Understanding Mpox
By Sue Coyle, MSW
Social Work Today
Vol. 23 No. 1 P. 16

Social workers can help their clients ascertain risk and find quality resources regarding mpox only when they themselves understand the virus.

The first case of mpox (formerly called monkeypox) in 2022 in the United States was reported on May 17. Since then, as of January 11, 2023, there have been 29,980 cases in the United States, with 21 reported deaths. Worldwide, there have been 84,471 cases. Mpox is not at the level of the ongoing COVID-19 pandemic in which nationwide more than 100 million people have been infected and more than one million have died. However, the mpox outbreak is of concern, particularly for the populations most at risk for infection.

As social workers, there’s a responsibility, then, to be aware not only of what mpox is but also of the resources available—nationwide and within local communities. Social workers must also recognize that the mpox outbreak has come with stigma and that stigma affects the way in which people discuss and absorb information about the virus.

By having a basic understanding of mpox, social workers can then help their clients—both those deemed most at risk and others—to best form their own foundational knowledge of the virus and take the steps necessary to find adequate resources, limit exposure to infection, and seek treatment.

Mpox
Mpox is a virus that comes from the same family of viruses as smallpox. The name monkeypox derives from the initial outbreak in 1958 when monkeys in a research facility in Denmark were diagnosed with it. However, the actual source of mpox remains unknown. The World Health Organization (WHO) describes it as a viral zoonosis, meaning that it is an infectious disease that has jumped from nonhuman animals to humans. But it’s known that not only nonhuman primates but also rodents can host the infection.

Mpox is spread through close personal contact with an infected animal or human. Alissa Davis, PhD, an associate professor at Columbia University School of Social Work, explains, “Mpox spreads through close, prolonged contact, usually involving skin-to-skin contact. It is primarily being transmitted through sexual contact, and the majority of cases are occurring among men who have sex with men (MSM). While anyone, regardless of sexual orientation or gender identity, can acquire mpox if they have had prolonged close exposure to someone who has mpox, MSM are disproportionately affected.”

In August, the CDC released data showing that 94% of the cases were among males who reported having had recent male-to-male sexual or close, intimate contact. Overall, as of August, 99% of the individuals infected were male.

Carmen Logie, MSW, PhD, Canada Research Chair in Global Health Equity & Social Justice with Marginalized Populations and a professor at the Factor-Inwentash Faculty of Social Work at the University of Toronto, adds that “The actual transmission is complex. [Experts] prefer the term sexually transmissible instead of sexually transmitted.” Transmissible allows for the understanding that other forms of close contact can also lead to infection. Individuals cannot assume that they are not at risk as long as they have not had sex with an individual infected with mpox. They are at risk if they have had close, intimate skin-to-skin contact of any kind.

Access to Information
The difference between sexually transmitted and sexually transmissible is one example of how important accurate information is in reporting on mpox from trusted entities such as the WHO and CDC, as well as media outlets. However, the dissemination of accurate information does not always happen or does not always happen quickly. This can lead to both misinformation and a lack of information. Such is the case with mpox.

“There has been a lot of misinformation about mpox posted on social media and other channels. Much of the misinformation revolves around how mpox is transmitted,” Davis says. “For example, I’ve seen claims that mpox can be transmitted through riding on the subway or through handshaking, but the risk of becoming infected through these situations is extremely low. There is misinformation that mpox is transmitted easily through the air, which is also false.”

An abundance of misinformation can not only lead to individuals taking unnecessary risks or precautions but also affect an individual’s health anxiety—defined as an irrational worry about a medical condition.

“In terms of health anxiety, people can suffer on a daily basis or only when they are triggered,” explains Ken Goodman, LCSW, board member for the Anxiety and Depression Association of America and creator of The Anxiety Solution Series. “Although anxiety is classified as a mental disorder, it can manifest itself in a physical way. And when a person experiences physical symptoms of anxiety, those symptoms can be misinterpreted as something very serious or fatal.”

In the case of mpox, “there is the possibility of exaggerating the danger, which can result in anxious behaviors like being on guard for sick people, excessive hand washing and sanitizing, and avoidance. All of these behaviors exacerbate anxiety,” Goodman says. He notes that uncertainty is the driver of anxiety, and any vague statements can trigger excessive worry and fear. “In the case of mpox, the statement close, prolonged contact, usually involving skin-to-skin is vague. What does this actually mean?” Goodman adds, “people want truthful information so they can ascertain their level of risk.”

Conversely, a lack of information can lead to individuals taking little to no precautions, which in turn can put them at risk. For example, when mpox first appeared in the United States in the spring of 2022, the media gave it a significant amount of attention. Six months later, the virus is still in the news but less consistently. That can be problematic, as it helps to remove it from individuals’ minds.

“While it’s true mpox cases in the US have continued to decrease, they have not disappeared entirely. If insufficient attention is paid to mpox, individuals may incorrectly assume that there is no longer any risk and reduce their protective behaviors. If that were to happen, we could see an increase in cases in the future,” Davis says.

Stigma
Access to accurate information is not the only obstacle individuals face in learning more about mpox and taking preventative steps. There’s also stigma attached to the outbreak that stems from several different facets of the virus. This stigma is not dissimilar to that attached to COVID-19 over the past three years or to HIV when it first appeared in the United States. Much of it has to do with othering.

