History has been marked and transformed by major epidemics and pandemics. This statement might risk sounding trivial if we were to forget that when transformation occurs there is always something that lingers and returns. Looking back on our experience with Aids, we might paraphrase Karl Marx¹1 Karl M. O Dezoito Brumário de Louis Bonaparte. São Paulo: Centauro; 2006., who claimed that facts of great importance in history occur twice, the first time as tragedy, the second as farce. While in the past we experienced the tragedy of the Aids epidemic and the way it led to the stigmatization of certain groups of the population, currently we are facing the emergence of a new health crisis caused by a virus popularly known as monkeypox; although it does not come from monkeys (they are only hosts for the virus).

The question we address in this editorial is: Could we be witnessing in the emergence of monkeypox the return of the pathologization of homosexuality? Afterall, the discourse being employed by institutions, the direction of some research, and the repetition of cliches and stereotypes seem to be reproducing a dispositive which, in the case of Aids, led to the stigmatization of certain groups of people.

It is well known that in the midst of the Aids epidemic of the mid 1980s we witnessed the emergence of the notion of risk groups, the transformation of certain sexual practices into social identities, and the stigmatization of vulnerable groups. The literature at the time showed that the use of the terms “risk groups” and “risky behavior” gave rise to a perception of Aids as a disease that is restricted to certain groups and populations, hampering prevention efforts. The disease was treated as distant and separate for some, as if different social groups are homogenous and do not mix. The epidemiological categories that these “risk groups” are placed in were widely debated and it became clear just how vague and problematic they were as a basis for prevention²2 Schiller NG, Crystal S, Lewellen D. Risky business: the cultural construction of AIDS risk groups. Soc Sci Med. 1994; 38(10):1337-46.^,33 Singer M. AIDS and the health crisis in the U.S. urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994; 39(7):931-48.. The implications of this stigmatizing discourse and these notions and forms of control persisted for decades, exemplified by the discriminatory ban on blood donations from homosexuals and bisexuals, which was only lifted by the Supreme Court in 2020⁴4 Oliveira J. Em decisão histórica, STF derruba restrição de doação de sangue por homossexuais [Internet]. São Paulo: El País; 2020 [citado 22 Ago 2022]. Disponível em: https://brasil.elpais.com/brasil/2020-05-08/em-decisao-historica-stf-derruba-restricao-de-doacao-de-sangue-por-homossexuais.html
https://brasil.elpais.com/brasil/2020-05... . And it now appears that certain aspects of this discourse are rearing their ugly head in the context of the monkeypox outbreak.

The first outbreaks of monkeypox were recorded in the 1970s in central and west Africa⁵5 World Health Organization. Monkeypox [Internet]. Geneva: WHO; 2022 [citado 23 Ago 2022]. Disponível em: https://www.who.int/news-room/questions-and-answers/item/monkeypox
https://www.who.int/news-room/questions-... . Important outbreaks have been detected this year in various countries around the world – according to the World Health Organization’s (WHO) website, cases of the new disease have been recorded in around ninety nations across five continents since 1 January 2022⁶6 Mathieu E, Spooner F, Dattani S, Ritchie H, Roser M. Monkeypox [Internet]. England: Our World in Data; 2022 [citado 22 Ago 2022]. Disponível em: https://ourworldindata.org/monkeypox
https://ourworldindata.org/monkeypox... . In August of this year, Brazil was among the five countries with the highest number of confirmed cases⁷7 Brasil. Ministério da Saúde. Boletim epidemiológico especial Monkeypox [Internet]. Brasília: Ministério da Saúde; 2022 [citado 22 Ago 2022]. Disponível em: https://www.gov.br/saude/pt-br/composicao/svs/resposta-a-emergencias/sala-de-situacao-de-saude/sala-de-situacao-de-monkeypox/publicacoes
https://www.gov.br/saude/pt-br/composica... . According to data from the Ministry of Health’s special bulletin on monkeypox, up to epidemiological week 32, which ended on 13 August 2022, there were 10,195 recorded cases, 3,040 confirmed cases (29.8%), 176 probable cases (1.7%), 3,737 suspected cases (36.7%), and 3,242 ruled out cases (31.8%)⁷7 Brasil. Ministério da Saúde. Boletim epidemiológico especial Monkeypox [Internet]. Brasília: Ministério da Saúde; 2022 [citado 22 Ago 2022]. Disponível em: https://www.gov.br/saude/pt-br/composicao/svs/resposta-a-emergencias/sala-de-situacao-de-saude/sala-de-situacao-de-monkeypox/publicacoes
https://www.gov.br/saude/pt-br/composica... . The average age of people infected with monkeypox among the confirmed and probable cases was 31; 93.2% of those infected were men, 45.9% were white, and 34.1% were black. The sexual orientation of people infected was not informed in more than 60% of the cases. Among the cases where sexual orientation was informed, 22.7% of infected men were homosexual and 2.4% bisexual, while 29.9% of infected women were heterosexual.

