The BMA's report, 'The Boxing Debate ' (1993) [Reference 1] found no evidence to suggest that boxing was any safer in the 1990s than in the 1980s, when the BMA began its campaign. Pro-boxing arguments point out that other sports result in injury. The BMA's opposition to boxing is based on medical evidence that reveals the risk not only of acute injury but also of chronic brain damage, which is sustained cumulatively rather than in any one recorded instance, in those who survive a career in boxing. The BMA believes that there is sufficient evidence for the risks of brain injury associated with boxing for the Secretary of State for Department for Culture, Media and Sport to initiate an independent inquiry into these risks.
International medical associations' perspectives on boxing In 1991, eleven national medical associations (Australia, Bangladesh, Canada, Denmark, Finland, Ghana, Ireland, New Zealand, Nigeria, Norway and South Africa) confirmed their opposition to boxing, and expressed their concerns regarding the dangers of boxing, believing that ultimately it should cease to exist. These medical associations state that modern medical technology demonstrates beyond doubt that chronic brain damage is caused by the recurrent blows to the head experienced by all boxers, amateur and professional alike.
"As long as it is legal to hit an opponent above the neck, there are no safety precautions which can be taken to prevent this damage".[Reference 2]
World Medical Association (WMA) policy (2005) states that:
"Boxing is a dangerous sport. Unlike most other sports, its basic intent is to produce bodily harm in the opponent. Boxing can result in death and produces an alarming incidence of chronic brain injury. For this reason, the World Medical Association recommends that boxing be banned". [Reference 3]
The President of the Australian Medical Association (AMA), Dr Mukesh Haikerwal, (2006) stated:
"International events based on the spirit of goodwill - such as Olympic and Commonwealth Games - are no place for interpersonal violence and injury" and that "it's time to remove boxing from the sporting line-up". [Reference 4]
Countries where boxing is banned or challenged Professional boxing is banned in a number of countries including Norway and Iceland. [Reference 5] In 2006 Sweden ended its 36-year ban on professional boxing allowing permission to be sought for individual events [Reference 6] although fully-fledged professional boxing is still banned.
There have been significant attempts in UK and USA to make boxing safer. Short of an outright ban, in the USA a Bill to "establish the United States Boxing Commission to protect the general welfare of boxers and to ensure fairness in the sport of professional boxing" has been considered. Although this Bill has failed a number of times, Senator McCain has stated that he will continue to campaign until it is passed. This Bill was introduced again, after amendment, in January 2007. [Reference 7]
Paul Flynn, Labour MP for Newport West, has been a long-term campaigner on boxing safety. In the wake of Paul Ingle's injuries(see appendix 2) he pursued his efforts in Parliament to ban blows to the head in boxing in 2000. [Reference 8] Although this campaign was unsuccessful Paul Flynn still remains strongly of the opinion that boxing is the most dangerous of all sports, and that there is compelling evidence for reducing injuries in other sports too. He still campaigns vigorously for this cause and believes that opposition to reform is weakening.
Injuries sustained during boxing Injury to the brain Boxing shares with a few other sports the potential for chronic brain injury. An unpublished survey of British neurologists in 1974 about their encounters with chronic traumatic encephalopathy (CTE) and its association with sport yielded 12 jockeys, five soccer players, two rugby players, two professional wrestlers, one parachutist and 294 boxers. [Reference 9]
Whereas much of the rest of a boxer's internal organs are protected by bone, fat, skin and well developed muscle, the soft tissue of the brain is protected only by the skin-covered skull and the three membranes, or meninges:
dura mater - the thick, tough layer that restricts movement of the brain within the skull, thereby reducing the chance of blood vessels stretching or breaking
arachnoid - the thin inner layer consisting of threadlike strands that attach it to the pia mater
pia mater - the thin delicate layer tightly attached to the surface of the brain.
