Why Women's Soccer Players Are Worried About Their Brains

Four clear jars sit atop a wooden shelf, each containing a human brain. An actual human brain. A faded-yellow liquid, the color aging books turn, surrounds each brain, almost seeming to make them float. These brains are just for display, but nearby a hundred or so others are waiting to be examined for various neurodegenerative diseases on this morning in early August at Boston's VA-BU-CLF Brain Bank, tucked discreetly behind the Veterans Affairs Hospital.

There will be a brain dissection in a few hours. Most of the brains are housed in large freezers, set at minus 80 degrees Celsius. It's eerie, peering inside those freezers. Each is filled with dozens of small, square containers, which hold various portions of brains. The containers are stacked on top of one another, identified by seemingly indecipherable coding.

These are people. People who had dreams, athletic prowess. Families, memories. Shortcomings, talents. Joys, disappointments. People now reduced to letters and numbers.

Almost all were younger than age 32 when they died. About half took their own lives. Forty percent have been found to have CTE, or chronic traumatic encephalopathy, a degenerative brain disease found in people with a history of repetitive brain trauma.

Most of the brains belonged to men. To football players.

Less than 5 percent belonged to women.

Yet, we know that female athletes have endured repetitive blows to the head, too. Girls soccer players, in particular, have been found to be about as likely to suffer concussions as boys football players—and three times more likely than boys soccer players. But very little is known about what that means for the future, because researchers are hardly studying the long-term consequences of repetitive hits over time in women.

"They're definitely still focused on football. They can't get past football," says neuropathologist Dr. Ann McKee, the director of the VA-BU-CLF Brain Bank, whose research has been integral to our expanding understanding of CTE. "Women aren't even on the radar."

That's a problem, McKee goes on, because while we don't have enough research to know how differently head trauma affects women than men over time, we do know that the effect does seem to be different. And more high school girls are playing soccer than ever—394,105 in 2018-19, up from 356,116 in 2009-10 and 17,970 in 1978-79, according to the NFHS. It's a trend that will likely only accelerate after the U.S. women's national team's gold medal-winning run at the World Cup this summer.

Over the past decade, women have played a major role in the narrative of men's football brain trauma. Mostly, they've been quoted in articles as advocates, as confidantes. The image has become increasingly familiar: the mothers, wives, girlfriends, sisters, daughters, cast in supporting, caregiving roles, mourning and questioning why this happened to the men close to them who have suffered playing a game they love.

But women are not only on the tragic periphery of CTE and head-trauma issues. They're at the heart of them. Though their place in it has mostly gone unexplored, untold, female athletes have their own stories to tell.

The only thing stopping Briana Scurry from taking her own life was thinking of the woman who gave her life. Robbie Scurry, her mother. I can't do that to her, Scurry would think. She didn't want anyone to have to tell her mother that she was gone.

But Scurry felt gone. Gone from the woman she used to be: the Hall of Fame goalkeeper, World Cup champion and two-time Olympic gold medalist.

Who am I? she'd ask herself.

A brutal concussion ended her career in 2010. Caused her to spiral down through three years of darkness, three years of "wilderness," as Scurry, now 48, calls them. She didn't recognize herself. Didn't know how to stop her head from pounding. How to stop suicidal thoughts from swarming her.

She was deeply depressed, rarely leaving her apartment because of light sensitivity and the intensity of her headaches and anxiety. She couldn't work and struggled to make money. She was receiving disability benefits. She'd forget where she put things. "I could barely function," she says. "I went from someone who could focus on the panel of a ball with 90,000 people watching on the biggest stage to save a penalty kick to someone who couldn't hold a thought in my head."

She saw doctor after doctor, none understanding what she was going through. They told her that she was past the point of recovery, that this was who she was going to be. "I wouldn't accept it," Scurry says. Finally, she had occipital nerve release surgery in 2013, which helped tremendously.

She is in a better state nowadays but has pledged her brain to be studied when she dies—one of many former national team players to do so, including Megan Rapinoe, Abby Wambach, Michelle Akers, Brandi Chastain and Cindy Parlow Cone.

Most of those players declined to be interviewed for this story. They've acknowledged the issue through their actions but don't seem to want to talk about it.

Out loud, at least.

