Under-representation of female athletes in research informing influential concussion consensus and position statements: an evidence review and synthesis
D’Lauro C, Jones ER, Swope LM, Anderson MN, Broglio S, Schmidt JD. Br J Sports Med. 2022 Jul 18:bjsports-2021-105045. doi: 10.1136/bjsports-2021-105045.
Female athletes are underrepresented in the data used to inform concussion consensus and position papers.
Medical professionals rely on concussion consensus and position statements to design their diagnosis and management protocols. These documents rely on evidence suggesting males and females have similar presentations and recovery; however, there may be clinically meaningful differences in the risk, presentation, and recovery of concussion among male, female, transgender, and non-binary athletes. While this disparity is acknowledged, it remains unclear if a gender imbalance in concussion research informs concussion consensus and position statements.
The authors evaluated the 3 influential consensus and position papers to quantify the female athlete composition of the research data informing clinical practice.
The authors performed a PubMed search in August 2021 using the terms “concussion position statement” and “concussion consensus statement.” English language was the only restriction. The authors selected The International Conference on Concussion in Sport (ICCS, 2017), National Athletic Training Association (NATA) concussion position statement (2014), and the American Medical Society for Sports Medicine (AMSSM) concussion position statement (2019). They selected these statements based on the citation patterns, publication of updated versions, and research on clinician use of these documents. The authors tallied the total number of male and female participants in each study cited within the 3 documents that recorded or implied gender information. If the original authors failed to state the proportion for sex or gender clearly, the current authors excluded that study.
Across all 3 statements, 375 citations were reviewed, including 171 papers with relevant gender and sex information (93 from NATA, 17 from ICCS, and 68 from AMSSM). Eighteen were cited in 2 of the statements, while 0 were included in all 3. Overall, the studies were ~80% male (NATA 80%, ICCS 88%, and AMSSM 79% male). Only 2 manuscripts included a female-only sample, while 69 manuscripts had an all-male sample.
The information clinicians receive regarding concussion care heavily depends on data among males. This is alarming because medical professionals rely on these expert-curated documents to guide their clinical decisions; however, the scientific evidence fails to represent female and non-binary athletes sufficiently. This disparity may lead to unequal treatment of these athletes who suffer concussions. For example, males and females differ in drug responses, substance abuse, and risk factors for other health conditions. Therefore, it would suggest that female and non-binary athletes respond differently than males to a concussion on both the physiological and psychosocial levels. It would be interesting to see if this trend occurs in other consensus and position statements. Furthermore, it would be helpful if future statements clearly describe how well the evidence represents the intended patient population (e.g., sex, gender, race/ethnicity).
Consensus and position statements should be a starting point and not a shortcut. Medical professionals should seek research outside the consensus and position statements to help aid their concussion practices toward female and non-binary athletes. Furthermore, when educating a female or non-binary athlete about what to expect after a concussion, we should seek out relevant research or explain to the patient that their personal experience may differ from what they find online or hear from professionals relying solely on the consensus or position statements.
Questions for Discussion
Do you primarily get your medical information from position statements? Have you noted disparities between sex, race/ethnicity, or gender? If yes, what have you done to fill the knowledge gaps in the position statements?
- Comparison of Three New Concussion Guidelines
- Does Sex and Contraception Influence Concussion Recovery?
- A Closer Look at Concussion 2016-202: Increasing Prevalence and Sex Differences
- Head Case: What Role does Age and Gender Play Following a Concussion?
Written by: Jane McDevitt
Reviewed by: Jeffrey Driban