Why does it seem like nobody cares about female concussions?

ESPN senior writer Peter Keating joins OTL to share his findings on concussions in female athletes, featured in ESPN The Magazine and on espnW.com.

This story appears in ESPN The Magazine's Body Issue 2017. Subscribe today!

EVERY FOUR YEARS or so, some of the world's most prominent scientists gather to synthesize and summarize the latest in brain-injury research. Since first meeting in 2001, the assemblage, called the Concussion in Sport Group, has grown in size and influence. Doctors, athletic trainers and media types around the world take their cues from the recommendations it publishes and from the Sport Concussion Assessment Tool (SCAT) it has developed. When members gathered in Berlin last October, Jiri Dvorak, then FIFA's chief medical officer, said they worked on behalf of some 1 billion professional and amateur athletes. For that 2016 symposium, around 400 medical and sports professionals met in the Grand Ballroom of the Ritz-Carlton hotel, with art nouveau stylings that hark back to the days before the world wars and trappings so posh that guests enjoy breakfast honey harvested from a rooftop beehive. Over two days, a stone's throw from where the Berlin Wall used to stand, the leading lights of the sports neuro-establishment made clear their role as gatekeepers of concussion research. Organizers closed the conclave to the media and swatted audience members off social media.

There was another group almost entirely shut out of the 5th International Consensus Conference on Concussion in Sport: female athletes.

Of the dozen sessions at the conference, not one was dedicated to sex or gender. Researchers made 24 oral presentations during the meetings; one focused on female athletes. Among the 202 research abstracts, nine, or less than 5 percent, studied women specifically. "Gender hasn't been a hot, hot topic," says one member of the Concussion in Sport Group.

Hot or not, the facts the conference could have displayed are shocking. Women suffer more concussions than men in the sports that both play, with an injury rate 50 percent higher, according to the most recent research. Female athletes with brain trauma tend to suffer different symptoms, take longer to recover and hold back information about their injuries for different reasons than males. Anyone involved in sports should have a grasp of these key facts. Yet the leading national and international guidelines for understanding sports concussions and returning injured athletes to play ignore key differences in how women and men experience brain injuries.

Here's what's even more stunning: All of that information was public knowledge eight years ago, when ESPN The Magazine first looked at the subject of concussions and female athletes ("Heading for Trouble," March 23, 2009)-and all of it is still true. The latest studies continue to find that women get brain injuries more often in sports also played by men. But research into why and how is lagging to nonexistent, as are efforts to reverse the trend. Which means millions of female athletes are putting their brains at risk unnecessarily.

"More and more of the athletes I have seen over time are young women, and I've found they get less information about concussion from their coaches, and from the media too, than men," says Jill Brooks, a clinical neuropsychologist who runs Head to Head Consultants in Gladstone, New Jersey, and who in 2004 conducted one of the earliest research reviews of sex issues in brain injury. "They are struggling to deal with their particular symptoms and often not being taken as seriously as they should be. The sports world is much more accepting of girls and women as athletes but still gives the topic of their concussions short shrift."

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FEMALE SPORTS SCIENTISTS pioneered the initial research into sex, gender and concussions more than a decade ago. Dawn Comstock, a professor of epidemiology at the Colorado School of Public Health and a 4-foot-11 former rugby player, started tracking injuries among high school athletes in 2004 and began reporting sex differences in brain injury in 2007. In May 2016, she told the House Energy and Commerce Subcommittee on Oversight and Investigations: "In gender-comparable sports, so sports that both boys and girls play, by the same rules, using the same equipment, on the same fields, like soccer and basketball, girls have higher concussion rates than boys." Tracey Covassin, professor of kinesiology at Michigan State and a certified athletic trainer, has been studying college sports since 2003, with similar results.

But when it comes to looking deeper into the experience of concussions among female athletes specifically, researchers for the most part have been uninterested, unwilling or unfunded. The frontier of knowledge has been stuck for years in epidemiology-studies, again and again, of who encounters a health problem in the general population and when, rather than how and why it strikes a particular group. "There's a huge gap in the science of brain injury," says Angela Colantonio, director of the Rehabilitation Sciences Institute at the University of Toronto. "There has been a lack of explicit consideration given to sex and gender. We're just starting to scratch the surface."

A major problem with concussion research is that very few people conduct it who don't have a stake in its outcome. I think these folks didn't want to see their names used in lawsuits.
Katherine Snedaker, clinical social worker

In the 2017 Consensus Statement on Concussion in Sport, which 36 of the scientists who met in Berlin published in April, and which runs more than 7,000 words, "gender" never appears and "sex" only once. It's just one item on a laundry list of factors, such as age, genetics and mental health, that the document notes "numerous studies have examined" for their potential impact on how athletes heal from concussions. The consensus statement doesn't actually evaluate what such research has discovered about the effects of sex or gender, except to say there's "some evidence" that teenagers "might be" most vulnerable to persistent symptoms, "with greater risk for girls than boys."

