Reacting to Warrior Girls: A Blog

From the Tucker Center for Research on Girls & Women in Sport

by Steven D. Stovitz, MD, FACSM — Assistant Professor, Department of Family Medicine and Community Health & Elizabeth A. Arendt, MD, FACSM — Professor, Department of Orthopedic Surgery

We share your concern with injury rates in athletes, and agree with your message that rates in certain sports with certain injuries tend to be higher in female athletes as compared to male athletes. As sports medicine physicians (and, parents) we agree that more research should be devoted toward the study of these facts. In addition, we are in agreement with your disdain for single sport specialization which appears to be a part of your book, but not a major part of the article to which our comments were directed.

In terms of your response to our comments, you included the statement, “It’s simply not true that I “imply� that all girls inherently contain every risk factor.� Our point was that girls tear their ACLs at higher rates than boys, but that we do not know why. Thus, researchers find attributes of girls that are different than boys and then say that the higher risk may be due to this or that particular attribute. You used circular logic by stating that the risk factors listed were known risk factors, all coincidentally noted to be more common in girls, and not theories trying to explain why girls tear their ACLs at higher rates than boys. In fact, your article included the following quote, “Girls, as their estrogen levels increase, tend to add fat rather than muscle…The influence of estrogen makes girls’ ligaments lax, …an injury risk when not accompanied by sufficient muscle to keep joints in stable, safe positions. Girls tend to run differently than boys — in a less-flexed, more-upright posture — which may put them at greater risk when changing directions and landing from jumps. Because of their wider hips, they are more likely to be knock-kneed — yet another suspected risk factor.� If that doesn’t imply that each of these distinct qualities place girls at higher risk, we have a disagreement on the definition of “imply.�

We suggested that you exaggerated the benefits of ACL injury prevention programs. To which you replied, “if the program works just half as well as its claims, I’d highly recommend it.� We agree. In fact, that’s our main point. The facts support the widespread implementation of ACL injury prevention programs. We are strong advocates of the work being done by Drs Hewitt, Bahr and others. Why not present the facts in a fair manner.

Finally, your reply to us included the following “They criticize my “over-the-top� and “emotional� approach. I am a journalist. We tell stories. We do tend to deal in more emotion than academics. I would not ask Drs. Arendt and Stovitz to put more emotion into their medical or epidemiological research. It’s unclear to me why they’d like me to subtract it from mine. “ We do not know how one can reply to such an argument.

Posted by Austin Stair Calhoun at 3:05 PM | Permalink | Comments (2)

I am gratified to see that you have opened a blog on my book, Warrior Girls, on the website of the Tucker Center. My hope was to start a needed discussion, and that has been occurring on the Internet and across various venues since its publication in June. I am, however, stunned by the tone of your moderator, and also by some of the comments that imply I have written a dishonest book. Those of us in journalism and academia have our own different and important roles to play. I wouldn’t dream of so casually labeling an academic’s work in such a way. Warrior Girls is the product of close to three years’ research and of hundreds of interviews with athletes, coaches, parents, doctors and scientists across various fields.

Readers of your blog are led to assume it’s some dashed-off political polemic, but it is anything but, and it has not been received that way by readers, reviewers or by the scientists who gave their time to me. More importantly, it has not been received in such a way by any of the girls and young women who I wrote about. (The book is not, by the way, a “best-seller,� just to correct that particular error.)

Now, to address some specific points: The moderator begins by writing: “The premise of the book asserts that “[the] immutable facts of anatomy and physiology� cause girls to incur significantly more sports injuries (e.g., ACL tears, concussions) than their male counterparts, resulting in what Sokolove terms a female “injury epidemic.� No careful or fair reading of the book could possibly conclude that is the premise of the book. What I write – and devote CHAPTERS to – is the belief of researchers that the prevalence of certain injuries (not just ACLs) seem to have gender-specific causes, probably related to movement patterns, but that these factors can be MODIFIED, and risks possibly lessened, through thoughtful training. I do state that male and female athletes are different, and those differences should be considered in how they are trained and coached in order to prevent injuries. That’s quite different than the moderator’s cherry-picked quote and the contention that I believe it’s all inevitable and therefore I must want to scare girls off the playing fields. Why would I have written a book that addresses research into sports injuries and new ideas on training methods – as well as, notably, critiques of how our youth sports culture is manufacturing injuries – if I believed female athletes were just doomed by biology and physiology? I didn’t, and readers have not interpreted the book that way.

