Monkeypox Infection Patterns in Women

This is the first series of global case studies of monkeypox infection in women ( cisgender and transgender ) and non-binary people in the ongoing outbreak.

The authors found different clinical presentations depending on gender identity and sexual practices.

Sexual contact is the most likely route of transmission in 89% of trans women and 61% of cis women and non-binary people, and almost a quarter of cis women are suspected of becoming infected without sexual contact .

An international collaboration of doctors, established and led by Professor Chloe Orkin at Queen Mary University of London, has published the first series of case studies of monkeypox infection during the 2022 outbreak in cisgender (cis) and transgender women (trans) and non-binary individuals assigned female at birth.

The case series, published in The Lancet , provides much-needed information on the risk factors, transmission routes and other clinical features of monkeypox infection. Until now, these groups have been underrepresented in research and little is known about how the disease affects women. These data will help guide the international response to the ongoing monkeypox outbreak.

This is the second series of monkeypox cases from the international group, whose first article in The New England Journal of Medicine this summer identified new clinical symptoms of monkeypox in men. The study proved influential in shaping international case definitions, thus contributing to the global response to monkeypox. This case series provides the most complete picture of the ongoing monkeypox outbreak occurring around the world, which the authors have discussed in a monkeypox clinical summary for The Lancet Seminars.

Doctors from 15 countries provided data on 136 women (69 cisgender, 62 transgender) and five non-binary people with confirmed monkeypox infection between May 11 and October 4, 2022.

In the first series of case studies, sexual contact was the suspected route of transmission for almost all men (95-100%). In the latest study of women, sexual contact is likely to be the route of transmission for the majority (73%), but not all cases . Differentiating between cis and trans women in these data reveals important information; For example, sexual contact is the most common route of transmission for trans women, but nearly a quarter of the cis women in the study are suspected of contracting monkeypox without sexual contact.

Women experienced a clinical presentation similar to that seen in men (mucosal ulcers and anal and genital ulcers). These clinical symptoms were frequently misdiagnosed as sexually transmitted infections (STIs), especially in cis women. While men and trans women were more likely to access sexual health and HIV clinics, most cis women attended a broader range of clinical settings, including emergency departments, primary care, and various hospital departments. . This reinforces the need for education for health professionals beyond sexual health clinics to ensure that monkeypox symptoms are not misdiagnosed and to limit further transmission.

Similar to the global case series in men, which identified monkeypox DNA in semen from 29/32 semen samples tested, this case series found monkeypox viral DNA in 100% of vaginal swabs taken (14/14). This strengthens the likelihood of sexual transmission through bodily fluids, as well as skin-to-skin contact . Although 26% of cis women live with children, only two children contracted monkeypox, a reassuring and important finding since children can be more severely affected than adults.

Lead author of the research Chloe Orkin, Professor of HIV Medicine at Queen Mary University of London and Director of the SHARE collaboration, said:

“During the global outbreak, case definitions have correctly focused on the most affected groups, sexually active men who have sex with men. The public health response has been designed to reach this group. However, as the outbreak progresses, it is also important to focus attention on underrepresented groups, such as women and non-binary people, to better understand their risk. It is important to describe how the infection manifests in women, since it has not been characterized until now and doctors need to be able to recognize the disease. These learnings will help inform and adapt effective public health measures to include these groups.”

Dimie Ogoina, Professor and Infectious Diseases Physician at the Niger Delta University Teaching Hospital, said:

“This series of monkeypox cases, which is the first to bring together cases from the global south and north, further illustrates that monkeypox is a problem for all genders and all regions .” “Greater investment in surveillance, research and development is needed to understand the differences and similarities in the clinical course and outcome of monkeypox across affected regions, especially in Africa.”

Research author Asa Radix, senior director of research and education at the Callen-Lorde Community Health Center in New York City and co-president of the World Professional Association for Transgender Health, said:

“People who identify as transgender, non-binary, and gender diverse are often absent from research representation. The inclusion of transgender women and non-binary individuals in this series illustrates the importance of demographic and outcome data being disaggregated by sex and gender, and is key to improving ongoing monkeypox surveillance and targeted public health interventions. ”.

