Concussion in professional wrestling: agency, structure and cultural change

ABSTRACT

In this article, we utilise the social dynamics of concussion in professional wrestling to examine and critique calls for cultural change as a solution to the crisis of concussion in sport. Drawing on interview data from wrestlers, promoters, referees and healthcare providers in UK professional wrestling, we illustrate the experiences, attitudes and subcultural norms exhibited in relation to concussion. Despite increasing concerns that brain injuries present unique risks to long-term health, wrestlers continue to embody a culture in which pain is ignored, and ‘playing’ with brain injury is linked to notions of masculinity and wrestling identity. We further explore the organisational features of wrestling, which facilitate and compound these risk-taking behaviours, and conclude by identifying the structural-cultural causes of concussion in wrestling. In sum, economic precarity encouraged risk-taking behaviours, while the ‘free agent’ status of many wrestlers obviated the potential for any continuity of healthcare or paternalistic protection. Moreover, changes to the dominant performative character of wrestling led many to undertake increasingly risky moves, and the serial nature of character development and the centrality of interpersonal negotiations in workplace practice threw precautionary attitudes into conflict with self-identity and social reputational concerns. We therefore conclude that existing public health interventions designed to address concussion in sport, and particularly the concept of cultural change, need to diversify from predominantly medical and psychology-based models and embrace more holistic, structural conceptions of culture.

KEYWORDS:

• Brain injury
• injury
• performance
• professional sport
• promoters
• structure
• violence

Introduction

Professional wrestling has a complex yet essential relationship with violence (Atkinson 2002). This ‘hybrid performance of theatre and sport’ (Smith 2008, 131) is renowned for being ‘fake’ (in the sense of being pre-planned rather than openly competitive) yet has a very real and well-documented incidence of serious injury (De Garis 1999). The first scripted wrestling bouts likely arose to enable injured competitors to fulfil existing exhibition bookings (Maguire 2005) but the subsequent desire to create more spectacular and entertaining forms of traditional, amateur, styles (e.g. Greco-Roman) led professional wrestling to exploit contemporary sensitivities towards violence, ‘deliberately exaggerating and dramatising the brutal physicality, intense competition and emotional responses commonplace in professional sport’ (Atkinson 2002, 54).

While wrestling ethnographers (Mazer 1998; Smith 2008) have documented how violence translates into pain and injury, more recently epidemiologists have recorded mortality rates of 25- to 49-year-old US wrestlers 4.5 times higher than the general population (Herman et al. 2014). Cardiovascular disease has been identified as the main cause but wrestling has also been affected by social concerns over concussion. Wrestling’s watershed moment occurred in 2007, when Chris Benoit became the first of (to date) six former professional wrestlers to be diagnosed with Chronic Traumatic Encephalopathy (CTE). A class action lawsuit against World Wrestling Entertainment (WWE) has been initiated by 60 former professional wrestlers; effectively shadowing the legal challenge that led the National Football League to make a landmark $1bn out-of-court settlement with former players (Corteen 2019).

Public health responses to concerns about sports-related concussion (SRC) represent a distinct challenge to activities in which tolerance of injury and acceptance of health-risks predominate. Although recognition of the relatively limited success of educational/awareness campaigns has invoked calls for more theoretically informed models (Kroshus et al. 2014), interventions continue to rely on positivist and reductive approaches which isolate risk variables, and seek to transfer biomedical understanding to lay communities (Malcolm 2020). Even the manifold calls for ‘cultural change’ (CDC n.d.; Register-Mihalik 2016) remain conceptually limited. Sarmiento, Donnell, and Hoffman (2017, 790), for instance, define cultural change as

the ways in which key audiences think and behave related to concussion … Changing the culture of concussion includes encouraging reporting of concussion, complying with appropriate concussion management plans, and other related shifts in social norms, attitudes, and behaviors around concussion to improve the health and safety of young athletes.

Problematically, such calls remain rooted in what has more widely been critiqued as the psychologisation of health promotion ‘essentially focus[ing] on individual rather than cultural behavioural change’ (Malcolm 2020, 86). Moreover, as McDougall et al. (2020) noted, there is a problematic tendency in the psychology literature to conceive of cultural change as a complete transformation rather than an ongoing process in which elements of continuity and change wax and wane over time. In addition to the more psychological facets of human behaviour (agency), we argue here that cultural-structural aspects are particularly important. More pertinently, for present purposes, we show that while attitudes might be relatively amenable to change, such changes are likely to be ephemeral unless accompanied by social structural shifts.

Professional wrestling

Traditionally, professional wrestling has been scripted around a moral narrative of good vs bad, championing hard work, religiosity and clean living (May 1999). However, although the basic structure of a story-lined combat that builds towards a climax is enduring (De Garis 2005), performances have become increasingly varied and nuanced with key themes increasingly including: 1) excitement, stimulated by the display of violence, sexualisation and theatrical storylines; and 2) intrigue, through high-risk situations, the serial nature of character transformation and open-ended narratives (Maguire 2005). Via this process, ‘standard’ wrestling moves have increasingly been transformed from centrepiece to mere segues for more dramatic and exciting moves (Atkinson 2002, 59). Particular moves have become associated with the persona of individual wrestlers making violence central to both competitive outcomes and displays. While the scripted nature of the outcome dominates the public imagination, ‘the means of victory may be more important than the end result’ (May 1999, 89).

Consequently, injury is a fundamental component of both the lived experience (Mazer 1998; Smith 2008) and scripted performance (Atkinson 2002) of professional wrestling. The direct causes of pain and injury are said to be miscommunication/misunderstanding, mis-timing (or asynchronicity) and device/prop failure (Smith 2008; Maguire 2005). Additionally, the term ‘shoot’ is used to refer to both accidental and non-consented-intentional violence (Chow 2014). While De Garis (2005, 197) describes wrestling in late twentieth-century America as ‘more of a hazing ritual than training process’, deliberately inflicting violence is normally an illegitimate act, only occasionally used as a vehicle for policing cultural norms and asserting social status (Smith 2008). However, the structure of different wrestling characters (‘good’ or ‘bad’), type of bout (e.g. ‘hardcore’, ‘death matches’) and dramatic narratives further mediates the risk of injury.

