Various studies suggest that women and girls sustain more concussions, at a higher rate than their male counterparts in the same sports.
A recent National Collegiate Athletic Association (NCAA) Injury Surveillance Program study, for example, shows the rate of concussion per 1000 athlete-exposures in football is 6.3 in females versus 3.4 in males. Similar differences were noted in basketball (6.0 in females versus 3.9 in males) and baseball/softball (3.3 versus 0.9).
Women are also known to experience more severe symptoms, and take longer to recover.
A study published in 2017 (Neidecker et al) compared the medical records of 110 male athletes and 102 female athletes, all of whom had endured a single sports-related concussion. Female athletes had symptoms for an average of 28 days, versus 11 in males.
In fact, multiple research studies have found in sports with similar rules between females and males, that rates of concussion are higher in women (Gessel, Fields, Collins, Dick, & Comstock, 2007; Hootman, Dick, & Agel, 2007; A E Lincoln et al., 2012).
But in-depth research specifically on the female brain injury experience is limited. Meanwhile, no female-specific brain injury guidelines exist in the sporting, military or healthcare arenas. Protocols and educational resources are also in short supply.
“I think some of it is misogyny,” says Katherine Price Snedaker, founder of Pink Concussions, the world’s first non-profit organisation for women and girls living with a brain injury.
Katherine was a social worker helping children with concussion when she started to notice differences between how parents of boys and girls responded to injuries.
“The girls’ parents were calling me weeks or months after the incident, yet with the boys’ parents it was within hours or days. I just kept seeing this pattern,” she says.
Katherine, who has three sons, initially put this down to bad parenting; but now blames widespread lack of awareness about female brain injury.
“If you don’t know what a concussion is, you’re going to be less likely to get the help in the time that it takes.
“People might have some of these symptoms, like headaches and nausea, anyway. If you don’t know what you’re feeling, you can’t know what to look for.”
Katherine (pictured above spreading the word about Pink Concussions) began looking for research on the differences between brain injuries in males and females, and while there was information out there, it was always in the small print, never the focus of the study itself.
She wanted to create a platform that would bring all of this information together, and so Pink Concussions was born.
That was in 2013 and, two years later, the organisation had enough support behind it to become an official non-profit.
Since then it has held seven international medical summits and scientific conferences and built up an advisory board of over 80 experts from around the world.
It also routinely works with major US health organisations, including the Centre for Disease Control and Prevention and NIH (National Institutes of Health); and provides support groups for more than 4,000 women and caregivers.
“My greatest goal is to work with the UN. We’re a small organisation and we’re all volunteers. The annual number of donations we take in is probably smaller than most school sports teams do, but we’re the only ones who do what we do.”
Pink Concussions is working to close the gap in research and awareness of female brain injury, through education, training and support. It also conducts its own research studies, exploring both sex and gender differences in brain injury.
As noted on its website, scientific research shows that female and male brains differ in more than 100 ways in structure, activity, chemistry, and blood flow.
Other potentially relevant sex differences include hormone levels, neck strength and head size.
Differences in gender – a social construct which is often but not always concordant with biological sex – include what Pink Concussions calls the “controversial explanation” that women are perceived as being more likely to report injuries.
Statistically, there are higher numbers of brain injuries in men than women, which goes someway to explaining why the vast majority of research has been studied from a male perspective.
It is increasingly evidenced, however, that women have more symptoms, feel them more intensely, take longer to recover and are more likely to experience post-concussion syndrome.
The lack of knowledge and awareness of female brain injuries, among women themselves, and in wider society, can have serious consequences.
If a woman’s recovery speed or symptoms don’t match expectations, this can lead to doubt, isolation and anxiety, beyond any she may already be experiencing, says Katherine. Women are therefore not prepared to cope with their injury.
“I think for many years, people just said it’s because women aren’t as tough as men. Women are weaker and complain more.
“I’ve seen some really great sports doctors say ‘oh, she’s just highly strung, or she’s just emotional’.”
It’s only very recently that researchers have started to study brain injury specifically in women, after years of men doing research on men, says Katherine.
