Beyond football players: The NCAA’s concussion gender gap

The NCAA knows even less about concussions among women than it does about those among men; will that change?

This is part two of the two-part “Life After Concussions in College Sports” series. In March, check out Timothy Bella’s “Life After Concussions in College Sports” panel at South by Southwest.

BOSTON – With 22 seconds left in a December 2012 game against South Carolina, Toni Kokenis stepped up to the free-throw line to try to protect Stanford’s two-point lead. She knew where she was, but had no idea what would happen next.

“I remember going to the line and being like, ‘Oh my gosh. I hope this goes well,’” she says.

An hour earlier, she was splashing water on her face during halftime, trying to shake concussion symptoms that had been lingering for the entire season. She hadn’t hinted to her coaches or teammates just how bad they had gotten.

Throughout the second half of the game, Kokenis, then the starting point guard for the No. 1 team in the nation, struggled to run back and forth between the two 3-point lines at opposite ends of the court. During timeouts, she’d fight overheating with cold towels and ice packs for her head. Now, Kokenis could no longer go through the motions — not when the game was on the line.

“So much of that time was a blur,” she says, looking at highlights from the game.

But to the rest of the arena, Kokenis seemed at the top of her game.

Kokenis, a 77 percent free-throw shooter the previous season, hit both of her shots, putting the Cardinal up three. Then, South Carolina fouled Kokenis again, sending her to the line for a second time in 12 seconds. Again, she’d hit both shots. With three seconds to go, South Carolina hit a 3-pointer, forcing the Gamecocks to foul Kokenis for a third time with 1 second on the clock. With a chance to ice the game, she did just that, sinking her two remaining free throws to seal a 53-49 win.

That sixth and final free throw concluded a 22-second stretch that felt endless for the hazy Kokenis.

“I remember talking to my mom after the game and saying, ‘I don’t know how that happened because I could not focus,’” she tells me.

It wasn’t the first time Kokenis would fight the haziness and headaches from her concussion symptoms. But it would be one of the last.

After at least five or six concussions — four that were diagnosed during high school and college and another one or two she believes she suffered during high school — Kokenis, a key part of the Cardinal’s Final Four runs in 2011 and 2012, was forced to retire from college basketball in the summer of 2013.

Three years after her retirement, however, the conversation around concussions among female athletes and what it means for life after sports has not advanced in the same way as it has for football-related concussions among male athletes. This is particularly evident in the college ranks, where concussion-related retirements of women in college athletics — particularly in sports that don’t generate the same level of revenue or attention as football programs — go virtually unnoticed.  

Toni Kokenis, right, against UC San Diego in November 2010.
AP/Marcio Jose Sanchez

Even in a groundbreaking decade in research on concussions, one with more increased awareness on head trauma in sports than any time in U.S. history, there’s still a noticeable knowledge gap between what we know about the effects of concussions on men and women. What we do know, however, only leaves us wanting more, especially when it comes to women who play college sports.

“There’s enough information out there about CTE [chronic traumatic encephalopathy], and I think female athletes are struggling to figure out, ‘Does the media coverage of football players – and their ultimate demise – apply to me?’” says Katherine Snedaker, executive director of the nonprofit PINKconcussions, who helped lead a very comprehensive study on the experience of sport-related concussion on women athletes.

Between 2004 and 2009, 35 percent of the estimated concussions for all Division I practices and games nationwide occurred in women-only sporting activities, according to the NCAA. Dr. Brian Hainline, the NCAA’s chief medical officer, has said female college athletes have between one and up to three times greater risk for concussion in at least three sports — soccer, softball and basketball — compared to their male counterparts.

In a 2014 summary of self-reported concussions among college athletes, about 10 percent of women student-athletes said they had been diagnosed, or believed they had suffered, at least one concussion during their college careers. And a July 2015 study from the University of Michigan found that women in college athletics “experience greater symptoms and poorer cognitive performance at preseason testing” compared to their male counterparts.

“The gender gap is as wide as it can be,” says Chris Nowinski, founder of the Concussion Legacy Foundation, a nonprofit focusing on research and education of sports-related head injuries. “There hasn’t been a lot of intensive research on difference in gender, outside of speculating on why the numbers are so different.”

Critics such as Nowinski wonder whether the knowledge gap in concussion research between the genders can be bridged, especially in a field so heavily focused on men’s sports — namely, football.

