Monkeypox, bioethics and the LGBTQI+ community

DOI: https://doi.org/10.57187/smw.2022.40003
Publication Date: 27.10.2022
Swiss Med Wkly. 2022;152:40003

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Julian W. März a,b, Tania Manríquez Roa a,b, Bettina Schwind a,c,d, Nikola Biller-Andorno a,b
                    
a Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Switzerland

b Digital Society Initiative (DSI), University of Zurich, Switzerland

c Swiss Tropical and Public Health Institute, Basel, Switzerland

d AIDS-Hilfe beider Basel (AHbB), Switzerland

A community disproportionately affected by the COVID-19 pandemic

The COVID-19 pandemic has been a challenging time for different communities, including the LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex, and other gender identities and sexual orientations) community, and has sharpened health inequalities already present before the pandemic. In his report to the United Nations General Assembly of 28 July 2020, the United Nations Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity, Victor Madrigal-Borloz, provided a detailed overview of ways in which the COVID-19 pandemic has affected the LGBTQI+ community [1]. Stay-at-home policies, quarantine and isolation, and social stress have severely increased their risk of victimization, particularly in the case of LGBTQI+ people living with unsupportive family members. In several countries, including, e.g., the United States, Turkey, Georgia, Ghana and Malaysia, powerful religious and political leaders have blamed LGBTQI+ persons for the COVID-19 pandemic, which has led to a sharp rise in (online) hate speech. In Uganda, lockdown policies have been instrumentalised for a crackdown on the LGBTQI+ community [1]. The mental health of many LGBTQI+ persons has also significantly deteriorated in many countries; in the US, for example, 50.0% of LGBTQI+ adult respondents in the US Census Bureau’s March – May 2022 Household Pulse Survey reported symptoms of anxiety (compared to 24.3% of non-LGBTQI+ adults) and 41.6% symptoms of depression (compared to 19.4% of non-LGBTQI+ adults) [2].

The 2022 monkeypox outbreak and the LGBTQI+ community

It is thus no surprise that the 2022 monkeypox outbreak in non-endemic countries has fuelled fears and stress in the LGBTQI+ community. As of October 5, 2022, the World Health Organization (WHO) reports 68,998 laboratory-confirmed monkeypox cases in 107 countries worldwide, of which 24,820 emerged in the WHO Europe and 43,181 in the WHO Americas region. 97.5% of cases for which such data is available have occurred in persons identifying as men, and 89.9% in persons identifying as gay, bisexual and other men who have sex with men [3]. It should, however, also be noted that the mortality of infections is low in comparison to COVID-19: Worldwide, there have only been 26 deaths from laboratory-confirmed monkeypox infections as of October 5, meaning a case fatality ratio of around 0.04%. In addition, worldwide reported case numbers peaked in mid-August 2022 but have declined since then [4].

In response, the World Health Organization determined the 2022 global monkeypox outbreak to be a public health emergency of international concern (PHEIC) on July 23, 2022. It is only the seventh PHEIC determined by the WHO Director General under the International Health Regulations (IHR) 2005, the others being H1N1 (2009), Ebola (West Africa, 2013-2015), Poliomyelitis (since 2014), Zika (2016), Ebola (Democratic Republic of Congo, 2018-2020) and COVID-19 (since 2020) [5]. In two significant ways, the monkeypox outbreak differs from the six other PHEICs determined by the WHO: First, it is the first PHEIC determined under the IHR 2005 of an infectious disease mainly transmitted through sexual contact (sexual contact is only a secondary means of transmission of Ebola and Zika). Second, the 2022 monkeypox outbreak is the PHEIC with the highest proportion of infections in gay, bisexual and other men who have sex with men determined under the IHR 2005. Both are key features that the 2022 monkeypox outbreak shares with HIV/AIDS, which continues to be one of the biggest global health problems even 40 years after the first case reports were published.

Two fears by the LGBTQI+ community are particularly prominent with regard to the 2022 monkeypox outbreak. First, since the beginning of the outbreak, fears of increased marginalization and scapegoating of LGBTQI+ persons have been voiced. The outbreak indeed comes at a very difficult time for the LGBTQI+ community in many countries. According to data from the Human Rights Campaign, more than 300 anti-LGBTQI+ bills have been introduced in US legislatures in the first five months of 2022, more than in all of 2021 alone, including Florida’s infamous "Don’t Say Gay" law [6]. A similar law has been passed in Hungary in 2021 and is at present under consideration by the Romanian legislature [7, 8]. In Latvia, lawmakers have (ultimately unsuccessfully) tried to instrumentalise monkeypox to impose a ban on the Riga Pride 2022, in a move to foment anti-LGBTQI+ resentment ahead of the upcoming general elections [9]. Anti-LGBTQI+ rhetoric is also on the rise in many other states, with, for instance, Giorgia Meloni, the new Italian Prime Minister, repeatedly attacking LGBTQI+ rights and same-sex families in particular.

