Super Gonorrhea Could Be the Next Gay Health Epidemic

As PrEP-use increases rates of condomless sex, the community may face yet another drug-resistant illness.

“It just feels better,” says Lucas, a gay New Yorker who's abandoned condoms since going on PrEP, even after experiencing multiple bouts of gonorrhea and chlamydia.

PrEP, or pre-exposure prophylaxis, is a pharmaceutical regimen consisting of a daily pill called Truvada that reduces the risk of acquiring HIV by nearly 100%. Rates of condom use have been declining for several years and the increasingly widespread adoption of PrEP may be accelerating that trend.

“I can’t stay hard for that long with a condom and I can almost never cum with one on," Lucas continues. "I take PReP and almost always only fuck raw with other people who are also on PreP, so I basically can’t get HIV. Gonorrhea and chlamydia can happen, but you just have to take a pill or get a quick shot and they’re gone."

Indeed, antibiotics are a powerful defense against many STIs, but in late March, the United Kingdom reported its first case of antibiotic-resistant gonorrhea. Will the gay community be prepared to defend itself if and when this super gonorrhea strikes the U.S.?

“We are concerned,” says Dr. Ellie Carmody, M.D., an infectious disease specialist and assistant professor of medicine at NYU Langone Health. “Increased rates of international travel clearly raise the likelihood that antibiotic-resistant infections will become intercontinental, as well. Without barrier protection, one very much increases one’s chances of acquiring gonorrhea.”

If untreated, long-term gonorrhea can cause genital swelling, infertility, and if it spreads to the bloodstream, arthritis, dermatitis, and possibly death.

Daniel Marin Medina

I have a confession to make. I was recently diagnosed with my very first sexually transmitted infection ever: anal chlamydia. Don’t worry, I took the doctor-prescribed antibiotic and told all of my recent sexual partners that they should also get tested and treated.

This is a new experience for me despite encounters with hundreds of men over 19 years. Until I started taking PrEP two years ago, I used condoms every single time I fucked. But lately, my condom use has been, let’s say, inconsistent.

For the vast majority of my gay sexual life experience, condom use was assumed by both parties. “Barebacking” was a dirty word used to describe high-risk anal sex.

“I remember a time not very long ago when even broaching the subject of barebacking would be a dealbreaker,” confirms James, another gay New York-based PrEP user.

Condomless sex was reserved for monogamous relationships, a few of which I was lucky enough to have. After long conversations with a new boyfriend and months of negotiating our mutual terror, that first time breaking each other’s metaphorical hymen was a momentous occasion. It created a bond and an intimacy that was hard to let go, prolonging some relationships past their expiration date. Until recently, barebacking was something I had experienced with only a few men.

Then PrEP happened.

Daniel Born/The Times/Gallo Images/Getty

SOWETO, SOUTH AFRICA NOVEMBER 30:(SOUTH AFRICA OUT): Thembelani Sibanda shows the Pre-Exposure Prophylaxis (PrEP), an HIV preventative drug during an interview on November 30, 2017 in Soweto, South Africa. Sibanda, who is not HIV-positive, takes a preventative drug due to his lifestyle that he feels puts him at risk of contracting the virus. (Photo by Daniel Born/The Times/Gallo Images/Getty Images)

Growing up in the '90s at the tail end of the AIDS epidemic in the United States, I had a hard time understanding how and why HIV/AIDS spread so quickly. My fourth grade sex-ed teacher demonstrated how to put a condom on a banana. It seemed easy enough. When I became sexually active in pre-9/11 America, I used condoms every time I had sex. It seemed like everyone did.

Why was using condoms so hard for so many gay men before us?

