Dr. Shira Heisler Discusses Monkeypox & Sexual Precautions

Monkeypox is a viral disease we’ve all heard discussions about lately. I had been wanting to interview someone regarding Monkeypox for quite a while but was unsure how to approach the topic, much less who to interview. My boyfriend heard Dr. Shira Heisler, medical director of the Detroit Public Health STD Clinic and assistant professor at Wayne State University in the division of infectious disease, on WDET Culture Shift talking about Monkeypox and immediately sent the interview my way. Shira discussed the topic in a far more inclusive manner than in other interviews I had heard with medical professionals.

With Monkeypox, even though I know it’s not an STI, it’s still something that is talked about that way and there’s a lot of misinformation about it. So, I was excited to get someone on record who’s a medical professional and can speak to this outside of the conflicting internet things I find. I spoke with Shira over the phone on August 11th, 2022, and told her why I was so excited to have her comment on the current state of the monkeypox virus for Spectrum Journal.

Note: Given that this is a situation with rapidly changing information as more research comes in, updates will be provided in brackets where relevant. While this article will continue to be updated, please keep in mind that there are currently frequent changes to our medical understanding of monkeypox. This piece is intended to serve as an overview of how we can sexually prepare ourselves with as much information as possible, yet it is not an all-encompassing report on the status of the virus, nor is it medical advice.

Please speak to your doctor for any questions pertaining to your own personal health, and call 313-577-9080 to get more information about your eligibility in the state of Michigan.

SH: I am so happy you reached out because it is so important for you and all of your customers and your network to know about it. So, I’m happy to be doing this.

ZL: I want to focus more on the social and sexual and relational questions. But just for like a good baseline, so everybody knows, what is Monkeypox? How does it spread? When did we start hearing about this being a thing that was an immediate concern in our communities versus something that was just being murmured about?

SH: I think the thing that’s complicated about this is that it’s confusing the medical community as well. Endemically, it comes from having close contact with an animal, but then it is spread through close contact between humans.

In early May we had the first case in the UK from someone who was traveling from Africa. It’s starting to spread way quicker than we’ve ever seen it spread. Unfortunately, the data was not very clear. This disproportionately affects men having sex with men. There was a really good NPR story that said maybe this actually originated in 2017 in Nigeria and that there were already murmurs that it had a sexual association – that’s kind of the term that we’re using now.  It is sexually associated. We are still learning.

Sexually transmitted means it goes through semen or vaginal secretions. So Syphillis and HIV are sexually transmitted. Monkeypox is different. It transmits through close contact. [I spoke again with Shira on 8-29-22, and she clarified that things have yet again changed, and monkeypox is confirmed as indeed being sexually transmitted. It isn’t official, but there is now data to suggest it is sexually transmitted as well.] There is a huge New England Journal of Medicine article with data from April to June of 2022, in this outbreak among 16 different countries and over 500 participants that had Monkeypox.

Data showed that showed 96% of people with monkeypox are men having sex with men and 95% of them were related to sexual encounters. That is what is very unique about what is happening in this outbreak. Previous to this outbreak we had not seen this being sexually related. What I want to implore and stress is that there is no such thing as a “gay disease” or a “gay infection”. Infections, bacteria, and viruses have no predilection of who you’re having sex with, but it spreads in close contact and close social networks.

Today what we are seeing nationally is that they’re happening in the close setting of bathhouses, the ballroom scene and afterparties, and a lot of sex parties. From the first time you emailed me at the end of July to now, it’s already evolving in that now it’s not those big events, but it’s somebody who went to those big events and is now giving it to partners. [8-29-22: We are now seeing that it’s no longer limited to these events, and people can’t point out direct exposures. We’re trying to figure out if there is there an asymptomatic spread occurring.]

