Sex differences in COVID-19

Published

2 years ago

April 17, 2023

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COVID-19 affects people differently, in terms of infection with the virus SARS-CoV-2 and mortality rates. In this Special Feature, we focus on some of the sex differences that characterize this pandemic. Share on Pinterest The data that are available so far indicate that there are significant differences between how the sexes respond to the new coronavirus.

All data and statistics are based on publicly available data at the time of publication. Some information may be out of date. Visit our coronavirus hub for the most recent information on the COVID-19 pandemic.Was this helpful?

There are many ways in which the pandemic itself affects peoples day-to-day lives, and gender understood as the ensemble of social expectations, norms, and roles we associate with being a man, woman, trans- or nonbinary person plays a massive part.

On a societal level, COVID-19 has affected cis- and transwomen, for example, differently to how it has cismen, transmen, and nonbinary people. Reproductive rights, decision making around the pandemic, and domestic violence are just some key areas where the pandemic has negatively impacted women.

However, sex differences understood as the biological characteristics we associate with the sex that one is assigned at birth also play an undeniable role in an epidemic or pandemic.

While sex and gender are, arguably, inextricably linked in healthcare, as in every other area of our lives, in this Special Feature, we will focus primarily on the infection rates of SARS-CoV-2 and the mortality rates that COVID-19 causes, broken down by sex.

In specialized literature, these effects fall under the umbrella term of primary effects of the pandemic, while the secondary impact of the pandemic has deeper social and political implications.

Throughout this feature, we use the binary terms man and woman to accurately reflect the studies and the data they use. Sex-disaggregated data lacking

Before delving deeper into the subject of sex differences in COVID-19, it is worth noting that the picture is bound to be incomplete, as not all countries have released their sex-disaggregated data.

A report appearing on the blog of the journal BMJ Global Health on March 24, 2020, reviewed data from 20 countries that had the highest number of confirmed cases of COVID-19 at the time.

Of these 20 countries, Belgium, Malaysia, Netherlands, Portugal, Spain, United Kingdom, and the United States of America did not provide data that was disaggregated, or broken down, by sex.

At the time, the authors of the BMJ report appealed to these countries and others to provide sex specific data.

Anna Purdie, from the University College London, United Kingdom, and her colleagues, noted: We applaud the decision by the Italian government to publish data that are fully sex- and age-disaggregated. Other countries [] are still not publishing national data in this way. We understand but regret this oversight.
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.

Anna Purdie et al.

Since then, countries that include Belgium, the Netherlands, Portugal, and Spain have made their data available.

The U.K. have made only a part of the sex-disaggregated data available for England and Wales, without covering Scotland and Northern Ireland while Malaysia and the U.S. have not made their sex-disaggregated data available at all.

At the time of writing this article, the U.S. still have not released their sex-disaggregated data despite the country having the highest number of COVID-19 cases in the world.

For more research-backed information and resources for mens health, please visit our dedicated hub.Was this helpful? Men more than twice as likely to die

Global Health 5050, an organization that promotes gender equality in healthcare, has rounded up the total and partial data that is available from the countries with the highest numbers of confirmed COVID-19 cases.

According to their data gathering, the highest ratio of male to female deaths, as a result of COVID-19, is in Denmark and Greece: 2.1 to 1.

In these countries, men are more than twice as likely to die from COVID-19 as women. In Denmark, 5.7% of the total number of cases confirmed among men have resulted in death, whereas 2.7% of women with confirmed COVID-19 have died.

In the Republic of Ireland, the male to female mortality ratio is 2 to 1, while Italy and Switzerland have a 1.9 to 1 ratio each.

The greatest parity between the genders from countries that have submitted a full set of data are Iran, with 1.1 to 1, and Norway, with 1.2 to 1.

In Iran, 5.4% of the women patients have died, compared with 5.9% of the men. In Norway, these numbers stand at 1.3% and 1.1%, respectively.

China has a ratio of 1.7, with 2.8% of women having died, compared with 4.7% of men.
Infection rates in womenand men

A side-by-side comparison of infection rates between the sexes does not explain the higher death rates in men, nor is there enough data available to draw a conclusion about infection rates broken down by sexes.

However, it is worth noting that in Denmark, where men are more than twice as likely to die of COVID-19 as women, the proportion of women who contracted the virus was 54%, while that of men was 46%.

By contrast, in Iran, where the ratio of deaths between men and women is less different (1.1 to 1), just 43% of cases are female compared with 57% cases in men.

Until we know the proportion of people from each sex that healthcare professionals are testing, it will be difficult to fully interpret these figures.

What we do know so far is that, overall, nine of the 18 countries that have provided complete sex-disaggregated data have more COVID-19 cases among women than they do among men. Six of the 18 countries have more cases among men than they do among women.

Norway, Sweden, and Germany have a 5050% case ratio.