“We see with HIV and mpox, these archetypes of the other—the ‘foreign’ other, the ‘immoral’ other, and the ‘visibly sick’ or unwell other,” Logie explains. “‘Foreign’ others have been blamed for epidemics for hundreds and hundreds of years. Fast forward to the ’80s, and the Haitians were blamed for HIV.”

Mpox has two distinct strains, both of which are named after geographic locations in Africa: Central African and West African. According to Forbes, when the mpox outbreak first made the news throughout the world, the media and others focused on the geographic location, so much so that photos of African patients were used in pieces about the spread of the virus. And in fact, in November 2022, the WHO announced that it would be changing the name of monkeypox to mpox in an effort to lessen the racist stigma associated with the name monkeypox. The WHO had previously stated that viruses should not be named after places or animals as it aids in potential discrimination. Both monkeypox and mpox will be used interchangeably for the next year.

The “immoral” other is, in this case, as with HIV, tied to sex. “Anytime an infection is known to be transmitted sexually, it automatically becomes stigmatized,” Davis says. “Many societies seek to control individuals’ sexual behaviors and penalize sexual behaviors that are considered by some to be ‘immoral.’ Understandably, individuals who feel they may be judged for their sexual behaviors are usually hesitant to risk disclosure of their behaviors by accessing prevention or treatment services for infections that are associated with sexual transmission.

“In addition, there remains a significant amount of structural LGBTQ discrimination and health inequality, as well as structural racial discrimination and inequality, which further impedes access to care. Stigmatizing attitudes held by some clinical providers and other individuals, combined with structural inequities in access to vaccines, testing, and treatment services, results in some populations being disproportionately impacted by mpox, in particular Black and Hispanic MSM,” she continues.

Logie adds that “Stigmatizing sex never works. It just stops people from having safer sex or feeling empowered.” It also may contribute to a lack of social support and access to services—something that’s crucial to individuals maintaining their health and wellbeing.

The third type of “other” that often emerges is visibly unwell. This was particularly of note during the initial HIV outbreak and, with mpox, can be related to the rash that develops. Again, stigmatizing individuals for their illnesses and visible signs of illness influences their ability and willingness to seek necessary treatment.

Overcoming the Barriers
To effectively end or severely limit the outbreak, these barriers—lack of access to accurate and the most complete information possible and the stigma surrounding mpox—must be overcome.

The first continues to improve. Messaging around mpox, including about those who are most at risk, is increasingly forthcoming. Logie says that some of the information was slow to come out because experts were, in fact, worried about adding to stigmatization. In Canada—Logie’s home—they consulted with LGBTQ groups to create appropriate and accurate messaging to best reach all communities.

As for the stigma, “One potential way to mitigate the effects of stigma could be to elicit community-developed messaging for mpox, such as through the use of crowdsourcing methods,” Davis says. “This could be one effective technique for creating nonstigmatizing messaging about mpox that is engaging to community members most at-risk and provides them with important information.”

Logie also advises looking to the communities, noting that there is strength and solidarity to be found. “People are relying on their community to bring them food [and help them when they’re sick.] There’s always been an LGBTQ community response. You see that in both HIV and in mpox.”

But to truly work past the stigma at least in terms of those who are most at risk and how sexual contact may be involved in transmission, society needs to become more sex positive. That’s just not the case right now. In fact, Logie says, “there’s no such thing as a sex positive society.”

Social Worker Involvement
That’s where social workers can come in. Social workers need to be sex-positive. They should be talking with their clients about gender and sexual orientation regardless of the social worker’s setting. They don’t need to be at an LGBTQ+-specific organization to have a conversation.

They need to be “comfortable talking about sex. We should already know these things to support our clients. We should always be curious about wanting to know our clients,” Logie says. “Think about what did I learn about sex work? What did I learn about STIs (sexually transmitted infections)? If you learned nothing, it’s up to you. Don’t wait until there’s a pandemic. Learn about it! Learn about sexual orientation and sex work disparities. It’s going to be amplified when there’s the next STI pandemic, or any pandemic.” Davis adds, “I think perhaps the biggest thing social workers can do is to be supportive of their clients, provide them with resources to accurate information about mpox in a nonjudgmental manner, and if possible, help them overcome barriers to accessing prevention and treatment services for mpox. This could include referring them to service providers who are LGBTQ-friendly or even accompanying them to get testing or vaccination if they need additional support.”

To do this well, social workers must understand mpox and the resources available and be able to discern what information is quality and what needs to be tuned out. Nationally, the CDC works to put out accurate and up-to-date information about the outbreak. Davis also recommends The American Sexual Health Association and Building Healthy Online Communities.

Locally, if social workers are not connected to or aware of the resources in their communities for LGBTQ support, health and wellness, and other areas of need, now is the time. As Logie said, don’t wait until the next pandemic. Continual ongoing learning is the only way that social workers can be best prepared to help their clients and communities through the mpox outbreak and whatever comes next.

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.

Reference
1. Mpox: signs and symptoms. Centers for Disease Control and Prevention website. https://www.cdc.gov/poxvirus/monkeypox/symptoms/index.html. Updated December 9, 2022.