Media coverage of the monkeypox outbreak and the approach taken by some public health researchers is all too familiar. The only knowledge we have of monkeypox so far is that the virus spreads via secretions or secretion droplets through sexual or close contact, direct contact with lesions or bodily fluids, or contact with contaminated materials such as sheets and towels⁸8 McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014; 58(2):260-7.. However, the fact that a relatively large percentage of cases so far have been in men who have sex with men (MSM) – an epidemiological category that includes gay and bisexual men and other men who have sex with men⁹9 Patel A, Bilinska J, Tam JCH, Fontoura DS, Mason CY, Daunt A, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022; 378:1-17. – has brought the memories of the Aids epidemic flooding back, alerting us to the possibility of a farcical repetition of history.

In a descriptive study of 197 patients with polymerase chain reaction confirmed monkeypox infection, 196 of the participants identified as MSM⁹9 Patel A, Bilinska J, Tam JCH, Fontoura DS, Mason CY, Daunt A, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022; 378:1-17.. In another study published in the New England Journal of Medicine, 98% of the 528 persons with infection were gay or bisexual men and 41% were living with HIV infection¹⁰10 Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al. Monkeypox virus infection in humans across 16 countries - April-June 2022. N Engl J Med. 2022; 387(8):679-91. doi: https://doi.org/10.1056/NEJMoa2207323.
https://doi.org/10.1056/NEJMoa2207323... . Studies like these make us wonder why research is targeting this group. Based on the overall case numbers so far mentioned above, this segment of the population does not account for the majority of cases yet appears to be the main focus of investigations. In the same vein, in an official statement released recently, the WHO Director General Tedros Adhanom Ghebreyesus suggested that MSM should reduce their number of sexual partners and casual sex⁵5 World Health Organization. Monkeypox [Internet]. Geneva: WHO; 2022 [citado 23 Ago 2022]. Disponível em: https://www.who.int/news-room/questions-and-answers/item/monkeypox
https://www.who.int/news-room/questions-... .

Once again, it is important to question the social implications of two phenomena that are repeating themselves: the identification of outbreaks in a segment of the population that was the first to report the disease to the health system; and the new WHO recommendations, which mix containment with an age-old obsession with homosexuality. In the light of the experiences of health agencies, services and professionals with the Aids epidemic and, more notably, critical studies showing how the epidemic set in motion a cycle of discrimination that has taken decades to break, it is worth reflecting on these blind spots so that we do no repeat past mistakes. It is important this time to design new forms of communication with society that do not reproduce social stigma.

The focus on MSM and the sterile guidance issued so far for preventing monkeypox, which ignores the social and psychic dimensions of the human being, need to be rethought in favor of another approach. For this we need to look back at the history of the Aids epidemic and how public health policies and initiatives, albeit with good intentions, have produced stigmatizing discourses and settings directed at particular population groups¹¹11 Ferreira JP, Miskolci R. “Reservatórios de doenças venéreas”, “HSH/MSM” e “PWA”: continuidades, rupturas e temporalidades na produção de bioidentidades no contexto da epidemia de AIDS. Cienc Saude Colet. 2022; 27(9):3461-74.. And the question we must ask is: Could the actions of the WHO, institutions (which base themselves on epidemiological discourse), and even some health researchers be reproducing the dispositive of Aids? And we also need to ask: What are the impacts of insisting on the logic of the pathologization of non-heterosexual practices?

