As the World Health Organisation declares the virus a global health emergency, it’s vital that we direct limited resources towards the people most at risk
Last weekend, the World Health Organisation (WHO) declared monkeypox a global health emergency. Having impacted countries in western and central Africa for years, the viral infection spread to the UK earlier this year, with case numbers reaching 2,137 last week.
When the WHO published a Twitter thread which stated that the virus is mostly affecting men who have sex with men (MSM – an umbrella term designed to include people who don’t identify as gay or bisexual), this prompted an immediate, widespread and furious backlash. Thousands of people chimed in to accuse the organisation of homophobia, suggesting that its efforts to name the most at-risk group constituted an effort to “blame” gay men, in line with a rising tide of anti-LGBTQ+ violence. Many have suggested that targeted interventions aimed at MSM form part of a wider effort to demonise queer people, and harken back to the days of the AIDS crisis. This framing, while in many cases founded on reasonable concerns, could not be more wrong. Not only that, it has the additional effect of obscuring the real problems with how the government is responding to the outbreak.
To be clear: it’s not in the least bit homophobic to acknowledge that monkeypox is almost exclusively affecting MSM – because this is what is happening. A recent study, examining 528 cases across 16 countries, found that 98 per cent of the people infected were gay or bisexual men. “According to the latest figures for the UK, there have been over 2,000 cases of monkeypox since May, and a small handful weren’t MSM,” says Deborah Gold, CEO of the National AIDS Trust. The government’s latest research found that only 13 women have been diagnosed, and no robust evidence of transmission outside of sexual networks of MSM. “There’s been a lot of learning around the stigmatising way that early health promotion around HIV happened in the 80s, and the impact that still has,” Gold continues. “But you have to respond to health conditions with evidence-based policies. If you ignore that, through a sense of over-sensitivity, you risk the harm to the community being greater.” What’s more, the best way to prevent a virus from spreading into the general population is through directing resources towards the demographic most impacted. This approach is in the interest of public health; not just for MSM but for everyone.
It seems that the COVID-19 pandemic has engendered a paranoid approach to infectious diseases. You can see this at play in a spate of fear-mongering attempts to univeralise the risk posed by monkeypox, with people on Twitter, many of whom are high-profile health professionals, trying to depict it as a direct sequel to COVID – something your granny is in danger of catching when she pops to the shops. There is one viral infographic doing the rounds which lists a disturbingly exhaustive number of ways in which monkeypox can be spread, from inhalation to touching an infected object. This information isn’t inaccurate per se, but it is misleading as to how the outbreak is actually developing. Monkeypox can be spread to populations other than MSM, but right now the evidence suggests this is happening in extremely rare instances. There’s an argument cropping up online that this is due to confirmation bias, a result of the fact that only MSM are being tested. It’s impossible to discount this possibility entirely, but there is currently no evidence to suggest that it’s actually happening.
Similarly, monkeypox can be transmitted through means other than sexual contact, but right now its mostly being transmitted through the kind of extended skin-to-skin contact that only really takes place during sex. There has been a huge amount of resistance to this idea, too, as though sexual transmission is inherently more shameful or stigmatising. But again, this is misguided. It is important that we are able to name how the infection is being spread. “Strictly speaking, it’s not a sexual transmitted infection, because it’s not transmitted via sexual fluids,” says Gold. “But based on the fact that there are now over 2,000 cases and it’s still within this network of MSM, you can make some sensible assumptions about how it’s being spread. I’m not saying it can never be passed on in other ways, because there are some outlier examples. But really, prolonged skin-to-skin contact is how it’s being passed on.”
Some experts have gone even further, arguing that it does make sense to conceptualise monkeypox as an STI. “I don’t think we should be afraid to think of it as a sexually transmitted infection. It’s nothing to be embarrassed about,” Dr Steven Thrasher, author of The Viral Underclass: The Human Toll When Inequality and Disease Collide and a professor at Northwestern University, tells Dazed. “Right now, it’s transmitting mostly through sex between men, and it’s important to name that so that’s where the majority of the research and resources go. At the same time, we can prepare for other ways it may transmit and change course as conditions evolve. Calling something an STI doesn’t preclude treating other modes of transmission; it just helps us name into existence ways to minimise sexual transmission.”
