Blaming Gay Men for Monkeypox Will Harm Everyone

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In Chicago last week, thousands of gay men gathered together for the annual International Mr. Leather conference. This four-day affair saw men from all over the globe come together to show off their leather gear, have lots and compete for the title of International Mr. Leather. IML is similar to Miss America, but the runway workers are wearing harnesses. (This year, Gael Chong Wo of Belgium was awarded the honor. )

I found myself very concerned about the event in part because, even by the low standards of the Centers for Disease Control and Prevention, community spread of SARS-CoV-2 was “high” in Chicago, causing uncontrollable community spread of that virus. It is not more or less worrying that gay men are coming and going from all over the world to attend a conference. Enragingly, the Society for Epidemiologic Research is also meeting in Chicago soon, despite the latest coronavirus surge. Graduations, weddings, concerts and banquets are churning on indoors, as if 10,000 people a month aren’t still dying of COVID.

But I was more concerned about monkeypox (MPX), making an appearance at IML as I am concerned about it making a way through LGBTQ Pride events this month. Monkeypox has largely been found in Western and Central Africa in the last few decades. While it is an endemic disease in rodents, many African countries have excellent public health practices to reduce the spread of the disease among humans. This is something that Europeans and North Americans have neglected. African countries don’t have a lot of antiretrovirals and pharmaceutical vaccines. But, as Science reported, countries like Nigeria use the kinds of effective nonpharmaceutical interventions with MPX that the United States and Europe have largely eschewed with the novel coronavirus: putting the effort in to perform surveillance, helping affected people isolate, sequencing viruses to track spread and sharing their findings with others.

But MPX has been popping up all over the world the last couple of months, with at least two strains in the U.S. alone, suggesting undetected global spread has been occurring for some time. The most severe outbreaks have been linked to gay saunas and raves in Europe as well as a Montreal gay sauna. As public health expert Gregg Gonsalves wrote in the Nation, there are 550 cases and counting. But MPX is not a “gay disease.” Indeed, as Bloomberg News reported, though MPX can (and currently is) moving through sexual contact, it it not a sexually transmitted infection; according to the World Health Organization, it is “transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding.”

But MPX is moving through networks of men who have sex with other men, in the midst of the two-year-plus COVID pandemic and the 42-year-plus AIDS pandemic. This creates a problem. The fact that MPX has long been a problem for people in Africa and men who have sex in North America and Europe with African men, means it is more easily transmissible than HIV/AIDS. However, MPX is less efficient than SARS/CoV-2. The COVID issue was not something that governments and businesses worldwide cared about. They were concerned about how it might affect wealth-building and health of the ruling class.

How do you stop transmission of a casually transmitted virus moving among despised populations (who live in what I call in my forthcoming book a viral underclass) without creating stigma and harming public health? To unpack this paradox and understand how to best address stigma and viral transmission right now, it might be helpful to look at the particularities of HIV/AIDS, SARS-CoV-2/COVID and MPX–for understanding what’s already been learned about each of them that might help us better understand how to address any of them.

HIV, a retrovirus that affects the immune system, is relatively inefficient. And while it is not a “gay virus,” it first came into mass consciousness because of how it began circulating among gay men in North Amercia in the 1980s. The virus moves most effectively through blood vessels and mucous membranes; it is more easily transmitted into receptive anal tissue than into receptive vaginal tissue, and an HIV-positive sex insertive partner is far more likely to transmit HIV to a receptive partner (anal or vaginal) than an HIV-positive receptive parnter (anal or vaginal) would be to transmit through an insertive partner’s penis. Despite the fact that the virus was present in the early stages and its disproportionate impact on men who sex with men from many parts of the globe, it is not universally true. In some countries, U.S. states and U.S. territories, like Puerto Rico, HIV moves more frequently through injection drug use and heterosexual sex than through male-to-male sex. In parts of the world, substantial transmission occurs through “vertical transmission, from parent to child. Although there are effective drugs, there is no approved or available vaccine for HIV. )

SARS-CoV-2, a respiratory virus, moves overwhelmingly through breathing and air–through close contact or, in indoor conditions, even among people sharing the same air who aren’t that physically close to each other. This virus is resistant to both vaccines and has effective medications. )

MPX also moves through close contact (though it’s unclear if it moves through semen or vaginal fluids) but contact has to be much closer than SARS-CoV-2. If you’re making out with someone at a party, MPX might move between the two of you, but it’s not going to move through either of you and a couple making out 50 feet away (while SARS-CoV-2 might move between any of the four of you).

MPX is very responsive to smallpox vaccinations, which were widely given in the U.S. and Canada until 1972, though not everyone over 50 received it; and while the U.S. has enough doses of smallpox vaccines stockpiled to inoculate everyone in the country, the older stored shots have significant side effects. However, Bavarian Nordic’s new Jynneos vaccine is approved for both smallpox and monkeypox, and it does not have the deleterious side effects.

Gay males socialize intimately in large groups at saunas, raves, and at conferences such as International Mr. Leather. At all of them right now, they are at risk for HIV (but condoms and antiretroviral medication decrease that risk), SARS-CoV-2 (less chance of death if vaccinated) and MPX (perhaps with some group immunity because “daddies” over the age of 50 may have had a smallpox vaccine as a child, though the effectiveness decades later is unknown). They are more likely to travel long distances between these gatherings, increasing the risk that any of these viruses could travel with them.

