Help Dr. Liz share Great Sex with the world. Get insider perks. All in one place.
give now (opens in new tab)

How do you continue to practice safe sex now that monkeypox is on the rise again?

Sep 16, 2022

How do you continue to practice safe sex now that monkeypox is on the rise again? 

So, one of the best frameworks that I have ever encountered that I really love is moving away from this idea of safe sex, which was very much founded in the ‘80s during the AIDS crisis and was looking at this kind of like very moralistic, almost binaristic thinking about sexuality, what is safe, what is unsafe, right?

If you consider the context where there was this disease on the rise, the government was literally doing nothing about it, it was killing tons of people specifically mostly affecting queer communities.

Does that sound familiar? 

The ways in which people might be educating on kind of like a public level about this is like keep yourself away from that dangerous gay disease.

And if you are someone who is around my age who was getting sex ed in the like early ‘90s, it was very much a how to not get AIDS or get pregnant class.

And very much in this like binary of always use condoms every time, that’s the only way to have safe sex. 

And while it is true that using barrier methods is very helpful, the way that I prefer to think about sexual safety practices is from a risk awareness model, which is rooted more in ideas related to things like harm reduction that came initially out of addiction specialties.

Harm reduction basically looks at how instead of telling people what is right or wrong, creating this moral framework that then builds shame that can actually then encourage less helpful behaviors rather than more helpful ones.

That can discourage the provision of resources in reducing harm instead of increasing resources to reduce harm. 

Can we move to a framework instead of acknowledges that people are going to make choices that are risky and help them acknowledge what risks they are taking and make choices about how to address those risks, make them less harmful if possible, and give them better resources in making those risk-based decisions. 

So, risk-aware sex is a model – oh, I used to know the name of the person who came up with it.

I will find that name and make sure my assistant puts it in the notes.

But risk-aware sex looks instead at how do you understand what the risks are and the decisions you make about sex, how do we move away from moralizing judgments about what kind of decisions about sexual risks are like good or bad, and instead empower people to make decisions that are in alignment with the amount and kinds of risks they feel good taking and that give them tools to help mitigate risk wherever possible. 

So with monkeypox, monkeypox from a public perspective, until the current outbreak started, on the CDC’s website, it stated explicitly that the primary transmission of monkeypox is respiratory.

That it can be – it is also spread through close contact, particularly like contact with affected areas that have source on them.

But primarily, respiratory transmission is how it is spread. 

As soon as monkeypox cases started happening in the United States, magically CDC’s website changed and no longer says that respiratory infection is the primary means of transmission for monkeypox.

Is it a coincidence that it is primarily being found in queer populations particularly men who have sex with men populations which can also include some trans folks, some sex work population. 

The reality right now is that in a lot of places, you cannot even get tested for monkeypox unless you are a man who has sex with men.

So, there are people who are not men who have sex with men who have monkeypox, who have been unable to get tested even with active source, even with an infection that looks like textbook monkeypox because they are not men who have sex with men and therefore, according to the CDC, they are not in the at-risk group and it can’t be monkeypox. 

So the reason that the vast majority of cases of monkeypox that we are seeing right now are in men who have sex with men communities.

It’s because that’s who we are testing. 

There is also a theory that the reason it was first caught by medical professionals who work with these communities like that it was first noticed by them is because queers went through AIDS.

And so when weird shit starts happening to our body, we go to the doctor right quick about it because we know that shit can get real bad real fast that the medical establishment is not on our side and so we better start getting a hold of it really, really quick otherwise it is going to get out of hand. 

People in queer communities are more attuned to these kinds of changes in their bodies and more likely to go talk to a doctor about it.

People – my parents are from the middle of the United States.

My dad grew up in Kansas. My mom was from Wyoming, lived a little bit in like Texas and some other places but primarily Wyoming.

They don’t go to the doctor unless it is an emergency.

My dad was recently hospitalized for several days.

He had a fever of 104, 105 and didn’t want my mom to call an ambulance because it would cost money even though my parents have money and like the doctors kind of wanted to send him home initially because as soon as the doctor came in, he perked up to put on as good a face as possible because that’s what you do when you are from the middle of the country. 

Queers don’t do that in the same way.

We tend to be much more assertive in terms of getting our healthcare needs met because we expect discrimination, we expect to be turned away, so there is more of an effort to make sure that we are heard, that we are seen, that we are tested for things. 

In addition, the community of like men who have sex with men is relatively small.