Néstor Perlongher¹²12 Perlongher N. O que é AIDS? São Paulo: Brasiliense; 1987. points out that the dispositive of Aids perpetuated the persecution and condemnation of non-normative sexual practices (where “normative” is understood to be a synonym for heterosexuality). The positions and policies of health agencies stem indirectly from the dictates of presumed and compulsory heterosexuality as an ostensibly neutral point of observation and analysis of what was going on. The notion of dispositive adopted here is inspired by Michel Foucault and consists of a set of discourses and practices that take the form of knowledge and powers that regulate, control, and produce truths that shape subjectivities and structure social relations¹³13 Foucault M. História da sexualidade I: a vontade de saber. 3a ed. Rio de Janeiro: Graal; 1980..

As Pelúcio and Miskolci¹⁴14 Pelúcio L, Miskolci R. A prevenção do desvio: o dispositivo da AIDS e a repatologização das sexualidades dissidentes. Sex Salud Soc. 2009; 1:125-57. point out, the dispositive of Aids triggered a shift in understanding of homosexuality from the psychiatric perspective – which for more than a century classified homosexuality as a mental disorder – towards one in which homosexuality is conceived as an epidemiological risk factor. At the deadly height of the Aids epidemic, sexual panic over homosexuals swept the country, molding prevention discourses that had stigmatizing and discriminatory consequences (such as the classification of risk groups). And now, after all these years, we are witnessing the return of a specter in the prevention measures recommended by national and international health agencies to address the global health emergency caused by monkeypox.

Veiled as epidemic control sustained by the epidemiological discourse, we are witnessing the return of a collective feeling of horror towards homosexual desire¹⁵15 Hocquenghem G. Le désir homosexuel. Paris: Fayard; 2000.^,1616 Rubin G. Thinking sex: notes for a radical theory of the politics of sexuality. In: Vance CS, editor. Pleasure and danger: exploring female sexuality. Boston: Routledge & Kegan Paul; 1984. p. 143-78. and the tense relationship between medicine and the pathologization of behaviors. A relationship that unfortunately tends to revert back to stigmatizing social categories, circumscribing vulnerable segments of the population while safeguarding an imaginary “normal” majority that is supposedly protected from the disease. Hence, what Perlongher ¹²12 Perlongher N. O que é AIDS? São Paulo: Brasiliense; 1987. called the dispositive of Aids and Pelúcio and Miskolci¹⁴14 Pelúcio L, Miskolci R. A prevenção do desvio: o dispositivo da AIDS e a repatologização das sexualidades dissidentes. Sex Salud Soc. 2009; 1:125-57. refer to as a process that transformed social understanding – where homosexuality is perceived to be an epidemiological threat – can acquire new traits in any given epoch, according to the underlying political and health context. Currently, via the monkeypox outbreak, the prevention discourse is going back to its normative and prudish roots, triggering new panic over sex between men. Health organizations and agencies are once again shying away from their commitment to control the epidemic, focusing not on the threat to global public health but rather the imaginary suppression of the virus by controlling and taming desire between people of the same sex.

The Aids epidemic is not only biological, but also cultural, shaped by discourse¹⁷17 Treichler PA. How to have theory in an epidemic - cultural chronicles of AIDS. 3rd ed. Durham: Duke University Press; 1999.. Hence the war metaphors used by biomedicine to talk about prevention and treatment¹⁸18 Sontag S. Doença como metáfora / AIDS e suas metáforas. São Paulo: Companhia das Letras; 2007. and the common understanding that Aids was a plague, punishment, and damnation, a threat to the established order. These metaphors, embedded in the social construction of Aids, are being brought back to life and redeployed during the public health emergency declared due to the spread of monkeypox. This is partially because it is opportune, given that MSM account for a relatively large share of initial cases. This is not to say however that the public health risk should be intimately linked to this group. After all, it is worth considering that the infection may have been found in this group because it was the first to have access to the diagnosis or report the problem to the authorities or, and even more worrying, it was the group that public health organizations decided to make more visible.

Unfortunately, the situation that played out at the deadly height of the Aids epidemic in the 1980s and 1990s is now threatening to return. As highlighted above, this threat means we need to learn from the lessons of the history of Aids to prevent the resurgence of discourses and practices that pathologize homosexualities. We therefore now turn to the abovementioned discursive fabric to understand its core elements.

