We need to talk about monkeypox without shame and blame

The recent global outbreak of monkeypox^[1] largely among men who have sex with men^[2] has raised concerns homophobia will undermine effective prevention efforts. There are also fears the disease will fuel homophobic stigma and discrimination.

Even the name monkeypox is stigmatising^[3] due to long-held racist appropriation of the term monkey^[4] and the false implication the virus is transmitted by monkeys.

The World Health Organization^[5] has said the name needs to change, but has not agreed on or announced a new one. Currently, advocates for the LGBTQA+ community^[6] are using the term MPX, the term I will use here.

MPX is, of course, not the first infectious disease to affect men who have sex with men. So there are things we must learn and things we must not repeat from the public health response to HIV.

Lessons from HIV

When HIV emerged among communities of gay and bisexual men in the 1980s, fear and uncertainty about the cause and nature of the virus led to vilification of gay and bisexual men^[7].

HIV was initially named “gay-related immune deficiency^[8]” or GRID and there was speculation it was caused by men’s excessive sex or drug use (specifically use of amyl nitrate^[9]).

As well as sparking calls for a crackdown on the rights and freedoms of LGBTQA+ communities, the view gay and bisexual men were to blame for HIV obstructed effective public health responses.

Famously, in the United States, then President Ronald Reagan made no public mention of HIV or AIDS^[10] until more than 12,000 American citizens had died, and HIV had spread widely into many communities.

Although today, globally, HIV affects more women^[11] than men, it is still difficult to disentangle HIV-related stigma from homophobia^[12] or stigma against other affected populations, including injecting drug users or sex workers.

Stigma creates barriers^[13] to HIV prevention as people are reluctant to talk about HIV or seek testing^[14] for fear of being associated with stigmatised groups. It also perpetuates a fundamental lack of empathy for people living with HIV.

For these reasons, it’s important we don’t approach MPX in these terms.

Read more: What's in a name? Why giving monkeypox a new one is a good idea^[15]

A new approach?

There are some reports^[16] of MPX being used to justify homophobic sentiment or actions. However, a crucial difference between this disease and HIV is the world has learned^[17] from HIV.

There is now better understanding of the insidious ways stigma and discrimination undermine public health^[18]. HIV also taught us to be cautious about the potential for public health messaging to contribute to stigma, especially when an illness is associated with marginalised cultural or racial groups^[19].

Health policy makers have been fast to condemn^[20] stigmatising media reporting of MPX. Meanwhile the community-based HIV sector has mobilised existing infrastructure and experience to support advocacy and MPX education^[21] for men who have sex with men.

Importantly, we now have better knowledge about the effectiveness of sex-positive approaches^[22] to preventing HIV and other sexually transmissible infections (STIs). Such approaches^[23] affirm the pleasures and benefits of sex, aim to build open dialogue about safe sex and ensure people can seek testing without fear of judgement or backlash.

Read more: Lessons from the history of HIV/AIDS in Australia – how activism changed the image of an illness^[24]

The impact of sexual moralising

We have learned lessons from HIV. However, MPX has exposed the ways sexual moralising is ever-present in public health, undermining sex-positive health promotion.

Observers of early media responses to MPX note efforts to avoid stigmatising gay and bisexual men have led to obtuse and confusing reporting^[25] about the ways in which the disease, although not classified as an STI^[26], can be spread through close physical contact and why gay and bisexual men may be at risk of exposure.

Reporting has been deliberately vague because there is very limited cultural space for speaking about group sex, casual sex or sex with multiple partners without these practices, and people involved, being shamed^[27].

Despite increasing acceptance of sexual diversity, people’s right to engage in pleasurable sex^[28] outside a married, monogamous relationship is rarely affirmed. Young women, for example, are shamed^[29] for having “too many” sexual partners, while calls for comprehensive, pleasure-based sex education^[30] are controversial.

Read more: Sex ed needs to talk about pleasure and fun. Safe sex depends on it and condom use rises^[31]

While the world has come a long way toward acceptance of same-sex marriage, homophobia often drives condemnation of gay and bisexual men’s sexual cultures.

