Is mpox an STI? The societal aspects and healthcare implications of a key question

This letter explores the societal aspects and healthcare implications that underlie thinking about mpox (formerly known was monkeypox), in the 2022 outbreak, as a sexually transmitted infection (STI). The authors examine what underlies this question, exploring what is an STI, what is sex, and what is the role of stigma in sexual health promotion. The authors argue that, in this specific outbreak, mpox is an STI among men who have sex with men (MSM). The authors highlight the need of critically thinking about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences.

we examine what underlies this larger question, exploring what is an STI, what is sex, and what is the role of homophobia in sexual health promotion. We argue that, in this specific outbreak, mpox is, in effect, an STI among MSM. This, in turn, underscores the need for important conversations about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences and societal transformations.

What is an STI?
The World Health Organization defines sexually transmitted infections as those which are "transmitted through sexual contact, including vaginal, anal and oral sex." Classic examples of STIs include syphilis, chlamydia, HIV, and gonorrhea. This definition, however, is somewhat more complicated on two fronts. First, some of the better known STIs, such as HIV, are also frequently transmitted non-sexually. For example, many countries have experienced outbreaks of HIV among people who inject drugs (e.g. Paraskevis et al., 2013). Conversely, some diseases that are not widely recognized as STIs, such as hepatitis C, can be transmitted via sex. Second, speaking about sexual transmission requires some shared understanding of what we consider to be 'sex'. As we will see in the next section, this is not necessarily straightforward.
Defining mpox as an STI would imply that the responsibility for managing it falls to sexual health services, where they exist. There are clear benefits to this: Sexual health clinicians and community partners have a wealth of expertise in developing effective interventions and messages that target men who have sex with men and other groups at risk for STIs, in the face of stigma (Race, 2021). However, sexual health is often chronically underfunded and tends to be difficult to access (Iacobucci & Torjesen, 2017). Adding acute or ongoing mpox outbreaks to the workload of sexual health providers, without building additional capacity, will deepen existing inequalities and access problems.
Defining mpox as an STI may also transform how it is perceived. Far from the global, societal threat that characterizes COVID-19, considering mpox to be an STI may cause it to be perceived as a problem only for certain individuals. In the case of HIV, the advent of effective medications in the Global North contributed to policy shifting from seeing the virus as a societal issue to seeing it as an individual health condition, thwarting social action and deepening inequalities (Catalan et al., 2021;Kagan, 2018).

What is sex?
In recent decades, there has been a broadening and transformation of the range of practices generally considered to be sexual contact. This includes the development of new technologies and the incorporation into the mainstream of traditionally minority activities, such as kink or BDSM (Plummer, 2003;Sundén & Paasonen, 2020;Wignall, 2022). For example, a recent debate in the BMJ centered on whether women engaging in 'anal sex' had specific sexual health needs (Gana & Hunt, 2022, see rapid responses). People who engage in more novel

Amendments from Version 1
This revised version adopts the term "mpox" (which came to replace "monkeypox"), and provides more information on what mpox is.

Introduction
Since May 2022, non-endemic countries have been experiencing an outbreak of mpox, formerly known as monkeypox, a disease cause by an orthopox virus. Historically endemic to countries in central and west Africa, since 2022, cases have been reported in countries without previous documented transmission. Mpox can be transmitted from animals to humans or from humans to humans (as in the 2022 outbreak) (Vaughan et al., 2022;Thornhill et al., 2022). On July 23 rd , 2022, the World Health Organization (WHO) declared mpox "a public health emergency of international concern" and, in August, the White House declared it a "public health emergency." At the time of writing (September 30, 2022), over 67,000 confirmed cases have been reported across 106 countries, mostly in Europe and the Americas by WHO.
Compared with previous or historic outbreaks in Africa (and, particularly, in Nigeria), the current outbreak presents some significant differences: over 97% of reported cases are male; among cases with available sexual orientation data, over 89% are gay, bisexual, or other men who have sex with men (MSM); a sexual encounter is the most commonly reported type of transmission (>87%) and a 'party with sexual contacts' the most likely reported exposure setting (over 50%). Case manifestations also differ, with anogenital lesions and single lesions being more common than in previous outbreaks (Català et al., 2022;Thornhill et al., 2022). These differences have led many (Fischer 2022, Highleyman 2022, Moniuszko 2022) to wonder: Is mpox, in the 2022 outbreak, a sexually transmitted infection (STI)?
Characterizing mpox as an STI does nothing to alter the biological realities of the virus, its symptoms, or the pain afflicted people experience. The wider implications, however, are numerous. At the individual and practical level, it might help stimulate the development of robust and targeted information about transmission for those most at risk. At the public health system and health service delivery levels, it will shape and influence key decisions around the surveillance and management of this current outbreak. At the policy and economic level, it will release -or in some cases limit -funding and political urgency. At the conceptual level, it will involve debates about the meanings of health, disease, and sex. Here, or previously less visible (to the mainstream) practices require targeted sexual health promotion and care, both because of the practical implications of some of those practices and because of the oftentimes negative societal perceptions and stigma that surround them (McGregor, 2015;Waldura et al., 2016;Sprott & Randall, 2017).
Different sexual practices may be related to diverse clinical presentations (Tarín-Vicente et al., 2022). The range of practices that specific communities, such as MSM, associate with sex but which do not consist of penile penetration also needs to be taken into account in the development of health promotion around mpox. Community organizations have, for instance, identified the need to develop guidance that directly addresses particular sex practices such as the eroticized wearing of rubber or leather, bondage, or watersports. These practices, however, may not always be recorded as 'sex' in surveys or statistical data, demonstrating how slippery the notion of 'sex' can be.

