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People wait to receive a monkeypox vaccine at an outdoor walk-in clinic in Montreal on July 23.Graham Hughes/The Canadian Press

Since the first North American cases appeared in May, the monkeypox outbreak has differed from its spread in West and Central Africa, where it is now endemic. Here, it is overwhelmingly affecting gay, bisexual and other men who have sex with men. And it is reminding researchers and health leaders of the last pandemic that disproportionately affected the LGBTQ+ community: the HIV/AIDS crisis of the 1980s.

Chief Public Health Officer Theresa Tam said on Aug. 12 that more than 99 per cent of Canadian monkeypox cases the federal government had information on were among men. This is in line with a 16-country survey that found 98 per cent of infected people were gay or bisexual men or men who identify as straight yet occasionally sleep with other men.

Yet the virus is not sexually transmitted – there is no strong evidence that it spreads through semen. It is transmitted through skin-to-skin contact, respiratory droplets and contaminated items such as bedding. Its concentration among men who have sex with men may be attributable to frequent sex with multiple partners, say public-health officials.

Stronger LGBTQ+ health initiatives have changed the game, making it easier to vaccinate communities at risk, but there are still concerns that monkeypox is being stigmatized as a “gay disease,” like AIDS was. Tackling such perceptions requires targeted messaging – and an understanding of the nuanced ways in which that stigma can manifest itself.

“But if we can get the outbreak under control early, which will require communication, getting the word out ensuring people have tools, then maybe we won’t have to deal with 40 years of stigma, which is what people with HIV are still dealing with today,” said Jody Jollimore, the executive director of the Community-Based Research Centre, an LGBTQ+ health organization.

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As monkeypox outbreak grows, fears of stigmatization for LGBTQ community on the rise

Mr. Jollimore said government officials had initially seemed “gun shy” about even discussing the proportion of cases among the LGBTQ+ community.

“We need to be talking more about actual risk and transmission, and that’s uncomfortable for some people because it does involve gay sex,” he said. “Our inability to talk about how people are getting monkeypox – to me, that’s where we’re seeing stigma.”

The government is now collaborating more with health workers in LGBTQ+ communities to boost messaging, Mr. Jollimore said. The thousands of vaccines administered across the country are proof that men who have sex with men will respond positively to messaging that addresses them, he added.

“That’s another legacy of the HIV movement and really testament to gay men’s willingness to work with public health.”

However, public-health messaging can also contribute to stigma. Dr. Tam said on July 27 that gay and bisexual men can reduce the risk by “practising safer sex,” including having fewer anonymous partners.

That kind of messaging smacks of moral judgment, said MacEwan University professor and LGBTQ+ youth researcher Kristopher Wells.

“What we also learned from HIV and AIDS is the importance of being sex positive. And right now, the messaging is about risk and is not sex positive. In fact, it’s sex negative, and it’s creating this fear again of intimacy and of engaging in any kind of sexual behaviour.”

Dr. Wells also cautioned that workers at testing and vaccination sites should avoid asking questions about people’s sexual history. Many regions have only made vaccines available for the LGBTQ+ community, but asking someone if they identify as gay or bisexual may drive away closeted men.

Aaron Flitchett, a high school teacher from Lethbridge, Alta., recently booked a vaccine appointment and said he was asked screening questions about his gender and sexual behaviour, including whether he had visited venues for sex such as bathhouses. This is part of the eligibility criteria for vaccination in Alberta, as the limited doses are prioritized for people at risk.

“It certainly makes me uncomfortable knowing that some government agency is collecting this very personal information in exchange for me getting access to a vaccine,” he wrote by e-mail.

Monkeypox spread may be slowing in Canada, Dr. Theresa Tam says

A spokesperson from the Public Health Agency of Canada (PHAC) said the government is aware of these concerns and is liaising with LGBTQ+ community health workers to develop “non-stigmatizing and non-discriminatory” messaging. The government has also pledged $1.5-million to health organizations across the country, many of which are running messaging initiatives of their own.

However, this information may not be reaching LGBTQ+ community members who need it. Mr. Flitchett said he had not seen any reliable information about mitigating risk and getting vaccinated on LGBTQ+ accounts he follows on Twitter or Instagram.

“I don’t see where the outreach is happening into communities that would be deemed higher risk or at risk,” he said in an interview. “Maybe these things are happening, but I think it would really help people to reduce their anxiety if they knew what was happening, where it was happening and how it was happening.”

Mr. Jollimore said a limited supply of the vaccine is also making it difficult to inoculate communities.

When Mr. Flitchett first tried to book an appointment this month, he was told there were no vaccines in Lethbridge; the closest doses were in Calgary, a two-hour drive away. He managed to secure an appointment once Alberta opened vaccination sites in Lethbridge and seven other municipalities on Aug. 10.

“That’s a question for the federal government too,” Dr. Wells said. “If this is now an international public-health crisis, how much of the vaccine supply is left? Is more coming? And how do we improve the rollout, make it more inclusive and more accessible?”

The PHAC spokesperson said 85,000 doses had been distributed through the National Emergency Strategic Stockpile as of Aug. 8. They declined to say how many were on order as “details concerning the procurement and stockpiling of medical countermeasures held by the NESS” could not be disclosed “due to security implications.”

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