Coronavirus in Context: Sex, Gender & COVID

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You're watching Coronavirus In Context. I'm Dr. John Whyte, Chief Medical Officer at Webb M.D. We've been spending a lot of time talking about the disproportionate impact of COVID on minority populations. But what about the impact on women. Does sex and gender matter? To answer this question, I've called two of my good friends.

Marsha Henderson, she's the former associate commissioner in the office of women's health at the US Food and Drug Administration. And Dr. Marjorie Jenkins, she's the dean of the University of South Carolina School of Medicine at Greenville. Thanks for joining me today.

Happy to be here.

It'll be fun, just like old times.

I hope it'll be fun. Let's start off with is there an impact that's different in women than there is in men? Marcia, let's start with you.

Well, I'm glad you asked that question. Let's first start by defining sex versus gender, because these are two terms that are often interchanged. But they are very different.

Sex is the biological issue for women and men. Typically, it's a binary, male and female, or man, woman, boy, girl. And of course there are variations, such as intersex. But usually we associate sex with biological differences, such as anatomy, hormones, X and Y chromosomes. So females have two X chromosomes, while males only have one X and one Y chromosome.

Gender is socially determined. And it relates to behavior. And that behavior is often culturally determined. So terms like masculine or feminine.

Gender refers to the roles, behaviors, activities, attributes, and even opportunities are related to gender. So as we talk about sex differences and COVID, these two issues will be very much important in the discussion we have going forward.

And Dr. Jenkins, fill us in on the latest data. Are men having higher mortality than women or is it women? What's going on here?

Yes, so early in the pandemic from Wuhan we saw that men were dying at much higher rates than women. We were attributing that to smoking rates in Wuhan, where 57% of men smoke versus 2% of women. But as the pandemic spread globally, we were saying in the UK and the United States and Canada, really across the world, that men had a higher mortality.

Now, this actually played out during the H1N1 pandemic, and also during SARS and MERS in 2003 and 2012. So it is, again, just following that same pattern with higher male mortality.

And why do you think that is? Is there a biological basis? Is it to what Marsha says, there's some cultural issues and societal issues? Why do you think we're seeing this difference?

We know that the ACE2 receptor is a way, a pathway for the virus to get into our cells, and cause COVID-19.

Particularly, in the lungs.

Particularly. And there are ACE2 receptors in the renal system and in other areas of the body. Also, we know that immune genes are located many on the X chromosome. Well, women have two X chromosomes and men have one X chromosome. So that is also portended to contribute to the mortality and morbidity of males over females.

Does it matter if you're pregnant or not?

Well, pregnancy is another condition. When women are pregnant, their cardiovascular system and their renal system are already stressed. So we are now seeing a much higher morbidity. Pregnant women in one study by the CDC, they looked at 91,000 reproductive-aged women, they found that 70% higher rates of severe COVID-19 and ventilator support requirements for pregnant women. So yes, much like what we see with influenza, in COVID-19, pregnant women are at higher risk.

And Marsha, why do you think we're not typically hearing about this? I mean, to be honest, I want to be fair to our listeners, you brought this to my attention. And you said, we should be covering, you know, differences based on sex and gender. You ran an office of women's health for many years. Why is it so hard to get people interested in looking at these differences?

Well, I think we have had many years of trying to encourage scientists and researchers to focus on sex differences. And we had been doing a much better job. Over the years, we know that at least with clinical trials, the number of women had dramatically increased, as well as the analysis. But I think that when you have things like a pandemic, people tend to regress. They tend to be in a hurry to try to just get a grip on the basic issues around this.

And so some things get put to the side, which is why we have to be vigilant. People like you who worked with us extensively at FDA, as well as others, need to put it front and center. And this is why, as Dr. Jenkins indicated, we used to have a thought that this was predominantly a respiratory illness. But now we know that it affects so many different systems of the body, data are critical. So as we look at the data related to this virus, we need to separate by sex so that we can have optimal treatment for both men and women.

Well, let's look at data. And when we were talking about minority populations, there's been a lot of discussion around people aren't accurately determining race and ethnicity. We saw that when we were all at FDA in terms of how that data was tabulated. But Dr. Jenkins, people could say it's male versus female. How hard can that be? But we're having challenges with the data, aren't we?

You know, part of the issue, if someone asked me, what could we do to really make a difference here on reporting by sex and gender? We would have across our states similar databases that would just take this variable and record it. But we have some states that are not reporting by sex or gender and are not reporting by race, ethnicity. This severely limits us in getting a full picture of this disease.

Why do you think that is? Why aren't they doing that? That seems so simple.

You know, I think as Marsha said, I tend to say that people don't do this intentionally. They are doing this because they're regressing to just trying to get our arms around this. But John, we've been in the pandemic for many months. We have lots of information. We really have no excuse to not report by these two variables.

Do we think there is also behavioral differences based on sex and gender, race and ethnicity? There was some data early on that talked about men aren't as good hand washers. They don't wear the masks consistently. How much behavior based on sex and gender do you think is playing into these differences in terms of transmission and ultimate cases and mortality? I'd like both of you to reply to that.

Well, you're right, John, it's been documented that women tend to have better hygiene then do men.

I said handwashing.

Handwashing is critical-- wearing masks. You know, men are risk takers. They tend to be the type of people that would be the last to wear a mask as opposed to women. You know, we tend to as women do sort of the typical, you know, let's protect the family in every possible way. And we really gravitate quickly to that response. And so handwashing, distancing, all of those things we tend to see more often in women then in men.