Discussion

Ours is the first case series to focus on and describe the risk factors and clinical presentations of monkeypox virus infection in cis and trans women and non-binary people assigned female at birth during the global outbreak. 2022. Previously published series or cohorts included almost exclusively men, primarily sexually active GBMSM, with the proportion of women ranging from 0% to 3.8%. Furthermore, most surveillance data sets do not distinguish between cis and trans women, preventing a detailed description and characterization of any differences in these two subpopulations that are generally underrepresented and underreported in HIV and AIDS research. sexual health.

Although women represent a minority of infections reported in the current monkeypox outbreak (<5%),20 we anticipate that this could change as the outbreak evolves. It is important to collect and report these infections to investigate sex and gender specificities in disease presentation. We observed many similarities in the transmission and clinical characteristics of trans women with those we previously reported for men, but we noted several differences for cis women and non-binary people.

Inequalities and social determinants of health have been reported to be a major underlying problem, especially for Black and Latino people in the US, who have been disproportionately affected by monkeypox during the current outbreak It accounted for only about a third of the cases. Nearly half of our cohort were trans women , a group more likely to be negatively affected by social determinants of health.

Trans women have higher rates of HIV and STIs than cis women and non-binary people, which could influence the acquisition and clinical course of monkeypox virus infection, and they also face barriers to access to medical care and social support. Our data showed that a higher proportion of trans women engaged in sex work (55%) compared to the proportion of cis women and non-binary people (3%), suggesting higher levels of precariousness and vulnerability, which could include factors such as homelessness, injection drug use, and immigration status.

Although 121 (89%) of the 136 people in this global case series reported having had sex with men, 59% of cis women and non-binary people had a regular male partner, while 73% of women trans people had multiple male partners. Having multiple sexual partners was a common risk factor for monkeypox virus infection in previous series in men. Sexual contact was thought to be the most likely route of transmission in 74% of our overall cohort. This value is lower than the 95-100% reported in series of men.

However, we found differences in trans women compared to cis women and non-binary people. Although clinicians were asked to select a single option for the suspected transmission route, no trans women (of those with a reported suspected transmission route) were thought to have acquired monkeypox virus infection outside of sexual contact. . Attendance at LGBTQ+ Pride events and large gatherings has been a prominent association in men during the global outbreak (32-36% attendance); In contrast, only 7% of all people in our series attended LGBTQ+ Pride or other large gatherings within the month before symptom onset.

18 (24%) of 74 cis women and non-binary people were thought to have contracted monkeypox without sexual contact, including through occupational contact and close nonsexual contact inside and outside the home . In particular, those who acquired monkeypox through non-sexual routes were less likely to have the anogenital lesions that have been characteristic of the global outbreak. More cis women and non-binary people were reported to have known contact with people with confirmed monkeypox virus infection (43%) than trans women (10%).

Finally, the incubation period was estimated based on the reported date of suspected exposure and the reported date of first symptom. As in other case series, the accuracy of an individual’s recollection of their potential exposure and symptom dates cannot be confirmed, and it is possible that early, subtle symptoms were underrecognized and underreported. which limits the precision of the estimated incubation period.

In summary , this series provides new insights into the epidemiology and clinical features of monkeypox virus infection in cis women, non-binary individuals assigned female at birth, and trans women worldwide, who previously represented a percentage small and undifferentiated in international surveillance reports. It also reinforces emerging data that correlate sexual practices with clinical presentation injuries.

In fact, the prominent mucosal and genital features that have been a defining feature of the global outbreak in men have been replicated in cis women, non-binary people, and trans women, as has the pattern of fewer lesions than women. previously described in the history. literature. We hope these findings will help clinicians consider the diagnosis and avoid misdiagnosis of monkeypox in women and non-binary people wherever they occur, and emphasize the importance of a detailed sexual history and testing for other STIs, including HIV .