The Curious Case of CTE: Mediating Materialities of Traumatic Brain Injury

Literature Review

As TBI has become a focal point of public debate about the health and safety of athletes of all ages, sports studies scholars have investigated the sociocultural implications of these injuries. This scholarship has been concentrated around several important research areas. These include the medicalization of sport-related concussion and contradictions within concussion diagnosis, treatment, and recovery practices (Malcolm, 2009, 2017); historical and contemporary examinations of institutional efforts to improve athlete safety (Bachynski & Goldberg, 2017; Benson, 2017; Harrison, 2014); analyses that expand definitions of “brain trauma” to incorporate competing conceptions of gender identity and (dis)ability (Morrison & Casper, 2012, 2016); and investigations into how public concern about TBI might shape gender norms in sports, with an emphasis on changing performances of hypermasculinity (Anderson & Kian, 2012; Furness, 2016; Liston, McDowell, Malcolm, Scott-Bell, & Waddington, 2016; Oates, 2017). Much of the critical scholarship has explored the impact of media discourses on dominant cultural values and public awareness about the issue. These studies demonstrate how media portrayals produce conflicting interpretations of how much public concern about TBI is influencing hypermasculine values associated with collision sports (Anderson & Kian, 2012; Cabot, 2017; Cassilo & Sanderson, 2018; Furness, 2016; McGannon, Cunningham, & Schinke, 2013; Oates, 2017). Analysis of social media content about concussions indicates how this method of facilitating awareness offers mixed results (Hull & Schmittel, 2014; Workewych et al., 2017). Yet, while often addressing CTE as one of the long-term health implications of sport-related TBI, these studies do not focus on examining the competing articulations of CTE across media discourses.

The mediation of CTE occurs in the context of a neuroscientific turn in contemporary biomedicine. Since the 1980s, scientific innovations have induced a form of popular neuroscience that has drastically changed how the brain is represented to mass audiences. Advanced capabilities of new imaging techniques, such as Positron emission technology or functional MRI, have led to an inundation of media and promotional discourses featuring colorful, captivating images of the brain. These visual renderings have served as an immense departure from past conceptions of the brain largely derived from laboratory analysis of preserved tissue; instead, modern brain scans are widely understood as providing glimpses into the active brain in living people (Dumit, 2004; Johnson Thornton, 2011). Through this imagery, media stories narrate complicated brain processes as accessible and visually intelligible bodies of knowledge; compelling depictions of the brain persuade audiences that psychosocial behaviour can be easily explained by looking at which parts of the brain “light up” in different colors (Dumit, 2004; Johnson Thornton, 2011; Rose & Abi-Rached, 2013). Even though the visual anatomy of these representations (lines, colours, and shading) is produced by intricate computer models and statistical algorithms operating behind-the-scenes, the images they produce are commonly mediated as an easy-to-read snapshot of the living brain in action.

The extensive media attention devoted to CTE relates to broader challenges facing scientists regarding how to disseminate findings through the media (Brossard, 2013; Peters, 2013). Science communication researchers continually debate how to capitalize on media visibility without oversimplifying or misrepresenting important conclusions. The difficulty of communicating advancements in neuroscience across media platforms has been a focal point of much of this scholarship (de Jong, Kupper, Arentshorst, & Broerse, 2016; Illes et al., 2010). Media portrayals of CTE are an important site for analysis since journalists produce representations in the context of the neuroscientific turn; yet, instead of flashy digitalized scans and colorful visualizations, media stories about CTE tend to revolve around visceral images of microscopic fragments of brain tissue. Moreover, these discourses facilitate a striking convergence of medico-scientific debate and emotionally charged accounts of athletes’ lived experiences.

Theory and Method

Morrison and Casper (2016) define CTE and other violent harms in football as “co-productions of masculinity and money, bodies and brutality, spectacle and showmanship, health and self-image—all speaking to the multiple positions of men in terms of corporeal, social, and economic capital” (p. 163). Media discourses are crucial sites for the public enactment of these intersections. Media renderings of CTE uncover contested material–semiotic relationships (Haraway, 1997) between embodied experience and cultural meanings produced in the context of commercialized sports. Media discourses evoke different ways of knowing and representing the material complexities of CTE but specifically produce contexts to examine how medico-scientific and lay knowledges are intertwined. I paid special attention to the ways in which discursive formations enable some stakeholders to emerge as authoritative experts on CTE while the knowledge of other actors was actively delegitimized (Foucault, 1990). I considered how stakeholders afford status to different types of knowledge about CTE and how this hierarchy could be influenced by broader socioeconomic conditions including the involvement of sports organizations (such as the NFL) with much at stake in the outcome of scientific and public debates about CTE.

