Supporting the mpox response for people with diverse sexual orientation, gender identity and/or gender expression in contexts where their rights are restricted

People with diverse sexual orientation, gender identity and/or gender expression (SOGIE) are a hard-to-reach population. This is because of restrictive legal frameworks, social exclusion, stigma and discrimination in service delivery. Because people with diverse SOGIE often avoid seeking healthcare at government health centres, mpox-related health services might not reach them. Contact tracing can be stymied by laws that criminalise same-sex behaviour. In contexts where sodomy laws are enforced and arrests are being made, listing same-sex partners can be akin to admitting to criminal behaviour, and providing contact details of sexual partners poses grave risks to them.

Laws that criminalise same-sex behaviour do not criminalise providing services for people with diverse SOGIE, but they justify marginalisation and can encourage discriminatory service provision. Healthcare providers and humanitarian workers supporting the mpox response need to know the framing and the impact of such restrictive laws to help them reach people with diverse SOGIE effectively without putting themselves or their patients at risk.

This brief provides a socio-behavioural analysis of the vulnerabilities, risks and resultant operational key considerations for working with people with diverse SOGIE in the mpox response. The World Health Organization (WHO) declared the second mpox Public Health Emergency of International Concern (PHEIC) in August 2024. The brief’s considerations are especially pertinent given that in the countries most affected by mpox, people with diverse SOGIE are at best stigmatised and at worst criminalised, necessitating a careful approach to ensure that they are reached adequately without creating further harms. This brief provides contextual information and practical recommendations to humanitarian aid workers and healthcare providers responding to mpox outbreaks in contexts that restrict rights related to SOGIE, with a specific focus on African settings. The brief provides an overview of the epidemiology of mpox as it relates to gay, bisexual and other men who have sex with men (GBMSM) and explains the specific medical and social vulnerabilities of this group. The brief then provides an overview of the relevant legal frameworks in the Democratic Republic of the Congo (DRC), Uganda, Nigeria and Burundi. These countries have reported high numbers of mpox cases during the most recent PHEIC, and the brief explains the consequences of each country’s legal framework for both healthcare and humanitarian aid provision.

Key considerations

• Gay, bisexual and other men who have sex with men (GBMSM), as well as other people with diverse sexual orientation, gender identity and/or gender expression (SOGIE), are a vulnerable population at risk for mpox. This vulnerability is due to criminalisation, social stigma and discrimination. These lead to social exclusion and barriers to healthcare access.
• GBMSM are at higher risk for severe mpox infection and poor outcomes because of a high prevalence of HIV among GBMSM and other social factors.
• The need for targeted risk communication for GBMSM and other people with diverse SOGIE must be balanced with the risk of reinforcing harmful stereotypes and contributing to the politicisation of sexual diversity. Community engagement and involvement are important for the mpox response – in healthcare provision, humanitarian aid and mpox-related research.
• Ensuring mpox treatment literacy is a crucial element of meaningfully involving GBMSM and people with diverse SOGIE in the mpox response. People with diverse SOGIE need to know about risk behaviours, prevention strategies, mpox symptoms and treatment options in order to make informed decisions that reduce their risk to mpox. Foregrounding mpox treatment literacy is thus an essential strategy to empower people with diverse SOGIE to develop strategies for prevention, testing and treatment.
• Mpox-related healthcare needs to centre confidentiality, informed consent and non-judgmental care. Fear of discrimination and stigma, as well as fear of being reported to law enforcement are key barriers to healthcare for people with diverse SOGIE.

Overall strategies

• Adhere to the principles of the ‘Respect, protect, fulfil’ guidelines^1,2 for research, humanitarian aid and healthcare provision.
• Follow WHO’s ‘Community-centred approaches to detection’³ to engage local communities of GBMSM and people with diverse SOGIE. Consult with affected populations (GBMSM specifically and people with diverse SOGIE more broadly) from the outset and throughout any activities.
• Develop localised strategies. Have a thorough and nuanced understanding of local contexts, local stakeholders and potential allies.
• Provide rights-based healthcare, emphasise and adhere to strict confidentiality and discretion, informed consent and community engagement.
• Partner with organisations for lesbian, gay, bisexual, transgender, intersex, queer or other diverse identities (LGBTIQ+), women’s rights or human rights. Partnerships will help provide an understanding of the local context and implications for local people with diverse SOGIE. Partnerships can also create a support and referral network outside of the formal health system.
• Embed mpox prevention and treatment services, as much as possible, into already existing services that are known to, and are affirming of, GBMSM. Treatment points for ‘key populations’ are likely to offer non-judgmental care to GBMSM and have a network of GBMSM clients. Provide training on mpox diagnosis, prevention and care to staff at key population health facilities.
• Centre discourses and risk communication on health aspects and access to healthcare. Keep descriptions of sexual transmission routes brief and factual. Work, as much as possible, with local Ministries of Health to ensure local buy-in and minimise the risk of politicisation.

