COVID-19: Analyzing Sex and Analyzing Gender

COVID-19: Analyzing Sex & Analyzing Gender

This case study was first released 28 May 2020, and is also available as a PDF here.

The Challenge

Although infectious diseases can affect everyone, sex and gender can significantly impact immune responses and the course of the disease in the human body. Importantly, the biological impacts of the pandemic intersect with broader social and systemic challenges, such as limited healthcare, and economic and logistic resources. In the case of COVID-19, current worldwide statistics show more men than women dying of acute infection (GlobalHealth5050, 2020), while women are projected to suffer more than men from the health, economic and social consequences of the pandemic in the long term. Innovative solutions beyond health, such as economic re-entry strategies, product development and AI solutions, also need to consider sex and gender.

Gendered Innovation 1: Studying Sex Differences in Immune Responses

The mechanisms leading to these differences can be hormonal (i.e. the different effects of testosterone, oestrogens or progesterone), genetic (biological females have two X chromosomes while males have only one) or related to differences in intestinal bacteria.

A more vigorous immune response may induce a higher risk of autoimmune disease in females, but also a better capacity to fight infection. Initial studies report a higher production of certain subtypes of antibodies, called IgGs, in females than in males after infection with SARS-CoV2 (Zeng et al., 2020).

These differences might be relevant to the sensitivity and specificity of serological tests. The receptor used by the virus to infect host cells is the ACE2 receptor. This molecule is encoded on the X chromosome and influenced by oestrogens and androgens circulating in the body (Bukowska et al., 2017).

This means that responses to the virus and to therapies may vary, especially for groups undergoing hormonal therapies, either after menopause or to align their physical appearance with their gender identity. The possible influence of oestrogens and progesterone on the body’s response to COVID-19 in people of any gender is currently being investigated in two small trials in the United States (NCT04359329 and NCT04365127).

Gendered Innovation 2: Focusing on Dosing and Sex-Specific Side Effects of Vaccines and Therapeutics

Women appear to experience a higher overall incidence of medication side effects than men. This might be related to biological differences, differences in therapeutic choices or differences in reporting (see Case Study: Prescription Drugs). Potential sex differences in response to and the efficacy of novel therapies and vaccines need to be taken into account (Tannenbaum et al., 2017). Different doses of vaccine may be needed for females and males, and side effects may occur at different rates.

For example, females are at higher risk of developing irregularities in heart rhythm (QT prolongation) due to physiological differences in the heartbeat (see Case Study: Heart Disease in Diverse Populations). This risk increases with the use of heart medication and many other therapies, such as hydroxychloroquine and azithromycin, currently being tested for use against COVID-19.

In addition, sex-specific issues, such as the provision of potentially life-saving therapies to pregnant women while preventing fetal complications, need to be considered in the design of clinical trials. This is particularly relevant in countries with limited healthcare resources, and where fertility rates might be higher, thus significantly increasing the numbers of potentially pregnant COVID-19 patients.

The Horizon 2020 project i-CONSENT investigates the intersection of the gender dimension and ethics in informed consent. It addresses the relationship between ethics and safety when people are participating in clinical trials, including co-decision-making between partners and the impact of self-determination and power (Persampieri, 2019).

Gendered Innovation 3: Consider Gender-Specific Risk Factors

Worldwide, women are more frequently employed in service professions, including healthcare. According to the European Institute of Gender Equality, women represent 76 % of the 49 million healthcare workers in the EU (European Institute of Gender Equality). Care professionals in hospitals, nursing homes and the community come into contact with the virus much more frequently than the general population. They are exposed to large numbers of SARS-CoV2 patients and may be exposed to higher concentrations of the virus (Liu et al., 2020). Women also perform the majority of caring duties in families and immediate communities.

Professional and private risks need to be factored into public health strategies. Healthcare workers are preferentially tested for SARS-CoV2, but is equitable access provided for informal caregivers and healthcare workers outside of hospitals? Is gender-sensitive budgeting applied in allocating emergency resources? Is personal protective equipment provided fairly to all individuals at comparable risk in healthcare institutions?

In addition to healthcare professionals, cleaning personnel and janitorial staff tend to be overexposed to the virus and require protective equipment. When developing personal protective equipment, anatomical differences need to be analyzed to ensure proper fit and to avoid ergonomic difficulties (Sutton, Irvin et al., 2014); gender-specific user preferences should also be considered (Tannenbaum et al., 2019).

An example of how an acute situation like the COVID-19 pandemic can be integrated into ongoing structural gender-mainstreaming activities is provided by the Horizon 2020 project ACT. ACT has developed a platform for communities of practice on gender equality in research organizations and has recently used its platform to host webinars offering insight into the gender dimensions of research funded on the pandemic.

Method: Analyzing Gender

Preventative measures should be designed in a gender-sensitive manner to reach everyone in the community. Women reportedly comply more with hand hygiene guidelines (Borchgrevink et al., 2013), and incentives to encourage such preventative behaviors should be gender-sensitive (Judah et al., 2009).

Gender affects the division of labour and care duties in families and communities. Women are more frequently employed in professions with a high risk of infection, such as healthcare, and are more frequently responsible for the care of sick family members (International Labour Organization, 2016).

The design of personal protective equipment needs to take anatomical differences into consideration as well as users’ gendered preferences. The allocation of protective equipment, therapies and financial aid should be gender-equitable. Finally, gender-sensitive design should be employed when developing digital platforms for preventative measures.

View General Method

 

Gendered Innovation 5: Considering the Gender-Specific Socioeconomic Burden of Public Safety Measures

Limiting physical contact is important in pandemics involving viral and bacterial agents that are transmitted person-to-person. A highly transmittable airborne virus, such as SARS-CoV2, has led to social/physical distancing measures and quarantines in many parts of the world. In most parts of the world, women are more likely than men to be non-salaried employees or self-employed. They also are more likely to work in the service industries, such as care, wellness, cleaning and food handling (International Labour Organization, 2016).

The enforced closure of the service industry during quarantine has impacted the non-traditional workforce in two distinct ways: “non-essential” workers lose their jobs, leaving individuals dependent on economic support from partners, families and the state; “essential” workers are required to continue their activities under significant physical and psychological stress. Both scenarios have the potential to shift established gender roles and to lead to a surge in stress, existential fears and violence in public and domestic settings (van Gelder et al., 2020). Understanding and empathising with potential survivors is an essential aspect of prevention that has been addressed innovatively in the Horizon 2020 project VRespect.Me, which developed a training app using virtual reality to place perpetrators of domestic violence in the position of victims (Seinfeld et al., 2018).

Socioeconomic measures also harbour the potential to exacerbate existing inequalities. The design of solutions should be intersectional (see Method: Intersectional Approaches), including dimensions such as social origin and ethnicity/migration, among others. The European Research Council project GENDERMACRO investigated the complex interconnections between female empowerment and household economics. Simply providing resources to a female household member might lead to unexpected negative consequences if gender dynamics, such as power relations, role assumptions and priorities, are not taken into account (Doepke & Tertilt, 2011). These findings are essential for the development of gender-sensitive policies to improve the economic situation for all household members, especially in times of crisis such as the COVID-19 pandemic.

Service restrictions affect many domains in a gendered manner, but are especially relevant in healthcare. Emergency departments worldwide are reporting a reduction in demand not related to COVID-19, sparking concerns about the potential lack of treatment of medical emergencies, such as heart attack and strokes (Tam et al., 2020). Routine reproductive healthcare might also suffer. Political decisions taken on health priorities in several countries have already affected access to contraception as well as to medically assisted reproduction and safe abortions.