Monkeypox, Sexual Health, and the Limits of Medical Technology

 “Even if we found a silver bullet for AIDS tomorrow, something else would come along.” I wrote quickly to get distinguished psychiatrist Richard Pillard’s exact words down as he spoke at Columbia University’s HIV Center in the early 2000s. He ruefully admitted that the human immune system simply wasn’t designed to handle the frequent introduction of bodily fluids from multiple sexual partners. Our research, therefore, was the “hope for the future” that would free people to engage in the range of behaviors they desired without the consequences. The body may have limits, but sexual behaviors shouldn’t. Enter medical technology.

Fast forward two decades. Monkeypox has now emerged almost exclusively among men who have sex with men (MSM)—according to the largest global data releases to date, 97 percent of cases affect MSM. Wider transmission has occurred in settings where multiple-partner sex takes place, often among strangers, such as sex-themed festivals for gay-identified men. In an effort to avoid stigmatizing the population being affected, early reports on the outbreaks emphasized that monkeypox can be spread by skin-to-skin contact and sought to downplay the sexual-activity aspect of transmission. However, the emerging data are so overwhelmingly consistent that public health advice is now being revised. Less than 1 percent of global cases have occurred through skin-to-skin contact; rather, research indicates that “sex between men is fueling monkeypox.”

In addition to containment and treatment, much of the public health discussion has centered around parallels between the HIV/AIDS epidemic, the troubled history of its handling, and its effect on the gay male population. I am reminded both of the AIDS crisis and the prediction that “something else will come along.” But today, we’ve forgotten the harsh lessons about our bodily limits that HIV/AIDS taught us, and instead we embrace a sexual ethic of non-judgmentalism and autonomy. Monkeypox reminds us of our natural limits—and the consequences of ignoring them.

AIDS Crisis Parallels

“What ever happened to the queens’ house downtown?” asked the man seated next to me. “Oh honey, they’re all dead,” his friend responded. I winced as I overheard their conversation. Fresh out of college in the early 1990s, part of my first professional job involved taking patients to their monthly “clinic day” appointments for HIV/AIDS treatment at the public hospital. All of them were young—in their twenties or thirties; none had reached forty. When I did Rob’s intake, we realized we had gone to the same high school—he was a senior when I was a freshman. Now Rob, and so many others, were dying. We would sit for hours: blood draws, lab results, T-cell counts, prescriptions issued, and finally the long wait at the pharmacy for AZT and other drugs. Names were called and the white paper bags, bulging with meds and wrapped with instruction papers and rubber bands, were collected. Then, we’d head back to the long-term care facility where I worked, where they now resided, and where they would pass away. One day after arriving home, I sat sobbing in my driveway, overwhelmed by so much death. Like these men, I experienced same-sex attraction and had had same-sex relationships. The moral status of our actions, in terms of homosexual behaviors, was the same. But I was keenly aware that, as a woman, I knew nothing of health risks like theirs.

For several years, then Surgeon General C. Everett Koop had been saying that anal sex was simply too dangerous to engage in. Though it made him uncomfortable to discuss, he said he had to be explicit because the “alternative is almost-certain death.” During that era, I met an atheist who had decided to be celibate. I was surprised, since there were no religious convictions holding him back. “Why?” I asked. He was blunt: “Because it’s too damn dangerous.” His partner had become HIV-positive within months of their breakup.

So how did we go from a surgeon general warning in 1987 that anal sex should not be practiced to a 2019 issue of Teen Vogue running articles promoting it under the guise of sex education? Monkeypox, thank God, is not a death sentence like HIV was back in the day. But even so, public health officials have been reticent to even suggest limiting the number of sexual partners for health reasons, morality aside. How did we get here?

Technological Triumphs

In his highly acclaimed book, The Rise and Triumph of the Modern Self, Carl Trueman writes:

First, there was the promiscuous behavior; then, there was the technology to facilitate it, in the form of contraception and antibiotics; and, as technology enabled the sexually promiscuous to avoid the natural consequences of their actions (unwanted pregnancies, disease), so those rationales that justified the behavior became more plausible (and arguments against it became less so), and therefore the behavior itself became more acceptable.

While the connection between contraception and the sexual revolution is evident to most of us, perhaps we have forgotten that penicillin and other effective treatments for venereal diseases helped enable the sexual revolution long before the advent of the pill.

The evolution of attitudes toward HIV gives us a more recent example of how technology affects sexual behavior. Medical advances in preventing and treating HIV have “created a new context in which sexual minority men are no longer subject to a greatly reduced life span.” Now men who have sex with men (MSM) can avoid becoming HIV positive, and premature death from AIDS is no longer inevitable. As technology blocked these negative consequences, the reasoning against male homosexual behavior became less obvious, and thus it became more socially acceptable. C. Everett Koop’s warning now seems irrelevant.

The Return of Risky Sex

Recent research also provides strong evidence that advances in medicine have led to increasingly risky sexual behavior. The gay male community, for example, engages in group sex with much less caution thanks to medical breakthroughs. As discussed in a recent study, a reduced threat of HIV led “people engaging in group sex activities” to become “less guarded about their sexual practices.” One participant discussed his surprise that some HIV-negative group sex participants aren’t even on the available pre-exposure prophylaxis meds (PrEP). Another commented on the condomless sex that takes place because of these medications. One participant summed up the situation: “With the development of drugs and so forth, HIV is no longer a death sentence so people don’t care, they truly don’t care.”

