An outbreak of monkeypox, a rare zoonotic disease caused by an orthopoxvirus, is currently ongoing and has spread so far to more than 20 countries, mostly affecting Europe, the Americas, Australia, and Israel, with more than 400 confirmed cases (https://bnonews.com/monkeypox/), becoming the largest monkeypox epidemic outside of western and central Africa, where it is endemic in eleven countries.¹ In the UK, where the first monkeypox case was reported on May 7, 2022, in a traveler returning from Nigeria, the National “Health Security Agency” (UKHSA) has reported that “a notable proportion of early cases detected have been in gay and bisexual men and so UKHSA is urging this community in particular to be alert” (https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates). Moreover, the “European Centre for Disease Prevention and Control” (ECDC) has stated that “the majority of cases have been in young men, many self-identifying as men who have sex with men (MSM)” (https://www.ecdc.europa.eu/en/news-events/epidemiological-update-monkeypox-outbreak). These statements have been promptly relaunched by media and social networks, some of which have morbidly covered some events and festivals, like the “Gay Pride Maspalomas (Gran Canaria) 2022”, held from May 5 to May 15, 2002, in Maspalomas, Great Canary (Spain), where about 80 000 people met from across the European continent. These mass gatherings were linked to the spread of the virus, while epidemiological investigations to determine the determinants of the transmission were still ongoing. Whereas in Africa, monkeypox cases are generally transmitted from infected animals, and human-to-human transmission began to emerge after the 1996–1997 outbreak in the Democratic Republic of Congo (DRC), linked to the discontinuation of vaccination against smallpox and the waning of immunity, poor hygiene and crowded living quarters, in developed countries other potential routes have been postulated, such as respiratory droplets, direct contact with mucocutaneous lesions, or fomites. However, mass media have generally stressed only or mostly the sexual transmission route, whilst it should be noted that monkeypox is not generally considered a sexually transmitted infection (STI) and can be spread to sexual partners through close skin-to-skin contact—whether monkeypox can be sexually transmitted still warrants further investigation.² All this special focus on MSM may contribute to fueling stigma toward an already highly marginalized community, that is disproportionately affected by STIs and diseases transmittable by means of close physical contact.

According to the sociologist Erving Goffman, stigma can be described as the fear to experience discrimination and negative societal attitudes because of a particular condition. Compared to the general population, marginalized groups, including the LGBTQI+ community, can be subjected to much higher levels of stigma due to the so-called “intersecting or layered stigma effect”—the compound effects of stigma arising from several stigmatized characteristics. Among the conditions (like overweight/obesity, child or mental health issues) that can be a source of stigma, venereal and dermatological diseases are particularly stigmatized, especially those causing visible disfigurements—even if transitory.³

Unfortunately, framing the monkeypox outbreak as only or mostly spreading by means of sexual intercourse and among MSM could worsen the situation, reminding us of what happened in the eighties during the HIV/AIDS epidemic. This risk is even higher in the infodemic era, where biased news spread easily and quickly. Discrimination and homo/bis/trans-phobia only contribute to generating new infectious cases, increasing health vulnerabilities, and widening disparities, undermining efforts to trace cases and implement public health interventions to control and contain the outbreak. Sexual orientation- and gender identity-related stigma represents a major barrier to health-seeking behavior, engagement in care, and compliance with treatment.⁴ Labeling a disease as “gay”, as Henry Kazal did in 1976 by coining the expression “Gay Bowel Syndrome” (GBS)⁵ or as it was done for HIV/AIDS which was previously known as “Gay-Related Immune Defense Disorder” (GRIDD) or “Gay-Related Immune Deficiency” (GRID), before the prominent biologist and LGBTQI+ activist Bruce Voeller (1934–1994) coined the term “Acquired Immune Deficiency Syndrome” (AIDS), should be considered an obsolete, deprecable, and highly stigmatizing practice,⁶ that is not even clinically useful. A much more meaningful approach would be to consider and communicate these episodes as a “clustering of diseases in certain high-risk groups,” identifying specific risk factors by means of thorough, extensive epidemiological investigations conducted in an evidence-based, data-driven fashion and devising ad hoc preventative and interventional strategies, since “a specific syndrome affecting the bowels of MSM” does not seem to exist.⁷ Therefore, avoiding attaching a stigma to the LGBTQI+ community should be avoided during the monkeypox epidemic.

Public health officials should balance the need for transparency, human rights, and sensitivity, and emphasize that monkeypox represents a global public health concern,⁸ not limited to specific communities, which spreads by means of direct, close physical contact, including (but not limited to) sexual intercourse, regardless of sexual orientation or gender identity. The “Joint United Nations Programme on HIV/AIDS” (UNAIDS) has, indeed, expressed concern for some statements, commentaries, and public conversations that have directly or indirectly portrayed monkeypox as mostly affecting LGBTQI+ individuals (https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2022/may/20220522_PR_Monkeypox). Proper, and effective communication should be timely, accurate, and evidence-based, in order not to fuel “monkeypox panic” (given the low case fatality rate, CFR, of 1%) and discriminating stereotypes, which could potentially impact societal, psychological, and behavioral responses as well as health outcomes. Moreover, global/public health communication should actively involve both the sender and the receiver (in this case, the health authorities/agencies and the LGBTQI+ community), since communication in healthcare is complex, multidimensional, and multistage, process.⁹ Paralleling the complexity of health-related communications, global/public health interventions and policies should be multicomponent and multilevel, organically and coherently integrating biomedical, and behavioral components. Barriers to sexual healthcare services (either perceived or structural) should be removed, and access to health provisions should be facilitated and enhanced. All relevant stakeholders should work together in the fight against the monkeypox virus. LGBTQI+ members should be empowered in hygiene and sexual health, adopting safe sexual behaviors, such as using condoms, immunizing against vaccine-preventable STIs (like hepatitis A and B, and human papillomavirus), and protecting against HIV by taking HIV pre-exposure prophylaxis (PrEP). Further, the epidemiology of STIs, including enteric infections, is changing, especially among the LGBTQI+ community, and the number of outbreaks caused by emerging sexually transmittable enteric pathogens resistant to antibiotics, such as Shigella flexneri and Shigella sonnei, and by other infectious agents is increasing worldwide.¹⁰ Therefore, urgent actions should be taken, with greater involvement of all the actors and more collaboration between the LGBTQI+ associations and the public health authorities. Such collaboration is highly needed also, and, especially, in the two-way/multiway processes of communication of global/public health-related messages to make them truly socially engaging, interactive, and community/population-relevant.^{2, 9}

AUTHOR CONTRIBUTIONS

Nicola Luigi Bragazzi conceived, drafted, and revised the article. Rola Khamisy-Farah conceived, and critically revised the article. Christina Tsigalou critically revised the article. Naim Mahroum critically revised the article. Manlio Converti conceived, and critically revised the article.

CONFLICT OF INTEREST

The authors declare no conflict of interest.