Wrestlers refer to their practice as ‘work’ (De Garis 2005). The term ‘work’ simultaneously captures the notion of employment (and the associated expectations of compliance with employers’ instructions), deception (wrestling loose and gentle while appearing stiff and strong) and collusion. Thus, while promoters decide the ultimate outcome and overarching narrative, ‘a polyphony of cooperatively evolved voices’ (De Garis 1999, 68) are required to create what wrestlers describe as kayfabe, or the representation of the dramatic as ‘real’. To create such ‘believability’, performances must be technically seamless and contain a logical continuity of both physical effect (e.g. no miraculous recoveries) and character representation (e.g. with clear reasons why a ‘goodie’ would transverse the ‘rules’). The combination of public performance and deception ensures that ‘tacit physical knowledge’ is a defining characteristic of this ‘community of practice’ (Chow 2014, 76), enabling the performance to be more dynamic, fluid and at times spontaneous (prized because there is nothing more real than ‘real’). Peers identify ‘good’ or ‘safe’ workers as those who conform to dressing room cultural norms, exercise restraint in the use of ‘real’ violence, and are not so overly self-protective of either their physical or character selves that they are detrimental to their ‘opponent’ (De Garis 2005; Chow 2014).

Relations between wrestlers have been thrown into sharper relief by the broader structural dynamics of the ‘industry’. As entertainment rather than sport, professional wrestling evades tighter regulation (Corteen 2019). For instance, researchers have consistently shown that healthcare support is usually quantitatively and qualitatively limited (Smith 2008; Kotarba 2001). Moreover, because professional wrestlers are essentially self-employed, performance is subject to interpersonal conflict as wrestlers compete for bookings and elusive contracts with high profile promotions (Corteen 2019). Conversely, an opponent’s cooperation is essential to executing the moves, which will enhance one’s ‘box office’ appeal. While a few professional wrestlers (in Britain) are primarily economically motivated – instead, they tend to focus on both getting a ‘pop’ (positive reaction) from the crowd and the respect of their peers – industry dynamics effectively create a paradox in which wrestlers must be self-interested and entrepreneurial, while also being recognised as trustworthy, safe workers.

Injury and concussion in sport and performance cultures

The inherent violence, frequency of injury, and negotiation of pain closely align wrestling with sport. Consequently, three theoretical principles that have historically guided sociological studies of sport, pain and injury are of particular concern (Atkinson 2019). Firstly, the ‘culture of risk’ or ‘sport ethic’, suggests that sport participants generally subscribe to a set of subcultural beliefs, which lead to the normalisation of high rates of injury, and rank performance concerns above longer term health. Secondly, injury in sport is closely linked to masculinity. The ‘pain principle’ describes the patriarchy-based belief that pain is both an inevitable experience and valued as character building (for men). Thirdly, Nixon’s (1992) notion of the sportsnet illustrates the significance of sport-specific organisational dynamics, as relatively powerful actors (administrators, coaches) maximise their probability of success by encouraging and cajoling athletes to take health risks.

More recently Kalman-Lamb (2018, 2019) has conceptualised pain and injury as part of the social reproductive labour athletes perform. Building on the classical Marxist theories of sport, Kalman-Lamb (2019, 518) argues that athletes and spectators are ‘caught in a dialectic that leads to the exploitation of each’. Athletes sacrifice their bodies in a dehumanising process, sustaining physical (injury) and emotional (isolation and alienation) damage the outcome or purpose of which is to sustain the commercial exploitation of fans and reproduce their (fans’) capacity to labour. There are, however, distinct parallels here to research on the tolerance of pain and injury in sport and artistic/performative subcultures. For instance, Turner and Wainwright (2003) highlight the normalisation of injury within the habits of professional ballet dancers, whose injury experiences are shaped by occupational demands normalised through (often) early age socialisation, increasingly demanding schedules/more athletic performances, and interactions within the ballet company community. McEwen and Young (2011, 156–157) similarly refer to the authoritarian organisational structure, the ‘ultra-competitive atmosphere’ and ‘self-abusive addiction’ in dancing subcultures. Together, these studies provide an important contribution to the literature in locating athlete experiences within the broader political economy of contemporary sport/performance. Indeed, some of Kalman-Lamb (2018) interviewees explicitly compare the performance of violence in ice hockey with that of WWE wrestlers.¹

Existing studies of SRC confirm and extend the validity of theories of pain and injury in sport. Researchers have identified the ‘failure’ of athletes to report concussion as evidence of the subcultural tolerance of such injuries (Liston et al. 2018). Gendered norms have also been shown to infuse media representations of SRC (Cassilo and Sanderson 2018), as have concerns about potential sex differences in concussion incidence and severity (Blyth, Alcock, and Tumilty 2021). Researchers have also highlighted the role of athletes’ networks of relations and particularly the pressures that teammates, parents, coaches and fans are thought to place on athletes to continue playing despite (brain) injury (Kroshus et al. 2015). Indeed, the study of concussions is fundamental to the development of Kalman-Lamb’s (2019, 525) thesis in that it is injury to the brain in particular that ‘produces the permanent subjective and affective lack’ that is characteristic of the exploitation of social reproductive labour.

In professional athletic contexts, concussions may be so frequently experienced that they defy accurate quantification and become perceived as routine workplace hazards (Caron et al. 2013). Moreover, knowledge of the potential dangers and prescribed management of concussion is likely to be disregarded in situations in which athletes judge their continued presence to be necessary or desirable. Malcolm (2009, 2017) shows that athletes frequently continue to play with concussion symptoms because they do not perceive their performance to be impaired. Injured athletes also avoid seeking medical care because the unique regulation of concussion (mandatory withdrawal from play, a specified and prolonged return to play protocol) combined with the limited efficacy of medical treatment, means that consultation magnifies rather than reduces uncertainties about career contingencies and thus the notions of self that are entwined with athletic performance.

