In The monkeypox epidemic that broke out this summer in the United States and In dozens of countries, men who sex with women were most at-risk. However, there were thousands of females who were also infected. and The first ever study of women found that many more cases may have been overlooked. and Nonbinary patients who have been diagnosed with the disease.

According to the case series, transgender women were more likely to contract infection than men through sexual contact, which accounts for 89 percent of all cases. published on Thursday The journal Lancet. But among cisgender women and Nonbinary persons who were born as females could only be connected to 61% of cases.

Nearly 25% of the cisgender women in this study could have been infected by HIV without having had sexual contact with infected persons, according to Dr. Chloe Orkin. and Queen Mary University of London. It was believed that the women had been exposed at their homes, jobs, or through close contact.

“The lesson here is that everybody needs to know about this,” Dr. Orkin agreed. While it’s appropriate that public health messages have mostly been directed at men who have sex with men, she added, “it’s important to recognize this is not the only group.”

After several months of rapid growth in case numbers, monkeypox has been contained in the United States. This is partly due to vaccination campaigns. and Changes in behavior for many high-risk persons. Since MayThere have been just over 29,000 cases In the United States, only about 1000 cases of the disease have been reported in the past month.

Scientists are still trying to figure out why the disease isn’t as well-known. and It spreads and Who is at risk?

In Dr. Orkin’s new study and Her colleagues discovered genetic material from the monkeypoxvirus in all 14 vaginal swabs that they tested. This suggests that the virus could be transmitted via genital secretions. The virus was also found in seminal fluid, according to studies in men.

However, monkeypox is not considered a sexually transmitted illness by public health officials. They argue that the virus can spread through physical contact.

Some experts disagree. The fact that monkeypox is transmitted sexually should not be considered a denial of its classification. and Some have suggested that syphilis can also be spread by close, nonsexual contact.

New York State added monkeypox on its list of sexually transmitted illnesses last month. But the Centers for Disease Control and This has not been changed by prevention. The agency will leave that categorization up to individual states, said Dr. Demetre Daskalakis, deputy coordinator of the White House’s monkeypox response. But it’s clear that sexual behavior drives cases, he said.

“If you took sex away, would we have had a monkeypox outbreak? Probably not,” He added. Even if skin-to-skin contact is the main reason for the spread during sexual activity, “it’s definitely a sexually associated transmission.”

Dr. Orkin facilitated an international collaboration this year. characterize monkeypox symptoms in 500 patients. These findings have led to the United States and Britain. and International countries can refine their disease case definitions.

The U.K. Health Security Agency was also established last month published a study It is estimated that around 40 percent of the population will be affected. and It is possible that 60 percent of monkeypox transmission occurs before the infected person develops symptoms.

This is intuitively understandable because patients with painful blisters will not be able to have sex after they develop them, said Tom Ward, an infectious diseases modeler at the agency. He stated that symptoms might not be present in everyone, but that some people who have been infected may not experience any symptoms.

Because of the sensitive nature and difficulty in tracking down contacts, it can be extremely difficult to track down people affected by a monkeypox epidemic. and Because monkeypox spreads anonymously, there aren’t any tests available that can detect it before the typical skin rash occurs.

“What it essentially highlights is that we still need a lot of research into the nature of asymptomatic and pre-symptomatic transmission of monkeypox,” Dr. Ward spoke.

A few people may feel mild symptoms, such as a sore throat, before they develop the rash.

Dr. Daskalakis stated that such individuals should remain home to protect others. But ultimately, he said, the possibility of pre-symptomatic spread doesn’t change the public health message to people at risk: immunization against monkeypox.

“Probably the strongest guidance is that if there is past history that would make you think that you’re at risk for monkeypox, it’s important to get vaccinated, and if there’s a potential for future risk, it’s important to get vaccinated,” He added.

This is the first study to identify monkeypox in transgender and nonbinary individuals, who often lack access to high-quality health care. and They are not often included in research studies.

“It’s very, very important that we report on both sex and gender differences, because both are important, and in some cases, they intersect,” Dr. Orkin spoke.

In The study involved researchers from 15 different countries who contributed clinical information on 69 cisgender and 62 transgender women. and Five nonbinary people were diagnosed with monkeypox in the period between 2002 and 2005. May 11 and Oct. 4. Oct. 4. and 21 percent were Black.

More than half of patients who participated in the study had sores on their anus or genitals, lips, eyes, or mouth. But some women — especially cisgender women — were initially misdiagnosed with other sexually transmitted infections.

Experts predicted that monkeypox would occur. “would have probably a slightly different pattern of transmission depending on social behaviors and norms within certain groups,” Dr. Abraar Karan is a Stanford University infectious disease physician.

This conclusion was supported by the new study. In Contrary to male monkeypox victims who have had sex with men over the past month, only 7 percent of patients in the study said they attended Pride events or similar gatherings. On average, transgender women had 10 partners in the past month. The cisgender woman had only one partner. and 7 percent of cisgender women stated that they had never been with a partner during the month prior.

“So the driver was not the same,” Dr. Karan said.

Many transgender females in the study had undiagnosed risk factors for monkeypox. and Homelessness due to untreated H.I.V. and injection drug use. H.I.V. was reported by half the transgender women. This compares to 8 percent for cisgender woman. and Over half of transgender woman were involved in commercial sexual work, as opposed to just 3 percent for cisgenders.

“Even though the absolute number of people who are trans and engaged in sex work may not be very large, the extremely high prevalence of H.I.V. and now monkeypox and other sexually transmitted infections means that public health agencies need to be thinking of ways to do outreach in this population,” Jay Varma is the Cornell Center for Pandemic Prevention’s director. and Response.

Many transgender women sought treatment at sexual health clinics. However, many of the women who were cisgender in the study went to primary or emergency care, where they were less likely to have heard about monkeypox symptoms. One in three cisgender females were diagnosed with the disease late or with another one; others were likely never diagnosed.

“It’s very likely that infections have been missed and not picked up at all,” Dr. Orkin spoke.

A little over one quarter of the cisgender females in the study had children. But the doctors found only two cases. The C.D.C.’s observations jibe with that finding.

Dr. Karan warned that children may not be reported cases due to the stigma attached to monkeypox. He said that more research is needed to determine how symptoms might vary among different populations, especially in countries where the virus is known to have caused widespread outbreaks over many years.