As the Centers for Disease Control and Prevention weighs whether to recommend limiting sexual partners, health officials in San Francisco, Chicago, New York and other US cities battling surges disproportionately sickening gay men are avoiding calls for sexual restraint, wary of further stigmatizing same-sex intimacy.
Public health authorities typically emphasize safer sex over abstinence to prevent the spread of diseases through intimate contact. But monkeypox is presenting new challenges in calibrating the right message to stop the rare virus from becoming endemic while limiting government intrusion into the bedroom.
“If people want to have sex, they are going to have sex,” said California state Sen. Scott Wiener (D-San Francisco), who is involved in the city’s monkeypox response. “I know people who normally go to sex parties who will not. People will make their own decisions about their own risk levels.”
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More than 6,600 cases of monkeypox have been detected in the United States. The virus primarily spreads through exposure to an infected person’s rashes or lesions, and this is the first outbreak in which contact during sex appears to be the significant driver. While infections are heavily concentrated among men who have sex with men, others can contract the virus through nonsexual contact and sharing contaminated items.
Many public health officials and activists who spent decades on the front lines of the battle against HIV/AIDS say they have learned it is futile to tell people to have less sex. That stance puts them at odds with the WHO, a top New York epidemiologist who condemned the city’s messaging and others within the gay community who say gay men deserve direct warnings before it is too late to end the outbreak.
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“It was devaluing gay men’s lives and health not to warn gay men,” said Dan Savage, a sex columnist who has criticized the public health response to monkeypox. “Now, here we are, really on the verge of monkeypox being endemic in gay communities all over the world, and how is that for stigma?”
Savage, who is not prude as a proponent of non-monogamous relationships and exploring fetishes, said public health officials should have advised gay men to curb their sex lives at the start of the outbreak in May, which experts suspect was supercharged by large festivals in Europe with rampant sexual activity.
Savage is taking his own advice, limiting sex to his husband and his boyfriend and skipping San Francisco’s Dore Alley festival this year.
A dozen Dore Alley attendees interviewed by The Washington Post said they took monkeypox seriously — without the government scolding them to do so. Many revelers kept their clothes on or donned full latex outfits inside crowded bars. One man sheathed himself in a monkeypox-inspired costume — a clear plastic rain suit over a rainbow outfit decorated with white polka dots that he said he wore to “make a statement” about the importance of avoiding skin-to-skin contact.
Several said they planned to avoid casual sex at after parties. Attendance was down by thousands compared with previous years, and participants remained spaced apart as they browsed booths hawking leather harnesses and gawked at men dressed as dogs.
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A 30-year-old festival regular who asked to be identified only by his nickname, Oni, citing privacy concerns, said he was being more cautious this year, especially given his day job as a masseuse. Sporting a black leather and chain corset, lace-up mid-calf boots, chartreuse face paint and a small set of horns, Oni said he didn’t plan to have sex and had received the monkeypox vaccine weeks earlier. He left as the festival became more crowded and skipped the bars entirely.
For the time being, he said, “no dark room sex parties, no orgies.”
San Francisco Public Health Officer Susan Philip said the city has learned over decades fighting HIV in coordination with LGBTQ organizations that messages of complete abstinence are ineffective and erode trust within the community.
Instead of shutting down Dore Alley, San Francisco officials focused on disseminating information about how the virus spreads to help people make their own choices. The San Francisco AIDS Foundation released a guide to a “filthy weekend — free of anxiety,” encouraging people to attend while taking steps to reduce risk, including dressing head-to-toe in leather or latex to minimize skin-to-skin contact.
But at the street festival itself, warnings about monkeypox were hard to find. Only one of the attendees interviewed said he received an informational pamphlet about the virus, even as organizers checked for proof of coronavirus vaccination.
Public health authorities worry about placing too much emphasis on sex as a mode of transmission because monkeypox also spreads in other ways.
Zandt Bryan, the sexual health and prevention program manager for the Washington State Department of Health, said urging people to have less sex unfairly places the onus on individuals to end the outbreak and distracts from other potential sources of transmission, such as dancing in packed clubs .
Approaching it from a purely [sexually transmitted infection] standpoint doesn’t really meet the challenge,” Bryan said.
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Some critics of early coronavirus restrictions accuse US public health officials of hypocrisy for telling Americans to forgo in-person schooling, religious services, and weddings and funerals to prevent the spread of coronavirus, while refraining from telling people to limit sex to contain the monkeypox outbreak.