That quote identified by the moderator as the “premise� of Warrior Girls speaks directly to the issue of concussions. What I stated was that with all the millions of dollars and the vast amount of attention devoted to studying concussions in male football players, no one was paying nearly enough attention to concussions among female athletes. In fact, concussion rates in women’s collegiate soccer and men’s college football are roughly the same. Most of the general public would be surprised by that. Concussions among women’s NCAA ice hockey players (in a small sample because it’s a relatively new sport) were more than twice that of football players. Does anyone disagree that we ought to pay some attention to concussions among the women, too – or should we just focus on all the cool new technology being rigged to football helmets so the boys will be OK?

The “immutable� fact of anatomy I referenced is that females tend to have smaller heads and weaker necks than men – that the neck works as a “shock absorber� – and therefore, female athletes may be more prone to concussions. Concussions in male soccer almost always result from head-to-head or elbow-to-head contact. Women and girls sometimes suffer concussions from head-to-ground contact and occasionally (although rarely) from heading the ball.

I am happy to have my facts (or “purported facts,� in the hackneyed construction of your moderator) knocked down. So if any medical professional disagrees that females tend to have smaller heads and weaker necks, I’d be happy to hear from them. Perhaps girls need to be encouraged – even more so than boys -- to wear protective headgear. If that headgear is judged insufficient, maybe research dollars need to be devoted to designing better ones. Concussions, particularly in teenagers, can have devastating effects. If we’re more worried about them occurring in boys than girls, devote more research dollars to studying concussions in boys than girls, and are afraid to even talk about a possible gender difference relating to how concussions are suffered, I would not say that serves the cause of women’s athletics.

Dr. LaVoi quotes a Cal State Fullerton professor: “Concerns regarding the supposed biological limitations of the female body to withstand rigorous athletic competition have historically served to justify restricting girls’ and women’s access to sport.�

I agree! In fact, I wrote: “It is not unreasonable to want to steer clear of the whole volatile subject of gender difference, of any research or discussion of it whatsoever. Women, almost always, have come out on the losing end of it . . . “ That was part of a chapter devoted in large part to the sorry, shameful history of research into gender difference. It’s fine that Dr. LaVoi would quote the California professor, but an odd omission that she wouldn’t note that Warrior Girls, the book at the center of this scholarly blog, made the very same point. What I concluded was that the history of research into gender difference – and fears that differences will be equated with inferiority – was inhibiting a needed conversation.

Dr. LaVoi goes on to state and restate that I have simply written a “biology as destiny� book, but she does not offer up any supporting evidence, grapple with the material or take specific issue with anything that I’ve written. The question I would pose to her is this: Did you really, truly read the book? Or are you just responding to the moderator’s prompt? (And by the way, it’s OK if the book does not appeal to you. Perhaps you have better things to read, or you’re so disgusted by what you presume to be my thesis that you can’t really engage with it. I understand. But what’s not intellectually honest is to comment on a book if what you’re really doing is adding commentary to commentary without engaging the original material.)

Drs Stovitz and Arendt write that I “fudged� statistics. I know and respect Dr. Arendt’s work. I would respectfully disagree with her view. The statistics they cite relate to a particular prevention program whose peer-reviewed research has reflected promising results on preventing ACL ruptures; if the program works just half as well as its claims, I’d highly recommend it. They criticize my “over-the-top� and “emotional� approach. I am a journalist. We tell stories. We do tend to deal in more emotion than academics. I would not ask Drs. Arendt and Stovitz to put more emotion into their medical or epidemiological research. It’s unclear to me why they’d like me to subtract it from mine.

I would note, however, that experts in this field whose research helped guide me told me repeatedly (pre- and post-publication) they were thankful for my project because it helped remind them that their real subject was people, not numbers. When a mother or father watch their teenage girl play soccer – after she has rehabbed from her second ACL injury – they are emotional. They are anxious and frightened. That is not emotion that I have to invent or hype up. It’s there, believe me.

