Monkeypox and the legacy of prejudice in targeted public health campaigns

In a press briefing held last 28 July 2022, the WHO’s Director General Tedros Adhanom Ghebreyesus urged men who have sex with men to reduce sexual partners/activities to help control the monkeypox outbreak.1 The statement was considered a major shift from initial WHO advisory, which included suggestions for ‘gay, bisexual and other men who have sex with men’ in a flyer published in 18 July 2022 that did not include explicit advisory on frequency of sexual activity or number of sexual partners.2

Current evidence shows monkeypox cases being identified in communities of gay, bisexual and other men who have sex with men who have had recent sexual contact with a new partner or partners (although the risk is not limited to these groups).3 However, critics have argued that public health messaging that specifically targets a marginalised group can undermine public health responses by hampering case detection, delaying symptom disclosure, discouraging health-seeking behaviour among targeted and currently marginalised groups.4 Some have proposed non-stigmatising approaches to public health messaging.5 6 In the news, opinions are divided with some arguing that such targeted public messaging are homophobic,7 while others arguing the opposite.8

In this piece, we argue that the current public health advisories that target marginalised groups rely on conceptual ambiguities that undermine public health responses to the monkeypox outbreak. In addition, the pitfalls arising from such ambiguities are compounded by the historical and continuing prejudice against the lesbian, gay, bisexual, transexual, intersex, queer/questioning, and asexual (LGBTIQA+) community.

In discussing the problem of targeted campaigns, we echo Oxman et al’s distinction between two interrelated functions of health communications during public health emergencies: to inform and/or to persuade.9 The informative function aims to communicate details about risks, areas of outbreaks and updates on treatment or prevention, among others. The persuasive function is action orientated and generally tends to extend the informative function to produce advisories, guidance or policies. Persuasive communications can range from implied recommendations (eg, encouraging washing hands) to explicit policies (eg, travel ban during pandemic). In the context of targeted campaigns, both informative and persuasive functions raise ethical issues, although in varying degrees. Public health statements from the WHO are considered norm-setting advisories to governments around the world, and targeted campaigns, especially those that fulfil persuasive functions, must be carefully assessed as they may do more harm than good to marginalised sectors particularly with regards to issues of social justice and health equity.10

Our concern about the current targeted campaigns largely begins with the generalisation of ‘gay, bisexual and men who have sex with men’ (hereafter men who have sex with men) for several reasons. First, the targeted category of men who have sex with men inappropriately leads to overemphasis on sexual activity as the primary risk factor and may lead to the misconception that monkeypox is a sexually transmitted disease. Such misconception can downplay the role of prolonged physical interactions not typically categorised as sex (eg, kissing or cuddling) in transmission, potentially undermining both the informative component (eg, communicating risk) and the persuasive component (eg, encouraging disease-preventive actions).

Second, the generalisation leads to vilification of homosexual intercourse that is not typically seen in public health advisories that involve the general population. In one way, both the informative and persuasive components of health advisories exemplified by the WHO director’s recent statements promote a prejudicial assumption that gay and bisexual men have more sexual partners and participate in higher frequency of sexual activities than the rest of the population. It appears that this underlying assumption partly motivates public health measures that focus on or starts with primarily controlling sexual activities as response to any outbreak occurring primarily among men who have sex with men. In comparison public health advisories during the first waves of the COVID-19 pandemic did not emphasise similar restrictions, and in contrast acknowledging the importance of sexual activities for mental well-being.11

Third, corollary to the first two reasons, the generalisation revives the myth of ‘gay disease’.12 While the WHO director’s statement could be taken as within the spirit of promoting the goals of public health, the statement and its implied directives targeting men who have sex with men should be taken within the context of historical and continuing health inequities. Without this context, targeted campaigns risk worsening the outbreak by restigmatising groups that are already stigmatised. The myth of gay disease promotes a moralistic public health messaging that implies culpability in health-damaging behaviour.13 The myth could perpetuate a negative self-image among men who have sex with men by framing homosexual intercourse as socially undesirable or immoral activity. As a result, some men in this network may be discouraged from attending to their health concerns that may reveal their sexual orientation or sexual activities. For example, in early 2020, concerns about inadvertent disclosure and stigma complicated South Korea’s efforts to contact trace early cases of COVID-19 linked to social venues in the Itaewon neighbourhood that catered to LGBTQ persons.14

In jurisdictions where homosexual activities are criminalised,15 international advisories that target men who have sex with men could have further harmful, if not fatal consequences. These jurisdictions already have limited availability of health services to sexual minorities and will likely not initiate new ones.16 Targeted campaigns that disproportionately fixate on sexual behaviours among minority groups create a shift in policy direction from one that provides comprehensive public health interventions to one that underscore individual actions, and corollary, a stigmatising environment targeted towards minority groups whenever diseases are not controlled. The stigma becomes internalised even by the general population who refuse to access and use health services for diseases presumed to be associated with sexual minorities for fear of persecution and prosecution.

While we acknowledge that a public health policy that is immune from the risk of stigmatisation may not exist, it remains important to map out the unintended consequences of public health communications, advisories and policies that centre marginalised groups.