The epidemiology of mpox in the current outbreak

During the first mpox PHEIC in 2022 to 2023, GBMSM were an important at-risk group. During this outbreak, mpox was frequently considered a sexually transmitted infection.⁴ In Western Europe and North America, GBMSM were the population group most at risk for mpox infection.⁵ In the WHO European region, 97% of recorded mpox cases were among GBMSM.⁶

Mpox is caused by the monkeypox virus (MPXV). Clades Ia and Ib of MPXV are largely responsible for the current outbreak in Central and West Africa, while clade IIb was responsible for the 2022-2023 outbreak.⁷ Clade 2b of MPXV spreads through close contact, most often during sexual activity. Some studies suggest it is also transmitted sexually.⁴ Clade Ia and Ib, responsible for the current outbreak in Central and West Africa, also spreads through close contact, although transmission during sexual activity is not the main recorded transmission. In the DRC, which has been the most severely affected in this second PHEIC, the mortality has been highest in children. However, there is some evidence of transmission during sexual activity, with sex workers being the main affected population.

In the current outbreak in Central and West Africa, surveillance data show little evidence of transmission among GBMSM. However, surveillance data from Central and West African countries usually does not disaggregate data based on SOGIE. A recent study from South Africa suggests that there are a substantial number of undetected cases of mpox among GBMSM,⁸ and evidence from Nigeria also points to cases among GBMSM.⁹ South Africa has legal protections against discrimination based on SOGIE.¹⁰ In other countries affected by the current outbreak, these protections do not exist. In most of the countries of the current outbreak, people of diverse SOGIE are marginalised and are considered a hard-to-reach population.¹¹ It is therefore unclear if the absence of transmission data among GBMSM reflects an absence of actual mpox transmission or a lack of data.

Globally, there is no definite information on the number of people with diverse SOGIE. Population size studies from the African continent estimate that GBMSM alone make up between 0.5% and 10% of the general population.^12,13 With such a sizeable population, people with diverse SOGIE will be affected by mpox regardless of its primary mode of transmission. Whilst people with diverse SOGIE share the risk of mpox transmission with the general population, they also face additional SOGIE-specific vulnerabilities that might place them at higher risk for transmission or of severe infection and poor outcome.

Why are people with diverse SOGIE vulnerable to mpox?

People with diverse SOGIE face two distinct, yet intersecting, vulnerabilities towards mpox. The first is that their socio-economic circumstances might place them at higher risk of transmission. The second is that prevalent comorbidities, especially HIV infection, increase their risk of severe mpox infection and a poor outcome. At the same time, the effects of SOGIE-related stigma and discrimination reduce their access to preventive healthcare, treatment and community support, which in turn compounds their risk of mpox transmission.

People of diverse SOGIE and social exclusion in African contexts

As elsewhere in the world, people with diverse SOGIE in African contexts are vulnerable to social exclusion due to a complex interplay of cultural, legal, religious and political factors.¹⁴ Historical accounts have documented the existence of diverse SOGIE in African contexts from pre-colonial times.^15,16 Nevertheless, as also experienced elsewhere, dominant social norms in African societies can frequently emphasise heteronormative family structures and rigid gender roles, factors which leave less room for acceptance of those who deviate from these expectations. This marginalisation can manifest in various forms, such as rejection by family members, harassment in schools, exclusion from employment opportunities and even violence.¹⁴

In several African countries, same-sex relationships are criminalised, with penalties ranging from fines to imprisonment – and in extreme cases, even death.¹¹ This legal environment reinforces societal rejection while also legitimising state-sponsored discrimination and discouraging individuals from openly expressing their identities.¹⁷ The lack of comprehensive antidiscrimination laws leaves people with diverse SOGIE without legal recourse when they are denied healthcare, housing or work because of their identity.¹¹ Religious beliefs, often deeply rooted in both Christianity and Islam, are also used to justify the exclusion of people with diverse SOGIE, framing them as immoral or unnatural. This rhetoric is frequently echoed by political leaders and the media, contributing to widespread misunderstanding and hostility.¹⁸

Media representations often perpetuate harmful stereotypes or erase LGBTIQ+ identities altogether, contributing to a culture that treats LGBTIQ+ people as outsiders. This leads to internalised stigma, mental health struggles and a sense of isolation among people with diverse SOGIE.¹⁹

In health emergency situations, people who identify as LGBTIQ+ face unique risks because their actual or perceived sexual orientation, gender identity or gender expression differs from dominant social and cultural norms. LGBTIQ+ individuals are at a greater risk of exclusion, exploitation, violence and abuse. They often encounter obstacles when trying to access humanitarian aid and services, including appropriate healthcare, safe shelter, gender-based violence support, education and livelihood opportunities.²⁰ Out of fear of being targeted, many LGBTIQ+ individuals hide their SOGIE, which makes it harder for humanitarian aid workers and healthcare providers to identify and support them, or to ensure they can safely access healthcare and other essential services. These obstacles are particularly severe for individuals whose affirmed gender identity does not match the gender listed on their official documents.

On a structural level, healthcare systems may also be ill-equipped to address the specific needs of people with diverse SOGIE, leading to disparities in access and quality of care.²¹ For people in intersectional positions – such as migrants or people with disabilities – the layers of marginalisation can compound, making exclusion even more severe.¹⁴ Social exclusion, in turn, limits their participation in civic life, access to resources and sense of belonging, perpetuating cycles of inequality.