Scurry thinks often of the teammates who suffered in secret, eventually drifting from the game.

"There's silence; that's the other problem," Scurry says. "Nobody talks about it. At the time, nobody was willing to discuss, 'OK, I left behind my beloved sport because my head hurt.'

"You think, 'I just don't want to play anymore,' but it's actually a symptom of your head injuries. It's part of the emotional changes, the mood changes and the very powerful ways a concussion can change you as a person."

Concussions are known to cause emotional distress and other symptoms, such as depression, anger, paranoia and impaired judgment. In 2016, researchers found that concussions significantly increased the long-term risk of suicide among adults.

Scurry understands why brain injuries are hard to discuss out loud. She used to cry after sharing her story. For some, there can be shame and fear and confusion. Not wanting to be perceived as weak or vulnerable or "hysterical," labels that have long been unfairly attached to women. It's taken female athletes decades to be seen. To be respected as this powerful, talented, brilliant.

There is also fear that people won't fully understand the pain of a brain injury because they can't see its effects on the body. But that doesn't mean they're not there. Or won't be there, down the line.

"I'm a knower. I would rather know than not know," Scurry says.

But she has noticed that others don't want to know. That the unknown is uncomfortable.

"It's a dark pool," Scurry says, "and you don't know where the bottom is." She pledged her brain to inspire visibility. "It's basically myself and my teammates coming out of the dark," she says.

"This is like a little black box, and we're basically saying, 'Hey, here, open the box.'"

Several elderly men in wheelchairs wearing "Korean War Veteran" hats await doctor's appointments on the ground floor at the VA Hospital.

McKee, 66, is best known for her landmark 2017 American Medical Association study that found the incidence of CTE to be considerably higher in football players than in the general population—the one in which 110 of 111 players examined had CTE. She studies veterans too.

Today, she's sitting upstairs in one of her offices. It's small, cozy. A microscope hovers above her desk. An old magazine cover of Vince Lombardi is tacked onto one wall. Multicolored Post-its are scattered with reminders about brains, about phone calls, like the one she's scheduled to have in an hour with the mother of a deceased 26-year-old former college football player who had CTE.

McKee has spent the past 12 years making hundreds of calls like this, to women like this.

She opens a cardboard box filled with slides revealing tau, the protein found in high levels in the brains of people who have CTE, forming clumps throughout the organ and killing brain cells. "These are all guys' brains, of course," she says, laying a few flat on the table. A 30-year-old man. A 25-year-old man. Then 27-year-old Aaron Hernandez, the former New England Patriots tight end who took his life while in prison for murder. He had CTE. She puts his slide under the microscope, revealing two darkened lines, each about a half-inch long, indicating a tau deposit: "You can't believe that people aren't taking this seriously."

Take her seriously, too. She's been told her research is garbage. That she is trying to ruin football. Ruin men. Ruin American life. "The NFL treated me like a dizzy dame," she says.

She is hesitant to speak out about the kind of vitriol she faces. She feels physically and psychologically drained from people saying nasty things about her work. "It bleeds your energy," she says.

But she keeps going. She's committed to the work. She's still accustomed to being the only woman at conferences. She remembers one in the '90s, in Moscow, where men asked her if she was a "real" doctor. They also discussed whether women were less intelligent because their brains are smaller.

Few inroads have been made in studying female athletes' long-term brain health since those days. "It's a major unaddressed issue," McKee says. She is eager to study more women, but there's only so much one person can do. As a woman who has spent her life studying men, constantly told stay in your lane, she already occupies a tricky position: "I still feel marginalized as a woman."

"We've had such a hard time pushing the rock up the hill, focusing just on football and traditionally male sports," she says. And as much as she and others, such as Dr. Bennet Omalu, have discovered about CTE, there is still so much unknown about how the disease manifests, even in men. It's extraordinarily complicated. There's still no way to detect CTE in a live person.

And hardly anything is known about how CTE might manifest differently in women. Which again is a problem because, according to Dr. McKee, there's every reason to believe that an accumulation of hits—hits that may not result in immediate, post-concussive symptoms but nonetheless rattle the brain—may have a different and possibly great impact on women. As would differences in injury treatment and management in women's sports.