Other countries where more women have developed COVID-19 include:
Switzerland (53% of women to 47% of men)Spain (51% to 49%)The Netherlands (53% to 47%)Belgium (55% to 45%)South Korea (60% to 40%)Portugal (57% to 43%)Canada (52% to 48%)Republic of Ireland (52% to 45%)

Greece, Italy, Peru, China, and Australia all have a higher number of confirmed cases among men than women.Why are men more likely to die?

Part of the explanation for why the new coronavirus seems to cause more severe illness in men is down to biological sex differences.

Womens innate immune response plays a role. Experts agree that there are sex differences, such as sex chromosomes and sex hormones, that influence how a persons immunity responds to a pathogen.

As a result, women are in general able to mount a more vigorous immune response to infections [and] vaccinations. With previous coronaviruses, specifically, some studies in mice have suggested that the hormone estrogen may have a protective role.

For instance, in the study above, the authors note that in male mice there was an exuberant but ineffective cytokine response. Cytokines are responsible for tissue damage within the lungs and leakage from pulmonary blood vessels.

Estrogens suppress the escalation phase of the immune response that leads to increased cytokine release. The authors showed that female mice treated with an estrogen receptor antagonist died at close to the same rate as the male mice.

As some researchers have noted, lifestyle factors, such as smoking and alcohol consumption, which tend to occur more among men, may also explain the overall higher mortality rates among men.

Science has long linked such behaviors with conditions that we now know are likely to negatively influence the outcome of patients with COVID-19 cardiovascular disease, hypertension, and chronic lung conditions. Why women might be more at risk

On the other hand, the fact that societies have traditionally placed women in the role of caregivers a role which they continue to fulfill predominantly and the fact that the vast majority of healthcare workers are women cold place them at a higher risk of contracting the virus and might explain the higher infection rates in some countries.

An analysis of 104 countries by the World Health Organization (WHO) found that Women represent around 70% of the health workforce. In China, women make up more than 90% of healthcare workers in Hubei province.

These data emphasize the gendered nature of the health workforce and the risk that predominantly female health workers incur, write the authors of a report on the gendered impacts of the pandemic that appears in The Lancet.

Although we cannot yet draw definitive conclusions because sex-disaggregated data is not yet available from all the countries affected, The Lancet report looks at previous epidemics for clues.

During the 201416 west African outbreak of Ebola virus disease, the authors write, gendered norms meant that women were more likely to be infected by the virus, given their predominant roles as caregivers within families and as frontline healthcare workers.

The authors also call out for governments and health institutions to offer and analyze data on sex and gender differences in the pandemic.
Why sex-disaggregated data are urgent

The report in The Lancet reads, Recognising the extent to which disease outbreaks affect women and men differently is a fundamental step to understanding the primary and secondary effects of a health emergency on different individuals and communities, and for creating effective, equitable policies and interventions.

For instance, identifying the key difference that makes women more resilient to the infection could help create drugs that also strengthen mens immune response to the virus.

Devising policies and intervention strategies that consider the needs of women who work as frontline healthcare workers could help prevent the higher infection rates that we see among women.

Finally, men and women tend to react differently to potential vaccines and treatments, so having access to sex-disaggregated data is crucial for conducting safe clinical trials.

As Anna Purdie who also works for Global Health 5050 and her colleagues summarize in their article, 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.
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 organizations must urgently face up to this reality.

Anna Purdie et al

For live updates on the latest developments regarding the novel coronavirus and COVID-19, click here.

World

What is the possible Gaza hostage and ceasefire deal – and what challenges could lie ahead?

Published

9 mins ago

July 6, 2025

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What is the possible Gaza hostage and ceasefire deal - and what challenges could lie ahead?

An Israeli delegation is heading to Qatar for indirect talks with Hamas on a possible hostage and ceasefire deal in Gaza.

The development comes ahead of a meeting between Israeli Prime Minister Benjamin Netanyahu and US President Donald Trump in Washington DC on Monday aimed at pushing forward peace efforts.

The US leader has been increasing pressure on the Israeli government and Hamas to secure a permanent ceasefire and an end to the 21-month-long war in Gaza.

Mr Trump said on Tuesday on social media that Israel had agreed “to the necessary conditions to finalise” a deal on a truce.

And Hamas, which runs the coastal Palestinian territory, said on Friday it has responded to the US-backed proposal in a “positive spirit”.

So what is in the plan?

The plan is for an initial 60-day ceasefire that would include a partial release of hostages held by the militant group in exchange for more humanitarian supplies being allowed into Gaza.

The proposed truce calls for talks on ending the war altogether.

The war in Gaza began after Hamas attacked Israel on 7 October 2023, killing 1,200 people and taking 250 others hostage. Dozens of hostages have since been released or rescued by Israeli forces, while 50 remain in captivity, including about 30 who Israel believes are dead.

