Last week, I went to my doctor’s office for a long-scheduled sexually transmitted infection checkup, and started to cry a few minutes into my appointment.
Like many gay men, I am on a daily drug called pre-exposure prophylaxis, or PrEP, which prevents me from becoming infected by HIV, even if I were to have sex without a condom or use injection drugs. At 44 years old, I am of the generation who knew about Aids before we even knew about sex; from childhood, I conflated sexuality and fear. PrEP was a gamechanger in taking that fear away.
But last week, HIV was not much on my mind, and almost as soon as the physician’s assistant closed the door, I burst into tears.
My doctor’s office is staffed almost entirely by gay people seeing gay patients, and the PA, like everyone there, was very kind. I told him that I hadn’t had much sex lately because I was concerned about monkeypox. Even though I had no fever, and even though I often get heat rash in the summer, I was terrified that some skin bumps could be monkeypox.
Because he was so nice, I blabbered on that I would never tell anyone else to feel bad if they contracted any infection. But my book was coming out the following week, and it was about viruses, and what if I had to cancel my launch because I had contracted a virus?
The PA very sweetly talked me through my feelings and told me that while he didn’t think I had monkeypox, we could do a test if I wanted. He also kindly, but very firmly, told me not to feel bad about feeling bad.
“We are all on the edge,” he said – him, me, every gay man we both knew. “It’s been a lot, for all of us.”
I realized in that moment how lucky I am to have a gay doctor’s office to take my body and my feelings seriously. And I realized how angry I was that, for the third time in my life, a viral pandemic was dictating my sex life, shaping my professional life, messing with my head, and keeping me from experiencing intimacy.
I am, of course, not alone in this. HIV, Sars-CoV-2 and now hMPXV – the virus responsible for monkeypox in humans – have all upended people’s lives, but their effects have not been felt equally. In all three cases, LGBTQ+ people were disproportionately affected.
This is the result of a few related factors, all of them closely linked to societal stigma. One is that LGBTQ+ people are, on average, more likely to be poor than straight people and thus more likely to be subjected to the confluence of conditions (incarceration, unemployment, a lack of insurance) that produce a viral underclass. Second, queer people do not get a good sexual health education, nor access to queer-specific health resources. And third, gay men have, on average, more sexual partners than straight people. Even when coupled, gay men are more likely to be openly non-monogamous.
This is nothing to be ashamed of; being trans or gay is good, and queer sex is good. But many people – even many queer people – have internalized the idea that contracting (or even talking about) STIs is bad, shameful and should be hidden.
I’ve studied viruses as a journalist, social scientist, and professor of sexual health for more than a decade. Many viruses, including HIV, HPV, hepatitis B and hepatitis C, are categorized as STIs by the CDC despite being transmitted in a variety of ways. In some places, a large percentage or outright majority of HIV cases now transmit via injection drug use. But a major way these pathogens still transmit is sexually, and it’s important to name that so that people having sex can know how to protect themselves and their partners.
For the same reasons, the emerging monkeypox epidemic should be talked about as an STI, particularly in light of new research from the current London outbreak and scandalously overlooked research into the 2017 outbreak in Nigeria that suggests monkeypox may have mutated to allow for transmission through genital secretion. This does not mean that hMPXV can only be transmitted sexually, but it acknowledges that gay sex is a major way such pathogens move.
Shame should not be a factor in these discussions. “Viruses are not conscious,” said Pedro Serrano, a public health researcher. “They simply follow the mechanistic drive to replicate.”
Viruses may not be conscious, but those who choose to punish us for contracting them certainly are. In America, an established (and currently ascendant) political movement exists to punish certain classes of people – trans people, women, gay people, those trying to prevent pregnancy – for having sex.
While monkeypox is threatening to repeat the patterns of the past, it is worth remembering that for gay men, this is not our first rodeo. We have loved one another and formed connections even as police officers, bosses, educators, viruses and families of origin have tried to keep us apart. It is wearying having to ask ourselves, once again: are intimacy and sex worth the risk? Still, now is the time to remember or learn anew that queer men of all ages have been doing this for decades.
Gay sexual intimacy, interrupted
After the Stonewall Riots of 1969, there was a brief window of time when queer men could have a lot of sex with relatively little worry.
But then, in the early 1980s, reports trickled in that young gay men were becoming marked by purple lesions and falling ill to an extremely rare form of cancer that usually only affected older men near the Mediterranean Sea. The era of Aids was upon us.
To Ash Kotak, monkeypox lesions were reminiscent of those purple Kaposi sarcoma lesions that he saw on loved ones when the Aids pandemic began. A London-based playwright who leads the campaign for the Aids Memorial in London, Kotak lost a “boyfriend, ex-boyfriend and many friends” to Aids and has been living with HIV himself since 1993.
“My friends and so many died due to a lack of an early response in the USA and the UK,” he told me. “The issue now is like then: the response is woefully inadequate with the same shaming of gay men, and blaming, too.”
Gay men responded to HIV by beginning to use an old technology that had previously been limited to straight people seeking to prevent pregnancy: condoms. Through peer-to-peer education, gay people taught each other how to have sex and intimacy in a safer way, saving countless lives. They also saved millions of lives when, through activism by the group Act Up, they upended the process for drug trials, paving the way for antiretroviral drugs (ARVs) for Aids and creating the medical architecture that was used to rapidly develop Covid-19 vaccines decades later.
