Monkeypox (MPV) remains highly polarizing and stigmatizing, especially among men who have sex with men (MSM)—who, according to the Centers for Disease Control and Prevention (CDC), account for 94% of confirmed cases in the U.S.*
*A major issue with discussions about MPV is knowing how to frame the virus accurately without stigmatizing people who are vulnerable, fearful, or recovering. One HIV physician, Joseph Cherabie, M.D., has dedicated his forum to combatting MPV misinformation, educating others on nonstigmatizing language, and describing scenarios that have helped the people he serves.
Cherabie is an infectious diseases physician and assistant professor of medicine at Washington University School of Medicine in St. Louis, Missouri. He is also the associate medical director of the St. Louis STI/HIV Prevention Training Center and associate medical director of the St. Louis County Sexual Health Clinic. Cherabie says that his work with diverse populations helps remind him that giving people “the awareness and information they need―that is sex-positive, gender inclusive, racial/ethnic minority–equitable and inclusive, and also nonstigmatizing”―is essential to providing care.
Cherabie recently spoke with TheBodyPro about how stigma manifests in medical spaces, alleviating concerns about monkeypox, and using trauma-informed care to empower patients.
This transcript has been edited for clarity and length.
The Stigma Against Sex
Juan Michael Porter II: Why do you think stigma is rearing its ugly head during the MPV outbreak?
Joseph Cherabie: I think it hearkens back to the overall stigma that we have both in the medical field and society when talking about sex. Whether it’s HIV, syphilis, herpes, or any of these infectious processes―whenever it’s an STI or in any way transmissible, all of a sudden a bias or moral judgment comes with it.
This is associated with [the belief that] people are having either too much sex or the wrong kind of sex. This is something we try to train against [in medical school], though the sexual health and sexual history section is always an add-on at the end that we go through if there’s time.
Porter II: Do you know many doctors who talk about sex in nonclinical terms with their patients?
Cherabie: I’ve asked my colleagues, “How many times have we spoken to our patients about pleasure when we talk about sexual health?” Usually, very few hands are raised.
Porter II: Why is that a problem?
Cherabie: When we talk about sexual health in medical school through the lens of disease prevention―such as trying to see if people qualify for PrEP with an HIV risk assessment, or talking about other STIs and asking, “Does it burn when you pee or is there a discharge?”―we rarely talk about all of the things that are going right.
We don’t normalize talking about sex among ourselves, and we don’t normalize talking about sex with our patients out of fear of overstepping a boundary, and that creates a stigma around things.
Porter II: Can you give me an example of how you’ve seen this play out?
Cherabie: Let’s talk about the whole discourse over whether MPV is an STI or not. What was the purpose of that discourse? What were we trying to do? We’re associating it so that if a child gets it, it’s associated with something sexual happening to a child. Or if it’s only occurring among MSM and their sexual networks, then it’s associated with, “They’re having too much sex.” It’s a stigma that we see across the board with respect to sexual health.
Porter II: Of course, this type of association is not new.
Cherabie: Yes. It was the same with the HIV crisis. Luckily for us, MPV doesn’t carry the same mortality, but it does carry morbidity. And let me be clear that I will never compare morbidity between HIV and MPV.
But with MPV, we’re talking about people who will be in a lot of pain for two to four weeks, and told to isolate themselves from people for two to four weeks until things heal. And if it’s only happening in a specific community―if it’s only among “them”—then it becomes, “They need to fix it; it’s their fault.”
This goes back to sex-positivity. We can just state the facts. We don’t need to apply a moral judgment to it. We don’t need to say “unfortunately” or bad things. Just state the facts.
Right now, 99% of MPV cases are among people who were assigned male sex at birth. Right now, [94%] of confirmed MPV cases are among gay and bisexual men who have sex with men. The reason we use that phrasing is so that we can say MSM and everyone will understand.
We can acknowledge that and then prioritize this group and say that right now we need to work harder. But we also need to acknowledge the fact that this is a group that has been neglected by the health care system for years, that has been stigmatized, discriminated against openly, and left out. And we have legislatures that are actually trying to allow people to refuse to [treat] us for religious reasons―all because this is associated with sex, and specifically associated with sex among LGBTQIA positivity.
Decoupling the Person From Population Statistics
Porter II: The implication is that these bad things are happening because this community is doing something wrong. How do you go about combating such misinformation among your patients?
Cherabie: You can decouple population statistics from the person sitting in front of you. That person sitting in front of you may be part of the population—and population statistics tell us about trends, right? So, in a presentation, I might bring up CDC slides that say, “Black and Latino MSM have the highest rates,” and all this stuff that might be factual. But while the slide is highlighting a clear racial and ethnic disparity, it’s not saying why.
Not only is it not saying why, but when I have Black and Latino MSM that tell me that they have only one sexual partner, I need to believe what they’re saying. But I’ve had people who I’ve trained under say, “Oh, but they’re Black MSM; they’re high risk.” So, I have these two things that I need to decouple.
