Abstract
This cross-sectional study systematically examines the contributions of COVID-19 and other underlying causes of death to the widened gender life expectancy gap from 2010 to 2021.
As life expectancy at birth in the US decreased for the second consecutive year, from 78.8 years (2019) to 77.0 years (2020) and 76.1 years (2021), the gap between women and men widened to 5.8 years, its largest since 1996 and an increase from a low of 4.8 years in 2010.1,2 For more than a century, US women have outlived US men, attributable to lower cardiovascular and lung cancer death rates related largely to differences in smoking behavior.1,2 This study systematically examines the contributions of COVID-19 and other underlying causes of death to the widened gender life expectancy gap from 2010 to 2021.
Methods
Analyses were performed from March to July 2023 using Stata, version 17.0 (StataCorp LLC) and Office Excel (Microsoft). Using mortality data from the National Center for Health Statistics, this cross-sectional study examines the association of changes in cause-specific mortality with changes in the gap in life expectancy at birth between men and women from 2010 to 2021, divided by pre– and post–COVID-19 years. We used a decomposition technique to partition changes in the life expectancy gap between men and women into component additive parts that identify the causes of death having the greatest assocation, positive or negative, with changes in life expectancy.3 Cause of death categories are based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. For further specificity, we partitioned changes in unintentional injuries into select components (unintentional poisoning [mostly drug overdose], unintentional transport-related injuries, and all other injuries). We estimated the differences between men and women in the age-adjusted death rates for the top causes of death associated with changes in the life expectancy gender gap. This study was exempt from review from the Harvard Longwood Campus institutional review board, and informed consent was not required because this study used deidentified data. This study followed the STROBE reporting guideline.
Results
The gender life expectancy gap increased 0.23 years from 2010 to 2019 and 0.70 years from 2019 to 2021. Prior to COVID-19 in 2020, the largest contributors to worsening life expectancy for men vs women were unintentional injuries (−0.23 years [−0.23246/−0.5116 = 45.4%]), diabetes (−0.05 years [10.1%]), suicide (−0.04 years [7.8%]), homicide (−0.03 years [5.3%]), and heart disease (−0.03 years [4.9%]) (Figure, A). This was offset by differential improvement for men vs women in mortality from cancer (0.12 years [43.1%]), Alzheimer disease (0.06 years [20.5%]), and chronic lower respiratory disease (0.04 years [12.3%]), among others.
Figure. Leading Contributors (Increasing and Decreasing) to the Differential Change in Life Expectancy Between Men and Women Before and After the COVID-19 Pandemic, 2010-2019 (A) and 2019-2021 (B).
Perinatal conditions: Certain conditions originating in the perinatal period (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] codes P00-P96); maternal conditions were pregnancy, childbirth, and the puerperium (ICD-10 codes O00-O99).
From 2019 to 2021, COVID-19 became the leading contributor to the widening gender life expectancy gap (−0.33 years [39.8%]) followed by unintentional injuries (−0.27 years [32.5%]) (Figure, B). The increasing maternal deaths among women and the relative reductions in cancer and perinatal conditions among men partially mitigated the increasing gap (Figure, B). From 2010 to 2021, unintentional poisonings (mostly drug overdoses) and unintentional transport-related injuries contributed 0.44 (86.3%) and 0.06 (11.8%) of the 0.51-year decrease in life expectancy from unintentional injuries. The absolute difference in age-adjusted death rates between men and women increased from 252 to 315 per 100 000 between 2010 and 2021, with a persistent gap for heart disease and widening gaps for COVID-19, unintentional injuries, and several other causes (Table).
Table. Differences in Age-Adjusted Mortality Rates for Men and Women by Underlying Causes, 2010-2021.
| Cause of deatha | Age-adjusted mortality rates per 100 000 | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| 2010 | 2019 | 2021 | |||||||
| Men | Women | Difference | Men | Women | Difference | Men | Women | Difference | |
| All causes | 887.08 | 634.93 | 252.15 | 846.71 | 602.75 | 243.96 | 1047.97 | 733.26 | 314.71 |
| COVID-19 | NA | NA | NA | NA | NA | NA | 131.31 | 81.66 | 49.65 |
| Unintentional injuries | 51.53 | 25.61 | 25.92 | 68.29 | 31.31 | 36.98 | 89.77 | 40.43 | 49.34 |
| Diabetes | 24.86 | 17.60 | 7.26 | 27.33 | 16.85 | 10.48 | 31.83 | 20.02 | 11.81 |
| Homicide | 8.36 | 2.26 | 6.10 | 9.61 | 2.39 | 7.22 | 13.17 | 3.09 | 10.08 |
| Heart disease | 225.07 | 143.25 | 81.82 | 204.77 | 126.21 | 78.56 | 219.54 | 135.65 | 83.89 |
| Suicide | 19.80 | 4.98 | 14.82 | 22.37 | 6.00 | 16.37 | 22.78 | 5.72 | 17.06 |
| Cancer | 209.86 | 146.75 | 63.11 | 172.91 | 126.17 | 46.74 | 172.02 | 127.65 | 44.37 |
| Alzheimer disease | 21.01 | 27.32 | −6.31 | 23.86 | 33.57 | −9.71 | 24.05 | 35.39 | −11.34 |
| Chronic lower respiratory | 48.73 | 37.96 | 10.77 | 41.63 | 35.65 | 5.98 | 37.62 | 32.53 | 5.09 |
| HIV | 3.85 | 1.42 | 2.43 | 2.10 | 0.72 | 1.38 | 2.08 | 0.64 | 1.44 |
| Viral hepatitis | 2.93 | 1.36 | 1.57 | 1.39 | 0.71 | 0.68 | 1.14 | 0.58 | 0.56 |
| Perinatalb | 4.65 | 3.79 | 0.86 | 4.17 | 3.40 | 0.77 | 3.99 | 3.40 | 0.59 |
| Residual | 266.43 | 222.63 | 43.80 | 268.28 | 219.77 | 48.51 | 298.67 | 246.50 | 52.17 |
Cause of death categories are based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).
Perinatal conditions (ie, certain conditions originating in the perinatal period [ICD-10 codes P00-P96]).
Discussion
This analysis finds that COVID-19 and the drug-overdose epidemic were major contributors to the widening gender gap in life expectancy in recent years. Men experienced higher COVID-19 death rates for likely multifactorial reasons, including higher burden of comorbidities and differences in health behaviors and socioeconomic factors, such as labor force participation, incarceration, and homelessness.4,5 Differentially worsening mortality from diabetes, heart disease, homicide, and suicide suggest that chronic metabolic disease and mental illness may also contribute. The increase in overdose deaths, homicide, and suicide underscore twin crises of deaths from despair and firearm violence.6 Limitations include binary gender classification and unexplored heterogeneity within disease classifications and across geographic and demographic subgroups. Future analyses could explore whether these trends changed after 2021, especially as the pandemic recedes, with further detail on specific causes.
Data Sharing Statement
References
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Supplementary Materials
Data Sharing Statement