The development of those ARVs meant that by 1996, “you didn’t need to die of Aids”, says Thomas Strong, a friend of mine and a Dublin-based American anthropologist and HIV activist who has been living with HIV since 2006 without any health problems.
“Then the question becomes, ‘How important is sex? Is it worth any risk?” Strong says, noting that the decline of nearly all Covid mitigation protocols suggests that, for our governments, “the economy is worth the risk”.
“Is sexual intimacy worth the risk?” he asks. “It’s in this context of values that vice is structured.”
ARVs have been so effective that when properly medicated, people living with HIV cannot pass HIV onward to sex partners. And the medication has been tweaked so that HIV-negative people can proactively avoid the virus, too. In 2012, PrEP was approved by the FDA, allowing people like me to enjoy sex with more intimacy and less fear. And since people on PrEP are required to get tested every few months, the drug also created an architecture for detecting and treating other STIs.
PrEP liberated younger gay men and other queer and trans people from the stress and fear around sex that remained even after the development of ARVs.
Jafet, a 27-year-old graduate student from Los Angeles who asked not to be identified by his full name, told me that when he first moved to San Francisco for college, having sex without a condom would fill him with terror and anxiety. When sexual partners taught him about PrEP, which he has now taken for six years, he felt liberated.
“I felt so privileged,” he said. “A generation before me didn’t have this freedom and luxury to enjoy sexuality without worry. And I felt lucky to be gay. I didn’t have to worry about a disease that is treatable but incurable, and I didn’t have to worry about pregnancy.”
Jarret, a 21-year-old from Idaho who also asked not to be identified by his full name, told me that he had never had sex without PrEP. Growing up the son of a minister who railed against gay sex, he was terrified of his own desires. “I really grew up believing I wan’t going to live very long because I was gay,” he said.
When he went away to college, he was afraid to do anything more than masturbate with another man – and even that would send him into a tailspin of “debilitating” anxiety about HIV. A therapist helped him get on PrEP, and he was able to have his first sexual experience without fear.
“It was very profound,” he said. “Everything I had feared in my head was gone. I was able to enjoy myself and not stress.”
From Covid to monkeypox
But then, in 2020, the dreaded coronavirus came along, with devastating effects for LGBTQ+ people. With breathing itself the major mode of transmission, techniques gay men were accustomed to using for safer sex, such as condoms, were no longer sufficient. Queer health educators instead encouraged people to practice masturbation, sexting, video sex or phone sex or to use “glory holes” in the early days of the pandemic.
Covid-19 vaccines paved the way for a very horny summer of 2021 – but it was to be just one summer, because by Pride month in 2022, monkeypox was on the move.
“With Covid, there was a quick government response,” noted Kotak. “With monkeypox, yet again, the queer community have had to push for a response.”
In the absence of government help, gay sex parties cancelled themselves, and community groups mobilized to demand the government distribute hundreds of thousands of vaccine doses that it owned but had chosen not to make available.
The outbreak is threatening all the progress that was made toward freeing gay men to have sex without fear.
Jafet told me that he’s stopped having sex out of worry, “especially because monkeypox is so visual”. It frustrates him that he can’t find a vaccine “in the summer, on vacation, when I should be able to enjoy the boys safely!”
When I spoke to Strong, he had been quarantined in Dublin for three weeks due to monkeypox. He had 50 lesions on his body. At times, it was so painful, he wanted to be hospitalized.
Monkeypox has brought up a fear he once expressed to me about his HIV diagnosis: “I am terrified that no one will ever touch me again.” But in conversations he’s had on Grindr – “I’m still flirting and chatting, even though I’m quarantining” – he has been pleasantly surprised that some gay men have said: “Well, I’ll see you in a few weeks when you’re better.”
“Our love of sex is going to save us,” he told me. “It’s going to teach us how to be human in an epidemic that wants to keep us apart”.
Refusing to be part of a viral underclass
The fight for our sexual freedoms is not without its enemies. This month, Jonathan Mitchell, an anti-abortion Republican and former solicitor general of Texas, filed a federal lawsuit seeking to limit access to PrEP. This attack on gay men’s sexual health is just one part of the misogynistic, homophobic, transphobic and anti-sex movement that is attempting to retract hard-won civil rights for women and LGBTQ+people in the US, from the overturn of Roe v Wade to the passage of the “don’t say gay” bill in Florida.
Shame is heaped upon gay men, just as it is heaped upon transgender or gender-nonconforming people, people seeking abortions in the US, and people in poor countries needing medicines and vaccines. We must all navigate medicalized sex lives, and that puts us in solidarity with one another.
When a virus like monkeypox moves in a way that can out us, the answer is not to shrink, or to hide, or to be embarrassed about the kind of sex we have.
Rather, these times demand that we refuse to be relegated to a viral underclass – and compel us to destroy the conditions that created such an underclass in the first place.
Steven W Thrasher, PhD, a former Guardian writer-at-large, is the author of The Viral Underclass: The Human Toll When Inequality and Disease Collide and a professor at Northwestern University