Sex and gender matter to health equity. The pandemic of coronavirus disease 2019 (COVID-19) illustrates this in the clearest terms. We are pleased that the Lancet Gender and COVID-19 Working Group, UN Women, UNFPA and others are bringing attention to the gendered elements of the outbreak. The impact on women in particular has been highlighted – in terms of immediate risks associated with their roles on the front line of health and social care, secondary impacts, such as reported risks of intimate partner violence during extended periods of social separation, and concerns around disproportionately low representation of women in the governance of epidemic management.
Here, we focus on one element: whether sex and gender matter to clinical pathways and outcomes associated with COVID-19.
Sex (taken to mean biological factors) and gender (embedded and enacted through the unequal distribution of power within social, political, legal, cultural and economic systems, and experienced through, for example, the expectations, norms and behaviours associated with identifying as a man, or a woman, or transgender or non-binary person at home, in the community, in the workforce, etc) interact to influence everyone’s health outcomes.
During previous epidemics of coronaviruses, male sex was associated with worse clinical outcomes due to severe acute respiratory syndrome (SARS) in Hong Kong, and a higher risk of dying from Middle East respiratory syndrome (MERS). Are sex and gender also likely to influence risks of acquisition and transmission of the virus that causes COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)? Sex-disaggregated data analysed from a gender perspective may provide us with some answers.
Working in collaboration with American broadcaster CNN, we reviewed data from the 20 countries with the highest number of confirmed cases of COVID-19 at the time of data collection (March 20th 2019). Data were collected from a variety of sources: national reporting systems published on websites, social media reporting from ministries of health or health officials, or requested from press offices in national ministries.
Among the 20 countries, we found that:
- Six provide sex-disaggregated data for numbers of confirmed cases and deaths (China, France, Germany, Iran, Italy, South Korea)
- Seven provide sex-disaggregated data for the number of confirmed cases only (Austria, Canada, Denmark, Japan, Norway, Sweden, Switzerland)
- No sex-disaggregated data could be located for seven countries (Belgium,[1] Malaysia, Netherlands, Portugal, Spain, United Kingdom, United States of America), although both the Netherlands and Spain informed us that they were in the process of compiling sex-disaggregated data but they were not available at the time of reporting
In Table 1, we present the total number of confirmed cases, deaths and the percentage of cases that are male in the 13 countries that have sex-disaggregated data. For the six countries reporting sex-disaggregated mortality data and confirmed cases, we report on the percentage of deaths occurring among cases in men and women, and then present this as a ratio.
Table 1. Sex-disaggregated COVID-19 data from 13 of the 20 most-affected countries
| Country | Total number of confirmed cases | Confirmed cases (% male) | Total number of deaths | Deaths (% male) | Male deaths/ confirmed cases (%) | Female deaths/ confirmed cases (%) | Deaths/confirmed cases (male:female ratio) | Date reported* |
| Austria | 2380 | 56% | 6 | NA | NA | NA | NA | 20/03 |
| Canada | 846 | 54% | 10 | NA | NA | NA | NA | 20/03 |
| China | 55924 | 51% | 2114 | 64% | 4.7% | 2.8% | 1.68 | 28/02 |
| Denmark | 1226 | 63% | 9 | NA | NA | NA | NA | 20/03 |
| France | 6378 | 47% | 161 | 58% | 3.1% | 2% | 1.55 | 15/03 |
| Germany | 16662 | 56% | 47 | 62% | 0.31% | 0.25% | 1.24 | 20/03 |
| Iran | 14991 | 57% | 853 | 59% | 5.9% | 5.4% | 1.09 | 17/03 |
| Italy | 35731 | 59% | 3047 | 71% | 10.3% | 6.2% | 1.66 | 19/03 |
| Japan | 827 | 55% | 33 | NA | NA | NA | NA | 20/03 |
| Norway | 1742 | 56% | 7 | NA | NA | NA | NA | 20/03 |
| South Korea | 8652 | 38% | 94 | 54% | 1.5% | 0.8% | 1.89 | 20/03 |
| Sweden | 1623 | 53% | 16 | NA | NA | NA | NA | 20/03 |
| Switzerland | 4840 | 49% | 43 | NA | NA | NA | NA | 19/03 |
The most recent sex-disaggregated data will be continually updated and available at globalhealth5050.org/covid19.
* The date of the report is taken from the source used for each country, and is the date at which sex-disaggregated data for the numbers of cases and deaths were last available. Data were compiled on 20th March 2020.
NA = Not Available
In countries that report confirmed cases by sex, we find a mixed picture, with three countries reporting more cases among women, and nine finding more cases among men. However, in all six countries that also report mortality by sex, the proportion of deaths among confirmed cases reported on the same day, is higher in men than women – in four of these countries, the difference is greater than 50%. In these six countries, the male to female ratio is lowest in Iran (9% higher in men than women) and highest in South Korea (89% higher in men than women).