Remarkably, given the relatively long-standing evidence of neurocognitive damage amongst boxers in particular (Liston and Malcolm 2019), and the rich and diverse range of studies in the sport, there has been relatively little concussion-related social scientific research involving those in combat sports. Yet we do know that professional fighters frequently conceal head injuries from others and many contravene concussion management guidelines, e.g. in relation to return to training/competition post-injury (Bennett et al. 2019). Matthews (2021) illustrates that while boxers both explicitly acknowledge their relatively high risk of concussion and even reasonably ‘expect’ dementia as a possible longer-term outcome, their experiential engagement and bodily competencies lead them to believe that they can recognise, manage and mitigate the risks of brain injury. Alhashmi and Matthews (2021) further explain the inconsistencies evident in fighters’ responses to concussion according to lay medical certainty dominated by performance ideologies and the role of coaches who provide practical and immediately purposeful guidance and thus become ‘experts on the street’.

To conclude this introduction, in this article we aim to explore the lived experience of concussion for professional wrestlers. We draw on interview data to provide the first analysis of concussion in professional wrestling highlighting: 1) the interdependence between the social consequences of revealing the injured self and the organisational and competitive dynamics of sport and physical cultures; and 2) the complexity of the culture of pain and injury, which is now a prime target of SRC public health interventions. While empirically the first study of its kind, more significantly, we also re-conceptualise cultural change in relation to health risk-taking behaviours and add nuance to what has been proposed as a primary solution to address this broader public health ‘crisis’. This work is important because, we argue, notions of cultural change need to incorporate the social structural dimensions of sports cultures if these public health policies are to be effective in reducing the incidence and consequences of concussion.

Methods

Data for this paper are derived from a British Academy funded, cross-disciplinary study designed to undertake a supportive health-check of independent professional wrestling in the UK. The project was led by a performance studies scholar who is also the co-founder of a wrestling ‘collective’. This enabled access to a subculture that has, traditionally, been relatively difficult to penetrate (De Garis 1999). Project co-researchers were a psychologist who conducts social constructionist research focused on mental health and a sociologist who conducts research on concussion (the lead author of this article). All authors participated in the study design and data collection. Ethical clearance was received from Loughborough University Ethics Board.

The specific timing of the funding award affected the project in two distinct yet interrelated ways. First, the project coincided with the first wave of the COVID-19 pandemic, which both halted live sports/performance and precluded in-person interviewing. Second, UK professional wrestling, like Hollywood and US Gymnastics, had its own public reckoning, calling out sexual abuse, bullying and predatory behaviour under the hashtag SpeakingOut. The cessation of wrestling and social isolation caused by Covid ushered in a period of heightened introspection and, e.g. led to the UK establishment of an All-Party Parliamentary Group (APPG) on Professional Wrestling (Davies-Jones and Fletcher 2021).

Study design

Sharing a commitment to a constructionist epistemology and interpretivist, qualitative methodology (Denzin and Lincoln 2000), we chose a semi-structured interview research design. The rationale for this was both practical – a time efficient way for multiple researchers to participate in data gathering at a time of restricted mobility – and methodological, as we sought viewpoints, perspectives and accounts of experiences in a way that would be supportive and empowering to the community. The team designed an interview guide incorporating the researchers’ respective areas of expertise, and consisting of the following key themes: biography, physical health, injury experiences, concussion, mental health, medical care and use of social media. Because of team members’ different degrees of knowledge and expertise of these topics, the interview guides were kept intentionally ‘high-level’ (e.g. give me a picture of the kind of physical toll that wrestling takes on your body?), which in turn allowed respondents to largely dictate the depth with which the respective topics were discussed. This structure also meant that the core interview guide was applicable to a range of people involved in wrestling. It should be noted that none of the interviewees were directly implicated in allegations of misconduct revealed in the reflexive moment of #Speaking Out.

Participants

Thirteen interviews with active wrestlers, three of whom were also wrestling trainers, were conducted. The project’s lead researcher used existing relations and industry contacts to recruit potential participants. A criterion-based purposive sampling technique was used as we: a) sought to provide a balance in relation to age and wrestling style while being inclusive of gender and ethnicity; and b) prioritised people who had previously spoken openly (in the community) about health and wellbeing concerns. To support our interpretive work and provide complementary insights into the wrestling subculture, interviews were also conducted with referees (2), healthcare staff (1) and promoters (2), although it should be noted that direct quotes from these interviewees are used sparingly in the findings, primarily as a way to further contextualise wrestlers’ perspectives.

All interviews were conducted via videoconferencing software. Interviewees were provided with participant information sheets and consent forms prior to the interview. Though conscious of the potential advantages of interviewing in-person (e.g. greater engagement and deeper social interaction), the context in which the research was conducted – a time of pronounced social isolation, the widespread uptake/extension of online social interactions, and in the midst of a major controversy affecting the wrestling community – meant interviewees were highly engaged and forthcoming, with interviews lasting between 30 and 115 min (mean 62 min). ‘Calls’ were recorded via the software and/or using a dictaphone and professionally transcribed (verbatim) for analysis. Transcripts were anonymised and respondents assigned a pseudonym designed to reflect their ‘real’ rather than their performance/wrestling identity (see Table 1).

Table 1. Interviewee details.

Pseudonym	Role	Interview Length (mins)	Sex	Details
Max	Wrestler	73	Male	Early 20s, known for flamboyant wrestling style
David	Wrestler	75	Male	Mid 30s wrestler
Joel	Wrestler	115	Male	Mid 30s, wrestler
Ellie	Wrestler	30	Female	Early 20s, female wrestler, in teaching/education
Michelle	Wrestler	44	Female	Mid 30s wrestler, often regarded as a veteran. Has a business career outside of wrestling
Andy	Wrestler/trainer	52	Male	Seen as a veteran wrestler and trainer
Oli	Wrestler	50	Male	Early 30s, wrestler with a bodybuilding background.
Pete	Wrestler/trainer	64	Male	Late 20s, wrestler and trainer with martial arts background
Emily	Wrestler	64	Female	Early 20s, ‘up and coming’ female wrestler, in teaching/education
Billy	Wrestler	62	Male	Early 20s wrestler with an acting background
Phil	Wrestler	103	Male	Mid 30s wrestler, in teaching/education
Ben	Wrestler/trainer	79	Male	Mid 30s, wrestler and trainer, seen as a respected veteran of wrestling
Luke	Referee	31	Male	Early 20s, referee and computer technician
Lewis	Referee	59	Male	Late 20s, referee and administrator
Will	Wrestler	45	Male	Late teens, up and coming wrestler.
Dan	Healthcare provider	55	Male	Healthcare professional with experience of working across sports.
Steve	Promoter	50	Male	Late 30s, with experience as an entertainments promoter more generally.
Holly	Promoter		female	Mid 20s

