Although many countries, including the United States, do not separate data by sex, it is now clear that more men than women die from COVID-19, even after adjusting for increasing age. In China, men and women were equally likely to contract COVID-19, but men experienced a 4.7% case fatality rate compared to 2.8% for women. In Italy, men were 65% more likely to die. And in New York, 61% of deaths are in men.
There are outliers: Massachusetts, Connecticut, and Pennsylvania all report slightly more deaths in women than men. This may be due to the higher populations of older adults in nursing homes in these states, where women outnumber men (61% of deaths in Massachusetts occurred in long-term care facilities), but across the globe a distinct gendered pattern has emerged: for every woman killed by COVID-19, 1.5 to 2 men succumb to this disease.
Is this difference by sex biological — due to the genetic and physical differences between men and women — or are we dealing with an increased risk by gender due to social, economic, and cultural factors? If these deaths can be better explained by looking at the social determinants of health, we may have found a gendered health disparity.
If we were to make a list of all the things men can do to protect themselves from dying of COVID, that list would look remarkably like a good recovery plan for sobriety.
Biologically, it is well understood that the immune systems of women are stronger. Many of the genes that create the immune system are on the X-chromosome, so women have two copies. This has consequences immunologically. Women have a stronger antibody response after vaccination, but they are also more likely to suffer from auto-immune disorders such as systemic lupus erythematosus. Men may be on the good side of the 9:1 female to male ratio for lupus, but they are also more susceptible to infections.
Men also have greater circulating levels of the enzyme ACE2, which is the protein that the virus uses to gain entry into cells. The more ACE2, the more viral entry, and the more infection. The higher levels of ACE2 in men increases all the more in the presence of heart disease or diabetes. Or with smoking. More men than women live with these health burdens.
With age, there are even more problems: the immune system changes. The primary tool of defense for the first half of our immunity — the innate immune system — is inflammation. It is automatic and very efficient at clearing the body of viruses and bacteria, but after living a life of chronic stress and many years continuous activation a low-grade, continuously smoldering inflammatory response leaves the male body more susceptible to chronic disease. The combination of age and male sex is known as “inflamm-aging.” The same process that was a benefit when we were younger now becomes a strain on the system. At the same time, the other half of our immunity — the adaptive immune system, which relies on cells to attack and clear pathogens — becomes less functional.
Not only do men smoke more and suffer greater burdens of chronic disease, but they experience more poverty, more housing insecurity, and more obesity than women. Men are less likely to have health insurance. Men are also less likely to wash their hands frequently, to wear masks in public, and often delay seeking care when sick. All of this adds up to put men at a disadvantage when it comes to surviving a COVID-19 illness.
So, there is plenty of difference between men and women biologically to account for the gender difference in case fatality rates of COVID, but the pandemic also forces us to look at gender differences that are not necessarily biological.
These are the social determinants of health, and men are still at a disadvantage. Not only do men smoke more and suffer greater burdens of chronic disease, but they experience more poverty, more housing insecurity, and more obesity than women. Men are less likely to have health insurance. Men are also less likely to wash their hands frequently, to wear masks in public, and often delay seeking care when sick. All of this adds up to put men at a disadvantage when it comes to surviving a COVID-19 illness.
As we begin to understand the gendered risk factors for COVID-19, we should also assume that they are at work in other diseases, such as addiction. For men in recovery from alcohol or drugs, or learning resilience to the trauma they face, it is important to remember that the inflammation of COVID-19 also occurs in active addiction.
Recovery is anti-inflammatory; it’s a way to boost our immune system, now and across our lifespan. If we were to make a list of all the things men can do to protect themselves from dying of COVID, that list would look remarkably like a good recovery plan for sobriety. There are things we learn to do in recovery to stay sober, sane and healthy: eat better and exercise, don’t isolate, have a home group, connect with others — help them and learn how to accept their help.
In time, we also learn acceptance, we experience serenity, we even become more employable, and with employment comes better access to healthcare. The habits of recovery positively affect the social determinants of health in recovering men. By slowing “inflamm-aging,” we build the “immune capital” that will protect us in our later years, so that if the day comes when we are exposed — to that sudden unexpected opportunity to relapse, or that unhealthy relationship, or that medical issue, or that viral attack — we are ready for it.
Gebhard, C., Regitz-Zagrosek, V., Neuhauser, H. K., Morgan, R., & Klein, S. L. (2020). Impact of sex and gender on COVID-19 outcomes in Europe. Biology of Sex Differences, 11(1).
Jin, J.-M., Bai, P., He, W., Wu, F., Liu, X.-F., Han, D.-M., … Yang, J.-K. (2020). Gender differences in patients with COVID-19: Focus on severity and mortality.
Márquez, E. J., Trowbridge, J., Kuchel, G. A., Banchereau, J., & Ucar, D. (2020). The lethal sex gap: COVID-19. Immunity & Ageing, 17(1).