“Monkeypox is not a gay disease.” “Anyone can get monkeypox.” We’ve heard this ad infinitum—and it’s accurate—but as we attempt to avoid stoking stigma and homophobia, I fear the LGBT community and the government aren’t doing enough to raise awareness and curb transmission.

The monkeypox outbreak outside endemic countries was first reported in the United Kingdom in early May. As of June 22, the Centers for Disease Control and Prevention (CDC) has identified 156 confirmed cases in the United States. Worldwide, there are now more than 3,000 cases. Most are gay, bisexual or other men who have sex with men.

Yet in the media, we’ve seen more articles addressing the delicate balancing act of raising awareness without triggering stigma than we have about how to actually tackle the outbreak. Many well-known voices on gay sexual health and HIV prevention have been publicly silent, failing to push back against misinformation. Many gay and bi men still don’t know about monkeypox. Meanwhile, people on social media are claiming the outbreak has no link whatsoever to gay sex, left and right alike are mocking harm reduction advice and straight women are panicking about their risk.

The LGBT community and its allies worry that emphasizing the predominance of monkeypox among men who have sex with men will trigger the same kind of stigma and homophobia we’ve seen with HIV. What’s more, focusing on the gay angle could lead other groups to think they’re not at risk. “Stigma distorts science,” says Demetre Daskalakis, MD, MPH, director of the CDC’s Division of HIV/AIDS Prevention. “The message is the same for everyone.”

But others are pushing back. “For fear of stirring up animus against gay men, officials today may be underplaying the role of sexual transmission in recent monkeypox cases,” medical historian Jim Downs, PhD, wrote in the Atlantic. Health officials and news outlets “are putting gay men at risk unless they prioritize them for interventions such as public-awareness campaigns, vaccines and tests.”

Putting it more strongly, sex advice columnist Dan Savage said on his podcast (as quoted in the Washington Post), “Early in the AIDS crisis, public health officials and news reporters didn’t raise the alarm about a new disease because they didn’t care about gay or bi men, they didn’t care whether we lived or died. Now, they are failing to raise the alarm because they care about us too much, so much so they don’t want to hurt our feelings or accidentally hand ammo to anti-gay bigots.”

Is Monkeypox Sexually Trasmitted? 

With more than 3,000 monkeypox cases in countries outside Africa, where the disease is endemic, only a handful are women, and most are men who have sex with men. Gay and bi men are more connected to sexual health services and more diligent about getting symptoms checked out, but this ascertainment bias is unlikely to fully explain the disparity.

Anyone can get monkeypox via close personal contact, including skin-to-skin contact and respiratory droplets at close range. However, it is not transmitted through the air over longer distances like the coronavirus that causes COVID-19, according to the CDC.

Viruses don’t discriminate based on identity, but they do so based on behavior—and some behavior provides a fortuitous niche for pathogens. As gay science writer Kai Kupferschmidt explains, sex with multiple partners and concurrent partnerships make it easier for diseases to spread, and anonymous encounters make them harder to trace. Many cases in the current outbreak have been linked to sex venues like saunas and circuit-type events that involve international travel, including a Pride festival in the Canary Islands, a fetish event in Belgium and the International Mr. Leather weekend in Chicago. Many of the men have presented with genital or anal lesions that resemble—and in some cases occur together with—common sexually transmitted infections (STIs).

We’re told monkeypox is not a sexually transmitted disease as traditionally defined, but that’s not as straightforward a definition as one might think. As sexual health journalist Rachel Feltman writes, “We have a weird line in the sand between things that are sexually transmitted, and then stuff you don’t have to feel bad about catching.”

We don’t know yet if monkeypox virus is transmitted via semen during sexual intercourse, but we do know that it’s transmitted through skin-to-skin or face-to-face contact during sex. Syphilis and herpes are also transmitted through contact with sores, and everyone agrees they’re STIs.

Monkeypox outbreaks among men who have sex with men could be epidemiology distinct from transmission happening within the general population in endemic countries. We’ve seen this before.

Hepatitis C is not traditionally considered an STI—and it’s seldom transmitted via heterosexual sex—but since the early 2000s, we’ve seen outbreaks of sexually-associated hepatitis C among gay and bi men. It’s not completely clear how this happens (via semen or contact with small amounts of blood during sex), but these outbreaks have been contained using the kind of test-trace-treat approach used to combat STIs. 

Some have suggested that it’s merely coincidence that the monkeypox outbreak is hitting men who have sex with men. We’re told it could just as easily have started among, say, college athletes or Spring Breakers. That’s possible, but if it did, the virus wouldn’t be spreading as fast or as far as it has. (Young straight men can only wish they had that much sex!)