“In brain injury, it’s been men doing research on men or male animals. When they use female animals it’s messy. If a lab rat goes through its menstrual cycle every six days, that really throws off results, so it’s pretty uniform that they don’t do research on female animals.”
Also, the majority of brain injury research has been conducted on athletes, and the sports with the highest risk of concussion, such as American football, rugby and boxing, are male-dominated.
“If you want to see a bunch of guys with a brain injury where do you go? The (American) football field. Football has always worked out well in providing men to be studied.
“The researchers need them as lab rats as much as they want the researchers. The two are entrenched in each other.”
But a study by the American Medical Society for Sports Medicine found that women are 12 per cent more likely to sustain a concussion than men in matched sports. Yet unlike in the men’s game, often these are not noticed or reported to medical professionals at the time of injury.
“Usually women’s sports are underfunded, and traditionally they have fewer medical staff on the pitch or the field.”
But it’s not just the sporting world which is neglecting to address the issue in women. In the military, safety and training equipment is often designed for men, says Katherine, and women are less likely to speak out about an injury for fear of being judged as “not tough enough”.
“Women are trying to operate and train on equipment that’s not necessarily made for them. A woman who might be the only female in her platoon, may be less likely to come forward if she’s injured, because she doesn’t want to be the one being pointed out,” she says.
Beyond the sporting world, those keen to study female concussion and chronic traumatic encephalopathy (CTE), would find a high volume of cases among domestic violence survivors, research suggest.
Blows to the head, face and neck combined with asphyxiation from strangulation, common in intimate partner violence (IPV), can lead to many women living with undiagnosed brain injuries.
In one of the first research studies into traumatic brain injury (TBI) in survivors of intimate partner violence, Pink Concussions board member Dr Eve Valera found that three quarters of the women she interviewed had sustained at least one mild TBI from their partners.
Eve, an assistant professor in psychiatry at Harvard Medical School, is now working on a new study, replicating many of those which have been conducted on male athletes, exploring the long-term effects of these brain injuries for women.
“If we’re talking about neurodegeneration in women we really know nothing. I call it an international public health epidemic. We have all these resources and money and studies on male athletes and there’s nothing like that with respect to women experiencing IPV.
“There’s a disjoint between what people are learning from sports or military data, where we see most repetitive head injury research, and what a woman may think is going on with her.
“There’s an awareness that playing football can lead to injuries that can have long-term neurodegenerative consequences but for the most part, there’s no public awareness that, if you’ve been in a physically abusive situation and you’re getting these types of blows to the head, you may have a long-term neurodegenerative disease.”
The lack of studies for women often means that survivors who do wish to speak up about their injuries find they have nowhere to turn. Eve has been contacted by women who have been turned away by researchers who cannot study them because of their sex.
“These women are left with no one. They call me and they’re desperate,” she says. “Where as male athletes feel like they have a place to go if they’re concerned about CTE, if you are an IPV survivor you don’t have anywhere to turn.”
Pink Concussions launched its campaign the ‘Pink Brain Pledge’ for this very reason. By partnering with several brain banks around the world, it is encouraging women to ‘take the Pink Brain Pledge’ and donate their brain to science. So far, 450 women have done just that.
“Any woman can pledge her brain for our programme. As much as we need women with brain injuries, we also need women without, for controls.”
Katherine believes studying these brains could lead to huge developments in brain injury research – and the key could be in looking at how hormone levels affect outcomes.
“We’ve proven the same thing over and over again, that there are differences. Now we’re trying to push the research to the next point. Let’s figure out why these things are happening.
“We look at what hormones people were born with, what hormones they are taking, and if you were born male, and you’re taking female hormones, how does that affect things?
“If hormones can control the outcome, then how can we take that and make an antidote or something that’s preventative or at least lowers your rate? We’re not there yet, but that’s my hope.”
This is not just a women’s issue. While females remain at the heart of Pink Concussions, the work the organisation is doing could help to improve education and medical care for all those living with a brain injury.
“Slowly we’re spreading out and women are learning more about brain injury. But I’m hoping that the gains we make in female brain injury we can apply to men too.”
For more information visit https://www.pinkconcussions.org
(Photos provided by the Schulich School of Medicine & Dentistry, Western University, Canada.)
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