The meninges allow a certain amount of protection, and in addition to these membranes the brain is suspended in cerebrospinal fluid. Even with this protection the meninges and deeper tissues within the brain can become bruised when the head is jarred or shaken. When a boxer sustains a direct blow to the head, likened to the effect of being hit by a 12lb padded, wooden mallet travelling at 20mph, the head rotates sharply and then returns to its normal position at a much slower speed. In addition, the different densities of the various parts of the brain also move at different rates and the overall result is to create a "swirling" effect inside the brain. The resulting tissue trauma includes damage from the brain hitting the inner surface of the skull - this can be at the site of impact, or at the opposite side of the skull due to a contrecoup effect (where the brain moves within skull and impacts the opposite side to the blow); ; tears to the nerve networks in between the brains hemisphere's; tension between the brain tissue and blood vessels may cause lesions and bleeding; pressure waves created causing differences in blood pressure to various parts of the brain; and (rarely) large intracerebral clots (as sustained by the boxer, Michael Watson in September 1991).
Doctors say the risk of damage is great even though the brain is protected by the meninges, because punches cause the brain to strike the walls of the skull
Blows received during boxing cause the brain to move within the skull, damaging blood vessels, nerves and brain tissue. Acute brain haemorrhage is the leading cause of boxing deaths [Reference 10]
The immediate effects of blows to the head include grogginess, weakness, paralysis, weakening of limbs, inability to focus and possible loss of consciousness, ie the "knock-out" (see appendix 3) for a list of symptoms after injury). The long-term effects of boxing on the brain are cumulative and may not show immediately after a match. Most signs of damage are more likely to appear towards the end of a boxer's career or even after retirement. Stretched nerve fibres may recover after many weeks but severed nerve fibres do not repair. Ex-boxers are less able to sustain natural ageing of the brain or diseases of the brain and may be more likely to suffer conditions such as Alzheimer's and Parkinsonism. Boxers' brains are smaller, surface grey matter is thinner, and fluid-containing ventricles enlarged because of the decrease in white matter. (See section on long-term effects).
'Dr. Robert Cantu, medical director of the National Center for Catastrophic Sports Injury Research at the University of North Carolina, is one of many who advocate brain scans before and after fights.' [Reference 11] More scanning may not be sufficient, as brain damage is always a risk; this is shown by the deaths of Leavander Johnson and Martin Sanchez, both having had MRI scans previously - four months and three days earlier respectively.
Injury to the eye Eyes are protected by hard bone on many sides but are very vulnerable to direct hits from below. Damage may result from direct contact or from shock waves set up in fluid contents. Most ocular injuries in boxing are those classed as concussional injuries - eg laceration and bruising of the lids, corneal and conjunctival abrasions hyphaema (haemorrhage into the anterior chamber of the eye) traumatic mydriasis (permanent enlargement of the pupil), recession of the angle of the anterior chamber which can lead to glaucoma in later life, dislocation of the position of the lens in the eye, choroidal haemorrhage (bleeding into the structures at the back of the eye) and retinal detachment following retinal tears. [Reference 9]
Problems found in 74 boxers applying for boxing licences in New York State between 1984 and 1986 have been reported.[Reference 12] This study is important because asymptomatic boxers were examined. In this study 66 per cent of those examined had at least one ocular injury, vision-threatening injuries occurred in 58 per cent. Significant correlations were found between the total number of bouts and the total number of losses and the presence of retinal tears.
Long-term risks of boxing In addition to causing some major acute injuries, boxing can lead to chronic damage following repeated trauma. Each time someone is hit on the head they may sustain a minor degree of brain injury. One neurosurgeon has claimed that eighty per cent of boxers have brain scarring as a result of the cumulative effects of blows to the head [Reference 13][Reference 14] Once damaged, the brain is increasingly susceptible to further damage. Boxing also damages the eyes, ears and nose - in some cases there may be permanent sight or hearing loss.
