hen Hannah al-Khaldi experienced a knock to the head in the final seconds of an Allianz Premier 15s game last season, there were no immediate signs of head injury or concussion. Days later, terrifying stroke-like symptoms began to appear. “The right side of my face and body went numb, I lost the ability to use my right arm, I couldn’t speak,” the 34-year-old prop recalls. And yet she says that she struggled to get an accurate diagnosis. Khaldi spent two weeks in and out of hospital, being told she was suffering from tension headaches and migraines: “The pain was blinding, I couldn’t function.” An MRI scan four weeks later found a cerebrospinal fluid leak from the brain. After a month of intense recovery, including an epidural blood patch through her spinal cord, Khaldi was cleared to play rugby again by a neurologist. She had kept in contact with the team doctor, yet her coaches were unaware of her head trauma. Feeling her place in a Premiership team was under threat, Hannah’s mental health suffered and, ultimately, she left for another club and eventually chose to stop playing in the Premiership. Al-Khaidi’s experience may be extreme but developments from the men’s game have left her concerned for the future. Earlier this month the Guardian revealed that lawyers acting on behalf of a group of nine former international players, including the England World Cup winner, Steve Thompson, lodged letters of claim with rugby’s authorities for negligence with the players suffering symptoms of neurodegenerative disease including early onset dementia. Yet while the discussion of concussion in sport is almost exclusively focused on men, while making a radio documentary earlier this year I was shocked to find that women are twice as likely to get concussions, experience more intense symptoms, and take longer to recover. Now experts are warning that female athletes could be more likely than men to develop effects such as sports-related dementia. “There is no reason not to believe that we will see these kinds of problems in women in the future or even more so,” said Dr Michael Grey from the University of East Anglia, who studies neuroplasticity and neurorehabilitation, particularly with respect to acquired brain injury. The link between concussion and early onset dementia shows it is not an injury to be taken lightly, yet it is not known why women are more prone to concussion. Dr Grey, who is leading the SCORES project at UEA (which stands for Screening Cognitive Outcomes after Repetitive head impact Exposure in Sport), a study looking at the cognitive function of former professional athletes compared to non-sporting professionals, said hormonal difference between the two sexes could be an explanation. It has been suggested that “women are more vulnerable to head trauma at a certain time of the month,” he said. Although this hasn’t been substantiated, Dr Grey added: “We can’t fully understand the difference or conclusively give a reason why until more research is done.” Dr Grey urged more women to join his study, saying: “It is likely, given what we know, that women are more prone to get sports-related dementia than men.” Women’s rugby is one of the fastest growing sports in the UK and concussion accounted for a fifth of all injuries in the 2017-18 women’s Premiership season. The higher concussion rate in women could also be attributed to the whiplash effect, given that women have comparatively weaker neck muscles than men, meaning that female players do not have as much control over their heads during contact, when the majority of head injuries occur. As a rugby player I have seen for myself the conversation around head injury grow in recent years and it inspired me to create a documentary about concussion in the women’s game. Things are now beginning to change. Another elite player, the DMP Sharks wing Igemi Ekoku, who experienced long-term symptoms from concussion that have left her unsure if she will ever play again, is calling for change. “There needs to be greater transparency and awareness on the potential long-term effects of concussion, on how they can affect a player’s life,” she said. Ekoku, who played for the club for the past two Premiership seasons, suffered an accident during training in February that left her unconscious. She was rushed to hospital where a CT scan showed nothing out of the ordinary, but like Khaldi and many others, her symptoms showed later. Over the next month, Ekoku developed exercise intolerance as a result of post-concussion syndrome, which deteriorated during lockdown. Soon, she found washing her hair or even standing up would exhaust her and trigger intense headaches. “Before my injury I was the fittest I’d ever been, and my life revolved around rugby and the gym.” Now she says she is having to adapt to a life where she is no longer fully independent. Like Khaldi, and as more studies are being conducted around concussion, she is concerned around health conditions that could develop in later life as a result of her rugby injuries. Both women hope that the sport of rugby can learn from their experiences. They admit that players accept there is a risk in such a high contact sport, but say they need to be fully aware of how an injury can change your life. Both are sympathetic to the male players’ lawsuit, but at the moment their motivation is education. Khaldi was approached by a sports injury lawyer to see if she wanted to make a claim as her injury prevented her from working for two months. She decided not to take any legal action, saying: “I don’t want to try and take money away from an already underfunded club and sport.” Ekoku added: “I think the RFU’s approach to head injury is good but as more evidence comes out about the long-term effects of concussion, rugby will have to adapt.”