These discourses reduce people living with HIV and Aids patients to the disease (“Aids carrier”), virus (“HIV-positive”), or the abject, and the singularities of infected persons are erased in favor of stigmatizing bioidentities¹¹11 Ferreira JP, Miskolci R. “Reservatórios de doenças venéreas”, “HSH/MSM” e “PWA”: continuidades, rupturas e temporalidades na produção de bioidentidades no contexto da epidemia de AIDS. Cienc Saude Colet. 2022; 27(9):3461-74.. Physical violence and discrimination against people living with HIV is by no means rare¹⁹19 Trevisan JS. Devassos no paraíso - a homossexualidade no Brasil da colônia à atualidade. 4a ed. Rio de Janeiro: Objetiva; 2018.. Examples include being thrown out of home, summary dismissal from work, and other forms of violence experienced on a daily basis, commonly referred to as “HIV discrimination”²⁰20 Barbosa Filho EA, Vieira ACS. A expansão da sorofobia no discurso político brasileiro. Argum. 2021; 13(3):134-47. doi: https://doi.org/10.47456/argumentum.v13i3.35656.
https://doi.org/10.47456/argumentum.v13i... .

It is important to stress that we are no longer at the beginning of the Aids crisis, when the etiologic agent of Aids had not been identified and there was no prospect of treatment. Entering the fifth decade of the epidemic, we now have a list of available antiretrovirals that suppress viral replication, enabling infection control; not to mention alternative methods of protection against HIV such as pre- and post-exposure prophylaxis (PrEP and PEP) – a vastly different reality to four decades ago. Thus, today it possible for people living with HIV to have an undetectable viral load and not transmit the virus – enjoying quality of life, especially in the physical health domain²¹21 Santos ECM, França Junior I, Lopes F. Qualidade de vida de pessoas vivendo com HIV/AIDS em São Paulo. Rev Saude Publica. 2007; 41 Supl 2:64-71..

However, we might talk of a new Aids crisis as the alliance between neoliberalism and movements against the advancement of human rights (especially sexual and reproductive rights) threaten the democratic state in Brazil, sabotage the public health system, and seriously weaken the capacity to implement public health policies and actions to tackle the Aids epidemic²²22 Agostini R, Rocha F, Melo E, Maksud I. The Brazilian response to the HIV/AIDS epidemic amidst the crisis. Cienc Saude Colet. 2019; 24(12):4599-604.. People living with HIV remain embedded in a context of stigma and human rights violations which, as we have witnessed in recent years, is only getting worse.

This is confirmed empirically by the recently published “People Living with HIV Stigma Index”, developed by UNAIDS in conjunction with NGOs and universities. The executive summary of the Brazil country report²³23 Unaids. Sumário executivo - Índice de Estigma em relação às pessoas vivendo com HIV/AIDS [Internet]. Brasília: Unaids; 2020 [citado 25 Ago 2022]. Disponível em: https://unaids.org.br/wp-content/uploads/2019/12/2019_12_06_Exec_sum_Stigma_Index-2.pdf
https://unaids.org.br/wp-content/uploads... shows that HIV-related stigma pervades all areas of life. There are reports that stigma may reduce the ability to fall in love, cope with stress, and develop trusting relationships. People who suffer stigma may also deliberately decide to not take part in social gatherings with friends or family and a substantial share opt not to have sex and to socially isolate. The findings also show that people may have feelings of worthlessness, which affects not only the individual but also inhibits relationships and social interaction. The report also shows that people living with HIV constantly face violations of basic human rights, including reproductive rights and the right to medical confidentiality.

Perlongher¹²12 Perlongher N. O que é AIDS? São Paulo: Brasiliense; 1987. ends his book on Aids by calling attention to the problem of conservatism, especially in religious organizations and rightwing groups, which has helped turn the epidemic into a new dispositive for social control of sexuality and desire. On the one hand we have a disease/syndrome with an infectious agent, signs, symptoms, treatments, and lines of care; on the other, an epidemic forged by society using moral agendas that interplay with and accentuate the violence and suffering experienced by the population directly affected by the disease. Beyond Aids, the recent experience of the Covid-19 pandemic has proven that we are living the epidemiological impacts in a historical context that is similarly prone to polarizations and political conflicts. Today, the field of public health finds itself in dark times, balancing between moral agendas that once again are turning vulnerable and stigmatized segments of the population into scape goats and pressure to align with normative identities, which, with apparently meritorious aims, tends to help transform practices into identities, categories, and other definitions that are “normalizable” and controllable.