It’s a small percentage of the population.

And during the summer months, they gathered a lot of hot spots for getting together, having fun, being in community, having sex, totally OK to have a lot of sex especially casual sex, totally cool.

And that’s really a space where it’s easy for it to spread. 

In a hot nightclub where everybody is shirtless and wearing very little clothing, very easy for monkeypox to spread.

In a hot area where it’s very humid outside, it’s much easier for monkeypox to stay alive for longer on surfaces and lead to fomite transmission. 

So when we are thinking about risk-aware sex during monkeypox, the reality is right now, there is a huge monkeypox outbreak starting in the United States.

It is rapidly growing and rapidly spreading and it is being undertreated, underfunded, underresearched, undercovered in the news media.

If you are someone who is either a trans person, a man who has sex with men, or there were a couple of other affected groups, there is a national program now where you can start trying to get your vaccination for monkeypox.

The vaccine for monkeypox is the same vaccine that they use for smallpox because they are related viruses. 

So if you’ve had a smallpox vaccine in the last 5 years, you are most likely covered for monkeypox.

After 5 years, it is unclear how much immunity remains because we don’t have good data on it.

The majority of people who got vaccinated for smallpox got vaccinated and then smallpox was eradicated and we stopped following them to see if anything else happened.

So when this has started, we don’t have good data on how long immunity actually lasts because nobody has had to really test it in the last couple of decades. 

I got vaccinated for smallpox in 2013 right before I deployed to Afghanistan and so I am banking on the facts that I have at least some immunity likely remaining and therefore, I’m not seeking to get in line for monkeypox vaccines. 

The other issues that right now monkeypox vaccines are not particularly available.

We have far less doses than we need to cover even just men who have sex with men populations.

Everybody needs two doses in order to be covered, that you have – and you have to get them a certain amount of time apart.

It takes I think 4 weeks in total for people to be fully immune.

So it is a slow process to get people vaccinated for this.

And there is very low supply.

A lot of places that have had the vaccine have had hundreds if not thousands more people applying for the vaccine than they had vaccines available. 

So if you want to practice risk-aware sex while monkeypox is a thing, it behooves you to talk to folks about what kinds of risky behaviors they are engaging in before you engage in risky behaviors with them.

So risky behaviors for monkeypox obviously would include sexual contact, cuddling, kissing, anything like that. 

In addition, because it is transmitted through respiratory transmission vectors, people who aren’t wearing masks indoors with other people especially in crowded spaces or people who are going to places that have a lot of shared surfaces that are not routinely disinfected.

So like for instance, a lot of kink spaces, they have wipes there for people to wipe down their stations.

Are those wipes actually rated for something like monkeypox?

Are they actually wiping them down?

If it’s a bed with sheets on it, is there something underneath that sheet you also need to wipe down?

So like asking people about what kinds of behaviors they’ve been engaging in that might be risky for monkeypox. 

If you are someone who absolutely cannot risk getting monkeypox, this may not be a good time to engage in sexual behavior with new partners who can’t – if you don’t feel like you can very, very certainly trust their report to you of the risks that they are taking and what that may mean in terms of monkeypox risk. 

If you are OK taking some risks, the things that I would consider are like how many people are you engaging with because each time you engage with new folks or you engage with folks you are engaged with again, you increase your risk. 

What precautions are you taking?

Are you masking indoors?

Are you masking with other people? 

If you are going to a kink club, are you wearing a mask there?

If you are going to a sex party, are you masking there? 

How much skin do you have exposed?

How many people are you touching? 

Just being aware of like what risky behaviors you are engaging in.

Because it is skin to skin transmission, using barriers may or may not help very much in terms of transmission, so things like condoms may not help a ton.

If you’re say in clothed and wearing gloves, that can help especially if you are also wearing a mask and/or goggles.

Those can help a lot. 

But just thinking about this, a lot of this is very similar to the same like ways that you can calculate and think about risk related to things like COVID because again, primary transmission of monkeypox is respiratory so things like masking, wearing gloves, the stuff that we did early in COVID before we knew it was almost entirely respiratory, things like washing your hands, wiping down surfaces before you touch them, wiping down things you come in contact with or bring in to your house, those are really helpful for monkeypox. 

If you want to have sex with new people, again, ask them a lot of questions about what they’ve been doing.

Ask them about like what their exposure risks might be.

Ask them if they have sought vaccine or if they’ve started that or if they’ve finished it.

