Monkeypox Is Not an STI, Despite Association Between Sexual Contact and Transmission

Because of its fast spread between sexual partners, many wonder if monkeypox is a sexually transmitted disease. Experts say that label is not accurate.

Gay Couple Having Serious Conversation holding hands
Photo: Joselito Briones / Stocksy

In a recent social media post on Twitter, Georgia House Representative Marjorie Taylor Green asked "If monkeypox is a sexually transmitted disease, why are kids getting it?" A week later, another Twitter user also posted a video in which Green alleged that monkeypox spreads through "gay sex orgies."

As monkeypox cases continue to climb in the U.S. and globally, this sort of misinformation is becoming increasingly concerning. In order to prevent case counts from rising precipitously, understanding how the virus spreads is critical.

About 98% of reported cases thus far are among men who have sex with men, World Health Organization (WHO) Director General Tedros Adhanom Ghebreyesus, MD said on July 27. The WHO leader also advised gay and bisexual men, for the time being, to reduce their number of sexual partners to slow the spread of monkeypox within those communities. Because of its fast spread between sexual partners, many are wondering whether monkeypox is actually a new sexually transmitted infection (STI).

Giving monkeypox that distinction, however, may be a step too far, Nicholas Turner, MD assistant professor of medicine at Duke University School of Medicine told Health.

"I see the association between monkeypox and sexual contact as really more coincidental," Dr. Turner said. "Sexual contact involves direct skin to skin contact, thus sexual contact appears as one risk factor."

Here's what we know about how monkeypox is spreading in communities of men who have sex with men, as well as a look at the potentially harmful fallout of calling the virus an STI.

Why Monkeypox Spreads Between Sexual Partners

While monkeypox is overwhelmingly spreading among men who have sex with men, this does not qualify the virus as a STI necessarily.

"Strictly defined, sexually transmitted infections are primarily or exclusively spread via sexual contact—like gonorrhea or chlamydia for example," Dr. Turner explained. "Monkeypox is quite different: it is spread mostly by direct contact with active lesions—likely also via respiratory secretions as well."

In other words, sexual activity is not a precursor to getting infected with monkeypox like it is for other STIs. Coming into close contact with a person who has monkeypox can certainly happen during intimate contact, but it doesn't necessarily have to.

In addition to direct contact with monkeypox sores, monkeypox can be spread through contaminated surfaces or objects, from a pregnant person to their fetus, or through respiratory secretions, according to the Centers for Disease Control and Prevention (CDC).

But researchers are still trying to determine if, like other diseases passed through sexual activity, monkeypox can be passed through sexual fluids, explained Abraar Karan, MD MPH, an infectious disease doctor and researcher at the Stanford University School of Medicine.

"Is it because you have contact with lesions on the skin or even in the rectum that aren't always present that you have transmission, or is it because of bodily fluids like semen?" Dr. Karan told Health. "That is not clear."

Given how the virus has been spreading in this outbreak, sexual fluids may be playing a role, in addition to the other confirmed modes of transmission for monkeypox, Dr. Karan suggested. But it's too soon in the outbreak to know with certainty if that is the case.

As for how monkeypox came to circulate in some communities of gay and bisexual men in the first place Dr. Karan said, there are a few clear factors at fault.

First, the U.S. stopped smallpox vaccinations in 1972,which left a younger generation of Americans relatively unprotected against pox viruses. Smallpox vaccines ACAM2000 or JYNNEOS are now being rolled out to hopefully slow the current monkeypox outbreak in the U.S., though there's no widespread immunity to monkeypox like there would have been decades ago.

The other reason we're seeing an outbreak right now, Dr. Karan said, is probably because of one or multiple amplifying events where a larger number of gay or bisexual men became infected with the virus. Those events may be two raves that took place in the spring, the Associated Press reported in May.

The third factor is that when there are fewer pox lesions or they're in more hidden spots on the body, the virus spreads more covertly.

"It's sort of a number of factors that came together at the same time—a large susceptible population and amplifying events, and then also potentially spread in ways that are not going to be visibly notable," Dr. Karan said. "If someone has tons of pox on their body, others are not going to be touching them or engaging in close intimate contact. But if you're transmitting before that's present or if it's only present in your rectum, for instance, where someone can't see it, then you could have a lot of transmission."

All of these factors combined may in part explain the current outbreak in communities of men who have sex with men, but monkeypox still isn't an STI. The bottom line, Dr. Turner explained, is that even as monkeypox seems to be spreading between sexual partners, close contact in general is to blame.

"Sexual contact is one form of direct physical contact," Dr. Turner said. "I do worry that putting too much attention on just sexual contact might delay recognition of monkeypox in other settings since it really is just direct contact—and not specifically sexual contact—that facilitates transmission."

STI Distinction—Stopping the Spread or Encouraging Stigmatization?

In addition to being being medically inaccurate in terms of how we understand the virus currently, some medical professionals are concerned that calling monkeypox an STI could be harmful for gay and bisexual men and to the general public.

There's concern that monkeypox circulating in gay and bisexual communities could lead to discrimination that stigmatizes male homosexual relationships and sexual activity, despite the fact that anyone having close contact with another person could contract and spread the disease.

And, for those outside those communities, it may give them a false sense of separation from the spread of monkeypox.

"Conceptualizing monkeypox as a sexually transmitted infection risks both further stigmatization of LGBTQ community members and overlooking other relevant transmission events" Dr. Turner explained. "There's nothing about this illness that singles out men who have sex with men or LGBTQ individuals—heterosexual contact with a person who has active lesions is equally likely to result in transmission."

The key point at this juncture is that there appears to be multiple modes of transmission.

"Sexual could be one, or it could be the main one in this outbreak," Dr. Karan said. "It's not the only mode and this is why we can have spillover to other people, including kids."

Slowing Disease Transmission

Even though monkeypox isn't an STI, Dr. Karan and Dr. Turner said that reducing close skin contact—especially by reducing the number of sexual partners a person has—is probably the best way to slow down the spread for now.

Men who have sex with men, because they are at a higher risk of catching monkeypox during this outbreak, can reach out to their doctors about getting a vaccine. At the moment however, that's easier said than done. In New York City, demand is so high that officials are delaying the second round of the shot so that a greater number of people can have at least some protection from monkeypox.

But having the tools in place and knowing which communities to target hopefully means that the monkeypox outbreak will be under control soon, Dr. Karan added.

"If we can control the outbreak and get a lot of vaccinations going in high risk communities, and then also get rapid diagnostic tests so people can test themselves quickly, isolate, get support for isolation, and then get people early antiviral so that they don't shed virus for as long, then all of those factors together can actually really bring the outbreak down quickly," he said.

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