Various factors have been proposed and examined to explain variations in gender health disparities, encompassing distinct biological risks, acquired risks, reporting biases, and healthcare experiences (Macintyre et al. 1996). The extent and direction of these disparities fluctuate based on specific symptoms or conditions and the life cycle phase. Female prevalence is consistently observed only in the case of psychological distress throughout the lifespan, whereas for several physical symptoms and conditions, it is less evident or even reversed. Despite the complexity and challenges in outlining a common path of explanation for these differences, different possible explanations have been suggested. Generally, the paradox is explained through multiple causes, employing various frameworks: it is possible to distinguish between social or biological differences between sexes and genders, or to define biological, behavioural, and social mechanisms. More exhaustively Bambra and colleagues identify four main generative factors: biological, social, economic, and public policy (Bambra et al. 2021), in particular:
Biological perspectives explore genetic and physiological differences between males and females, potentially influencing susceptibility to certain health outcomes. For instance, immune system variations in sexual chromosomal expressions may impact autoimmunity diseases like Systemic Lupus Erythematosus (SLE) (Wilkinson et al. 2022).
Social explanations focus on gendered behaviours tied to social rules and roles. Traditional masculinity habits lead to health-damaging behaviours in men, while women may experience mental strain due to the imbalance resulting from juggling dual roles in both work and family (Wang et al. 2008). Other health risk factors, such as homicides, are more frequent among men (Lu et al. 2023), as is the consumption of drugs or alcohol (Fonseca et al. 2021, Kossova et al. 2020).
Economic factors, such as low rates of female occupation, the gender pay gap, and labour market segregation, contribute to women's higher rates of poverty and morbidity. Women are also more prone to precarious employment or working in low-wage sectors of the economy (AUTHORS). Overall, female workers tend to have a better health condition than housewives, although this pattern was stronger for low educated women (Bambra et al. 2021, Artazcoz et al. 2004).
Public policy explanations emphasize macro-level determinants shaping gender inequalities, with mixed effects on health outcomes. European family policies, including childcare and parental leave, aim to address gendered care burdens, but their impact on health inequalities remains heterogeneous, crossing with other factors, amplifying them or reducing their effects (Gómez-Costilla et al. 2021).
According to Bambra and colleagues, these four generative factors in shaping the ‘gender health paradox’ could interact with the COVID-19 pandemic effects (Bambra et al. 2021). Recently, scholars highlighted various points of attention, including sex differences in the severity of symptoms and mortality due to COVID-19. Males were more likely than females to require intensive care unit admission, likely due to biochemical sex differences in specific immune factors (ACE2 enzyme, T cell response, and others) (Wilkinson et al. 2022). Other scholars emphasize higher psychological distress in women during the more dramatic periods of the COVID-19 outbreak, perhaps explained by a greater negative reaction to adverse events tied to the pandemic (Szabo et al. 2020, AUTHORS). A particular concern is the augmented risk for women for intimate partner violence. A literature review by Kourti et al. shows that lockdown led to constant contact between perpetrators and victims, resulting in increased episodes of domestic violence suffered by women (Kourti et al. 2023). Examining the occupational structure, women are more present in healthcare and assistance services, directly experiencing a higher risk of exposure to COVID-19 (Bandyopadhyay et al. 2020). Moreover, according to Utzet and colleagues (Utzet et al. 2022), the suspension of activities during lockdown also had indirect gender impacts, particularly affecting women in roles such as healthcare, cleaning, geriatric care, and food retail. These sectors, already marked by precarious conditions and indicators of poor health before the pandemic, faced intensified challenges. Women, whether essential or non-essential, engaged in telework, took on the majority of household caregiving responsibilities, potentially contributing to declining mental health during lockdown, especially for the most vulnerable women.
Collectively, these factors could accelerate the ‘gender health paradox’, increasing mortality in men and worsening health in women.