My investigation entailed a Foucauldian discourse analysis of media content to detect what ways of knowing dominate media representations of CTE and how these knowledges are entangled with socioeconomic forces (Markula & Silk, 2011). I purposefully gathered a critical case sample of media sources (news stories, documentary films, popular books, etc.) and scientific studies that offer a rich illustration of dominant understandings of CTE (Patton, 2002). This sample was drawn from a larger collection of contemporary and archival sources concerning sport-related TBI, assembled between 2012 and 2018. I obtained this material through web alerts, extensive social media analysis, and systematic searches of scientific journals. My methods are not intended to ensure objectivity or completeness but rather to highlight important trends and contradictions within broader media discourses that could inform larger case studies or longitudinal research about this phenomenon (King, 2005). The representations I examined vividly mediate the discursive tensions between medico-scientific and lay expertise but also articulate how (taken together) these ways of knowing struggle to conceptualize the ambiguous and puzzling materialities of CTE.

Defining CTE: Diagnosis and Fear

The scientific “discovery” of CTE is commonly associated with neuropathologist Bennet Omalu (famously portrayed by Will Smith in Concussion, Landesman, 2015), who published the first evidence of CTE in the brain of a deceased American football player named Mike Webster (B. I. Omalu et al., 2005). Scientific definitions of CTE identify the progressive growth of tau protein that materializes as a neurological response to repeated head impacts. Tau protein typically develops in tangles that slowly strangle neurons and inhibit brain function (McKee, Stein, Kiernan, & Alvarez, 2015). The lived experience of CTE is typically associated with mood changes, aggression, and depression, as well as cognitive impairments including memory loss and dementia. Scientists believe that these indicators often emerge years after the onset of brain trauma and can increase in severity over time (Concussion Legacy Foundation, 2016). Prevailing scientific definitions of CTE emphasize repetitive brain trauma as the main contributor to neurological damage associated with the condition; in fact, a leading theory contends that CTE may be more closely linked to the accumulation of countless subconcussive impacts rather than isolated instances of concussion (Bailes, Petraglia, Omalu, Nauman, & Talavage, 2013).

The uncertainty underlying the medico-scientific classification of CTE as a disease is fueled by an inability to identify its associated biomarkers in living people. Scientists currently work under the assumption that CTE can only be reliably diagnosed postmortem. ¹ The tangles of tau protein characteristic of CTE are only perceptible through complex analysis of brain tissue that must occur postautopsy. This process entails preserving the brain in formalin, then dividing the tissue onto glass slides. The slides are then “stained” with an amino bath that tints the miniscule fibers of tau protein dark brown and renders them visible through a microscope (Klimas, 2011). This diagnostic procedure is painstakingly portrayed in the films League of Denial (2013) and Concussion, while images of brain tissue sliced on laboratory tables are common features of news reports about CTE. That scientific confirmation of a CTE diagnosis can only be obtained postmortem has compelled many athletes to donate their brains for study after they die (Fainaru-Wada & Fainaru, 2013; Kounang, 2016).

The medical diagnosis of CTE serves as a considerable departure from the representational practices characteristic of the neuroscientific turn. Rather than relying on the technological authority of modern digitally enhanced visualizations of the “new” active brain, a definitive CTE diagnosis is exclusively obtained through analysis of the “old,” messy, wet brain (cf. Johnson Thornton, 2011). Forms of popular neuroscience emerging around CTE are grounded more in morbid photographs of dismembered brain tissue than colourful brain scans. In spite of numerous efforts to create reliable technologies enabling medical diagnoses in living people (ESPN Staff, 2017; Maese, 2017), the corpse remains the privileged object in the study and representation of CTE (cf. Waldby, 2000). Since medical definitions of CTE are largely contingent on postmortem diagnoses, it remains difficult for doctors to conclusively determine whether living athletes are developing the condition. This uncertainty is compounded by the challenge of delineating whether an athlete’s psychological or neurological state is related to CTE or other experiences and ailments. Many of the symptoms and biological indicators that scientists associated with CTE are also characteristic of other neurocognitive conditions such as Alzheimer’s or Parkinson’s disease (Gardner & Yaffe, 2015).