Ask them if they know anybody who has had monkeypox because the other thing is the dormancy windows or how long it takes before – from the time that you catch monkeypox to the time you start showing any lesions is anywhere between like 3 days and 3 weeks.

So there is a fairly variable latency period where people are potentially contagious but not yet showing any lesions. 

If you – if the person has any like strange bumps that they don’t know what they are, could be mosquito bites, could be monkeypox especially if they have a bunch of bites that came up at the same time, it is highly possible that that is monkeypox. 

So like looking at people’s bodies, just checking them visually to see like are there any lesions here or are there any things that look kind of like pimples.

It’s a hard-raised bump.

If you look online, there are great sources for monkeypox lesions in a variety of stages so you can see what they look like over time. 

Once someone has developed any lesions, they are considered contagious until the last of their scabs has fallen off.

So that can be a period of 3 to 6 weeks sometimes so it can also be a very long contagious period if you do catch it. 

Keep in mind, monkeypox is remarkably painful.

There are multiple people who have been admitted to the hospital not because their life was being threatened by the monkeypox directly but because the pain was so severe, they couldn’t sleep, they couldn’t use the bathroom.

They needed very significant intervention in terms of pain control in order to be able to function at all.

They can be disfiguring.

You can get lesions anywhere so you could get lesions on your face.

So just be aware.


This is a time where if you want to take risks, I think be aware of the risk you are taking and like understand for yourself what that risk means if it goes wrong.

Part of risk awareness is not assuming that everything goes right.

It’s not assuming that as long as you do A, B, C, you’re going to be just fine and everything is going to be great.

It is figuring out like how likely is it that this unwanted outcome will happen?

How will I feel if that unwanted outcome happens and then what can I do to mitigate the risk to a point where it feels like a reasonable risk-benefit equation? 

So just be cautious, right?

Be cautious.

Ask people that you are going to engage with a lot of questions.

If you are wanting to go to like a kink party or a crowded indoor club or something like that, just think about like what risks you’re entailing, what other ways that you can decrease your own personal risk of transmission, and just be aware. 

The reality is, a lot of folks who take no precautions will never get monkeypox and a lot of folks who take a ton of precautions will get it.

So it’s not like getting monkeypox is not a judgment that you necessarily did the right or wrong decisions.

There aren’t necessarily right or wrong decisions.

And be aware of your own risk tolerance here.

How much risk are you willing to take of catching monkeypox and are the choices that you are making worth enough to you to incur the risk that they would create? 

So think about it from that risk-aware perspective.

If I am incurring risk, are there things that I can do to make it less risky?

So like if I’m wanting to go to a nightclub, maybe I wear my P100 Elastomeric Mask so that I make sure I’m not getting any respiratory exposure.

Maybe I wear like slightly more covering clothing even though it might be hotter.

It will make sure that I’m having less skin exposure.

If I’m going to be hooking up with people, maybe I ask a ton more questions first about like have they been going to these different things that are high risk lately.

Maybe I hook up with fewer people than I might otherwise do. 

So just figuring out what you can do to manage your risk.

Remembering that like sometimes shit happens and you catch a virus.

It doesn’t mean you are a bad person. But being mindful like what the risks are. 

And I think again, one of the big misconceptions that has been promoted a lot is that somehow this is a sexually-transmitted infection.

Monkeypox is a sexually-transmitted infection the same way that the flu is a sexually-transmitted infection in that you can transmit it while having sex.

But the act of sex has literally nothing to do with the transmission.

The only association that it has at this point for monkeypox is that some people’s outbreaks are happening in genital regions or anal regions.

But like that doesn’t mean that it was a sexually-transmitted infection the way that we think about something like gonorrhoea or Chlamydia.

It is not the sex that gives you monkeypox.

It’s the touching and the breathing close to each other and the kissing.

It’s the sharing space, the close contact, the fomites, the respiratory exhalation like that’s what gives you monkeypox. 

So, you’re not a terrible, awful, dirty, slut person if you happen to catch it.

You are not like a pure angelic person if you didn’t.

Just make decisions like understand what your risk is, be honest with yourself about whether you are OK with that risk and then make choices that feel like they are in alignment with what risk you feel OK taking. 

Sign up now for special content and exciting news delivered to your inbox.



Help Dr. Liz share Great Sex with the world. Get insider perks. All in one place.
big thanks to my sponsors!

Get the Book

Your practical, no BS guide to non-monogamy.
Buy it now
linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram