# The COVID-19 Crisis, A Powerful Indicator of the Impact of Gender on Health: A Comparative Study Between France and the USA

Catherine Vidal, Jennifer Merchant

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Catherine Vidal, Jennifer Merchant. The COVID-19 Crisis, A Powerful Indicator of the Impact of Gender on Health: A Comparative Study Between France and the USA. 2021. inserm-03405060

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# The COVID-19 Crisis, A Powerful Indicator of the Impact of Gender on Health: A Comparative Study Between France and the USA

September 2021

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# The COVID-19 Crisis, A Powerful Indicator of the Impact of Gender on Health: A Comparative Study Between France and the USA

## Plan

## Introduction

1. Mortality linked to COVID-19: men more affected than women

1.1 Biological causes?

1.2 Differences between the sexes in COVID-19 mortality: multiple reasons

- *Age, sex, and mortality linked to COVID-19*

- *Comorbidities, sociocultural context, ethnicity, and mortality linked to COVID-19*

2. COVID-19 and lockdown: health and social repercussions that affect women and men differently

2.1 Work life and economic situation

2.2 Lockdown and psychological impact

2.3 The weight of lockdown on sexual and reproductive health

2.4 Lockdown and violence

3. Absence of women in COVID-19 crisis units and in the media

4. Conclusions and outlook
Introduction

In the majority of the world’s regions, the figures are striking: men are statistically more likely to die of COVID-19 than women. Another observation is that lockdown measures and the health and social repercussions of the pandemic have thrown into stark relief, as rarely before, the situations of inequality between women and men, both in France and in many other countries.

These observations underline the extent to which considering the question of gender - combined with that of sex - constitutes an essential dimension to better understand the mechanisms of infection and develop treatment and prevention measures. With this in mind, we have compared the impact of COVID-19 in France and in the USA – two countries that differ widely in terms of culture, economy, and healthcare policies.

We will see that this comparison paradoxically highlights many similarities which have social gender relations as their common denominator – a major source of health, social and economic inequalities to the detriment of women. A second salient point concerns the dysfunction of public policies in the USA that struggle to guarantee an egalitarian healthcare system to ensure the rights of women.
Regarding the French and US healthcare systems

Overall quality of health, for both women and men, is better in France than in the USA. The main reason for this lies in the public health coverage system (social security) that French nationals and immigrants living in France benefit from. In the USA, there are only two national social security programs: Medicaid for people living below the poverty line (almost 20% of the total population) and Medicare for anyone aged 65 and over (14% of the total population). Concerning the other categories of Americans, health insurance is paid for by the employer, or they pay for their own insurance, or they take out bank loans in the event of illness, even to finance childbirth. The differences in health quality between the two countries are also linked to sociocultural factors: dietary habits, working conditions, etc. that affect physical and mental health.

According to a 2019 report by the Organisation for Economic Co-operation and Development (OECD), the USA ranks poorly for all health indicators. Life expectancy is lower there than in most other industrialized countries. Although the proportion of adults who smoke in the USA is among the lowest of the OECD countries, alcohol and drug use is higher, as is the obesity rate.<fnref n="1" /> Strikingly, of all developed nations, the USA has the worst maternal mortality rate and ranks last in access to sexual and reproductive healthcare for its population. In 2019, the maternal mortality rate for non-Hispanic Black women was 44 deaths per 100,000 births, i.e. 2.5 times the rate of non-Hispanic White women and 3.5 times that of Hispanic women (12.6%).²³

1. Mortality linked to COVID-19: men more affected than women

In April 2021, an epidemiological review by Santé Publique France (the French Public Health Agency) showed that men accounted for around 56% of deaths linked to COVID-19. In the USA, this figure was 54.2% (August 2021), according to figures from the Centers for Disease Control and Prevention (CDC).<fnref n="4" />

According to a meta-analysis from December 2020 based on data from 47 countries (Peckham 2020), there is no difference between the sexes on the worldwide scale when it comes to infection. However, men are almost three times more likely than women to be hospitalized in intensive care (2.84 times), and their probability of death is also higher (1.39 times).

<footnote n="1">¹. https://www.oecd.org/fr/sante/systemes-sante/panorama-de-la-sante-19991320.html</footnote>

<footnote n="2">². http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)31470-2.pdf</footnote>

<footnote n="3">³. https://www.cdc.gov/nchs/data/hestat/maternal-mortality-2021/maternal-mortality-2021.html</footnote>

<footnote n="4">⁴. https://covid.cdc.gov/covid-data-tracker/#demographics</footnote>
Are women spared by their biology? Do their genes and hormones afford them natural protection? The reality is clearly much more complex than that (Vidal 2020).

## 1.1 Biological causes?

The supposed protective role of gonadal hormones in vulnerability to COVID-19 is regularly cited in media and social networks. For example, *The New York Times* led its April 27, 2020 issue with: "*Can Estrogen and Other Sex Hormones Help Men Survive Covid-19?* " The article mentioned two clinical trials ongoing in the USA that are testing the effects of administering estrogen and progesterone in male patients with moderate symptoms of the disease. Another clinical trial is studying the influence on the course of the disease of using drugs to reduce testosterone levels. However, the hormone hypothesis contradicts the fact that in the population of the most vulnerable elderly people, post-menopausal women – whose gonadal hormone levels are very low – are still more resistant than men.?? In addition, preliminary studies suggest that SARS-CoV-2 affects certain female populations more: pregnant and postmenopausal women and women with polycystic ovary syndrome (Gotluru 2021).