Sitting in the Golden Theater watching the 2011 Broadway revival of Larry Kramer’s The Normal Heart, I began to form an answer. The play, about a group of gay men in New York City during the height of the AIDS epidemic desperately trying to save their community, justifiably rips into President Reagan and Mayor Koch’s administrations for refusing to acknowledge the health crisis and the media’s failure to cover the story. I wept several times throughout the play. But the moment indelibly etched into my brain was when the character Mickey Marcus, played by the brilliant Patrick Breen, rants:

“I’ve spent 15 years of my life fighting for our right to be free and make love whenever, wherever… And you’re telling me that all those years of what being gay stood for is wrong… and I’m a murderer. We have been so oppressed! Don’t you remember how it was? Can’t you see how important it is for us to love openly, without hiding and without guilt? We were a bunch of funny-looking fellows who grew up in sheer misery and one day we fell into the orgy rooms and we thought we’d found heaven. And we would teach the world how wonderful heaven can be. We would lead the way. We would be good for something new.”

For the first time in my life, I understood how we (the royal we) were complicit in the spread of AIDS. We won our freedom in the sexual revolution of the 1970s and we weren’t going to let anyone take it from us. Of course, HIV/AIDS didn’t mean we had to stop fucking—it just meant we had to use condoms. But would we voluntarily give up the freedom to fuck bare? Our refusal to give up that freedom would come at an enormous cost. Hundreds of thousands would die before the gay community collectively embraced condom use.

Joan Marcus

The 2011 Broadway cast of The Normal Heart.

Fast-forward 30 years and PrEP has rewritten our “safe” sex practices, ushering in a new gay sexual revolution in which sex is no longer associated with death and disease. To many, we’ve won back our freedom.

“PrEP means not being afraid anymore,” says my friend James. “It didn't matter how proactively safe I was before PrEP. When I waited for my results from an HIV screening, I’d convince myself that because there are two possible outcomes from the test, my odds were 50-50. When I get tested now, I’m not afraid anymore.”

I initially looked at PrEP with apprehension. Condoms had kept me healthy through 17 years of sexual activity. I remained HIV-negative and never once acquired gonorrhea, chlamydia, or syphilis despite hundreds of sexual encounters. Can gay men—can I—risk abandoning the one tried and true method for staying healthy? HIV seemingly came out of nowhere. There were no warning signs. We weren’t prepared. Sex columnist Dan Savage warns, “Those of us who are old enough to remember before AIDS and after AIDS know that hitherto unknown sexually transmitted infections can emerge and kill everybody you know.”

It took nearly a generation for a majority of the community to collectively learn to practice safe sex. What happens if we forget? Indeed, young gay men entering their sexual maturity in the PReP era never experienced the mass death of the 1980s, the fear in the 1990s, and the continued paranoia of the 2000s. What happens if another super bug pops up out of nowhere? How long will it take for the entire community to learn to use condoms again? Will we be ready next time?

Tom Herde/The Boston Globe via Getty

SAN DIEGO, CA - AUGUST 13: Members of Act Up stage a protest in front of the Convention center, protesting GOP policies on AIDS awareness and Gay rights. (Photo by Tom Herde/The Boston Globe via Getty Images)

Members of Act Up stage a protest in front of the San Diego convention center in August 1996.

Those questions became a little more urgent in March when doctors in the U.K reported the country’s first case of antibiotic-resistant gonorrhea. Health officials think the patient acquired the strain from a sexual encounter with a woman in Thailand. Dr. Manica Balasegaram, director of the World Health Organization’s Global Antibiotic Research and Development Partnership, says there’s been reports of similar drug-resistant gonorrhea in the recent past in France, Japan, and Spain. Since the diagnosis in the U.K., two more cases popped up in Australia. One of those two cases also seems to have been acquired in Southeast Asia.

In 2006, the Centers for Disease Control (CDC) had five recommended treatment options for gonorrhea—now the U.S. has only one option remaining: an intramuscular injection of ceftriaxone (of the cephalosporin class of antibiotics) used in combination with an oral dose of azithromycin. The CDC reports that 30% of new gonorrhea infections each year are resistant to at least one of those two drugs.

