There's a gender gap in sports concussion research. Here's how Abby Wambach and other …

Abby Wambach had only one diagnosed concussion in her long and laureled career. It came in April 2013, two months before she broke Mia Hamm’s world record for national team goals for either gender. 

Playing against the Washington Spirit with her Western New York Flash, Wambach took a vicious blow to the head when her own defender cleared the ball and clobbered her teammate from close range. Wambach crumpled to the ground and balled up, clutching her head. The referee waved off the Flash trainer, refusing the medical attention for a player who was obviously struggling. Wambach got up, and the game went on. When it ended, Wambach sank to her knees and mumbled incoherently before stumbling off the field.

Wambach now recalls feeling like she “was dying.” She had long gaps in her memory after the concussion. She couldn’t remember the moment itself. She walked into the wrong locker room after the game, compounding her confusion. 

“That was really the beginning, for me, of this process of educating myself around head trauma,” Wambach tells Yahoo Sports. Up until that point, she thought she had steered clear of head trauma. Or, at least, nothing was ever diagnosed. But amid a national wave of increased understanding and awareness of concussions, it changed her approach to the game.

“I knew that [I] was kind of at the end of my career,” she recalls. “I wasn’t heading the ball nearly as much, mostly because I just didn’t want to get another concussion. Yes, I still put myself in positions to head the ball. Yes, I still scored goals with my head. But I started to think twice. And before this concussion, I didn’t really think twice. I thought I was invincible, for some reason, which I think is really dangerous.”

Abby Wambach and other USWNT legends are doing their part to close the gender gap in female athlete brain research. (Paul Rosales/Yahoo Sports)

Now, Wambach thinks a lot about how often she taped up her ankles before playing, without ever worrying about her brain. She was a physically bruising striker who, at 5-foot-11, towered over defenses and, remarkably, scored more goals with her head than her feet. She headed the ball constantly. She was forever putting her head into the fray — sometimes suffering cheap shots, too.

The science now shows that, long-term, a series of blows to the head that aren’t full-on concussions can still collectively amount to the same kind of damage.

“I can’t speculate how many micro-concussions or head impacts I took, but I do know that it’s probably in the hundreds of times,” Wambach says. “I think about it now and I’m like, ‘God, that feels like such a stupid thing to have done for so many years.’ But it’s where I made a living.”

When she was young, Wambach always figured she’d just deal with whatever physical consequences her career left her with later on. “Well, now I’m in the later,” she says. And even though the 40-year-old has no post-concussion symptoms, “that doesn’t make me any less worried for the future.”

These days, she coaches her stepdaughters. They’re heading the ball now.

“I’m terrified for them,” Wambach says. “I cringe whenever players go up to head a soccer ball. I cringe at my former, risk-taking self. Because we only have this one brain.”

She’s wistful about it all. “There is beauty in heading,” Wambach says. “And there is a time and place for heading. For me, it is literally how I made a career for myself. There is a bittersweet-ness to this whole thing. But now in my retirement, I’m really terrified about what could possibly be down the road for me.”

Startling disparities with female athlete concussions

In sports, the gender gap in compensation is well documented. But there also exists a gender gap in concussions — and our understanding of those concussions.

“In sports that women and guys play, like basketball and soccer, you’ll find that the women have 2-3 times the reported incidence of concussion,” says Dr. Robert Cantu, one of the world’s leading concussion doctors and a co-founder of the CTE Center at Boston University and the Concussion Legacy Foundation. These numbers are borne out by reviewed and repeated studies, he says. 

In May, a study by the American Academy of Orthopedic Surgeons measured an increase in the number of head injuries in high school athletes, in spite of growing awareness.

Girls’ soccer had a higher proportion of concussions relative to other injuries than the boys, about 30 percent to 25 percent. Meanwhile, the rate of reported concussions in girls’ soccer grew by 21 percent from the 2010-14 period to the 2015-17 period. In fact, girls’ soccer came second only to football in the number of concussions — 10.2 concussions for every 10,000 practices and games for football, to 8.4 for girls’ soccer. Boys’ soccer, by contrast, had just 3.5 concussions per 10,000 games and practices.

“So why do women have more reported concussions than guys?” Cantu asks. “That’s the $64,000 question that we don’t have an answer to. More probably than not, part of the answer is that women’s necks are not as strong as guys’ and therefore their brains are exposed to greater accelerations for a lesser hit because the neck isn’t rigid. That maybe is one answer. Other people have speculated — no definite proof — that as a group, women are more honest in reporting signs and symptoms of concussion.”

Head injuries are a big risk in soccer, and not just at the highest levels. (Joe Petro/Icon Sportswire via Getty Images)

It isn’t just concussions that lead to CTE, it’s repetitive head injury. Soccer is rife with blows to the head, mostly from heading balls kicked high or hard, but also from flying elbows, head-to-head collisions, flying goalkeeper fists or some other impact. 