People with diverse SOGIE and risk of mpox transmission

The WHO has identified several reasons why populations are at risk of mpox infection.³ Several of the reasons are especially relevant to people with diverse SOGIE in African contexts:

• Individuals in heavily populated areas, such as densely populated urban areas and informal settlements. High population density increases the risk of close contact with someone with mpox and, at the same time, limits access to hygiene facilities. Typically, economic precarity predisposes people to have to live in dense urban areas or informal settlements. This is where the intersection of SOGIE-related vulnerability arises: many LGBTIQ+ individuals experience social and economic exclusion and are at risk of economic precarity.¹⁴
• Individuals who engage with multiple sex partners. Whilst the sexuality of sexual and gender minority individuals is diverse and different for every person, some people engage in sex with multiple partners or have concurrent partners. This places them at higher risk of mpox transmission, both through close contact and sexual transmission. Sexual and gender minority communities often have close-knit sexual and social networks. The interconnected nature of sexual and social networks within these communities facilitated the rapid spread of mpox in the 2022 global outbreak (with MPXV clade IIb). Even though the spread of MPXV clade Ia and Ib in the current outbreak mostly occurs outside of sexual networks, this does not mean that GBMSM communities are not at risk.
• Individuals who engage in sex work. People with diverse SOGIE have limited economic opportunities due to social stigma and discrimination. For economic reasons, they might engage in sex work (particularly in contexts where their rights are restricted), which, in turn, increases the transmission risk for mpox.

Risk of severe disease and medical complications from mpox

The WHO states that ‘immunocompromised individuals, including those living with untreated or uncontrolled HIV infection or those who have advanced HIV disease’ are at higher risk of severe disease and medical complications from mpox.³ Emerging research from South Africa confirms that among people living with HIV, mpox has a higher mortality rate. Across sub-Saharan Africa, GBMSM are at higher risk of HIV infection than men in the general population.²² In all countries of the current mpox outbreak, studies show that estimates of HIV prevalence among GBMSM is higher than in the general population: between 4% and 13% in Burundi,²³ 24% in the DRC,²⁴ and 12% in Uganda.²⁵ GBMSM are thus at greater risk for severe disease and medical complications from mpox, regardless of the transmission route.

These vulnerabilities are influenced by the wider social contexts in which GBMSM live. Most countries on the African continent have restrictive legal frameworks, as well as conservative social and political attitudes towards sexual and gender diversity.

Implications for the mpox response

People with diverse SOGIE are vulnerable to mpox transmission because of their SOGIE-related social exclusion or because of their sexual practices, or both. Because people with diverse SOGIE are an at-risk population for HIV, GBMSM also have a higher risk of severe disease and medical complications from mpox. This risk is compounded by SOGIE-related barriers to access to healthcare, including specific barriers for mpox testing and treatment, as well as to obtaining vaccinations.

The WHO emphasises that addressing mpox effectively requires collaborating with the most affected communities.²⁶ As outlined, GBMSM in Central and West Africa are at risk of mpox transmission due to their social circumstances. They also live in socio-legal contexts characterised by the criminalisation of same-sex behaviour, as well as politicised homophobia and social stigma. In many cases, these risks are complicated by existing co-infection with HIV.

Practical considerations for engaging people with diverse SOGIE in the mpox response

When engaging people with diverse SOGIE in the mpox response, healthcare providers and humanitarian aid workers will encounter the arguments between providing rights-based healthcare and dominant norms linked to culture and morality. It is crucial to be clear about the legal framework: receiving evidence-based healthcare is a right that is applicable to all citizens of a country, regardless of their SOGIE. Providing such healthcare is not prohibited under laws that seek to restrict same-sex sexuality or expressions of diverse SOGIE.

Any healthcare provider, humanitarian aid worker or researcher working with people with diverse SOGIE, or addressing health concerns related to SOGIE, enters a contested field, which is further described in the sections below. They must position themselves (and are inevitably positioned) within a push-pull of the various powers that play out in these contestations. They might encounter attempts to politicise their healthcare provision.

Mpox risk communication and community engagement (RCCE) and healthcare provision have to be evidence-based and adhere to medical ethical obligations and standards. They also have to mitigate existing harms related to stigma and criminalisation, and also ensure that they are not contributing to these harms. The section below provides practical advice.

Centring rights-based healthcare

To counter stigmatisation, harmful stereotypes and politicisation, mpox response efforts for people with diverse SOGIE must be grounded in human rights principles, emphasise equality and shared responsibility, and challenge stigma by promoting accurate, inclusive and respectful messaging that affirms the dignity of all people. Again, the HIV response can be helpful to understand what this could look like: the essential argument is that it is in the interests of everyone’s health to ensure easy access to healthcare services for people with diverse SOGIE.