This ambiguity surrounding CTE is mediated through compassionate stories of athletes who, in the absence of scientific certainty, express fear about the health of their brains. An April 2017 article in The Sporting News about former NFL running back Charlie Garner featured the headline, “Charlie Garner’s post-football life ruled by fear as his brain fails him” (Yasinkas, 2017). Retired NHLer Keith Primeau, whose career ended prematurely due to repeated concussions, expressed concern about CTE in a 2011 interview with the Toronto Star, saying, “I guess my biggest fear is that when I do begin to show signs [of CTE], that it’s drastic, that my drop-off is rapid. That scares me” (Starkman, 2011). NFL Hall of Famer Cris Carter cited the ambiguity around CTE as contributing to his health anxieties, “I would say there is some type of fear. [There’s a] fear of the unknown” (Payne, 2017). Former NHL star Eric Lindros told the New York Daily News that “to not be worried about [CTE] would be impossible…” (P. Leonard, 2016), whereas retired NFL offensive lineman Eugene Monroe has been vocal in justifying his decision to leave football as largely motivated by fears about CTE. As Monroe elaborated in The Guardian, “I am terrified” (Guardian Sport, 2016). Media scholar David Altheide (2002) describes how discourses of fear are commonly articulated through mass media to frame situations for audiences and set agendas for forms of public action. The heart wrenching portrayals of athletes expressing fears about their health defines the severity of the concussion problem in sports such as football and hockey, while inviting feelings of empathy for players facing an uncertain future.

Yet Altheide also explains how fear can be a powerful framework for developing identities and engaging in social life. Media coverage of CTE has emerged as a space for athletes to publicly diagnose themselves in ways that shape their identities and everyday experiences. These self-diagnoses are typically based on perceived emotional, behavioural, and cognitive decline, or the assumption that a CTE diagnosis is inevitable based on a player’s history of brain trauma. On a 2017 episode of his radio show, retired NFL quarterback Boomer Esiason commented, “If I died tomorrow and my brain was taken and researched and I was found to have CTE, which most likely I have…because I think all football players probably have it” (Gartland, 2017). Retired NFL linebacker Leonard Marshall told Yahoo! Sports in June 2017, “I’ve been diagnosed with [CTE]. I know there’s data that says you should not be able to diagnose CTE in the living. I think that’s a bunch of crap” (Adelson, 2017). Reports about the death of Todd Ewen described how the respected tough guy was convinced he was developing CTE (Mirtle, 2015). Retired Chicago Bears linebacker Lance Briggs also told NFL analyst Rich Eisen in 2017, “I just want people to understand what it’s like to live with [CTE], knowing that I do have it” (Thompson, 2017). Despite the belief that scientists are currently unable to test for CTE in living people, these public declarations express a substantial degree of diagnostic certainty.

Media coverage of these self-diagnoses enables a medicalized “person at risk” discourse around CTE. Athletes and journalists, in such cases, extrapolate upon possible risk factors (e.g., histories of brain trauma) and lived experiences (e.g., memory loss, depression) to arrive at an “unscientific” CTE diagnosis. More and more athletes are engaging in an endless “tracking down of risks” that shapes their identities around the possible (but not confirmed) onset of CTE (Johnson Thornton, 2011; Rabinow, 1996). These practices encourage the formation of self-monitoring and self-managing subjects who are compelled to read their everyday experiences through a neuroscientific lens (Johnson Thornton, 2011; Rose & Abi-Rached, 2013). Broader neuroscientific conceptions of the brain as something to be continually worked on and optimized have also influenced athletes’ conceptions of CTE risk and practices of self-surveillance. In addition to traditional medical remedies, popular pseudo-scientific “brain training” programs have infiltrated media conversations about CTE, with some athletes declaring they can treat and even avoid CTE by following diligent cognitive exercise regimes (Junod & Wickersham, 2017; Shaver, 2015). CTE, then, functions as more than a medical diagnosis, but a discursive framework through which athletes seek to reconcile their physical, cognitive, and emotional health.

