Viewing the COVID-19 Pandemic Through a Sex and Gender Lens

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) responsible for the coronavirus disease 2019 (COVID-19) pandemic has highlighted the role that sex and gender play in every aspect of our lives. The National Academy of Sciences defines sex as based upon one's genes and gender as a person's self-representation as male or female based upon social interactions. ¹ In response, the nonprofit iGIANT^® (impact of Gender/Sex on Innovation and Novel Technologies) has reviewed the impact of gender and sex during this pandemic.

iGIANT^® accelerates the translation of research into gender- and sex-specific design elements, such as programs, policies, products, and protocols, across the health, retail, information technology, and transportation sectors. This pandemic magnifies sex and gender differences within these sectors. For example, male patients suffer from higher mortality rates across the globe including 53.6% of COVID-19 deaths in the United States; female health care and essential workers are infected more than their male colleagues while using ill-fitting personal protective equipment (PPE); and society increasingly depends on virtual platforms and transportation industries in which women experience greater challenges. ²

Men and women may respond variably to infection and therapeutics, resulting from sex-specific differences in immunity, hormones, and drug metabolism. The same overactive immune response that predisposes females to autoimmune conditions could also help battle infections such as COVID-19. Women have stronger innate and adaptive immunity including immune memory, enabling a rapid effective immune response against pathogens postvaccination and upon reinfection. ³ This is critical to understand when developing vaccines. If women innately have stronger immune responses, then clinical trials should consider vaccine administration for women in smaller or less frequent doses, which, if proven safe and effective, can conserve vaccines for more individuals. This concept has been explored for the influenza vaccine. ^4,5

Hormonal therapies may prove useful against COVID-19, given the varied impact of the male and female endocrine axis on immune health. Estrogen and progesterone stimulate the immune system, with progesterone having anti-inflammatory properties. ^3,6 Opposingly, testosterone suppresses the immune response. ³ Given the sex gap in COVID-19 mortality rates, the immune-modulatory effects of estrogen and progesterone are now being studied as potential therapeutics even for male patients.

Drug pharmacokinetics and pharmacodynamics in males versus females must be assessed before establishing sex-specific dosing guidelines for COVID-19 treatments. Anatomic differences including height, weight, body surface area, and total body water influence a drug's volume of distribution. ⁷ Reporting disaggregated data and representing men and women in all phases of clinical trials and cohort studies will ensure comparable efficacy and safety of COVID-19 therapies.

The COVID-19 pandemic also reveals sex and gender differences in retail, including in the availability and design of PPE for health care professionals and other essential workers. The focus of product development is often misplaced on marketing strategies rather than biological differences. ^8,9 Females comprise three-quarters of essential health care workers; yet, first-choice N95 respirators only successfully fit 85% of women, in contrast to the higher 95% male rate. ^10,11 This poses health risks given facial anthropometric differences between males and females. ¹² Ill-fitting N95 masks lead to poor seals, skin abrasions, and alternative reliance on surgical masks that inadequately filter smaller airborne particles. ^13,14 Sex and gender factors must be incorporated in the design of masks, respirators, gowns, gloves, footwear, and eye protection to ensure effective defense against COVID-19 and enhance workplace safety.

As COVID-19 initiates virtual events, there is increased reliance on the information technology sector. Women may have smaller hands and fingers with a highly developed sense of touch and harder keyboard striking, leading to repetitive stress injuries. ¹⁵ One study reported that 37% of female engineering students used medication for computer-associated pain and discomfort, as opposed to only 19% of males. ¹⁶ Prolonged electronic exposure during the pandemic may be associated with more severe injuries in women.

Gender differences also exist in the usage of the electronic health record (EHR) with female physicians spending greater EHR time responding to messages, performing clinical reviews, and writing notes. ^17,18 These gender-specific patterns are linked to higher rates of female physician burnout, which may be exacerbated during the pandemic in response to the surge of patients. ^17,18

Furthermore, gender bias detection methods, such as GenderMag, expose software biases in data structures, algorithms, and usability. Several software problem-solving features disproportionately support male analytical approaches. ¹⁹ However, women have statistically distinct information processing styles and motivations for using software features, with lower computer self-efficacy and experimentation. ¹⁹

Given differences in learning and cognitive processing, software design must be gender inclusive. This applies to artificial intelligence (AI), a rising technology that similarly over-represents men in the development process. Male users experience lower error rates while utilizing facial and speech recognition software. ^20,21 Furthermore, AI temperature screening systems used for COVID-19 may not account for menopausal females' natural temperature changes. ²² Sex and gender variances must be recognized as AI is harnessed for screening, diagnosis, and drug development. ²³

COVID-19 has also impacted essential transportation services. Female transportation workers face disproportionate burdens within this gender-segregated industry, lacking decision-making and leadership roles. ²⁴ Given female employees are over-represented in customer interaction and cleaning positions but lack adequate PPE, they are at higher virus exposure risk. ²⁴ Employers infrequently acquire PPE designed for women, impeding female protection and productivity in hazardous workplaces. ²⁵

Over 25% of female transport worker survey respondents experienced at least four incidents of workplace violence. ²⁶ The risk is currently heightened within unsupervised work environments due to social distancing measures. In addition, female transport workers face job insecurity as transportation sectors experience rising unemployment rates during the pandemic. ^24,27 Financial instability coupled with pandemic shelter in place orders increases domestic violence risk as women spend more time at home. ^28,29

The COVID-19 pandemic provides an opportunity to employ a gender and sex lens in innovation across the health, retail, information technology, and transportation sectors. Women are disproportionately harmed with myopic designs in these fields, placing them at increased health and occupational risks. There is a critical need for gender- and sex-inclusive designs to improve the safety and quality of life, including work performance, for everyone in every environment.