The U.K. patient’s infection was resistant to both cephalosporin and azithromycin. When his doctors quadrupled the standard dose of cephalosporin, it still failed to work. Finally, the doctors turned to a different antibiotic called ertapenem, which is used to treat severe infections of the skin, lungs, stomach, pelvis, and urinary tract, and to prevent infections after surgery. After three days of intravenous use, the antibiotic prevailed. Follow-up tests confirmed the patient was cured.

“When used correctly, antibiotics are lifesaving medicines that fight bacterial infections,” Anne Schuchat, M.D., principal deputy director of the CDC, explains. “Antibiotic misuse—for example, taking the drugs unnecessarily, taking the wrong antibiotic, or not taking them exactly as prescribed—creates fertile ground for the growth of antibiotic resistance.”

Gonorrhea is the second most commonly reported disease in the United States. There are nearly 400,000 reported cases of gonorrhea per year, yet CDC estimates that just as many cases may go undiagnosed. A 2013 CDC report named antibiotic-resistant gonorrhea among the three most urgent threats of its kind in the country. The next year, President Obama signed an Executive Order to develop the National Strategy to Combat Antibiotic-Resistant Bacteria (CARB), a multi-pronged approach calling for the prevention, detection, and control of antibiotic resistance. In 2016, the CDC launched a new program called Strengthening the U.S. Response to Resistant Gonorrhea (SURRG). The CDC reports, “This collaboration between the CDC and health departments around the country is designed to strengthen capacity in those health departments to rapidly detect resistant gonorrhea and act quickly to stamp out transmission through rapid field investigations.”

Jose A. Bernat Bacete

Bioengineered. Scientific experiment in a Molecular Biology Laboratory with Arabidopsis seedlings, DNA extraction sequence of plants.

There may be hope on the horizon. Researchers across the world are searching for better responses. The Imperial College London and the London School of Hygiene and Tropical Medicine have tested a new antibiotic, closthioamide, on gonorrhea samples in a laboratory setting. Very low amounts of the closthioamide demonstrated effectiveness against strains of gonorrhea that were shown to be resistant to other antibiotics. The study’s results are promising, but the antibiotic has yet to be tested on animals and humans. The process for approving new drugs is slow and there’s no telling if the drugs will be ready if and when there’s a major super gonorrhea outbreak.

“We expect to see further cases of multi-drug-resistant gonorrhea in the future," Dr. Gwenda Hughes, head of the Sexually Transmitted Infection (STI) Section at Public Health England, warns. "We urge the public to avoid getting or passing on gonorrhea by using condoms consistently and correctly with all new and casual partners.” The CDC also recommends using condoms to prevent the spread of gonorrhea.

Not everyone, however, is convinced condoms will be enough to prevent a super gonorrhea outbreak.

“Ideally, it won’t get here,” hopes Reggie, a gay New York-based PReP user who frequently travels to Thailand for work. “And even if it does, using condoms won’t stop me from getting it. Let’s remember the way it’s transmitted. When it comes to gonorrhea, oral sex is just as risky.”

Unlike HIV, which can only be transmitted through bodily fluids like blood, semen, pre-seminal fluids, rectal fluids, vaginal fluids, and breast milk, gonorrhea can be transmitted through any contact with the penis, vagina, mouth, or anus of an infected person.

Daniel Marin Medina

“If a cluster of super-gonorrhea were to break out in New York, I would probably change my sexual practices,” says Tom, another gay New York PReP user. “But I don’t assume that using condoms would necessarily protect me more, since I got gonorrhea twice even when using condoms 100% of the time for anal sex. I would also have to stop sucking dicks if I wanted a true protection plan against drug-resistant gonorrhea.”

Reggie adds, “I can’t think of a single person I know that has protected oral sex.”

When I was diagnosed with this recent bout of chlamydia, the doctor treated me with the same antibiotics used to treat gonorrhea: an injection of ceftriaxone and an oral dose of azithromycin. Sure, my butt was sore for a few hours from the injection, and the azithromycin gave me a bit of a stomach ache. But the next day, my symptoms had cleared up. It seems almost too easy, right?

I worry that one day soon, if and when super gonorrhea strikes the U.S., it won’t be.

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