PHThe claim that skin-to-skin contact during séx between men, not intercourse itself, drives most monkeypox transmission is likely backward, a growing group of experts say.
Since the outset of the global monkeypox outbreak in May, public health and infectious disease experts have told the public that the virus is largely transmitting through skin-to-skin contact, in particular during séx between men.
Now, however, an expanding cadre of experts has come to believe that sĂ©x between men itself â both anal as well as oral intercourse â is likely the main driver of global monkeypox transmission. The skin contact that comes with sĂ©x, these experts say, is probably much less of a risk factor.
In recent weeks, a growing body of scientific evidence â including a trio of studies published in peer-reviewed journals, as well as reports from national, regional and global health authorities â has suggested that experts may have framed monkeypoxâs typical transmission route precisely backward.
Reconceiving the primary risk factors for transmission is crucial because of how it may affect guidance on reducing the risk of infection, including the question of whether demanding that people with the virus self-isolate has any substantial impact on transmission.
âA growing body of evidence supports that sĂ©xual transmission, particularly through seminal fluids, is occurring with the current MPX outbreak,â said Dr. Aniruddha Hazra, medical director of the University of Chicago sĂ©xual Wellness Clinic, referring to monkeypox and to recent studies that found the virus in semen.
Consequently, scientists told NBC News that the Centers for Disease Control and Prevention and other public health authorities should update their monkeypox communication strategies to more strongly emphasize the centrality of intercourse among gay and bisĂ©xual men, who comprise nearly all U.S. cases, to the virusâ spread.
On Aug. 14, Dr. Jeffrey Klausner, an infectious disease physician at the University of Southern California, and Dr. Lao-Tzu Allan-Blitz, a resident physician in global health at Brigham and Womenâs Hospital in Boston, published an essay on Medium in which they reviewed the science supporting the argument that during the current outbreak, monkeypox is largely transmitting through anal and oral intercourse between men.
âIt looks very clear to us that this is an infection that is transmitting sĂ©xually the vast majority of the time,â Allan-Blitz said.
This debate, however, is far from settled.
Dr. Rosamund Lewis, technical lead for monkeypox at the World Health Organization, told NBC News it was âunfortunate but trueâ that âwe donât know yetâ whether the virus is predominantly transmitted through intercourse.
âCompletely reading the situation as uniquely due to anal or oral sĂ©x is highly likely to be overreach,â she said. âThe correlation may appear to be strong, but that does not explain the whole picture of disease caused by this virus. So we need to keep an open mind.â
Some experts in infectious disease see evidence supporting the argument that monkeypox at least transmits more readily through intercourse.
âAt this point,â said Dr. Paul Adamson, an infectious disease specialist at the UCLA School of Medicine, âIâm not sure we can say it is primarily the sĂ©xual transmission and not the skin-to-skin contact that also occurs during sĂ©x that is contributing to the most transmission during this current outbreak. However, emerging data seem to suggest that monkeypox might be more efficiently transmitted sĂ©xually.â
Parsing the evidence
In an interview, Klausner, who has submitted a version of his and Allan-Blitzâs essay to a scientific journal for publication, distilled the evidence that he said supports the hypothesis that sĂ©x itself fuels the global outbreak into four major points.
First, he noted that, according to the WHO, more than three quarters of global monkeypox cases are among men 18 to 44 years old. This is a typical age breakdown for diagnoses of sĂ©xually transmitted infections among gay and bisĂ©xual men, he said. Whatâs more, in recent studies of pooled monkeypox cases among this demographic, 17% to 32% of those diagnosed with the virus received a sĂ©xually transmitted infection (STI) diagnosis at the same time.
Second, during the global outbreak, atypical to what has historically been seen in the 11 African nations where the virus has become endemic since first being identified in humans in 1970, monkeypox lesions have in the majority of cases occurred in menâs ******* and anorectal areas. This, experts told NBC News, suggests that these were the sites where the virus first passed into the body.
In a study of 197 monkeypox cases in London men published July 28 in The BMJ, the British Medical Associationâs journal, researchers found that 56% had lesions in the ******* area and 42% had them in their anorectal regions. And in a study published July 21 in The New England Journal of Medicine, a global team of researchers pooled 538 monkeypox cases â also all in men â from around the world and found that 73% had lesions in the ******* or anorectal areas.
Third, researchers have found monkeypox in semen and have been able to culture that virus, which suggests it could transmit through ejaculation. Also, the authors of two recent studies have detected the virus after taking anal swabs among men who had monkeypox but were asymptomatic, which indicates that the virus might transmit from the anorectal area during anal intercourse before people develop symptoms. Experts say more research is needed on both these fronts.
Referring to bodily fluids such as semen, vaginal fluids and blood, the WHOâs Lewis said, âResearch is underway to find out more about whether people can spread monkeypox through the exchange of these fluids during and after symptomatic infection.â
Finally, Klausner noted that scientists have identified an association between specific séxual acts and the location of monkeypox lesions.
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