Through a rights-based approach, the HIV response for GBMSM in African countries has aimed to deliver healthcare grounded in dignity, equality and without discrimination, even in environments where homosexuality is highly stigmatised or criminalised. Recognising GBMSM as an important population at heightened risk of HIV, this approach focuses on ensuring access to services without fear of judgment, violence or legal repercussions. This approach has worked by centring a rights-based approach to healthcare – emphasising confidentiality, informed consent and community engagement. Engagements with government officials have emphasised the need for adequate healthcare services to ensure pandemic control, regardless of considerations of public morality related to specific risk behaviours. In many countries, community-led organisations have played a crucial role, using peer outreach, safe spaces and mobile clinics to build trust and reach GBMSM who avoid mainstream healthcare due to fear of disclosing their SOGIE or mistreatment.²⁷ These initiatives operate discreetly, centre confidentiality and collaborate with sympathetic healthcare providers trained in SOGIE sensitivity, allowing services to be delivered in hostile legal and social climates. The initiatives often employ strategic invisibility to avoid the politicisation of their healthcare services. Rights-based strategies go beyond healthcare delivery to also involve advocacy to push for policy change, the removal of legal barriers and the protection health rights for GBMSM.

Through this approach, international agencies, in collaboration with local governments, have increased HIV surveillance, HIV testing, adherence to HIV treatment and HIV prevention uptake among GBMSM across African contexts. The main priorities of this approach have been safety, respect and community ownership. These should also be important priorities for engaging people with diverse SOGIE in the mpox response. As a result of different local contexts, the mpox response aimed at GBMSM and people with diverse SOGIE will need to be adapted to these different contexts, and there can be no one-size-fits-all approach. The local political, legal and social circumstances will need to be considered in deciding how to engage people with diverse SOGIE, what RCCE efforts to employ and how to engage with government officials.

Considerations for humanitarian aid workers and healthcare providers

Healthcare providers and humanitarian aid workers should offer inclusive and non-judgmental care for people with diverse SOGIE. Confidentiality is the most important aspect of this care, especially in contexts where SOGIE-related rights are restricted.

Legal aspects

• Providing healthcare to GBMSM and other people with diverse SOGIE is not
• Confidentiality of the physician-patient encounter is paramount. The existing laws that criminalise same-sex behaviour do not require healthcare providers to report knowledge of same-sex behaviour.
• Healthcare provision should be guided by the Hippocratic oath and ethical guidelines, which emphasise confidentiality and non-judgmental healthcare provision (regardless of a patient’s SOGIE).

Community engagement

• According to the WHO, ‘building community partnerships is an essential strategy for health promotion, risk communication, detection and care for mpox patients across all levels of the response’.³ This is even more important for engaging GBMSM and other people with diverse SOGIE.
• Seek out collaborations with organisations that provide services to GBMSM or other people with diverse SOGIE. Where these do not exist, seek out collaborations with human rights or women’s rights organisations who might be willing to work on issues related to SOGIE. Partner with these organisations to support health promotion, risk communication and detection of possible mpox cases.³
• Prioritise local involvement to understand the local context, adequately assess local risks and be able to provide appropriate referral and support.
• Ensure that people with diverse SOGIE have the knowledge they need to understand their mpox risk and mpox symptoms, and to have access to adequate mpox prevention, testing and treatment.
• Engage with GBMSM and other people with diverse SOGIE as early as possible and throughout the mpox response. This includes consulting on programme approach, framing, risk communication materials, healthcare provision and engagements with local government.

Working with colleagues

• Encourage non-judgmental and inclusive service provision among colleagues.
• Be prepared to counter stereotypes, stigma or blame if you encounter it.

Direct care for GBMSM and other people with diverse SOGIE

• Mpox-related healthcare needs to centre confidentiality, informed consent and non-discriminatory care. Be non-judgmental in all interactions.
• Understand the social and clinical mpox vulnerability of people with diverse SOGIE.
• Strictly adhere to ethical healthcare provision guidelines: always ensure and guarantee strict confidentiality.
• Use gender-neutral language.
• Ensure that patients with diverse SOGIE have mpox treatment literacy.
• Be prepared to ensure safety beyond the consulting room – be prepared to link to civil society organisations or lawyers, or both, should your patients need assistance.

Risk communication

• Provide clear and targeted risk communication to GBMSM and other people with diverse SOGIE. GBMSM networks are frequently close-knit, and LGBTIQ+ organisations have a wide reach to GBMSM and other people with diverse SOGIE. To avoid harmful visibility and stigma, disseminate targeted risk communication material through existing networks and organisations rather than through the media.
• Be cautious when communicating with local media since ‘overemphasis on the role of sexual transmission can result in stigma’³. Communications should focus on transmission routes (rather than sexual identities) and avoid moralising judgments.

Considerations for researchers

Laws criminalising sexual and gender diversity, in combination with the social and institutional prejudice that is enabled by these laws, increase research-related risks for individual LGBTIQ+ research participants, local partner organisations and academic researchers. At the same time, in contexts where LGBTIQ+ people’s rights are contested, research knowledge on sexual orientation, gender identity and health disparities is powerful scientific evidence that shapes law, policy and public discourse. For example, research findings that showed a disproportionate burden of HIV among GBMSM, coupled with research findings that showed how people with diverse SOGIE encountered barriers in accessing healthcare due to discrimination, convinced the High Court of Botswana to decriminalise same-sex sexuality in 2019. Conversely, the Constitutional Court of Kenya, also in 2019, refused to decriminalise same-sex sexuality. The court said that the research evidence it saw had not been based in Kenya and was thus insufficient.