One other point on Stovitz and Arendt: They write, “We don’t know why girls suffer ACL injuries at rates higher than boys. Theories include factors such as differences in strength, joint laxity and gait. The author presents each theory as a “known risk factor� implying that all girls inherently contain every risk factor which places all females at enormous risk.�

It’s simply not true that I “imply� that all girls inherently contain every risk factor. What I do write is that the greater rates of non-contact ACL tears – in sports like soccer and basketball that males and females play under similar rules -- certainly do indicate that girls and women, in general, are more at risk.

In my book, I write of a club soccer team in South Florida in which 18 mid-teen girls had suffered a total of eight ACL ruptures. I wrote of a high school soccer team in Bethesda that in the span of a few weeks suffered two ACL tears, a serious ankle sprain, a back injury and two serious concussions. If someone can find boys teams with similar rate of injuries, I’d be surprised. Last season, two starters on Uconn’s women’s basketball team were lost to ACL tears. The season before that, the Pac-10 conference lost nearly every one of its point guards to ACL tears. Not long before Abby Wambach broke her leg before the Beijing Games, two of her teammates on the U.S. women’s soccer team were lost within the span of about a month to ACL tears. It wasn’t big news. It was routine. None of the other players expressed any surprise. They’d seen it before, repeatedly.

The overall concern of your scholars seems to be that my book – as well as any overt discussion about injuries among women athletes – is going to drive women off the playing field. I’d say it is injuries that takes athletes off the field – not information and discussion. And not one of the hundreds of emails I've received from female athletes, or parents of athletes, have said the book had induced anyone to leave their sport.

It is interesting to me that Dr. Wiese-Bjornstal is the one contributor to the blog who did not reflexively attack my work, despite what seemed like an open invitation to do so. I don’t think it’s coincidental that she described herself as a parent of a female athlete -- as I am, as well. (My daughter is an NCAA athlete.) I would suspect she knows what’s going on at field level and the physical and emotional toll.

The moderator offers up “concluding thoughts.� Concluding thoughts? We’re done? Maybe that’s why you didn’t get any comments. Visitors to your site didn’t feel invited into an open or fair-minded conversation. What are we concluding? All thoughts of girls and sports injuries, now that my book (and reputation for honest work) has been discredited?

The moderator also writes that the Tucker Center “felt it necessary to provide a scholarly� critique of my book. With all due respect, what I’ve seen so far does not seem scholarly. With few exceptions, contributors did not engage with the material – they wrote from their own preconceived notions. I strongly suspect that some may have felt superior enough in their opinions to critique the book without actually reading it.

More importantly, does the Tucker Center – and do other advocates for women’s sports – also feel that it is necessary to take on the injury issue, support research, call attention to prevention programs, speak out forcefully about an unhealthy youth sports culture that is hurting kids? I write that the youth sports culture, with its emphasis on year-round play and early specialization, is bad for all kids – but is taking a greater toll on girls. That is one of the premises of the book, and I stand by it.

There’s a problem out there, and I believe that advocates of women’s sports – those at the Tucker Center and elsewhere who have done important work in advocating for Title IX and its rigorous enforcement – have a responsibility to take it on as a cause.

I would respectfully request that you post this response on your site. Thank you.

Sincerely,
Michael Sokolove

Posted by Austin Stair Calhoun at 3:02 PM | Permalink | Comments (0)

by Nicole M. LaVoi, Ph.D. — Associate Director, Tucker Center

Let me begin by stating that sport injuries and sport injury prevention are very real and important issues—for both girls and boys. However, framing the issue of sport injuries as an inevitable biological difference based on the sex of the athlete is sensationalistic and irresponsible. First, an argument based primarily on biology and physiology altogether ignores that sport performance (and therefore injury) is also shaped by social forces such as coaches’ and parents’ beliefs about what it means to be a “female athlete.� Second, this sort of deterministic approach assumes that males, by definition, are naturally (physically) superior to females. In this framework, male athletes are the norm to which females are constantly compared, and any gender differences are therefore constructed as inherent female deficiencies. The consequence of such biology-is-destiny arguments? Professor Cheryl Cooky, Cal State-Fullerton, sums it up best: “Concerns regarding the supposed biological limitations of the female body to withstand rigorous athletic competition have historically served to justify restricting girls’ and women’s access to sport.�

