Does Traumatic Brain Injury Have a Gender?

By Daniel R. Morrison and Monica J. Casper

In the words of American poet Adrienne Rich, “All wars are useless to the dead.” Yet, while victims abound, the wars of men and women are not the same. Men clash on artificial turf wearing shoulder pads and helmets and on foreign soil bearing lethal arms. Women, too, now play football and go to war, but many women are embattled in their own homes. And unlike football heroes and soldiers, they do not benefit from sustained media attention or public concern. They are missing bodies in more ways than one.

There was a cringe-inducing moment in the January 22th NFC Championship game between long-time rivals Green Bay and Chicago when 6’2”, 225-pound Packers quarterback Aaron Rodgers was struck helmet-to-helmet by 6’7”, 283-pound Bears defensive end Julius Peppers. Rodgers suffered a bloody lip while his head visibly bounced around inside his helmet like a ball bearing. He did not sustain a serious injury in this playoff game, although he had suffered two concussions earlier in the season. The Packers defeated the Bears 21-14 (much to my Chicago-born chagrin) and will now battle the Pittsburgh Steelers in Super Bowl XLV. The Reverend Liana Rowe describes the upcoming game in blue-collar terms as “meat versus steel”—sure to be a bruising, mannish spectacle on February 6th.

Regardless of the game’s outcome and Rodgers’ headline-making yet minor injuries, the dialogue about head trauma in football is ongoing and contentious. In 2010, the National Football League (NFL) announced it would invoke tougher penalties for helmet-to-helmet hits including fines and possible suspension. Strong reaction followed this announcement, with defensive players displaying predictable anger. Many noted in the ensuing media coverage that restrictive rules and penalties make it difficult for them to do their jobs, while others described learning at an early age to play football with hard-hitting tactics. Most commentators matter-of-factly portrayed football as “a “dangerous game” with known risks, including concussions, while at least one player implied that increased enforcement of contact rules would lead to a feminization of the sport. Numerous blogs and a Facebook page even suggest that Americans should “Screw the Pussification of Football.”

Of course, despite the raging gendered debate at all levels of the game from Pee Wee Football to the NFL, the gridiron is not the only rough and tumble arena in which head injuries thrive. Traumatic brain injury (TBI) is also a signature wound of our current wars in Iraq and Afghanistan, although these battles are not televised on Monday nights. An embodied, physical marker of geopolitics, TBI is prevalent among combat veterans injured by improvised explosive devices (IEDs), rocket propelled grenades (RPGs) and other weapons that blow up. The Defense and Veterans Brain Injury Center estimates that approximately 22 percent of troops suffer from TBI, with men experiencing injuries at one and a half times the rate of women. Screening of injured soldiers at Walter Reed Army Medical Center found that a staggering 41 percent of service members presenting for treatment had some form of TBI.

TBI has multiple consequences, both at the level of the individual body and more broadly. Commonly characterized as mild, moderate, or severe, TBI can result in loss of consciousness for a minute or for days, and the effects of TBI can be short-lived or permanent. Health professionals now understand TBI in its moderate and severe forms to cause degeneration in neural connections throughout the brain—connections that might be supplemented by other neural connections, but that rarely return. Depending upon the location of these connections within the brain, service members with TBI can experience a variety of behavioral changes, many of which are consistent with that other signature injury of war, PTSD.

Compared to the injured of previous armed conflicts, today’s troops are surviving combat-related physical trauma at unprecedented levels, leading to an increased incidence of TBI. Approximately 12 to 14 percent of wounded soldiers in the Vietnam War sustained some form of closed-head injury, and mortality from brain injuries to U.S. soldiers in that conflict was 75 percent or higher. Soldiers with such injuries were rarely treated in hospitals, as they died on the battlefield or shortly thereafter. In contrast, 22 percent of wounded soldiers from the current Iraq and Afghanistan wars who passed through Landstuhl Medical Center in Germany had injuries to the head, face or neck. In short, our troops are far more likely to survive combat now than troops in the past but they may return home with debilitating injuries and psychological trauma.

According to the Operational Medicine and Medical Force Readiness Office, advances in diagnosing and treating brain trauma during the Vietnam War and other conflicts led to improvements in trauma care on the battlefield and in hospitals. Some advances are technological: Kevlar body armor and helmets are relatively new additions to a troop’s armament. They also serve as one reason for the higher percentage of TBIs: soldiers are partially shielded from bullets and flying debris, improving survival rates after injury. Kevlar helmets have also reduced the number of injuries sustained from penetrative head wounds, those wounds where bullets, shrapnel or fragments of objects such as vehicles enter the skull. Unfortunately, helmets and armor cannot completely protect a soldier’s vulnerable face, head and neck—and they cannot prevent closed brain injuries produced by bomb blasts from IEDs, land mines and other explosive weapons.