It is crucial that research recruitment includes participants with diverse SOGIE so that SOGIE-related particularly vulnerabilities can be delineated more accurately and provide an evidence base to inform an appropriate response. This means recruiting participants with diverse SOGIE as well as recording participants’ SOGIE in the data. Given the potential vulnerabilities of people with diverse SOGIE, researchers need to ensure ethical practice for safe participation.

A main resource for research involving GBMSM in rights-restricted African contexts is Respect, Protect and Fulfil: Best Practices Guidance in Conducting HIV Research with Gay, Bisexual and Other Men who Have Sex with Men (MSM) in Rights-Constrained Environments.^1,2 Initially published in 2011,¹ a revised version with additional case studies was published in 2015.² These guidance documents focus on studies related to HIV, but their lessons and recommendations are equally important for mpox-related research. They serve as a vital tool for researchers and community organisations, offering practical guidance on how to design and implement meaningful research with GBMSM in rights-restricted contexts. They include comprehensive checklists of considerations and share valuable insights through case studies, helping to inform ethical and effective research practices. The guidance documents underscore the complexity of developing and executing community engagement strategies and highlight the importance of context-specific and study-tailored approaches. Importantly, guidance documents stress the importance of flexibility: researchers should continually reassess and adapt their community engagement methods and activities in response to evolving challenges, political developments, community dynamics and emerging needs.

The following considerations for researchers are adapted from research and guidance documents.^2,28

Research risks and disadvantages

• Identify potential risks and disadvantages related to the socio-legal environment; involve local GBMSM representatives in these assessments.
• Continually reassess and adapt your community engagement methods and activities.
• Ensure that referrals are in place for support and care (including psychosocial and legal support).

Research ethics

• Involve local GBMSM in all assessments of research ethics at all stages of the research to identify potential risks and mitigation strategies before, during and after the research process.
• Where a review by institutional or government research approval boards might contribute to safety risks for local partners or study populations, consider establishing a community review board instead.

Structural inequity and injustice

• Engage with structural inequalities in locally appropriate ways.
• Understand the socio-politico-legal context.
• Build links, collaborations and networks with stakeholders who can make a positive change in policy and practice.

Understanding sexual and gender diversity

There are many different terms used today to describe people with diverse sexual orientations, gender identities and gender expressions. While recognising that language continues to change, this brief uses the terms ‘people with diverse SOGIE’ as an inclusive way to refer to people whose identities or characteristics do not fit dominant ideas of male and female binary gender roles. See Appendix 1 for a list of terminology and acronyms related to sexual and gender diversity.

The socio-legal context of people with diverse SOGIE in Central and East Africa

Legal frameworks criminalising same-sex behaviour, homophobia, transphobia, discrimination and human rights violations can pose challenges for humanitarian aid workers, healthcare providers and researchers wanting to provide mpox-related services to sexual and gender minority populations. Such legal frameworks contribute to the marginalisation of these populations and can make these populations difficult to reach. This section explains the laws, policies and social contexts that have an impact on sexual and gender minority populations in Burundi, the DRC, Nigeria and Uganda, the countries most affected by the current mpox outbreak. Appendix 2 has an overview of all relevant laws in these countries.

Legal frameworks related to people with diverse SOGIE

There are several laws that affect people with diverse SOGIE and their access to healthcare, as well as the provision of healthcare to GBMSM. These laws include relics from British colonial penal codes related to sexual behaviour, laws that provide protection from discrimination and laws that affect access to and availability of health-related information.¹¹ Importantly, none of the existing laws make it illegal to identify as gay, bisexual or a man who has sex with men. Instead, these laws criminalise sexual behaviour. This is an important distinction. None of these laws prohibit providing healthcare to GBMSM or other people with diverse SOGIE. However, the laws contribute to an environment of state-endorsed homophobia and transphobia. As a consequence of such laws, healthcare workers may refuse to provide services to LGBTIQ+ patients, report LGBTIQ+ patients to the authorities or discriminate against LGBTIQ+ patients in health facilities.²⁹

Over the past 20 years, African governments who inherited British colonial sodomy laws have expanded these, leading to an extension of criminalised activities or a harshening of punishments, or both. Also, across most countries, laws and discourses related to people of diverse SOGIE have become increasingly politicised. Politicians and leaders introduce new anti-homosexuality laws to reinforce notions of pan-African opposition to what they assert as new forms of Western imperialism.³⁰ Such efforts are frequently backed by evangelical groups, mostly from the United States of America.³¹

Parliamentary debates about new laws, as well as court cases challenging existing laws, have become heavily politicised public spectacles during which government officials denounce homosexuality in order to limit political dissent and consolidate political power.¹⁸ It is important to understand these developments and their impact on the health and health-seeking opportunities for people of diverse SOGIE.