Procedure

The lead author conducted an analysis of the interview data, focussing specifically on their area of existing expertise (SRC) and utilising a reflexive thematic analysis (Braun and Clarke 2019). While this approach stemmed from underpinning philosophical sensibilities, the semi-structured nature of the interview guide/data required an approach that embraced interpretation of participants’ individualised experiences and involved the researcher’s active involvement in meaning-making. Following familiarisation through an initial reading of the individual transcripts, a second phase of more systematic coding took place. This led to the identification of preliminary codes, which were subsequently refined and grouped around 12 areas or themes (concussion causes, effects, responses, and concerns; economic and interpersonal pressures, healthcare support, role of referees; and masculinity, secrecy, trust and performance contingencies). Through the iterative development of a thematic map, three domain summary themes were subsequently connected: a) experience, b) organisational issues and c) culture. Inevitably the researchers’ sociological orientation and prior knowledge of the SRC literature influenced this interpretation of data, as advocated by Braun and Clarke (2019). Nevertheless, a review of the themes in relation to their fit with both the coded extracts and across the data set was undertaken prior to the final writing up phase of the reflexive thematic analysis.

In the writing up process, Tracy’s (2010) ‘big tent’ criteria were considered as we attempted to consolidate the rigour of the research. Co-authors both examined the interview transcripts independently and commented on drafts of the article, acting as critical friends, encouraging reflexivity and suggesting alternative insights. For instance, the third author’s greater experiential knowledge of wrestling subculture was influential in altering the lead author’s initial interpretations of the significance of the absence of concussion injuries in training. In doing so, we sought to develop an analysis which has meaningful coherence, namely: informed by the data, aligning with the aims of the research and providing a persuasive and coherent narrative. Political interventions (Davies-Jones and Fletcher 2021) suggest that this is both a worthy topic and a significant contribution with practical and theoretical implications. Initial findings were subsequently presented back to the UK wrestling community at a dissemination event in order to establish resonance and, through work with the APPG, will lead to the development of a code of good practice for UK professional wrestling. The degree to which this code is adopted and influences practice will be a key measure of the social impact of the research and thus how we authors would like it to be judged.

Results and discussion

Our analysis led to the following discussion, consisting of three parts. First, we explore wrestlers’ experiences of, attitudes towards, and behaviours in relation to SRC to provide evidence of cultural change and its existing limitations. Second, we look more directly at organisational issues; the role of multiple actors (medics, referees and promoters) in the wrestling ‘sportsnet’ and how they contribute to the wrestlers’ health and wellbeing in relation to brain injury. Finally, we argue that the primary causes of concussion within wrestling can be located in the structure and culture of the wrestling ‘industry’, causes which range from the underlying economic and organisational structure to the performance logic of professional wrestling.

Experiences, attitudes and behaviours in relation to concussion

Interviewees’ accounts of pain and injury demonstrated the parallels between wrestling and ‘other’ sports in which athletes deny and normalise injury and use pain experiences to create their subcultural community identity (Atkinson 2019). Indicatively, Michelle described how she continued to wrestle through various injuries despite re-injury, hospitalisation and fears of being permanently paralysed. Emily stated that, ‘I can’t remember a time when my back didn’t hurt. Like even during Lockdown and not wrestling’.

Similar to some previous studies of wrestling (Smith 2008), concussion was positioned as a common injury. Personal experiences ranged from having never been concussed to having had too many to quantify, but most believed concussions to be commonplace and simply ‘just the name of the game’ (Ben). Consequently, concussion in wrestling was viewed, as it is in boxing (Matthews 2021) and ice-hockey (Caron et al. 2013), as a routine and unremarkable occupational hazard. Michelle (cited above), contextualised concussion in a broader injury history of multiple broken bones,

a lot of neck and back problems … And then just, I don’t know, probably loads of concussions, I don’t know, I couldn’t tell you how many concussions I’ve had which is again scary. Black eyes, commonplace, a couple a year probably.

Wrestlers further identified how attitudes to pain and injury were perceived to be gendered:

[risk taking is] kind of almost like a badge of honour for that individual. And I think that’s … quite [a] toxic kind of thought process … you know I’m manly, I can keep going kind of thing, this toxic masculinity idea that you know ‘we’re tough’ (Pete).

I think some wrestlers could take it as, ‘I had the concussion but I’m gonna wrestle tomorrow’, and that makes them seem like, ‘oh they’re really tough they are’, you know, they’ve got a reputation of being really tough and just … nothing fazes them. A power kind of thing. I think that could be the mentality for some. (Emily).

The broader health and wellbeing concerns in US wrestling and the Benoit case in particular had shaped attitudes in the UK. Phil commended the work of former wrestler and Concussion Legacy Foundation campaigner Chris Nowinski and argued that while older generations often experienced musculoskeletal injuries and died of steroid-induced heart attacks, US wrestlers from the 2000s ‘are all just going to be brain dead’. Referees and promoters described how they had seen changes in wrestlers’ attitudes and behaviours. Reflecting on these changes, a veteran wrestler stated, ‘back then … concussions were treated like, … I don’t know, stubbing your toe … I don’t think that was … people not caring, I just think people didn’t understand’ (Michelle). Conversely, a wrestler in his 20s conveyed ideas about the qualitative distinctiveness of brain injury, which infuse media coverage of this injury ‘crisis’ (Malcolm 2021), and have been used to justify the extensive public health interventions for concussion:

[Concussion is] so serious that it’s not something that I would take a chance on … like I’m totally fine with those [physical injuries] because once they look fine, when they feel fine, you know you’re fine. But when it’s something like your head, … where it’s not always obvious like what is causing it or you know like are you OK or are you imagining it or whatever … like when it’s something in the head, that worries me (Max).