Malcolm (2017) explains how the sports medicine community has worked effectively to define sport-related brain injuries as an issue that should be addressed primarily through medico-scientific means. Indeed, the medical paradigm is so engrained within public understandings of these injuries that they also enable dispersed processes of self-management that extend beyond the clinic and the direct purview of medical professionals (Clarke, Mamo, Fishman, Shim, & Fosket, 2003). Malcolm describes how media representations of sport-related brain injuries commonly reaffirm medical authority at the expense of nonspecialist knowledge of embodied experience. CTE media discourses reproduce this hierarchy, as the condition is first and foremost defined as a disease that can only be diagnosed postmortem. Yet this medicalized conception of how a set of symptoms “becomes” CTE does not account for other types of knowledge or states of being associated with the condition. Before neurophysiological characteristics become categorized as CTE through postmortem analysis, they materialize as lived experiences that resist definitive medical diagnosis and are often a source of speculation and fear. This tension is mediated through portrayals of athletes describing their experiences of cognitive or emotional transformation that they identify as CTE in the absence of scientific or technological “truth.”

While both medico-scientific and lay knowledges provide windows into how CTE is experienced as a neurophysiological state and discursive framework, media reports often position these ways of knowing in stark opposition to each other. Similar to public perceptions of many illnesses and diseases, medico-scientific understandings of CTE are privileged in media representations of the condition. Self-reported lay knowledge, even when communicated by athletes experiencing symptoms linked to CTE, does not earn credibility until it can be confirmed through verifiable medico-scientific practice (cf. Epstein, 1995). The inability for both scientists and athletes to definitively identify causes and effects of CTE produces marked tensions between these ways of knowing. The uncertainty that characterizes both medico-scientific and lay knowledge of CTE, however, reveals substantial limits to the capacity of these discursive frameworks.

Mediating Uncertainty: A Matter of Cause(s) and Effect(s)

The underlying tone of media coverage about CTE is crucially shaped by three key media texts: the book and documentary League of Denial (Fainaru-Wada & Fainaru, 2013; Kirk, 2013) and the 2015 feature film Concussion. It was largely through League of Denial that media audiences became familiar with CTE. The book and film detail how the NFL actively worked throughout the 1990s and early 2000s to obscure a growing body of scientific evidence linking football to brain damage (Furness, 2016; Oates, 2017). The League of Denial series also frames advancements in research as the work of a group of noble advocates on the side of science, who fearlessly expose the deceit of the NFL and its in-house committee of manipulative scientists. In fact, the first few pages of the League of Denial book contain a list of “principal characters” that dominate the narrative that follows; the list includes NFL executives, members of the league’s infamous Mild Traumatic Brain Injury Committee, and a group of scientists recorded under the subtitle, “The Dissenters.” League of Denial most carefully details the stories of two of the “dissenters”: neuropathologists Ann McKee and Bennet Omalu (Oates, 2017). The favorable portrayals of McKee and Omalu contrast these likeable scientists with the callous and greedy representatives of the NFL. League of Denial portrays McKee, a leader in the BU CTE Center, as a caring advocate for athletes, who grew up in the American Midwest cheering for the Green Bay Packers. The Nigerian Omalu is represented as an affable, eccentric immigrant whose research is strengthened by his lack of investment in America’s ritualized celebration of NFL football. This mode of dramatization is extended in Concussion, in which Omalu is shown as courageously disseminating his findings despite harassment from the NFL and legal authorities, death threats, racism, and institutional blacklisting—overcoming all obstacles in his heroic pursuit of the American dream.