In the online discourse around monkeypox, lots of people are quick to invoke the AIDS crisis as a rhetorical cudgel, despite clearly knowing very little about it. The idea that these targeted interventions are a throwback to the stigmatising, neglectful way that gay men were treated during the 1980s is historically illiterate. The problem with the state’s response to the AIDS crisis, on either side of the Atlantic, was not that it was too quick to allocate resources to gay men and other vulnerable demographics. It was that it failed to act for a long time because it didn’t care that these people were dying. The approach we are seeing now, in which MSM are being prioritised, is profoundly different, and is in many cases being advocated by activists and campaigners with decades of experience in fighting for HIV justice. “While it’s understandable, it’s a shame to see people frame this MSM-centered approach, which is explicitly a result of post-AIDS crisis victories and the services which grew out of its aftermath, as some kind of AIDS parallel,” says Marianne*, a sexual healthcare support worker at the frontline of the outbreak.
Where people are correct to be concerned, and where the AIDS comparison is arguably more apt, is the threat of the conservative right weaponising the outbreak as an means to demonise gay men – this is already happening and will no doubt get worse. Particularly in the US, which is currently experiencing a resurgent wave of anti-LGBTQ+ violence, this is a well-founded anxiety. But we shouldn’t allow the right, who will exploit this crisis regardless, to determine our own response. It’s unfortunate timing for an infectious disease to emerge that’s mostly affecting queer people, but an effective public health strategy needs to be based on evidence. We can’t shy away from this because we are scared of how the homophobic right will react, however legitimate those fears might be. “In everything we do, we have to work very carefully about how we spread the message,” says Gold. “I don’t want to diminish the fact that there is a risk of building stigma. But while you have to think about that risk carefully, it can’t stop you from taking the action you need to take.”
If we want to rail against state homophobia, a better place to start would be the chronic underfunding of sexual health services, which are now under immense added strain without being afforded any additional resources. Not only is monkeypox having a disproportionate impact on MSM, it’s also having a knock-on effect where overstretched services are struggling to provide HIV care, PrEP provision and other vital sexual health treatments. There is an urgent need for added capacity which is not being met. “After an individual person comes in thinking they might have monkeypox, the entire room has to be disinfected,” explains Gold. “This takes time, and some sexual health clinics may only have one or two rooms where they can see people. It’s putting immense pressure on a system which started out enormously underfunded.” In terms of vaccine provision, the ‘drop-in’ approach we saw last weekend only really serves people who are willing to queue for hours, effectively with a banner reading ‘I AM GAY’. This means it’s likely to exclude people who aren’t comfortable with being publicly outed.
According to Marianne, sexual health services are well-placed to tackle the outbreak, and all the patients she’s seeing are happy to be treated within that context. “But these services are really struggling to even deliver this narrowly targeted response – we were already struggling to get back to normal capacity after Covid and years of cuts,” she says. “In this context, being expected to handle a new outbreak with no extra resources is putting huge pressure on a service already at breaking point. It would be great to see less attention on whether we are directing too many monkeypox resources to MSM and more on how little resources we have all round.”
Similarly, there is a dire lack of support for people who contract monkeypox and then have to self-isolate, in some cases for up to three weeks or even longer. For many, this can be financially ruinous, particularly if they are on a zero-hour contract or reliant on sex work. As it stands, there is no access to the kind of support services available during the earlier stages of the COVID pandemic. “There is a real need for some kind of financial support for people who are being asked to self-isolate,” says Gold. The fact that this kind of support is not being provided, along with the long-term underfunding of sexual health services, is more deserving of our anger than public health bodies accurately naming who is most at risk.
People are right to be worried about the homophobic stigma that might arise as a result of the outbreak, but we should not capitulate to the idea that it’s inherently shameful to have a disease – to do so would be fighting on the enemy’s terms. Denying the fact that MSM are disproportionately affected feels like a form of respectability politics, a cop-out from the harder task of fighting the existence of such stigma in the first place. Going forward, we should instead focus our efforts on looking out for one another, as well as ensuring that the state allocates the resources necessary to contain the outbreak and support the people affected.
*Names have been changed