This story has been updated. It was originally published on August 20, 2022.

Although the World Health Organization has labeled the latest monkeypox outbreak a global emergency, vaccination and treatment options continue to be scarce in the US. Many infected people have been left to their own devices—some for weeks—before they’ve been able to access medication that will improve their condition. Understanding how the virus spreads and how to prevent infection will be key as authorities work to close the gaps in their response.

As bad as it sounds, it’s worth noting that monkeypox is rarely lethal (there have been no reported deaths in the US so far) and seldom requires hospitalization. Even so, the skin lesions that are one of the most common symptoms of the virus can be extremely painful without proper medication. 

Of the more than 40,000 monkeypox infections worldwide—about a third of which are in the US—transmission has mainly concentrated within a specific community comprised of gay, bisexual, and queer men who have sex with other men (GBMSM, in short), and their sexual network. Whether you identify as such or are currently at a low risk of contracting monkeypox, you should know how the virus can spread and how to stay safe.  

How monkeypox spreads

Unfortunately, there’s a lot about this new monkeypox outbreak we still don’t understand, in part because it’s not like previously studied outbreaks in West and Central Africa. The skin lesions, for example, are showing up in different locations—infected people in past outbreaks tended to have lesions all over their bodies, but lesions are now appearing mainly on peoples’ genitals and anuses, and in their mouths. Studies investigating the current outbreak have found changes in the virus’ DNA, but scientists are still trying to figure out exactly why this version of the disease has spread so quickly and so far. 

What we do know is that people with monkeypox are infectious from their very first symptoms to when the last lesion has completely healed, meaning all scabs have fallen off to reveal a new patch of skin. This entire process, according to the Centers for Disease Control and Prevention, usually takes two to four weeks

As far as we know, the current monkeypox outbreak is spreading in three ways: prolonged skin-to-skin rubbing, mostly in the context of sex; direct contact with contaminated surfaces; and transfer of respiratory fluids, such as mucus and saliva.

Let’s break it down. 

Skin-to-skin contact

This is, by far, the most efficient way monkeypox jumps from one person to another. It happens when highly infectious secretions from the rash caused by the virus make their way into the skin of a healthy person. These secretions carry more viral particles than any other fluid in an infected person’s body and can be up to three times more infectious than their saliva

“​​Let’s say you touch a lesion and the virus gets on your hand. Unless you have a break in the skin, you should be ok,” says Scott Roberts, assistant professor of infection prevention at Yale University’s School of Medicine. The problem is that we tend to touch our mouths, eyes, and faces throughout the day, which means you can infect yourself with viruses lingering on your digits, he explains. 

Because sex entails a lot of constant and persistent touching, involves the exchange of multiple bodily fluids, and the inherent friction can tear skin, it has become the main driver of monkeypox. So far, sex has been responsible for 91.5 percent of transmissions, and 97 percent of cases have been within the GBMSM community. This is why some experts believe monkeypox could be classified as a sexually transmitted infection, or STI. But Roberts isn’t one of them.

“The reason that we’re seeing the spread through sexual contact is not that it’s a sexually transmitted infection, but rather the close, prolonged contact in an intimate encounter, where you’re touching parts of the skin, kissing, sharing bodily fluids,” Roberts says. “All of that is a good scenario for a virus to spread.”

Several studies have found traces of monkeypox in semen, but only one of them, published by Italian researchers in The Lancet Infectious Diseases, showed the virus in the sample could replicate and actually infect another person. At the moment, this evidence doesn’t support the claim that monkeypox can be transmitted directly through the exchange of semen and vaginal fluids, but that might change as we learn from ongoing research. 

Some people are also reluctant to identify monkeypox as an STI due to the stigma it could attach to the LGBTQI+ community. But this new label could also help the government form a more efficient strategy against monkeypox.

“I don’t really care whether people want to say, ‘Is it going to go in a textbook under STI?’” says Jay Varma, professor of population health sciences at Cornell University’s Weill Cornell Medical College. “What I care about is that we focus all of our efforts as much as possible on sexual networks and we strengthen sexual health services. Every time we’re talking about preventing monkeypox in schools among non-sexually active kids, or in massage parlors, we’re moving attention away from people that need attention the most.”    

Keep in mind that skin-to-skin contact doesn’t mean you’ll get infected by just brushing shoulders with someone who has monkeypox—you need a high viral load for that to happen. 

“It definitely requires a much longer time of close and prolonged contact if you don’t touch somebody’s lesions,” says Roberts.

Coming into contact with infected surfaces

Monkeypox secretions can easily seep into porous surfaces, including clothes, bedding, bandages, towels, and even upholstery. The virus is actually pretty resilient in this type of environment, too, especially in dark, cool, and humid conditions, which allow it to survive for weeks, and even months

Still, according to the latest WHO report on monkeypox, cases caused by contact with infected material only account for 0.15 percent of the total, making them highly unlikely. 