Through the explosion of media coverage about sports-related brain injuries and CTE, McKee and Omalu (as well as others such as BU scientist and spokesperson Chris Nowinski) have become household names through frequent media appearances. Yet the framing advanced in League of Denial and the style of media coverage it inspired has encountered substantial resistance from sports stakeholders. Much of this backlash has predictably come from traditionalists who decry changes to the rules of collision sports as threatening the hypermasculine cultures of these sports. These anxieties have coalesced in the misguided perception that scientists and the “liberal media” are undertaking a “war on football,” seeking to soften or feminize the sport and erase it from the American cultural landscape (Oates, 2017). Many conservative members of elite hockey communities similarly oppose rule changes that might disrupt the violent nature of the sport (Klein, 2011; Smith, 2016). Some of this resistance, however, has also come from scientists and journalists who express concern about how media coverage has skewed public understandings of CTE. Critics argue that, despite widespread apprehension about the prevalence of CTE among athletes, there is little scientific consensus regarding how and why the condition develops.

Concerns about the misrepresentation of CTE draw from the uncertainty communicated through scientific literature on the topic. The 2017 International Consensus Statement on concussion in sports implores researchers to exercise restraint before drawing conclusions about CTE, declaring, “A cause-and-effect relationship has not yet been demonstrated between CTE and [sport-related concussion] or exposure to contact sports. As such the notion that repeated concussion or subconcussive impact cause CTE remains unknown” (McCrory et al., 2017). Systematic reviews have warned that substantial gaps remain in scientific understandings of the pathologies and symptoms associated with CTE (Asken et al., 2017). Researchers are also exploring the influence of other physiological, genetic, or lifestyle factors that may contribute to the onset of CTE. Kuhn, Yengo-Kahn, Kerr, and Zuckerman (2017) write that scientists are still unsure if “other relevant comorbid factors…including genetics, cardiovascular health, and substance abuse” could be at play in the development of CTE (2017, p. 1). Even the BU 2017 study identifying CTE in 110 of 117 brains of deceased NFL players acknowledged a selection bias in how they obtained the research sample, stating that “caution must be used in interpreting the high frequency of CTE” reported in their findings (Mez et al., 2017, p. 368).

These comments describing the uncertainty pervading scientific understandings of CTE appear at odds with the powerful assertions of causation characterizing many media stories on the topic. An August 2017 CNN television report on BU CTE research included a banner graphic reading “Study: Football Causes Brain Damage” (Smerconish, 2017). Deadspin foreshadowed the results of a 2016 national poll with the headline, “The One Thing All Americans Can Agree on Is That Football Causes Brain Damage” (Draper, 2016). In the aftermath of Kevin Turner’s CTE diagnosis, Nowinski commented, “What Kevin Turner’s case shows is that when you start playing football at 5 years old, and you’re successful, it destroys your brain” (Golen, 2016). Perhaps the most notorious manifestation of this trend, however, is from Concussion, in which Will Smith portrays Omalu explaining the suicide of former NFLer Terry Long by declaring, “Football gave him CTE and CTE told his brain to drink a gallon of antifreeze.”

In response to these provocative, decisive statements, scientists, and journalists have called for caution in how media stories represent CTE. Journalist Daniel Engber (2012) writes, “It’s now speculated, assumed, and even asserted outright that repeated knocks to the head leave football players with [CTE] and that this form of brain damage…might have caused their downward spiral into depression and suicide.” Yahoo! Sports writer Eric Adelson (2017) argues that “CTE has become a catch-all reason for troubling symptoms in many athletes” despite inconclusive evidence about how it is connected to collision sports. Adelson interviews scientist Kevin Bieniek, who warns about the dangers of inferring causation when examining the effects of CTE, “We can never make causal inferences where CTE made [someone] drink or made [someone] commit suicide.” Bieniek continues, “We always avoid the word ‘cause.’ We say ‘associated with.’” Some researchers who have issued the most fervent calls for improved safety regulations and greater accountability from sports leagues have cautioned against drawing clear-cut conclusions from CTE studies. Following Boogaard’s CTE diagnosis, BU researcher Robert Cantu advised, “It is important not to overinterpret the finding of CTE in Derek Boogaard.” Robert Stern, Cantu’s BU colleague, echoed, “Boogaard’s clinical history was complex, so it is unclear as to if or how much CTE contributed to his behavior, addiction, and death” (Branch, 2015, p. 326). These accounts are shaped by (and contribute to) the uncertainty surrounding CTE. They serve as calls for caution regarding how journalists and media audiences interpret the limited scientific evidence about what causes CTE.

