How to Handle the Rise of an Antibiotic-Resistant STI

Australian adult performer Peggysue Winters first noticed the pain in her abdomen while masturbating.

It was a pinching, pinpoint pain that got worse when she moved her torso.

When she got checked by her doctor, she was sent home with a recommendation to take ibuprofen.

Then the pain got worse. Much worse.

It would be two months before Winters learned she had a sexually transmitted infection called Mycoplasma genitalium.

The infection, commonly referred to as Mgen, resulted in flu-like symptoms and the development of pelvic inflammatory disease, which caused scar tissue to grow between Winters’ internal organs, creating debilitating pain. It took several rounds of antibiotics, abdominal surgery to separate her organs from scar tissue, and nine months off work before Winters was back on her feet.

While she no longer has chronic pain, she said, intercourse can still be painful. The infection also left her infertile.

“I’d never heard about Mycoplasma genitalium until I contracted it,” Winters said. “How can anyone know to test for this if they don’t know it exists?”

The Tyee spoke with sex workers in Canada, the United States and Australia who said they only learned about Mgen in the last year and have been pushing for more access to testing and treatment ever since.

But getting screened for Mgen is more complicated than getting checked for other STIs, according to sexual health experts.

To start, doctors don’t recommend screening for Mgen unless you have symptoms, said Dr. Troy Grennan, physician lead for the provincial HIV/STI program at the BC Centre for Disease Control.

Generally, if you feel healthy, then you don’t need to worry about Mgen, he said, adding that even if you have an asymptomatic infection it’s possible for your body to fight it off on its own.

But if patients experience pelvic pain, discharge or vaginal bleeding after sex, or have inflammation of the urethra or cervix, they should see their doctor, as these symptoms can be associated with Mgen. Mgen may also cause preterm delivery, miscarriage and pelvic inflammatory disease, which can lead to infertility.

Like herpes or HPV infections, Mgen is not a reportable disease in Canada, so the exact number of infections aren’t known, Grennan said. He estimates less than five per cent of the population has Mgen.

Dr. Catriona Bradshaw, an expert in Mgen, said between one and two per cent of a population is usually infected.

Bradshaw is the head of the genital microbiota and mycoplasma group at the Melbourne Sexual Health Centre, a department of the Alfred Hospital and Monash University in Australia. She’s also a professor at Monash and the University of Melbourne.

In Australia it’s estimated around 1.6 per cent of the population (or 400,000 people) has Mgen. Infection rates are closer to 1.7 per cent in the United States.

While similar national estimates don’t exist for Canada, a 2023 study found that up to 5.7 per cent of men living in Montreal who have sex with men have Mgen. A 2013 Toronto study found 4.5 per cent of men and 3.2 per cent of women had Mgen.

Bradshaw said estimates on how many of those infections could develop into pelvic inflammatory disease are mixed, but that in general an Mgen infection doubles your risk of developing pelvic inflammatory disease.

People with internal sex organs are more likely to develop pelvic inflammatory disease after contracting gonorrhea, followed by chlamydia, than they are from Mgen, Bradshaw said. She’s seen research that screened people with internal sex organs who had pelvic inflammatory disease for Mgen and found around 6.5 per cent of patients had an infection, she said.

Why doctors don’t screen for Mgen

In general, it’s not recommended to screen people for Mgen, despite the fact that the STI can pass between sexual partners and cause varying levels of illness from person to person, said Bradshaw and Grennan.

Bradshaw said it’s important to understand the difference between screening and testing.

Screening for an STI means you check if a healthy person with no symptoms has an infection, she said. Testing for an STI is when you have evidence that something is causing harm and use a test to confirm the infection.

If a person has symptoms, they should be tested, agreed Grennan and Bradshaw. But if you’re healthy, a doctor will likely be hesitant to screen for Mgen.

This is mainly because of concerns around antibiotic resistance.

Two decades ago, doctors could cure Mgen with the “highly effective and cheap” antibiotic azithromycin, Bradshaw said. But over time the Mgen bacterium that could be killed off using azithromycin died off, and a resistant strain survived and spread. Bradshaw said that today around 50 per cent of global cases are resistant to azithromycin, with closer to 80 per cent resistance among men who have sex with men.

The second antibiotic used to fight Mgen is moxifloxacin, which is “not widely available, highly expensive and can cause serious drug interaction that can lead to fatality and cause very serious side-effects,” Bradshaw said. Moxifloxacin also can’t be used during pregnancy.

In Australia around 25 per cent of Mgen infections are now resistant to moxifloxacin too, Bradshaw said. Mgen researchers are looking for other treatments. In the meantime, she said, they have a number of antibiotics up their sleeves and can cure between 60 and 70 per cent of infections.

“But we’re still left with a small percentage of patients with an incurable infection and don’t have the antibiotics to cure them,” she said.

Grennan said the same two antibiotics are used in Canada and similar antibiotic resistance has developed here. He said the third line of defence is an antibiotic called pristinamycin, but it's hard to get in Canada.

All antibiotics have risks, and sometimes you have to use “pretty big guns” to treat Mgen, Grennan said. “If the infection isn’t causing harm, then treatment is an unnecessary risk,” he added.