What is the role of stigma in sexual health promotion?
If mpox is defined as an STI, it will be directly associated with sex and, more specifically, with 'gay sex,' since men who have sex with men -often wrongly subsumed under the label 'gay' -remain disproportionally affected in the current outbreak. Commentators have argued that this might lead to deepening stigmatization and further attacks on LGBT people, who might be seen as 'dirty' or 'reckless,' and it could also become a tool to further criminalize sex between men. This is far from new: HIV has, for decades, been leveraged to legitimize and justify pre-existing homophobic, transphobic, and racist agendas (Weeks, 1981). By emphasizing sex between men, there remains a risk that health promotion programmes could reinforce stereotypes of MSM as inherently 'promiscuous' (with all the stigma associated with multiple or anonymous sexual partners). Consequently, the marginalization experienced by affected people could be compounded. Further, the association of mpox with being gay could discourage MSM who do not see themselves as gay or bisexual -for example, MSM who identify as heterosexualfrom adequately engaging with health information and services.
Some might argue, therefore, that it is preferable to avoid such associations between mpox and sex. Indeed, assertions that 'anyone can get mpox' circulate widely across health and popular outlets. However, these assertions do not reflect the data which suggest, as discussed above, that men who have sex with men have mostly contracted mpox in 2022, and that sexual encounters -not household contact or sharing of towels or touching door handles -have been reported as the leading route of transmission. If policy around mpox is embedded with narratives that fail to emphasize the role of sex between men, there is a risk that accurate, evidence-based information will not reach key groups and may lead to inadequate or inappropriate measures being implemented. Perhaps more dangerously, incomplete information about actual transmission routes and settings may lead to the assumption that gay men, based on the simple fact of being gay, are vectors of disease.

So, is mpox an STI?
We want to answer this question because whether mpox is, or is not, an STI alters how it is understood within societies and has implications for healthcare policy, funding, and practice. On balance, we believe that mpox should be regarded in countries where it is not endemic as an STI because most transmissions reported to date have occurred during sexual encounters and in sexual settings. This view is limited to the current context, framed by wider assumptions about what sex, sexual health, homophobia, and public health look like. Further, we are mindful that -similar to hepatitis C (Rauch & Wandeler, 2021) -mpox might be an STI only in certain communities, namely MSM, and do not discount other routes of transmission.

From messaging and technology to social understanding and action
That mpox may be an STI among MSM in the current outbreak in non-endemic countries raises questions about what kind of public health messaging could be developed and delivered that both provides evidenced-based information to the communities most at risk while avoiding further stigmatization. This is further complicated by the 'social life' of viruses: They are always responded to within the context of pre-existing social and political agendas and ideologies, ones that often reflect prevailing power structures (Pickersgill et al., 2022;Treichler, 1987). However, co-producing communication strategies with MSM communities themselves is a vital first step.
There is a real risk that mpox could becomes associated with gay men through homophobic tropes. However, this risk will not be resolved by simply avoiding discussion of the epidemiological evidence. Instead, mpox underscores the need for concerted structural and systemic interventions that specifically address ongoing homophobia and stigma. This is particularly relevant for STIs: stigma remains a key barrier to effective prevention and care for HIV worldwide-as highlighted by UNAIDS, and it may well also determine the evolution of the current mpox outbreak. Responses to mpox could serve to propel better understandings of the intersectional inequalities that MSM experience, and accelerate the collapse of barriers to sexual health care (Eaton et al., 2015;Titanji, 2022).
Rather than focusing on systemic change (large scale structural and social changes that could prevent or help address present and future outbreaks), the focus of policymakers when confronted with epidemics has too often been placed on developing technological fixes: early diagnostic tests, increasing vaccine production, effective treatments, etc. As important as they are, tests, vaccines, and pharmacological treatment alone will not solve mpox. While an intervention may rely on a specific vaccine or drug, it requires a nuanced understanding of how communities make sense of health, disease, and risk (Auerbach & Hoppe, 2015;Garcia-Iglesias, 2022).
I think it would be useful to initially provide a definition of monkey pox, and maybe a sentence or two explaining how it was first detected amongst men outside Africa. And it is not clear to me what sort of "systemic changes"-the phrase used in the final paragraph-would be required to deal with what now seems to be a declining outbreak. I am sympathetic to the call for better understanding of communities and the social dimension of epidemics, but I would like a more concrete discussion of what this would mean in terms of the current monkey pox situation.

Does the article adequately reference differing views and opinions? Partly
Are all factual statements correct, and are statements and arguments made adequately supported by citations? Yes

Is the Open Letter written in accessible language? Yes
Where applicable, are recommendations and next steps explained clearly for others to follow? Yes dangers of stigmatisation.] It would be useful to examine responses in several of the countries reporting major outbreaks to ask how far they have adhered to the suggestions in this paper.
I think it would be useful to initially provide a definition of monkey pox, and maybe a sentence or two explaining how it was first detected amongst men outside Africa. And it is not clear to me what sort of "systemic changes"-the phrase used in the final paragraph-would be required to deal with what now seems to be a declining outbreak. I am sympathetic to the call for better understanding of communities and the social dimension of epidemics, but I would like a more concrete discussion of what this would mean in terms of the current monkey pox situation.

Does the article adequately reference differing views and opinions? Partly
Are all factual statements correct, and are statements and arguments made adequately supported by citations? Yes

Is the Open Letter written in accessible language? Yes
Where applicable, are recommendations and next steps explained clearly for others to follow? Yes Reviewer Expertise: Inclusion Health; Gender and Sexual Minority Healthcare; Sexual Health; Nursing I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.