Burundi

Article 22 of the Constitution of Burundi guarantees every person equality before the law.³² The same article states that people might not be discriminated against on the basis of sex. The constitution guarantees every person the right to access healthcare (Article 55).³²

However, Burundi criminalises same-sex sexual activity under Article 567 of its Penal Code,³³ which explicitly prohibits sexual relations with someone of the same sex. Penalties include fines and imprisonment for up to two years. Under the constitution, marriage between persons of the same sex is forbidden (Article 29).³² In recent years, Burundian authorities have made several arrests under this law. In 2023, law enforcement took attendees of an HIV educational workshop into custody and charged them with ‘homosexual practices’.³⁴ As a response to this incident, the president of Burundi publicly stated that homosexuals should be stoned in stadiums.¹¹ Beyond the criminalisation of same-sex sexual activity, a 2024 report by ILGA World documents that Burundi has implemented measures to ban and confiscate books and educational content on sexual and gender diversity.¹¹ Given the conflation of HIV education and advocacy with homosexuality during the 2023 arrests, it is possible that authorities might interpret this to include other health-related information aimed at sexual and gender minority populations.

DRC

Article 47 of the Constitution of the DRC guarantees the right to health.³⁵

Same-sex sexual activity is not explicitly criminalised. However, it has been reported that new legislation was proposed in 2024, with the aim of criminalising same-sex activity as well as ‘acts and gestures assimilated with homosexuality’.¹¹ At the time of writing, it is unclear whether this legislation will be passed.

In general, sexual and gender minority individuals face widespread discrimination and societal stigma. Homosexuality is stigmatised and politicised. In the past, government authorities have made public statements that characterised ‘homosexuality and lesbianism, along with their associated practices’ as ‘degrading’ and ‘unconstitutional’.¹¹ In 2023, the local media oversight body issued restrictions on content related to sexual and gender diversity, and demanded that media outlets do not participate in ‘promoting homosexuality’ – a phrase usually used to denigrate opinions that do not expressly condemn sexual and gender diversity.¹¹

The legal environment does not provide specific protections against discrimination based on sexual orientation or gender identity, leaving sexual and gender minority individuals vulnerable to various forms of abuse and marginalisation.

Nigeria

The Constitution of Nigeria guarantees the right to health.³⁶ It mandates that the state’s policy should prioritise the health, safety and welfare of all persons, including access to adequate medical and health facilities.

In Nigeria, same-sex behaviour is criminalised through a mix of federal, state and customary laws.¹¹ At the federal level, both the Criminal Code Act of 2004 and the Penal Code (Northern States) Federal Provisions Act of 1959 prohibit same-sex sexual acts. In addition, 12 northern states have implemented Sharia Penal Codes, which impose severe penalties – including the death penalty and corporal punishment – for same-sex behaviour. These also outlaw diverse gender expressions. The Same-Sex Marriage (Prohibition) Act of 2013 further bans same-sex marriages and civil unions. Notably, Section 7 of the Act defines civil unions in broad terms, effectively criminalising various forms of same-sex relationships. Public displays of ‘same-sex amorous relationships’ are also punishable under this law.

In recent years, there has been considerable evidence of the law being actively enforced, with LGBTIQ+ individuals frequently facing arrest – both individually and in groups – often accompanied by police violence and brutality. Reports have consistently documented ongoing discrimination and violence against LGBTIQ+ people, including assaults, mob attacks, harassment, extortion and denial of basic rights and services.³⁷

State officials intimidate people with diverse SOGIE through public rhetoric and incite negative sentiments against sexual and gender diversity. In 2024, the Nigeria Police Force – the country’s primary law enforcement and security agency – issued a press release in response to a social media video featuring individuals openly identifying as LGBTIQ+.¹¹ In the statement, police announced that arrest orders had been issued for all those appearing in the video and suggested that simply identifying as queer could be considered a crime. Police further called on the public to report ‘suspicious activities’ and to assist law enforcement by providing relevant information.

Any public information about sexual and gender diversity runs the risk of being highly politicised. In 2023, Nigerian officials sought to ban an educational book because it used the word ‘gay’ to denote ‘happy’ – officials named it ‘immoral’ educational content and argued that this was an attempt to subvert public morality and to ‘intentionally’ introduce ‘a pro-LGBT’ stance’.¹¹

Uganda

Same-sex sexual activity is illegal in Uganda. The original Penal Code was introduced during British colonial rule when British laws were imposed on Uganda. After independence, Uganda kept these laws and, in recent years, has repeatedly tried to make them stricter. Under the Penal Code of 1950, acts described as ‘carnal knowledge against the order of nature’ and ‘gross indecency’ are criminal offences, with penalties of up to life in prison. In May 2023, the government introduced a new law – the Anti-Homosexuality Act 2023 – which expanded existing laws targeting LGBTIQ+ people. This new legislation introduced harsher punishments, including the crime of ‘aggravated homosexuality’, which carries the death penalty for repeat offenders. Both men and women can be prosecuted under these laws.

There is strong evidence that these laws are being actively enforced.³⁸ People with diverse SOGIE are regularly arrested, often in large groups, and may be held without charge. Reports describe abuses such as forced anal examinations and other forms of mistreatment while in custody. Discrimination and violence against LGBTIQ+ people remain widespread, including cases of assault, harassment, extortion and denial of services.³⁹ Human rights organisations have documented the extent to which the Anti-Homosexuality Act has impacted the lives of LGBTIQ+ people since its enactment in 2023. A report shows that in the period of July to August 2023, LGBTIQ+ persons were subjected not only to state-sanctioned arrests and arbitrary investigations but also evictions, beatings and blackmail from state and non-state actors.³⁹ Such an atmosphere of fear has important consequences for people’s health and ability to seek healthcare.