In fact, the writers and scientists delivering these warnings frequently place blame on the media for cultivating misinformation about CTE. Engber (2015) writes that pervasive scientific uncertainty around CTE “…hasn’t stopped the media machine, which seems inclined to tie every former athlete’s suicide to game-related damage to his brain.” Adelson (2017) states that “the inundation [of information about CTE] is not from boring research papers; it’s from sad headlines. Just about every postmortem diagnosis makes national news.” Adelson continues, “sweeping statements like ‘millions of innocent people are at risk’ make for a better headline than ‘we have a lot more studies to do.’” Kuhn and his colleagues (2017) write, “despite knowledge gaps, media may have propagated an agenda of one-sided headline news and a sensationalised state of fear.” The outcome of this state of fear is described to Adelson (2017) by neuropsychologist Beth Bieroth who explains that “there are a lot of people who are convinced they have this condition…the most distressing thing is when you have athletes with a history of one concussion, or two, who are coming in having decided they have CTE and their life is now over.”

Altheide (2002) illuminates how fear discourses can inflate conceptions of risk and normalize perceptions of dread and panic. He writes that through the normalization of fear, “nuances blend, connotations become denotations, fringes mix with kernels, and we have a different perspective of the world” (p. 3). Attention-grabbing media stories about CTE may indeed overstate the conclusiveness of relevant scientific studies or be accompanied by sensationalized headlines provoking fear among audiences and athletes. Yet Altheide reminds us that fear can define events to serve political purposes or support calls for action. Whereas fear is frequently used by those in positions of power to discipline groups of people, the mobilization of fear in media representations of CTE has bolstered activism and legal efforts to reprimand influential stakeholders and advocate for high-profile (yet precarious) labor forces. Moreover, when writers and scientists criticize the “media machine” for cultivating unfounded fears about levels of CTE risk, they further delegitimize lay knowledge and experiences of athletes who fear they have the condition. These critiques give the impression that athletes’ fear of CTE is an exclusive product of the discursive realm of media misinformation and not grounded in athletes’ embodied experiences of their physical and mental health. These contradictions are especially evident in the varying positions on how best to improve the health and safety of athletes but also in defining the disparities between the materialities of CTE and how they are represented.

Discussion

My analysis of CTE media discourses reveals two important tensions underlying public debates about sport-related TBI. First, my examination reveals discursive clashes between emotionally charged representations of CTE as a widespread, urgent public health problem and commentary cautioning audiences about the degree of scientific uncertainty surrounding CTE. These contradictions make the basis for collective action appear unclear. Whereas most scientists and journalists seem to share a genuine concern for the well-being of athletes, the media discourses I examined illustrate profound disagreements between key stakeholders about whether CTE requires immediate and drastic action. Much of the divergence revolves around interpretation of evidence from CTE studies and determining what types of evidence justify modifications to the organization of collision sports.

These conflicts are vividly illustrated in the context of youth football. Scientists such as Omalu and McKee contend that existing evidence linking repeated brain trauma to CTE is sufficient to mandate sweeping changes to the organization of the sport. In a 2015 New York Times op-ed, Omalu argues that the risk of developing CTE should keep parents from putting their children in tackle football leagues (B. Omalu, 2015). In January 2018, the McKee-led BU lab made headlines for finding evidence of CTE in the brains of four deceased teenage football players and simultaneously reaffirming the group’s position that children should not play tackle football before the age of 14 (Kalter, 2018). In contrast, many scientists and journalists believe that the current body of scientific evidence (specifically the lack of a cause-and-effect relationship between sport-related TBI and CTE) does not warrant modifications that would severely alter the nature of collision sports. Writing about the 2018 BU study, health journalist Kevin Lomangino (2018) warns that sports media risked overstating the link between youth football and CTE. Lomangino then laments that disproportionate media coverage of research conducted by McKee’s lab could have unfortunate consequences, namely, that fear of CTE might scare off parents from registering their children for football (Lomangino, 2018). Responding to the same BU study, neurologist Javier Cardenas tweeted that the findings were “very important but [they don’t] change my view on the age in which an athlete begins to play [tackle] football or any other contact sport. However, [they] clearly emphasize the need to reduce exposure to contact” (@theconcussiondr, 2018). While the importance of reducing exposure to head impacts might serve as a source of common ground for researchers, how much contact needs to be eliminated from these sports (and how to implement these changes) remains a source of debate. While McKee and Omalu (among others) argue that the best way to reduce the incidence of head impacts is to completely remove tackling from youth football, other scientists and journalists advocate for smaller, incremental interventions (e.g., rule changes, improved protective equipment, and better medical protocols) that don’t drastically alter the culture of the sport (Bachynski & Goldberg, 2014).