Other studies are exploring the avenue of sex-related genetic factors implicated in immune defenses and mechanisms of viral penetration in the cells (Gotluru 2021, Channappanavar 2017, Takahashi 2020). In a recent study (Grzelak 2021) on the kinetics of humoral response to a moderate form of COVID-19, it appears that men have more antibodies than women one month after infection. But over the next six months, the antibody level decreases more slowly in women than in men, regardless of age or weight. The causes of this immune particularity (if confirmed) are not known. The question is open regarding the possibility of sex-based differences in terms of vaccine efficacy and susceptibility to variants (Bunders 2020, Gaebler 2021).

Worthy of mention is a large-scale study published in *Nature* in 2021 on the genomes of 50,000 patients and 2 million control subjects from 19 countries (Covid-19 Host Genetics Initiative). Thirteen DNA sequences (loci) have been correlated with more or less severe forms of COVID-19, some of which are associated with pulmonary, auto-immune, and inflammatory diseases. The article does not mention differences between the sexes.
So far, the results of research into COVID-19 pathophysiology in women and men are
still too preliminary to envisage targeted therapeutic and vaccine strategies based on sex.

1.2 Differences between the sexes in COVID-19 mortality: multiple reasons

Since the start of the pandemic, several countries have developed statistical and
demographic tools to count COVID-19 deaths and compare data between countries (Harvard
GenderSci Lab, 2020; Riffe 2020). Globally, while there are more men than women among
COVID-19 related deaths, the extent of male disadvantage differs from one country to the
next depending on interactions of many factors: age, sex, comorbidities, and social, cultural,
and economic context.

*Age, sex, and mortality linked to COVID-19*

A fundamental point when it comes to comparing and interpreting the data is to
calculate the COVID-19 mortality rates by age and sex. In fact, the pyramid of ages within the
population varies by country and region. Given the vulnerability to the virus of elderly people,
men in particular, their proportion in a given population plays a decisive role in the number of
deaths.

**In France**, Inserm's "Epidemiology center on the medical causes of death" (CépiDC) has mobilized to monitor in real time the evolution of the number of COVID-19 death certificates by sex, age, region, and department. On the maps and charts available so far, it is reported that the data are incomplete. Weekly statistics for some departments cannot be presented, in order to preserve data confidentiality.<fnref n="5" />

The difficulties in collecting data also concern the GEODES Cartographic
Observatory of Santé Publique France, whose objective is also to monitor the COVID-19
epidemic by region, department, sex, and age group.<fnref n="6" /> In fact, in the majority of the
publications of the Weekly epidemiological bulletin (BEH), statistics on the number of people
who died with a COVID-19 diagnosis do not distinguish between men and women.<fnref n="7" />

<footnote n="5">5. https://opendata.idf.inserm.fr/cepidc/covid-19/index.html</footnote>

<footnote n="6">⁶. https://geodes.santepubliquefrance</footnote>

<footnote n="7">7. www.santepubliquefrance.fr/dossiers/coronavirus-covid-19</footnote>
It is important to note the mobilization by the French Institute for Demographic Studies (INED) to provide free access to national and international data on deaths linked to COVID-19, which are documented and detailed by sex, age group, and place of death.<fnref n="8" /> The site provides information accessible to a wide readership in order to shed light on the potential of the data but also the limits and pitfalls to avoid when using them (Garcia 2021).

**In the USA,** Harvard University is taking a similar approach. The *GenderSci Lab* research group, led by Sarah Richardson, has been collecting all of the COVID-19 cases that have occurred since April 2020 in the country's 50 states.<fnref n="9" /> These figures, updated each week, reveal that it is not an absolute rule that men are more vulnerable. Indeed, the differences between the sexes in terms of prevalence and mortality vary greatly from one state to another. In Dakota, Kentucky, Massachusetts, and Rhode Island, mortality is highest among women (53 to 56%). However, in the states of New York, Oregon, California, and Nevada, mortality is highest among men (56 to 58%).

When all aspects of the age factor are taken into account (by comparing the percentage of COVID-19 deaths with the population age pyramid of each state, bearing in mind that women have a longer life expectancy than men), excess male mortality is more common but with strong variations. In the states of New York, Texas, and New Jersey, twice as many men as women have died from the infection compared with the usual mortality rates. However, in Kentucky, Maine, New Hampshire, Utah, and Vermont, equal numbers of men and women have died from COVID-19. The GenderSci Lab has published a recommendation guide for researchers and the media on statistical bias and the impact of factors linked to sex and gender on COVID-19 mortality.<fnref n="10" />

*Comorbidities, sociocultural context, ethnicity, and mortality linked to COVID-19*

Another major element to take into account is that of comorbidities that for a given age group, can affect men and women differently (Shattuck-Heidorn 2020). Chronic cardiovascular and respiratory diseases, diabetes, kidney and liver diseases, obesity, psychiatric disorders, immunodeficiency, are proven risk factors for death from COVID-19. The prevalence of these diseases varies by sex and gender, in connection with the social,

<footnote n="8">⁸. https://dc-covid.site.ined.fr/</footnote>

<footnote n="9">⁹. https://www.genderscilab.org/covid-19-project</footnote>

<footnote n="10">¹⁰. https://www.genderscilab.org/blog/covid-communication</footnote>
cultural, economic, environment, etc. Thus, in many countries (including France and the USA), heart disease, diabetes, and obesity are more common in men, whereas women are more affected by asthma. There are many risk factors linked to gender: alcohol consumption, smoking, occupational exposure, respect of prevention measures, access to healthcare, etc.