ZL: Obviously, it’s impossible to compare it 1-to-1 with any other type of infection. It’s its own unique thing, but it almost reminds me of how HPV is very misunderstood in that it’s not a fluid exchange. It is close contact with mucus membranes. Similarly, with herpes, it is something that can certainly have a sexual association, but at the end of the day, it’s open lesions on the mouth and/or genitals, but you can get a herpes outbreak anywhere on your body, although that’s less common.

SH: Correct. I think that’s a great comparison. It really is like when we’re giving guidance about herpes. For example, if your parent had oral herpes and then they kissed you and you got it which is common.

ZL: Yeah. I was born with it! [laughs] Is viral shedding a thing with monkeypox in the same way?

SH: Great question. We are learning that. The difficult thing is our testing right now. In terms of Monkeypox, we are seeing that there’s this thing that we call the prodromal period which also you can get with herpes (and particularly your first outbreak of herpes) is you have fevers, muscle ache, severe exhaustion is a very common symptom that people are talking about. But we don’t have a test for that phase. We don’t have a blood test. We only have a swabbing of the lesions and we know you are infectious at that stage which leads to a very big problem because we’re living in COVID, as well as other viruses, and these are the same symptoms. So, it sucks! It’s really hard. I will say, in terms of transmission, again unlike with syphilis and HIV, you can transmit it via linens, towels, and even sharing of food and utensils. But, there have been a lot of things in the media about monkeypox being found on surfaces such as door handles. That may be true, but it doesn’t necessarily mean that it’s infectious. Again, it is through close, intimate contact.

ZL: I like that term “sex associated” because I mean, you’ve answered so many of my questions at once. Correlation does not equal causation as far as who is “at risk” or who is contracting Monkeypox. It makes me think about how I’ve had a lot of friends who say well, I am wanting to get the vaccine. I am someone who has sex with men who have sex with men, and therefore I would like a vaccine, and there are mixed results from doctors either being like, sure here you go, or not prioritizing them. What would your advice be for someone who feels they should be eligible but fears they may not be prioritized? How do they bring that to their doctor?

SH: Yeah, so, that is a big issue. First of all, I want to say that I’m very happy to say that Michigan expanded its eligibility last Tuesday, August 9th, it got expanded and this is amazing. So, it now includes the criteria that you just mentioned. It did not include that before.

But the thing is, we are in limited supply. At this moment in time, we are doing pop-up vaccine clinics because there’s just all this bureaucracy. We did one at Ruth Ellis, at a ballroom, town hall.

There’s going to be one in Corktown. They’re going to do one at Body Zone. So, trying to get to these places where maybe people don’t know about the vaccine until they go where the people are. That person would qualify now.

ZL: So let’s say you’re someone who’s doing in-person sex work, or have physical contact with people at work, no matter what your job is, but you have to anxiety on how to communicate that to a doctor, that sounds like a great alternative for a place to get that information and get a vaccine that’s outside of a medical office. Do you have any other advice for somebody who’s having anxiety about bringing it up?

SH: Yeah, that’s what we want to do. The state health department’s priority is getting shots in arms, and I agree with that. This is a two-dose vaccine by the FDA 28 days apart and we’re going to a one-dose strategy with a delayed second dose until we get more vaccines. [8-29-22: Now, the new administration technique is intra-dermal – it’s 1ml vs 5ml – so one vial can now give 5 doses. With new changes in administration, they can now go back to the two-dose strategy because we have 5x the doses. The data is new and therefore minimal, but it supports this method.]  We want more people to have protection than a select few.

These are difficult, difficult questions. Who gets the vaccine? Are we doing this one-dose thing? These are really hard questions that we’re grappling with and I think it’s one of the difficult things that I grapple with as somebody who’s in this work. I work predominantly with the LGBT+ population and we’re seeing disparities, sexual disparities that we’ve already seen dramatically with HIV and Syphilis. And now, once again, we’re battling the same problem and it just feels so unfair.

Just to be kind of frank, like Monkeypox, the skin lesions aren’t nice looking. It sucks. You know, it just plays into all these tropes of homophobia and stigma and it really— It’s hard. It’s really— It’s difficult.