There’s enough information out there about CTE [chronic traumatic encephalopathy], and I think women are struggling to figure out, ‘Does the media coverage of football players – and their ultimate demise – apply to me?’

Katherine Snedaker

Founder and executive director, PINKconcussions

In December, Nowinski told America Tonight that the NCAA has “no motivation in changing” current policies to help better protect past and present student-athletes, adding that the governing body has done “the worst job of any level of sports in terms of the protections they offer their players.” The most jarring example of safety concerns regarding concussions in women college athletes is the ongoing lawsuit from Casey Conine, a former University of Illinois women’s soccer player who has accused the university of ignoring concussion protocol, forcing her to end her soccer career.

Now, in the run up to an expected settlement in a concussion lawsuit involving the NCAA and thousands of former college athletes affected by head trauma, Nowinski’s skepticism of the NCAA has been echoed by former female athletes — from Division I college programs in basketball, soccer and volleyball — interviewed for this story.

Kokenis and other women who have had to retire from their sport because of at least one concussion are part of a growing group of women who are finding their voice, and gaining their footing, on a topic of research that has been mostly dominated by one gender and one sport.

“If I knew everything I know now, I would have not let myself play in certain games with those concussion symptoms,” says Kokenis, now a first-year law student at Northeastern University in Boston. “That’s a lot of responsibility to put on a player who’s expected to perform and contribute for her team. And it’s just way too much to expect one player to do herself.”

Inside her Boston apartment, blocks away from Northeastern’s law school, she turns to me with a look of helplessness for what’s still happening for women college athletes: “No one knows what to do when a woman athlete has a concussion.”

The final game

In February 2013, on the weekend of her daughter’s 21st birthday, Marie Kokenis made the trip from Illinois to Oregon to see her play several games against the state’s schools. She remembers how her daughter talked about how tired she was. The interaction gave Marie a bad feeling; her daughter’s previous issues with head trauma often triggered terrible memories for her.

“I was afraid every time she stepped on the court,” Marie says, fighting through tears. “Everybody would always wonder what was wrong with her.”

Coming into Stanford with at least one reported concussion in high school, Kokenis would find head trauma in all forms at Palo Alto, whether it was an elbow to the head during a pickup game or a collision with a photographer’s camera as she slid underneath the basket. With each injury, Kokenis says she started to feel the effects — constant headaches, the need for sleep, the up-and-down mood swings and a sensitivity to light — for longer.

This was not lost on Tara VanDerveer, the Cardinal’s Hall of Fame coach, who leaned on Kokenis for her all-around play and leadership during the guard’s second Final Four appearance. Though concussions were mostly rare in women’s college basketball, VanDerveer, who has 973 wins and two national championships in her 37 years as a college head coach, had seen them before. She coached Jamie Carey, a former Stanford player who was medically disqualified in November 2000 due to concussions. Carey went on to transfer and resume her playing career at the University of Texas, but the experience stuck with the Cardinal coach. 

Toni Kokenis, middle, against UCLA in March 2011.
AP/Gus Ruelas

“The more and more concussions you get, the less and less it takes to get them,” VanDerveer tells me. “For Toni, I think they just added up, hitting a certain amount of tread on her ‘concussion tire.’”

The pressure on Kokenis’ concussion tire was put to the test on Feb. 3, 2013. The game against Oregon State felt like the rest for Kokenis: Everyone on the court sped by her; the shooting guard struggled to keep up.

“I don’t know why I was still playing,” she tells me, almost trying to laugh it off.

As she was boxing out an Oregon State player sprinting for a rebound, Kokenis hit the back of her head on her opponent. Then, in the same swift motion, Kokenis’ head lurched forward into the head of a teammate, who was waiting in front of her for the rebound. Kokenis’ head was sandwiched, taking two quick hits in the same play.

Coupled with the symptoms she had been battling all season, Kokenis couldn’t take it anymore. Slinking down the court at a snail’s pace, Kokenis, with tears coming down her face, begged for a timeout. That night in Corvallis, Oregon, would be the last time she’d walk off the court. 

“I remember looking at my mom, making eye contact with me, just shaking my head,” Kokenis says. “We knew that it was done.”

She’d miss the rest of the season. Five months later, in July 2013, she officially announced her retirement.

“I’m still sad to think about what could have been for her,” VanDerveer says.

The decision seemed like an easy one, but it was no less difficult for her parents.

“You have to know when to hang it up,” her mother says. “I don’t want her to have early brain issues.”

