Why Does COVID-19 Affect Men More Than Women?

Since the start of the COVID-19 pandemic, the SARS-CoV-2 virus has taken a harder toll on men. Data collected in China from as early as January found that men were being infected at higher rates. As the virus spread across Europe in early March, deaths were consistently higher among men. In March, men accounted for 70% of all COVID-19 deaths in Italy. When the virus made its way into the United States, the pattern persisted. 

As of last week, COVID-19 has killed almost 17,000 more American males than women, according to recent data from the Centers for Disease Control and Prevention (CDC). In 41 of the 47 countries with confirmed cases, more males have died than females. As of June, in all states but Massachusetts, death rates are higher among males. Despite this stark difference, the role gender plays in COVID-19 mortality has received less attention than other risk factors, like age and race. 

“The World Health Organization (WHO) has been saying for more than two decades that we need to break [diseases] down by gender,” Derek Griffith, PhD, Director of the Center for Research on Men’s Health at Vanderbilt University, tells Verywell. “Through every kind of outbreak or epidemic, there is a differential effect among men and women.”

When it comes to why that differential effect exists in COVID-19, it’s worth looking at the biological and behavioral factors.

Biological Factors

Biological sex plays a large role in the way an individual’s immune system’s response to a virus. The X chromosome contains a high number of immune-related genes, and because females have two X chromosomes, their immune system is better equipped to fight off infection.

One way the immune system defends itself is by producing T-cells that kill infected cells and coordinate an antibody response to a virus. Without them, the body has a harder time reacting and responding to foreign pathogens.

An August study from Yale University found that male patients produced fewer T-cells in response to SARS-CoV-2, suggesting their body was less able to produce a coordinated immune response to the virus. With age, the body becomes less efficient at mounting an immune response and activating T-cells, which explains why the T-cell count was even lower among older patients in the study. Older, male patients favored worst with the lowest T-cell count, suggesting that sex played a role in weakening the immune system. 

An October study suggests that the male immune system shows a tendency to fight against itself. In a study of 987 patients with life-threatening COVID-19, scientists found that 101 patients had developed autoantibodies, which are essentially molecules that mistakenly target a person’s own cells, rather than the virus. These autoantibodies latched onto healthy immune cells and neutralized them, limiting their ability to produce the molecules necessary to fight the virus. Of those 101 patients with autoantibodies, 94% were male.

Researchers told the Washington Post they weren’t sure why men were more prone to eliciting this response, but the findings suggest yet another element of the male immune system that makes it more susceptible to a poor response to COVID-19. 

Men also show higher rates of comorbidity, which means they are more likely to have multiple health conditions that, when coupled with COVID-19, can make the effects of the virus much worse. Hospitalizations for COVID were six times higher and deaths twelve times higher among those with pre-existing conditions, according to the CDC. The most common underlying condition was heart disease, which tends to affect males at higher rates. 

Behavioral Factors

A large reason for this disparity is behavioral. In a study Griffith co-authored for a special COVID-19 report, he and his team found that men were less likely to wash their hands, practice social distancing, wear a mask, and proactively seek medical help. The last one, according to Griffith, is no surprise. 

“There are things men are socialized to learn about health,” Griffith says. "Men are more likely to put off seeking medical attention unless it severely impedes their ability to perform basic functions, like work."

Because some coronavirus symptoms mirror those of flu, it isn’t clear if individuals should seek immediate care for something like a cough or a fever. When men experience these symptoms, they may not be responding in the same way as women, Griffith says. He suggests that men may downplay the severity of their COVID-19 symptoms, which would be consistent with the attitude men have historically adopted towards other health issues.

When looking at the relationship between male behavior and COVID-related deaths, Griffith and his researchers hypothesized that the rate might be higher among males because they were working in jobs that might lead to greater exposure. But, their preliminary research suggested the opposite: More females in the U.S. were actually essential workers, which helps explain why the infection rate is relatively the same among men and women.

Some of the pre-existing conditions that increase likelihood of a more severe infection among men can be attributed to behavior. Studies show that men have consistently been heavier smokers than women, which can lead to heart and lung disease, as well as lung cancer. 

Griffith says that because COVID-19 tends to affect the heart and the lungs, “it makes sense that [men] would be more likely to struggle with a disease that attacks through those additional mechanisms.”

Implications

The findings suggest that future COVID-19-related studies should continue looking at sex as a biological variable in the prognosis, prevention, and care of the virus. Additionally, understanding the behaviors associated with gender that might affect health outcomes are just as important. 

On the behavioral end, Griffith proposes changing the messaging men receive around seeking care for COVID-19. In his study, he suggests public outreach should identify and focus on what motivates men to engage in preventive behaviors, like testing or visiting the doctor. For example, some men might be more motivated to engage in behaviors that reduce their risk of contracting or transmitting COVID-19 if the messaging they received focused on the effect the virus was having on their racial or ethnic group, community, or family.

Griffith says that understanding these motivations, rather than coercing or shaming men into seeking care, will help change the attitude men have towards preventative health measures.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.