The connections between PTSD, TBI and a more diffuse “combat stress” (historically known as “shell shock”) are complex and fluid; it is often unclear where one condition ends and the next begins. Beyond the poignant and disturbing narratives of TBI that showcase behavioral and psychological symptoms in people’s everyday lives, there is another institutional level affecting these events. It is now well documented that many of our veterans receive inadequate health care for mental and physical wounds received during combat service, exacerbating their conditions, sometimes to tragic levels. Journalists who track veterans of the Iraq and Afghanistan wars note that suicide and other violence may follow a return to the U.S. for some soldiers. Female partners of male troops may be subjected to consequences of TBI-induced changes in behavior in the victims of TBI—a kind of bimodal gendered suffering that builds on and contributes to the legacy of militarized violence documented by scholars such as Cynthia Enloe and Katharine Moon.

While women troops are also subject to TBI, PTSD, and other injuries—including sexual assaults by fellow troops—civilian women “at home” (whether that home is the United States or countries in which we maintain military bases) are often secondary victims of violence passed through men’s combat experiences and related injuries. For example, the Fort Carson, Colorado, home front, just south of Colorado Springs, was no safe haven for women. Soldiers in the town were charged with 57 cases of domestic violence in 2006, and by mid-December 2008 that number had nearly tripled to 145, allegedly due to TBI. Rape and sexual assault cases increased from 10 in 2006 to 38 as of mid-December 2008. And in a particularly shocking example of war’s carnage, several Fort Carson soldiers were charged with murder. A 2009 report from the U.S. Army Center for Health Promotion and Preventive Medicine found that combat stress was one of many risk factors that led to the homicides. The Fort Carson case illustrates the potent intersection of intimate violence and geopolitical trauma, in which combat-induced TBI, violence against women and insufficient health care together lead to substantial harm. It is clear that the disabling effects of TBI spread throughout communities in hierarchical ways; men’s bodies and lives are disrupted by TBI, but women disproportionately experience negative social consequences in their vulnerable roles as wives, partners, girlfriends and acquaintances.

Similar to the controversy about brutal hits in football, there has been significant media coverage and public dialogue about combat-induced TBI. Research on traumatic brain injury is abundant in universities, the nonprofit sector and the National Institutes of Health, and the resulting data are used to advocate for increased attention to TBI and services for those affected. This is undeniably a social good. People, including veterans, suffering from traumatic brain injury, PTSD and other head injuries need care and treatment, especially if they are to function adequately in everyday life. Of course, a more cynical view might question why extensive resources are being devoted to investigating and treating combat-induced TBI when we continue to maintain a significant military presence in Iraq and Afghanistan. Every day, our troops are injured and every day, more veterans return home deeply traumatized by their combat experiences, with repercussions for their loved ones, communities and society writ large.

But what we are not paying attention to when we focus our lens predominately on male victims of TBI, such as combat veterans and football players, and the need for better protective gear? What of the silent epidemic of domestic violence in the United States, through which women suffer high rates of traumatic brain injury? The National Coalition Against Domestic Violence estimates that one in four women will experience domestic violence in their lifetimes, 85 percent of domestic violence victims are women, and 1.3 million women annually are victims of physical assault by an intimate partner. These women experience brain injuries in large part because a woman’s head and face are principal targets during an assault. Women are pushed down stairs, shot or stabbed in the head and face, punched until they bleed, cracked on the skull with heavy objects, shaken violently and strangled until their oxygen supply is cut off. In one study, 92 percent of abused women had been hit in the head by their partners and eight percent had been struck in the head more than 20 times in the previous year. For these women, TBI is more than a diagnostic category; it is a dismal fact of life and a gruesome testament to their all-too-common circumstances.

It would seem, then, that traumatic brain injury does indeed have a gender, and that the pathways to harm (and to protection) differ for men and women. While football players and veterans garner substantial media coverage and civic consideration, ordinary women are hurt by their intimate partners, often and sometimes fatally. These women are our mothers, daughters, sisters, friends, neighbors, co-workers and students. According to NOW, three women each day are murdered in this country by a boyfriend or husband and one-third of all women murdered in the United States are killed by an intimate partner.  These women deserve more than a rain of fists and the prolongation of a silent epidemic about which too few people care. They deserve to move through the world without fear, like brawny defensive ends, and to live in peace and security.