Against this dark backdrop, the field of health – in particular biomedicine – faces the challenge of tackling disease, especially health emergencies like Covid-19 and monkeypox, without bringing back to life old ghosts that only serve to contribute to the spread of fresh sexual panic. Drawing on studies and experiences of the Aids epidemic, it is therefore crucial to call into question the focus on MSM and the WHO recommendation to reduce their number of sexual partners and casual sex, taking into consideration different social, political, and economic contexts. We urgently need to question what underlies this approach, which once again targets MSM, and, learning from the lessons of history, draw attention to its potential impacts.

Although possibly justified by the data, the discourse initially employed by the WHO has moral undertones and implications, reproducing the logic of regulation and normalization of “deviant” sexualities, who are the first and most affected by both diseases. The parallels with the Aids epidemic are striking. The WHO recommendation is potentially stigmatizing and can increase vulnerability. The underlying discourse can have negative impacts on health and human rights, especially sexual and reproductive rights, which are currently under attack from the extreme right.

Public policies need to be evidence-based and focus on health education and actively involving people in their own care. Panic, shame, guilt, war metaphors, and other types of moral rhetoric have already proved to be harmful, negatively affecting prevention efforts²⁴24 Kerr L, Kendall C, Guimarães MDC, Mota RS, Veras MA, Dourado I, et al. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine (Baltimore). 2018; 97 Suppl 1:9-15. doi: https://doi.org/10.1097/MD.0000000000010573.
https://doi.org/10.1097/MD.0000000000010... and adherence to treatment and inflicting mental harm and suffering²³23 Unaids. Sumário executivo - Índice de Estigma em relação às pessoas vivendo com HIV/AIDS [Internet]. Brasília: Unaids; 2020 [citado 25 Ago 2022]. Disponível em: https://unaids.org.br/wp-content/uploads/2019/12/2019_12_06_Exec_sum_Stigma_Index-2.pdf
https://unaids.org.br/wp-content/uploads... . As mentioned above, the idea that only “others” get infected, as during the Aids epidemic, helps drive the spread of disease (as shown by the rise in incidence in supposedly “non-risk groups”, such as heterosexual women or people living in rural areas). There is absolutely no justification for reintroducing ineffective prevention measures. These measures only serve to create a division between “us” and “them”. The identification of risk groups creates a false sense of security among the rest of the population, who, safeguarded by health agency guidance, consider themselves immune to infection.

It is important to stress that monkeypox is not a sexually transmitted infection (STI) and we already know how it spreads. Although monkeypox DNA has been detected in semen, there is not enough evidence to confirm that infection can spread through semen, vaginal fluids, amniotic fluids, breastmilk or blood⁵5 World Health Organization. Monkeypox [Internet]. Geneva: WHO; 2022 [citado 23 Ago 2022]. Disponível em: https://www.who.int/news-room/questions-and-answers/item/monkeypox
https://www.who.int/news-room/questions-... . Labeling monkeypox as a STI at this point could give people who are not having sexual relations the misleading idea that they are immune to the disease. That constitutes misinformation²⁵25 Howard J. Por que chamar a varíola dos macacos de IST é mais do que apenas um rótulo [Internet]. São Paulo: CNN Brasil; 2022 [citado 23 Ago 2022]. Disponível em: https://www.cnnbrasil.com.br/saude/por-que-chamar-a-variola-dos-macacos-de-ist-e-mais-do-que-apenas-um-rotulo/
https://www.cnnbrasil.com.br/saude/por-q... .

At the height of the (homo)sexual panic over Aids, the medical historian Sander L. Gilman²⁶26 Gilman SL. Disease and representation: images of illness from madness to AIDS. Ithaca: Cornell University Press; 1988. Seeing the AIDS Patient; p. 245-72. analyzed the fatal choice made by public health agencies at the time. This analysis serves as a warning so that the same movement does not repeat itself with monkeypox. The author said the following about Aids:

It could be said therefore that linking this public health threat to the sphere of venereal diseases of old is one of the vehicles of a moral crusade against non-normative sexualities.

This editorial sought to show that statements linking the spread of monkeypox to non-normative sexual practices and/or identities should be questioned. It is important not to make the same old mistakes and be aware of the dark times we are living in to make sure that this new health emergency does not bring old ghosts to life, fueling prejudice and permitting new forms of discrimination. Those working in the field of public health have the accumulated knowledge and experience necessary to act responsibly and show justice and respect to MSM and other non-normative groups who have historically faced stigma and discrimination and, more recently, witnessed renewed attempts to pathologize sexuality and gender.

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