Black Americans have died of COVID-19 at much higher rates than white Americans. It is well understood that the driver of these racial disparities is racism and social inequality, not genetics.
In contrast, many researchers have assumed that sex disparities in COVID-19 mortality are largely due to differences in biology. Our research challenges this narrative about COVID-19 sex differences. COVID-19 offers an example of how a focus on male-female sex differences, without looking at intersecting variables, can obscure important determinants of individual risk.
In our analysis of COVID-19 mortality patterns by race and sex in Georgia and Michigan, which was published Monday in the Journal of General Internal Medicine, we find that contrary to blanket claims of men’s higher mortality, Black women have over three times the COVID-19 mortality rate of both white and Asian men. Black women in the United States are dying from COVID-19 at a higher rate than every other group, male or female, except Black men.
Since the start of the pandemic, our lab has probed patterns of sex disparities in mortality from COVID-19. Our US Gender/Sex COVID-19 Data Tracker shows that the COVID-19 sex disparity varies greatly across states. For example, the rate of COVID-19 deaths among men in New York is 1.3 times higher than the rate among women, while in Connecticut the rates are equal. If biological reasons alone were driving the sex disparity in COVID-19 outcomes, we would expect to see a relatively similar sex disparity across different localities.
Our study adds to this picture of heterogeneity by showing that the sex disparity also varies widely across racial groups. We found that Black men died at a rate that was 1.7 times the rate that Black women died of COVID-19, while white men died at a rate that was only 1.3 times the rate of white women. In fact, the disparity in COVID-19 mortality rates was greater among women than it was between white men and white women.
Headlines like “Battle of the Sexes Against COVID-19” frame sex disparities in COVID-19 outcomes as a matter of essential biological differences between the sexes. Our findings support a contrary view, that biological factors at best play a small role. Rather, social factors influenced by structural gendered racism are key to the patterns of sex disparities revealed by the COVID-19 pandemic. These findings caution against public health messaging emphasizing a higher COVID-19 risk among men that does not also include social context.
Thirty years ago, Kimberlé Crenshaw coined the term intersectionality to describe how Black women face a unique form of oppression as a result of living at the intersection of racism and gender-based discrimination. Crenshaw offered a useful analogy of traffic at a four-way intersection. An accident at the intersection could be caused by cars traveling in any direction. Like the traffic, discrimination can come from many directions, and like the accident, oppression of Black women can come from both racism and sexism.
COVID-19 exposure risk is higher for essential workers. Comorbidities such as cardiovascular disease and diabetes increase risk of severe COVID-19. Death from COVID-19 is also higher among older age groups. Histories of racial and gender stratification shape each of these factors. For example, Black men have the highest rates of death due to cardiovascular disease, and Black women are overrepresented in nursing assistant and home health aide roles. Our findings support recommendations by Black feminist health science scholars to center the needs of Black women when addressing COVID-19. For example, COVID relief legislation should target jobs disproportionately performed by women of color and continue to support prohibitions on evictions, since women of color are evicted at higher rates than men.
Incredibly, more than a year into the pandemic, our study is the first to detail how COVID-19 mortality rates vary by both race and sex. Analyses looking at COVID outcomes by both race and sex have been hamstrung by a lack of data. Michigan and Georgia are the only states reporting COVID-19 mortality in a format that can be analyzed by race and sex.
To push states to report more comprehensive data by demographic and social variables, the GenderSci Lab created a regularly updated report card that details which social categories states report for COVID-19 cases and deaths. The average grade is a D.
The report card shows that since last summer, states have improved their reporting of COVID-19 outcomes by race, sex, and age. But states do poorly at reporting the intersections among these categories. Without such data, there is no way to know, for example, the number of deaths among Black women who are 50-59 years old. In fact, only five states report any intersections between demographic categories at all. State and local health departments must make data available in a format that allows intersectional analyses across racial groups, ethnicity, sex, age, and, ideally, also socioeconomic variables.
Without looking at the intersections between gender and race, the blanket claim that women with COVID-19 fare better than men makes invisible the high death rate among Black women.
Tamara Rushovich is a PhD candidate in population health sciences and Sarah S. Richardson directs the GenderSci Lab at Harvard University.