The Role of Social Networks to Counteract Stigmatization Toward Gay and Bisexual Men Regarding Monkeypox

Research on the effects of social media has evidenced their influence on public opinion concerning health issues. However, there are scarce analyses that pay attention to this influence when health advice generalizes certain groups’ sexual practices. This generalization occurred with monkeypox, men who have sex with men, after two World Health Organization’s (WHO) recommendations launched in 2022. Therefore, this is the issue that will be deeply explored in the article. Drawing on the methodological strategy of social media analytics (SMA), 2313 tweets have been reviewed focused on people’s reactions in front of WHO’s statements of July 2022 about monkeypox and men who have sex with men behaviours. Findings illustrate that there is positioning against the generalizations caused due to WHO’s statement creating a public discourse against the stigma of homosexual and bisexual men. This positioning is directly linked with people’s claims to follow the evidence and valid claims on public health issues. Using social networks for claiming the use of rigorous data and evidence may contribute to a significant change in public opinion and health organizations.

he general purpose of this article is to show discussions and messages on social networks about a specific health issue and its role in shaping public opinion.In our case, attention is paid to the World Health Organization (WHO) statement advising men who have sex with men about the risk of catching monkeypox.This statement approached on July 18th of 2022 (World Health Organization [WHO], 2022b) created great controversy, particularly on social networks, and opened new discussions and debates about generalizations which have been produced.This statement includes the following words: Public health advice on monkeypox for gay, bisexual and other men who have sex with men, (…) Cases have been identified in communities of gay, bisexual and other men who have sex with men who have had recent sexual contact with a new partner or partners 1 .
Before this statement, WHO launched another stance on May 21st which informed about the high percentage of infection in men who have sex with men: "Based on currently available information, cases have mainly but not exclusively been identified amongst men who have sex with men (MSM) seeking care in primary care and sexual health clinics (WHO 2022a)" 2 .
Public opinion, including international and national newspapers, and news agencies around the world published a summary of this statement, but in this study, the emphasis will be given to citizens' responses on social networks, particularly on Twitter.Drawing on the methodological strategy called social media analytics (SMA, hereinafter), which will later be explained in more detail, a detailed analysis of the messages in this social network has been articulated.We start with the hypothesis that this public response on social media was one of the elements that have influenced public opinion to position against the stigmatization of gay and bisexual men.
Drawing on the data managed by WHO, monkeypox predominantly emerged in central and west Africa, near tropical rainforests although rapidly increased in urban areas.These animals who hosted this virus include rodents and non-human primates 3 .However, according to a report elaborated by the European Centre for Disease Prevention and Control (2022) from early May to July 7th, monkeypox appeared in 26 European Union and European Economic Area countries reporting 4.908 cases which implied 65% of all cases registered worldwide in 2022 4 .Considering the last data and recommendations from WHO, monkeypox is spread person by person in different ways: face-to-face, skin-to-skin, mouth-to-mouth, or mouth-to-skin contact, including sexual contact.This last way created a public debate because a relevant number of cases identified were of men who have sex with men.Therefore, WHO started a set of recommendations advising this group about the risk of infection.
Literature connected with the purpose of our study can be divided into two main lines: firstly, the analysis of the impact of social media on public opinion, and secondly, the employment of social media and its influence on health issues.Concerning the first one, the historical analysis of public opinion conducted by communication science authors (Flecha, 2022;Habermas 1985;Lippmann 2017) becomes the precedent for examining the role of social media in the field in the last years (Anstead & O'Loughlin 2015;Huang et al., 2017 , 2017;Schillinger et al., 2020).These investigations are directly linked with the evaluation of social policies aimed at evidencing if citizens are in favour or against them.
In parallel, advancing to the second research line which is also connected with the first one, there is extensive literature that delves into the effects of social media in health care.For instance, reactions on social media to campaigns addressing public health problems such as smoking have been analysed paying particular attention to interactions among users on different social network platforms (Zhan et al., 2019).On the other hand, previous research explores how the use of social media is becoming an information tool for acquiring more health information, like medicines safety (Hoegberg, 2018;Schillinger et al., 2020).These studies conclude that social media is impacting users' perception of health issues.Similarly, Nawaz and colleagues (2017) also identified that healthcare professionals and citizens use social networks, like Twitter, for exchanging information which then is crucial in decision-making processes.From a close approach, Pulido, Villarejo and col leagues (2020) reviewed Twitter and Weibo to shed light on fake news that emerged on social media about the COVID-19 pandemic.The authors concluded that the Chinese platform was more accurate in informing about this health problem than Twitter.
Starting from all these research efforts, the present article will provide unprecedented knowledge about the role of social networks (Twitter) in refuting generalizations about a health problem that are not accurate with the existing evidence and stigmatize sexual minorities.Thus, new insights about how social media is influencing discourses on monkeypox will be approached.

