When monkeypox strikes gay men, officials debate warnings about limiting partners

SAN FRANCISCO — Thousands of gay men dressed in leather, latex — and often far less — partied along Folsom Street here this past weekend during the annual fetish festival. Even after the city just declared the monkeypox outbreak that hit its gay community a health emergency — a day after the World Health Organization urged men to sleep with fewer men to reduce transmission — officials said. San Francisco public health officials made no attempt to curb the festivities or warn participants to have less sex.

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 U.S. cities battling disproportionately sickening outbreaks of gay men are cautiously avoiding requests for sexual restriction. in further stigmatizing same-sex intimacy.

Public health officials often emphasize safer sex over abstinence to prevent the spread of disease through intimate contact. But monkeypox is presenting new challenges to calibrate the right message to prevent the rare virus from becoming endemic while limiting government intrusion into the bedroom.

“If people want to have sex, they will have sex,” said California state senator Scott Wiener (D-San Francisco), who is involved in the city’s response to smallpox. “I know people who normally go to sex parties who don’t. People will make their own decisions about their own risk levels.”

More than 6,600 cases of monkeypox have been detected in the United States, prompting the Biden administration to declare a public health emergency on Thursday to raise awareness. The virus mainly spreads through exposure to a skin rash or injury from an infected person, and this is the first outbreak where contact during sex appears to be the main factor. While infections are heavily concentrated among men who have sex with men, others can contract the virus through non-sexual contact and sharing contaminated items.

Many public health officials and activists who have spent decades on the front lines of the battle against HIV/AIDS say they have learned that it is useless to tell people to have less sex. That stance puts them at odds with the WHO, a leading New York epidemiologist who has condemned messages from the city and others within the gay community that say gays deserve direct warning before it’s too late to end the outbreak.

“It was devaluing the lives and health of gay people not warning gay people,” said Dan Savage, a sex columnist who has criticized the public health response to smallpox. “Now, here we are, really on the cusp of monkeypox being endemic in gay communities across the world, and how is that stigma?”

Savage, who is not a prude as an advocate of non-monogamous relationships and exploiting fetishes, said public health officials should have advised gay men to restrict their sex lives at the start of the outbreak in May, which experts suspect was overwhelmed by major festivals. in Europe. with unrestrained sexual activity.

Savage is following her own advice, limiting sex to her husband and boyfriend and skipping San Francisco’s Dore Alley festival this year.

A dozen Dore Alley participants interviewed by The Washington Post said they took smallpox seriously — without the government reprimanding them for doing so. Many partygoers kept their clothes on or donned full latex outfits inside crowded bars. A man donned a monkeypox-inspired costume – a clear plastic rainsuit over a rainbow-colored 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 parties. Attendance dropped by the thousands compared to previous years, and attendees remained spaced apart as they roamed the stalls touting leather harnesses and gaping at men dressed as dogs.

A 30-year-old festival-goer who spoke on the condition that he be identified only by his nickname, Oni, citing privacy concerns, said he was being more cautious this year, especially given his daily job as a massage therapist. Sporting a black leather corset and chain, mid-calf lace-up boots, chartreuse face paint and a small set of horns, Oni said she had no plans to have sex and had received the smallpox vaccine weeks earlier. He left when the festival got more crowded and skipped bars altogether.

For now, he said, “no sex parties in dark rooms, no orgies.”

San Francisco public health officer Susan Philip said the city has learned over decades of fighting HIV in coordination with LGBTQ organizations that complete abstinence messages are ineffective and erode trust within the community.

Instead of shutting down Dore Alley, San Francisco officials have focused on releasing information about how the virus spreads to help people make their own choices. The San Francisco AIDS Foundation has released a guide to a “dirty weekend – anxiety-free,” encouraging people to attend while taking steps to reduce risk, including dressing head-to-toe in leather or latex to minimize contact. skin to skin.

But at the street festival itself, warnings about monkeypox were hard to come by. Only one of the participants interviewed said that he received an informational pamphlet about the virus, even as organizers verified proof of vaccination against the coronavirus.

Public health officials are concerned about placing too much emphasis on sex as a mode of transmission because monkeypox spreads in other ways as well.

Zandt Bryan, sexual health and prevention program manager at the Washington State Department of Health, said asking people to have less sex unfairly places the onus on individuals to end the outbreak and distracts from other potential sources of transmission, like dancing in crowded clubs. .

“Approaching it from a purely [sexually transmitted infection] point of view doesn’t meet the challenge,” Bryan said.

Some critics of the initial coronavirus restrictions accuse US public health officials of hypocrisy for telling Americans to drop out of face-to-face school, church services, and weddings and funerals to stop the spread of the coronavirus, while refraining from telling people to limit the spread of coronavirus. sex to contain smallpox. outbreak.

Public health officials reject comparisons to the early days of the coronavirus pandemic, when they demanded masks and closed public spaces. They noted that the novel coronavirus was unknown, far deadlier and airborne, with hospitals crammed with patients at various points over the past two years. Monkeypox has known treatments and vaccines, although they have been difficult to access; it hasn’t killed anyone in the United States either, and hospitalizations are uncommon.

The World Health Organization has focused on sex as a key driver of the outbreak and declared a global emergency in July, noting that infections were especially pronounced in men who have multiple male sexual partners or attend events with frequent sexual activity.

WHO Director-General Tedros Adhanom Ghebreyesus, at a press conference last week, said the outbreak could be stopped by a collective effort by government and individuals. He said men who have sex with men should consider reducing the number of sexual partners, avoiding new ones, and exchanging contact information to allow for contact tracing and post-exposure vaccination.

WHO officials said calling for temporary changes in sexual behavior is a modest step that many gay men are already taking.

“It makes common sense: a reduced number of contacts equates to a reduced risk of exposure,” said Andy Seale, WHO consultant on HIV, hepatitis and sexually transmitted infections. “It’s really about sharing whatever data we get in a stigma-free, non-moral, non-judgmental way so people have access to the data and understand what we’re seeing.”

Demetre Daskalakis, a senior CDC official leading the U.S. smallpox response, told a meeting of HIV organizations this week that “it’s a good plan” to consider limiting partners, stressing that “this isn’t a forever thing, it’s a good plan.” one thing for now”. until vaccines are more widely available. He said the agency is revising its monkeypox guidance for safe sex, which currently only tells people with symptoms to avoid sex.

In New York City, a top health department epidemiologist publicly criticized the agency’s leadership for not asking men who have sex with men to abstain from anonymous sex for several weeks. Don Weiss, director of surveillance at the agency’s Bureau of Communicable Diseases, also criticized the health department for issuing a press release in July advising people who choose to have sex while sick with chickenpox to avoid kissing and covering their wounds; Weiss said taking these measures does not stop infected people from passing on the virus.

“We cannot vaccinate our exit from this, nor can we isolate our exit,” 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 preacher, but this is the exposure we need to PREVENT.”

He continued to press his case with colleagues over the next few weeks.

“This disease is entirely preventable if only we had the courage to send prevention messages,” Weiss wrote in a June 22 email. “We seem paralyzed by the fear of stigmatizing this disease while totally ignoring epidemiology. If we had an outbreak associated with bowling, wouldn’t we warn people to stop bowling?”

Weiss, who declined to be interviewed, posted a letter from the agency on his website showing he was reassigned following his criticism.

Patrick Gallahue, a spokesman for the health department, declined to comment on Weiss’ transfer but rejected his request for temporary abstinence.

“For decades, the LGBTQ+ community has had their sex lives dissected, prescribed and proscribed in myriad ways, mostly by straight and cis people,” Gallahue said in a written statement. “Our guidance and advice is grounded in science and history — including scientific reviews of how poorly abstinence-only guidance historically has done in preventing the transmission of STIs — with this shameful legacy in mind.”

Critics of recommendations to limit sexual partners say they fail to heed lessons learned from decades of 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 contracting HIV and adherence to antiretroviral therapy that makes the virus non-transmissible to those who are infected.

“We saw a lot of people early in the HIV epidemic calling for public sex places like bathhouses to be closed. This did not stop the spread of HIV. People still found ways to have sex,” said Tyler TerMeer, chief executive of the San Francisco AIDS Foundation.

Gay rights activists are concerned about messages that appear to disapprove of same-sex intimacy and encourage growing attempts by the religious right to expel gays from public life, including nationwide movements to remove books on LGBTQ issues from school libraries and a New Florida law that prohibits classroom instruction or discussion about sexual orientation for young elementary school students.

Still, Jim Downs, a historian who has studied the history of HIV/AIDS, said the monkey chickenpox outbreak arrived in a much better environment for gay men.

“The difference now is that public health officials are not demonizing, pathologizing or criminalizing gay sex; they’re just putting out a different message, which is: pause,” Downs said. “Gay people are still under scrutiny; are still the target of prejudice and discrimination. But we also have more social and cultural acceptance, so we can really get a message out about sex that doesn’t indicate who we are as people.”

Nirappil reported from Washington.