She adds: “It’s not just football players who get concussions.” 

Stories like Kokenis’ are beginning to gain traction throughout college athletic departments.

In basketball, players like Texas’ Chelsea BassUCLA’s Lauren Holiday and UNLV’s Diamond Major all ended their careers in the last three years. Each suffered anywhere from two to five instances of head trauma during high school and college. This month, Toledo’s Nancy Kessler announced her decision to step away after at least four concussions.

But perhaps no sport in women’s athletics has been under more scrutiny for concussions than soccer, with recent, notable retirements from Stanford’s Emily OliverNorthwestern’s Anna Cassell and Utah’s Molly Poletto, who each suffered at least two reported concussions during the course of their high school and college playing careers.

It’s not just football players who get concussions.

Marie Kokenis

Toni's mother

In Chapel Hill, North Carolina, Caitlin Ball, a member of the University of North Carolina’s women’s soccer team, suffered five concussions within a 15-month period — four in soccer and another one while hiking. Ball, who retired in 2014, is thankful for the program for honoring the rest of her scholarship, but is still surprised by people’s reactions when they learn about her history with concussions.

“If you ask the normal fan, they would be somewhat surprised that any women’s soccer player has had to retire due to head trauma,” Ball says. “There’s quite a few cases every day, week, month and year, but it’s not terribly talked about at all.”

It was something of a different situation for Emily Peters in 2009. Before Peters ever played a game for the women’s soccer team at the University of Pittsburgh, she was forced to retire, suffering an estimated eight concussions — only three of which were ever diagnosed. After she retired, she slipped into depression and suicidal ideation, relying on marijuana to help her eat and sleep. The experience, which has taken up a quarter of her life, has left a sour taste for Peters.

“It got to a point where I was feeling shitty or shittier,” says Peters, who continues to fight symptoms, such as vertigo, six years after stepping away from soccer. “I know universities have put out certain rules, kind of like, ‘wash your hands’ signs. The NCAA has a lot of room to grow, and the teams and universities aren’t doing their part, either.”

Toni Kokenis during an October class at Northeastern University's School of Law.
Timothy Bella

The transition into retirement wasn’t easy for Kokenis, whose lingering symptoms forced her to take three incompletes during the semester she retired. Refocusing her attention back toward her academics proved to be difficult, especially given that she was still trying to disconnect herself from the team, and sport, for which she’d sacrificed so much for so many years.

To get her mind off basketball, she needed to build new connections. She filled the void by taking a more active role in Stanford’s LGBTQ community.

She started dating Melanie Polin, who lived in the same dorm as Kokenis during her junior year — a year in which Kokenis was, as Polin remembers it, in “full-blown concussion-symptom mode.” 

Polin, through the ups and downs of Kokenis’ fight with concussion symptoms, says she’s proud of her girlfriend’s life changes.

“Sometimes, she still has to take a bit of a step back or take a nap during the day,” Polin says. “From my perspective, it’s been hard to see how disruptive that has been on her ... but Toni has exemplified what it means to lose a core part of your identity, and come back from it and build something totally different.”

In Boston, Kokenis settles into her second class of the day at 10:30 a.m. on a Thursday in October. Not many, if any, in the class know her past life featured two Final Four appearances. Here, she’s just Toni. The class of 70 students looks at liability and risk — two words that followed Kokenis when she decided to retire. It’s a decision that still she still thinks about today.

“Once college athletes medically retire, you’re kind of forgotten. It’s like, ‘You did your time, you helped us do this and that, but what are you doing for us now?’” she says. “And it wasn’t my choice. I didn’t choose to leave. I got injured representing my school and giving all of myself to my school and community.”

Finding a strong voice

It started with a misquote from Jim Nantz. On the morning of Super Bowl 47 in 2013, Nantz, the lead play-by-play man for CBS Sports, went on “Face The Nation” and claimed that “a women’s soccer player is two and [a] half times more likely to suffer a concussion than a college football player.” As more media outlets pointed to the inaccuracy of the statement, which came as NFL Commissioner Roger Goodell was sitting on the same set, the gaff got the attention of Snedaker, who knew the information was “buried in short sub-paragraphs on gender in larger research studies.”

Seeing inaccurate information on concussions among women on such a big platform drew attention to the need for more readily available, accurate information.

