To this hour bewail the injury

It seems I grew up in a male purdah -I think all men did, and perhaps most still do. And yet, the triumph of women in academics, business, and sports in particular, has begun to open the male curtain a little. No longer would most of us be surprised to find women competing at the highest levels in sports as disparate as, say, rugby and tennis, soccer and hockey -albeit in their own leagues for now. Still, this is a fairly large departure from the days when sports were largely -if not completely- male dominated.

Women were not thought to have either the temperament or the musculature important for effective competition that their male counterparts so obviously possessed. Add to that their differing hormones which suited them for the roles to which society had long assigned them, and males felt they could relax in their smug complacency, secure in the knowledge that there were things that women just could not do -and also had no desire to.

Furthermore, because of the nuisance of the cyclic fluctuations in female metabolism, sexual differences were often discounted as too expensive and too variable to be taken into account in medication design and testing, so many of the drugs available on the market that were only tested on males were assumed to work as well in either sex. Unfortunately -although predictably- this led to problems in both outcome and side effects. In fact, I discussed some of these issues in an essay I wrote several years ago: https://musingsonwomenshealth.com/2016/10/12/women-are-from-earth/

More recently however, although many sports have become increasingly aware of the different types of dangers in their respective competitions, it comes as no surprise that there was an assumption that the occurrence of concussions in female athletes mirrored the frequency, symptomatology, and outcome in their male cohorts.

I don’t wish to embark upon a gendered jeremiad, because studies and evidence of sex difference is slowly accumulating, and in the more gladiatorial sports, there still seems to be a preponderance of men, so perhaps it makes sense to start with the effects of concussions on them -but nevertheless…

Thank goodness there was an interesting essay on female concussions in an article in BBC Future entitled, helpfully enough, Why women are more at risk from concussion written by David Robson: https://www.bbc.com/future/article/20200131-why-women-are-more-at-risk-from-concussion

‘Concussion is changed neurological function as the result of a bump, blow or jolt to the head. The violent movement of the head causes a momentary release of various neurotransmitters that throws the brain’s signalling out of balance. It can also cause the neural tissue to swell and reduce the flow of blood to the brain – and along with it, the glucose and oxygen – starving our nerve cells of their fuel… The potential long-term impact of concussion is now well known and has led many sports associations to change their rules and procedures to reduce the danger of injury. But there is low awareness of the potentially higher risks to female players and the possible need for differing diagnosis and treatment, including among healthcare professionals… Recent research… suggests that female athletes are not only more likely to sustain a concussion in any given sport; they also tend to have more severe symptoms, and to take longer to recover.’

I still remember the words we once used to describe the symptoms in boxers towards the end of their careers: punch-drunk. Of course, I was fairly young then, but I don’t remember the word ‘concussion’ being used with any frequency; I assumed an appreciation of the concept was fairly recent, and yet ‘Concussion is thought to have first been distinguished from other types of brain injury more than 1,000 years ago, by the Persian physician Rhazes, but sex differences in concussion have only been the subject of serious research within the last two decades or so.’ Then again, ‘The sex differences in concussion were also obscured by the fact that many of these injuries are the result of accidents in sport, and girls and women were historically less likely to compete in events where concussion has attracted most attention.

‘Tracey Covassin, who is now based at Michigan State University, has been one of the leading researchers looking at potential sex differences in concussion… In soccer, basketball and softball…  she found that female players are almost twice as likely to suffer a concussion as male ones.’ And their symptoms were often different. ‘While male concussions are more likely to be followed by amnesia, for instance, female ones are more likely to lead to prolonged headaches, mental fatigue and difficulties with concentration, and mood changes… Female athletes also seem to require more time for those symptoms to disappear.’

The problem is that sometimes the differences were attributable to sexual stereotyping and hence glossed over. That’s a fraught subject with many of the (largely male) therapists, but where there’s smoke, there’s often fire. For example, ‘Some researchers have proposed that it may be due to the fact that female necks tend to be slimmer and less muscular than male ones… the brain is free to move within the skull – it is like jelly tightly packed into a Tupperware container – and this means that any sharp movement of the head can cause it to shift around, potentially causing damage.’ So, ‘anything that helps to protect the skull from sharp movements should protect you from concussion – and that includes a sturdier neck that is better able to buffer a blow.’ Currently, there are a few team physiotherapists who have devised exercises to help strengthen these muscles -especially in rugby players where padding and helmets are certainly not de rigueur.

There are other theories why female concussions are different. For example, ‘small anatomical differences within the brain itself. Female brains are thought to have slightly faster metabolisms than male ones, with greater blood flow to the head… if a head injury momentarily disrupts that supply of glucose and oxygen, it could cause greater damage.’

There is even some evidence that the cyclic nature of female hormone production may also play a role in susceptibility to concussions. For example, ‘Researchers at the University of Rochester School of Medicine and Dentistry… found that injuries during the follicular phase (after menstruation and before ovulation) were less likely to lead to symptoms a month later, while an injury during the luteal phase (after ovulation and before menstruation) resulted in significantly worse outcomes.’

Clearly research of female concussions is still in its early stage, but even these preliminary findings might suggest some possible mitigating strategies. For example, some studies have demonstrated the benefit of suppressing endogenous cyclicity in hormone production with, say, oral contraceptives.

And yet, perhaps the most hopeful thing is the recognition of the dangers of concussion in both sexes. It isn’t something that only occurs in high-contact sports like rugby or hockey; it’s something which crosses the gender divide with seeming ease. It’s the mask we’re beginning to see through, the condition that finds itself harder and harder to camouflage.