Biologically, women have thinner, weaker necks, and according to Chris Nowinski, Ph.D., co-founder and CEO of the Concussion Legacy Foundation, that's been found to make them more susceptible to concussions, though there has been almost no research focusing on the effects of heading exclusively in girls and women's soccer. Only one study has been published on the topic, according to the CLF. "We're further with women veterans than we are with women athletes," McKee says.

That's partially because female athletes, in this case soccer players, are just now reaching the ages of 40, 45, 50, the point at which long-term consequences from recurring hits typically would begin to be felt. Women have mostly only been full-time athletes since Title IX in 1972. The U.S. women's national team played its first match in '85. The first FIFA Women's World Cup occurred in '91.

"I wouldn't have expected to see much until now," says Dr. Robert Stern, Professor of Neurology at Boston University School of Medicine and Director of Clinical Research at B.U.'s CTE Center. "And if there is something, I would expect it to be a major growing problem over the next 10 to 20 years."

Up until 2016, when the U.S. Soccer Federation banned heading before the age of 10 (and limited heading for children aged 11 to 13 to 30 minutes per week), coaches weren't restricted from having girls (and boys) head the ball as often as they wanted, as young as they wanted. But we know that kids' brains are still developing at that age, and that trauma can impact that development.

Plenty of research has pointed out potential negative consequences of heading. But again, the bulk of that research has not focused on girls and women. A recent study led by Dr. Michael Lipton at the Albert Einstein College of Medicine found that heading can alter cognitive function, but 78 percent of the study's participants were male.

The question is: Do blows to the head affect girls and women differently? And what about in the future?

Akers, a member of the '91 and '99 Women's World Cup championship teams and one of only two women to score five goals in a single World Cup match, aims to spread awareness. She suffers from chronic migraines. "I've headed the ball a million times, so how has this possibly affected me?" Akers says. "What might have happened to my brain?"

"My point is," she adds, "why aren't we talking about this more?"

Part of the reason has to be limited awareness of women's sports as a whole. In 2015, a study found that women's sports receive just 4 percent of all sports media coverage. Concussions and CTE have spread to public consciousness largely because of football and the newspapers, magazine stories, movies and documentaries that bring an abundance of awareness to those issues.

And death.

There are a number of high-profile football players who were found to have CTE: Junior Seau, Aaron Hernandez, Ken Stabler. Women's soccer doesn't have those examples. With less public awareness, most people still likely conflate brain trauma with football, with men's sports.

"It's the same reason why men get paid more than women, or why the U.S. women's national team is asking for equal conditions compared to the men's team," Akers says. "The priority isn't necessarily on how things can affect women. There's an inequality there that's cultural."

There are other reasons for lack of study: Sample size. The slow process of science. Securing funding for any topic is challenging, especially without compelling preliminary data.

There are some signs of progress, though. A nonprofit called Pink Concussions has devoted itself to improving "the pre-injury education and post-injury medical care for women and girls challenged by brain injury including concussion incurred from sport, violence, accidents or military service." And as a result of advocacy from players like Akers, and with funding by the Concussion Legacy Foundation and the National Institute on Aging, there will be a landmark study beginning in October led by Stern and Dr. Jesse Mez called SHINE (Soccer, Head Impacts and Neurological Effects). They'll examine 20 former women's soccer players over age 40 who have played at the game's highest levels and will compare their findings to those of other studies of neurodegenerative diseases involving both women and men.

It's a start, but it's still nowhere near gaining the momentum that is needed.

"You don't get that same sense of urgency," Nowinski says. "People aren't funding studies on long-term effects. They're not investing in it."

Emily Oliver didn't yet realize she had suffered a concussion during her high school game. But later that night, when her coach asked her to drop off a ball bag at her car, she found herself aimlessly walking around the parking lot. She had forgotten why she was there and where she needed to go.

The next day, she was diagnosed with the first of four concussions she'd suffer as her career continued. She'd later help Stanford win the 2011 national championship as starting goalkeeper and NCAA College Cup Defensive MVP. But few outside of the Cardinal program knew how hit after hit shattered her sense of stability. Made her question if she'd ever recover.

"You get to a point where you don't even remember what being normal feels like anymore," says Oliver, now 27. 

