COVID-19 and Women’s Health
By Dr. Samia Noursi
Since March 11 of this year, when the respiratory illness coronavirus disease 2019 (COVID-19) outbreak was declared a pandemic, more than 700,000 people have died.1 Johns Hopkins University estimates that as of August 20, 2020, there have been more than 22 million confirmed COVID-19 cases worldwide—with more than 173,000 deaths and over 5 million cases in the United States.2 Antibody testing suggests that the United States may actually have 10 times the number of cases currently documented, according to the Centers for Disease Control and Prevention (CDC).3 Although we know more about COVID-19 and its impacts than we did when the pandemic was declared, we still have a great deal to learn.
To date, there have been a limited number of COVID-19 studies that have disaggregated data by sex. Preliminary data do indicate that the proportion of confirmed cases between the sexes is roughly equal. However, higher mortality rates have been reported for men.4
This apparent negative male bias is most likely attributable to both biological sex and gender roles and norms. Male and female immune systems respond to viruses differently, for a variety of reasons—such as differential expression of genes located on sex chromosomes and distinct levels of hormones (estrogens, progesterone, and androgens).5 In fact, females across species mount more robust innate and adaptive immune responses than males,5 generally leading to greater protection with vaccines.6 Regarding COVID-19, recent findings suggest that levels of angiotensin-converting enzyme 2 (ACE2)—which allows severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, to invade cells and replicate and is linked with severe coronavirus-related disease7—are higher among men than women,8 which may contribute to poorer outcomes. Additionally, male and female steroid hormones may influence potential modulators of SARS-CoV-2.9 However, less is known about the exact cell types expressing ACE2 and transmembrane serine protease 2 (TMPRSS2) that serve as cells of entry and pathogenesis for SARS-CoV-2.
Concurrent with these biological differences are the gender roles and norms that play a significant role in health outcomes. 10, 11, 12 One gender difference that may contribute to the negative male bias in COVID-19 is men’s lower likelihood of visiting a doctor despite having higher rates of chronic diseases.13, 14 Men may be delaying care for chronic conditions that increase risk for severe illness from COVID-19.12, 15 Globally, COVID-19 illness severity also is related to smoking among those hospitalized for the virus,16 and more men smoke than women—including in the United States.17
In addition, women typically are more health-conscious, including about COVID-19, according to one recent survey.18 Compared with women, men were less likely to know how COVID-19 is spread or that symptoms include cough, fever, and shortness of breath. Importantly, men were more likely to report behaviors that increase risk for COVID-19. For example, men reported washing their hands nearly four times less frequently than women and leaving the home more often.18
Even though women seem to be dying of COVID-19 less often than men, women are experiencing significant effects in other ways. Being the predominant members of the front-line health workforce (70% globally)19 puts women at higher risk of exposure to SARS-CoV-2 infection, particularly when they lack adequate personal protective equipment. In addition, women represent nearly 60% of essential workers, such as grocery clerks, pharmacy and convenience store employees, airline workers, and first responders.20 In fact, women are 68% of pharmacy staff and 53.3% of hospitality and food workers.21 Essential workers often lack paid leave and typically cannot afford to miss work to care for family members—or themselves, which also puts others at risk.22
The pandemic is a source of tremendous stress for all women. Survey data from the United States indicated that stay-at-home orders were linked with worse mental health, but only among women; moreover, women were more likely to report COVID-19-related worry or stress.23 Increased financial worries and child care responsibilities did not account for the gender gap,24 so more research is needed to understand why women report more negative mental health effects from stay-at-home orders. With schools closed since March, many women have had disproportionately more stress and responsibilities, including home-schooling children and managing their psychological responses to COVID-19.25 This situation has been even more difficult for single mothers. (In the United States, 23% of family arrangements are single-parent households.)26 Many health care workers, who are disproportionately women, also have reported COVID-19-related anxiety, depression, and insomnia in multiple studies—with women providers showing a higher prevalence of negative impact on mood than their male counterparts.27 In response to the rising concerns about the pandemic’s emotional impact, experts have called for efforts to safeguard people’s mental health.28 (Both the National Institute of Mental Health and CDC offer suggestions for coping and stress management.)
Another effect of the stay-at-home orders on women’s mental and physical health is increased risk of intimate partner violence (IPV).29, 30 In the United States and other countries, stay-at-home orders were associated with surges in calls to IPV hotlines and limited access to services, including shelters.29, 31, 32 Incorporating IPV screening into all clinical encounters, as has been suggested generally, is one of the tools we have to address pandemic-related IPV.33, 34 Health care and other social service professionals should be extra vigilant to identify women who have experienced or are at risk for IPV and follow the standard procedures for addressing the issues.
Across the world, groups that have been historically marginalized—such as members of racial and ethnic minority populations, people with underlying health conditions, and individuals with low income—are disproportionately affected by COVID-19 illness and death.35 In the United States, communities of color bear a disproportionate burden of COVID-19. As of August 3, Black Americans account for about 22% of the coronavirus deaths but only represent 13% of the U.S. population.36 Members of racial and ethnic minority communities have increased their COVID-19 exposure risk through working in public-facing essential roles or residing in crowded living spaces.37 In addition, they are less likely to participate in work and other vital activities remotely because of digital inequalities,38 and alarmingly, many lack access to testing and treatment.39 Furthermore, those who do not speak English may have difficulty obtaining culturally responsive information about the pandemic.40, 41 In addition, even when members of marginalized groups are able to access care, they often mistrust medical systems due to historical abuses.42
There is much that we do not know about the COVID-19 pandemic, but we are learning more and more every day. We also are getting closer to effective treatments and a vaccine. There are still serious grounds for concern, but there are grounds for hope, too. Individuals need to do their part. Stay informed about COVID-19 by visiting the NIH website. Consider participating in a clinical trial. (See details here.) Follow CDC guidelines (also on the NIH website) for staying healthy and reducing the risk of disease transmission. And keep yourself and those around you safe by wearing a mask!
Dr. Samia Noursi is ORWH’s Associate Director for Science Policy, Planning, and Analysis. The author acknowledges Zenobia Bryant, Ph.D., for her contributions to this blog post.