Since the global outbreak of Mpox began last year, the disease has been articulated by public health bodies in Australia and China in various ways which perpetuate myths and stereotypes that stigmatise homosexual and bisexual men, as well as other men who have sex with men.
On July 28, 2022, Australia’s Chief Medical Officer declared Mpox to be a communicable disease incident of national significance, before and after which the Australian Government and the Departments of Health of Australia’s States and Territories published and updated fact sheets about Mpox focusing on key questions such as ‘who is at risk’, ‘How is Monkeypox spread?’ and ‘How is Monkeypox prevented?’
In China, the General Office of the National Health Commission of the People’s Republic of China (中華人民共和國國家衛生健康委員會辦公廳) made an official announcement of the publication of a Guideline for Prevention and Control of Mpox (2022 Version) (猴痘防控技术指南[2022年版]) along with an official fact sheet about Mpox by the Department of Health of the Government of the Hong Kong Special Administrative Region (香港特別行政區政府衛生署衛生防護中心) and an official fact sheet issued by the Taiwan Centres for Disease Control (衛生福利部疾病管制署).
I look at how three key issues in both Australian and Chinese contexts are communicated—who is at risk, how Mpox is spread and how it can be prevented—which point to a number of problematic narratives and assumptions that occur repeatedly in public domains.
Of course, Mpox is a real disease that is transmitted between human beings, contagious, and damaging. Yet the Mpox epidemic is at the same time an epidemic of meanings and interpretations which could be expressed differently to minimise stigmatisation and discrimination.
Describing who is at risk
What is striking about the narratives of Mpox is that they are not entirely new. Mpox is described as a sexually transmitted infection mostly among men who have sex with men, such as stated by the Victorian Department of Health (the government health body in Australia’s second-most populous state). Similarly, in defining who is at risk, the Department of Health of New South Wales (Australia’s most populous state) declared that people at highest risk are men who have sex with men, particularly those who are travelling to outbreak areas, have multiple sexual partners or attend large parties or sex on premises venues. Other Australian jurisdictions published similar material, such as South Australia.
These statements by health authorities accurately reflect the fact that Mpox mostly affects men who have sex with men. However, these gender/sexuality-focused definitions and categorisations—either using terms in relation to gender (men who have sex with men) or sexuality (gay, bisexual)— suggest a real danger of further stigma being generated towards this group. One could argue that the health authorities emphasised the particular group so they can better protect themselves, but gay/bisexual communities have suffered tremendously because of the stigmatisation, minoritisation, and marginalisation in the context of infectious diseases since the outbreak of HIV/AIDS in the 1980s. It is important to recognise the way language can be triggering and stigmatising.
Official narratives about Mpox in Australia could be improved by using more supportive, inclusive and less stigmatising language. Person-centred language is one way to address this issue. Person-focused phrases emphasise people over and above their gender, sexuality, sexual acts, behaviours, and places they go to, which I argue re-centres their humanity. For example, I advise against using acronyms such as MSM (men who have sex with men). Further, it would also be less stigmatising to include explicit acknowledgment that ‘…the risk of exposure to monkeypox is associated with behaviours involving close physical contact, not with an individual’s gender or sexuality’. This would help Mpox to be understood as a disease that is not so readily associated with homosexuality and assumed male promiscuity.
I acknowledge that the Federal Department of Health in Australia states that ‘anyone who has been in close contact with someone with MPX, either within Australia or overseas, is at risk’ thereby indicating that Mpox is not confined to gay-bisexual groups. I also acknowledge that some states specified other groups at risk of infection, including sex workers. However, emphasis on a person’s occupation (such as sex work) may also cause stigma resulting in negative self-image, self-isolation, shame, and despair.
To improve the public messaging about the ‘risk’ of Mpox, authorities should use phrases such as ‘affected community’/ ‘population’ or ‘high-incidence population’ rather than ‘high-risk people’ or ‘people at high risk’. Choosing appropriate language would acknowledge societal challenges and accurately describe disease dynamics. Critical attention to the very process of describing Mpox can challenge the universalising description of Mpox as a STD, which holds traditional beliefs and stereotypes about sexually transmitted diseases onto Mpox. Adopting appropriate words and phrases, such as ‘affected community’, is more specific, accurate and can remove judgment of human behaviour, gender, and sexuality.
The language guide to HIV developed by The National Institute of Allergy and Infectious Diseases (NIAID) of the US, which encourages the use of affirming and non-stigmatising language (in English), can help us improve our public messaging about Mpox.