Given the hybrid relationship between wrestling and ‘sport’, and the absence of any wrestling specific public health initiatives, it appears that these elements of cultural change have largely been organic through the practice community. However, the limits of cultural change became evident through interviewees’ descriptions of behaviours that were far removed from the precautionary principles of SRC public health. Supporting previous research (Malcolm 2017), interviewees revealed that in wrestling subcultures, loss of consciousness was both the primary indicator of concussion but on its own an insufficient marker of concussion.² Others created somewhat personalised diagnostic criteria, which legitimised their decision to continue wrestling despite experiencing the signs and symptoms of concussion. Crucially, there is a general belief that it is possible to be concussed and still be functional and perform (Malcolm 2009; Liston et al. 2018). Phil reflected on viewing the recording of a match in which he received a kick to the head:

I got to watch that match back about a year ago … and it was bizarre because I had blacked out, but the Phil in the ring didn’t, he carried on wrestling, he wrestled the rest of that match … When I came to, I was backstage, and then I went to the hospital. But I have no recollection of finishing this match whatsoever, but I did. And I got to watch a match of mine that I’d never seen before, which is a very peculiar thing to do!

Interviewer: How were you? Any good?

Phil: It was good until that kick … I was quite sloppy after that … You could notice something was wrong … [But] I held myself enough … I was quite impressed with myself!

Thus, within wrestling, broader cultural values of athletic identity construction and, for some, masculinity, are bolstered by a manifest willingness to ‘play hurt’ (Roderick, Waddington, and Parker 2000). Lay understandings of concussion remain prominent and precautionary behaviours advocated in SRC public health models are either not recognised or rejected. Despite evidence of changing knowledge and awareness of the potential severity of concussion wrestlers, like boxers (Matthews 2021), believed that they could largely self-manage and mitigate the risks of concussion.

The wrestling ‘sportsnet’ and wrestlers’ health

The previous section evidenced a prevailing culture of risk in wrestling despite growing concerns in relation to health, and concussions in particular. In this section, we focus on the capacity of those who more broadly constitute the wrestling ‘sportsnet’ to respond to concussion injuries. Specifically, what is the role of healthcare providers, referees, and wrestling promoters in managing concussion?

Aligning with previous studies (Kotarba 2001), interviewees noted that medical support was inconsistently provided, often ad-hoc and relatively low-skilled. Wrestlers identified recent improvements and associated better healthcare with larger and wealthier promotions. However, the absence of safeguarding regulations (Corteen 2019) meant that there was nothing comparable to medical support frequently associated with professional team sports (Malcolm 2017), or even the (frequently inadequate) pre-competition medical screening of participants evident at ‘other’ combat sports (Channon, Matthews, and Hillier 2020). Indeed, the degree to which this medical provision was still novel was reflected in the sentiments of wrestlers who said, ‘I’ve wrestled at so many shows without first aiders, it’s actually quite a treat, … when it was first coming up, you know first aiders and masseuses, I was like, wow this is nice’ (Ellie).

Even where promoters provided medical support, wrestlers’ experiences were invariably negative. The healthcare professional we interviewed described his frustration at the reluctance of others to attend to potential concussions: ‘I’ve tried to engage the paramedics on this matter and they continue eating their sandwich’ (Dan). This subsequently puts referees at the centre of concussion management, even though they had no stipulated or formal concussion protocols to follow and are not required to have first aid training. Luke explained the complexities of trying to look out for wrestlers’ health concerns while facilitating the performance of wrestling:

in that moment, because again you’d have a whole crowd around you and you’ve got that moment before the other guy comes in to do his next big move or sort of be like, ‘are you Ok … are you concussed?’ And … it’s very hard to then work it out, you need to stop everything, slow it down, which admittedly you can do a bit (emphasis added).

The reluctance to halt matches was exacerbated by the anticipated conflict with wrestlers if a referee took such precautionary action. Indicatively, Billy noted that, ‘in wrestling, it’s really, really not cool if you don’t finish a match … it’s almost shameful because you’re breaking character’. In practice, therefore, concussion management in wrestling can fall to an individual who has minimal or no training, is primarily occupied by other duties, and works under conditions in which precautionary interventions are likely to lead to interpersonal conflict.

The tension between ‘real’ and ‘scripted’ or performed injury (Atkinson 2002) further complicated the safeguarding of wrestlers. Promoters and referees recalled instances where they had either been fooled into believing a wrestler was genuinely injured or had later discovered that wrestlers were more significantly injured than had initially been disclosed. Even the wrestlers themselves spoke of how they could not always intuitively assess (Smith 2008) their opponents’ condition. As Billy (who ironically has an acting rather than sporting background) explained;

there’s been times when like someone’s sold really well … I had someone in a hold and they like passed out and I was like what? How strong am I? And I took the hold off … I was like ‘are you alright?’ And he was like ‘yeah, yeah’ (Billy).

Billy went on to explain how he watched another wrestler takes a kick to the head,

I was like ‘that’s an incredible sell, like that looks so legitimate to me’, and that’s because it was, he just got kicked in the head and the rest of the match he was forgetting things (Billy).

The scripted nature of wrestling creates significant difficulties for concussion management and, in particular, the potential for ‘real’ concussions to go undetected.

As a consequence, wrestlers largely managed concussions independently of promoters. In every case, the experience was perceived negatively. For instance, Phil recalled seeking emergency medical help; ‘I went to hospital, they said I had a concussion, didn’t get a CAT scan or anything like that, just you know, “don’t go to sleep straight away kind of thing”’. Max, who had experienced multiple concussions described his negative experiences of various medical providers:

whenever I got concussion I always went to A&E to … just to make sure that they know, and like they never do anything, like they say take paracetamol and I’m like, ‘God … I didn’t need to wait four hours to be told that’ … I just feel like they don’t really know what advice to give, and they just say rest … they seem clueless. [Seeing a family practitioner is] a waste of time, … there’s nothing they can do, “you look fine, so blah blah blah”.

I don’t find that funny at all.

