The spread of monkeypox has ignited a debate within the New York City Health Department over whether the agency should encourage gay men to reduce their number of sexual partners during this summer’s outbreak.
Inside the department, officials are battling over public messaging as the number of monkeypox cases has nearly tripled in the last week, almost all of them among men who have sex with men. A few epidemiologists say the city should be encouraging gay men to temporarily change their sexual behavior while the disease spreads, while other officials argue that approach would stigmatize gay men and would backfire.
The internal divisions peaked when the health department issued an advisory last week suggesting that having sex while infected with monkeypox could be made safer if people avoided kissing and covered their sores. Several officials at the agency were outraged, saying the agency was giving misleading and even dangerous health advice, according to several epidemiologists within the department and a review of internal emails.
The advice on safer sex was not medically sound, said Dr. Don Weiss, the director of surveillance for the department’s Bureau of Communicable Disease, in an interview. He believes the department should advise those at risk of monkeypox to temporarily reduce their number of partners, saying, “We’re not telling people what they have to do to be safe.”
His concerns are shared by some of his colleagues, emails and interviews show, indicating growing frustration and pessimism within the ranks of the health department as the window for controlling New York City’s monkeypox epidemic — the largest such outbreak in the United States — quickly closes.
Monkeypox has been spreading globally since early May. In New York City, where nearly all monkeypox patients are gay or bisexual men, there were 618 documented cases of monkeypox in the city as of Monday, although Dr. Weiss said that the true number of infections was far higher, because testing has been limited.
The strategy favored by Dr. Weiss, who has long played a frontline role in the department’s response to disease outbreaks, has received little traction within the department.
In fact, the agency in a statement Monday argued against such an approach. “For decades, the LGBTQ+ community has had their sex lives dissected, prescribed, and proscribed in myriad ways, mostly by heterosexual and cis people,” the statement said.
The city’s response to monkeypox is grounded in the science and history of “how poorly abstinence-only guidance has historically performed,” the statement said, “with this disgraceful legacy in mind.”
The field of public health has long struggled with how best and even to what degree public health officials should tell people to change their sexual behavior in times of outbreak.
The debate is influenced by the early years of HIV/AIDS, when terror and stigma ran high. The stakes are far lower with monkeypox, given that no one in the United States has yet died from the disease, treatments and vaccines exist, and for many the illness appears to pass relatively quickly.
Still, some epidemiologists say an aggressive response now — while transmission is predominantly limited to gay and bisexual men — could prevent the virus from becoming endemic in New York or reaching a broader swath of the population.
Some public health experts say that many gay men are likely to reject advice that could be seen as discouraging or stigmatizing gay sex. These experts say that such advice shifts the blame onto gay men for the outbreak and could lead them to view public health authorities with distrust.
What to Know About the Monkeypox Virus
What is monkeypox? Monkeypox is a virus endemic in parts of Central and West Africa. It is similar to smallpox, but less severe. It was discovered in 1958, after outbreaks occurred in monkeys kept for research, according to the Centers for Disease Control and Prevention.
“Telling people not to have sex or not to have multiple sex partners or not to have anonymous sex is just a no-go, and it’s not going to work,” said a longtime AIDS activist, Charles King, who is chief executive of Housing Works, which provides housing and social services to the homeless and those affected by HIV
“People are still going to have sex, and they’re going to have it even if it comes with great risk,” he said.
But there may be a middle ground, some experts said, noting that urging people to temporarily reduce their number of sexual partners or avoid sex parties where they might have multiple partners is not the same as a message of abstinence or monogamy.
“Name the risk factors and behaviors and give people options,” said Dr. Dustin Duncan, an epidemiologist of infectious diseases among sexual and gender minority groups at Columbia University.
He offered an example: telling people they could reduce their risk of getting monkeypox by “having one consistent casual partner as opposed to multiple people” seemed a reasonable message at the moment, he said.
Dr. Weiss said that asking people to change their sexual behavior — even if just for a month or so — was the most potent weapon available right now for reducing monkeypox transmission. Vaccine supply is limited and had been initially doled out via hard-to-get appointments during daytime hours at a few clinics, although mass vaccination sites have opened in recent days.
He has at times suggested that the Department should promote short-term abstinence, a relatively fringe position. At other times he has suggested that the department should warn gay men to refrain from anonymous sex.
Dr. Weiss said his recommendations have been largely ignored by the department’s senior leadership, who seem “paralyzed by fear of stigmatizing this disease,” he wrote in an email to colleagues this June.
“If we had an outbreak associated with bowling, would we not warn people to stop bowling?” he wrote.
So far, the health department’s reluctance to publicly encourage people to change their sexual behavior, unless they are actively infected with monkeypox, mirrors the broader messaging about the outbreak by the federal government.
The department’s advice, posted on its website, notes that “Having sex or other intimate contact with multiple or anonymous people (such as those met through social media, dating apps, or at parties) can increase your risk of exposure.”
At an online “town hall” event last week about monkeypox, the city’s health commissioner, Dr. Ashwin Vasan, said the department’s goal is to be “sex positive.”
“We want to in no way stigmatize sex at all,” Dr. Vasan said. “We want to be very clear there are certain activities and one of them is intimate sexual contact that places you at higher risk in certain settings.”
Other health experts, have, like Dr. Weiss, publicly called for a temporary change in sexual behavior. At an online briefing last week by the Infectious Diseases Society of America, Dr. Lilian Abbo, associate chief medical officer for infectious diseases at Jackson Health System in Miami, urged people to use condoms and said that having unprotected sex with multiple partners is “actually exponentially increasing the spread.”
“We all can take part in preventing the continued spread, and that’s important that everyone takes a bit of ownership and understands that you can put others at risk,” she said.
Dr. Weiss, who has held the same job for 22 years, investigating and responding to new outbreaks for the Bureau of Communicable Disease, said he felt obliged to speak out publicly because he felt the department’s public statements were at times irresponsible. He pointed to the news release issued on Friday containing several prevention tips for “those who choose to have sex while sick.”
It stated that covering up monkeypox sores with clothes or bandages while having sex “may help reduce — but not eliminate” the risk of transmission. The release also said “for those who choose to have sex while sick, it is best to avoid kissing and other face-to-face contact.”
Dr. Weiss said it was “ludicrous” to suggest these steps would meaningfully reduce the risk.
The Health Department’s guidance to the public has often highlighted nonsexual routes of potential transmission, such as hugging or contact with bedding. While those are certainly possible routes of transmission, the result — Dr. Weiss said — was to make people overly concerned about casual physical contact and not sufficiently aware that most monkeypox infections in New York appeared to be transmitted through sex.
Dr. Weiss said he has supervised a team of epidemiologists who reviewed many of the city’s monkeypox cases. In most, patients have had lesions on the penis, anus or in the rectum, suggesting, he said, that the disease is spreading mainly through sexual contact.
He also said that reports of asymptomatic spread and the presence of the virus DNA in semen should have resulted in the department’s recasting their public advice.
“I know I sound like a Bible-thumping preacher,” Dr. Weiss wrote recently to a group of epidemiologists in a Department of Health email chain.
But, he has argued, “If we don’t act soon, it may be the point of no return.”
Sharon Otterman contributed reporting.