The Anti-Homosexuality Act of 2023 initially also limited healthcare access for LGBTIQ+ individuals, criminalised the act of renting property to them and imposed a duty to report suspected acts of homosexuality. The duty to report suspected acts of homosexuality also applies to healthcare providers. Importantly, the Constitutional Court of Uganda struck down those specific provisions in 2024, saying that they violated the right to health and the right to privacy.

Socio-legal vulnerability: the impact of discrimination on access to healthcare

Whilst most of these laws criminalise sexual behaviour, their effect is more widespread. SOGIE-related stigma and discrimination are major barriers to healthcare access for people with diverse SOGIE in many African contexts, especially in contexts where restrictive laws are actively enforced.⁴⁰ Where healthcare policy does not recognise sexual and gender diversity, institutional healthcare spaces remain hostile to people with diverse SOGIE.⁴¹ This prevents people with diverse SOGIE from receiving timely, appropriate and respectful healthcare services. Healthcare providers may hold prejudiced views or lack understanding of diverse SOGIE, leading to verbal abuse, denial of care or breaches of confidentiality.⁴² As a result, many people with diverse SOGIE avoid formal healthcare systems out of fear of discrimination, mistreatment or being outed. This is especially true for people seeking care related to sexual or mental health, including HIV-related care, during which they might have to disclose their SOGIE. In response, many people with diverse SOGIE turn to alternative sources of care, such as community-based clinics, informal networks or LGBTIQ+-led organisations that offer safe, affirming and confidential services: in a 2019 study across Southern and East Africa, nongovernmental organisations were the primary source of healthcare for people with diverse SOGIE.⁴³ These alternative providers often fill critical gaps, offering peer support, counselling, HIV testing and treatment, and health education tailored to the needs of people with diverse SOGIE.

Implications for the mpox response

People of diverse SOGIE are a hard-to-reach population. This is because of restrictive legal frameworks, social exclusion and stigma and discrimination in service delivery. Because people with diverse SOGIE avoid seeking healthcare at government health centres, mpox-related health services might not reach them. Contact tracing can be stymied by laws that criminalise same-sex behaviour. In contexts where sodomy laws are enforced and arrests are being made, listing same-sex partners can be akin to admitting to criminal behaviour, and providing contact details of sexual partners poses grave risks to them.

Laws that criminalise same-sex behaviour do not criminalise providing services for people with diverse SOGIE, but they justify marginalisation and can encourage discriminatory service provision. Healthcare providers and humanitarian workers in the mpox response need to know the framing and the impact of such restrictive laws, so that they can effectively reach people with diverse SOGIE without putting themselves or their patients at risk.

Visibilities: Harms and opportunities

To effectively reach GBMSM in the mpox response, it is important to clearly communicate transmission risks and options for prevention in a way that takes SOGIE-specific vulnerabilities into account. This means that information needs to address the specific social circumstances or the specific sexual behaviours that place GBMSM at risk. However, such information can inadvertently reinforce harmful stereotypes, apportion blame or contribute to the politicisation of sexual and gender diversity. As outlined in the legal section above, unless sexual and gender diversity is framed as explicitly bad in public communication, such communication can be perceived or be framed as ‘promotion of homosexuality’. This is especially the case in contexts where homosexuality is heavily politicised. It is therefore important to understand the risks associated with visibility; for this, it is helpful to turn to lessons learned from the HIV response.

Reinforcing stereotypes and apportioning blame

In African countries, the HIV response for GBMSM has increasingly focused on recognising GBMSM as an important population at higher risk of infection.⁴⁴ Such efforts to prevent and treat HIV, while crucial for public health, have at times unintentionally reinforced prejudicial stereotypes about GBMSM. In many contexts, particularly where same-sex relationships are stigmatised or criminalised, the association between HIV and men who have sex with men has been framed in ways that portray GBMSM as vectors of disease or inherently risky.⁴ Public health messaging, research and media coverage have often focused disproportionately on GBMSM as a ‘key population’. Whilst the strategy has been successful in widening health service coverage to GBMSM,⁴⁵ it has also inadvertently foreground GBMSM as carriers of disease, fed into colonial discourses of Africans as ‘hypersexual’⁴⁶ and reinforced stereotypes of gay and other men who have sex with men as inherently ‘promiscuous’, foregrounding their sexual behaviour over any other aspect of their sexual or gender identity.⁴

The public health focus on GBMSM, while intending to highlight their heightened vulnerability, can inadvertently reinforce the idea that HIV is primarily a ‘gay disease’. This framing has fuelled moral panics, social stigma and discrimination, suggesting that GBMSM are to blame for the spread of HIV rather than acknowledging the structural barriers – such as lack of access to healthcare, stigma and criminalisation – that increase their risk. In some cases, health campaigns have lacked nuance or cultural sensitivity, reinforcing harmful narratives instead of promoting empathy and understanding. In this way, HIV has been leveraged to legitimise and justify preexisting homophobic, transphobic and racist agendas.⁴⁷