Thus, cultural change in terms of greater awareness and concerns regarding SRC only minimally impacted on concussion management in practice. Neither referee had ever stopped an event due to concussion concerns, and the continued paucity of medical provision was such that not one interviewee recalled an instance of either a concussion being formally diagnosed or a wrestler being medically cleared to continue participating at a wrestling event. Interviewees further noted that concussions were the only injuries that wrestlers would not discuss on podcasts or on social media. Ultimately, the importance of conforming to dressing room norms as part of the subcultural expectations of being a ‘good worker’ (De Garis 2005) meant that concussion injuries were hidden from public view;

I think its one of those things where it is kept quiet … you won’t see … a report of the show and this guy got a concussion during this match … [so] I don’t think it’s kind of out there in public enough for people to say, look there’s a problem with this … I think it’s kind of a … behind closed doors secret sort of thing (Andy).

The cultural-structural causes of concussion

The most frequently identified direct cause of concussion was a kick to the head. Such contact was always attributed to asynchronicity (Smith 2008), or the failure to correctly execute a planned move. No interviewee implied that a ‘shoot’ had been intentional or referred to concussion injuries due to device/prop failures. While some concussions were attributed to executing more complex and high-risk moves, the resultant injuries were again mainly seen as accidental. As Oli said, ‘I’ve only ever landed on my head once … just one of the things that happens’. Reflecting wrestling as a community of practice (Chow 2014), the most accusatory statement of unsafe working was, ‘I feel that they could and should have done it lighter than they did’ (Joel). However, a consciousness of social structure derived from a sociological lens enables us to de-centre the causes of concussion related to human agency (participant attitudes and behaviours). The social and structural features of wrestling – explored in this final section – included the kind of performance culture considerations and economically exploitative relations discussed by Kalman-Lamb (2018, 2019). However, wrestling also provided evidence of a broader range of factors, which included occupational (dis)organisation, interpersonal pressures and the influence of longer-term dramatic performance narratives.

First, many argued that accidental forceful contact frequently occurred due to the performative character of wrestling. It was noted that following similar trends identified in the US (Smith 2008), UK wrestlers had adopted stylistic changes, which increasingly spectacularised and dramatised violence. The creation of excitement through displays of violence was apparent in the move towards ‘more spectacular bumps’, and ‘[W]orking a little bit more risky, so it looks more legitimate’ (Oli). Billy explained how he personally had chosen to take risks for greater visual appeal, saying, ‘I know it’s [taking kicks to the neck] going to look so much better than hitting my hand’ and, echoing Kalman-Lamb (2018), argued that others used the euphoria of spectator adulation to validate potentially negative and injurious experiences: ‘Sometimes people chose not to protect themselves because they want it to look good, because they want to be that top level where it’s like whoa, do you remember that moment’ (Billy). Thus, one of the primary motivations for professional wrestlers – generating audience response – has led to cultural shifts towards more dramatic displays of violence (Atkinson 2002; Maguire 2005). Older wrestlers saw these developments as increasing the incidence of concussion;

I mean concussion is obviously a big one. I worry these days about people taking like very high neck … head bumps … like I’m not too comfortable doing that kind of bump because I know the implications … neck injuries and head injuries are so serious that it’s not something that I would want to take a chance on. … [Younger wrestlers have] got their goals and they’ve got a way they think they have to perform in order to get there, and I don’t want to be the guy to go up to them as the grumpy old man with twenty years’ experience saying, ‘you young’uns shouldn’t be landing on your head like that’. And it feels obvious to me (both laugh) and that’s how we were told, you know, ‘don’t … don’t drop each other on your heads, you’ve got to look after each other, you’ve got to both walk away and you want to both be able to do this’ … In the name of getting a pop, I think people are maybe pushing the envelope a bit too far now (Andy).

Second, economic pressures generated risk-taking behaviours amongst wrestlers. A wrestler noted that, ‘if you’re a person who relies on wrestling, [you] can’t afford to be getting knocked out and having to be dropping out of wrestling all the time’ (Joel). Oli further explained a multiplier effect of the economic and social implications of enforced withdrawal:

firstly they [wrestlers] are not bringing in any money … [then there’s] the potential to be losing bookings going forward, then there’s things like not being able to sell merchandise … and the added factor of I’m not wrestling so someone’s going to take my spot.

Like ‘other’ artistic performers (Turner and Wainwright 2003; McEwen and Young 2011), the desire simply to be part of the main event created significant pressure to continue with injury, and like other athletes (Roderick, Waddington, and Parker 2000), the desire to remain at the centre of the competition created further pressure to return to the sport after injury. However, the ”sportsnet” in which UK professional wrestlers were immersed provided distinct dynamics to the pressures of uncertainty experienced by other injured athletes. In contrast to team sports where most of the previous concussion research has been conducted (e.g. Malcolm 2009), wrestlers’ independent contractor status created an acute supply and demand imbalance of ‘talent’ (Corteen 2019). The sense of ‘replaceability’ performers experienced (Kalman-Lamb 2018) led to heightened employee compliance:

There’s a kind of take it or leave it aspect with wrestling … this is what we’ll pay you … if you don’t like it, I will find someone else that will do it … there are more wrestlers than there are spots on shows, it’s very competitive (Andy).

The convergence of economic dependence and an excess supply of labour meant that, in contrast to previous (psychology) researchers who have identified authoritative figures in the sportsnet (normally coaches) as a source of pressure on injured athletes to continue (e.g. Kroshus et al. 2015; Caron et al. 2013), promoters were seen as most likely to restrain wrestlers from competing after concussion. However, in the absence of a supportive organisational and economic structure, rather than seeing this as a positive precautionary measure, wrestlers viewed these moves with scepticism:

these dickhead promoters will go on their podcasts and speak publicly about how they always want talent [wrestler] to be honest with them about when they’re hurt and when they’re not able to wrestle and they’re like, ‘well, why would they be?’ … I look at how you treated my friend when he broke his jaw and, then why would I come to you and tell you guys, ‘I think I’ve got a concussion’ (Joel).

Thus, even where promoters recognised a duty of care to wrestlers, the embedded nature of employee-promoter conflict drove greater health risks, which in turn encouraged wrestlers to continue participating post-concussion.