So I often say, John, that we have masculine and feminine-type behaviors, right? That these are behaviors. Therefore, they're gendered. Gender is a spectrum.

Masculine behavior does tend to be those risk takers. They tend to be the ones that throughout society and thousands and thousands of years of evolution tend to be the more invincible ones, you are out there, you know, foraging, protecting the family. And I think that that does lend itself to the 21st century behaviors that we're seeing. Men are much less likely to also physical distance. So we do know that those behaviors are more likely to increase the risk of contracting the novel coronavirus.

And then what are the ripple effects in women being impacted given the role they play in society. Do we need to consider that from a policy perspective?

Well, one of the things we've also learned, regrettably, is that women tend to go home, stay home, be with the children. So as so many schools are closed or are doing virtual learning, we find that disproportionately it is the woman in the partnership that is at home with the children doing these things. And this has an effect on income and the workplace. You know, one of the things that we know with women is they often come out of the workplace and it has a negative effect on their career opportunities. And we certainly hope that with this virus it will not be complicated by the staying home of women.

I think another area, John, that we're seeing regrettably is that as men and women are forced to cohabitate more during the coronavirus and be quarantined together that we are seeing an increased rate of domestic violence. And so that, again, is something that we really need to look at in the policies. And I looked at an international organization and looked at their interim guidelines for the novel coronavirus for treatment and addressing this. And sadly, they only looked at men and women differently in the section on pregnancy.

We really have to move sex and gender out of just those things that only women can do in saying that those are women's issues. Because they really do ripple. And there's intersectionality that happens around race, gender, etc that contribute to much more long-term problems for our society.

So let's be practical in the last couple of minutes. For those women that are watching this episode, what do we tell them. What should they be doing? What should they be thinking about differently? Let's start with you, Dr. Jenkins.

Well, I think women need to be proactive in their health, keep themselves and their families as much as possible safe, take the guidelines. We know what will help keep us from contracting this virus. Know that if you are in an unsafe space that there are resources in your community that can help you. Confide in your doctor, confide in another resource, a nonprofit organization in your community if you are ever at risk. And just to also know that where you can be an advocate for yourself and your health is to really work within your organization, your state, your community to ensure that the data for this pandemic is separated by men and women.

We deserve to know the difference for both men and women.

And I would simply add that one of the opportunities that has arisen from this epidemic is a lot of online virtual treatment opportunities. I know that many people have postponed going to have their annual physicals or to keep up with their chronic illnesses. And we now find that many clinics offer that opportunity. And it particularly helps women who often may not have child care or transportation. And so this is an opportunity to be able to keep up with that.

I also think about low income women, because they often say I don't have insurance, I don't have time, I don't have money. And I always recommend community and migrant health centers, which are available at no cost or low cost. And they are also doing virtual annual physicals, as well as helping with health care concerns that are brought to their attention. So as this pandemic keeps us at home and quarantine to a great extent, there are some benefits that have arisen from it. And that certainly includes virtual health care.

Men are at high risk. Remember, we started with men are dying at higher rates. There is a dramatic impact on the family when we lose the male or the breadwinner. So there's also that ripple effect. So men are much less likely to engage with the health care environment, to go to an appointment, to get those chronic appointments done. It's usually women who are driving that for the family. So just to remember that our males are dying at higher rates from this pandemic. And that they need to be encouraged to keep up with their health and also those behaviors that will risk mitigate for them.

And then finally, the three of us were always quite involved in clinical trials. The low representation of women particularly in clinical trials. What are we seeing about vaccine trials. Should we be encouraging our listeners to participate? Many of them are still undergoing recruitment.

Well, I always encourage people to participate when appropriate in a clinical trial. And you know the most recent data indicates that people of color have lower rates of recruitment for the vaccines and treatments. And we all know why that is. There is certainly a distrust of the health care system. And some of that is, you know, based on evidence, historical evidence. But certainly I encourage everyone who can, if invited, should consider a clinical trial.

It's the only way we will know what will work most effectively and optimally. I would also add to that that this virus has unmasked a lot about the health care system that will need correction. And I always think of women not only as care givers and certainly to be responsible for their own health care, but as policy makers. We will have to look to new policies. You know, as I think about my own career in many years taking public health, there used to be three tenets related to public health.

And one was the right to refuse treatment. So certainly if you're invited to be in a clinical trial, you don't have to accept. But I say open your mind to considering it and get the questions asked that you need to ask. Another is do no harm. But the last is treat all. And I'm very worried about assuring that all people in this country get treated once that vaccine is available-- men and women. Because we now see that we're interrelated. We can't isolate ourselves from this disease for but so long.

So as our neighbors are ill, that has a risk for all of us. So as many of us as possible who certainly reflect the nature of the disease, which is disproportionately affecting people of color in very negative ways, I would encourage participation at all levels.

These are Phase III large trials. So they have already gone through some safety analysis. And so people may be frightened to participate in a clinical trial. But remember, if you do participate you're paying it forward for those millions and millions who are going to receive this vaccine. I would also say there is a responsibility on the part of the principal investigators, on the part of the organizations and companies that are going to be making these vaccines to ensure that we have looked at the safety and efficacy by sex, gender, and race ethnicity.

Well, we started off by talking about the impact of sex and gender on COVID. Both of you have helped provide your insights. I want to thank you for that. And I hope we can check in with both of you as we learn more information, as we get better data, to really make sure that we have equitable treatment and equitable testing as well. Thank you both.

Thank you.

Thank you for bringing this to the forefront, John. Very important.

And thank you for watching Coronavirus in Context.

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