Several Europe-based contact-sport federations fund the meetings of the Concussion in Sport Group. FIFA, the International Federation for Equestrian Sports, the International Ice Hockey Federation, the International Olympic Committee and World Rugby split the costs of the Berlin conference, totaling approximately 250,000 euros (about $284,000), according to two sources at the group. Any of those organizations could be threatened if evidence emerges that it should have managed repetitive blows to the head better among particular kinds of athletes, such as adolescents or repeat concussion victims-or females. And the 30 co-authors of the consensus statement who filed conflict of interest disclosures declared 132 potential entanglements among them. All of which has some brain-injury research advocates concerned that the authors might have hedged their conclusions to avoid exposing their patrons to financial or legal liability. "The statement is extremely disappointing," says Katherine Snedaker, a clinical social worker in Norwalk, Connecticut, and founder of the research and advocacy group Pink Concussions, who attended the Berlin conference. "But a major problem with concussion research is that very few people conduct it who don't have a stake in its outcome. I think these folks didn't want to see their names used in lawsuits."

Even one of the consensus statement's co-authors echoes this criticism. "A lot of intelligent brains have been added to the committee," says Robert Cantu, professor of neurosurgery at Boston University and a founding member of the Concussion in Sport Group. "But I think some are so happy to be part of all this, sometimes they don't look hard enough at the research. And you've got to ask if that serves as a huge protective force for the organizations who put up the money to fund the meetings."

"We reviewed the literature on clinical recovery from concussion," says Grant Iverson, a professor of physical medicine and rehabilitation at Harvard Medical School and co-author of the consensus statement. "We examined many predictors and modifiers. Sex was one of them."

But when it comes to women specifically, the group has a particularly egregious history. Its third consensus statement, published after parleys in Zurich in 2008, included two ambiguous sentences about whether sex or gender influences the likelihood or severity of concussion risk. Four years later, again after meetings in Zurich, the fourth consensus statement also devoted two sentences to females-the same two sentences. Those sentences even cited the same three sources. From 2008 to 2012, women's participation in sports grew rapidly, rising 13 percent in the NCAA alone. Public interest in concussions also exploded, as the NFL crisis reached full tilt. And during those years, about 300,000 females aged 19 or under went to U.S. emergency rooms with sports- or recreation-related brain injuries. Yet the international consensus found nothing new to learn or say.

"The topics we focus on, we go into pretty thoroughly," says one researcher in the group. "Other material, we pretty much don't touch at all. Which is how stuff slides from one year to the next, not only unchanged but not updated."

"It was a cut-and-paste job, down to the footnotes," says neuropsychologist Brooks, who attended two earlier international consensus conferences but was not invited to Berlin.

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Andy Mead/YCJ/Icon Sportswire

Facing pressure, US Lacrosse recently adopted standards for women's headgear, but there's little research to inform guidelines.

MOST ATHLETES AND fans have learned about concussions from a decade of reports about former NFL players struggling with the long-term effects of taking blows to the head. As devastating as many of those stories are, the risks of brain injury can get worse the further competition moves from the epicenter of high-stakes sports that is professional football. Lower revenues and remote facilities can translate to poorer medical advice and treatment; scarcer media coverage sometimes means fewer people notice injuries in the first place. And these conditions often apply to women's collegiate sports, where some 214,000 female athletes compete under the regulatory umbrella of the NCAA. Division II women's soccer, for example, which Angel Mitchel played at Ouachita Baptist University in Arkansas.

Mitchel took to soccer from the age of 4, playing with her two older brothers in Mansfield, Texas, and dreaming of a pro career. "I would do whatever it took to play," she says. "Soccer was my life."

That all changed on Tuesday, Sept. 13, 2011, when Mitchel, then a sophomore at OBU and known by her unmarried name, Palacios, collided with a teammate while going for a header during a practice drill. The other player's skull crashed into Mitchel's face, knocking her dizzy and sending her to her knees. With her left eye already swelling shut, she lurched to the sideline, where she told her athletic trainer she felt sick. She had already suffered two concussions in high school.

The trainer asked whether Mitchel was dizzy. Was she nauseated? Did she have a headache?

"Yes ... yes ... yes," Mitchel replied.

She says the trainer sent her back to her dorm room with an ice pack. Nobody told Mitchel to see a doctor or checked on her that night. The team gave her an online neuropsychological test the next day, but the results weren't clear because she still couldn't use her left eye. Woozy, sensitive to light and stabbed by migraines, she stayed out of sight as much as she could for the rest of the week.