The contrasting ways in which scientists interpret evidence and make corresponding calls for action are further complicated by the NFL’s and NHL’s influence on public debates about CTE. The NFL specifically has partnered with research institutes in ways that shape the scientific process and, in some cases, been a troubling example of industry involvement in public health research (Bachynski & Goldberg, 2017). Yet the league has also launched extensive public relations campaigns promoting superficial changes to rules and medical guidelines as the best way to make football safer (Bachynski & Goldberg, 2014; Benson, 2017). These campaigns draw substantial attention to the degree of scientific uncertainty concerning CTE and leverage the social power of ignorance to deflect criticism regarding the league’s inaction. Following Sullivan and Tuana (2007), ignorance is not merely a lack of knowledge, but an explanatory resource that can be manufactured and maintained; what we don’t know can sometimes be made visible rather than hidden from view. When NFL commissioner Roger Goodell or NHL commissioner Gary Bettman offer statements about how little we know about CTE or call for more research, these moments provide convenient ways for their organizations to shed culpability for the medical predicaments of retired players; certainty is ever-elusive and there are always more studies to be done. These affirmations of ignorance place the burden of proof on scientific communities who are deemed responsible for providing definitive knowledge before meaningful action can take place. Thus, proclaiming a need for more conclusive evidence is a strategic way for sports powerbrokers to delay making radical changes to league rules or styles of play, all the while selling their respective organizations as conscientious advocates for “good science” (Bachynski & Goldberg, 2014, 2017; Benson, 2017). The calls for caution pervading contemporary CTE media discourses, however, are inextricably entangled with the NFL’s history of unethical influence over scientific literatures about TBI and the widespread skepticism their deceitful practices induced. This legacy, paradoxically, now aids in the league’s efforts to delay consensus and “manufacture doubt” about the relationship between CTE and collision sports (Goldberg, 2012).

Second, my media analysis exposes conflicting conceptions of how, when, where, and why CTE comes into being. Media stories are a site through which multiple actors (journalists, scientists, athletes, and sports organizations) struggle to represent the complex materialities of CTE. In other words, these media discourses are characterized by clashes between different ways of knowing CTE: as a medical diagnosis, as an object of scientific study, as a cultural phenomenon, and as lived experience. Such conflicts are largely facilitated by the privileging of medico-scientific definitions of CTE, through which the condition is primarily conceptualized as a disease that can only be identified through postmortem study of brain tissue. Thus, within this classification, CTE definitively comes into being only through postmortem diagnosis; all other ways of knowing the condition (clinical symptoms, personal accounts of emotional or cognitive experiences) are secondary and lack the authority of scientific “truth.”

Yet the scientific uncertainty surrounding CTE points to the uncomfortable limits of medical knowledge and the challenges of putting this knowledge into meaningful practice. Dominant scientific conceptions of CTE are predicated upon a relationship of causes and effects: Repetitive brain trauma provokes neurobiological responses, which gradually induce the onset of CTE. Even while developments in scientific research illuminate how the onset of CTE is an overwhelmingly complex process influenced by multiple factors and circumstances, establishing a cause-and-effect relationship between brain injury and CTE remains the benchmark for justifying radical changes to sports cultures. It is important that scholars guard against conservative logics presuming that, without a critical mass of CTE diagnoses, it is unreasonable to consider how life playing a collision sport might play a role in an athlete’s cognitive or emotional well-being. Media discourses about CTE also hint at the potential consequences of not knowing—what if isolating the underlying cause of CTE eludes the capabilities of future scientific inquiry? What is the way forward for athletes living in fear if scientists never discover the “smoking gun” link between repetitive brain trauma and CTE? As Frost (2011) writes, in exploring the vast multiplicity of factors that can lead to the onset of a given condition, researchers must find ways to confront the potential impossibility of identifying direct causes and effects. This state of not knowing is constrained not only by the limit of current medical technology or scientific practice but by the sheer complexity of the processes under examination.