The proposal would reportedly see about half of the living hostages and about half of the dead hostages returned to Israel over 60 days, in five separate releases.

Eight living hostages would be freed on the first day and two released on the 50th day, according to an Arab diplomat from one of the mediating countries, it is reported.

Five dead hostages would be returned on the seventh day, five more on the 30th day and eight more on the 60th day.

That would leave 22 hostages still held in Gaza, 10 of them believed to be alive. It is not clear whether Israel or Hamas would determine who is to be released.

Hamas has sought guarantees that the initial truce would lead to a total end to the war and the withdrawal of Israeli troops from Gaza.

A Hamas official has said Mr Trump has guaranteed that the ceasefire will extend beyond 60 days if necessary to reach a peace deal, but there is no confirmation from the US of such a guarantee.

Possible challenges ahead

And in a sign of the potential challenges still facing the two sides, a Palestinian official from a militant group allied with Hamas said concerns remained.

The concerns were over humanitarian aid, passage through the Rafah crossing in southern Israel to Egypt and clarity over a timetable for Israeli troop withdrawals.

Hamas’s “positive” response to the proposal had slightly different wording on three issues around humanitarian aid, the status of the Israeli Defense Forces (IDF) inside Gaza and the language around guarantees beyond the 60-day ceasefire, a source with knowledge of the negotiations revealed.

But the source told Sky News: “Things are looking good.”

The Times of Israel reported Hamas has proposed three amendments to the proposed framework.

According to a source, Hamas wants the agreement to say that talks on a permanent ceasefire will continue until an agreement is reached; that aid will fully resume through mechanisms backed by the United Nations and other international aid organisations; and that the IDF withdraws to positions it maintained before the collapse of the previous ceasefire in March.

Mr Netanyahu’s office said in a statement that changes sought by Hamas to the ceasefire proposal were “not acceptable to Israel”.

However, his office said the delegation would still fly to Qatar to “continue efforts to secure the return of our hostages based on the Qatari proposal that Israel agreed to”.

Another potential challenge is that Mr Netanyahu has repeatedly said Hamas must be disarmed, which is a demand the militant group has so far refused to discuss.

Hamas has said it is willing to free all the hostages in exchange for a full withdrawal of Israeli troops and an end to the war in Gaza.

Israel rejects that offer, saying it will agree to end the war if Hamas surrenders, disarms and goes into exile – something that the group refuses.

Previous negotiations have stalled over Hamas demands of guarantees that further negotiations would lead to the war’s end, while Mr Netanyahu has insisted Israel would resume fighting to ensure the group’s destruction.

US

Texas floods: The victims and people missing that have been named so far

Published

9 mins ago

July 6, 2025

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Texas floods: The victims and people missing that have been named so far

Details of those who have died and those who are missing after US flash floods are slowly emerging – with several young girls among those unaccounted for.

At least 69 people have died from the flooding in Texas, with an unknown number of people – including 11 girls and a counsellor from Camp Mystic in Kerr County – still missing.

As much as 10ins (25cm) of heavy rain fell in just a few hours overnight in central Kerr County on Friday, causing the banks of the Guadalupe River to burst at around 4am local time.

Tributes to those who died, and appeals for those who are still missing, are now being shared.

Who are the victims?

Renee Smajstrla, eight

Renee’s uncle Shawn Salta confirmed the eight-year-old had died, and said she was one of 700 children staying at Camp Mystic.

“Renee has been found and while not the outcome we prayed for, the social media outreach likely assisted the first responders in helping to identify her so quickly,” he said.

“We are thankful she was with her friends and having the time of her life, as evidenced by this picture from yesterday.

“She will forever be living her best life at Camp Mystic.”

Sarah Marsh, eight

Mountain Brook mayor Stewart Welch confirmed the death of eight-year-old Sarah, from Alabama, who was a pupil at Cherokee Bend Elementary.

“This is an unimaginable loss for her family, her school, and our entire community,” he said. “Sarah’s passing is a sorrow shared by all of us, and our hearts are with those who knew and loved her.

“As we grieve alongside the Marsh family, we also remember the many others affected by this tragedy.”

Eloise Peck and Lila Bonner, both nine

Eloise’s mother Missy Peck told local broadcaster FOX4 that her daughter and Lila were best friends and cabinmates at Camp Mystic.

Writing about her daughter on Instagram, Ms Peck said: “She lost her life in the tragic flooding… our family is grieving and processing this unimaginable loss together.”

Lila’s family told NBC Dallas Fort Worth, a local affiliate network of Sky’s US partner network, that they were in “unimaginable grief”, and said: “We ache with all who loved her.”

Janie Hunt, nine

Janie’s family confirmed her death to a reporter from NBC Dallas Fort Worth, who said “her mother tells me she’s devastated”.

