According to , monkeypox can be described as "sexually transmissible" -- that is, sex is one of multiple modes of transmission, animal-to-human (zoonotic), as well as human-to-human from respiratory secretions, close contact with skin lesions, and contaminated fomites. So far in the current monkeypox outbreak, the spread of the virus is primarily through close personal and sexual contact.
Given these circumstances, public health messaging that monkeypox is also a sexually transmitted infection (STI), in addition to the other established modes of spread. Yet, there is major public discourse that seems intent on redefining sex and STI so that monkeypox is not classified as also an STI. While I understand the politics and concerns about stigmatization, we must face the facts and make evidence-based decisions in the interest of the greater good. Moreover, I argue that classifying monkeypox this way can actually help fight stigma by focusing on behaviors in which any and all people can engage.
There is compelling of the and of sexual contact in the transmission of the monkeypox virus in the current outbreak. By specificity I mean that the of those infected have had a recent history of sexual contact. Taken together, the following -- based on the Bradford Hill criteria (for evaluating research evidence) -- strongly imply that monkeypox is also an STI:
- The strong association between sexual contact and infection
- The high level of consistency (across time and location) of the association between sexual contact and infection
- The gradient effect of increased risk of infection from having multiple sex partners
- The temporality of the association between sexual contact and infection, that is, the sexual contact preceded the infection
- The biological plausibility of the association between sexual contact and infection -- that is, it makes scientific sense that infection can occur in this way (close skin to skin contact), which is highly likely to occur during sexual contact
- The association between sexual contact and monkeypox is analogous to a few STIs (particularly, 1 and 2)
The current almost exclusive is misguided and a disservice to all. If this continues, it can prove counterproductive to controlling the spread of the virus, by misleading the public into believing that susceptibility to monkeypox infection is restricted to a particular group. HIV/AIDS has taught us that it is not who you are but what you do, and sex (of all forms) is a universal experience, across populations, regardless of sexual orientation. In this regard, the classification of monkeypox as an STI will help to reduce group-specific stigma by placing the focus on risk behaviors rather than on any particular group of people.
Furthermore, classification of monkeypox as also an STI, will facilitate effective and efficient diagnosis, and by creating a general awareness of sex as a risk factor for infection. In addition, it will allow for the development of focused and differentiated health education messages and campaigns, as well as the allocation of adequate resources to control and prevent the spread of the monkeypox virus. Failure to do so can significantly hurt efforts to stem this outbreak, which has the potential for exponential growth. There is strong evidence that sexual contact is the primary mode of transmission for the current outbreak, which strongly implies that monkeypox is also an STI. Let's not ignore the evidence.
Rossi A. Hassad, PhD, MPH, is an epidemiologist and professor at Mercy College in Dobbs Ferry, New York. He is a fellow of the American College of Epidemiology and a Chartered Statistician of the Royal Statistical Society in the U.K.