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CIDRAP Commentary

No question monkeypox is an STI by H. Hunter Handsfield, MD

Whether or not monkeypox (MPX) should be labeled a sexually transmitted infection (STI) isn't much of a debate among STI experts.

So far, more than 95% of cases in the United States have been acquired during sexual contact among men who have sex with men (MSM). To not call it an STI is nearly equivalent to saying syphilis isn't an STI because exceptions to sexual transmission are common in some settings.

Read more here:

Isolation of viable monkeypox virus from anal and urethral swabs, Italy, May to July 2022

Davide Moschese1 , Giacomo Pozza2 , Davide Mileto3 , Andrea Giacomelli2 , Miriam Cutrera3 , Maria Vittoria Cossu1 , Maddalena Matone1 , Martina Beltrami2 , Federica Salari3 , Spinello Antinori4 , Alessandra Lombardi3 , Giuliano Rizzardini1

Since May 2022, a large outbreak caused by monkeypox virus (MPXV) is taking place, with, up to 15 August 2022, over 31,799 people having been infected with this virus in non-endemic areas [1]. This current outbreak involves human-to-human transmission, which may occur through contact with infectious material or infected people, including contact with skin lesions, or exposure to the respiratory droplets of a MPXV-infected individual during prolonged face-to-face contact [2,3]. These types of direct contacts can happen during intimate interactions between individuals, including sex [2,3]. MPXV genetic material has previously been identified in oropharyngeal and skin samples of monkeypox patients [4]. In addition, MPXV DNA has recently been detected in faeces, semen and urine from such patients, as well as in nasopharyngeal and rectal swabs [5-12]. We aimed to investigate the presence of live MPXV in anal and urethral swabs of patients with MPVX infection attending our sexual health clinic in Milan, Italy between 15 May and 7 July 2022.

Position Statement: Monkeypox is a Sexually Transmitted Disease

A Position Statement on Monkeypox as a Sexually Transmitted Disease

September 2, 2022

Executive Summary

The rapidly developing outbreak of monkeypox constitutes a national and international public health emergency. Our current public health strategies are predicated on transmission dynamics from historical outbreak. Numerous reports from the current outbreak have highlighted 1) a temporal association between sexual activity and monkeypox disease, 2) an association between specific sexual practices and location of lesion development, 3) that specific sexual practices conferring risk for other sexually transmitted infections occur with notable frequency among cases of monkeypox, 4) that Monkeypox virus can be detected and isolated from sexual fluids, and 4) a high frequency of anogenital lesions prior to disease dissemination suggesting direct inoculation during sexual activities. Finally, a growing body of evidence suggests that sexual transmission is the predominant mode of transmission for Monkeypox virus.

We therefore conclude that monkeypox is a sexually transmitted disease. Labeling it as such will help focus our public health interventions, such as vaccinations, testing, and treatment. Moreover, understanding the primary mode of transmission can help facilitate focused awareness and education programs, as well as allow for behavioral modifications to reduce exposures, which in turn may augment outbreak control efforts and prove to be cost effective. We recommend that governments and other policy-making bodies define monkeypox as a sexually transmitted infection for monkeypox.


University of Southern California

University of California Los Angeles

University of California San Francisco

Former, CDC Director Division of STD Prevention
Former, California Dept Public Health Chief STD Control Branch

Former, Medical Officer CDC Branch Chief, HIV and Tuberculosis

Former, San Francisco Dept Public Health Director STD Prevention Services

Lao-Tzu Allan-Blitz, MD1

Monica Gandhi, MD, MPH2

Paul Adamson, MD, MPH3

Ina Park, MD, MS4

Gail Bolan, MD5

Jeffrey D. Klausner, MD, MPH6

1. Chief Medical Resident, Global Health Equity, Brigham and Women's Hospital; Teaching Fellow, Harvard School of Public Health and Harvard Medical School

2. Director UCSF-Bay Area Center for AIDS Research; Professor of Medicine and Associate Chief, Division of HIV, Infectious Diseases, and Global Medicine Department of Medicine, University of California, San Francisco; Medical Director Ward 86 HIV Clinic, San Francisco General Hospital

3. Assistant Clinical Professor of Medicine, Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles

4. Professor of Medicine, Department of Family and Community Medicine and Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco School of Medicine; Medical Director, California Prevention Training Center