Whether it concerns COVID-19 or previous epidemics, the socioeconomic profile of the victims and also their ethnic profile are key factors in understanding the disparity between the sexes in terms of susceptibility to infection and mortality (Bajos 2020, Danielsen 2020, Williamson 2020).

**In France,** statistics from the National Institute of Statistics and Economic Studies (INSEE) have revealed marked differences in excess mortality linked to COVID-19 depending on country of birth.<fnref n="11" /> In March-April 2020, for people born in France, the increase in deaths was almost identical for both sexes (+25% for women and +26% for men). On the other hand, the increase in deaths was higher among people born in a Maghreb country (+61% for men and +44% for women), as well as for those born in another African country (+131% for men, +88% for women), and for those born in Asia (+101% for men, +79% for women). Among the factors contributing to the increased mortality of people born abroad, the INSEE report points to their concentration in densely populated regions highly affected by COVID-19, cramped housing, and the more frequent use of public transport for professions whose activity was not restricted during lockdown.

It must be remembered that ethnic statistics are prohibited in France, which limits the analysis of data on the links between COVID-19, sex, and ethnicity. This is not the case in the **USA** where researchers have long been studying the health status of immigrant populations and minorities. According to the latest CDC surveys, racial and ethnic minorities are disproportionately affected by COVID. The hospitalization rate for Black Americans, Native Americans and Latinos is four to five times that of Whites. For example, in Chicago and Louisiana, 50% of COVID-19 cases and 70% of deaths concern Black people, though they represent only 30% of the population. The reasons for this excess mortality are linked to the high risks of minorities becoming infected in, for example, the healthcare, public transport, and service industries... where working from home is impossible. Finally, minority

<footnote n="11">¹¹. https://www.insee.fr/fr/statistiques/4627049#consulter</footnote>
populations do not always have health insurance and the healthcare they receive is inferior, for reasons of racial prejudice.<fnref n="12" /> <fnref n="13" /> <fnref n="14" />

## Sex and gender in viral epidemics prior to COVID-19

Several examples demonstrate the importance of taking gender into account in viral infections. The 1918 Spanish influenza pandemic predominantly affected men, particularly manual workers and those in the military. These groups were the most exposed to close contacts with others and more affected by tuberculosis, making them more vulnerable. Mortality in men from the wealthy classes was the same as that of women.

In coronavirus infections such as SARS-CoV-1 (Severe Acute Respiratory Syndrome epidemic in Asia) and MERS (Middle East Respiratory Syndrome), men were more affected than women. Once again, social context played a decisive role. For SARS, the mortality of men was 10% higher than that of women. But after taking into account factors related to age, comorbidity, professional activity and lifestyle, the death rates were similar for both sexes. As for MERS, transmitted primarily by camels, elderly men who traditionally tend to them were the predominant victims.

## 2. COVID-19 and lockdown: health and social repercussions that affect women and men differently

### 2.1 Working conditions and economic situations

Throughout the world, surveys have shown that women have been more affected by the crisis than men.<fnref n="15" /> In rich countries, one of the reasons is that women are overrepresented in precarious jobs and **impacted** sectors such as tourism. In developing countries, 47 million women fell below the poverty line, wiping out decades of progress.<fnref n="16" />

**In France**, the COCONEL survey conducted by a consortium of researchers and the polling institute IFOP followed, throughout the month of March 2020, the perceptions and behaviors of a representative sample of the population in relation to COVID-19 and lockdown.<fnref n="17" /> The results show strong sex-based disparities in working and living conditions,

<footnote n="12">¹². https://jamanetwork.com/journals/jama/fullarticle/2764789</footnote>

<footnote n="13">¹³. « Deaths by Race/Ethnicity » : https://covid.cdc.gov/covid-data-tracker/#demographics</footnote>

<footnote n="14">¹⁴. « Deaths by Race/Ethnicity : State by State » : https://covidtracking.com/race/dashboard</footnote>

<footnote n="15">¹⁵. https://www.unwomen.org/gender-equality-in-the-wake-of-covid-19</footnote>

<footnote n="16">¹⁶. Programme des nations-unies pour le développement PNUD, https://www1.undp.org/content/undp/fr/home/news-centre/news/2020/_COVID-19_will_widen_poverty-gap-between_women_and_men_.html</footnote>