The worst one came in a game against Santa Clara. A player undercut Oliver while she was jumping up to catch a free kick. She landed on the back of her head. A referee asked her if she felt OK, and she said yes and kept playing.

In the days that followed, she struggled to read, skipping paragraphs. Her eyes failed to track words. She couldn't go outside because it was too bright, so she'd stay in her room with the shades closed. She was depressed and emotionally irritable over the next five months.

"It was demoralizing. I felt hopeless," Oliver says. "Every day you wake up and you're not better. It was like, 'Am I ever going to get better? Is this my life?'"

When she was finally cleared to play, in the fall of her junior year, she was still dealing with heavy mood swings because of the medication she was taking. She battled migraines heading into the Final Four game against North Carolina. Her symptoms worsened that winter break and through the next semester. She started to feel better, though, by the fall and was elected a team captain.

Then three games into the season, against Portland, she was hit again. After the game, the athletic trainer asked her to name the months backward. She missed April twice. "We're diagnosing this as your fourth concussion," the athletic trainer told her. "The medical staff is recommending you go down the road of medical retirement."

Oliver was stunned. Devastated. But proud of the decision she then made to retire. She knew it was right, even if she would miss her senior season and miss out on a professional career. These days, she misses soccer most during August. The start of the season. She misses the urge to compete. She feels jealous of the women who can.

She feels much better than she did back then but doesn't necessarily want to think about possible future impacts of the hits she took.

"I don't know that I want to know what that means for me," she says.

Living through them was hard enough.

McKee spends most of her days in B.U.'s brain bank. Her team is about 100 brains behind. There are just that many to examine, and it's a slow, meticulous process. In efforts to work less, McKee says she isn't going to give any more talks. She finds that difficult. On stage, she isn't talking about a brain like some abstract object in a textbook. She's talking about someone's brain.

Someone's life that mattered beyond sports.

Someone's life that still matters to those he is survived by.

There are so many questions, and she doesn't have all the answers. No one really does.

It is difficult for McKee to give answers, in particular, about women, because much of this generation is still alive. It's also true, McKee surmises, that those alive might be hesitant to discuss brain donations or their symptoms in fear of being perceived as weak or vulnerable. "Especially for the military population, women with brain trauma," McKee says. "I think they are even less likely to come forward than a man because they don't want to be marginalized, because we already feel that." B.U.'s bank has yet to declare a woman with CTE.

CTE does exist in women, though, recorded in two instances: One, in 1991, of a 24-year-old woman with autism who banged her head often; the second, in '90, of a 76-year-old woman whose husband had physically abused her for decades.

There have been several men's soccer players who have been diagnosed with CTE, including Jeff Astle, Brazilian star Bellini, Patrick Grange and Curtis Baushke. But of course, there are simply more cases of men's soccer players to study, because of their game's longer history and the greater number of men who have played than women.

And because CTE can only be diagnosed posthumously, it's difficult to learn much about the disease for anyone. One question multiplies into so many more: Why do some people get it and others don't? How does a person's genetic history factor into the equation? What is the effect of other variables that might increase or decrease the resilience to showing manifestations of CTE? If bias in healthcare causes some doctors to take women's pain, and especially the pain of women of color, less seriously, how does that affect the data? Are researchers considering how transgender women and women who don't have XX chromosomes might be affected? Does CTE affect different parts of the brain in men and women?

Research is advancing, however, most notably with an April study in the New England Journal of Medicine. Stern, the lead author, used PET scans in attempting to detect tau buildup, and thus perhaps CTE, in a living person. The researchers tested 26 living former NFL players between the ages of 40 and 69 and found that "tau PET levels were significantly higher in the former NFL players than in the control group, and that the tau was in the same areas of the brain as in post-mortem cases of diagnosed CTE." It was an important step. But the study didn't include one woman.

It's not all about CTE either. There are other long-term problems stemming from repetitive head trauma. We just don't know how exactly that manifests in women yet, and more inclusive research could help. "If repetitive headers and the collisions that are caused by attempting headers are causing CTE or other neurogenerative diseases," Nowinski says, "if we can establish that today, we can save a bunch of women and girls a lot of trouble in the future by changing how we play the sport.

"Until we have these answers, we're still going to have 11-year-olds heading soccer balls."

