Although gender equality in sports continues its steady progression, there
is 1 area that appears to be linked with disparity of a different sort:
A growing body of research suggests that compared with male athletes,
female athletes at both the high school and collegiate levels have a higher
risk for concussion and worse related outcomes.
"There is an increased frequency of concussion among females when
compared to males in sports with similar rules, such as soccer and volleyball,
and females tend to report more and increased severity of symptoms associated
with a concussive injury than males," Vernon B. Williams, MD, founding
director of the Kerlan-Jobe Center for Sports Neurology and Pain Medicine
at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, California, told
Higher Frequency, Worse Symptoms
The difference in incidence is noted in the American Medical Society for
Sports Medicine's position statement on
concussion in sports, and has been supported by numerous studies.1 Most recently,
research described in 2016 in the
Journal of Athletic Training examined concussion injury rates of 1702 National Collegiate Athletic
Association athletes participating in soccer, ice hockey, basketball,
softball, baseball, and lacrosse.2 The results show that rates were 1.4
times higher among females than males in all sports except for lacrosse
(injury rate, 4.84 vs 3.46, respectively), and the return-to-sports interval
was longer for women vs men in both soccer, which is the sport most associated
with concussion in females, and basketball.2
In addition to greater frequency, concussion-related symptoms appear to
be worse in female athletes as well. Using a 22-item post-concussion symptom
scale, a study published in 2013 in
The Physician and Sports Medicine compared scores of males and females with sports-related concussion. No
matter how soon after the injury they presented to the clinic, females
had higher scores than males (30.9 vs 15.8, respectively;
"However, brain injury research, including sport concussion research,
has long been viewed through a masculine perspective partly due to findings
that [traumatic brain injury] in general occurs about twice as often in
males as it does in females," said Katherine Snedaker, LCSW, executive
director and founder of PINK Concussions, a nonprofit organization focused
on female brain injury. "While studies show that females may have
different injury rates, symptoms, and rates of recovery, the medical community
does not yet have any female-specific guidelines, protocols, care plans,
or education resources for women with brain injury, including concussions,"
she said in an interview with
The Influence of Sex and Gender
Although the exact mechanisms are unclear, both sex and gender differences
may account for the observed differences. "There are theories related
to the size and strength of neck musculature, [which are] generally smaller
and weaker in females, which may increase the forces experienced during
contact and participation," Dr Williams explained. "There are
also potential relationships to hormonal influences and even phase of
the menstrual cycle that could play a role."
In a study published in 2014 in the
Journal of Head Trauma Rehabilitation, for example, women who were in the high-progesterone luteal phase of
their cycle at the time of injury had worse scores on measures of quality
of life and neurologic functioning than those in the follicular phase
or women receiving oral contraceptives.4
As for gender role influences, it is possible that "females may report
more symptoms at the time of a concussive injury because they are generally
more expressive or because there are fewer cultural prohibitions against
'complaining' or being unable to 'tough it out' as compared
to males," according to Dr Williams. "Sociocultural influences
affect reports of pain and other symptomatic conditions, so it is likely
that they affect concussion reporting and the experience of symptoms as
well." These aspects will need to be explored in future investigations.
Recent findings indicate that it can take longer for female athletes to
achieve symptom resolution, and that they experience more severe academic
dysfunction after concussion.3,5
They may also require more treatment interventions than males; for instance,
research conducted at the Connecticut Children's Medical Center found
that female athletes were more likely to require academic accommodations, vestibular therapy, and medication during
In the evaluation and treatment of concussed patients, practitioners should
consider the full range of factors, including sex and gender, that "contribute
critical information to the clinical picture," advises Dr Williams.
"Neurologists and other clinicians evaluating and managing concussions
should be aware of the very unique and individual nature of the injury."
Snedaker adds that female patients and individuals who are key to their
recovery should be educated about sex differences relevant to concussion.
"Since more men than women have brain injury, a woman and the people
around her will most likely know more men than women who have had concussion,"
she noted. As such, the patient may doubt herself if her experience differs
from that of affected males she might know, and family members, teachers,
and employers may judge her case to be abnormal, or they may suspect malingering
or the presence of issues unrelated to brain injury.
"Without proper education of [the] patient, family, and community
supports, women and girls with brain injury, including concussion, can
experience an additional lack of support, doubt, isolation, and anxiety
beyond that which comes with brain injury," she said.
Harmon KG, Drezner JA, Gammons M, et al.
American Medical Society for Sports Medicine position statement: concussion in sport.
Br J Sports Med. 2013;47:15-26. doi: 10.1136/bjsports-2012-091941
Covassin T, Moran R, Elbin RJ.
Sex differences in reported concussion injury rates and time loss from
participation: an update of the National Collegiate Athletic Association
Injury Surveillance Program from 2004-2005 through 2008-2009.
J Athl Train. 2016;51:189-194. doi: 10.4085/1062-6050-51.3.05
Berz K, Divine J, Foss KB, Heyl R, Ford KR, Myer GD.
Sex-specific differences in the severity of symptoms and recovery rate
following sports-related concussion in young athletes.
Phys Sportsmed. 2013;41:58-63. doi: 10.3810/psm.2013.05.2015
Wunderle K, Hoeger KM, Wasserman E, Bazarian JJ.
Menstrual phase as predictor of outcome after mild traumatic brain injury in women.
J Head Trauma Rehabil. 2014;29:E1-E8. doi: 10.1097/HTR.0000000000000006
Wasserman EB, Bazarian JJ, Mapstone M, Block R, van Wijngaarden E.
Academic dysfunction after a concussion among US high school and college students.
Am J Public Health. 2016;106:1247-1253. doi: 10.2105/AJPH.2016.303154
6. Kostyun RO, Hafeez I.
Protracted recovery from a concussion: a focus on gender and treatment
interventions in an adolescent population.
Sports Health. 2015;7:52-57. doi: 10.1177/1941738114555075