<footnote n="17">¹⁷. https://www.ehesp.fr/2020/04/08/etude-coconel</footnote>
with more marked worsening in the most impoverished social categories. It is the economic situation of women that has deteriorated the most. Among those who were working as of March 1, 2020, only two out of three were still at work two months later, versus three out of four men (Lambert 2020). A very large proportion of executives worked from home, whereas almost half of all manual and non-executive workers, many of whom women, were stopped. With the closure of schools, single mothers who had to stop working were particularly penalized by the loss of income. However, it should be emphasized that partial unemployment measures taken by the government have made it possible to limit the destruction of jobs and the mass withdrawal of women from the labor market.<fnref n="18" />

The personnel who continued to work was present on site with a high risk of exposure to infection. This situation has particularly affected women who are overrepresented in "care" work and in the service industries: nurses and nursing assistants in hospitals (90% female), retirement homes (90%), care assistants (97%), mass retail checkout operators (90%), teachers (83% women at primary level), school staff, cleaning staff (76%). These are the roles with the highest proportion of infected employees.<fnref n="19" /> <fnref n="20" />

Added to these data are those of two major surveys coordinated by Inserm – EpiCoV (Epidemiology and living conditions) and SAPRIS (General population health, practices, relationships, and social inequalities during the COVID-19 crisis) – the results of which are in the process of publication.<fnref n="21" />

<footnote n="18">¹⁸. https://blocnotesdeleco.banque-france.fr/billet-de-blog/le-travail-des-femmes-pendant-la-crise-de-la-covid-19</footnote>

<footnote n="19">¹⁹. https://www.haut-conseil-egalite.gouv.fr/parite/actualites/article/femmes-providentielles-mais-femmes-invisibles-sous-payees-surchargees</footnote>

<footnote n="20">²⁰. https://www.lecese.fr/actualites/crise-sanitaire-et-inegalites-de-genre-le-cese-alerte?</footnote>

<footnote n="21">²¹. https://www.sapris.fr ; https://www.epicov.fr/</footnote>
What is "care"?

It is a term that encompasses two concepts. The first being the moral values of being attentive to and looking after others. These capacities are those historically assigned to women who have to look after children, the sick, the elderly...

The second corresponds to social and professional care and service activities, which are most often provided by women. The COVID-19 epidemic has put the spotlight on these various professions that meet essential daily life needs and are often invisible and poorly paid or not at all.

- Sandra Laugier: *Le Souci des autres. Ethique et politique du care*, Editions de l'EHESS, 2005.

- Pascale Molinier: *Le Care monde. Trois essais de psychologie morale*, ENS Lyon Editions, 2018.

The recognition of COVID-19 as an **occupational disease** was the subject of a decree published in France's *Official Gazette* on September 15, 2020. The status of occupational disease is now automatically granted to healthcare workers with a severe form of COVID-19 requiring oxygen. The other categories of workers must encounter a committee of experts in order to benefit from this recognition.<fnref n="22" /> French state health insurance figures published in February 2021 show that the percentage of professionals recognized as infected with coronavirus is low. Only 437 out of 16,919 declarations received resulted in recognition, representing a coverage rate of 2.6%. This is partly due to the fact that demonstrating the situation is complicated for non-healthcare professional categories in contact with the public during the health emergency, particularly for those who ensured the essential functioning of the country (food, public transport, security, cleaning, etc.). Women have played a massive role in this.<fnref n="23" />

Finally, it should be emphasized that the pandemic period has also had the consequence of worsening **failure to seek treatment**, a phenomenon that is more marked in women. According to a survey by the "Observatory for the non-take-up of rights and services" (Odenore), 64% of women declared having not taken up an essential medical procedure, versus 53% of men. The reasons for this are socioeconomic: drop in income, loss of employment, single-parent family (Beltran 2020).

<footnote n="22">²². https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000042328917</footnote>

<footnote n="23">²³. https://www.lecese.fr/actualites/crise-sanitaire-et-inegalites-de-genre-le-cese-alerte</footnote>
**In the USA** as in France, the health crisis has particularly weakened service industry jobs where women predominate (retail trade, catering, tourism, caring, cleaning, etc.). Women have been more numerous in giving up work to care for children. The COVID-19 crisis has also revealed the inequalities faced by African American women in the labor market. The average pay gap between Black women and White men is 37%, while it is 17.7% between women and men in the general population.<fnref n="24" /> <fnref n="25" />

There is no national **unemployment** benefit program in the USA. While the Department of Labor records the number of job seekers across the country for statistical purposes, it is up to each state/jurisdiction to allocate unemployment benefits according to its own eligibility criteria. The economic crisis linked to COVID-19 has not given rise to short-time working measures, unlike France.

The recognition of COVID-19 as an **occupational disease** has not been declared at the national level, except for federal employees (prison, law enforcement and other professions at risk of infection). A federal agency - the Occupational Safety and Health Administration (OSHA), which is part of the Department of Labor, https://www.osha.gov/ - registers employee complaints at national level for accidents or illness at work. The compensation procedure is managed by each state according to its own laws – where these exist. If this is not the case, workers turn to the justice system.

## 2.2 Lockdown and psychological impact

The effects of the crisis have been felt in the private sphere in connection with the reorganization of everyday domestic life and socioeconomic insecurity. The "mental burden" of women saw a marked increase with housework and supervising their children's home-schooling, tasks which for the most part fell to them.