5. Former Director, Division of STD Prevention, US Centers for Disease Prevention and Control; Former Chief, STD Control Branch, California Department of Public Health; Former, Director, STD Prevention, San Francisco Department of Public Health

6. Professor of Medicine, Infectious Diseases, Population and Public Health, Keck School of Medicine, University of Southern California, Los Angeles, CA; Former Medical Officer, US Centers for Disease Prevention and Control; Former Director, STD Prevention and Control Services, San Francisco Department of Public Health

Washington Post

World ignored monkeypox threats, including signs of sexual transmission

By Mark Johnson, August 12, 2022

Details evidence since 2019 that monkeypox was capable of being trasmitted sexually.

NBC News

Sex between men, not skin contact, is fueling monkeypox, new research suggests

by Benjamin Ryan

Since the outset of the global monkeypox outbreak in May, public health and infectious disease experts have told the public that the virus is largely transmitting through skin-to-skin contact, in particular during sex between men.

Now, however, an expanding cadre of experts has come to believe that sex between men itself - both anal as well as oral intercourse - is likely the main driver of global monkeypox transmission. The skin contact that comes with sex, these experts say, is probably much less of a risk factor.

Read more:

Wall Street Journal Opinion

Gay men can fight monkeypox ourselves - by changing how we have sex

by Benjamin Ryan

Today, in the face of the ballooning monkeypox outbreak, gay and bisexual men, among whom almost all 9,492 U.S. diagnoses have occurred, stand at a similar crossroads. A virus transmitting overwhelmingly via sexual contact between men is causing great suffering. And while public health leaders now robustly support gay men, they are still failing to provide timely prevention and treatment and are often fumbling the messaging.

The Daily Signal Commentary

Monkeypox Primarily Affects Gay Men. Why Are We Scared to Say It?

by Douglas Blair (July 28, 2022)

Monkeypox seemingly sprung out of nowhere to infect large swathes of the globe, replacing COVID-19 as the malady du jour. Experts say the number of monkeypox cases is severely undercounted, and the World Health Organization just declared the disease a global health emergency.

Monkeypox has hit America particularly hard. Our nation has the most recorded cases on Earth, with nearly a third centralized in New York City.

So, are we due for a new plague on par with the coronavirus?

According to the data, not unless you're a gay guy.

A study published in the New England Journal of Medicine reported that 98% of those infected around the world were gay or bisexual men who were having sex with other men.

That seems to indicate definitively that a specific demographic is more at risk for contracting monkeypox than others.

Yet the messaging strategy surrounding monkeypox seemingly has sought to obfuscate this fact. Buried under a mountain of menus on the Centers for Disease Control and Prevention website is this nugget specifying who should get vaccinated: "Currently, this outbreak is largely affecting gay, bisexual, or other men who have sex with men."   Clink link to keep reading

NYT Guest Essay

We Can Fight Monkeypox Without Hysteria or Homophobia

by Kai Kupferschmidt

BERLIN - As I stayed home in late July, listening to the director general of the World Health Organization declare monkeypox a public health emergency of international concern, many of my friends were out celebrating Pride. The decision to affirm an emergency about two months into a global outbreak was the right one. But it felt far too late...



The New York Post Editorial 

NYC monkeypox madness repeats ugly COVID Story

New York City loves to trash science and embrace politics when it comes to public health. Just witness its insane monkeypox saga...


U.S. Messaging on Monkeypox Is Deeply Flawed

Officials seem unwilling to be direct about who is most at risk of the disease.

By Jerusalem Demsas

Is the LGBT Community Doing Enough to Fight Monkeypox?

Efforts to avoid stigma and homophobia could be keeping us silent when we need to be speaking out.

June 22, 2022 • By Liz Highleyman

Monkeypox is a gay thing. We must say it

We're doing a disservice to the gay men who most need important Monkeypox information - while misleading everybody else.

July 21, 2022 • By Mark S. King

Experts Aim to thread thread needle on monkeypox messaging to MSM

"We don't let people hold us back from warning people, and providing them with the best information to protect their health," Duchin said. "Right from the get go, we have been clear about the risk to MSM."

June 9, 2022 by Stephanie Soucheray

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