ZL: I think you’ve done such a great job of addressing what I’m trying to understand. While there are aspects of the stigma that are reminiscent of the 1980s, fortunately, we aren’t experiencing a death rate that is similar to HIV. How should we practically adjust our dating and sex lives? I mean, ideally, we’re all having safer sex conversations with all our partners, but people are like, well I don’t know if I need to disclose that I have HPV. I don’t know if I need to disclose that I have oral herpes if they’re so common. Always erring on the side of caution is what you want to do, but what’s a realistic and practical way for somebody to approach this with an intimate partner or a potential intimate partner?

SH: It’s great to be kind of talking to someone like you who has a sex-positive philosophy. This creates a really big problem. What I’m telling my friends and my patients is, if you’re going to go these things, try not to go to these close contact events with a ton of people and it sucks to say that. I think we’ve worked so hard on what it means to be sexually liberated and with no judgment, and really loving whoever we want to love and in any fashion, and now we have to come back and say, hey if you want to be safe and healthy, maybe at this moment in time, it’s not the best. It’s not the safest decision because this isn’t just like, wearing a condom. It’s not.

ZL: Yeah, a condom is only covering a small portion of the body. It’s always good to wear a condom but, as you were saying, nothing can fully protect us when it’s spread from close contact.

I think what’s so frustrating also is that with HIV, there are so many very intimate alternatives to partnered sex, like mutual masturbation. That doesn’t inherently involve contact, but if we’re not having fluids directly exchanged, we’re safe. And now we’re saying that actually, all those things that we were doing to avoid direct fluid contact are also now unsafe. So, what’s your advice for someone who’s feeling this increased fear and paranoia of all intimacy given that the things that were once safe are now unsafe for different reasons? What’s your advice for someone who’s just kind of like, how do I have any intimacy?

SH: Yeah. Before I answer the actual question, I want to just call out that this sucks. A lot of times I don’t have a great answer and that’s the reality of this that makes this work difficult. With HIV, we’re really lucky we’re not currently living in the early 90s. I get to tell you that when you get to be undetectable, you can’t even transmit the virus. You can have kids. You can do all the stuff. And now I can’t say that, and that’s the reality. What we can say is, as opposed to HIV where you don’t see symptoms necessarily, most likely you are not contagious with monkeypox if you don’t have any symptoms. So, now we’re asking people, are you having a rash or skin lesions, are you feeling fatigued, muscle aches, and even though it doesn’t necessarily turn out to be Monkeypox, those people just shouldn’t be out.

ZL: Yeah. We have a different standard of what qualifies us as having to stay inside now.

SH: So let’s use this as an opportunity. Let’s use this as an opportunity to start approaching these things in a more compassionate, honest, humane way which is without judgment, but asking our partners, are you okay? If you’re not, let’s meet up at a different time. 

ZL: Yeah. I think that’s an optimistic and realistic takeaway. We just need to add it into our existing checklist of being sexually safer or, you know as safe as possible because everything has got somewhat of a risk to it and this is just another thing to account for.

After wrapping up my questions, Shira and I chit-chatted about Spectrum Boutique, and that led to one more fact worth mentioning – sharing sex toys is a mode of transmission for Monkeypox. Shira’s advice? Clean them! Clean them, especially before sharing them, with soap and water (or boil them if boilable.) Use non-porous materials.

Shira will keep us updated on what is going to be happening with the vaccine. Again, please call 313-577-9080 to schedule screenings for eligibility and schedule an appointment in the state of Michigan. Huge thanks to Shira for spending time with me to address these difficult questions.

Dr. Shira Heisler is the medical director of the Detroit Public Health STD Clinic and assistant professor at Wayne State University in the division of infectious disease. Shira lives in Detroit with her husband Zak, her amazing children Noa and Ami, and her sweet pup Rumi.