**In France**, several investigations into the psychological impact of lockdown have revealed a marked risk of **domestic burnout** in women. Single-parent families are particularly exposed to this risk of exhaustion, but also to the risk of isolation, in urban and

<footnote n="24">²⁴. https://voxeu.org/article/expanding-gender-gap-us-due-covid-19</footnote>

<footnote n="25">²⁵. https://iwpr.org/iwpr-publications/fact-sheet/shortchanged-and-underpaid-black-women-and-the-pay-gap/</footnote>
rural areas.<fnref n="26" />

The world of work is equally concerned. The number of employees of either sex on sick leave for psychological disorders rose from 9% to 18% after the first lockdown.<fnref n="27" /> <fnref n="28" />

Female-dominated occupations have been particularly overexposed to **psychosocial risks** (nurses, nursing assistants, cashiers). During the second lockdown, 58% of female employees suffered from psychological distress.<fnref n="29" />

The closure of **universities** intensified the economic and psychological vulnerabilities faced by students, particularly female students: 40% of female students and 31% of their male counterparts stopped their paid activity during the first lockdown. According to the "Observatory of student life", 36% of female students showed signs of psychological distress versus 25% of male students.<fnref n="30" />

Many studies focus on the current and future consequences of the health crisis and lockdown on the **mental health** of the population: increase in sleep disorders, addictions, depression, anxiety, etc. The international COCLICO survey (Coronavirus Containment Policies and Impact on the Population's Mental Health) aims to assess the effects of lockdown on mental health, the associated factors, and their evolution over time. The first results of the French branch of the survey indicate the occurrence of psychological distress in 33% of respondents, including 12% with severe distress. The populations most at risk have been identified, particularly women in situations of economic and social precariousness.<fnref n="31" /> <fnref n="32" /> In March 2020, Santé Publique France launched the CoviPrev survey in the general population in order to monitor changes in behavior (barrier measures, lockdown, alcohol and tobacco consumption, diet, and physical activity) and mental health (well-being, disorders), as well as

<footnote n="26">²⁶. https://www.lecese.fr/actualites/crise-sanitaire-et-inegalites-de-genre-le-cese-alerte</footnote>

<footnote n="27">²⁷. Baromètre annuel Absentéisme Maladie 2020, https://newsroom.malakoffhumanis.com/actualites/malakoff-humanis-presente-les-resultats-2020-de-son-barometre-annuel-absenteisme-maladie-545f-63a59.html</footnote>

<footnote n="28">²⁸. https://www.liberation.fr/france/2020/12/17/teletravail-un-salarie-sur-deux-en-detresse-psychologique_1808978/</footnote>

<footnote n="29">²⁹. https://www.50-50magazine.fr/2021/01/07/les-penibilites-invisibles-des-metiers-occupes-par-les-femmes/</footnote>

<footnote n="30">³⁰. http://www.ove-national.education.fr/enquete/la-vie-detudiant-confine/</footnote>

<footnote n="31">³¹. www.irdes.fr/coclico</footnote>

<footnote n="32">³². https://www.irdes.fr/recherche/2020/qes-249-les-inegalites-face-au-risque-de-detresse-psychologique-pendant-le-confinement-premiers-resultats-enquete-coclico.html</footnote>
their main determinants. The first published results on mental health do not include an
analysis based on sex.<fnref n="33" />

**In the USA,** as in France, surveys carried out during the pandemic have revealed widespread poor mental health, mainly among locked-down families, "key" workers, students and more particularly among women. The increase in domestic violence is an aggravating factor. In a survey conducted by the Kaiser Family Foundation (KFF), 53% of women said the COVID-19 crisis had a significant negative impact on their mental health (anxiety, depression, sleep disorders, suicidal thoughts) versus 37% of men.<fnref n="34" /> Women from ethnic minorities have been particularly affected.<fnref n="35" />

## 2.3 The weight of lockdown on sexual and reproductive health

Lockdown and strong pressure on the hospital system have made access to healthcare more complicated in general, with a particular threat to the sexual and reproductive rights of women.

### In France

#### Access to abortion

During the first lockdown, the statistics of calls to the national toll-free number "Sexuality, Contraception, Abortion" revealed that reports of difficulties related to abortion or contraception had increased by 320% compared with the same period of 2019.<fnref n="36" /> Indeed, the medical teams and services that provided abortions have to a large extent been redirected towards fighting COVID-19. In addition, the limitation of travel had complicated the possibility of obtaining a medical consultation within the legal deadlines. This resulted in diagnosis delays and abortion requests beyond the deadline at the time the lockdown was put into place.