“When a football player retires, they’re given a stage in which to note their history,” says Snedaker, a mother of two sons who suffered multiple concussions of their own. “I’m not sure a female athlete in equestrian or polo or field hockey who is retiring from concussion is going to make any sort of influence. I don’t think women have a strong enough voice in the first place.”

To help find that stage, Snedaker actually had to help create one. Through PINKconcussions, her nationwide initiative on female concussions, Snedaker teamed up with researchers from Clemson University for the first-ever study on the effect of concussions on women, titled, “No Guts, No Glory: What price does she pay to play the game?” The study, which polled 520 former female athletes with varying sports backgrounds, crystallizes the bigger issues in play for women at the collegiate level:

  • Nearly 58 percent of the women polled who have suffered at least one concussion — and continue to play organized sports today.
  • More than 69 percent of the women polled continue to play through a head injury, and never report it, while experiencing symptoms such as headaches, blurred or double vision, dizziness, slowed thinking and nausea.
  • More than half of the women polled are still suffering from symptoms they believe could only be caused from their head injuries.

“Our research showed women do not always report concussions as commonly thought in the past; and they hide concussions for different reasons than the male athletes — due to their lack of awareness of concussions and lack of resources like an athlete trainer,” Snedaker says of the results of the study. “Women’s sports need more concussion education for their athletes, education targeted specifically for women and athletes trainers present at their practices and games."

If the NCAA hopes to change those perceptions surrounding its concussion research of women athletes, it starts with research and legislation. In May 2014, the NCAA announced a partnership with the Department of Defense (DoD) on a $30 million study on concussions among student-athletes and military members. As of Dec. 15, 2015, 21 schools and 17,500 student-athletes had enrolled in the study, according to the Concussion Assessment, Research and Education (CARE) Consortium.

Once college athletes medically retire, you’re kind of forgotten. It’s like, ‘You did your time, you helped us do this and that, but what are you doing for us now?’ And it wasn’t my choice ... I got injured representing my school and giving all of myself to my school and community.

Toni Kokenis

Drs. Thomas McAllister and Steve Broglio are two of the medical professionals leading the CARE Consortium, overseeing two of the three major branches of the research effort.

McAllister, chair of Indiana University’s School of Medicine Department of Psychiatry, oversees the fiduciary oversight of the effort. He acknowledges that there’s “a big gap” in what we know between men and women who suffer concussions.

“There are indications that given equivalent biomechanical force exposure or hits that females may be more likely to get a concussion. And there is some emerging evidence suggesting that the resolution of symptoms after a concussion takes a little bit longer in females,” McAllister says. “But other than that, we don’t know enough really about why, or if, either of those are true.”

Broglio, director of the NeuroSport Research Laboratory at the University of Michigan, is coordinating the research on the concussion history among college student-athletes. Broglio is confident the findings in the ongoing study will help bridge the gender gap “sooner rather than later.”

“The data will allow us to address the things we know about men and things we don’t know about both genders,” Broglio says.

While the NCAA-DoD study is a step in the right direction for women’s athletics, Snedaker is pushing for even more female-specific concussion research in college athletics.

“They’re starting from behind and are trying to make up for lost time,” says Snedaker, referring to the NCAA’s efforts on concussion research. “They have the money and the expertise to do this. I’m always optimistic they’ll do the right thing.”

Toni Kokenis with her cat, Simba, in October 2015.
Timothy Bella

Back in Boston, Kokenis makes the walk back to her apartment after class to make a Greek salad, laughing at the idea of her friends poking fun at “the Greek girl making a Greek salad.” She plays with her orange cat, Simba, for a few minutes before heading back out the door for class and work at Squashbusters, a nonprofit run by Northeastern that serves as an after-school program for middle-schoolers.

Kokenis didn’t think she’d be in law school or in Boston, but there’s a sense of calm that comes over her when talking about her concussions and what it means to be a woman athlete who retired because of them. 

Still, Kokenis is cautious. She hasn’t accepted a single offer to play recreational basketball in the last three years. After a while, I ask — given all of the concussions she’s suffered — whether she’d ever play basketball again.

“Probably not,” she says.

There’s a long pause before she follows up: “But I don’t know. Maybe some day.”

To learn more about concussions in women athletes, check out the International Summit on Female Concussion and TBI in Washington, D.C., later this month. To hear more from Emily Peters and Dr. Steve Broglio, check out Timothy Bella’s “Life After Concussions in College Sports” panel at South by Southwest in March.

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