Why are we seeing more deaths per case among men diagnosed with COVID-19? There are several potential explanations, not least is the possibility that the data may be skewed. The included countries differ widely in their demography, health system and surveillance capacity and COVID-19 response, which affect the number of people tested, and numbers of cases and deaths detected and reported. At this early stage of each epidemic, the case fatality ratio does not measure true mortality. Findings from previous coronavirus infection outbreaks, however, lead us to suspect this is not simply a reporting artefact.
Sex (biology) certainly plays a role. The immune system differences between men and women are well-described, and are known to contribute to responses to infectious diseases. However, biological explanations are likely only part of what is driving inequalities in outcomes. In the six countries reporting sex-disaggregated COVID-19 mortality data, evidence across a range of health behaviours, illness outcomes and life expectancies tend to show a worse picture for men than women.
Preliminary reports of people with severe COVID-19 disease have found associations with existing co-morbidities including hypertension, cardiovascular disease and some chronic lung diseases including chronic obstructive pulmonary disease. These conditions tend to be more burdensome among men globally. This disease burden may in part be driven by higher levels of risky behaviours, which are consistently found to be more common among men than women worldwide. For example, rates of smoking tobacco and drinking alcohol are all substantially higher in men than women. These behaviours are associated with both the risk of developing co-morbidities now found to be associated with adverse outcomes in COVID-19, and with behaviours that are intimately bound up with gender norms, and how these norms are constructed and exploited in societies.
The notion that sex and gender have an impact on health is not novel. Over the past 25 years, data from the World Bank and later from the Institute for Health Metrics and Evaluation (IHME) have consistently shown higher levels of ill-health and lower life expectancies in men than women. However, the Global Health 50/50 2020 Report found that many global health organisations have yet to adequately respond to evidence of the gendered burden of disease. The absence of gender-responsiveness is particularly notable when it comes to men’s health, but is also frequently noted in programmes addressing women’s health needs other than sexual and reproductive health. The Report also found that non-communicable diseases, some of which appear to be associated with severe COVID-19 infection, are particularly neglected by the global health ecosystem.
At this point in the pandemic, we are unable to provide a clear answer to the question of the extent to which sex and gender are influencing the health outcomes of people diagnosed with COVID-19. However, experience and evidence thus far tell us that both sex and gender are important drivers of risk and response to infection and disease. It is therefore of some concern that only a minority of countries report publicly comprehensive sex-disaggregated data. We applaud the decision by the Italian Government to publish data that are fully sex- and age-disaggregated. Other countries listed in Table 1 include those that should have the capacity to do the same (e.g. the USA, UK and Switzerland), but are still not publishing national data in this way. We understand but regret this oversight.
The lack of sex-disaggregated data and gender analysis is not unique to the COVID-19 response but reflects wider trends in global health. The Global Health 50/50 2020 Report found that, among 200 organisations assessed, fewer than four out of ten fully sex-disaggregate data on their programmatic delivery.
At a minimum, we urgently call on countries to publicly report the numbers of diagnosed infections and deaths by sex. Ideally countries would also disaggregate their data on testing by sex. These recommendations are in line with WHO guidance since at least 2007.
Sex-disaggregated data are essential for understanding the distributions of risk, infection and disease in the population and the extent to which sex and gender affect clinical outcomes. As the COVID-19 pandemic unfolds, sex-disaggregated data can help guide pathways for clinical care, addressing questions such as whether older men with co-morbidities require additional prevention or earlier intensive intervention than younger people or those without co-morbidity.
In the longer-term, and once the impact and extent of the pandemic is better understood, taking a gender lens to understanding why some people are more at risk than others will be essential to building resilience in the health system, constructing a global health system that is fit for purpose in the 21st century and truly delivering on commitments to health and well-being for all. 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 national and global health systems that work for everyone. National governments and global health organisations must urgently face up to this reality.
[1] A 22 March unlabelled bar chart was located with the sex and age breakdown of confirmed cases in Belgium, but it did not report numerical figures by sex/age.
About the authors
Anna Purdie1, Sarah Hawkes2, Kent Buse3, Kristine Onarheim4, Wafa Aftab5, Nicola Low6, Sonja Tanaka7
1 University College London, UK; Global Health 50/50, UK
2 University College London, UK; Global Health 50/50, UK
3 Joint United Nations Programme on HIV/AIDS, Switzerland; Global Health 50/50, UK
4 University College London, UK; Global Health 50/50, UK
5 Aga Khan University, Pakistan; Global Health 50/50, UK
6 Institute of Social and Preventive Medicine, University of Bern, Switzerland
7 Global Health 50/50, UK
Views are those of the authors and not necessarily those of the organisations that employ them.
Competing Interests : We have read and understood the BMJ Group policy on declaration of interests and declare no competing interests.