The ball seemed bigger than Esther Lovett's body when she began playing soccer at three. Like a little bumblebee, buzzing up the field, she was energized, focused. She headed the ball many times before age 10—the year of her first concussion. Sometimes she felt a little dazed after a header, but she'd snap right back. That's soccer. That's playing year-round. That's dreaming of the pros.

She is 20 now, heading into her sophomore year of college. She struggles to answer the question How many concussions have you had? because there are ones she knows she's had and ones she doesn't know she's had, and a number doesn't convey what having pounding headaches every single day for the past six years feels like.

She chooses five. Five diagnosed concussions. "Definitely more than that," Lovett admits. The worst one came at age 13, back in April 2013. A girl took a shot on goal and hit her in the back of her head. Few noticed it happened because it was not a particularly obvious, gruesome hit. Her coaches didn't take her out. She really thought she was good. "I played the rest of the game," she says, "even though I could barely see. I didn't really know which side of the field I was on."

A horrible, nauseating headache throbbed the next day. She couldn't read the whiteboard at school a few days later. Pain continued for weeks, months. "It was terrifying," says Barbara Piette, her mother. Lovett can only wonder if she is still suffering because of years of hits that came before, like the time in middle school she was on defense, marking the goal post for a corner kick. A girl on offense ripped a shot on goal that hit her straight in the face. Her head smacked back against the post. Her nose was bleeding, and her coaches checked to see if it was broken. No one thought to also check for a concussion.

There are times she is frustrated, thinking about that moment, but she didn't have control. She was a child who just wanted to play the game she loved. A child who did not have the medical knowledge or wherewithal in the moment of trauma to understand what was happening. Because that medical knowledge didn't exist then and, in some ways, still doesn't now.

"It's a lot for a kid," she says. "The onus sort of falls on you to self-diagnose: Come out if you think you have a concussion. What does that mean?"

Her doctor told her she'd have to stop playing after the 2013 concussion. She did stop playing but was more susceptible to additional concussions and suffered three more that were diagnosed after that, non-sports concussions, including one in 2015 that led her to take a medical leave and defer junior year.

Leaving soccer was painful. Lonely. Especially when the ball had almost been a best friend. But she has morphed into an advocate, sharing her story so she can help other girls.

She stayed up all night before her 18th birthday to pledge her brain right after the clock struck midnight. She sent in the form at 12:01. She is the youngest person to ever pledge to the CLF.

Lovett still suffers daily headaches. Migraines occasionally. Some dizziness still, some nausea. "There are so many people silently suffering with this and soldiering on and thinking, as I did, that there isn't anybody else going through this," Lovett says. "You think something's crazy about your case. About you."

When B/R reached out to FIFA for comment about concussions and repetitive subconcussive hits in soccer, a FIFA spokesperson said protecting the health of players is a "top priority" and that it takes these issues "very seriously" but that: "To our very best knowledge, there is currently no true evidence of the negative effect of heading or other subconcussive blows. Results from studies on active and former professional football players in relation to brain function are inconclusive."

However, the idea that repetitive subconcussive injury can have neurological consequences is widely accepted by the medical community at large, as well as the Centers for Disease Control.

"This is a corporate response to a problem that they may be responsible for," Nowinski says, referring to FIFA's comments. "It's not that different from the NFL's original response to research on long-term effects, or the smoking industry's original response to research on the long-term effects of smoking."

The SHINE study will involve neurological examinations, motor examinations, cognitive assessments, MRI scans of the brain, blood tests, lumbar punctures and more. "If girls are more prone to concussion," Stern says, "they also may be more prone to subconcussive injuries that are so much more common and are associated with heading—that may possibly be a critical factor for later-life disease."

The hope is that with increased knowledge will come increased awareness and, in turn, increased attention paid to what can be done to make the game safe as it continues to grow in popularity.

"The imperative," Stern says, "is that we must study it.

"We don't want to wait until it's too late."

Mirin Fader is a staff writer for B/R Mag. She's written for the Orange County Register, espnW.com, SI.com and Slam. Her work has been honored by the Associated Press Sports Editors, the U.S. Basketball Writers Association, the Football Writers Association of America and the Los Angeles Press Club. Follow her on Twitter: @MirinFader.