On Saturday, Mitchel says, her coach instructed her to run laps. She was still sick-she had thrown up earlier that day-and appealed to the trainer, who she says told her: "You don't want to make the coach mad."

I knew I wasn't right, and what was happening was wrong.
Angel Mitchel, soccer player

As Mitchel broke into a trot, the sun burned into her head, vomit swelled again from her guts and pain wracked her whole being every time her feet hit the ground. The intensity and folly of her pain fused into anger. "I knew I wasn't right, and what was happening was wrong," she says.

After a lap around the field, Mitchel stopped and decided she needed to go to an emergency room. Mitchel says that, after that, her coach said she could skip the rest of practice. In fact, he said, she should expect to sit out for a long time.

Doctors found that Mitchel had a severe concussion. She already had recall problems and diminished sensations in the left side of her body. And if she kept engaging in physical activity, she could permanently damage her brain.

Mitchel had a black eye for three months. Her migraines persisted for three years. She never played soccer again. Officials from OBU declined to comment.

Mitchel's experience is an extreme version of what many women experience after sports concussions: isolation, inadequate attention, improper clearance, intimidation. The NCAA for its part has been very late to respond to these issues. It didn't have any guidelines covering brain injury at all until 2010. It required schools to have personnel trained to handle concussions at contact-sports games only because of a massive settlement it reached in 2014. Mitchel, now 24, is justifiably proud of joining the legal action that led to that deal; "I know we have a long way to go," she says, "but it's a great start."

Yet the NCAA doesn't actually enforce how its members implement its new rules. It has never disciplined a school for failing to file a concussion plan or for maintaining inadequate personnel or for returning an injured player to the field. There's still no mention of sex or gender in its best practices for diagnosing and managing concussions or in the concussion fact sheets it distributes to students and coaches.

Maybe the best indication of the NCAA's priorities is simply this: Its chief medical officer has a staff of seven to address college-age health and safety issues from mental health to sexual assault. Meanwhile, its compliance desk has more than 50 employees who police amateurism among athletes.

For all that, Brian Hainline, the chief medical officer of the NCAA, says he has "fire in his eyes" about concussions, and he emphasizes that brain trauma in sports is an issue "much bigger than football." Indeed, in a column on the NCAA's website, he wrote: "We need to spread the word: Yes, female athletes also suffer with concussion, and they may be uniquely predisposed to this neurological event."

It's true that Hainline was close enough to Elliot Pellman, the notorious former chairman of the NFL concussions committee, for Pellman to blurb a book on back pain that Hainline published in 2007. And that in Hainline's early days on the job at the NCAA, it seemed as if he too might simply make excuses for how sports programs were treating athletes with brain injuries.

But Hainline has a touch of the seeker about him, and he has taken to his role as college sports' concussion-education booster-in-chief. His efforts helped create the Grand Alliance, a $30 million project the NCAA and Department of Defense launched in 2014 to study brain injury in student-athletes and cadets and promote concussion education. Over the past three years, the initiative has enrolled more than 28,000 subjects; 1,931 had concussions, and scientists are examining their brains and bodies over time. It's a highly regarded effort, and Hainline is enthusiastic about working with respected partners to assert leadership in brain-injury research. "We all need to take a step back and stop saying nothing is happening," he says. "Cooperation I never dreamed could happen is happening right now. Concussion has brought us to this place of magic."

But while about 35 percent of the athletes involved with Grand Alliance research are female-the largest cohort of women with concussions ever studied-the effort probably won't report anything new that's sex-specific for years, if ever. To see why, it helps to understand why women and men might experience concussions in different ways.

Scientists have known for a long time that women are more open than men about reporting injuries. Recent research shows they don't just describe more symptoms after concussions, they exhibit more too. An important example comes from Shannon Bauman, a sports physician who began studying brain injury after she got inadequate attention for a concussion she suffered playing hockey. From 2014 to 2016, Bauman tracked 207 injured athletes at Concussion North, the specialty clinic she runs in Barrie, Ontario. She found women averaged 4.5 objective signs of concussion, such as poor balance or vision, versus 3.6 for men. They also took longer to recover; 35 percent of females still showed symptoms six months after their injuries.

"Maybe the reason we talk more about our symptoms isn't because we're weak or vulnerable," says Snedaker, a former athlete who went through more than a dozen concussions of her own before becoming an advocate. "Maybe it's because we have more symptoms and they last longer."

Biomechanics might be one reason for that. On average, women have shorter and thinner necks than men and approximately 50 percent less neck strength. In general, that means females have less of a buffer against anything their heads might slam, whether it's a ball, another player's elbow or the ground. Their skulls experience greater acceleration when their bodies whiplash-and it's that motion that jars a brain and leads to a concussion, like scrambling a yolk without necessarily cracking an egg.