Public health officials reject comparisons to the early days of the coronavirus pandemic, when they mandated masks and shut down public spaces. They noted that the novel coronavirus was unfamiliar, far deadlier and airborne, with hospitals overrun with patients at various points over the past two years. Monkeypox has known treatments and vaccines, although they have been challenging to access; it also has not killed anyone in the United States, and hospitalizations are uncommon.
The World Health Organization has zeroed in on sex as a major driver of the outbreak it declared a global emergency in July, noting infections were especially pronounced in men who have multiple male sexual partners or attended events with frequent sexual activity.
WHO Director General Tedros Adhanom Ghebreyesus in a news conference last week said the outbreak could be stopped by a collective effort of government and individuals. He said men who have sex with men should consider reducing their number of sexual partners, avoiding new ones, and exchanging contact information to allow for contact tracing and post-exposure vaccination.
WHO officials said asking for temporary changes in sexual behavior is a modest step many gay men are already taking.
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“It makes common sense: A reduced number of contacts equals a reduced risk of exposure,” said Andy Seale, a WHO adviser on HIV, hepatitis and sexually transmitted infections. “It’s really about sharing whatever data we get in a stigma-free, moral-free, not-making-any-judgments manner so individuals have access to the data and understand what we are seeing.”
Demetre Daskalakis, a top CDC official leading the US monkeypox response, said at a meeting of HIV organizations this week that “it’s a good plan” to consider limiting partners, stressing that “this is not a forever thing, it’s a for now thing” until vaccinations are more widely available. He said the agency is reviewing its monkeypox guidance for safer sex, which currently tells only people with symptoms to avoid sex.
In New York City, a top epidemiologist at the health department has publicly criticized agency leadership for not urging men who have sex with men to abstain from anonymous sex for several weeks. Don Weiss, director of surveillance for the agency’s Bureau of Communicable Disease, also blasted the health department for issuing a news release in July advising people who choose to have sex while sick with monkeypox to avoid kissing and to cover their sores; Weiss said taking those steps does not prevent infected people from transmitting the virus.
“We cannot vaccinate our way out of this, nor can we isolate our way out of this,” Weiss wrote to other health officials in a June 16 email, which he posted on his personal website. “The only way out is to abstain. I know I sound like a bible thumping preacher, but this is the exposure we need to PREVENT.”
He continued to press his case with colleagues over the coming weeks.
“This disease is entirely preventable had we the courage to send out prevention messages,” Weiss wrote in a June 22 e-mail. “We seem paralyzed by the fear of stigmatizing this disease while we totally ignore the epidemiology. If we had an outbreak associated with bowling, would we not warn people to stop bowling?”
Weiss, who declined to be interviewed, posted a letter from the agency on his website showing he was reassigned after his criticisms.
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Patrick Gallahue, a spokesman for the health department, declined to comment on Weiss’s reassignment, but pushed back against his call for temporary abstinence.
“For decades, the LGBTQ+ community has had their sex lives dissected, prescribed, and proscribed in myriad ways, mostly by heterosexual and cis people,” Gallahue said in a written statement. “Our guidance and advice are grounded in science and history — including the scientific reviews of how poorly abstinence-only guidance has historically performed in preventing transmission of STIs. — with this disgraceful legacy in mind.”
Critics of recommendations to limit sexual partners say they fail to hear the lessons learned from decades trying to end the HIV/AIDS epidemic, with public health officials emphasizing safer ways to have sex with condoms and, more recently, daily pills that drastically reduce the risk of getting HIV and adherence to antiretroviral therapy that renders the virus untransmittable for those who are infected.
“We saw a lot of folks at the beginning of the HIV epidemic calling for the closure of public sex venues like bathhouses. That did not stop the spread of HIV. People still found ways to have sex,” said Tyler TerMeer, executive director of the San Francisco AIDS Foundation.
Gay rights activists are concerned messaging that comes across as disapproval of same-sex intimacy emboldens escalating attempts by the religious right to drive gay people out of public life, including movements around the nation to remove books about LGBTQ issues from school libraries and a new Florida law that bans instruction or classroom discussion about sexual orientation for young elementary school students.
Still, Jim Downs, a historian who has studied the history of HIV/AIDS, said the monkeypox outbreak has arrived in a much better environment for gay people.
“The difference now is public health authorities are not demonizing, pathologizing or criminalizing gay sex; they are just putting out a different message, which is, ‘Pause,’” Downs said. “Gay people are still scrutinized; they are still subject to prejudice and discrimination. But we also have more social and cultural acceptance, so we can actually put out a message about sex that doesn’t indict who we are as people.”
Nirappil reported from Washington.