1.1. Did COVID-19 widen the existing gender gap in mortality?

Life expectancy fell more sharply in 2020 for males than for females, and the partial recovery in 2021 was also smaller for males. COVID-19 is more deadly for males, but how much more so, given that in France, at all ages, and for all causes of death combined, males have a greater risk of dying in the year than females of the same age? For a man aged 70, for example, the risk is twice as high as for a woman of that age. The risk is also doubled at age 40, although much lower than at age 70 for both sexes.

Females are biologically more robust than males, but the disparities are due mainly to differences in their activities and behaviours. Throughout their lives, men take more risks than women and more frequently engage in unhealthy behaviours. For example, men drink and smoke more than women do. Women are generally more attentive to their health and more frequently seek healthcare [3].

Consequently, all-cause mortality is higher for males than for females. Male excess mortality varies by age, with a ‘double-spike’ profile (Figure 1 and online appendix [in French]^: https://nakala.fr/10.34847/nkl.ce3dox36): the first spike occurs at young adult ages, when mortality is very low and deaths are due mainly to external causes (suicides and accidents, traffic accidents especially), and the second at ages 55–74.

For men aged up to 54 years, excess mortality due to COVID-19 is lower than excess all-cause mortality. Starting with the 55–64 age group, however, the situation is reversed (Figure 1). This may reflect a higher infection risk for men due to their behaviour—less compliance with social distancing rules, greater social interaction, less remote working—but also higher prevalence of comorbidities (hypertension, diabetes) than women over age 50 [5], resulting in increased case fatality rates (risk of dying of the disease once infected).

Male excess mortality from COVID-19 has evolved since the start of the pandemic (Figure 2). Across all periods, it peaks at around 65–74 years, but in the first half of 2020, a first spike is observed at ages 25–34. This could be explained by greater risk exposure among young men than young women, as is the case for accidental deaths, but also by the high COVID-19 mortality among young male foreigners. The first wave was especially deadly for foreign-born people, especially those from Africa and Asia. They are very numerous in the regions most affected by this wave (Paris region and eastern France) and often hold jobs with high exposure to infection and for which remote working is not possible. And among these African- and Asian-born foreigners, mortality was higher for men than for women [6].

This first spike at ages 25–34 levelled off over time, with both sexes becoming more equally exposed to the virus as normal activities gradually resumed. The main spike at ages 65–74 also partly disappeared in the second half of 2021, perhaps thanks to vaccination. At these ages, more than 10% of women are unvaccinated, compared with just 8% of men [7] (see online appendix), perhaps because men took priority for vaccination over women of the same age due to their higher prevalence of comorbidities. Men also appear more willing to be vaccinated than women, or at least more compliant with health guidelines. This is surprising, given that men are generally found to pay less attention to their health than women.

1.2. How does France compare with other countries?

In France, male excess COVID-19 mortality is around the average with respect to other countries (Figure 3). It is higher in Italy and Spain, and lower in England and Wales and in the United States. The age profiles are similar in Latin countries (Italy, Spain, France), with a sharp spike for men in their 60s. The spike is less pronounced in England and Wales and in the United States, and occurs closer to age 50.

In-depth analyses taking account of comorbidities and detailed vaccination rates by sex and age will be needed to shed light on these differentials. But we do not yet have this information for all countries; let us hope it becomes available soon.