The inconsistencies across the media stories I examined illustrate how CTE defies a straightforward material-semiotic divide, through which human actors project meaning onto passive material objects. The multiple ways of knowing that materialize through these media discourses do not offer a coherent picture of the intricacies of CTE but rather foster uncertainty and ambiguity. The media representations calling for caution regarding the overinterpretation of scientific findings clash with compassionate portrayals of fearful and dejected athletes, certain they are living with CTE. Accounts reaffirming the magnitude of scientific conclusiveness collide with reports describing complex combinations of CTE-related experiences that thwart universal cause-and-effect relationships. These contradictions demonstrate how the materialities of CTE currently exceed the medico-scientific and lay discourses through which the condition is commonly known. The media coverage of CTE sheds light on the ways in which the complexity of the material brain resists these representational logics. New materialist analyses of neuroscience underscore the inherent complexity of brain matter and its refusal to be fully predictable (Pitts-Taylor, 2016). The material intricacy and uncertainty currently defining CTE demonstrates that it too resists coherence and defies explanation.

Conclusion

Media discourses are important sites through which multiple actors conceptualize CTE as a scientific, medical, and cultural problem. My analysis illustrates that most stakeholders share concerns about the well-being of athletes at risk of developing CTE; yet by assessing the legitimacy of conflicting scientific and lay knowledges, many of these actors communicate contrasting positions on the best ways to reconcile the medical and cultural implications of CTE. My analysis highlights the formidable tensions between the need to immediately address the physical and psychological impacts of collision sports and the perceived degree of scientific conclusiveness required to justify drastic change to how these sports are played. Media portrayals of scientific uncertainty have worked to delay (rather than accelerate) challenges to the socially acceptable levels of violence in collision sports and how this violence impacts the lives (and brains) of athletes (irrespective of whether they are ever diagnosed with CTE). As sports executives and researchers issue precautionary calls for more conclusive evidence, countless athletes are exposed to repeated head impacts without the benefits of future knowledge gained from pending scientific investigations.

The media discourses I examined also demonstrate that the material complexity of CTE currently evades the discursive formations through which it is most commonly conceived. Importantly, the medico-scientific conceptions of cause(s) and effect(s) struggle to represent the multiple “becomings” of CTE. Defining CTE exclusively as a disease, moreover, inevitably invokes notions of “cure.” While there are indeed ongoing efforts to locate pharmaceutical or technological cures for CTE, the only way to definitively reduce CTE risk is to eliminate the head impacts with which the condition is linked. Such a course of action requires drastic forms of organizational and cultural transformation, whereas medical cures for CTE can function within (and not against) violent traditions of collision sports. Medicalized conceptions of CTE as a disease not only frame the condition as a matter of causes and effects but also constrains the conceivable realm of solutions available to those concerned with the well-being of athletes. Broadening the range of material-semiotic articulations of CTE could offer different avenues for improving the lived experiences of athletes. Research defining TBI as a disability could have important applications within the context of sports and CTE (Morrison & Casper, 2012). As disability studies scholars have effectively theorized disability to include the sociocultural contexts in which these bodies are located, engaging with disability studies frameworks may more successfully connect CTE to its social and economic conditions.

These recommendations can guide future research exploring broader and diverse contexts impacted by brain injury and CTE. As this article was limited to media coverage of elite men’s football and hockey in North America, researchers would be well served to expand media analyses of CTE to include other sports environments including women’s hockey, rugby, soccer, and auto racing. Examining the articulations of CTE risk for women is paramount given the lack of gender-specific research on the disease, despite statistical trends illustrating that women could be more susceptible to sports-related brain injury (Brennan, 2016). Sociocultural studies of CTE should also continue to interrogate how race and social class are implicated in representations of “objective” scientific results (Benson, 2017). Broader examinations of the social and emotional impacts of CTE would also work to advance conceptions of brain injuries as messy lived experiences that extend beyond medically proscribed assessments of trauma. These types of investigations would enable greater understanding of public constructions of CTE and the social construction of “brain trauma,” while supporting efforts to hold stakeholders accountable for the well-being of those susceptible to brain injuries.