Saturday, 3 Jun 2023

Opinion | How Gay Men Saved Us From Mpox

For weeks, the same awkward scene played out again and again in sexually transmitted infection clinics across the United States. Half-naked gay men stood with their pants around their ankles while clinicians crouched between their legs, swabs at the ready. The clinicians were covered head-to-toe in hazmat chic: gowns, gloves, face shields and N95 respirators. The men were covered in something much worse: painful lesions, on their genitals, their anuses and sometimes even their faces and limbs.

It was July of 2022, just last summer, and an outbreak of mpox — formerly known as monkeypox — was in full swing. From a handful of cases in a few cities in early May, the outbreak surged to more than 16,000 cases in 75 countries and territories just two months later. It was terrifying.

The sudden appearance of so many mpox cases everywhere and all at once was shocking. Aside from an occasional case among travelers from countries in West or Central Africa, where the virus is endemic, mpox was extremely rare in Europe or North America. The United States had seen only one outbreak, back in 2003, among Midwesterners with pet prairie dogs that had been housed with infected African rodents. There were 47 cases then and no documented cases of human-to-human transmission.

This time was different. In early May of 2022, mpox found its way to gay raves in Spain and Belgium, huge annual parties that draw men from all over the world. Clothing was scant, grinding was plentiful and when the parties were over everyone flew home. Within weeks, mpox cases — resulting from human-to-human transmission — began cropping up in cities worldwide.

While the outbreak caught the public unaware, public health officials had been warned. Five years earlier, Dr. Dimie Ogoina had observed unusual cases in Nigeria, first in an 11-year-old boy and then among young men who’d reported multiple sex partners or encounters with sex workers. He soon realized that this was not “the regular monkeypox we know” and tried to alert the scientific community about the possibility of sexual transmission.

And just as we were grappling with proof that Dr. Ogoina was right about everything — right that something had changed, right that mpox was transmitted sexually and right to raise the alarm — testing revealed that the mpox virus could survive on linens or clothing for more than two weeks. While we were both primarily concerned for those already suffering from mpox and those at highest risk of contracting the virus, we feared what might happen if mpox made its way into hotel rooms and onto cruise ships and college campuses. (Think of all those frat house couches that are rarely cleaned.) This outbreak could become an epidemic, perhaps even a pandemic.

Luckily, we were wrong.

While mpox could live on surfaces, it turned out it didn’t spread that way. The virus required close, sustained contact to spread, which is why it was fanning out overwhelmingly through sex. So this outbreak that started in gay and bisexual communities mostly stayed in those communities, but not for long. On Jan. 31, 2023, the federal government declared an end to the mpox emergency, as average case counts fell from a peak of over 450 per day in early August to less than five during the last week of January. While the outbreak in the United States lasted just under nine months, it caused plenty of damage, resulting in more than 30,000 cases and 42 deaths.

While the outbreak ended faster than many believed it would, it was far worse than it needed to be, representing both a public health triumph and a public health failure. Both health officials and the media failed to expediently warn and engage the gay community in the outbreak’s crucial first weeks.

When the first cases were reported among gay and bi men in the West, health authorities and the media couldn’t bring themselves to say the word “gay.” To avoid stigmatizing gay and bi men, early reports buried the lead. The Associated Press didn’t mention that this outbreak was being seen almost exclusively in gay men until 15 paragraphs into one report; other reports didn’t mention gay and bi men at all. A gay man scanning headlines in May of last year might have learned of an outbreak — but unless he had traveled to West Africa recently, or had contact with infected rodents or primates, he could have easily concluded that he wasn’t at risk.

While this desire to avoid stigmatizing gay and bisexual men was understandable, it wasn’t helpful. We know gay sex has been unfairly blamed for everything from natural disasters to the fall of Rome. But in their efforts to avoid stigmatizing the community, health authorities and the media failed to effectively warn gay and bi men. Ignorant of the threat as the virus spread, gay and bi men couldn’t take steps to protect themselves and their partners.

Unfortunately, stigma and discrimination found the community anyway. Gay men with mpox were turned away from urgent care clinics and emergency rooms. Phlebotomists refused to draw their blood. Like its predecessors Covid-19 and H.I.V./AIDS, mpox had all the makings of a public health disaster. It took nearly two months into the outbreak for testing to become widely available. A dearth of vaccines created “Hunger Games”-like scenarios in cities throughout the country, with vaccine clinics opening and then shutting their doors for lack of supply. Cases began to appear in a small handful of transgender people and cisgender women and children, raising alarm about wider spread.

