First international study of monkeypox in women

Monkeypox is a rare viral infection that in 2022 began to spread in countries where the disease had not previously occurred, above all among men who have sex with men. Of all those infected by the virus in Europe and North America, only some 5 percent have been women. In recent weeks, however, there has been a sharp overall decline in its spread. Up to and including the first week in November, the Public Health Agency of Sweden had registered a total of 212 cases of monkeypox in this country.

The study, now published in The Lancet, reports on 136 cases of women with a confirmed monkeypox infection in the period up to the beginning of October 2022. They included cis women (registered as girls at birth, who have retained their female gender identity), trans women (registered as boys at birth, but with a female gender identity), and non-binary people who were registered as female at birth.

Cis women stand out

Of the 136 cases in the study, roughly half relate to cis women and half to trans women, with only occasional cases concerning non-binary individuals. The study expands knowledge of symptoms, clinical risk factors and pathways to healthcare for both trans and cis women.

Anna Grahn, associate professor of infectious medicine at the University of Gothenburg and infectious disease specialist at Sahlgrenska University Hospital, contributed one patient case to the study.

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“Many of these cis women have needed to see a doctor several times before getting the right diagnosis. And that’s partly because instead of going straight to a gender clinic or infectious diseases clinic, they chose the hospital emergency department or the local health center. In this group, it’s also more common for them to get infected without sexual contact — from other close skin-to-skin contact or from body fluids. Among cis women, as many as a quarter are thought to have been infected without direct sexual contact, which is interesting,” Grahn comments.

For the trans women, the transmission pattern was more like the pattern in the group of men who have sex with men, in that these women too became infected almost exclusively through sexual contact. In common with the male group, too, the trans women usually sought care at an infectious diseases clinic.

Few children infected

Roughly one-quarter of the cis women had children at home, but only two children had been infected. In the researchers’ view, this was another key finding from the study.

The results confirm previous findings that the infection is sexually transmitted, through both bodily fluids and skin-to-skin contact. Another key conclusion from the case study is that there may be a need for broader training in monkeypox for health professionals other than those whose work concerns infection and venereology.

Until now, cis women, trans women, and non-binary women have been underrepresented in research, and much is unknown about how monkeypox affects women. Professor Chloe Orkin of Queen Mary University of London leads the research collaboration.

“We need to know what the infection looks like in women, and doctors need to be able to recognize the disease. What they learn will help inform and individualize effective public health programs, to make them inclusive of these groups,” Professor Orkin comments.

In Sweden, researchers at Karolinska Institute and Stockholm South General Hospital have also contributed a case description to the study.

Title: Human Monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series