Traumatic brain injury: sex, gender and intersecting vulnerabilities


Over the past decade, traumatic brain injury (TBI) has emerged as a major public health concern, attracting considerable interest from the scientific community, clinical and behavioural services and policymakers, owing to its rising prevalence, wide-ranging risk factors and substantial lifelong familial and societal impact. This increased attention to TBI has resulted in increased funding and advances in legislation. However, many questions surrounding TBI remain unanswered, including questions on sex and gender trends with respect to vulnerability to injury, presentation of injury, response to treatment, and outcomes. Here, we review recent research efforts aimed at advancing knowledge on the constructs of sex and gender and their respective influences in the context of TBI, and discuss methodological challenges in disentangling the differential impacts of these two constructs, particularly in marginalized populations.

Key points

  • The effects of biological sex, as well as gender, which represents an amalgamation of social, biological, cultural and behavioural elements, are underappreciated in traumatic brain injury (TBI) research and practice.

  • Differential environmental exposures, biological vulnerabilities to injury, and gender disparities in norms and role expectations affect the reported prevalence and incidence of TBI.

  • Preclinical studies of TBI provide inconsistent results on the neuroprotective effects of sex hormones.

  • Certain groups of men and women are more vulnerable to TBI than others, owing to the unique interactions between their biological, behavioural, social and cultural conditions preceding injury and at the time of injury.

  • The transition from an injury event to disability in TBI is affected by a plethora of factors, including attitudes at local, family and societal levels, economic deprivation, and endorsement of civil rights legislation.

  • Explicit and consistent consideration of the interrelated constructs of sex and gender in TBI research will produce a better understanding of the different mechanisms that shape the health status trajectory and outcomes of TBI.

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Fig. 1: Determinants of TBI outcome.
Fig. 2: Scopes and limitations of TBI studies.


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This work was supported by the Alzheimer’s Association under award AARF-16442937, by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the NIH under award R21HD089106 and the Canadian Institutes of Health Research (CIHR) Institute for Gender and Health grant #CGW-126580. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Alzheimer’s Association, NIH or CIHR. We gratefully acknowledge the involvement of J. Babineau, information specialist at the Toronto Rehabilitation Institute–University Health Network for her help with the comprehensive literature search in MEDLINE and Web of Science.

Review criteria

The search strategy was developed in collaboration with a medical information specialist at a large rehabilitation teaching hospital. MEDLINE and Web of Science electronic databases were searched from inception until July 2017 (Supplementary Box 1). All searches were limited to studies in the English language. A repeat search was performed in all databases in May 2018 to identify the most recent publications. The following medical subject headings (MeSH) were used to identify publications of interest: “brain injuries, traumatic”, “gender identity”, “sex characteristics” and “social determinants of health”. “Intimate partner violence”, “homeless persons”, “prisoners” and “accidents, occupational” were also explored. The search was supplemented with citations from identified articles.

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T.M. and S.M researched data for the article. All authors made substantial contributions to discussions of the content, wrote the article and reviewed and edited the manuscript before submission.

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Correspondence to Tatyana Mollayeva.

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Mollayeva, T., Mollayeva, S. & Colantonio, A. Traumatic brain injury: sex, gender and intersecting vulnerabilities. Nat Rev Neurol 14, 711–722 (2018).

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