The precarity of wrestlers’ economic existence (Corteen 2019) exacerbates the risks of concussion in three further and potentially distinct ways. First, wrestlers typically work for multiple promoters. Consequently, injured wrestlers frequently disregarded the advice to seek emergency medical treatment;

A lot of people don’t take them seriously because they will get a concussion and, then the first aider or the medic on the show that’s there can only advise them to go … to A&E, they can’t actually physically take them to A&E, they just advise ‘you need to go to A&E’, and it’s not very often they will go. … they usually tell the medic, ‘yeah I’ll go’, and they won’t, and then you’ll see them on the show the next day, wrestling on the show, when they just got a concussion the day before (Emily).

Emily went on to explain wrestlers’ thought processes behind such decisions:

… we’re all independent wrestlers, and I think that sense of independence is you do what you want to do, and people can only advise you on what to do, there’s no rulebook to say if you don’t go to A&E then you’re not going to be wrestling tomorrow. But they can’t say that … promoters can’t say that, because it’s probably not that promotion they’re wrestling for the next day, so they can go off and not tell anybody they had a concussion and then no one can say anything.

Thus, not only does wrestling evade much of sports concussion regulation (e.g. formal concussion protocols or tests), but the relative ‘looseness’ of a sportsnet (Nixon 1992) in which contact between wrestlers and promoters is intermittent also constrains precautionary behaviours. Moreover, and moving beyond Kalman-Lamb’s (2018, 2019) analysis, we see evidence not simply of employer–employer exploitation, but workers’ exploitation of each other which is certainly shaped, but not necessarily determined, by the broader set of economic relations.

Second, the interpersonal competition evoked in the negotiation of workplace rewards and practice (Chow 2014), has significant implications for the causes of concussion. When wrestlers negotiated the means (as opposed to the end) of victory (May 1999), the invisibility of longer-term symptoms could be problematic:

and then you say, ‘oh I don’t really want to do this move because I know I’m going to get concussed from it’ and then they [say] ‘you look fine to me’, so then they don’t believe you and they just think, ‘oh you just don’t want to do this move’. It makes it seem like you’re lying when you’re not (Max).

Max went on to explain how these discussions were shaped by power dynamics;

if they’re more well-known than you and you go and ask them ‘oh I don’t’ really want to do your finisher’, they’ll be like, ‘Who the hell are you? Who do you think you are telling me I can’t do my thing’.

According to the norms of the wrestling subculture, the resistance/negotiation of collusion was interpreted as a deviance from the role of ‘good worker’ (De Garis 2005). Consequently, the reported outcomes of these negotiations were never precautionary. Because ‘there’s just that unwritten rule of like you know you’re trusting someone with your body’ (Michelle), such negotiations go to the heart of wrestlers’ identities as members of this community of practice. As Joel said, ‘if you object to certain moves your opponent will object and turn it round as if to say, “if I decide I don’t want to take this kick [to the head] then … I’m insulting you”’. Phil similarly described how if a wrestler declined to make certain moves in order to avoid concussion, ‘people take offence … they think I’m not a safe worker’ (Phil). Respecting the requests of the co-performer/opponent was seen as fundamental to the collaborative nature of wrestling ‘work’ (Chow 2014), but because a) it generally took place in private; and b) it was imbued with latent status competition, it had significant and generally negative implications for the incidence of concussion.

Third, the serial nature of character development and the intentionally open-ended narratives of professional wrestling (Maguire 2005) meant that concussion risk-taking involved a distinct long-term cost–benefit evaluation. As noted, many wrestlers feel compelled to continue despite injury in order to complete the (contractually agreed) storyline. But storylines frequently extend across multiple weeks. The wrestlers’ mindset was illustrated by Emily, who described having been taken back stage with a broken arm, ‘[what] I was thinking in my head, is how many bookings … how many opportunities … all this pain going on, in my head, all I was thinking was … I’m gonna get these back’. Dramatic narratives created further pressures which negatively impacted on safety. Joel described his experience, which he saw as a typical potential scenario following concussion:

two days after that [concussion] … they were going to [be] basically like doing a storyline with me and kind of turning me into one of their major players … basically leading me to some credibility to win a championship, like a major championship … [I knew that if the injury was disclosed] then they would probably do everything in their power to try and stop me from wrestling those matches … And that means that the whole storyline would be delayed … I don’t know whether the storyline could continue in the same fashion and not only that, it makes you concerned of your job security, you know … Like if I get injured now … and then this match goes away, then what’s going to happen? … And that’s not based on like any kind of paranoia, that has literally happened to hundreds of wrestlers.

While the importance of upcoming fixtures influences the propensity of all athletes to continue whilst injured (Roderick, Waddington, and Parker 2000), the scripted nature of ‘competition’ in wrestling exacerbated pressure. For wrestlers, these opportunities are somewhat ephemeral, have relatively unpredictable timing and lead to greater risk-taking regardless of the anticipated/scripted outcome. Consequently, for wrestlers as for other athletes, disclosure of concussion creates heightened levels of uncertainty about future participation, earning potential and career contingencies (Malcolm 2017). Moreover, participants’ behavioural decisions are constrained by the key considerations of display, style, economic necessity, relations with both employers and co-workers (Turner and Wainwright 2003), and character transformations integral to wrestling performance (Maguire 2005). Yet because wrestling entails a relatively even balance between display and competition, risk taking is distinctively influenced by reputational concerns. Max described how he had existing bookings in which he was scripted to lose a championship belt. Experiencing post-concussive symptoms, he wanted to withdraw, but anticipated a risk of reputational damage as others might perceive him to have done so strategically to retain the title-holder status. These issues add to rather than detract from concerns about winning/losing, commitment to the team, and notions of masculinity that have been identified as contributing to athlete’s non-compliance with conservative concussion management.

Conclusion

In contrast to most SRC research, which focuses on team sports, our findings expand the understanding of concussion in combat sports and begin a much overdue consideration of concussion in display-based sports (like cheerleading), in which concussion concerns are growing. In so doing, we demonstrate that behaviours that seemingly disregard the risks of concussion are not solely attitudinal (e.g. commitment to a sports ethic or one’s teammates) or the result of face-to-face interactions (e.g. pressures from coaches) but are deeply embedded in the social structure of sport. These structures incorporate norms such as masculine behaviours, playing hurt (Roderick, Waddington, and Parker 2000) and being a good worker (De Garis 2005), but extend further into the organisational arrangements, occupational conditions and commercial contingencies of wrestling. Although there are undoubtedly some esoteric characteristics to professional wrestling, a balance between the respective evaluation of competition and performance – what Kalman-Lamb’s (2018, 2019) describes as social reproductive labour – is intrinsic to physical cultures more generally.