Richard ‘Dick’ Eastland, owner of Camp Mystic

Kerr County judge Rob Kelly told the Washington Post that Mr Eastland, who owned the camp died in a helicopter on the way to a Houston hospital.

Local outlet The Kerrville Daily Times reported he was killed while trying to save the girls from the flash floods.

“It doesn’t surprise me at all that his last act of kindness and sacrifice was working to save the lives of campers,” guest columnist Paige Sumner said in the Daily Times’ tribute to Mr Eastland.

Blair and Brooke Harber, 13 and 11

RJ Harber told CNN his daughters died during flooding in Kerr County, saying Blair “was a gifted student and had a generous kind heart”.

He added that Brooke “was like a light in any room, people gravitated to her and she made them laugh and enjoy the moment”.

He also said both his parents were still missing.

Jane Ragsdale, owner of Heart O’ the Hills camp

On Heart O’ the Hills’s website, the camp confirmed it was “right in the path of the flood” along the Guadalupe River.

While there were no campers in residence, Jane Ragsdale died. The camp said: “We at the camp are stunned and deeply saddened by Jane’s death.

“She embodied the spirit of Heart O’ the Hills and was exactly the type of strong, joyful woman that the camp aimed to develop with the girls entrusted to us each summer.”

Julian Ryan, 27

Relatives of Mr Ryan told local news broadcaster KHOU 11 that he died saving his family from floodwaters in Texas Hill County.

They described how he tried to smash a window to help them escape the rising water, but it cut his arm and he bled out before help could arrive.

Who is still missing?

Penny, Emlyn, and Madelyn ‘Emmy’ Jeffrey, 11

Christin Jeffrey Jones posted on Facebook that her parents Penny and Emlyn Jeffrey are missing, as well her niece Madelyn ‘Emmy’ Jeffrey.

She said her family were in Hunt, Texas, and “were spending the night at their cabin on the river at Casa Bonita which is now completely gone”.

“We ask for continued prayers and miracles,” she said. “Please share the word.”

Charlene and Mike Harber, 74 and 76

RJ Harber also told CNN that his parents, Charlene and Mike Harber, are still missing.

He believes the couple have died.

Politics

Another tantrum from the Labour backbenches is inevitable

Published

3 hours ago

July 6, 2025

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Rachel Reeves hints at tax rises in autumn budget after welfare bill U-turn

In common with many parents across the country, here’s a conversation that I have with my young daughter on a semi-regular basis (bear with me, this will take on some political relevance eventually).

Me: “So it’s 15 minutes until your bedtime, you can either have a little bit of TV or do a jigsaw, not both.”

Daughter: “Ummmm, I want to watch TV.”

Me: “That’s fine, but it’s bed after that, you can’t do a jigsaw as well.”

Fast-forward 15 minutes.

Me: “Right, TV off now please, bedtime.”

(Pause)

Daughter: “I want to do a jigsaw.”

Now replace me with the government, the TV and jigsaw options with axing welfare cuts and scrapping the two-child cap, and my daughter with rebellious backbenchers.

Politics latest: Former Labour leader calls for wealth tax on assets above £10m

That is the tension currently present between Downing Street and Labour MPs. And my initial ultimatum is the messaging being pumped out from the government this weekend.

In essence: you’ve had your welfare U-turn, so there’s no money left for the two-child cap to go as well.

As an aside – and before my inbox fills with angry emails lambasting me for using such a crude metaphor for policies that fundamentally alter the lives of some of the most vulnerable in society – yes, I hear you, and that’s part of my point.

For many in Labour, this approach feels like the lives of their constituents are being used in a childish game of horse-trading.

So what can be done?

Well, the government could change the rules.

Altering the fiscal rules is – and will likely remain – an extremely unlikely solution. But as it happens, one of Labour’s proverbial grandparents has just popped round with a different suggestion.

A wealth tax, Lord Neil Kinnock says, is the necessary outcome of the economic restrictions the party has placed on itself.

Ever the Labour storyteller, Lord Kinnock believes this would allow the government to craft a more compelling narrative about whose side this administration is on.

That could be valuable, given one of the big gripes from many backbench critics is that they still don’t really understand what this prime minister stands for – and by extension, what all these “difficult decisions” are in aid of.

The downside is whether it will actually raise much money.

The super-rich may have lots of assets to take a slice from, but they also have expensive lawyers ready to find novel ways to keep their client’s cash away from the prying eyes of the state.

Or, of course, they could just leave – as many are doing already.

In the short term, the future is a bit easier to predict.

If Downing Street is indeed now saying there is no money to scrap the two-child cap (after heavy briefing in the opposite direction just weeks ago), an almighty tantrum from the backbenches is inevitable.

And as every parent knows, the more you give in, the harder it becomes to hold the line.