Some argue that boxers have a lower risk of death per year from acute injury than other sports. But these figures do not take into account the effect of repeated minor brain damage, a fact that is relevant in few other sports. Neither does this reflect the fact that there are fewer boxers than, say, rugby players, and that boxers only compete in a few fights each year. Given the smaller number of people involved, the shorter length of boxing matches compared with, say rugby, and the longer intervals between matches, the real risk of serious injury per boxing encounter is far higher than in any other sport. Once these factors are considered, it can be seen that a boxer faces a far greater chance of death or debilitating injury each time they enter the ring than does a rugby player when he/she steps on to the pitch. Doctors are gravely concerned about the risk of serious impairment to those who survive a career in boxing. These are the post-traumatic brain diseases which can result in a progressive failure of brain function. This health hazard is almost unique to boxing. In the last few years fighters have been left wheelchair bound, blind and comatose after going into the ring. All boxers are at risk of acute and chronic brain and eye injuries. Boxing, therefore, cannot be justified on health and safety grounds as an appropriate or legitimate 'sport'.
Eighty per cent of professional boxers have serious brain scarring [Reference 13][Reference 14] and many retired boxers suffer from neurodegenerative disorders. These include Alzheimer's and Parkinson's, or more direct brain trauma, such as dementia pugilistica, also called chronic or post traumatic encephalopathy, (more commonly known as punch-drunk syndrome), caused by repetitive blows to the head over a long period of time and primarily affecting career boxers. Symptoms begin anywhere between six and 40 years after the start of a boxing career, with an average onset of about 16 years. The condition, dementia pugilistica, which occurs in people who have suffered multiple concussions, commonly manifests as dementia, (declining mental ability), and parkinsonism, (tremors and lack of coordination). A minority of boxers further developed speech difficulty, muscular movements like involuntary nodding of the head, hand tremors, and leg dragging. In severe cases, symptoms of memory loss, shuffling gait, dizziness and mental deterioration are observed, similar to that of Parkinson's Disease. Two of the best known sufferers of these conditions are Muhammad Ali, crowned world heavyweight boxing champion three times, North American Boxing Federation champion and Olympic gold medal winner, who suffers from pugilistic Parkinson's syndrome, and Wilfred Benitez, who was crowned world champion in three separate weight divisions, and is the youngest world champion in boxing history, who suffers from dementia pugilistica. Other famous boxers who are sufferers include Joe Louis, Beau Jack and, more recently, Jerry Quarry, Mike Quarry, Emile Griffith, Willie Pep and Freddie Roach.
Review of evidence The BMA has been calling for more studies of boxers to be undertaken over longer periods of time. In addition it suggests that the British Boxing Board of Control (BBBC) and the Amateur Boxing Association of England (ABAE) are in a unique position to assist in recording injuries to both brain and eye. Regardless of statistics, however, an overriding point is that damage to the brain in sporting activities is incidental; in boxing, such injury is deliberate. Indeed, the clearest deciding factor in boxing is the knock-out which necessarily results in the risk of significant neurological injury.
The small sample sizes involved in studies into the effects of boxing make it very difficult to extrapolate the findings to the entire boxing population. Unfortunately, none of the studies have followed boxers throughout their careers and into retirement, enabling a longitudinal analysis of the progressive deterioration in neurological function. General conclusions can however be made:
Safety Many people think that boxing could be made safer, for example, by using head guards or shorter rounds. Evidence suggests that these changes have minimal effect and in some cases might even have the reverse effect. Even the existence of medical specialists at ringside would not protect boxers suffering acute haematomas etc.
Professional boxers Studies confirm that professional boxers suffer from a cumulative effect of damage to the brain, often resulting in dementia pugilistica. This damage may not show up until after the boxer has retired.
Amateur boxers The evidence is far less clear cut and a number of studies found no evidence of cumulative brain damage. The sample populations were relatively tiny and most authors felt that it would be difficult to extrapolate their findings with any degree of certainty. That said, research into acute traumatic brain injury in amateur boxing has concluded that participation in amateur boxing matches may diminish neurocognitive functioning despite the use of headgear. [Reference 15] More recently, a Swedish study found that when examining the cerebrospinal fluid of amateur boxers levels of one of the markers for neuronal damage, neurofilament light (NFL), were four times as high in boxers after a fight as in healthy non-athletes, and up to eight times as high in boxers who had taken more than 15 high-impact hits to the head. Levels of NFL took three months to return to normal.[Reference 16] Rules and regulations of boxing and medical controls, however, differed widely from country to country, so it can be difficult to make comparisons.