Though Sokolove does indicate that we should also be concerned about sport injuries males sustain, rarely, if ever, are books published devoted to the negative consequences of sport participation on the health and well-being of boys and men. Interestingly, a search for a similar book or article on the “epidemic� of male sport injuries yielded nothing, despite published research which indicates that NFL players’ life expectancy is 15-20 years lower than the general American male population and that many suffer ill effects from playing professional football, including obesity, heart disease, chronic pain and crippling arthritis.

The anatomy-is-destiny perspective also ignores the reality that some female athletes are stronger, have better motor skills, and are more coordinated than some male athletes, and that risk for injury runs along a continuum, rather than a sex-determined binary. In the final analysis, males and females are more similar than they are different—both compete in sports and both get injured in a variety of sports and physical activities. As a result, concerns relating to all the correlates of sport injury, social and psychological as well as biological and physiological, need to be given equal consideration.

Posted by Austin Stair Calhoun at 12:14 PM | Permalink | Comments (13)

by Steven D. Stovitz, MD, FACSM — Assistant Professor, Department of Family Medicine and Community Health & Elizabeth A. Arendt, MD, FACSM — Professor, Department of Orthopedic Surgery

As sports medicine providers, we are aware of the devastation that an ACL tear can have on both the musculoskeletal system and the mental health of an adolescent. In certain sports, females sustain a higher rate (not a greater number) of non-contact ACL injuries when compared with males. However, the emphasis on the emotional interplay among the athletes, parents, and coaches Sokolove writes about detracts the focus from a more scientific presentation of injury risk. Warrior Girls suffers from the following: 1) False comparisons—One major theme is that females simply can’t do what males do. Therefore, when they try to “act like males,� meaning be competitive, powerful and aggressive, they will inevitably become injured. 2) Misrepresentation of scientific literature—We don’t know why girls suffer ACL injuries at rates higher than boys. Theories include factors such as differences in strength, joint laxity and gait. The author presents each theory as a “known risk factor� implying that all girls inherently contain every risk factor which places all females at enormous risk. 3) Fudging of statistics—Imagine something happens in 0.1% of population X, and 0.2% of population Y. You could say that the difference between the populations is 0.1% (i.e., the absolute difference), or you could say that the difference is 50% (i.e., the relative difference). While both numbers have meaning, when discussing an ACL injury prevention program, Sokolove only presents the relative difference—in this case, 74% fewer ACL tears occurred in girls who completed an ACL prevention program compared to girls who did not complete the program. A more honest (and accurate) approach would be to present both numbers. 4) Emotional language—“The ACL does not tear so much as it explodes�, and “parents scream ‘No! No! Oh, no!’ from the sidelines.� Such overwrought language permeates Sokolove’s writing and contributes to the sense of fear he creates when discussing the “injury epidemic� he claims exists.

There is an identifiable gender disparity with regard to non-contact ACL injuries. To address this concern, parents and coaches could, for example, be much more aware of ACL injury prevention training and its many benefits for females and males. Unfortunately, these critical messages get lost within Sokolove’s over-the-top and misleading approach.

Posted by Austin Stair Calhoun at 12:28 PM | Permalink | Comments (0)

by Toben F. Nelson, Ph.D. — Assistant Professor, Epidemiology & Community Health

Warrior Girls tells compelling stories of exceptional young women as they struggle with serious sports injuries—stories that need to be told. The author is sensitive to the hard-won gains that have opened doors for young women to experience the benefits of sport. We cannot go back. Higher sport injury rates among girls is not evidence of weakness nor an indication they should not play. But that does not excuse serious efforts at understanding the etiology and distribution of sports injury, with the goal of prevention. Sokolove does raise important questions about sport injuries, but the prescriptions he offers are preliminary and unsatisfying. Should we push young women to play hard? Should we allow them to push themselves? Do young women lack the self-awareness to know when they have gone too far? Such questions send us backward, not forward.

