A section of skin tissue harvested from a monkey infected with monkeypox virus, seen at 50x magnification on day four of rash development in 1968. Photo: US CDC
- When news broke that monkeypox appears to be disproportionately affecting gay and bisexual men, Jih-Fei Cheng, an associate professor at Scripps College, thought, “Here we go again.”
- This association recalled the early days of the HIV/AIDS epidemic, when what we knew of the condition was limited to its impact on the queer community.
- As of May 27, about 300 cases have been reported in the US and Europe, and many countries have reported that nearly all of these cases have been in gay and bisexual men.
- There is absolutely no evidence to suggest that monkeypox is spread specifically through sex, or through gay sex in particular. It is spread through skin-to-skin contact.
- Though the possibility of sexual transmission can’t yet be ruled out, skin-to-skin contact can easily explain infection patterns, said infectious diseases expert Kartik Cherabuddi.
When news broke that monkeypox appears to be disproportionately affecting gay and bisexual men, Jih-Fei Cheng, associate professor of feminist, gender, and sexuality studies at Scripps College, thought: “Here we go again.” For Cheng and many others, the association of an emerging infectious disease with gay and bisexual men starkly recalled the early days of the HIV/AIDS epidemic, in which little was known about the condition beyond its impact on the queer community – an observation that led to its being called “gay cancer” for a time.
As of May 27, about 300 cases have been reported in the US and Europe, and many countries have reported that all or nearly all of these cases have been in gay and bisexual men. Many of the men affected seem to have contracted monkeypox at events that were initially reported as “raves” but were in fact a 10-day gay pride event in the Canary Islands and a five-day fetish festival in Belgium. A gay sauna in Madrid may also have been a major transmission site.
When this link became clear, health officials responded swiftly. On May 23, John Brooks, head of the Epidemiology Research Team in the US Centres for Disease Control and Prevention’s Division of HIV/AIDS Prevention, made an explicit appeal to gay and bisexual men in a news briefing. On May 24, the gay dating app Grindr, in partnership with local health agencies, displayed a monkeypox warning to users across Europe; Brooks suggested in the press briefing that similar warnings may soon be coming to US users.
There’s an obvious sense in this approach: If an infectious disease is disproportionately present in a particular community, then reaching out directly to that community may be the most effective way to contain its spread. But some experts worry that linking monkeypox with gay and bisexual men risks repeating the mistakes of the early days of the HIV/AIDS epidemic.
First, the facts: There is absolutely no evidence to suggest that monkeypox is spread specifically through sex, or through gay sex in particular. It is spread through skin-to-skin contact, and sex – gay, straight or otherwise – tends to involve quite a bit of skin-to-skin contact. Though the possibility of sexual transmission can’t yet be definitively ruled out, there is no strong reason to think it is taking place when skin-to-skin contact can easily explain infection patterns, says Kartik Cherabuddi, associate professor of infectious diseases and global medicine at the University of Florida.
As far as experts can tell, monkeypox is disproportionately affecting gay and bisexual men as a direct result of events where large numbers of men were repeatedly in close contact – sexual or otherwise – over the course of several days. “All it takes is one person who might have monkeypox” to prompt an outbreak in such an environment, says Ronald Valdiserri, professor of epidemiology at Emory University’s Rollins School of Public Health.
And once the virus is circulating within a particular community, members of that community become more likely to contract it – after all, gay and bisexual men are most likely to be in close physical contact with other gay and bisexual men. That, in Valdiserri’s view, is enough reason for public health organizations to work to raise awareness of monkeypox among gay and bisexual men. “The choices they make are their own choices, but you like to ensure that people have the appropriate information up front,” he says.
But Tonia Poteat, associate professor of social medicine at the University of North Carolina, isn’t convinced that there is a strong public health imperative to reach out to gay and bisexual men in particular, at least at this point. Monkeypox is much, much less transmissible than SARS-CoV 2, and by May 26, the US had reported only nine cases. She also notes that the preponderance of gay and bisexual men among known cases doesn’t necessarily translate into a similar bias among all cases. Because of HIV/AIDS, she says, gay and bisexual men are more likely to have contact with the health care system, and they are probably more likely to seek immediate medical attention for a new, unexplained rash.
Given those facts, Poteat says, the messaging could have looked quite different. “What we know is how monkey pox is transmitted,” she says. “That’s what people really need to know. They don’t necessarily need to know the sexual behavior or the sexual orientation of people who might have been identified.” After all, scientists think monkeypox can be spread through any sort of close contact – hugging, contact sports, touching someone’s bed linens or towels – not just sex.
But the statistical association between monkeypox and gay and bisexual men has become a focus – and now that it has, Valdiserri says he does does worry about the risk of compounding stigmas. Infectious disease and sex, and sexually transmitted diseases in particular, are already highly stigmatized. Even though monkeypox does not appear to be sexually transmitted in the traditional sense (through semen and vaginal secretions), sex is a likely cause of its spread, and it has now been publicly linked to events and locations, like a fetish festival and a gay sauna, that might push the margins of acceptability for some people. And the discomfort and fear that people may feel about an outbreak of a new disease, and about certain types of sex, may then adhere to gay and bisexual men as a group.
“It sort of feeds this message that men who have sex with men are somehow more infectious in some way than other people—and that’s a dangerous subtext,” Poteat says.
Another is that sexual behaviors could become the focus in attributing blame for monkeypox. That blame can be dangerous when directed toward a marginalized group – as has been the case for Asian Americans during the COVID-19 pandemic – and it can cover up other roots of disease spread, like global inequality. “We have to be very careful not to to stigmatize sexual behavior precisely because that deters us from understanding that structural violence is at play,” Cheng says. He notes that activists during the early days of the HIV/AIDS epidemic called for structural remedies like universal health care and housing, and that the continued lack of those remedies today played a major role in the spread of COVID-19 in the US.
There’s another link Cheng sees between monkeypox today and HIV/AIDS activism: solidarity with women fighting for reproductive rights. Both he and Poteat noted that this monkeypox outbreak is being partially attributed to individual sexual behavior at a time when bodily autonomy is being steadily eroded in the US. Roe v. Wade appears poised to fall, and an increasing number of states are criminalizing trans children’s right to gender-affirming care. The past few months have also seen a rise in rhetorical attacks on gay and bisexual men, from Florida’s so-called “Don’t Say Gay” bill to the increasingly widespread use of the term groomer to suggest that queer men are a danger to young boys.
True, there are some major differences between 2022 and 1981, when HIV/AIDS cases were first reported. For now, same-sex marriage is still legal across the US, and certain gay and bisexual men – albeit typically white, wealthy men – are extremely visible in public life. But it would be wrong to conclude on that basis that gay and bisexual men, especially men of colour and poor men, are not vulnerable to discrimination. “Homophobia has not evaporated,” Valdiserri says. “It’s better in some areas than in other areas. But it hasn’t gone away.”