A recent study published in The Lancet described the clinical and epidemiologic features of infection with monkeypox virus (MPXV) in cisgender (cis) and transgender (trans) females and non-binary individuals.
From May to November 2022, more than 78,000 MPXV infections have been reported in over 100 countries that have historically not documented MPXV infections, with the monkeypox (MPX) outbreak being designated a Public Health Emergency of International Concern by the World Health Organization (WHO) in July 2022. Sexually active gay, bisexual, and other men who have sex with men (GBMSM) have been almost exclusively affected by MPXV in the ongoing outbreak.
Around 28% to 47% of people diagnosed with MPX live with human immunodeficiency virus (HIV). The sustained spread of MPX has not, so far, occurred outside GBMSM networks; however, the spread of MPXV to females is a significant concern, mainly due to the potential for severe consequences to fetuses if pregnant individuals contract MPXV.
Epidemiologic surveillance datasets have not distinguished between cis and trans women. It has been reported that, out of over 25,000 MPX cases in the United States, 3.8% occurred in cis women and 0.8% in trans women. The number of MPXV infections among females is likely unknown and probably underestimated, given the international case definitions specifying GBMSM as an at-risk group.
About the study
In the present study, researchers described the clinical and epidemiologic characteristics of MPXV infection in a cohort of women and non-binary individuals from 15 countries. Participating clinicians identified non-binary individuals and women with MPXV infection and asked them to participate.
Confirmed MPX was defined as having a positive MPXV-specific polymerase chain reaction (PCR) test in specimens collected from any anatomical site. Contributing centers were provided with structured, deidentified case-report spreadsheets developed and adapted by participating clinicians to include variables relevant to women and non-nary individuals.
The spreadsheets used free-text fields and dropdown menus to allow clinicians to capture data from paper or electronic medical records. The spreadsheets primarily focused on demographic features, occupation, potential exposures, clinical findings, HIV status, early symptoms, diagnosis, concurrent sexually-transmitted infections (STIs), complications, and HIV status.
The present case series included 136 women and non-binary individuals from 15 countries and three WHO regions who presented from May 11 to October 4, 2022. Of these, 68 were from the European region, 65 were from the region of the Americas, and three were from the African region. The median age was 34 years, with most individuals being Latinx (45%), followed by White (29%) and Black (21%) individuals.
Sixty-nine individuals were cis women, 62 were trans women, and five were non-binary individuals assigned the female sex at birth. Overall, 89% of participants reported sexual activity with men in the past month. Thirty-four trans women, two cis women, and non-binary individuals reported active/current sex work.
Nineteen individuals had children, including one non-binary person; two children subsequently contracted MPXV. Thirty-seven individuals had HIV, primarily trans women. Among these, 36 were on anti-retroviral therapy. Trans women had more sexual partners in the past three months than others.
Sexual contact was suspected to be the most likely transmission route in 100 MPX cases. Non-sexual suspected transmission routes included occupation exposure, household contact, and close non-sexual contact. Seventeen individuals had a concurrent STI. Forty-one trans women presented to HIV or sexual health clinics, and 13 presented to emergency departments. Non-binary individuals and cis women frequently presented to emergency departments and HIV/sexual health clinics.
The median incubation period was seven days, based on presumed exposure and symptom onset dates available for 51 participants. Seventy-six individuals presented with systemic features. Skin lesions were observed in 124 individuals. At least one anogenital lesion was present in 95 individuals.
Mucosal lesions involving the eye, anus, vagina, or oropharynx occurred in 65 participants. Vulvar lesions were present in 42 cis women and non-binary persons assigned the female sex at birth. Perianal skin lesions were observed in 45 trans women and 17 cis women, and non-binary individuals.
Vaginal sex was reported by 35 out of 46 subjects with vaginal lesions, and anal sex by 49 individuals with anal lesions. Overall, thirty-four participants lacked anogenital lesions. The median number of lesions (10) was similar for cis and trans women. All skin and vaginal swabs were positive for MPXV, whereas 73% of nasopharyngeal swabs were positive.
Seventeen participants were hospitalized for cellulitis, bacterial superinfection, severe anorectal pain, abscess, odynophagia, ocular lesions, infection control purposes, or altered mental balance. MPXV infection was treated with tecovirimat. Tecovirimat treatment was more common among subjects with HIV infection than those without. Six participants received post-exposure vaccination, and 11 received pre-exposure vaccination.
In summary, the current case series offered insights into the clinical features and epidemiology of MPX in cis women, trans women, and non-binary persons. The authors noted that the prominent mucosal and genital features commonly observed in men in the ongoing outbreak replicated in cis/trans women and non-binary individuals.
Anogenital lesions reflected sexual practices; that is, most participants reporting vaginal and anal sex had lesions near those anatomical sites. Together, these findings will help clinicians with MPX diagnosis in cis/trans women and non-binary persons and underscore the significance of sexual history and testing for STIs.