In October, the New England Journal of Medicine published a Scottish study of more than 7,500 former professional soccer players that discovered 3.5 times higher rates of neurodegenerative disease as the cause of death than in the rest of the population. Former soccer players were five times likelier to have had Alzheimer’s, four times likelier to suffer from Motor Neuron Disease, and twice as likely to live with Parkinson’s.

In the game in which Wambach suffered her concussion, she wasn’t even subbed off. That was seven years ago. But this kind of thing keeps happening, even as awareness spreads. Just last summer, the Washington Spirit’s Rose Lavelle took a blow to the head from the ball so hard that all of Providence Park in Portland could hear it. But she talked her way back onto the field, even though she was obviously still affected.

USWNT legends committing brains to science

Michelle Akers, the first superstar of American women’s soccer, doesn’t remember how many concussions she had, exactly, over the course of her two-decade playing career. She likes to joke that it’s because she had too many concussions. But the fact that she doesn’t know, that nobody knows, is central to the problem here. We don’t know enough.

For Akers, there were the diagnosed concussions. Three of them, she thinks. She had one in China early in her national team career, back in the late 1980s. She had another early on in the 1995 World Cup. And she had a third right before the 1999 World Cup, which broke her eye socket. 

“But we all know more happened,” Akers says. “At the same time, I know I also had the smaller concussions [sub-concussive hits] that are undiagnosable. But enough to have some effects now. You can’t tie everything in to one or several events, but I’m sure it must have had an effect.”

Akers gets migraines so bad that they make it impossible to do anything that day. She’s 54 now, and she wonders if it might get worse as she gets older. She thinks it’s possible she has chronic traumatic encephalopathy, the debilitating and degenerative disease that has famously felled scores of former NFL players.

“I’ve had concussions,” Akers says. “I’ve had concussion-related after-effects. And who knows? Because our research is in the infant stage still on what happens to a brain over time with repeated injuries. That’s one consideration.

<p class="canvas-atom canvas-text Mb(1.0em) Mb(0)–sm Mt(0.8em)–sm" type="text" content="“I headed the ball a lot. A lot.”&nbsp;” data-reactid=”71″>“I headed the ball a lot. A lot.” 

Brandi Chastain, famous for twirling her jersey over her head after converting the penalty kick that clinched the 1999 Women’s World Cup, headed the ball a lot, too. 

“I took on the responsibility of the defender that I would be brave and I would compete for air balls and would take care of those things,” she says now. “And I felt really good about it. I loved heading the ball. And there wasn’t anybody around saying, ‘Hey, you might not want to do that.’

“Nobody diagnosed concussions back then,” Chastain continues. “It was, ‘You got your bell rung. Shake it off. Get back out there.’ I don’t know if I ever had concussions. I’m sure I did. I can honestly say I don’t recall ever having nausea, forgetfulness. Blacking out — possibly once. The likelihood is high, but there was never any diagnosis.”

Cindy Parlow Cone knows for sure that she had concussions, because they ended her 10-year national team career in 2004.

“When I was playing, you would see stars, and we didn’t really have the understanding that we do now that that wasn’t normal,” she says. “I’ve seen a lot of stars in my playing career. When I was playing, it wasn’t a concussion unless you were knocked out.”

Since then, she has risen to the presidency of the United States Soccer Federation, taking over following the resignation of Carlos Cordeiro in March. Parlow Cone considers herself lucky. Most of her lingering concussion symptoms have abated since she was forced to retire in 2006, two years after playing her 158th and final national team game at only 26 years old. 

Her extensive attempts to recover came to nothing. She had a lot of headaches. Visual tracking issues. Jaw pain.

“The doctor said I could go back to playing, but they couldn’t really say what would happen if I got another concussion,” Parlow Cone says. “And so I made the decision to go ahead and retire because I was struggling with post-concussion symptoms for years. So I wanted to preserve what I had, because I was hoping I still had a lot of years yet to live. It was not an easy decision to make.”

In the last few years, all three women have committed their brains to science when they die, to study the impact of all those head injuries. They are joined by Wambach and fellow U.S. women’s national team icons Brianna Scurry and Megan Rapinoe.

(Left to right) Michelle Akers, Cindy Parlow Cone and Brandi Chastain are all pledging their brains to research, and that’s important for a number of reasons. (Meg Oliphant/Getty Images)

Why public pledges are so crucial to women’s research

The brains are the key. We won’t fully understand the difference in the danger soccer poses to women and men until more women’s brains can be studied. That’s why Chris Nowinski, a co-founder of the Concussion Legacy Foundation and a key figure in the reckoning with traumatic brain injuries in American sports, has been lobbying female athletes to commit brains to the CTE Center when they die. 

The CTE Center now has nearly 1,000 brains in its bank, but only 2 percent of those are from women. “Brain donation is a critical way to understand the long-term effects,” Nowinski says. “We just can’t image CTE and other neurodegenerative diseases and so we need more brains to study.” 

But getting women’s brains is much harder than getting men’s.

“It’s been remarkably difficult to recruit the brains of women into the brain bank,” Nowinski says. “Part of that is because our brain bank is a majority football players; part of it is cultural reasons because Title IX [is still fairly recent and] we don’t have a lot of older female athletes. I think part of it is also just a cultural bias that families are fine with donating their father’s brain but may be more sensitive with their mother’s brain.”