In the Chinese context, Mpox has not been quite so focused on the (homosexual) male body. Mainland China’s official Guideline does not include mention of men who have sex with men in its definition of Mpox and prevention guidelines. However, p.3 of the Guideline states:多國疫情顯示，猴痘病毒已發生人際傳播，主要為男男同性戀聚集性疫情.
Many cases of Mpox in multiple countries show that the Mpox virus spreads from person to person, the majority of the cases have been found in male-to-male homosexual clusters. (Translation by author)
In Taiwan, communication from the Centres for Disease Control states that the [confirmed] cases are mostly found among men but not limited to men who have sex with men ‘…個案以男性為主，但不限於男男性行為者(men who have sex with men, MSM’).
This does not mean the seemingly inclusive language in the official narrative of Mpox by Chinese authorities is an explicit articulation of non-discriminative inclusivity.
Page 39 of mainland China’s Guideline frames Mpox as a foreign virus, which accords with a history in China of framing homosexuality as a foreign disease that is foreign to the modern Chinese nation. This closely aligns with the narrative of domestic news reports such as ‘歐美出現罕見的猴痘疫情：我們應該擔心嗎？’ (Should We Worry about the Rarely-Infected Mpox Cases Found in Europe and America?). Similarly, the Taiwan Centres for Disease Control (衛生福利部疾病管制署) published an official Guideline for the Prevention and Control of Monkeypox (猴痘防治工作手冊) on 29th June, 2022, stating:
流行病學資料顯示，個案以男性為主，但不限於男男性行為者(men who have sex with men，MSM)，多數個案具歐洲、北美國家旅 遊史。 (p.2, the Guideline)
Epidemiological studies show the cases are mainly found in males but are not limited to men who have sex with men, most of whom had travelled to Europe and North America.
At the same time, as the Centre for Health Protection, Department of Health, the Government of the Hong Kong Special Administrative Region (香港特別行政區政府衛生署衛生防護中心) explains, most of the Mpox cases were identified among men who have sex with men seeking medical help in primary care and sexual health clinics (officially in traditional Chinese: 這些個案大多數發現於向基層醫療或社會衞生科求診的男男性接觸者) especially in European and North American countries (特別是在歐洲或北美國家).
As I have argued elsewhere, in China the subject of male same-sex desire, as a defining linguistic and cultural other to the heterosexual nation, has consistently been characterised as foreign. For example, themes of travel, exile, and diaspora in cultural and literary productions in Taiwan are persistently associated with those who are erotically and romantically attracted to people of the same sex.
China is home to the world’s largest lesbian, gay, bisexual, and transgender (LGBT) population. As Lisa Rofel in her monograph Desiring China: Experiments in Neoliberalism, Sexuality, and Public Culture observes, the ambivalence over homosexuals appears in public culture debates, such as well-known legal cases and informal conversation. The limited support for or acceptance of ‘homosexual’ people in Chinese culture is extended only within specific contexts to specific groups of sexual subjects. The existence of homosexuality and other non-normative sexual identities and desires are not denied, but the community is rarely celebrated, remembered, represented, and discussed in a public manner. For example, LGBT-related TV programmes and other cultural productions could be sometimes censored as unsuitable for the general population. It’s also unclear whether ‘men who have sex with men’ who have been affected by Mpox in China have been allocated the medical resources needed.
The narratives used by Chinese authorities in relation to Mpox can further cause discrimination to marginalised communities, as elsewhere.
Describing how Mpox is spread and prevented
The Victorian Department of Health’s fact sheets, while acknowledging that ‘anyone who comes in very close contact with someone with MPX, particularly where skin-to-skin contact occurs, can become infected’, also places emphasis on men ‘who have sex with men, particularly those who are travelling to outbreak areas, have multiple sexual partners or attend large parties or sex on premises venues’, including ‘saunas, adult cinemas/lounges, beats and sex parties’ and who are ‘sexually active HIV negative/positive gay, bisexual, and other men, non-binary people assigned male at birth, or trans people who have sex with men (including cis and trans men)’. This is likely to contribute to the stigmatisation of these categories of people.
Further adding to the emphasis on the ‘homosexual’ nature of Mpox transmission is the fact that the Victorian Department of Health published a specially formulated document titled ‘Monkeypox (MPX) virus – Information for gay, bisexual and other men who have sex with men’ as a separate attachment which can be downloaded. In their words, there are ‘a few things you can do to protect yourself’, which include:
- Limit your sexual partners or create a sex bubble until you are vaccinated.
