Multi-ethnic group of women, photo by andresr/Getty Images

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(The RAND Blog)

Women and COVID-19: Studying the Impact of Sex and Gender

Photo by andresr/Getty Images

The current COVID-19 pandemic presents a unique opportunity to examine the potential value of asking questions about sex and gender differences to inform ongoing policy decisions.

Even 30 years after the founding of the National Institutes of Health Office of Women's Health Research, which is dedicated to remedying the lack of clinical information by sex and gender, funding still lags dramatically for study of the extent and nature of differences between men and women. Much of current medical evidence is based largely on men. Funding focused on the clinical study of women is still limited, just a fraction of the total NIH budget.

Crucially, in COVID-19, differences are emerging in the way people develop the disease by factors such as age and underlying health conditions, and not surprisingly, also by sex and gender. Evidence from other viral outbreaks suggests differences in immune expression of disease and response to vaccines and treatments by sex. Early evidence from COVID-19 indicates differential risks, by sex and gender and race related to differences in care access and employment risk.

Funding agencies, including the NIH and foundations, have the opportunity to expand understanding about COVID-19 biology, clinical presentation, treatment, and recovery, by ensuring that sex and gender are key foci of knowledge discovery efforts along with age and health risk factors. WHAM! (Women's Health Access Matters) and the nonprofit RAND Corporation are currently addressing the impacts of this lack of funding.

Failure to test for and report sex and gender differences results in one-size-fits-all answers despite the evidence that in many cases, one size does not fit all.

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The roadmap for such work is clear from the many other disease areas in which sex and gender effects have been discovered. There are two methods that should be employed jointly: incorporate analyses by sex and gender into research, and separately develop funding for formulation and testing of sex and gender-based hypotheses. Failure to test for and report sex and gender differences results in one-size-fits-all answers despite the evidence that in many cases, one size does not fit all.

Attention to sex and gender differences for COVID-19 must be part of the accumulating evidence base from the start of this pandemic. The alternative is to follow the dangerous path of prior clinical research—late consideration of the potential for differences, allowing mistaken and potentially deadly misunderstandings based on the failure to consider sex and gender from the start. One example is heart disease. Women's heart attack symptoms often differ from the “classical” male symptoms, yet clinical trials for cardiovascular disease enroll fewer women than men, and only a minority of these studies report outcomes by sex and gender. An accurate understanding of gender effects also requires awareness of the role of social and cultural factors.

The uncertainty of the COVID-19 pandemic is frightening, and daunting. But we have a new opportunity to ask timely questions to understand differences in risk and outcome, including about how women and men differ. For this novel virus, the lessons learned will inform clinical diagnosis and care—crucial given the lack of information clinicians have now. The lessons learned will also teach us all how to ask better questions to generate actionable knowledge to help men, to help women, for the benefit of everyone.


Chloe Bird is a senior sociologist, Lori Frank is a senior behavioral scientist, Andrew Dick is a senior economist, Melanie Zaber is an associate economist, and Denise Quigley is an associate policy researcher at the nonprofit, nonpartisan RAND Corporation. Anula Jayasuriya is chief science officer, WHAM!

RAND was recently commissioned by the nonprofit WHAM! to quantify the health economic effects of not studying women separately from men across a spectrum of diseases, and is commencing work on that project.

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