What to do to effectively address these risks without stigma?

First, realize that health is not just about the absence of disease. As Julia Marcus, a Harvard epidemiologist, said to me bluntly, “Health is not just the absence of illness.” Also, it’s important to have fun and connect with others.

We are not the only ones who have such large numbers. From Memorial Day to Father’s Day, to all the graduations and weddings that will take place in between, June is a prime month to gather in good weather, especially for those who have been here for a while. Mr. Leather is no better or worse than a June wedding–and if culture were easy to change, millions of people wouldn’t be gathering for anything indoors this June in the midst of a COVID wave.

There is a small group of experts in MPX, HIV, and COVID. Yet the ones who know what to do the best (and who’ve been affected the most) in Africa are not only ignored, they’re stigmatized. When researchers in South Africa first shared with the world their excellent work sequencing the Omicron variant, people from their country were banned from Europe and the United States. Scientists working at containing MPX outbreaks in countries such as Nigeria and Cameroon for years or decades have found their warnings to their colleagues in Europe and North America have been “ignored.”

Another group to listen to is the gay men. Before gatherings go underground, we need to make sure that people have the best ways to get together. People need to gather to celebrate marriages, congratulate graduates, to eat and have sex (outside if necessary). But while this is a guiding principle, facilitating such connection with different kinds of viruses will require modified approaches–especially when dealing with highly transmissible viruses like SARS-CoV-2 or MPX.

In New York City in March 2020, there was a period of a few days when the government made it clear a lockdown was coming but, even though it was inadvisable, people could still gather publicly until that date. During that time, a gay party for sex was scheduled to meet. It was a hotly debated topic among gay New Yorkers; ultimately, I was among those who called for the cancellation of the party (though I also joined the New York City Department of Health in encouraging people to practice sex with a partner they lived with, as well as masturbation, phone sex, video sex, sex with a barrier and/or sexting). COVID advocated for a different approach to AIDS due to the different transmission characteristics of HIV and SARS/CoV-2. In the height of New York’s AIDS years, the city had closed bathhouses, a foolhardy decision given that safe sex education and condom distribution happened in such settings (while it did not when group sex was secret). It’s a little more complicated with an airborne illness like COVID, where the mere presence of breathing together increases COVID transmission, the opposite effect condom distribution has on decreasing HIV mitigation.

But, it’s possible. Saunas require state IDs to be entered. This can make them useful for contact tracing. However, the stigma of homophobia might discourage people from cooperating. (In South Korea in 2020, an outbreak of COVID traced to a gay sauna created massive stigma.) These are also potential sites to address public health issues among the population in an effective manner. For instance, in 2013, meningitis–another disease which can move through sexual contact–was affecting gay men in New York (as it is now affecting gay men in Florida). Volunteer doctors like Demetre Daskalakis, now director of HIV/AIDS prevention for the CDC, went to sex clubs like Paddles and admnistered a meningitis vaccine to willing men. It was a successful campaign that stopped the outbreak. It was an effective campaign that helped stop the outbreak. A similar campaign could be used to get vaccines to gay men to protect the community against MPX. This would help to protect the public and reduce the need for a mass vaccination campaign of the same scale as the one we just experienced. Also, given that so many of them were born out of the AIDS crisis, LGBTQ organizations should actively use their events, knowledge and infrastructure to minimize risk, educate people on how to watch for symptoms, and maximize contact tracing capabilities throughout Pride. But while groups like GMHC have put out press releases on MPX and the app Grindr is advising users to watch for symptoms, there is a lot more LGBTQ organizations can and need to do, including lobbying LGBTQ politcians to put real public health resources into this emerging crisis.

Language also plays a significant role. In social media or traditional journalism, calling someone a “Patient Zero” is unfair, ableist and stigmatizing in ways that hurt not just the unlucky person but the whole community. Dehumanizing to refer to someone as a host is unacceptable. MPX has been around a long time. Anyone who is unlucky enough not to have it should not be referred to as a “host”.

This brings me to my final point: It must be safe for people to report symptoms, get tested, and receive care. People who are infected fear the stigma and financial ruin they might experience if they come forward. This will lead to transmission going undiagnosed, which can harm many bodies as well as our collective public. It is cheap and easy to point fingers at a leather conference or an unmasked indoor wedding; it takes more resources to offer free testing, treatment, and support for isolation, which have already been dialed back for COVID and don’t yet exist for MPX.

To deal with this latest virus outbreak, it’s worth looking at how those most affected have managed pandemics long ago. It’s also worth looking at how a world where a viral underclass has all the resources they need to live a healthy life would prevent pandemics from coming in.

This is an opinion and analysis piece. The views expressed by the author/authors are not necessarily those Scientific American.

ABOUT THE AUTHOR(S)

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    Steven W. Thrasher is a professor at Northwestern University in the Medill School of Journalism and the Institute for Sexual and Gender Minority Health and Wellbeing. He is author of the forthcoming book The Viral Underclass:

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