Gender differences in COVID-19: the importance of sex-disaggregated data
An analysis of the situation in Italy and worldwide as at 25 April 2020
The COVID-19 pandemic is affecting the whole population, although its impact varies based on several factors. Sex and gender seem to play a very important role in this regard. In particular, gender (i.e. the range of socially-constructed characteristics differentiating a male from a female) accounts for significant differences in the way this pandemic is affecting the daily lives of people. For example, the Istituto Superiore di Sanità (ISS) has recently reported an alarming number of cases of domestic violence against women, many of whom are suffering repeated physical and psychological abuse as they are forced to spend more time at home with abusive men.
Sex differences, based on inborn biological characteristics (such as sex chromosomes and hormones), are even more apparent during an epidemic or a pandemic like the current one. However, updated and disaggregated data are needed to really understand the extent to which sex and gender are influencing health outcomes.
Lack of sex- and gender-disaggregated data
Before examining sex differences in the COVID-19 pandemic in more detail, it is worth noting that only an incomplete picture can be presented, as not all countries have collected and reported sex- and gender-disaggregated data. The article “Sex, gender and COVID-19: Disaggregated data and health disparities”, published on the blog of online journal BMJ Global Health on 24 March 2020, reviewed data from the 20 countries with the highest number of COVID-19 confirmed cases at that time. Among these 20 countries, Belgium, Malaysia, the Netherlands, Portugal, Spain, the United Kingdom and the United States had not provided sex-disaggregated data. Reaffirming its strong commitment to studying gender differences, Italy released disaggregated data from the start. Some countries eventually made their data available, but those that provide comprehensive sex-disaggregated data are still a minority.
Deaths: more men are dying than women
An international organization promoting gender equality in healthcare, Global Health 50/50 has started compiling publicly available sex-disaggregated data on COVID-19 reported by national governments. In addition to confirming the under-reporting of sex-disaggregated data, its analysis clearly shows that men are dying from COVID-19 at a higher rate than women across most of the countries that provide comprehensive data. According to data published in Italy’s integrated surveillance bulletin (23 April 2020 update), the case fatality rate for men is nearly double that for women (17.1% and 9.3%, respectively). Comparable differences are being recorded in other European countries (including Greece, the Netherlands, Denmark, Belgium and Spain) and elsewhere in the world (e.g. China and the Philippines). In some countries, such as Thailand and the Dominican Republic, the male/female (M/F) ratio is even higher, that is over 3:1 (3.8 and 3.2, respectively). Among the countries providing sex-disaggregated data, only India and Pakistan have reported a slightly higher COVID-19 fatality rate for women, with a 0.9:1 M/F ratio.
SARS-CoV-2 infection diagnosis in men and women
Sex and gender differences in diagnosed cases are less clear. The available data are insufficient to draw any conclusion on infection rates by sex, at least until the exact proportions of men and women tested for the virus are known. Italy and other countries, such as Belgium, the Netherlands, Portugal and Denmark, have reported a higher percentage of cases among women. In others, such as Singapore, Pakistan and India, infection rates seem to be much higher among men.
In Italy and other countries, the majority of infected healthcare workers are women
Special consideration should be given to reported cases of infection among healthcare workers. In Italy, 69% of infected healthcare workers are women, and other countries, such as the United States, Spain and Germany, have reported similar data (73%, 72% and 75%, respectively). An explanation could be that women account for the majority of workers in this category, but further studies are needed to draw definitive conclusions.
Why are sex-disaggregated data important?
Proper understanding of sex and gender differences in terms of incidence and fatality is a first step to investigate the biological and/or social mechanisms underlying such differences with a view to identifying specific preventive strategies and therapeutic targets for men and women. Intervention policies that take into account the needs of female frontline workers (e.g. healthcare workers) could help prevent the higher infection rates currently observed among women in this group. In addition, since men and women tend to respond differently to potential vaccines and treatments, access to sex-disaggregated data would be essential to conduct more appropriate clinical studies. Therefore, understanding sex and gender in relation to global health should not be seen as an optional add-on, but as a core component of ensuring effective and equitable global health systems.