Further, different chemicals naturally course through the bodies of men and women. As a basic example, research has shown that fluctuating levels of estrogen leave women far more susceptible to migraines than men, and migraines and concussions seem to cause similar problems inside the brain. It also turns out that, until puberty (when sex hormones start flowing), young boys and girls get concussions at comparable rates and share similar symptoms. Some neuroscientists have wondered about the effects of sex-specific hormones that either stress or shield the brain when it's concussed.

In a series of groundbreaking studies that started 25 years ago, Robin Roof, then a researcher at Rutgers, found that progesterone, a female sex hormone, reduced brain swelling and improved cognitive function after injuries in rats. The implications were huge: Maybe progesterone could mitigate the impact of brain injury. But the subject wasn't studied much again until 2013, when a team from the University of Rochester recorded data on the menstrual cycles of women who went to emergency rooms with concussions. It found that females who were injured at a point in their cycles when their progesterone levels should have been high suffered more symptoms afterward. "That's counterintuitive, because in animal studies, progesterone has a neuroprotective effect," says Jeffrey Bazarian, one of the Rochester researchers. "But concussion might disrupt its production, shut it off and lead to an abrupt decrease in the blood."

That's an interesting theory, but it's speculative. Hormones interact with one another in complex ways. And large-scale clinical trials of progesterone on brain-trauma victims have failed to show any significant benefit. So Bazarian is left with a nagging question: "How can there be such a discrepancy between rodents doing so well with progesterone and what we've seen so far in humans?"

"We can look at reporting, and we can look at neck strength," Brooks says. "But we have got to get to how the brain works in men and in women, which means studying how hormones affect its function."

That, however, is not a subject the NCAA is pursuing in its research. Its Grand Alliance with the Defense Department is on its way to amassing more than 25 million data points from athletes, information that an "advanced research core" will study with sophisticated neuroimaging devices and comb for biomarkers, or substances in the blood that indicate brain injury. But it will not collect statistics on where female athletes are in their monthly cycles, nor will it analyze blood samples for sex hormones. Those are "interesting and important questions," says Steven Broglio, a professor of kinesiology at the University of Michigan and one of the scientists leading the Grand Alliance's research. "[But] no study can address every concern. Hopefully, future research will take on this challenge."

"I understand you have to pick the low-lying fruit first, but five years from now, it's going to be too late to go back and get this data," Snedaker says. "If you're not going to look at what makes us different, then don't put us in the studies."

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BEHIND CLOSED DOORS, some women's sports advocates aren't comfortable looking for differences between male and female injuries. Treating male and female athletes differently could revert to stereotypes that women have been fighting for decades-that they aren't up to the challenges of sports or need special pleading or are simply weaker than men.

But medical science has a long history of judging females by male standards, all too often with terrible results. Medical schools typically use men's bodies to teach students about disease, and doctors are more likely to miss or wrongly diagnose symptoms among female patients. The classic example is a heart attack: Women are more likely to feel as if they have the flu than to experience chest pain. And medical research historically has used male subjects to study treatments, producing findings on everything from aspirin to Ambien that didn't apply accurately to women.

Brain injury, then, is one of many examples where even studies that include women almost never come to separate conclusions about them. In 2016, the Archives of Physical Medicine and Rehabilitation reviewed the scientific literature on concussion since 1980. It found that of 221 published papers, just 7 percent of them broke out their data by sex. "Brain science follows society," Brooks says. "Men are making a lot of the decisions about women's health. I've had to conclude that instead of making change from the top down, I have to try from the bottom up, helping one patient at a time [as they] become healthy, informed, strong women."

Sports concussions are an acute case because so much attention and funding has followed pro football. Most obviously, while the NFL's concussion studies have been riddled with junk science and conflicts of interest, the league has helped tilt research toward helmeted sports. Last September it pledged $60 million toward developing new concussion technology, possibly including a new helmet, and $40 million for researching head injuries. And now the NCAA and the DOD are entering the field.

Naturally enough, parents around the country, many concerned about long-term brain damage and CTE (chronic traumatic encephalopathy), have started to demand greater protection for their daughters-even when science isn't ready to tell them just what to ask for. For example, U.S. Lacrosse, facing pressure from alarmed advocates, parents and state legislators, recently adopted its first standards for women's headgear. It's still optional, but helmets must now meet new guidelines-even though the federation doesn't actually have any evidence that the new equipment will reduce concussions. "This is a national experiment," says Andy Lincoln, who conducts research for U.S. Lacrosse. "There is a need for more information on head impacts and exposures in women's and girls sports."

Yes, there is. So what happens next, as public opinion, and soon enough, lawyers, politicians and salesmen, fill the vacuum left by the institutions that govern women's sports and the scientists they sponsor?

"I'm very concerned," Hainline says.

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