This situation led the Health Minister to take exceptional measures (French health emergency law of March 23, 2020):

<footnote n="33">³³. https://www.santepubliquefrance.fr/etudes-et-enquetes/coviprev-une-enquete-pour-suivre-l-evolution-des-comportements-et-de-la-sante-mentale-pendant-l-epidemie-de-covid-19</footnote>

<footnote n="34">³⁴. https://www.kff.org/coronavirus-covid-19/poll-finding/mental-health-impact-of-the-covid-19-pandemic/</footnote>

<footnote n="35">³⁵. https://pubmed.ncbi.nlm.nih.gov/33263142/</footnote>

<footnote n="36">³⁶. https://www.planning-familial.org/fr/contraception/sexualites-contraception-ivg-</footnote>
- Extension of the deadline for medical abortion at home from 5 to 7 weeks of pregnancy

- Possibility to prescribe medical abortion via telemedicine to limit travel and/or take into account difficulties accessing healthcare facilities

- Possibility to obtain the contraceptive pill, even if the prescription has not been renewed

- Possibility for medical abortions beyond the legal period for abortion (12 weeks of pregnancy) on the grounds of "psychosocial distress" – when continuing the pregnancy would seriously endanger the woman's health.<fnref n="37" />

### Access to ART (assisted reproductive technology)

In Spring 2020, ART centers had to close, their activities considered as non-priority. They then resumed with an activity reduced by 30 to 50% depending on the centers, leading to delays in medical procedures (artificial insemination, in vitro fertilization, collection of gamete donations, etc.).

The French Biomedicine Agency publishes regularly updated recommendations on ART activities in relation to COVID-19. The July 2021 version includes a document summarizing the main questions raised by couples undergoing ART, including vaccination, whilst emphasizing that the scientific data on the effects of the virus on female and male fertility, pregnancy and ART are still rare and incomplete.<fnref n="38" />

## In the USA

### Access to abortion

In the USA, the pandemic has translated very concretely into increased pressure to close clinics that perform abortion. Long before the economic upheavals of COVID-19, many women already could not afford the cost of an abortion. Since 1980, the Hyde Amendment (renewed annually with each vote of the new federal budget) prohibits Medicaid – federal health insurance program for the poor – from financing abortion. However, the majority of patients who have abortion are poor. Half of these women live below the poverty line. Women from Black, Latin American, and Native American communities are the most affected.

<footnote n="37">³⁷. https://ivg.gouv.fr/ivg-et-mesures-exceptionnelles-en-periode-covid-19.html</footnote>

<footnote n="38">³⁸. https://www.agence-biomedecine.fr/Recommandations-sur-les-modalites-de-prise-en-charge-des-couples-dans-le</footnote>
Since the start of the pandemic, anti-abortion movements have increased their demands, arguing that abortion is not essential healthcare and that banning it would allow healthcare workers to deal exclusively with cases of COVID-19. In 2020, twelve states attempted to ban abortion, including Alaska, Iowa, Louisiana, Mississippi, and West Virginia. Some federal courts (Alabama, Ohio, Oklahoma, Tennessee) have succeeded in blocking the bans, but restrictions remain in place in many states.

In response, pro-abortion movements have demanded greater access to telemedicine-assistance in providing the abortion pill. Reproductive health advocacy organizations (Aid Access, Plan C, Self-Managed Abortion, Safe and Supported Project) provide information and support on their platforms on how to use the abortion pill safely. But many legal and regulatory obstacles persist. Some states require that the doctor prescribing the abortion pill be physically present with the patient, a remedy limited by the mobilization of doctors to the COVID-19 front. Regulations exclude midwives, often more available than doctors for medical abortion.

So far, there are no statistical data that compare the number of abortions before and during COVID-19. According to a qualitative study of twenty abortion service providers in private clinics in the southern and midwestern USA, staff interviewed reported increased difficulties in enabling patients to obtain an abortion: abrupt closure of clinics, need to call on itinerant doctors, limits imposed by the legislator on telemedicine, intensification of the activities of anti-abortion demonstrators, unconstitutional regulations prohibiting medical abortion.<fnref n="39" />

## Access to ART (assisted reproductive technology)

The work of US professional networks in the ART field has revealed that the pandemic has significantly reduced the activity of the 400 infertility clinics nationwide.<fnref n="40" /> <fnref n="41" />

<footnote n="39">³⁹. Carole Joffe, « COVID-19, Health Care, and Abortion Exceptionalism in the United States », 26 août 2021 : https://onlinelibrary.wiley.com/doi/full/10.1363/psrh.12182</footnote>

<footnote n="40">⁴⁰. https://www.fertstert.org/article/S0015-0282(20)30619-1/fulltext</footnote>

<footnote n="41">⁴¹. In Vitro Fertilization Market Size, Share & Trends Analysis Report By Type (Fresh Donor, Frozen Nondonor), By Instrument (Disposable Devices, Culture Media), By End-use, By Region, And Segment Forecasts, 2021 – 2028, July, 2021. https://www.grandviewresearch.com/industry-analysis/in-vitro-fertilization-market#utm_source=Social&utm_medium=Twitter&utm_campaign=covid19-alertCP_2-Aug-2021_hc&utm_content=in-vitro-fertilization-market</footnote>
The impact on women has been greater than on men.<fnref n="42" /> It should be noted that the closures of IVF centers around the world, and more particularly in the USA, resulted in a $6 billion decrease in the ART market between 2019 and 2020.

## 2.4 Lockdown and violence

Everywhere in the world, violence against women (and children) escalated during COVID-19 (North, 2020). The main reason was the lockdown, which socially and physically isolates families and increases tensions between people (Van Gelder et al., 2020).