The case that changed boxing history In September 1991 the British boxer Michael Watson went into the ring for a World Boxing Organisation (WBO) super middleweight bout with Chris Eubank. He came out of the fight in a coma, and endured a desperate nine-year battle back to health.
The 26-year-old fighter sustained two massive blood clots on his brain which left him paralysed down his left side and in need of round-the-clock medical care. In 1999 he won a High Court compensation claim against boxing's governing body. The BBBC were found to be negligent in the care that it had provided for Watson, who suffered brain damage during the bout. It was suggested that he would have made a much better recovery if a doctor skilled in specialist emergency treatment, had been available ringside to give immediate assistance. [Reference 17]
Following Watson's injuries the BBBC has implemented stricter medical procedures, including a ringside doctor trained in resuscitation and head injuries. Neurosurgeons at the local hospital must be aware of the fight and there are numerous medical checks on the fighter both before and after the bout to check for injuries. All of these new measures were in place for Paul Ingle's bout (2000) - nevertheless he suffered horrific brain injuries (see appendix 2).
Boxing after serious injury - The case of Joe Mesi Las Vegas athletic Medical Advisory Board recommended that heavyweight boxer Joe Mesi stay out of the ring after he suffered bleeding on the brain during a brutal fight in 2004. They heard evidence that Mesi might have had up to three subdural haematomas during the bruising 10-round unanimous decision victory over Vassiliy Jirov in March 2004. The injuries resulted in his indefinite suspension by the Nevada Athletic Commission, effectively banning him from boxing anywhere in the USA. The suspension was officially lifted when his Nevada boxing license expired at the end of 2005 and he was unable to renew the license due to the concerns of Nevada boxing officials. Mesi has since been licensed by the Puerto Rican, Louisiana State, Arkansas State, West Virginia state and the Michigan State Boxing Commission and has competed in six professional bouts, with another scheduled for September 2007.
Deaths from boxing At least 140 boxers, including two women, have died worldwide due to injuries sustained in training or in bouts since 1990. For information on specific ring tragedies see appendix 2.
The Nevada State Athletic Commission approves approximately 113 bouts per month between male professional boxers, and another 2.5 bouts per month between female professional boxers (based on data for 2002 and 2003). [Reference 18]
Between January 1979 and February 2007, there were 337 months. There were seven documented deaths of professional male boxers in Nevada during those 337 months. Thus, the death rate for male professional boxers in Nevada appears to be about 92 deaths per million participants: (7 deaths/[337 months x 113 bouts per month x 2 fighters per bout]) x 1,000,000
While the number of deaths in boxers is significant and serious, it should also be recognised that a professional boxer's risk of suffering a significant non-fatal injury is also very high, for example, in 2003, an Australian study documented 107 serious injuries during 427 bouts, many of which were to the head and hands. [Reference 19] With this knowledge, it obvious that promoters should routinely provide healthcare benefits for their boxers, there is however, no law requiring them to do so, and with the risks faced it is unsurprising that such measures are rarely implemented.
Counter-arguments to banning boxing Supporters of boxing claim that if it were outlawed there would be more injuries caused by illegal boxing, undertaken without strict medical controls. Anecdotal evidence however, indicates that in countries where boxing has been banned, such as Sweden, Iceland and Norway, this has not been the case. Supporters argue:
to outlaw boxing would be a denial of freedom of choice. If somebody wants to take up boxing, then it is their right
those who want to stop boxing say it is a dangerous sport. Yet far more injuries are sustained in other sports such as football, rugby, and horse-jumping. These pursuits do not attract the same venom as boxing. Deaths occur in three-day eventing, but there's no outcry over that
boxing is safer than it has ever been. In the amateur game, you have to undergo a strict medical before you get your medical card
a doctor is always at the fight and he cannot leave until the show is over. The St John Ambulance is on duty, and sometimes an ambulance with a paramedic. In professional boxing, medical expertise is ringside
boxing helps with discipline and character and should not be banned.