That’s why Nowinski and Cantu set about recruiting high-profile female soccer players to commit to brain donation and to do so publicly. “It takes leaders like these women to change the culture and help people realize brain donation among female athletes is important as well, and is OK, and that it’s what female athletes want,” Nowinski says.

Until that becomes more common, we won’t have a full picture of the effect of concussions in women.

“We desperately need women’s brains,” Cantu says. “We don’t have a case yet of CTE in women. If any of these players would be predisposed to CTE, it would be an elite woman who played many, many years of the sport in which there was a considerable amount of head trauma, which is the case in soccer. It’s hugely important.”

‘How can I help leave the game in a better place?’

Akers had more than 30 surgeries on one knee in an attempt to regain its usefulness in everyday life. But when she spent two years emailing and calling doctors and researchers to learn more, it wasn’t about her bum knee. She wanted to know more about the effect of brain injuries. She wanted to find out about donating hers when she died. 

<p class="canvas-atom canvas-text Mb(1.0em) Mb(0)–sm Mt(0.8em)–sm" type="text" content="“I’m an organ donor,” she says. “It’s on my driver’s license. So if I die suddenly, I won’t be in need of my corneas or tissue that they can harvest to save other people’s lives. So to me, a little bit of a pun intended, it’s a no-brainer. It’s difficult to understand why someone would not let that all be used for science or to save lives, so that’s what I’m doing.”” data-reactid=”102″>“I’m an organ donor,” she says. “It’s on my driver’s license. So if I die suddenly, I won’t be in need of my corneas or tissue that they can harvest to save other people’s lives. So to me, a little bit of a pun intended, it’s a no-brainer. It’s difficult to understand why someone would not let that all be used for science or to save lives, so that’s what I’m doing.”

Eventually, she connected with Nowinski and Cantu, and she found a future home for her brain. “Nobody else was asking for my brain, so it wasn’t like there was a big competition,” Akers says. “It’s not hard. I like to help. I like to make a difference. It’s an easy choice.”

Chastain co-founded the Institute of Sports Law and Ethics at Santa Clara University. Her husband is the head women’s soccer coach there, and Chastain has been a long-time volunteer assistant. Through ISLE, she connected with Nowinski and Cantu. 

“Of course, it’s a scary proposition because you start thinking about donating your body parts and then you think about mortality,” Chastain says. “But it got me thinking about the legacy of what we’ve done. And yes, we’ve won some World Cups and we’ve won some Olympics, and that’s all amazing. But how can I help leave the game in a better place? After thinking about that, I realized that this donation would forever change what we know about the game and if, in fact, it helps one player stay healthy or have a longer career, then that legacy is more important than the winning part. Because then we’ve secured health and wellness for her and her family going forward.”

Chastain also set about lobbying U.S. Soccer to restrict heading in youth soccer, which it did in 2015 — banning heading for children who are 10 or younger and limiting it to 30 minutes a week in ages up to 13. Chastain and others have also pushed for the American game to become more technical and modern, played on the ground, rather than in their air, to reduce the risk of head injury. 

In a survey U.S. Soccer sent out to its youth club membership, 92.5 percent of respondents self-reported that they had adopted the federation’s guidelines on heading in youth soccer. Meanwhile, 72 percent said they no longer work on heading in practice and almost half said headers have completely or almost entirely disappeared from their weekly games.

Meanwhile, the federation’s chief medical officer, Dr. George Chiampas, sits on FIFA’s nine-member medical committee where he advocates for further reforms to help prevent concussions. Parlow Cone has worked on changing substitution rules for players who might be concussed — allowing for temporary substitutions, for instance.

A year ago, the Concussion Legacy Foundation began a longitudinal study on the long-term effects on brain trauma in women’s sports called SHINE, which stands for Soccer, Head Impacts and Neurological Effects. The SHINE study, the first of its kind in women’s sports, will study 20 former women’s pro soccer players as they age. 

All of these efforts are good, positive developments. But the scientists still need the source material, the brains, to be able to do their work properly. Which is why high-profile players going public with their concussion history and intentions of donating their brains is so important.

“I love the game of soccer,” Chastain says. “I want to make sure that players are safe. It just is a reasonable, responsible thing to do. The outcome, hopefully, will give us some information, good or bad. It will give us some perspective which will help us make better choices.”

Akers puts it more simply. “When I die, they can have my brain,” she says. “Good luck.”

<p class="canvas-atom canvas-text Mb(1.0em) Mb(0)–sm Mt(0.8em)–sm" type="text" content="Leander Schaerlaeckens is a Yahoo Sports soccer columnist and a sports communication lecturer at Marist College. Follow him on Twitter @LeanderAlphabet.” data-reactid=”113″>Leander Schaerlaeckens is a Yahoo Sports soccer columnist and a sports communication lecturer at Marist College. Follow him on Twitter @LeanderAlphabet.

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