mandatory concussion training for coaches 27, and Hammer Head swim caps (which provide extra protection against head injuries) are promoted by USA Artistic Swimming for use in practice settings 28. Dance has no NGB and, therefore does not have any standardized concussion protocol, but resources are available online that are tailored to dancers 29.
Sport-specific nuance is critical to developing concussion protocols for all athletes, especially in aesthetic sports. One critical nuance that is left out of concussion protocols across aesthetic sports is the issue of gender. Aesthetic sports are comprised of predominantly female participants, yet no concussion prevention mentions the fact that women and men experience concussions differently, and certain factors need to be taken into consideration when looking at female sport-related concussions. These factors are discussed more in Bridging the Concussion Gap, linked here.
Aesthetic Sport Devaluation Limits Concussion Prevention Efforts
Aesthetic sports are constantly ridiculed and criticized as “not really being sports,” despite the fact that every single aesthetic sport requires an immense amount of athleticism and subjects its athletes to intense training regimens the same way male-dominated sports do.
Dance and cheerleading are not considered sports under Title IX, as the NCAA sanctioned them as “spirit” activities. When we don’t sanction aesthetic sports under the NCAA, sports receive less funding and public awareness, reducing the ability of aesthetic sport staff to implement concussion protocols and safety measures the same way majorly funded sports (like football and soccer) do. Not sanctioning sports under the NCAA also means that athletes are not entitled to the same level of Title IX protections that athletes competing in sanctioned sports are. Diving and swimming are often combined within the NCAA, meaning that diving’s high rate of concussion is lessened by swimming’s infrequent rate of concussion.
In regards to concussions specifically, we have not seen the volume of athlete death and other catastrophic injury due to TBI in aesthetic sports as we have seen in sports like football and wrestling. Certain aesthetic sport organizations collect concussion data annually (namely, USA Cheer, USA Gymnastics, and USA Artistic Swimming), but many others don’t, which means we don’t have a clear picture of what the real concussion rate is in these sports. However, there is no reason to wait to collect this data before taking steps to protect athletes. We already know the risk exists and that the effects of these injuries devastate athletes. Proactive prevention is the responsibility of any sport organization, and waiting for future catastrophic injury to catalyze concussion discussions contributes to the needless suffering of athletes.
Public pressure has largely been the primary force behind major safety initiatives in sports. The NFL, NHL, and FIFA all implemented policies after awareness of concussion harms increased. When we downplay concussion risk in aesthetic sports and trivialize aesthetic sports by not treating them as sports, we hinder the capacity for meaningful change. Even as concussion rates increase in frequency and severity in aesthetic sports, we have yet to see the creation of new safety materials that would be useful in an aesthetic sport setting, the collection of annual concussion reporting data for all aesthetic sports, or the implementation of safety protocols that take female-specific differences into account. It is imperative that we begin treating all athletes on an individualized level with respect and sport-specific nuance that prioritizes safety above all else.
Prioritizing Athlete Health and Accurate Resources
Aesthetic sporting organizations should consider how the culture of their sports – one of perfectionism, toxic resilience, and objectification through prioritizing athlete facial expressions over safety – currently impacts their athletes, as well as how it could be changed.
Athletes deserve safe sporting environments where education on response and management is tailored to their athletic experience. To achieve the protection of aesthetic sports athletes, demographic vulnerabilities like gender and sex must be taken into account. Aesthetic sport athletes should be equally represented in research discussing concussions and athletics, and coaches have a responsibility to stay educated on best practices regarding concussions, especially in high-risk contexts such as aesthetic sports.
Most importantly, we need to start treating aesthetic sport athletes like athletes. The exhaustive training regimens and injury risk warrant respect. Demoting these athletes to “spirit” or “not really sports” simply reduces public awareness of substantial public health concerns within sport, and reduces the likelihood that aesthetic sports will become safer. All athletes need prevention education, safeguards, and resources that fit their needs.
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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
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