During the early phase of the ongoing coronavirus disease 2019 (COVID-19) pandemic, the mortality rate among men was notably higher than in women. Researchers deduced that biological sex-related factors played a primary role in susceptibility to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Based on biomedical findings, endocrinological and immunological mechanisms likely to result in mortality were proposed. The understanding of these mechanisms may guide sex-specific clinical and public health interventions.
A new article published in Social Science & Medicine presented the first longitudinal study of sex disparities across states of the United States (U.S.). This study utilized a 55-week dataset of COVID-19 cases and mortality from the U.S. Gender/Sex COVID-19 Data Tracker at Harvard University (2020).
Sex disparities also involve differences in sex-related biological variables, gendered norms and behaviors, non-gender/sex-related variables that are differentially distributed across sexes, and a combination of the above factors.
The data tracker used in this study records weekly sex-disaggregated COVID-19 cases and mortality from 50 U.S. states and the District of Columbia, from state public health websites. All data were collected, validated, and publicly shared in graphical and tabular forms online. The study addressed a significant lag in reporting between state and federal levels.
It was observed that sex disparities and mortality rates were highly heterogeneous, within and among the states. Variation in the sex disparity was attributed to underlying state-level factors. Thus, social and contextual factors play a crucial role in the resultant sex disparities in COVID-19 outcomes. Similarly, geographical variability also poses an impact on the patterns of sex disparity.
The results revealed a modestly higher aggregate COVID-19 mortality among men. Men in the U.S. continued to have higher all-cause mortality rates than women before COVID-19, which is consistent with the pre-COVID-19 disparities.
Biosocial factors are implicated in these gender inequalities relating to COVID-19 outcomes, rather than an infection-specific etiology. The unequal distribution of pre-existing health conditions amongst the two genders, across various groups, is also to blame. Furthermore, gender/sex disparities associated with underlying health conditions may influence the probability of death post-infection, and hence, may alter outcomes of COVID-19 between men and women.
Besides, in the early pandemic, owing to the lower number of cases, small changes in fatality rates would render high variability in mortality rates among the two genders. In fact, women showed a greater tendency for having confirmed COVID-19 test reports. Again, this difference was attributed to well-documented discrepancies in surveillance testing rates – for instance, mandatory testing for pregnant women before delivery. Additionally, higher rates of testing among women also led to lower case fatality rate projection in this population as a greater number of COVID positive cases with mild or no symptoms were being recorded.
Role of social factors
Furthermore, differences in testing rates amongst various socioeconomic classes and geographic locations cannot be ignored. Certain ethnic groups were reported to have faced barriers in accessing healthcare even during the pandemic. The economic divide may also have contributed to the disparities as COVID-19 testing came with a cost. Meanwhile, busy lifestyles and time constraints could have been an important factor for some individuals to opt against prompt testing.
Besides, previous evidence supports that lower access to healthcare for women could have contributed to the under-reporting of COVID-19 mortality among women. Incidentally, long-term care facilities (LTCFs) which have 70% women residents, had been under-counting and under-reporting during the early phases of the pandemic. This could have added to the gender-related disparities in the overall estimates of the COVID-19 deaths.
Gender-related social factors, such as – health behaviors, occupational exposures, race/ethnicity and socioeconomic status, remained consistent across geographies. This was depicted in the heterogeneity of sex disparities in the COVID-19 outcomes. Health behaviors varied amongst genders. Women and girls were more likely to follow mask-wearing and handwashing protocols and exhibited higher compliance with public health and social distancing recommendations. Whereas men were less likely to be concerned about their own health and the health of others in the context of COVID-19, and were less compliant to public health measures.
First-line workers experienced higher age-adjusted COVID-19 mortality rates. Many of these occupations, such as transportation, are highly gender-stratified. Thus, gender-linked occupational exposures contributed to disparities in COVID-19 outcomes.
Homeless and incarcerated people are also at high risk for SARS-CoV-2 exposure and fatality. Furthermore, gender-expansive and LGBTQ+ individuals may also face biosocial vulnerabilities to COVID-19 – they often experience a higher prevalence of cardiovascular disease and bear the disproportionate burden of HIV, which may contribute to fatal outcomes.
On the other hand, racial disparities have been reported in the U.S. In Michigan, the COVID-19 mortality rate among Black women was five times larger than that of white women and nearly four times greater than that of white men. Such disparities were linked to persistent racial discrimination and resource deprivation, differences in comorbidities, and lack of healthcare access.
Socio-economic status also plays a critical role. People in lower-paid occupations were more likely to engage in second jobs and unpaid care work and were less likely to have personal protective equipment and health insurance or paid sick leave – increasing their chances for exposure.
Overall, the findings pointed out that gender-related and other social factors, for example – age demographics, gendered and racialized occupational stratification, and comorbidities, are more relevant than biological sex in conferring gender/sex disparities deleterious COVID-19 outcomes.
The results emphasized that the role of gender and sex in COVID-19 disparities can be fully comprehended through accessible and transparent data on COVID-19 outcomes involving sex and gender identity, race, class, comorbidities, occupation, as well as other relevant demographic variables, along with quantitative and qualitative data on gendered behaviors, occupations, and comorbidities.