Providing Public Health Information Without Creating Stigma

Roberta Villa, MD


March 27, 2023

The world has been abuzz with discussions of the new versions of Road Dahl's children's books, which are now devoid of noninclusive language in the name of diversity. Worrying about how communication relating to illness has the potential to be stigmatizing might seem to suggest that we're one step closer to what some would call "the dictatorship of political correctness." Others, however, believe that this is simply a way to extend respect to all.

In medicine, the topic is not new, but it has recently returned to the forefront by way of two very different infectious disease epidemics whose only commonality is  that most cases have occurred in males from the LGBTQ+ community. This is a fact, not a moral judgement. The question is, are we allowed to point out this fact? Or rather , is it beneficial to point it out? And also, how can we say it in such a way that it has a positive, not harmful, effect on public health?

The case most talked about is the skin disease caused by a virus which, up to a few months ago, was known as monkeypox. We have a vaccine that affords protection, but it is only available in limited quantities. How can we set out which group needs to be prioritized for vaccine rollout without acknowledging and communicating with those at greater risk?

The Shigella Epidemic

The lesser-known epidemic is bacillary dysentery, caused by Shigella flexneri and Shigella sonnei, two bacteria that are normally transmitted via orofecal infection. This infection happens predominantly in countries with poor sanitation but, in recent years, the sexual transmission of these bacteria between men has become common. The cases described are all in adult males who, when responding to questionnaires, report in high percentages having recently had sexual encounters with other men. The disease, which is characterized by fever, abdominal pain, and diarrhea, is, for the most part, self-limiting. However, it can sometimes present as a serious illness, especially in people with a compromised immune system, in older adults, or in the very young. In these cases, doctors may have to resort to prescribing antimicrobial treatments.

The public health authorities, especially in the United Kingdom, are worried that the bacteria isolated from these patients are extensively drug-resistant, due to the presence of an extended-spectrum beta-lactamase. Furthermore, the enzyme is coded by a gene contained in a plasmid transmitted horizontally between different types of enterobacteria, which means that the circulation of these extremely resistant bacteria could become a threat to public health. How can we warn those at risk of becoming infected and of unknowingly infecting others without saying how it is transmitted?

Harmful Associations

Recently, during a lesson on science communication, I tackled the topic of stigma associated with infectious diseases. I explained how wrong and dangerous it is to associate an infectious disease with a place, animal, or group of people, for the purposes of containing the disease. We've seen it with "swine" flu, a disease for which pigs held no responsibility, with Middle East Respiratory Syndrome, which, due to this geographical prejudice, was not recognized for some time when it arrived in Korea.

The most prominent example, however, is perhaps HIV. Focusing on the so-called "at-risk categories," homosexual men and drug addicts of both sexes, gave heterosexual people a false sense of security, meaning many were infected thinking that the HIV warning didn't affect them. On the other hand, it put people off from getting tested for fear of being branded "untouchable."

For this reason, in 2015, the World Health Organization (WHO) drew up a document of best practices for naming new diseases of public health interest to avoid the risk of discriminating against a particular group. On the basis of these documents, in recent months, the WHO rushed to rename monkeypox, opting for the more neutral "mpox." But when I stood in front of 20 or so of my communication students and explained that last summer this disease was spreading around the world almost exclusively among men who have sex with men (MSM), my audience, sensible and attentive, demanded, "How can you say something so discriminatory?" Right when I was giving my lesson on fighting stigma.

Yet, it was by involving the LGBTQ+ community that we were able to offer vaccinations to the people most at risk, thereby getting the epidemic under control quickly. In the case of mpox, it's not yet clear whether the new outbreak, often characterized by particularly painful lesions on the penis and anus, derives from a sexually transmitted variant of the virus. But because close contact is part of intercourse, it's possible that in this case the high — not exclusive — rate of spreading among MSM is a result of incidental events. An infected person returning from Africa seems to have attended one or more large gatherings in Europe during late spring last year, causing the epidemic to be more concentrated in this community.

Regarding shigella, however, it is more likely that sexual practices more common among men are at the root of the epidemic. The UK Health Security Agency is responsible for informing the most at-risk groups without fear of discriminating against them. In this context, their job is to highlight that sexual contact involving the anus and feces constitutes an elevated risk and to explain how to reduce this risk, such as by paying close attention to personal hygiene and changing condoms after every sexual encounter.

Facts, Not Labels

Infectious agents don't discriminate against people, but they are transmitted more or less easily depending on our behavior. If we explain that HIV can be contracted from occasional unprotected sexual encounters, this information is valid for both homosexual people and heterosexual people, protecting both groups. If we talk about the risk for infection from blood-contaminated needles and other medical instruments, this method of transmission encompasses not only "drug addicts" — which, as a category, also includes people who take drugs not administered using a syringe — but also those who have been exposed to the virus in a healthcare setting before the necessary precautions were taken.

Similarly, mpox or shigella doesn't affect gay or bisexual people as such. They affect these groups when they are exposed to an increased risk after multiple sexual encounters with strangers, especially if the encounter is made more extreme and violent by taking drugs (a practice known as "chemsex").

Therefore, it's important that even doctors avoid labeling their patients and instead focus their attention on behaviors, risky or otherwise, regardless of who is exhibiting them. This is why nowadays we're using the term "men who have sex with men" more and more, rather than homosexuals. It's not just another way to say it. From a strictly medical point of view, an individual's sexual orientation is not important. It doesn't matter whether they're homosexual, bisexual, or define themselves as heterosexual while having, or having had, sex with men only occasionally, or for work. All that matters is whether a person is exhibiting a behavior that puts their health at risk and what this behavior is, and in this case, only advice on preventive measures should be given, without creating a stigma.

This article was translated from Univadis Italy.

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