Method
The research question on which this study is based is: Are posts on social media, in particular Twitter, contributing with validity claims and evidence to the public opinion on regards to the WHO's statement on monkeypox and men who have sex with men?To respond to this question, a sample of 2001 tweets in English and 312 tweets in Spanish were reviewed.The keywords considered within this analysis followed the hashtags: #Monkeypox & #WHO, and #Virus Mono & #OMS, and the selected date range of this analysis was between July 18th to July 31st of 2022.This range has been chosen aimed at collecting citizens' reactions to the statement launched by WHO on July 18th.In this regard, our interest was to identify same-day and later opinions about monkeypox and men who have sex with men.
This study follows a communicative orientation (Roca et al., 2022) framed on the Communicative Methodology of Research (CMR, hereinafter) that has as one of its main objectives to identify successful practices and actions which are overcoming social inequalities or discriminations.Therefore, knowledge obtained through the research process is oriented to improve reality.The CMR has been recognized by the European Commission as one of the best methodological approaches to studying vulnerable groups (European Commission, 2010).Furthermore, the research program Horizon Europe has included co-creation as the method to involve citizens and users in the research process, drawing inspiration from CMR (European Commission 2018).
In our study, the examination of tweets conducted has been articulated to unscramble how reactions on social media platforms are contributing to public opinion about a health issue.Therefore, findings have been structured with the idea of showing evidence of the generalization that WHO has provoked around monkeypox and men who have men with other men.
The data-collection technique which has been utilized for conducting this analysis has been Social Media Analytics (SMA, hereinafter) (Pulido et al., 2021).This technique consists of exploiting comments, posts, and debates that are publicly given on Twitter and are related to the WHO's statement.As it has been abovementioned, different hashtags have been evaluated, and the combination between them has been also considered.We initially analysed all messages that contained those words and additionally explored the threads where such messages were inserted to include reactions and responses.Within this exploitation, other hashtags emerged which are strongly linked with the positioning of users in that debate.Among these hashtags were identified: #lgbtiq+, #virus, #emergency, #outbreak, #emergency, #stigma, #hiv and #health.
Drawing on the basis of Social Media Analytics and the combination of the aforementioned hashtags, this research has also considered the SISM -Social impact in social media methodology, which has made it possible to complement the analysis of content on the networks (Pulido et al., 2018).The SISM, which was established by the European Project IMPACT-EV of the 7th Framework (Flecha 2014(Flecha -2017)), proposes to consider the social impact of the research presented in social media.In this sense, in this study, apart from including tweets from individuals not linked to the world of research, special emphasis was also placed on organisations or researchers who provided data and evidence that dismantle monkeypox hoaxes based on scientific data.
Finally, we would like to point out that the data analysis has followed this SISM's orientation and it has been based on the inductive method.This has made it possible to establish specific analytical categories to respond to the initial hypothesis.Thus, the content review of the tweets made it possible to create two central categories linked to the rejection of generalisations and the provision of scientific evidence.More detail is provided in the following section.

Results
he analysis of the tweets exploited in the study shows two connected lines of responses in Twitter's users concerning Monkeypox and men who have sex with men.The first one illustrates tweets and debates where questioning and rejection of generalizations incited by WHO's statement are realized.The second one provides validity claims (Flecha, 2022;Habermas, 1985) and evidence aimed at counteracting these generalizations.We draw from the Habermas' conceptualization that a validity claim is a claim whose purpose is to reach the truth and get a consensus without a power position influence.