When we’re talking about statistics or population trends, we’re talking about one thing. When we’re talking about MPV and the fact that it is greatly affecting our community at this point, we’re highlighting the need for us to get resources. We’re not highlighting, “They are the only risk group. They are doing something wrong. They are the only people who can get it.” But that is the narrative right now: “I’m a woman, and if I get it, I will be neglected.”
Porter II: Is that true?
Cherabie: No. If you have an actual exposure to MPV, regardless of your sexual orientation, gender identity, any of that, then I will treat you the same. But when it comes to preventative mandates right now, in terms of post-exposure, we need to emphasize that we’re prioritizing this group and meeting this group where they need to be met.
But ultimately, you have to decouple that from the person sitting in front of you, and you have to treat the person in front of you with dignity and respect and listen to what they’re saying in a sex-positive, gender-inclusive approach towards sexual health.
Porter II: Is that something you do in your practice?
Cherabie: I always talk with every one of my patients about sexual health goal-setting. What does good sex mean to you? And how can we get you to that? And I have some patients tell me, “You know what? I’m not ready to have sex. I’m just not in the right place.” And if they say, “I’m not having sex,” I always ask them, “Do you mind me asking why not in a nonjudgmental way? I just want to know what your reasons are.” And if they say, “I’m worried about HIV criminalization,” or “I’m a cisgender Black woman who has HIV, and putting that out there on a dating app means that I’m going to get a lot of flack”―we talk about it. And if I can’t speak to that experience, I have peer support groups that can help guide the conversation.
Uncoupling and removing that stigma comes back to treating the person in front of you with the dignity and respect that they deserve, acknowledging them for who they are and meeting their needs where they are. That’s how you remove stigma and discrimination, because the person in front of you has a disease process.
If that person had chickenpox, we would not treat them the same way [we’d treat someone with an STI]. If I gave you a false statistic that claimed [the incidence of] a particular STI was 90% higher in one population compared with another, would you bat an eyelash?
Porter II: I have to admit that I’d accept it initially and verify later.
Cherabie: That’s because we associate something with sex without normalizing discussions about sex.
Understanding the Nuances Is the Art of Medicine
Porter II: Looking back at your point that women who are diagnosed with MPV will not be left out of care, how do you create messaging that communicates that doctors will take care of a person regardless of who they are or where they are?
Cherabie: I think the messaging has to [consider] each case on a one-by-one basis and understand that there are nuances in medicine―there’s no black and white. There’s never been a disease process that has been perfectly defined by a textbook or by guidelines or by case definitions. And that’s where the art of medicine requires you to put things together and figure stuff out.
If an individual happens to be a cisgender woman, and she happens to have lesions that look very similar to MPV, and I take a sexual history and she has had new sexual partners―I’m going to test her for MPV. And that’s included in the differential [diagnosis]. It’s when we don’t include [it in] the differential that we get a disparity.
Again, focus on the person in front of you, focus on what you are seeing, and put pieces together and see what the pretest probability tells you. If you are MSM, your pretest probability at this point is higher than cisgender women who are abstinent or having sex with cisgender men. And again, there are some cisgender women who have sex with MSM. There are nuances to everything.
So, if a cisgender woman has these typical lesions in the genital region or around her mouth and they look exactly like MPV, and she tested negative for herpes and tested negative for shingles, then the pretest probability incrementally increases. That is the art of medicine, because we don’t sit there and only go through algorithms. If we only went through algorithms, then a machine could do this.
Making Patients Feel Safe
Porter II: This gets to something that Whitney Irie, Ph.D., M.S.W., at Harvard Medical School once told me about developing the continuum of care instead of risk profiles for HIV, or building a robust rapport to dismantle barriers, with the understanding that “because you are someone who has the opportunity to expand into different types of sexual lifestyles by your choice, it’s my obligation as a provider to provide educational resources.”
Cherabie: I love Dr. Irie, and yes!
Porter II: She’s brilliant. But even when one has a rapport with their doctor, having a conversation about sex can feel fraught because one doesn’t want to get yelled at if they’ve done something “bad.” How can doctors bring patients into the conversation so that they feel safe and comfortable with sharing what needs to be known?
Cherabie: By asking if it is OK. “Is it OK if I ask you some questions about your sexual health?” It’s all within the lens of trauma-informed care that we’re working towards, especially in a lot of our sexual health spheres. Understanding that people are coming to us—more likely than not—having experienced some form of trauma in their life, especially with respect to sexual health. So, giving the power back to the patient. “Is it OK if I ask you questions about your sexual health?”
Let’s say I’m doing a pelvic exam. You’d say, “Right now, I’m going to put my hand on the inside of your thigh. Is it OK if I put my hand on the inside of your thigh? The next part is the speculum exam. Let me know if there’s any pain or if I can in any way help to decrease the amount of pain of this exam by letting me know if you feel uncomfortable in any way.” Give the power back to the people, ask for permission, and check in if someone feels uncomfortable.
Porter II: Can you give me an example?
Cherabie: “I noticed that you became more uncomfortable. Do you mind me asking if something made you uncomfortable?” And reiterating that sex is a healthy part of life that people should be able to enjoy. Reinforcing that “you get to define what good sex means to you.” Not me, and definitely not the media.