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Mpox (monkeypox)

Hi Alice,

So I'm wondering some stuff about mpox. Why is mpox being spoken about as if it's a gay STD? Mpox can be spread through nonsexual contact and fomite transmission, according to health authorities, and many other diseases such as the flu and corona can be obviously spread through sexual intercourse (via close contact). Additionally, according to the CDC, Ebola can be spread through semen of a previously infected male a while after recovery while not symptomatic (which appears to be unlike mpox in which it's only spread while actively symptomatic and, although mpox is extremely severe, it doesn't last for more than several weeks) but Ebola isn't thought of as a STD (and of course Ebola can obviously be spread through nonsexual as well as sexual contact) just like corona and the flu among many other diseases. Yet mpox is basically now thought of as being a STD — and a gay STD at that — whereas other diseases that also spread through nonsexual means like mpox aren't. This is very concerning to me both because it would be contributing to ineffective containment measures which would let mpox continue spreading and because it could lead to an increase in discrimination against an already marginalized demographic. What's going on here?

Dear Reader,

You're completely right that mpox (formerly known as monkeypox) is, at this point in time, not considered a sexually transmitted infection (STI)! In fact, it’s considered a zoonotic disease, meaning that it normally inhabits animal species but will sometimes be transmitted from those animal reservoirs to humans and from there be transmitted from person to person. While this virus has historically resulted in limited outbreaks in several countries in West and Central Africa, the current outbreak in 2022 is different in that the spread between humans has been sustained resulting in relatively large number of cases that have occurred in many countries outside those where it has previously been reported. This transmission occurs primarily via skin-to-skin contact. Much of the current spread has been reported among sexual partners due to close skin-to-skin intimate contact.  While the majority of cases of mpox in this current outbreak have been reported among men who have sex with men, unfortunately, the way the risk of mpox has been communicated to the general population, especially in the United States, has caused some to believe that mpox only affects people in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities — more specifically, gay and bisexual men and other men who have sex with men (MSM). As you’ve noted, MSM — and LGBTQ+ folks more generally — aren't the only people who can contract or spread mpox. Thinking of mpox transmission in this limited way also has the potential to create stigma, or negative beliefs about certain people or groups that have social and safety consequences. Clearly, this is a complicated (and emerging!) issue: for more on mpox, continue reading! 

First things first: mpox is a virus, an orthopoxvirus to be exact. There are quite a few viruses in that family, but the one you've likely heard of before is smallpox. Luckily, mpox is less severe than its cousin smallpox. Between people, mpox may be spread in a few ways:  

  • Skin-to-skin contact with infected lesions in the form of rash or sores: This is the most common and highest risk mode of transmission and can include contact such as massaging, kissing, touching genitals, among plenty of other examples. 
  • Respiratory secretions: This is a less likely route of transmission. It occurs through consistent contact with respiratory droplets, which leave the mouth and nose when coughing, sneezing, talking, or breathing.  
  • Fomite transmission: This route of transmission is also less likely than skin-to-skin transmission. It occurs by touching objects or surfaces (such as sharing towels or bedding) that have been in close contact with an infected lesion.

Previous outbreaks were characterized as typically having limited human-to-human transmissions and a higher number of lesions that were located on the hands, feet, face, and mouth. The 2022 global outbreak is behaving and transmitting in ways uncharacteristic of prior outbreaks, with frequent lesions in the genital and anal areas and on surfaces such as the mouth or rectum. But there’s still a lot to learn about the relative risks of respiratory and fomite transmission. Additionally, mpox infections nowadays appear to be presenting with fewer total lesions, with over half of early diagnoses including ten or fewer lesions. Both the location and smaller number of lesions may make infections during the 2022 outbreak harder to notice and diagnose. While skin-to-skin contact is the most common, there’s still a lot to learn about the relative risks of respiratory and fomite transmission.

In reviewing that list, you may have noticed that sexual contact wasn’t mentioned as one of the modes of transmission. Here’s where things get nuanced: mpox itself isn't characterized strictly as “sexually transmitted,” meaning spread through contact with the genitals or bodily fluids (i.e., semen, vaginal secretions, blood) of another person through sexual contact. However, sex does often involve a lot of skin-to-skin contact as well as the exchange of respiratory secretions through kissing and heavy breathing while in close proximity, all of which increase the risk of mpox transmission. Additionally, people diagnosed with mpox during the global 2022 outbreak are exhibiting far higher rates of skin lesions in the anal and genital area, an area that doesn’t typically have much casual skin-to-skin contact with anyone except sexual partners. This may further be contributing to the false idea that mpox is a sexually transmitted infection.

Other symptoms of mpox to look out for include:  

  • A rash with pimple-like blisters (numbering anywhere between a few to a few thousand); some of the blisters may progress to include pus.
  • A fever (often one to three days before the appearance of the rash)
  • Headache
  • Swollen lymph nodes
  • Muscle aches
  • Fatigue

It usually takes about 6 to 14 days for symptoms to develop after exposure to mpox, though in some cases it might take up to 20 days. The symptoms then might last anywhere from two to four weeks until the skin lesions fully heal with formation of new skin at the site of the sores. Unfortunately, mpox is contagious as long as symptoms persist and until lesions have fully healed. To diagnose mpox, a health care provider may take a swab from the rash and perform a polymerase chain reaction (PCR) test to confirm the infection. It’s strongly recommended that anyone who has symptoms or a known exposure to a person diagnosed with mpox immediately reach out to a health care provider in order to determine the best testing and treatment options. 