- Check that your partner/s are free of rashes, lesions or sores that could be MPX.
- Don’t share your bed or sex toys with anyone outside of your sex bubble.
- Exchange contact details with sexual partners
- Leave your contact details with sex-on-premises venues – you don’t have to leave your name.
This list of preventive measures based on stereotyped (homo)sexual behaviours, with established evidence that transmission of Mpox can be heterosexual, the narrative continues to construct MSM and homosexual, bisexual men at large as active transmitters of Mpox through promiscuous sexual practices. The list of ways to ‘protect yourself’ can be better articulated in a number of ways. Messages should reach those most vulnerable to infection without exaggerating sexual indulgence and suggesting severe penalties associated with stigmatised, sexualised condition of homosexuality. Description of Mpox could be better worded if authorities could reach the at-risk communities with vital health information without the same potential for stigmatisation. They should, for example, emphasise research and clinical control over the disease without ignoring the facts. For example, information should focus on the nature of the disease, its cause and origin and what individuals regardless of their gender and sexuality can do about it. In addition, the focus on men who have sex with men risks obscuring the possibility that others could also be infected, which ultimately undermines efforts to contain the outbreak.
As mentioned earlier, the National Institute of Allergy and Infectious Diseases of the US developed an HIV language guide to encourage the use of non-stigmatising language. Alternatively, public authorities and scientists can use available resources, such as the American Medical Association’s Manual of Style guidelines where chapters on grammar, punctuation, abbreviations, capitalisation, manuscript preparation, and editing provide up-to-date examples and entries (for example, the singular they).
In the Guideline issued by the National Health Commission of the PRC, the popular terms, phrases, and expressions frequently, and promiscuously used in the Australian context are absent in the accounts of spreading and preventing Mpox. Using inclusive language in Chinese, the Guideline describes how Mpox is spread: person-to-person transmission is mainly through close contact and can also be through droplets in long-term close contact. Contact with virus-contaminated items may also cause infection (‘人與人之間主要通過密切接觸傳播，亦可在長時間近距離接觸時通過飛沫傳播，接觸病毒污染的物品也有可能感染, p.5).
However, interestingly, a senior Chinese health official was reported to advise people to avoid contact with foreigners to prevent Mpox infection after the first known case of the virus in mainland China was reported. Impractical suggestions like this indicate a lack of accurate information and awareness combined with outdated beliefs, leading people to fear contracting Mpox, getting tested for Mpox, and talking about Mpox.
The Guideline issued by the Taiwan Centres for Disease Control states that male patients are advised to refrain from sex of any kind and use condoms throughout sexual practice within three months of developing symptoms (建議男性病患於出現症狀後三個月內應避免各種性行為，或全程使用保險套). In Hong Kong, even though it is indicated that most confirmed cases are found among men who have sex with men seeking medical advice from primary health care and hospital services (向基層醫療或社會衞生科求診的男男性接觸者), the section of preventive measures uses non-sexualised, ungendered terms such as 市民 (city citizens) and人 (person, human being).
The language of Mpox in the Chinese context, characterised by a sense of inclusivity, does not necessarily mean that the motivations behind it are less discriminatory. The rationale behind the way of describing the virus in the Chinese language is complicated not only by the fact that the guidelines are official and thus authoritative but also by the fact that, while sexual minorities in mainland China have more space now to live their identities and form their communities, there are ‘no protective national laws’ or ‘national political discourse on LGBT matters’, and no ‘specific ministry or government department has responsibility for issues relating to sexual orientation and gender identity’.
Across languages and borders, the stigma and trauma of its discriminative origin allows Mpox to be used as a neologism (if not a metaphor) for a (male) homosexual lifestyle. Mpox, in scientific and medical terms, has largely been defined as a ‘homosexual’ social problem, which has the effect of stigmatising particular groups, as well as potentially eliminating the possibility that Mpox is a contagious disease that can infect people regardless of their sex, gender, and sexuality.
The use of less stigmatising language plays a crucial role in instilling an awareness of social, cultural inclusivity and diversity in society. As scientists and health authorities have the power to represent people, communities, and ideas respectfully, accurately, and inclusively, they can choose to communicate their ideas to the public using less stigmatising language to help dismantle stigma around Mpox. Health authorities should develop guidelines that encourage more inclusive, empowering language. Consultation with people in communities affected by diseases or disabilities and people of different ethnicity, occupation, age, sexual orientation, and gender, among others should be central.
Image: People in a street. Credit: Jeffrey Czum/Pexels