Even after it was evident that this painful, potentially disfiguring or even fatal infection was spreading through gay men’s sexual networks, public health officials and the media were hesitant to give the same advice they had given freely at the beginning of the Covid pandemic: Limit your number of sex partners and express your sexuality in socially distanced ways.

But while health officials and journalists hesitated, gay and bi men sprang into action. Young men with lesions covering their faces took to social and mainstream media, telling the public that they were dealing with “the worst pain I’ve experienced in my life” and, perhaps the most telling, “I’d rather have Covid.” Benjamin Ryan, a gay journalist, and Carlton Thomas, a gay doctor, risked cancellation — e.g., being yelled at on Twitter — to dish out what Dr. Thomas referred to as “tough love” advice for their community: Slam the brakes on sex outside of committed relationships; seek immediate medical care for symptoms; and get vaccinated as soon as possible.

And the gay community listened.

Gay party promoters canceled long-planned events and individual gay men temporarily deleted hookup apps from their phones and reduced their sexual contacts. The Centers for Disease Control and Prevention verified these shifts in behavior, reporting that half of gay men surveyed reduced their number of sex partners, one-time sexual encounters and use of dating apps during the outbreak. And gay and bi men got vaccinated in droves; two-thirds of those surveyed by the Pew Research Center in September 2022 reported that they had already received an mpox vaccine or were planning to do so. Gay and bi men endured frustrating attempts to secure appointments for the crucial first dose of the two-dose series and hourslong waits at pop-up vaccination sites. Of the over one million doses of the Jynneos vaccine (protective against smallpox and mpox) administered in the United States since June 2022, more than 90 percent were given to men (presumably gay and bisexual men).

Communications teams at the C.D.C. made great strides during this time. They acknowledged the realities of gay sexuality and its breadth of expression, using the actual language gay men use when discussing sex with each other. The words “fetish gear” appeared on a C.D.C. website for the first time; the clinical term “anus” became the more user-friendly “butthole,” and instead of “public sex environments,” the C.D.C. spoke frankly about “back rooms” and “sex parties” and the risk of contracting mpox in those spaces.

While those warning gay men to cut back on sex until they were vaccinated against mpox experienced accusations of fomenting stigma — echoing pushback experienced by gay men who urged others to avoid bathhouses and start using condoms at the start of the AIDS crisis in the early 1980s — efforts to shoot the messenger were less aggressive than in years past. One key difference between H.I.V./AIDS and mpox: Many of the messengers were gay and bisexual men themselves, including gay journalists, doctors and average citizens with access to social media, plus a generation of gay men who had been inspired to pursue public health careers in the wake of AIDS.

The C.D.C.’s chosen spokesman to lead national conversations on mpox and gay men’s sexual health wasn’t a straight doctor in a lab coat who squirmed at the mention of gay sex. Instead, it was Dr. Demetre Daskalakis, an out gay man who not only attends raves but posts shirtless selfies on social media to prove it. This was a messenger the community would listen to.

Gay and bi men had already written the playbook on activism and advocacy throughout the H.I.V./AIDS epidemic, resulting in more than $7 billion in federal funding for H.I.V. research, prevention, treatment and social services. Furious over the federal government’s initial response to mpox, they mobilized and organized, protesting at local Department of Health and Human Services offices and filing a complaint with the Massachusetts state attorney general over denial of mpox testing and treatment.

So while an early and frankly honest public health response could have blunted the outbreak, resulting in far fewer cases and far less suffering, the swift collective action of gay and bi men prevented catastrophe. If the broader American public had responded to the threat of Covid-19 the way gay and bi men responded to the threat of mpox, we might have seen fewer cases (there have been 100 million to date) and a lower death toll (1.1 million and counting). When the next infectious outbreak strikes (and surely it will), the public would be wise to channel gay and bi men: communicate openly without stigmatization, organize and insist on access to effective prevention, diagnosis and treatment.

There’s another important lesson about the gay community that health officials and journalists need to remember going forward: When it comes to emerging health threats — even ones that can spread sexually — gay men can handle the truth. You can give it to them straight.

Ina Park (@InaParkMD) is a professor of family and community medicine at the University of California San Francisco and the author of “Strange Bedfellows: Adventures in the Science, History and Surprising Secrets of S.T.D.s.” Dan Savage has been writing “Savage Love,” one of the most widely read sex advice columns in the country, for more than 30 years and is also the host of “Savage Lovecast.”

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