Thus, when monkeypox emerged, the answer was not to refrain from group sex parties, but to get vaccinated as quickly as possible. Abstaining from behaviors that are demanded as birthrights is out of the question; health must be preserved another way.

Blaming the Body, Not Behavior

Our culture forgets that technology has provided a man-made shield against the natural consequences of unhealthy behaviors. Our collective vision is blurred, largely because there has been a purposeful decoupling of negative health outcomes from sexual behaviors in order to avoid stigmatizing the people engaging in them. Yet it can become a difficult dance when trying to state the facts while also trying to obscure them. HIV/AIDS has a vastly disproportionate impact on MSM/gay-identified men that has nothing to do with either innate susceptibility or unjust stigma; rather, it has everything to do with “two behavioral risk factors: receptive anal sex and promiscuity.”

However, from the number of partners to the type of sex, our cultural orthodoxy insists that the body and not the behavior is to blame. For instance, a 2019 article explained in detail that 80-90 percent of HIV infections would disappear in gay men if the transmission rate during anal intercourse were equal to that of vaginal intercourse. Because the risk in anal sex is eighteen times higher than vaginal, the author stated, “it’s not primarily behavior that puts gay men at such a high risk of HIV. It’s biology.” The fact is that the vagina, fit for sexual purpose, has rich protective layers of epithelial cells that “provide both structural and immunological defense mechanisms against STI pathogens.” Yet the HIV-risk article (since updated) reads as if such differences are mere happenstance. But such reasoning is to demand life in a world different from the one we inhabit—that male-to-male behavior be equally healthy and compatible with human biology as male-to-female.

Consequences of this type of sex are not limited to HIV. The risk for anal cancer is twenty times higher for men who have sex with men who are HIV-negative and up to forty times higher for MSM who are HIV-positive. And going against the design of the body can lead to more than just disease, such as diminution or destruction of function. Male or female, gay or straight-identified, there is a heightened risk of fecal incontinence from engaging in this behavior. Of course these risks failed to make the pages of Teen Vogue, which advised the young that “anal sex can be perfectly safe if you take the correct precautions.” Less dangerous? Perhaps. “Perfectly safe?” Dangerous deception.

To say that such risks are biological rather than behavioral is a reckless lie. Sexually transmitted diseases (STDs) are at epidemic levels, and men who have sex with men have the highest case numbers of all. The CDC reported 2019 as the sixth year in a row for all-time high STD rates, and in 2020 they continued to rise. Men using pre-exposure prophylaxis for HIV have exhibited higher rates of other STDs; PrEP guards against one type of infection, but not others—the unhealthy behaviors continue as do the consequences.

Recent data show that 17 to 32 percent of men diagnosed with monkeypox are diagnosed with another STD at the same time; 41 percent are already living with HIV. And now antibiotic resistant STDs are emerging—once again, “something else” is coming along. Socially, would we change our behaviors if gonorrhea, chlamydia, or syphilis become untreatable again? Would anything make our culture advocate restraint? The cheap sex market’s demand for silver bullets is already exceeding supply.

Love Sets Limits

True love sets limits for our protection and our highest good. Human flourishing involves physical health. In most other matters involving bodily health, from diet to physical activity level, we are encouraged to take measures to ensure and protect our health. But not in the sexual realm. Our culture refuses to accept limitations on sexual freedom. Thus, more and more demands must be made from our medico-technology. For instance, at the conference mentioned earlier, there were presentations on experimenting to create rectal spermicides because so many men still refused to wear condoms—the dent in pleasure wasn’t worth the protection.

Rabbi Levi Yitzhak tells a story in which two drunken friends are together in a tavern, espousing their affection and love for one another. One friend turns and says, “Tell me what hurts me.” Startled, his friend replies, “How do I know what hurts you?” The punch line is: “If you don’t know what hurts me, how can you say you love me?” Recently, a deacon in my friend’s church gave a homily on loving the gay community, yet when she spoke with him afterwards, he apparently knew nothing of the sexual health risks gay-identified and MSM face. I’m continually surprised by those who espouse love for the gay community, yet do not seem to know or even acknowledge what hurts its members. Condoning harmful sexual behavior isn’t a form of love. Rather, the loving response is to discourage behaviors that lead to damage, illness, and even death. Monkeypox is just the latest reminder of our bodies’ inherent limits and the suffering that ensues when we ignore them. There will certainly be others in the future.

Yet our culture seems to think that almost no behavior is off limits, no matter how dangerous or even deadly, if engaged in for erotic reasons. Men’s Health magazine runs mainstream articles on “choking” and “breath play,” advising how to asphyxiate yourself or your partner without causing serious injury or death. When a teen died engaging in autoerotic asphyxiation, some lamented the lack of “sex education” to teach young people about risky sex acts and how to engage in them safely. But parents who tragically lost their kids to a dangerous Tik Tok “black out” challenge aren’t speaking out about teaching kids how to do it safely.

I am beginning to wonder if our culture will ever pause before glibly explaining how to make inherently damaging and dangerous sexual practices “safer.” Will we ever reply again with the wisdom of a surgeon general and the frankness of an atheist? Some behaviors are just “too damn dangerous.”