“The disease carries different weight”: Gendered pathways of mpox burden during Sierra Leone's 2025 clade IIb outbreak

Epidemics become socially consequential through the institutions that interpret illness and organise how people respond. This article examines how gendered social relations shaped mpox burden during Sierra Leone’s 2025 clade IIb outbreak. We conducted a secondary gender-focused analysis of qualitative data from 140 participants across four districts. Participants included mpox survivors (n = 42), healthcare workers (n = 38), community members (n = 36), and contact tracers (n = 24). Data came from 94 semi-structured interviews and 12 focus group discussions. Analysis used the Framework Method, scene-based charting, cross-case matrices, and negative- and boundary-case review. The source dataset recorded sex as female or male and did not separately collect gender identity. We therefore analyse gender as a social process that shapes the roles, relations, expectations, and institutions through which mpox acquired meaning. Among participants recorded as female, diagnosis was often interpreted through sexual reputation and household judgement. Household conduct frequently communicated that judgement without a spoken accusation. Among those recorded as male, burden centred more often on work, provision, and occupational standing. Healthcare-worker burden extended from facilities into households, neighbourhoods, and children’s schools. Recovery continued beyond clinical discharge through intimacy, mutual aid, bodily visibility, and social re-entry. Gender-responsive outbreak responses should address the institutions that organise stigma, workforce burden, and social recovery. Sex-disaggregated case counts alone will not locate them.