The politicisation of sexual diversity

Struggles over the rights of people with diverse SOGIE have become the ‘new frontier’ in culture wars from Argentina to Zimbabwe.⁴⁸ Located in complex global power dynamics, these struggles have come to be seen as part of a wave of neocolonial globalisation that threatens not only the sovereignty and traditional values of individual countries, but also their economic independence. At the same time, national governments have identified sexual orientation and gender identity as new grounds on which the nation and citizens can be constructed.⁴⁹

Politicised homophobia refers to the deliberate use of anti-LGBTIQ+ sentiment by political leaders and institutions to serve political agendas – often to gain popular support, deflect attention from governance failures or assert national identity in opposition to perceived Western values.¹⁸ It operates by framing homosexuality as ‘un-African’ and morally deviant, leveraging deeply rooted cultural, religious and nationalistic beliefs. Political actors may pass, enforce or strengthen anti-LGBTIQ+ laws, spread inflammatory rhetoric or scapegoat LGBTIQ+ communities to galvanise public opinion. This tactic is often intensified in response to the growing visibility of people with diverse SOGIE, particularly through advocacy, media representation and health-related programming.⁵⁰

Efforts to prevent and treat HIV among GBMSM, though crucial for public health, have sometimes been co-opted into these narratives. Targeted HIV interventions for GBMSM have been portrayed as evidence of a foreign LGBTIQ+ ‘agenda’, leading to increased suspicion and backlash.¹⁸ Instead of being seen as health-focused, these programmes are framed by opponents as promoting homosexuality. As a result, GBMSM and broader populations with diverse SOGIE are further stigmatised, undermining both their safety and access to healthcare. Politicised homophobia not only perpetuates discrimination but also hampers public health efforts and deepens social exclusion.

Implications for the mpox response

Mpox-related programmes and interventions must adhere to ethical healthcare standards and respect human rights, including for people with diverse SOGIE. Healthcare providers and humanitarian aid workers should be willing to challenge discrimination and criminalisation. At the same time, this needs to be done thoughtfully and always after a thorough assessment of potential harms. This means that there needs to be a context-specific approach to the mpox response for people with diverse SOGIE.

Mpox RCCE efforts should be targeted at specific at-risk populations, including GBMSM specifically and people of diverse SOGIE broadly. This approach ensures that at-risk populations have appropriate knowledge to minimise transmission risk, and to build trust and encourage health-seeking behaviour for prevention and care. RCCE should consider the impact of legal and social stigma. At the same time, RCCE efforts need to be context-appropriate to reduce the risk of harmful visibility and political backlash.

All RCCE efforts should be designed in partnership with local civil society organisations, including HIV service providers, others who are aware of SOGIE-related needs and communities of people with diverse SOGIE.

Further resources

Overview of laws and policies related to people with diverse SOGIE:

• Mendos, L. R., & Rohaizad, D. R. (2024). Laws on us: A global overview of legal progress and backtracking on sexual orientation, gender identity, gender expression, and sex characteristics, 1st Edition. ILGA World.
• ILGA World database with frequently updated country profiles for socio-political information.

Establish healthcare points for GBMSM in response to mpox:

• amfAR, The Foundation for AIDS Research, International AIDS Vaccine Initiative (IAVI), Johns Hopkins University – Center for Public Health and Human Rights (JHU-CPHHR), & United Nations Development Program (UNDP). (2015). Respect, protect and fulfil: Best practices guidance in conducting HIV research with gay, bisexual, and other men who have sex with men (MSM) in rights-constrained environments. Revised November 2015.
• UN Refugee Agency – UNHCR. (2025, January 27). Protecting lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ+) persons. UNHCR Emergency Handbook.

Helpful case studies of community engagement programmes in rights-restricted contexts:

• World Health Organization. (2014). On the ground: Programmes serving the needs of key populations (No. WHO/HIV/2014.50).
• World Health Organization. (2025). Interim guidance on strengthening community detection and response during the mpox outbreak.
• National LGBT Health Education Center. (2016). Providing inclusive services and care for LGBT People: A guide for health care staff.

Appendix 1. Terminology and acronyms related to sexual and gender diversity

Adapted from resources from the UN Refugee Agency (UNHCR) ²⁰ and the National LGBT Health Education Center.⁵¹

Source: Author’s own.

Appendix 2. Overview of laws affecting people with diverse SOGIE

Information based on Human Dignity Trust, Country Profiles: https://www.humandignitytrust.org/ (accessed 25 April 2025).

Burundi

Source: Author’s own.

Nigeria

Source: Author’s own.

Uganda

Source: Author’s own.

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Authors: Alex Müller (Charité Center for Global Health and University of Cape Town).

Acknowledgements: Mark Heywood, Tessa Lewin, Hayley MacGregor and Megan Schmidt-Sane reviewed the brief and provided feedback. Editorial support provided by Harriet MacLehose. This brief is the responsibility of SSHAP.

Suggested citation: Müller, A. (2025). Supporting the mpox response for people with diverse sexual orientation, gender identity and/or gender expression in contexts where their rights are restricted. Social Science in Humanitarian Action Platform (SSHAP). www.doi.org/10.19088/SSHAP.2025.023

Published by the Institute of Development Studies: May 2025.

Copyright: © Institute of Development Studies 2025. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

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