Monkeypox and transgender women: The need for global initiative.

Dear Editor:

We would like to highlight the importance of addressing the data gap on monkeypox among travestis and transgender women (TGW) as this viral disease might add to the social vulnerabilities and stigma faced by these populations. We conducted a search in Pubmed for articles containing “monkeypox” AND “transgender” published by October 3, 2022 that revealed only two articles: one was a case report of a transgender woman coinfected with neurosyphilis, HIV and monkeypox published in this journal on September 2022 [1]. The second one reported an electronic survey to assess monkeypox exposure mitigation strategies employed by men who have sex with men (MSM) and TGW in the United States [2].

From the case series published so far, just a few describe disaggregated data by gender identity. A Spanish cohort of 185 participants registered no monkeypox cases among TGW [3]. Official data from the United States’ Center of Diseases Control showed that TGW represented less than 1% of monkeypox cases identified in the United States [4].

In Rio de Janeiro, Brazil, the Instituto Nacional de Infectologia Evandro Chagas (INI-Fiocruz) is a major referral center for monkeypox diagnostics and care. INI-Fiocruz diagnosed the first monkeypox case in Rio de Janeiro State in the Brazilian Southeast on June 14, 2022 [5]. The Institute has an established and solid relationship with TGW communities, providing a suite of comprehensive wellness and care options, including specialized services, such as sexual health, endocrinology, HIV prevention and care, and mental health [6]. In addition, we offer social services, such as name rectification and civil requalification at a mobile unit (through an established partnership with the Rio de Janeiro state court), continuous cash provision benefit, free transportation pass, as well as an art-focused program that includes risk reduction workshops, theater and movies sections, and participation in community movements and activities.

Between April 1 and September 9, 2022, 358 (26.0%) of 1379 individuals tested for HIV at our service self-identified as TGW. Almost all of them (357/358, 99.7%) reported sexual contact with cisgender men in the previous 6 months, with a median number of 3 sexual contacts and almost 28% reporting a considerable higher number (24% between 10 and 100 and almost 4% over 100 sexual contacts) (Table 1 ). Since June 12, 2022, the number of monkeypox cases has been sharply increasing in Brazil, with the country ranking second globally on October 3, 2022. Although TGW are highly vulnerable for HIV and other sexually transmitted infections (STI), the number of TGW with monkeypox diagnosis in our cohort was very low. As of October 8, 2022, among 340 individuals with confirmed monkeypox only two were TGW (0.59%). These disparities could be explained by distinct sexual networks for the different populations without shared transmission so far, which have been described for TGW, their sexual partners, and MSM for HIV infection [7].

Table 1

Sexual behavior characteristics of TGW tested for HIV between April and September 2022.

	n/N (%)
Gender of sexual contacts in the previous 6 monthsa
Cisgender men	357/358 (99.7)
Cisgender women	19/358 (5.3)
Transgender men	15/358 (4.1)
Transgender women	13/358 (3.6)
Number of sexual contacts in the previous 6 monthsb
0	25/323 (6.7)
1	79/323 (22.2)
2–9	119/323 (33.2)
10–100	86/323 (24.0)
>100	14/323 (3.9)
Median (IQR)	3 (1,11)

N = 353 individuals were tested for HIV at Instituto Nacional de Infectologia Evandro Chagas (INI-Fiocruz).

N = 323 reported on sexual contacts in the previous six months.

The lack of information on gender identity has always limited the availability of data on trans populations. Recent important efforts to produce disaggregated data in HIV prevention and care have focused also on both conducting studies and generating data on trans populations. Dissemination of further reliable data showing the real impact of different health conditions among TGW is important toward understanding the real burden of monkeypox on TGW, so that friendly and proper services can be organized and provided in a timely manner.

In this sense, health services must provide a comprehensive sexual assessment, including gender-diverse populations. In addition, most vulnerable people, including TGW, might face different barriers not only to access the health system in general, but also to guarantee financial conditions to allow for home isolation in the context of monkeypox. As we learned from the experience with COVID-19, we also outline the importance of structuring public policies to address the hurdles that the most vulnerable face to guarantee adequate conditions for home isolation and financial and food security. Therefore, we call for an initiative to promote worldwide research and reporting monkeypox data disaggregated by gender identity. This will inform health services and public health programs, which will be able to tailor interventions and structure adequate responses based on community engagement and stigma-free strategies to tackle this infectious emergence.

Funding

This research did not receive any specific grant from funding agencies.

Author’s contributions

We consider that all authors equally contributed on this manuscript.

Declaration of competing interest

Nothing to declare.