### In France

During the first lockdown, police interventions in domestic issues increased by 42% compared with the same period in 2019. During the second lockdown, the "arretonslesviolences.gouv.fr" platform recorded a 60% increase in reports compared with 40% during the first lockdown. Domestic violence represented the bulk of police custody from the start of the lockdown.

The lockdown context complicated assisting victims. Support and accommodation structures have seen their financial and operational difficulties accentuated by health imperatives (Economic, Social and Environmental Council [ESEC]).<fnref n="43" /> Several measures have been taken by the public authorities: systems for reporting violence in pharmacies, shopping centers, on the Internet, via SMS through the extended availability of 3919, the national hotline for women who are victims of violence. Additional resources have been allocated for accommodation and assistance to associations fighting against violence against women.

<footnote n="42">⁴². https://www.abdn.ac.uk/news/14623/</footnote>

<footnote n="43">⁴³. CESE: https://www.lecese.fr/travaux-publies/combattre-toutes-les-violences-faites-aux-femmes-des-plus-visibles-aux-plus-insidieuses</footnote>
## In the USA

In the USA, more than 10 million women are victims of domestic violence each year.<fnref n="44" /> A figure that rose by 8.1% in major US cities during lockdown. Calls to the emergency services increased by 9.7%. In a survey carried out in May 2020, one third of women who had suffered violence had difficulty seeking services in response to the violence they experienced (Lindberg et al., 2020). The Young Women's Christian Association (YWCA), the largest center for services and accommodation for abused women, reported that most of its centers across the country were full, especially in the states most affected by COVID-19. So far, no national assistance program for women and children who are victims of violence has been put in place.<fnref n="45" />

## 3. Absence of women in COVID-19 crisis units and in the media

According to data published by the United Nations Development Program (UNDP) and UN Women, crisis units set up by governments worldwide to fight COVID-19 have four times more men than women, despite women representing 70% of the international healthcare workforce.<fnref n="46" />

## In France

The handling of the crisis in governmental bodies and the media has revealed the invisibility of female experts in the fields of biology and medicine. Yet they are highly present in many research disciplines: medicine, epidemiology, sociology, economics, etc.<fnref n="47" /> However, managerial positions in hospitals, universities and research centers are mainly held by men, meaning that it is they who are generally called upon by the public authorities. At the start of the health crisis in March 2020, the COVID-19 Scientific Advisory Board was comprised of 2 women and 9 men. In July 2021, it was comprised of 5 women and 11 men.

According to two studies by France's Higher Audiovisual Council (CSA) and Audiovisual Institute (INA), the health crisis has accentuated the under-representation of

<footnote n="44">⁴⁴. https://ncadv.org/STATISTICS</footnote>

<footnote n="45">⁴⁵. https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/Domestic-Violence-During-COVID-19-February-2021.pdf</footnote>

<footnote n="46">⁴⁶. https://www1.undp.org/content/undp/fr/home/news-centre/news/2021/Womens_absence_COVID-19_task_forces_perpetuate gender_divide_UNDP_UNWomen.html</footnote>

<footnote n="47">⁴⁷. https://expertes.fr/</footnote>
women in the media. During lockdown, the percentage of female experts on the channels of the national public broadcaster France Televisions was less than 20%, a figure that is usually around 40%. The same situation exists in the print media. A survey carried out by the French Association of Science Journalists (AJSPI) revealed that in January 2021, 70 to 80% of scientists interviewed in the print media (generalist or specialist) were men.<fnref n="48" />

These issues are a central focus of the government report by Member of Parliament, Céline Calvez, which was published in 2020. This report analyzes the presence and speaking time of women in various media during the health crisis and formulates proposals for fighting against the inequalities of representation between women and men.<fnref n="49" />

## In the USA

At the start of the pandemic, only two of the 27 members of the White House Coronavirus Task Force were women. Since the election of Joe Biden, this entity, renamed the White House COVID-19 Response Team, now has 6 women among its 16 members. The Gender Inequality Research Lab (GIRL) at the University of Pittsburgh has launched a research program on the representation of women in leadership positions and within national units fighting COVID-19. A report on the data specific to each state is in progress.<fnref n="50" />

Regarding the place of women in the media, the report entitled "The Missing Perspectives of Women in COVID News", funded by the Bill & Melinda Gates Foundation, provided an overview of the international situation.<fnref n="51" /> Three indicators were measured: women cited as sources of expertise, reports in which the protagonists are women, and the time devoted to sex equality issues in the context of COVID-19. The results show considerable bias in favor of men, both in northern countries (UK, France, USA, among others) and southern countries (India, Kenya, Nigeria, and South Africa). This bias is part of the actual political invisibility of women in the health crisis decision-making processes in the countries analyzed.

