Sex disparities in COVID-19 outcomes in the United States: Quantifying and contextualizing variation

Abstract

This paper presents the first longitudinal study of sex disparities in COVID-19 cases and mortalities across U.S. states, derived from the unique 13-month dataset of the U.S. Gender/Sex COVID-19 Data Tracker. To analyze sex disparities, weekly case and mortality rates by sex and mortality rate ratios and rate differences were computed for each U.S. state, and a multilevel crossed-effects conditional logistic binomial regression model was fitted to estimate the variation of the sex disparity in mortality over time and across states. Results demonstrate considerable variation in the sex disparity in COVID-19 cases and mortalities over time and between states. These data suggest that the sex disparity, when present, is modest, and likely varies in relation to context-sensitive variables, which may include health behaviors, preexisting health status, occupation, race/ethnicity, and other markers of social experience.

Understanding the Impact of Sociocultural Gender on Post-acute Sequelae of COVID-19: a Bayesian Approach

“…Our study adds to increasing evidence indicating that COVID-19 sex disparities cannot solely be explained by sex-specific biological mechanisms and are also explained by gendered or sex-specific patterns in health behaviors, contextual factors, and pre-existing health conditions. (7) In line with this notion, sex hormone status, hormone replacement, or hormone deprivation therapies were not associated with PASC in either sex in our study, although it has recently been proposed that the symptoms of PASC may overlap with those of perimenopause. (32) Similarly, psychosocial and behavioral factors and their interaction with sex/gender remained amongst the strongest predictors of PASC, even when only hospitalized patients were analyzed who, amongst all study groups, were best characterized regarding biological (clinical and laboratory) variables.…”

“…Consistent with our conclusion, substantial variation in the magnitude and direction of COVID-19 sex disparities across geographical localities, amongst racial and ethnic groups, and over time exists, all of which are better explained by contextual factors than biological variables. (7,33,34) The risk predictors for PASC selected by our models confirm previous reports indicating that psychosocial stress has substantially increased in women during the pandemic. Indeed, women have been disproportionately affected by imposed quarantine and lockdown measures given that typical feminine roles such as parenting, homeschooling, and other caring duties are still predominantly assumed by women.…”

“…Consistent with our conclusion, substantial variation in the magnitude and direction of COVID-19 sex disparities across geographical localities, amongst racial and ethnic groups, and over time exists, all of which are better explained by contextual factors than biological variables. (7, 33, 34)…”

“…(3,4) However, these findings have very recently been questioned or refuted. (5)(6)(7) In addition, factors beyond innate sex, such as institutionalized gender and culturally entrenched roles and norms, have been widely ignored in analyzing the causes of sex and gender disparities in COVID-19 outcomes, an omission that has been criticized by several institutions including the Canadian Institutes of Health Research and the European Parliament. (8,9) Increasing evidence suggests that severe acute respiratory syndrome coronavirus (SARS-CoV)-2 can cause a prolonged disease course beyond acute illness.…”

Characterization of Clinical Features of Hospitalized Patients Due to the SARS-CoV-2 Infection in the Absence of Comorbidities Regarding the Sex: An Epidemiological Study of the First Year of the Pandemic in Brazil

“…Although several studies, including ours, observed worse outcomes of COVID-19 in male patients, these data should be interpreted carefully, since several other characteristics might also play a role in the COVID-19 prognosis apart from gender. For instance, a recent report observed a higher mortality rate from COVID-19 in males in USA counties [ 42 ]. However, even before the pandemic, USA men had higher all-cause mortality rates than women [ 42 ], and perhaps COVID-19 did not change this dynamic, since another report observed a similar increase in crude excess in both sexes in 2020 [ 43 ].…”