Questioning and Rejecting
Tweets on rejecting the WHO's statement show different types of rejection.One of these typologies refers to spreading the virus.For instance, there is a tweet from a black woman who argued that is not true that the virus is spread only by having sexual relations.She affirmed that monkeypox can be spread by sexual contact but also by touching daily things and then touching other parts of the body.She insists on the relevance of doing research on the field instead of judging or making any generalizations about it.
There is another typology of rejection, the most common one, which is directly linked to stigmatization.Tweeters show their refusal of WHO's statement saying that is causing stigmatization of homosexual or bisexual men.In this sense, different user profiles have powerfully contributed to this debate, such as public personalities (actors), health care workers, directors of security engineering, and LGBTIQ+ activists among others.An actor maintains that is necessary to provide news of monkeypox with medical evidence and expert advice.He sustains that in front of this kind of health problem it is relevant to stand united and not polarize society and make certain minority groups more vulnerable with a stigma.Similarly, a health care worker explains the relevance of presenting information properly, particularly with diseases that are disseminated worldwide.He also points out that there is a lot of misinformation which is causing stigma that should be contrasted with scientific evidence.In the same line, an activist affirms that the way WHO approached monkeypox is promoting stigmatization and this is generating a false feeling in non-homosexual persons.She says this is not a gay virus and that situation is quite connected with the beginning of VIH, therefore disinformation is quite dangerous.
There are other tweets which are questioning WHO's approach to claiming responsibilities and, if they would be possible, taking legal actions.In this regard, a discussion is set up between different tweeters and a sportsman where claims for responsibility are exposed.In that case, a university professor denounces the sportsman's statement, inspired by WHO's report, which is devoid of research and scientific evidence disseminating information based on biases.Claiming for legal actions is another tweet that it can be found in this debate.For instance, an educator affirms that legal actions should be executed against any organization or party that is labelling monkeypox as a disease based on sexual orientation.

Providing validity claims and evidence
One of the main lines of reasoning which can be identified in Twitter after WHO's statement is related to providing validity claims and rejecting generalizations in front of the virus.These tweets try to show the truth by giving more information about monkeypox spreading ways.Apart from the significant number of users who argue that monkeypox is not only sexually transmitted, but others also offer more details.By the way, there is a tweeter who explains that monkeypox exists since the 50s and infection occurs when there is proximity to a person who has the virus.In the same vein, there is a user who assures that monkeypox cannot be defined as a gay disease because the people that are more at risk are those more sexually active with multiple partners that are not inevitably gay.Lastly, we would like also to mention the tweet of a lawyer talking about the dangerousness of WHO's statement and concluding that lessons from HIV's struggle should be considered.In that struggle, the focus has been placed on the virus and not on the people who become infected.
Along the same lines, another significant number of tweets delves into the virus and expose or demand scientific evidence on health.For example, there is a user who explains that research in the field shows that not all people who were diagnosed to have monkeypox exposed their sexuality and those who did were significantly men in relation to other men.Likewise, the Twitter account of a Social Enterprise provides another relevant evidence: monkeypox is being detected in men who have sex with men because this community's health is usually more monitored and screened.
Finally, the last point which will be presented in this section concerns dismantling fake news and disinformation.Several tweets have been found from Medical Associations or Research bodies that remember the relevance of not disseminating fake news about monkeypox.In fact, a Medical Association is confirming that monkeypox is not a sexually transmitted disease and should not be explained like that.On the other hand, there is a Research Institute that informs that one of the Regional Offices of WHO has informed that monkeypox is transmitted by physical contact regardless of the sexual orientation or gender identity of the person.