<footnote n="48">⁴⁸. https://www.liberation.fr/france/2021/01/28/plus-de-70-des-scientifiques-interroges-dans-la-presse-ecrite-sont-des-hommes_1818678/</footnote>

<footnote n="49">⁴⁹. https://www.culture.gouv.fr/Espace-documentation/Rapports/Rapport-sur-la-place-des-femmes-dans-les-medias-en-temps-de-crise</footnote>

<footnote n="50">⁵⁰. https://www.gspia.pitt.edu/CentersandInstitutes/Initiatives/GenderInequalityResearchLab%28GIRL%29</footnote>

<footnote n="51">⁵¹. https://www.iwmf.org/wp-content/uploads/2020/09/2020.09.23-The-Missing-Perspectives-of-Women-in-COVID-19-News.pdf</footnote>
"Women and COVID-19" international mobilization

- The COVID-19 Global Gender Response Tracker created by UNDP and UN Women, hosted on the COVID-19 Data Futures Platform, provides insight into gender disparities in responses to COVID-19, from gender-based violence to economic recovery and social protection measures targeting women. It has been updated since its launch in September 2020 to include more than 3,100 measures taken in 219 countries and territories.<fnref n="52" />

- In March 2020, the international Gender and COVID-19 Working Group, federating doctors and researchers in the biomedical, human, and social sciences, published an opinion piece in medical journal *The Lancet* on the impact of the epidemic on women's health and their social and economic conditions (Wenham et al 2020). It also emphasizes the fact that there is very little representation of women in the national and global COVID-19 policy arenas, both at the WHO and in US government administrations. The aim of the group's research program is to prepare practical recommendations for health institutions and governments concerning the respect of women's rights in the management of the pandemic.

- These concerns are shared by the UN Human Rights Council and its COVID-19 Working Group which has published a declaration on the risks of discrimination against women and girls linked to the pandemic.<fnref n="53" /> It has called on States to take a gender sensitive intersectional approach in their responses to COVID-19 and implement the following measures:

- Make testing universal and free and follow-up with confinement strategies that do not put women and girls at greater risk of violence and abuse.

- Ensure access to treatment and provide paid sick leave without discrimination for women.

- Expand the systems of social protection, housing subsidies, increased support for child and elderly care.

- Ensure access to healthcare services, including sexual and reproductive health services.

- Provide protection against discrimination and abuse of domestic workers, many of whom are migrant workers.

<footnote n="52">⁵². https://data.undp.org/</footnote>

<footnote n="53">⁵³. https://www.ohchr.org/en/issues/women/wgwomen</footnote>
4. Conclusions and outlook

If we attempt to take stock of the progress of numerous research studies on the
pandemic, it is important to stress the importance of the contribution of the human and social
sciences, fields of study which have proven to be particularly responsive to the crisis situation
alongside research in biology and medicine. These studies have highlighted the negative
impact of COVID-19 on the inequalities between women and men at all levels of social,
economic, and political life. The lockdown has exacerbated sex-based social roles within
families and their imbalances, going against the dynamics of progress in recent decades.
Women have been more exposed than men to the fallout from the pandemic in terms of
economic insecurity and psychosocial risks at work. These are all situations likely to weaken
their physical and mental health: lack of access to healthcare, difficulties in exercising sexual
and reproductive rights, increased domestic violence, psychological distress, etc.

All of these findings underline the need for gendered indicators to analyze and monitor
the effects of the health crisis. This consideration is essential for developing crisis
management and exit policies that correctly take into account the inequalities between women
and men. In this area, France lags behind the USA. The use of gendered data is not yet the
norm. Many surveys are conducted without taking this aspect into account. Cross-referencing
with ethnic data is also lacking.

It should be noted that in France, the fallout from COVID-19 has also had its positive
points. The mobilization of many civil society actors (medical staff, patients, researchers,
associations, etc.) led public authorities to take exceptional measures to guarantee the rights of
women, particularly in the realm of abortion, the mechanisms for reporting violence and
financial assistance to associations. Meanwhile, the lack of female experts in the media and in
decision-making bodies has been the subject of a government report which formulates
proposals to combat inequalities in representation between women and men.

In the USA, where research has benefited from gendered data, it is regrettable that this
information has not been translated into public policies. Dysfunctionning in access to
healthcare, health insurance, and unemployment benefits have had harmful consequences in
terms of public health, especially for women and minority groups. This is illustrated by the
fall in access to abortion during the pandemic and even after... A law passed in September 2021 in Texas prohibits abortion beyond 6 weeks and offers rewards to witnesses who report anyone engaged in an abortion process: the woman, her doctor, her spouse, the Uber driver who took her to the clinic, etc.<fnref n="54" />

To conclude regarding the situation in France, we recommend that the various measures taken in the health emergency context be sustained beyond the crisis period to ensure that women's rights are guaranteed on the health and socioeconomic levels.

As the ESEC report puts it very well, "*for many of us, the way in which the COVID-19 pandemic has called into question dynamics of progress towards equality, which had been considered acquired, constitutes a surprise and a warning on just how much fundamental work remains to be done.*" This conclusion is in line with the ethical concerns of the "Gender and Health Research" group, whose objective is to fight inequalities between women and men in terms of health and access to healthcare, and to propose measures to remedy them.

<footnote n="54">⁵⁴. https://www.lemonde.fr/international/article/2021/09/02/pourquoi-la-loi-tres-restrictive-au-texas-menace-le-droit-a-l-avortement-aux-etats-unis_6093173_3210.html</footnote>
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