Exchange of respiratory droplets

A study published by the scientific publication The Lancet in early August found traces of the virus in the mouths and throats of monkeypox patients, which means there is a chance of infection whenever you’re exposed to their saliva or mucus. This could happen while kissing, sneezing, or simply being in close, prolonged face-to-face contact with an infected person.   

But monkeypox is not airborne, and it doesn’t behave like COVID-19, where microscopic droplets can infect you if enough of them get into your nose and mouth. Researchers including those who worked on the Lancet study have said that the viral load in a monkeypox patient’s airways is nowhere near as high as the one from lesion secretions. That means transmission from respiratory fluids—though possible—is a lot less likely. So much so, in fact, that it would require three hours of sustained face-to-face contact with a monkeypox patient at a distance of 6 feet for you to get infected. The COVID-19 virus, on the other hand, can spread after only 15 minutes in the same context.  

How to prevent monkeypox

As mentioned above, because the outbreak is mostly contained within the GBMSM community right now, authorities have given its members priority access to the limited monkeypox vaccines and treatment options. Still, resources are scarce and in places like New York City, vaccines are disproportionately reaching more white people over Black folks and Latinx. But vaccines are not 100 percent effective, so you should strive to reduce your own risk as much as possible—even if you got a shot.

Be smart about your sexual partners

If you are part of the GBMSM community, the safest thing you can do is reduce your number of sexual partners, says the CDC. Approach this as you did your COVID quaranteam back in 2020—you don’t have to abstain from sex, but you should limit your intimate contact to a closed circle of people you know are not taking unnecessary risks or presenting symptoms. Practicing safe sex by wearing a condom or using a dental dam is also a good idea—it not only limits the amount of exposed skin (albeit not much), but it can also protect you in case researchers confirm monkeypox can indeed be transmitted through sexual fluids. 

You should also keep in mind that there are a lot of ways to have sex, and some don’t require touching or even being in the same room with your partner. Take this as an opportunity to be creative and explore these options as sexual alternatives.

Anonymity is another problem. We know the thrill of having sex with strangers is, well, the “strangers” part. But when it comes to stopping the spread of a virus, it’s better to stay in the know. Anonymous sex rarely gives people the chance to have honest conversations about their levels of monkeypox exposure, potential symptoms, or vaccination status. Talking to someone before tearing off their clothes will allow everyone involved to stay safer, make informed decisions, and clearly establish how much risk you’re comfortable with. 

And since you’re already having a conversation, don’t forget to exchange real names and contact information with potential partners. These include people you kiss, have penetrative sex with, and do everything in between. This will make it easier to get in touch if any of you end up with monkeypox symptoms in the future. 

And if you don’t trust yourself to break the spell of anonymity, try to avoid contexts where anonymous sex is most likely to happen, like sex clubs, sex parties, and any other contexts where on-site casual sex is common.

Get the monkeypox vaccine

Getting vaccinated against monkeypox is also important for prevention. Each state has different parameters for vaccine eligibility, but generally, every member of the GBMSM community and their sexual network should be able to get the two-shot inoculation. To find out if you qualify, contact your local health department. Keep in mind that since supplies are low, it might take you a while to get an appointment—if you can get one at all. That’s why it’s crucial to reduce your exposure as much as possible as a complementary measure.

Keep your distance and keep things clean in high-risk situations

Reducing your exposure to non-sexual skin-to-skin contact with strangers is also a good idea, the CDC says. Although very few monkeypox cases have stemmed from these types of interactions, you may want to consider covering your skin if you’re going to a crowded party. A long-sleeved shirt and pants may not be ideal club attire, but they will reduce your potential exposure. 

If you know someone who’s infected with monkeypox, avoid seeing them until the infection has subsided. And if you live with or will otherwise be in close contact with them, maintain your distance, cover your hands with disposable gloves, wear a tight-fitting face mask, and put on a long-sleeved shirt and pants you can wash or place in a sealed container immediately afterward. Otherwise, make sure they’re isolated in their own space and follow CDC guidelines to manage waste and the cleaning of common areas they still have access to. 

“Monkeypox is actually a pretty easy virus to kill,” Roberts says. “Alcohol wipes, soap and water, disinfectant, all of that really easily kills the virus.”

In general, you should regularly disinfect surfaces like kitchen counters, door knobs, and light switches, the CDC says. You should also do dishes and laundry at separate times, and wash your hands frequently with an alcohol-based sanitizer, or soap and water. If you’re not sure whether your cleaning products will do the trick, the EPA has a list of approved disinfectants

Don’t forget your pets

Finally, remember that monkeypox is a zoonotic disease, which means it can transfer from humans to certain animals, like dogs, hedgehogs, and other rodents—and vice versa. Keep your pets safe by preventing any contact between them and any infected person, even one that lives with you. If possible, ask a friend or family member in a separate household to take care of your pet for as long as the infection lasts. If your pet contracts monkeypox, the CDC recommends alerting your vet immediately so they can run tests and help you come up with a treatment and isolation plan.