Aspects of monkeypox stigma among men who have sex with men in the Netherlands: exploring perceived severity, perceived responsibility, and norm violation

The monkeypox (MPX) virus is not a novel occurrence, but cases were only reported a few times a year until May 2022 when transmission of MPX spread globally and was declared a global public health emergency by the WHO shortly after [1,2]. In the WHO European Region, the outbreak of MPX cases is largely targeted towards men among whom men who have sex with men (MSM) who represent the vast majority of the cases [3]. Most likely transmission routes were sexual contact in the majority of cases [3]. Also in the Netherlands, MSM are being considered as the population at risk of MPX, with PrEP users and MSM living with HIV labelled at highest risk due to their sexual risk behaviors [4,5]. Monkeypox could therefore become labelled as a MSM-specific infection which might elicit stigmatization towards this population, similar to the beginning of the HIV epidemic [6]. The current scientific MPX literature focuses predominantly on the epidemiology and clinical outcomes of MPX, but psychosocial aspects such as stigma are under-investigated. However, as exemplified in the HIV stigma literature, stigma can have consequences that are not only highly detrimental for the individual but also for the public health response, resulting, for example, in poor use of HIV prevention strategies and treatment adherence [7]. Therefore, we aim to report on psychosocial aspects of MPX among MSM in the Netherlands that may underlie MPX stigma using data of an online cross-sectional survey that was distributed among MSM on dating apps in a previously established cohort. Goffman conceptualized stigma as an “attribute that is deeply discrediting” imposed by society that reduces someone “from a whole and usual person to a tainted, discounted one”. When the attribute becomes linked to “discrediting dispositions” (e.g., negative evaluations or stereotypes), these may come to be widely believed in the community. We set out to investigate several beliefs that are known to underlie HIV stigma [8] and are likely similar for MPX, such as perceived societal beliefs about the severity of MPX, perceptions that people who acquire MPX are blameworthy (perceived responsibility), associations between these infections and behaviors that violate some individuals’ norms such as sex between men (norm violation), as well as other variables that relate to stigma such as disclosure intentions and expected stereotypes. Given the novel nature of MPX, in this study, we aim to describe each of these variables to explore aspects of MPX stigma, and compare where possible to other infections that are also seen as MSM-specific such as common STIS, including HIV, syphilis, gonorrhea, and chlamydia. From the HIV stigma literature it is clear that aspects of stigma may also be associated with other variables relating to other forms of stigma such as sexuality-related stigma, we will also examine the associations between perceived responsibility (i.e., perceptions that people who acquire MPX are blameworthy) and other variables relating to sexuality-related stigma such as internalized homonegativity (IH) and outness about one’s sexual orientation, as well as social interactions with individuals with MPX (knowing others with MPX), as all have been shown to be significantly associated with internalized stigma in an HIV context. We hypothesize that IH, not being out and not knowing others with MPX are all indicative of internalized stigma relating to their sexuality and increased fear of being perceived as gay or as having sex with men [9,10], and therefore more likely to perceive MPX as one’s own responsibility. 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