MPOX has transgender link

Mpox infections have been strongly linked to sexual contact, particularly among gay and bisexual men, but a new global study shows that the impact is now being felt by other genders.

The WHO declared that Mpox was ‘a public health emergency of international concern’ in July 2022, and between May and November that year, more than 78,000 infections were diagnosed in 109 countries that had not historically reported cases of Mpox. 

Building on the Share-Net international clinical network established at the beginning of the Mpox outbreak, the team of global collaborators reported data for 136 people infected with the virus (comprised of 62 trans women, 69 cis women, and five non-binary individuals) across 15 countries.  

Overall, sexual contact was the most common route of transmission, with non-sexual routes (including household and occupational exposures) reported only in cis women and non-binary people. 

Nearly 90% of all individuals reported sex with men, and for trans women, commercial sex work was reported by 55% of individuals and was the strongest occupational link to infection. 

“Previously published series or cohorts included almost exclusively men, primarily sexually active GBMSM, with the proportion of women ranging from 0% to 3·8%,” the authors said. 

“Furthermore, most epidemiological surveillance datasets have not distinguished between cis and trans women, thereby prohibiting a detailed description and characterisation of any differences in these two subpopulations, which are generally under-represented and under-reported in sexual health research. 

“Almost 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 individuals… and face barriers to accessing health care and social support. 

“Our data showed that a higher proportion of trans women engaged in sex work compared with the proportion of cis women and non-binary people (3%), suggesting higher levels of precarity and vulnerability, which might include factors like homelessness, injection drug use, and migrant status.” 

Fewer individuals without sexual exposure had anogenital lesions, but otherwise the presentation did not differ from previously reported, predominantly male cohorts: anal mucosal involvement (proctitis or ulceration) occurred in 56% of trans women and 11% of 70 cis women and non-binary people, with oral (and eye) presentations (both perioral and mucosal) reported by 24% of individuals. 

Trans women, as in the male case series, often had more localised infections with mucocutaneous involvement, not always accompanied by systemic symptoms, and the findings emphasised that doctors needed to be aware of the differing clinical presentations according to gender identity and sexual practices. 

“Although women account for a minority of infections reported in the current monkeypox outbreak (<5%), we anticipate that this might change as the outbreak evolves,” the authors said. 

The research also showed an overlap between the clinical manifestations of monkeypox virus and other clinical syndromes (such as varicella; hand, foot, and mouth disease; herpes simplex; and syphilis) and the need for ongoing clinician education to better recognise and test for monkeypox virus infection.