Discussion
The findings presented in this article are responding to our initial research question: "Are posts on social media, in particular Twitter, contributing with validity claim and evidence to the public opinion on regards to the WHO's statement on monkeypox and men who have sex with men?"In this respect, the study we have conducted illustrates how social media is becoming a platform not only to denounce disinformation on health issues but also to provide validity claims and evidence which are counteracting this misinformation and generalizations about a global disease such as monkeypox.Therefore, our analysis sheds light on the utility of social networks to generate knowledge on health that has an evidence-based approach or can open new discussions with more detailed argumentation.
These results have significance concerning previous investigations in the field.Although these indeed show how social networks are useful to exchange health information for decisionmaking processes (Nawaz et al. 2017) or to go deeper into several diseases or medicines (Hoegberg, 2018;Zhan et al., 2019); our exploration gives new details about the powerful impact of social networks to dismantle generalizations that discriminate and stigmatize vulnerable groups, such as gay or bisexual men.As would be explained in the conclusions, this is an important step to creating a public opinion that can be constructed more democratically and with a rigorous basis.Therefore, the analysis carried out through the SMA technique offers relevant information about how civil society and researchers can become active citizens in online spaces aimed at eradicating non-evidence judgments.More detail about these last insights will be also described in the conclusion.
However, the investigation realized has several limitations that should be underlined.Firstly, it is quite difficult to measure exactly the impact of social networks in the transformation of public opinion because there are other structural variables or political relations which would have to be considered.Concerning this limitation, there is another methodological strategy that could complement the knowledge obtained during the study.Thus, in-depth interviews with policymakers and representatives from WHO need to be undertaken to elucidate the effects of social networks on the change of WHO with monkeypox and men who have sex with men.This is an issue that will be taken into account in further studies to be performed on this topic.The second limitation is regarding the SMA technique which exploits the data on Twitter, but detailed information on the profiles of users has not been deeply analyzed.Besides, other social networks have not been reviewed either, such as Weibo, Instagram, or Facebook.

Conclusión
This study has revealed that citizenship has a relevant role in the shaping of public opinion about health issues.Fake news, generalizations, and misinformation are questioned through social media around the world because people have more scientific information at their fingertips than ever before, and at the same time, science people and bodies have a stronger voice in social networks (Pulido et al., 2020).In the case studied in this article, findings make visible reactions in front of WHO's statements although the effects of these reactions have not been recorded.However, it is important to note that in one of the documents prepared by WHO, particularly in the Questions and Answers section, WHO made a response to the stigmatizing messaging related to monkeypox: We have seen messages stigmatizing certain groups of people around this outbreak of monkeypox.We want to make it very clear that this is not right.First of all, anyone who has close physical contact of any kind with someone who has monkeypox is at risk, regardless of who they are, what they do, who they have sex with, or any other factor.Secondly, stigmatizing people because of an illness or a disease is unacceptable.Stigma is only likely to make things worse and stop us from ending this outbreak as fast as we can (WHO 2022c, n.p) 5 Apart from that, WHO has also started a campaign to rename the monkeypox virus after researchers, public health officials, and social movements have assured that this name is stigmatizing several vulnerable groups like the LGBTIQ+ community 6 .Thanks to statements of these bodies, like the New York City Department of Health and Mental hygiene 7 and the Joint United Nations Programme on HIV and AIDS, or citizens and social movements, such as the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) 8 ; monkeypox is being approached avoiding stigmatization.For instance, the New York City Department of Health and Mental hygiene claims for a change in the name of the virus because: Continuing to use the term "monkeypox" to describe the current outbreak may reignite these traumatic feelings of racism and stigmaparticularly for Black people and other people of colour, as well as members of the LGBTQIA+ communities, and it is possible that they may avoid engaging in vital health care services because of it (p.1-2).
Similarly, the Joint United Nations Programme on HIV and AIDS has also supported this change appreciating very much the effort of the "LGBTIQ community for having led the way in raising awareness" (United Nations Programme on HIV and AIDS [UNAIDS] 2022, n.p).In this sense, the role of LGBTIQ+ non-governmental organizations, like ILGA, has become crucial for changing WHO's public messages about monkeypox and its link with men who have sex with men.One of the web posts of this movement on this issue summarized the words of the WHO Europe regional director after these dynamics in public opinion: "It's clear that cases in other population groups (beyond MSM), including women and children, are increasing.Close-contact sexual transmission is the key mode of spread, but cases are being detected through household transmission episodes, and sometimes with no clear exposure history at all" (International Lesbian, Gay, Bisexual, Trans and Intersex Association [ILGA] 2022, n.p).