If diagnosed with mpox, taking these steps are critical to reduce the chances of spreading the illness to someone else:

  • Remain isolated away from other people while symptomatic until skin lesions are fully healed over with a new layer of skin. If possible, use a separate bathroom, bath towels, and laundry hamper from other household members.
  • If it’s impossible to remain completely isolated from household members, cover all parts of the rash with clothing or bandages and wear a close-fitting mask when using shared spaces. Regularly disinfect the surfaces in shared spaces. If you need to leave isolation to seek necessary medical care, follow the same tips around covering the rash and wearing a mask.
  • Be the only person to handle your laundry, bedsheets, linens, or towels while symptomatic. Once recovered from mpox, launder or disinfect all items that have been worn or handled while you were symptomatic before you allow other people to come into contact with them.

People in areas where mpox is spreading more rapidly may wish to take additional precautions to minimize their risk of contracting this virus. Since it spreads most easily through skin-to-skin contact, it may be wise to stay cautious in areas where minimal clothing is worn and skin-to-skin contact is likely to occur, such as festivals, nightclubs, concerts, or other crowded spaces where you may have close skin contact. You may also choose to limit the number of people you have skin-to-skin contact with to reduce the chance of exposure. You can stay informed of the spread in your region by checking your local or state health department's website, which may help you make decisions about the activities and people you're comfortable engaging with.

There are also two vaccines available in the United States, both of which were originally developed for smallpox; however, the preferred vaccine is the one licensed for mpox use under a U.S. Food and Drug Administration (FDA) Expanded Access application. The vaccine, which was used in previous mpox outbreaks, is about 85 percent effective from prior studies. This vaccine may also be used as post-exposure prophylaxis (PEP) in the days following a mpox exposure to decrease the likelihood of development of the disease. Because there is a limited supply of vaccine in the US, many states and municipalities are prioritizing those who they believe are at highest risk for being exposed to and contracting mpox . Based on early data of the current outbreak, mpox seems to be initially spreading among MSM — not because of any innate or genetic factor but rather because LGBTQ+ people tend to have tight-knit social and sexual networks where they tend to socialize, date, and live together. Because of this, many states are prioritizing MSM for vaccination, especially folks who have multiple or anonymous sexual partners. To learn more about mpox vaccines, check out the CDC’s website. To find out if you’re eligible for a mpox vaccine, contact a health care provider or your local department of health.

While modern-day antiviral medications reduce the risk of complications of mpox , it’s wise not to underestimate the potential severity of a global outbreak. The skin lesions (particularly those occurring around the eyes, in the mouth, genital and anal areas) may be extremely uncomfortable or painful and some people may experience permanent scarring. Additionally, some groups of people are more predisposed to have serious illness, if they develop mpox, such as those who are pregnant or breastfeeding, those who are under the age of eight, those with a history of eczema, and those who are immunocompromised. Taking precautions to prevent the spread of mpox and seeking out appropriate treatment if you start to notice symptoms can help ensure that those who may be at higher risk of severe disease don’t come into contact with it.

Reader, to address the second part of your question about mpox being wrongly considered not just an STI, but an STI that only impacts LGBTQ+ people. You're absolutely right that discussing mpox in this narrow way has significant implications for the health of communities and the well-being of LGBTQ+ people who might be subject to stigmatization. In some regions, mpox has been disproportionately affecting LGBTQ+ communities, particularly MSM. However, people outside of LGBTQ+ communities have been diagnosed with mpox. The longer this outbreak goes on, the more likely it will spread beyond these initial communities.

The stigmatization of mpox is part of a historical pattern. When new diseases have emerged, they’re most likely to impact marginalized groups of people who already lack access to resources, particularly health care; these same groups may then face the blame for the disease’s spread. The emergence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is likely the most notable example of this in recent history. It was originally thought that only gay men could get HIV, and as a result, LGBTQ+ people faced increased discrimination and hostility. Research into HIV treatment and prevention was systematically neglected because it was primarily affecting stigmatized groups such as MSM and intravenous drug users, and because of this, HIV was allowed to spread unchecked. Now, it’s a global disease that affects many people across all identities. Historic examples such as this highlight the negative impacts of stigma: it causes people to deny or hide their disease and avoid health care out of fear of judgement, mistreatment, or worse, and it leads to worse health outcomes for all people. It also might cause folks who aren't in the perceived risk group (in this case, heterosexual people) to feel a false sense of safety or security, and they might be more likely to enter higher-risk situations.

Reader, your observations of the false and harmful information spreading (no pun intended) on mpox are quite perceptive. When new outbreaks of unfamiliar infectious diseases arise, it’s not uncommon to hear rhetoric that places the blame on specific groups of people, even claiming that they're using the disease to harm others or act in a predatory manner. In many cases, these rumors are targeted towards marginalized groups and are rooted in hate and bigotry, rather than science. Unfortunately, it can be difficult to interpret scientific jargon about an emerging disease and instead find it much easier to believe these harmful rumors. In this case, language is key when discussing how diseases spread in order to avoid unfairly focusing on or blaming one group or another. Nuance is critical when putting out communication to avoid this type of bias and blame, even if the intent of the messaging isn't to stigmatize or cause harm. This is something that national and local health officials contend with as they share new information, and they sometimes miss the mark. On an individual level, there are a few steps you can take, such as staying up to date on mpox information in your community and speaking out against the use of stigmatizing language that could harm marginalized groups. If enough people like yourself step up and speak out, who knows what change is possible.

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Originally published Oct 24, 2022

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