Women and boxing In October 1996, the Amateur Boxing Association of England announced their plans to allow women to box, a move which was finally sanctioned in October 1997. [Reference 20] The first bout was scheduled for 2 October 1997, between two 13 yr olds - Emma Brammer and Amanda Prime, this bout caused a great deal of controversy at the time, with the BMA finding itself in the unlikely position of being allied with many boxers, in their opposition to the bout. The bout was postponed twice before it finally took place without pre-announcement in March 1998. [Reference 21] An argument raised in favour of women boxing is one of equal opportunities.
Objections to women's boxing as an amateur sport come from many directions in Britain. With some thinking that boxing is fit only for males - too "physical" to be a female sport, while others say that all boxing should be banned because of injuries suffered by professionals. Trauma to the breast can cause a condition called fat necrosis, in which part of the tissue dies and becomes a hard lump - the effectiveness of breast protection is limited.
Children and boxing Boxing does not provide a unique opportunity for working class boys to "better" themselves, which is a popular, if patronising, argument. The BMA believes that the government should give more consideration to the provision of leisure facilities for the young, particularly in inner cities.
There are two main reasons for banning children under the age of 16 years from boxing:
children have little awareness of risk, specifically the risk of chronic encephalopathy, which develops only after a lag period measured in decades or more
there is no place in contemporary society for a youth sport which has, as its primary goal, the infliction of acute brain damage on an opponent.
The medical and ethico-social issues implicit in this subject have been analysed by Professor J Pearn. [Reference 22] Children's boxing is sometimes defended on the grounds that they learn to "work through their aggression" with discipline. The BMA believes there are many other sports, such as athletics, swimming, judo and football, which require discipline but do not pose the same threat of brain injury. While young boxers do not have as powerful a punch as mature boxers, some studies have found that young boxers exhibit early evidence of brain damage. This danger was highlighted in 1987 by the death of 15-year-old amateur boxer Joseph Strickland, due to brain damage.
Mixed martial arts As with boxing the BMA opposes mixed martial arts (MMA) fighting and calls for a complete ban on this type of contact sport.
Ultimate Fighting Championship (UFC) is a mixed martial arts organisation, and was started as a tournament to find the world's best fighter, irrespective of their style. Early UFC fights were extremely brutal, and was described as "human cockfighting" by Senator John McCain who sent letters to all 50 governors in the United States of America (USA) calling for it to be banned. Political pressures eventually sent the UFC underground, nearly extinguishing its public visibility. This was short-lived however and the UFC has re-emerged and is now more socially acceptable than ever, and has returned to pay-per-view television. MMA is currently undergoing a surge in popularity, with global media coverage, and tournaments regularly taking place in the UK.
The UFC uses an octagonal metal caged enclosure, "The Octagon", to stage bouts, which last 3-5 rounds of 5 minutes each, or until submission, knock-out or disqualification. Because of its 'no holds barred' nature, the UFC fighters are open to a myriad of injuries, including subdural haematoma, thought to be the most common cause of fatalities in boxing. [Reference 23][Reference 24] In addition to fractures, tears, sprains of the ligaments and muscles, primarily knees, shoulders and ankles, there is also the risk of "subclinical electroencephalographic perturbations" due to the use of neck-holding manoeuvres. [Reference 25] Injuries sustained in full-contact fighting arts, in particular martial grappling arts and professional MMA competitions, have not been well catalogued in peer-reviewed medical and scientific research methods, there is however, some evidence of increased risk of brain and joint injuries; with brain injuries more common in striking sports while joint injuries are more common in grappling sports. [Reference 26]
Since 1993, with the inception of UFC and the introduction of MMA to the American mainstream there has been only one death reported, that of Douglas Dedge in 1998. It should be noted, however, that MMA tournaments such as UFC are still in their infancy; so it is too early to draw any meaningful conclusions.
British Medical Association (1993) The Boxing Debate. London: British Medical Association.
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