Do girls take longer than boys to recover after a concussion? A recent study of middle- and high school athletes they found that the female athletes took twice as long to be symptom-free as the male athletes. Shockingly, the female athletes took nearly a full month to report being symptom-free, while the male athletes took less than two weeks. It was reported widely across the media as evidence the young women may have a special problem with concussions.
This conclusion, unfortunately, is not well supported. Meta-analyses (which look at the full body of literature on a topic) have found conflicting evidence regarding male-female differences in concussion recovery. Consensus statements on sport-related concussion have not deemed there to be sufficient reason to distinguish between the genders for return-to-play protocols or guidelines on handling the injury. And the study itself has important flaws.
There are hundreds of thousands of female athletes who have scholarships, professional careers, and Olympic hopes at stake, and let’s not forget the basic principle that our girls deserve equal opportunity as the boys to participate in sports. These conclusions have real consequences, and we need to get our information right. One of the strongest predictive factors for prolonged post-concussion symptoms is expectation of recovery—those who believe they will recover quickly are more likely to do so. So if we label women in this way, it can have a direct, negative effect on their recovery from concussion.
The study by Dr. John Neidecker, an orthopedic doctor in North Carolina, looked at the medical records of 110 boys and 102 girls who attended his sports medicine clinic after a concussion. While boys reported being symptom-free in under 2 weeks, it took girls almost one month. A big problem here is the lack of an objectively determined point of recovery—the researchers can’t be faulted here, because, at the moment, we have no objective marker of concussion recovery. But, they did not corroborate these results with any additional, objective tests that could have told us more about the patients’ brain function. So, the only evidence they show is how long it took until the kids said they were symptom-free.
Self-reporting is the bane of concussion research. Athletes notoriously underreport symptoms in the preseason as well as after concussion. We are also assuming that any symptoms that follow the concussion are because of the concussion, but this is not always true. On top of this, neurocognitive tests are not as objective as we think. Many athletes will “tank the baseline”: deliberately underperform on preseason tests so that if they do get concussed, their post-injury testing won’t look so bad, and they can get back to competing.
Men’s teams have good reason to try to minimize injuries. An interesting study by Michael Cusimano, a neurosurgeon at St. Michael’s Hospital in Toronto, Canada, looked at the culture of men’s sports by interviewing adolescent boys’ and girls’ hockey teams. In boys’ hockey, themes of heroism and masculinity fed into the likelihood to hide concussion symptoms, citing them as weaknesses and that they were just “part of the tradition of hockey.” Boys faced more pressure to win than girls, and this made them more likely to return to play early. In fact, the researchers’ findings echoed others who reported that males “returned to play sooner after suffering the same severity concussion as females and were twice as likely to be noncompliant with return-to-play guidelines.” The researchers found that girls, on the other hand, were more likely to report concussion injuries and less likely to return to play prematurely. For girls, desire for academic more than athletic achievement may increase their likelihood to take more time to recover from concussion before returning. Boys will be able to make a substantial income should they go pro; girls, not so much. Part of the pressure on boys to continue compete is the prospect of a lucrative professional career—this makes them more likely to report that their symptoms are gone, so they can get back out playing.
An illuminating study in 2011 assessed 167 children with concussion and found that emotion-focused coping strategies (e.g., “I let my feelings out to reduce my stress”) were associated with increased symptom reporting compared with problem-focused coping strategies (e.g., “I convinced myself that things were not as bad as they seem”). While the researchers did not directly compare the sexes, it is easy to see that socialization of males dictates that they ignore their emotions and focus on problems, while for women the opposite is true. If women are socialized to cope with emotion-focused strategies, they are more likely to report symptoms for longer.
There may very well be gender differences in concussion, but when looking at subjective measures we need to be careful to look at the whole picture and consider context. If we put the focus on female athletes by declaring that they “take longer to recover,” we are assuming that male athletes are taking the right amount of time. But given what we are still learning about long-term contact sport participation and repeated concussions, maybe it isn’t that female athletes are taking longer—it’s that male athletes aren’t taking long enough. If we prematurely accept the premise that boys recover faster, we risk abandoning them to the perils of their own false ideas of heroism.
Melissa McCradden is a former competitive athlete and holds a PhD in neuroscience. She is currently completing a Master’s degree in bioethics and is a postdoctoral fellow investigating sport-related concussion with Dr. Michael Cusimano at St. Michael’s Hospital in Toronto, Canada.