Though the personal stories Sokolove highlights are compelling, they restrict our vision of the full problem—if we use only the comparison of girls to boys, we remain limited in our overall understanding. While it might be tempting to wonder about the physical attributes of young women that may make them susceptible to injury, we also need to ask questions about the conditions that contribute to injury rates among young men. Fundamental inequities still exist between sport opportunities for boys and girls. Do differences in field conditions, types of equipment or coaching styles contribute to higher injury rates?

Some excellent work has been done to study sports injury using NCAA Injury Surveillance data. Although these data are the best available, they are incomplete, and as a result, reliable answers about adequate prevention remain elusive. Expanding the set of questions we ask—and collecting the right data to answer them—will go far in furthering our understanding of the complexities surrounding this issue. Sports participation can be a safe and rewarding pursuit. We should continue to strive to protect young women (and men) from the risks they encounter in sport through rigorous science.

Posted by Austin Stair Calhoun at 12:21 PM | Permalink | Comments (0)

Diane Wiese-Bjornstal, Ph.D. — Associate Professor, School of Kinesiology; Association of Applied Sport Psychology Certified Consultant

In many ways I was a “warrior girl�; still am, I think. So I truly do understand what these girls feel: The over-powering desire to mask pain, injury, or fatigue so as not to miss a moment of playing time, give less than 100%, or appear weak. But fortunately for me, this style wasn’t an option at the tender age of 10 or younger as it is for girls—and boys—today, so I survived relatively unscathed at least until college. Being a Sport Psychology Professor by day and a mild-mannered soccer mom by night, I view the topics in Sokolove’s book through two lenses. As a scholar, I see that our studies of the psychological reactions of athletes post-injury have illustrated the same full spectrum of cognitive, emotional and behavioral responses reflected in the book’s many anecdotes. Sadly, some young athletes express “relief� after sustaining an injury because they feel it is the only way to escape the pressures of sports and still “save face.� Pre-injury studies reveal that those athletes who are physically and mentally fatigued—self-imposed, such as perfectionist standards, and other-imposed, such as pressure from coaches or travel time—are more likely to sustain injuries.

As a mom, I see that parental responsibility for athlete health is often abdicated to coaches. The unhealthy decisions that parents sometimes make for young athletes—and that Sokolove highlights with such powerful examples as “we can’t stop her, she has a mind of her own,� or “I don’t want to ‘waste’ her talent�—are simply bogus. I admire those parents described in the book who drew the line in the sand when an athlete’s health was in jeopardy. But parents should also realize their beliefs and values about physical activity greatly influence their child’s behavior. Research indicates that far too often, parents perceive girls are more vulnerable, and thereby allow, even encourage, greater risk taking for boys which, ironically, puts them more at risk for injury than girls. This research finding provides additional evidence against the biology-is-destiny argument.

In sum, we must help all of our children learn to take reasonable risks within healthy boundaries in all aspects of life, sports included.

Posted by Austin Stair Calhoun at 12:34 PM | Permalink | Comments (1)

Warrior Girls is based on sensationalistic journalism rather than empirical evidence. Sokolove skillfully links the sport ethic—striving for distinction, accepting risks, playing through pain, and not accepting barriers in the pursuit of goals—with a Mars-Venus dichotomy whereby females are routinely portrayed as different from (and inherently inferior to) males. He seems determined to create a moral panic for already overly concerned sport parents who are understandably trying to do what is best for their daughters. In Sokolove’s worldview, parents are confronted with a falsely constructed dilemma—wanting equal sport opportunities for their daughters, but in so doing, placing their daughters in harm’s way. A more honest and constructive book would have examined the current structure of organized youth sport—a system characterized by early specialization, a win-at-all cost philosophy, and undertrained coaches and parents. In sum, a system that can be detrimental to both girls and boys.

Posted by Austin Stair Calhoun at 3:14 PM | Permalink | Comments (1)

If you'd like to add an opinion or entry that is distinctive from the perspectives included above, please email your entry to Austin Calhoun (calho029@umn.edu), who will moderate all posts.

Posted by Austin Stair Calhoun at 4:24 PM | Permalink | Comments (0)