Monkeypox symptoms vary by gender identity, sexual practices

Transgender and cisgender women and nonbinary people assigned female sex at birth had similar presentations of monkeypox compared with men, according to data published in The Lancet.

The case series, which is the first to investigate monkeypox in women and nonbinary people on a global scale, also determined that presentations varied by sexual practices.

“During the global outbreak, case definitions have rightly focused on the most affected groups, sexually active men who have sex with men,” lead author Chloe Orkin, MD, MSc, a professor of HIV medicine at the Queen Mary University of London, said in a press release. “The public health response has been tailored to reach this group. However, as the outbreak progresses, it’s important to also focus attention on underrepresented groups, such as women and nonbinary individuals, to better understand their risk. It is important to describe how the infection manifests in women as this has not been characterized until now and doctors need to be able to recognize the disease.”

Orkin and colleagues invited researchers in geographic areas reporting high numbers of monkeypox infections to contribute to the study. Those who participated asked women and nonbinary patients who presented at their practices between May 11 and Oct. 4, 2022, and who had polymerase chain reaction-confirmed infections to participate in the study.

There were 62 transgender women, 69 cisgender women and five nonbinary participants. Because there were few nonbinary participants, they were included in analyses with cisgender women to create a group of people assigned female sex at birth.

Clinical information

In total, 121 (89%) participants reported having sex with men in the past month and 37 (27%) had HIV. Transgender women more commonly had HIV compared people assigned female sex at birth (50% vs. 8%).

Sexual contact was the most common method of transmission, with this mode of infection being the most probable for 45 (61%) cisgender and nonbinary participants and 55 (89%) transgender women. Other methods of transmission included occupational exposure, household contact and nonsexual close contact, and were only reported in cisgender women and nonbinary people.

Presentation

Analyses of participants with data available revealed that 124 (93%) of 134 participants had skin lesions. Of participants with further information, 105 (87%) of 121 had vesiculopustular lesions, 95 (74%) of 129 had at least one anogenital lesion and 65 (55%) of 119 had mucosal lesions involving the vagina, anus, or oropharynx or eye.

Vulvar lesions were more common in cisgender women and nonbinary people compared with transgender women (59% vs. 2%), as were vaginal mucosal lesions (34% vs. 0%). Transgender women more commonly had perianal skin lesions (76% vs. 24%) and anorectal mucosal lesions (56% vs. 11%) compared with participants assigned female sex at birth.

Notably, reported anal and vaginal sex were associated with lesions in those areas, but reported oral sex was not associated with oral lesions.

“Individuals who identify as transgender, nonbinary and gender diverse are often absent from research representation,” Asa E. Radix, MD, senior director of research and education at the Callen-Lorde Community Health Center in New York City, said in the release. “The inclusion of transgender women and nonbinary individuals in this series illustrates the importance of demographic and outcome data being disaggregated by both sex and gender and is key to improving ongoing monkeypox surveillance and targeted public health interventions.”

References:

• First study of monkeypox infection in women provides new insights to inform public health response to ongoing outbreak. www.eurekalert.org/news-releases/971578. Published Nov. 17, 2022. Accessed Nov. 23, 2022.
• Thornhill JP, et al. Lancet. 2022;doi:10.1016/S0140-6736(22)02187-0.