Second, there are widespread fears of inaction or neglect of the monkeypox outbreak by policymakers. The Biden administration, for example, was slammed by a bipartisan group of US senators for its hesitant monkeypox response, slow roll-out of monkeypox vaccines and vaccination gaps in communities of color on September 14, 2022 [10]. In Switzerland, the federal government has also been heavily criticized by the largest political association of gay and bisexual men for its slow response to the monkeypox outbreak and for not having purchased monkeypox vaccines and therapeutics until mid-August [11]. In many of these critiques resonate experiences from the early years of the AIDS pandemic of the 1980s, which was largely ignored by policymakers since it was considered a "gay disease": In late 1982, when more than 500 persons had died from AIDS, the disease was still mocked by officials of the Reagan administration; it was only in 1985, when more than 12,000 persons had died from AIDS, that then US President Ronald Reagan first acknowledged the threat it posed to public health [12, 13].

LGBTQI+ health and bioethics

Research has identified a broad range of health inequalities suffered by the LGBTQI+ community, many of which can be explained by increased minority stress. For instance, depression, anxiety disorders and suicide rates are estimated to be around two to three times higher in LGBTQI+ adolescents compared to their non-LGBTQI+ peers [7]. In the US, it is estimated that around one-fourth to one-third of homeless teenagers are LGBTQI+ [14]. UNAIDS estimates that the lifetime risk of HIV infection in gay, bisexual and other men who have sex with men is around 28 times higher than in adult men in the general population [15]. In the UK Government Equalities Office National LGBT Survey 2018, 40% of participants reported having been targets of hate speech or hate crime due to their sexual orientation or gender identity by persons they do not live with and 29% by persons they lived with [16]. A US study found that 16% of LGBTQI+ adult participants reported experiences of discrimination in healthcare encounters, and 18% reported avoiding healthcare altogether due to fears of discrimination [17].

The ongoing monkeypox outbreak raises many ethical questions: How should monkeypox vaccines be allocated on the global and the national level? To what extent are digital health surveillance and contact tracing ethically permissible, considering that they would require the large-scale collection of data on sexual contacts? How should health communication be conducted to counter the marginalization of the LGBTQI+ community in the context of the monkeypox outbreak?

Beyond these substantive questions, bioethicists will also need to address important structural issues: How can the perspectives and experiences of LGBTQI+ persons best be mobilized for addressing bioethical issues? How can pandemic preparedness and management be adjusted to best respond to the needs of LGBTQI+ persons? How can bioethics contribute to the promotion of LGBTQI+ persons having equal access to healthcare, and how can it foster the inclusion of LGBTQI+ healthcare needs in public health policies and health professionals’ training (see [18])?

In a message on the occasion of the International Day Against Homophobia, Biphobia and Transphobia 2020, United Nations Secretary-General António Guterres wrote the following: "Together, let us stand united against discrimination and for the right of all to live free and equal in dignity and rights" [19]. In this spirit, it is now time for bioethicists to help devise ways to promote health justice for LGBTQI+ persons.

Webinar invitation

Monkeypox, Bioethics and the LGBTQI+ Community (Online)

November 3, 2022, 3 – 4.30 pm (Zurich); 11 am – 12.30 pm (Brasilia); 10 – 11.30 am (Washington, D.C.)

Please click here to register.

The Forum for Global Health Ethics, an outreach project based at the Institute of Biomedical Ethics and History of Medicine (IBME) of the University of Zurich, and the Swiss Medical Weekly are organizing the interdisciplinary webinar "Monkeypox, Global Health Ethics and the LGBTQI+ Community".

Speakers include international experts in the areas of global health ethics, human rights law, epidemics ethics, LGBTQI+ bioethics, public health and community-based HIV initiatives:

  • Cleiton Euzebio de Lima, Senior Advisor (Community and Key Populations), Joint United Nations Programme on HIV/AIDS (UNAIDS);
  • Julian W. März, Research Fellow, Institute of Biomedical Ethics and History of Medicine, University of Zurich;
  • Stephen Molldrem, Assistant Professor, Bioethics and Health Humanities, University of Texas Medical Branch (UTMB), Galveston, School of Public and Population Health;
  • Carla Saenz, Regional Bioethics Advisor, Pan American Health Organization (PAHO).

For more information on the webinar, please click here.

Acknowledgments

We are very grateful to Supriya Subramani for our conversations and her support with expertise on the topic of monkeypox crisis communication and stigma.