Of course, not all gay and bi men have highly active and varied sex lives, and some heterosexuals do. Sex venues and events that cater to straight people do exist, but they’re few and far between, and a smaller proportion of the heterosexual population participates. While everyone should be aware that they’re potentially at risk through close personal contact, it’s not homophobic to acknowledge that some groups are more at risk than others.

What Can We Do Now? 

Fighting stigma and homophobia is crucial, but being cagey about who’s getting monkeypox right now might not be the best the way to do this. As Downs wrote, “Tiptoeing around the issue carries its own risk.”

And it’s futile. Homophobes are going to homophobe. The right will use monkeypox to shame and blame gay men—that’s what they do. Many conservatives are squicked by gay sex (and any type of non-reproductive, non-monogamous or kinky sex), along with trans kids and drag queens. Attacks on LGB and especially T people are rampant and rising, and staying silent about monkeypox isn’t going to stop them.

Plus, some liberal allies aren’t helping. COVID pundits with large Twitter followings but little grounding in HIV or harm reduction are telling gay men to just stop having sex—an approach we know doesn’t work. Liberals and conservatives alike are passing around a smear campaign by the UK Daily Mail that suggests the CDC is encouraging people with monkeypox to have sex. Some are promoting condoms and universal masking, seemingly failing to grasp that monkeypox is not HIV and it’s not COVID.

Instead of trying to keep things on the down-low, the LGBT community could be doing more to raise awareness, offer harm reduction advice and push the government to provide more testing and vaccines.

Guided by Daskalakis, the CDC is taking a time-tested harm reduction approach. The main message of its Social Gatherings, Safer Sex & Monkeypox factsheet is: “If you or your partner have recently been sick, currently feel sick, or have a new or an unexplained rash or sores, do not have sex and see a healthcare provider.” But if you’re going to do it anyway, here are some tips for making it as safe as possible.

We need to push for more widespread testing. As PrEP activist James Krellenstein and others have argued, the CDC’s monkeypox testing system is a bottleneck. Some 70 state labs can test for orthopox (the virus family that includes monkeypox and smallpox), but confirmation of monkeypox is done centrally by the CDC, a process that can be cumbersome and time-consuming.

And this system won’t scale as the outbreak spreads. With tests effectively rationed, we’re seeing reports that testing is being withheld, even from people with known risk factors. Sexual health clinics, sex venues and gatherings should be able to test for monkeypox the way they now do for HIV. And testing should by no means be limited to men who have sex with men.

Community clinics, venues and events are also potential sites for a wider vaccination campaign. Smallpox vaccines prevent monkeypox too, and vaccination is currently underway for close contacts of known cases. But many experts and advocates think vaccines should be offered more broadly to groups at greater risk. Canada and the U.K. have already expanded vaccine access for gay and bi men considered at higher risk, using criteria similar to those used to assess eligibility for HIV PrEP.

However, supplies of the new safer vaccine (brand names Jynneos or Imvanex) are limited, and the old stockpiled smallpox vaccine can cause adverse events and isn’t safe for people with HIV. Experts say smallpox vaccination for general population isn’t indicated at this time to control the current monkeypox outbreak. But perhaps, suggests European AIDS Society president Sanjay Bhagani, MD, restoring population orthopox immunity “may be the key to preventing future outbreaks.” Such an effort would hopefully prioritize countries in Africa, where the disease has been ignored by the west for decades.

It’s not all bad news. Sexual health services, sex venues and Pride events can raise awareness and offer targeted services, especially for gay and bi men. HIV has taught us about harm reductions and trade-offs. We know from experience how to manage sexually transmitted—or transmitted sexually—diseases without canceling events, closing sex venues or demanding abstinence or monogamy.

“Our LGBTQ and AIDS organizations have been built for this moment,” long-time HIV activist Gregg Gonsalves, now at Yale School of Public Health, recently wrote. “They have decades of experience in education and outreach with gay men, have shaped policy responses to protect our rights in the context of a pandemic, and fought and won many victories for us. Yet now they are strangely silent.”

Efforts to stem stigma can come across as suggesting that gay men having lots of sex is a bad thing. The silence about how monkeypox is spreading strikes me as an effort to “sanitize” gay sex to avoid offending the public and triggering homophobes. We saw something similar after the advent of PrEP, when gay men trying to protect themselves from HIV were derided as “Truvada whores.”

But shaming people for having sex only works if you think sex is shameful. Or as David Holland, MD, of Emory University, puts it, “We wouldn’t have to worry about stigmatizing gay men in the monkeypox outbreak if we didn’t still stigmatize gay men’s sexuality in general.”

Click here to learn the basics about monkeypox.