Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions

Derek M. Griffith, PhD; Garima Sharma, MD; Christopher S. Holliday, PhD, MPH; Okechuku K. Enyia, MPH; Matthew Valliere, MPA; Andrea R. Semlow, MS, MPH; Elizabeth C. Stewart, DrPH, MSPH; Roger Scott Blumenthal, MD

Disclosures

Prev Chronic Dis. 2020;17(7):e63 

In This Article

Abstract and Introduction

Abstract

Data suggest that more men than women are dying of coronavirus disease 2019 (COVID-19) worldwide, but it is unclear why. A biopsychosocial approach is critical for understanding the disproportionate death rate among men. Biological, psychological, behavioral, and social factors may put men at disproportionate risk of death. We propose a stepwise approach to clinical, public health, and policy interventions to reduce COVID-19–associated morbidity and mortality among men. We also review what health professionals and policy makers can do, and are doing, to address the unique COVID-19–associated needs of men.

Introduction

The novel coronavirus disease 2019 (COVID-19) is shining a spotlight on the neglect of men's health at local, state, national, and global levels.[1] According to the largest body of publicly available sex-disaggregated data from global government sources, although no apparent sex differences exist in the number of confirmed cases, more men than women have died of COVID-19 in 41 of 47 countries,[2] and the overall COVID-19 case-fatality ratio is approximately 2.4 times higher among men than among women.[3,4] In the largest survey of 72,314 suspected or confirmed cases of COVID-19 in China (men, 63.8% of cases; women, 36.2% of cases), the case-fatality ratio was higher among men (2.8%) than among women (1.7%).[5] Another study from China, of critically ill patients, showed that men with comorbidities such as hypertension, cardiovascular disease, chronic kidney disease, and diabetes had the highest mortality[6] and US data showed similar patterns.[4,7,8]

A report on 3,200 COVID-19–related deaths from Italy showed higher death rates among men than women across all age groups, with men accounting for more than 70% of deaths.[3] A multinational health research database using the TriNetX Network showed that among 14,712 male and female patients with confirmed COVID-19, men were older, were more likely to be hospitalized, and had a higher prevalence of hypertension, diabetes, coronary heart disease, obstructive pulmonary disease, nicotine dependence, and heart failure. Men also had higher all-cause mortality than women (8.1% vs 4.6%).[9] Moreover, the cumulative probability of survival was significantly lower among men after adjusting for age, comorbidities, and use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs).[9]

In the United States, as of June 2020, 57% of deaths caused by COVID-19 have been men. With the exception of Massachusetts, all states in the United States have reported higher mortality among men.[10] However, the United States has not been consistent in reporting sex-disaggregated data. In a recent analysis of 26 states, only half reported sex as a variable.[10] Age is a significant risk factor for COVID-19 mortality, and a vast majority of the COVID-19 deaths in the United States has been among people older than 75; in addition, rates of preexisting health conditions (eg, hypertension, obesity, diabetes) exacerbate disparities in mortality by class, race, and sex/gender.[8] Exploring the differences in COVID-19 morbidity and mortality across these sociodemographic strata are beyond the scope of this commentary, yet we recognize and note that race, ethnicity, sexual orientation, gender identity, and other factors are important and should call attention to particular populations during the COVID-19 pandemic.

In this commentary, we discuss factors that may put men at a disproportionate risk of dying of COVID-19. Although it can be useful to compare determinants of men's health to those of women's health, our approach helps to identify why, how, and under what conditions key determinants of health affect the health outcomes of men.[11] This approach facilitates efforts to identify strategies to intervene and improve the health of men during this public health crisis and beyond.[12] After we examine the determinants of men's risk of dying of COVID-19, we describe what medical providers, public health professionals, and policy makers can do, and have been doing, to address the unique needs and risks among men.

The sex gap in COVID-19–associated mortality is not easily explained by any single biological or social factor.[3] Recognizing the difference between sex and gender in health outcomes while discerning the influences one has on the other is important.[13] Differences in sex are biological. These include differences in reproductive organs and their functions, sexual hormones, and the gene expression of chromosomes. Gender is the performance of socially constructed roles, behaviors, and attributes considered socially acceptable for men and women. Consequently, we use a biopsychosocial approach that considers biological and psychosocial factors that affect men's health and how these factors may intersect.[14]

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