Impact of sex and gender on COVID-19 outcomes in Europe

Biol Sex Differ. 2020 May 25;11(1):29. doi: 10.1186/s13293-020-00304-9.


Background: Emerging evidence from China suggests that coronavirus disease 2019 (COVID-19) is deadlier for infected men than women with a 2.8% fatality rate being reported in Chinese men versus 1.7% in women. Further, sex-disaggregated data for COVID-19 in several European countries show a similar number of cases between the sexes, but more severe outcomes in aged men. Case fatality is highest in men with pre-existing cardiovascular conditions. The mechanisms accounting for the reduced case fatality rate in women are currently unclear but may offer potential to develop novel risk stratification tools and therapeutic options for women and men.

Content: The present review summarizes latest clinical and epidemiological evidence for gender and sex differences in COVID-19 from Europe and China. We discuss potential sex-specific mechanisms modulating the course of disease, such as hormone-regulated expression of genes encoding for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) entry receptors angiotensin converting enzyme (ACE) 2 receptor and TMPRSS2 as well as sex hormone-driven innate and adaptive immune responses and immunoaging. Finally, we elucidate the impact of gender-specific lifestyle, health behavior, psychological stress, and socioeconomic conditions on COVID-19 and discuss sex specific aspects of antiviral therapies.

Conclusion: The sex and gender disparities observed in COVID-19 vulnerability emphasize the need to better understand the impact of sex and gender on incidence and case fatality of the disease and to tailor treatment according to sex and gender. The ongoing and planned prophylactic and therapeutic treatment studies must include prospective sex- and gender-sensitive analyses.

Keywords: COVID-19; Gender; Immune system; Renin angiotensin aldosterone system; Sex.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Angiotensin-Converting Enzyme 2
  • Betacoronavirus*
  • COVID-19
  • Coronavirus Infections / epidemiology*
  • Coronavirus Infections / immunology
  • Coronavirus Infections / metabolism
  • Coronavirus Infections / therapy
  • Europe
  • Female
  • Humans
  • Male
  • Pandemics
  • Peptidyl-Dipeptidase A / metabolism
  • Pneumonia, Viral / epidemiology*
  • Pneumonia, Viral / immunology
  • Pneumonia, Viral / metabolism
  • Pneumonia, Viral / therapy
  • Risk Factors
  • SARS-CoV-2
  • Serine Endopeptidases / metabolism
  • Sex Characteristics
  • Treatment Outcome


  • Peptidyl-Dipeptidase A
  • ACE2 protein, human
  • Angiotensin-Converting Enzyme 2
  • Serine Endopeptidases
  • TMPRSS2 protein, human