Funding

None.

Photo credit

CDC / Cynthia S. Goldsmith, Russell Regnery

References

1. United Nations Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity. Violence and discrimination based on sexual orientation and gender identity during the coronavirus disease (COVID-19) pandemic (July 28, 2020): United Nations General Assembly, A/75/258. Available from: https://documents-dds-ny.un.org/doc/UNDOC/GEN/N20/197/62/PDF/N2019762.pdf (last access Sep 23, 2022).

2. File T, Marlay M. LGBT Adults Report Anxiety, Depression During Pandemic: United States Census Bureau. Available from: https://www.census.gov/library/stories/2022/06/lgbt-adults-report-anxiety-depression-during-pandemic.html 

3. World Health Organization (WHO). 2022 Monkeypox Outbreak: Global Trends (September 23, 2022). Available from: https://worldhealthorg.shinyapps.io/mpx_global/

4. Mathieu E, Spooner F, Dattani S, Ritchie H, Roser M. Our World in Data - Monkeypox. Available from: https://ourworldindata.org/monkeypox

5. Wilder-Smith A, Osman S. Public health emergencies of international concern: a historic overview. J Travel Med. 2020 Dec;27(8):taaa227. http://dx.doi.org/10.1093/jtm/taaa227.   

6. Campo-Engelstein L. Why Bioethics Needs Pride: Anti-LGBTQ Laws and Health Disparities (June 2, 2022). Available from: https://bioethicstoday.org/blog/why-bioethics-needs-pride-anti-lgbtq-laws-and-healthdisparities/ 

7. März JW. Hungary’s new anti-LGBTQ law: the medical profession must speak out about the harm it does to LGBTQ adolescents’ health. Lancet Reg Health Eur. 2021 Aug;8:100199. http://dx.doi.org/10.1016/ j.lanepe.2021.100199.  

8. Thoreson R. Romania — Latest EU Hotspot in Backlash Against LGBT Rights (June 13, 2022). Available from: https://www.hrw.org/news/2022/06/13/romania-latest-eu-hotspot-backlash-against-lgbt-rights 

9. Middleton L. Europe’s Monkeypox Outbreak Sparks Fears of Anti-LGBTQ+ Backlash - LGBTQ+ campaigners fear the outbreak could fuel homophobia (July 27, 2022); 2022. Available from: https://www.globalcitizen.org/en/content/europe-monkeypox-LGBTQ-homophobia-worldhealth/ 

10. Mahr K. Biden administration officials take bipartisan flak on monkeypox response (September 14, 2022). Available from: https://www.politico.com/news/2022/09/14/biden-monkeypox-response-slammed-senate-00056728

11. Coviello M. Verfahrene Situation bei der Affenpocken-Impfung: wieso es in der Schweiz mit der Beschaffung stockt. Available from: https://www.nzz.ch/schweiz/affenpocken-impfung-wieso-es-in-derschweiz-mit-der-beschaffung-stockt-ld.1698262

12. Gonsalves GS, Mayer K, Beyrer C. Déjà vu All Over Again? Emergent Monkeypox, Delayed Responses, and Stigmatized Populations. J Urban Health. 2022 Aug;99(4):603–6. http://dx.doi.org/10.1007/s11524-022-00671-1

13. New York City AIDS Memorial. HIV/AIDS Timeline. Available from: https://www.nycaidsmemorial.org/timeline

14. McCann E, Brown M. Homelessness among youth who identify as LGBTQ+: A systematic review. J Clin Nurs. 2019 Jun;28(11-12):2061–72. http://dx.doi.org/10.1111/jocn.14818.

15. Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Global AIDS Update 2022. Available from: https://www.unaids.org/en/resources/documents/2022/in-danger-global-aids-update

16. UK Government Equalities Office. National LGBT Survey - Summary Report; 2018. Available from: https://www.gov.uk/government/publications/national-lgbt-survey-summary-report

17. Casey LS, Reisner SL, Findling MG, Blendon RJ, Benson JM, Sayde JM, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019 Dec;54(S2 Suppl 2):1454–66. http://dx.doi.org/10.1111/1475-6773.13229.

18. März JW, Holm S, Biller-Andorno N. Monkeypox, Stigma and Public Health. Lancet Reg Health Eur. Forthcoming.2666-7762

19. United Nations Secretary-General. Secretary-General’s message on the International Day Against Homophobia, Biphobia and Transphobia (May 17, 2020). Available from: https://www.un.org/sg/en/content/sg/statement/2020-05-17/secretary-generals-message-the-international-dayagainst- homophobia-biphobia-and-transphobia

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