Sex differences in excess mortality during the COVID-19 pandemic: a longitudinal ecological analysis of 34 high-income countries.

Authors

Katarzyna Doniec, Jonas Schöley, Mine Kühn, Jennifer Beam Dowd

Published in

EClinicalMedicine. Volume 98. Pages 104072. Epub Jul 23, 2026.

Abstract

The COVID-19 pandemic was a significant global mortality shock. In addition to baseline differences in mortality risk, males often face a survival disadvantage in crisis situations such as famines and epidemics. Although many countries have reported higher numbers of male COVID-19 deaths, the evolution of sex differences in mortality over the course of the pandemic, and how these differences compare using both relative (accounting for higher male baseline mortality) and absolute measures remains underexplored. This study aimed to assess absolute and relative sex differences in all-cause excess mortality during the COVID-19 pandemic across three pandemic phases in 34 high-income countries.
We examined sex differences in excess mortality from February 2020 to July 2023 using data from 34 countries in the Short-Term Mortality Fluctuations dataset. We estimate both absolute (male excess mortality-female excess mortality) and relative (male P-score-female P-score) sex differences in pandemic-related all-cause excess mortality. We analysed sex differences monthly and across three pandemic phases: pre-vaccine, post-vaccine, and endemic.
In most countries, absolute male excess mortality exceeded that of females during the pre-vaccine phase of the pandemic. A significant absolute male disadvantage in excess mortality rates was observed in 60% (81/136) of age-group-country combinations in the pre-vaccine phase, decreasing to 51% (70/136) in the post-vaccine phase and 23% (31/136) in the endemic phase. In contrast, a male disadvantage was less common for relative changes: a significant male disadvantage in excess mortality P-scores was observed in only 28% (38/136) of age-group-country combinations in the pre-vaccine phase and 14% (19/136) in the post-vaccine phase. The remaining combinations showed either no significant sex difference or a female disadvantage, with little evidence of relative sex differences during the endemic period. Sex differences in absolute excess mortality tended to grow with age, but there was no clear pattern in the relative sex differences across age groups.
While previous research has highlighted a male disadvantage in COVID-19 mortality based on absolute death counts, our study shows that this pattern was concentrated in the pre-vaccine phase and declined over time. Relative increases in all-cause excess mortality were often similar between sexes and, in some cases, greater among women. These findings suggest that sex differences in pandemic-related mortality were more varied than commonly assumed and underscore the importance of using both absolute and relative measures to assess the impact of health crises on population subgroups. Finally, our results suggest that COVID-19 did not produce lasting shifts in sex differences in mortality.
This work was supported by the European Research Council (ERC-2021-CoG-101002587) and the Leverhulme Trust (Grant RC-2018-003) for the Leverhulme Centre for Demographic Science.

PMID:
42542596
Bibliographic data and abstract were imported from PubMed on 02 Aug 2026.

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