A central response to SRC concerns has been the debates about potential rule changes (and resistance on the basis that this could undermine the ‘essence’ of a sport). In contrast, the performative basis of wrestling means that rule changes cannot be either the sole or main solution, because defying ‘rules’ - or at least conventions – and continuous innovation (wrestling, for instance, breaks barriers as a mixed-sex ‘combat sport’) is fundamental to wrestling’s ongoing appeal (Maguire 2005). Nothing could or should be ‘unthinkable’ because wrestling is mimetic rather than ‘real’ (Atkinson 2002). What is ‘real’, or at least more tangible. is the structural and cultural dynamics of an industry in which acceptance and/or prosperity is predicated on conformity to notions of ‘good working practice’. Because this is comparable to the notion of a ‘good attitude’ which mediates pain and injury behaviours in professional football (Roderick, Waddington, and Parker 2000) we contend that the ideas explored here are more generally applicable to sports.

What then do we learn from this study on concussion public health and in particular calls for cultural change? First, greater awareness of, and even anxiety over the risk of brain injury are shown to be necessary rather than sufficient preconditions for behavioural change. Evaluations of risk are fundamentally contextual and therefore as much socially structural as they are agentic or psychological. Athletes might explicitly justify their own risk-taking behaviours in relation to perceptions of injury severity/ability to perform, commitment to teammates/winning/performance, or even pressure from significant others, but this bias stems from a limited understanding of the influence of social structural features. For instance, not one interviewee cited the lack of appropriate medical provision for wrestlers, the limitations of biomedical knowledge, or the absence of concussion training for referees, as increasing wrestlers’ risk of personal harm. Instead, the perceptions of risk, which had evidently magnified in recent years, were largely attributed to the community of practice and the self-interest of their co-performers (in terms of innovative wrestling styles and moves). Following Kalman-Lamb’s (2019) we could conceptualise this as a form of alienation and false consciousness of athlete-workers.

Moreover, calls for cultural change cannot be premised on assumptions that concussion management plans or avenues for reporting concussion both exist and are known to sports participants. Such assumptions already presuppose something approaching the most medicalised of sporting environments (Malcolm 2017). More tangibly, changing the culture of concussion should entail consideration of athlete support structures. If athletes have no healthcare support, healthcare support that is not oriented towards athletes’ concerns or healthcare support insufficiently empowered to protect athletes from harm, concussion is likely to remain a sporting crisis. Whoever is on the ‘frontline’ and thus best placed to identify and intervene in cases of suspected concussion (in this study referees) requires appropriate training, mandate, and organisational support for their interventions. Because attitudes and behaviours are socially rooted, cultural change necessarily requires revising structural arrangements.

SRC cultural change will therefore require a more holistic conceptualisation of culture, including participants’ need for security, in both the financial sense and in terms of identity. Where the reporting of concussion incurs either an economic loss or community disengagement, it will be resisted and/or rejected. This warrants, for instance, longer-term contracts, more sustained guarantees of income, and the creation of meaningful opportunities for those who have experienced brain injury to remain engaged in ‘non-combat’ roles. It also requires a duty of care on promoters and/or wrestlers’ representatives to ensure interpersonal power imbalances are not abused and responses that balance increasingly spectacular forms of performance against increasingly precautionary attitudes and interventions. It requires that brain injury is more openly discussed and deeply considered as an ‘occupational hazard’, contingencies for managing how both scripted and non-scripted brain injury is accommodated within performances, and how brain injury can be incorporated in the short and long-term scripting of performance narratives. It requires, ‘a polyphony of cooperatively evolved voices’ (De Garis 1999, 68), the opportunity and forum for the practice community to undertake a reflective assessment of how existing cultural norms contribute to health risks. Conceptually, it requires recognition of the interdependence of cultural norms with social structural relations.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The work was supported by the British Academy [SRG20\200575]

Notes on contributors

Dominic Malcolm

Dominic Malcolm is Professor of Sociology of Sport at Loughborough University. His research interests focus on the intersection of sport, health and medicine and in particular the sociocultural aspects of concussion in sport. He is also Editor-in-Chief of the International Review for the Sociology of Sport.

Anthony Papathomas

Anthony Papathomas is Senior Lecturer in Sport and Exercise Psychology within Loughborough University’s School of Sport, Exercise, and Health Sciences. His research is informed by interpretivism, and he deploys qualitative methodologies to explore the experiences of marginalised groups. Anthony’s principal focus is mental health in sport and specifically athletes living with mental illness. His research has been funded by organisations such as the English Institute of Sport and the International Olympic Committee.

Claire Warden

Claire Warden is Professor of Performance and Physical Culture at Loughborough University. Her work focuses on interdisciplinary modernisms, performance practices and the intersection of sport and art. She is the former chair of the British Association for Modernist Studies, co-editor of Performance and Professional Wrestling (Routledge 2016), co-founder of Arts Council-funded Wrestling Resurgence, and co-hosted the first wrestling symposium at the Houses of Parliament in November 2022.

Notes

1. We do not use Kalman-Lamb’s work uncritically.Despite its obvious debt to Marx, Kalman-Lamb’s thesis is largely ahistorical. Kalman-Lamb acknowledges that such historicism would be ‘a worthy project’ (Kalman-Lamb 2019, 521) but it is actually fundamental to completing a thesis linking social reproductive labour and violence to (the development of) capitalism and to counter prior research (e.g. Elias and Dunning 1986) which argues that violence as a structural feature of sport predates capitalism and has developed in style and substance across the capitalist period relatively independently of structural economic change. Additionally, the work suffers from a simplification of the embodied affective dimensions of sport. Contrary to Kalman-Lamb’s reading, Elias and Dunning (1986) attribute ‘affective deprivation’ to a range of factors including but which also cannot be reduced to, capitalism.

2. While no sign or symptom of concussion is alone sufficient to provide a clinical diagnosis, it is recommended that participants withdraw from activity following any loss of consciousness (McCrory et al. 2017).