This is most visible in relation to public health. For example, when pre-exposure prophylaxis (PrEP) first became available to prevent HIV, public funding for it was critiqued^[32] by some on the grounds this amounted to subsidising gay and bisexual men’s promiscuity^[33].

When considered through the lens of public health, casual sex is often equated with irresponsibility^[34]. People’s right to seek sex and intimacy can also be devalued or seen as irrelevant^[35].

We know, however, acknowledging the significance^[36] of sexual identities and sexual connection in people’s lives is the best way to engage communities in sexual health promotion.

Read more: Monkeypox isn’t like HIV, but gay and bisexual men are at risk of unfair stigma^[37]

A sex-positive approach

As current vaccine supplies for MPX are limited in many jurisdictions, including Australia, priority access is being given^[38] to high-risk groups, including men who have sex with men who have multiple sexual partners.

Given men are being asked to disclose their sexual practices to obtain a vaccine, assurance of non-stigmatising health care will be essential for this program to be successful.

A sex-positive approach to MPX prevention will also support more open conversations so people can gain a better handle on risk and prevention, no matter who they are.

Read more: Australia secures 450,000 new monkeypox vaccines. What are they and who can have them?^[39]

References

1. ^{^} monkeypox (www.health.gov.au)
2. ^{^} men who have sex with men (www.npr.org)
3. ^{^} is stigmatising (theconversation.com)
4. ^{^} racist appropriation of the term monkey (www.npr.org)
5. ^{^} World Health Organization (www.who.int)
6. ^{^} advocates for the LGBTQA+ community (www.aconhealth.org.au)
7. ^{^} vilification of gay and bisexual men (theconversation.com)
8. ^{^} gay-related immune deficiency (ajph.aphapublications.org)
9. ^{^} amyl nitrate (theconversation.com)
10. ^{^} made no public mention of HIV or AIDS (www.nbcnews.com)
11. ^{^} HIV affects more women (www.unaids.org)
12. ^{^} HIV-related stigma from homophobia (www.unaids.org)
13. ^{^} Stigma creates barriers (theconversation.com)
14. ^{^} seek testing (doi.org)
15. ^{^} What's in a name? Why giving monkeypox a new one is a good idea (theconversation.com)
16. ^{^} some reports (www.latimes.com)
17. ^{^} the world has learned (www.scientificamerican.com)
18. ^{^} stigma and discrimination undermine public health (www.thelancet.com)
19. ^{^} marginalised cultural or racial groups (www.nihr.ac.uk)
20. ^{^} fast to condemn (www.theguardian.com)
21. ^{^} advocacy and MPX education (www.acon.org.au)
22. ^{^} sex-positive approaches (pubmed.ncbi.nlm.nih.gov)
23. ^{^} Such approaches (doi.org)
24. ^{^} Lessons from the history of HIV/AIDS in Australia – how activism changed the image of an illness (theconversation.com)
25. ^{^} led to obtuse and confusing reporting (www.theguardian.com)
26. ^{^} although not classified as an STI (theconversation.com)
27. ^{^} being shamed (www.nytimes.com)
28. ^{^} right to engage in pleasurable sex (www.ippf.org)
29. ^{^} shamed (www.ncbi.nlm.nih.gov)
30. ^{^} pleasure-based sex education (theconversation.com)
31. ^{^} Sex ed needs to talk about pleasure and fun. Safe sex depends on it and condom use rises (theconversation.com)
32. ^{^} was critiqued (www.ncbi.nlm.nih.gov)
33. ^{^} promiscuity (blogs.bmj.com)
34. ^{^} often equated with irresponsibility (onlinelibrary.wiley.com)
35. ^{^} seen as irrelevant (www.ncbi.nlm.nih.gov)
36. ^{^} acknowledging the significance (www.who.int)
37. ^{^} Monkeypox isn’t like HIV, but gay and bisexual men are at risk of unfair stigma (theconversation.com)
38. ^{^} priority access is being given (theconversation.com)
39. ^{^} Australia secures 450,000 new monkeypox vaccines. What are they and who can have them? (theconversation.com)