Bradshaw said she sees patients who had been screened by their family doctor, test positive for Mgen and “have had multiple courses of antibiotics.” It has become an incurable infection but it has “never caused them any symptoms at any time,” Bradshaw said.

In general if a patient tests positive for Mgen and wants to get treated, a doctor will work with them to do that, Grennan said. In Canada there’s also a policy of contact tracing and treatment, where when a person tests positive for Mgen all of their sexual partners within the last 60 days will also be treated with the same antibiotic.

But what is supposed to happen with Mgen and what actually happens can be a different story, said B.C.-based adult performer Sarah Moon.

Moon had sexual contact with Winters a little over a year ago while the pair were producing content together. A couple of months later, Moon got a call from Winters letting her know she’d tested positive for Mgen and that Moon should go get checked.

Grennan said Mgen transfers between genital fluids and that penetrative sex carries the highest risk of transfer, but oral sex or sharing toys could also transfer the bacteria. There’s about a one in two chance an infection can pass between same-sex partners.

The problem was Moon couldn’t find a B.C.-based clinician who knew what Mgen was, let alone how to test for it. No doctors she spoke with seemed to be aware of the policy Grennan told The Tyee about, which should have ensured Moon got treatment right away without being tested.

Moon said she asked to be tested at five different medical clinics across the province and spoke to several different clinicians before finding someone willing to look up the infection and test her for it. She said she asked the clinic to email her test results and never heard back.

“I had to take time off work,” Moon told The Tyee. “I couldn’t ethically shoot with someone with this hanging over my head.”

Finally, in September, six months after getting the call from Winters, Moon flew to Australia to visit a clinic in Melbourne that tests people for Mgen if they have been exposed or are symptomatic.

“I had to fly to the other side of the world,” Moon said, exasperated.

Grennan said Moon should have been treated right away using the same antibiotic Winters was treated with. However, as she never developed symptoms and tested negative, it’s likely she was never infected or cleared the infection on her own, he said.

Not every doctor will be fully up to speed on STIs, Grennan said. While that’s understandable, he said, he recommended they contact the clinical experts at the BCCDC STI program if they have any questions. Patients wanting to speak with those clinical experts can visit the BCCDC STI clinic near City Hall in Vancouver, Grennan said. The clinic is open six days a week and is free and confidential, and patients are not required to be enrolled in B.C.’s provincial health care.

Grennan said that if a healthy-seeming patient with no symptoms asked to be screened for Mgen, he’d have a discussion with them about the risks of the STI and why clinicians don’t want to screen for Mgen.

Why sex workers disagree with the current public health strategy

B.C. sex worker GoAskAlex said that a person has a right to know if they have an STI that they could pass to partners.

“Everyone should have the ability to at least get tested,” she said. “Even if you’re not going to be treated for it, it will impact your choices around who you are intimate with and what barriers you use.”

Alex said she learned about Mgen when Winters posted a video about her experience with the STI on Instagram.

Alex said she was “really shocked” to learn there was an STI she had never heard of. She said she found it “really unsettling” to learn she was at risk of contracting an STI despite the regular testing she and her co-workers do for their jobs.

All of the adult performers The Tyee spoke to said that it is industry standard to get tested for STIs every two weeks. In B.C. that means getting checked for chlamydia, gonorrhea, HIV, syphilis and hepatitis C. Testing is also available for herpes, human papillomavirus, hepatitis A and B and trichomoniasis if a recent sexual partner tests positive or if you think you’ve come in contact with an infection.

Alex said Mgen should be added to the list, noting how south of the border, adult performers are expected to get tested for Mgen every 30 days.

Oregon-based adult performer Corwin Prescott said U.S. industry standards are generally set by the Performer Availability Screening Service, which lets performers easily track and share their screening results. As of Nov. 13, PASS required a monthly Mgen test.

Independent performers working outside of the big adult entertainment studios may not use PASS but they still follow the standards set by it, Prescott said.

Outside of the industry it’s harder and more expensive to get tested for Mgen, he added. His family doctor told him it would cost US$1,000 for a test. A test through Talent Testing Service, which is set up for sex workers, charges US$40 for a test.

Alex said Canada’s lack of testing for Mgen concerns her on a personal and a professional level.

Alex is Métis, is neurodivergent, has ulcerative colitis and is an ostomate.

“I already have multiple disabilities, live with a permanent medical device and have had multiple surgeries on my abdomen,” Alex said. “I don’t want to collect anything else.”

She’s also allergic to several antibiotics and worries she wouldn’t be able to be treated for Mgen. “Avoiding the infection is the top priority,” Alex said. “But how can you prioritize if you don’t know if you have it or have been exposed to it?”

On a professional level, Alex and Moon said the lack of Mgen testing limits where they can work and who they can safely have sex with for their job.

Canadian co-stars are a risk because they can’t get tested, and U.S. co-stars may not want to work with someone who can’t be regularly tested, Alex and Moon said.

Prescott said he would avoid working with anyone who couldn’t be tested because it puts future screen partners at risk.

Moon said that going forward she’ll be minimizing any risk of infection in her personal and professional life unless that partner is able to show her a negative Mgen test.

Alex also has a strategy to minimize her risk but worries that could affect her job.

“I’ve used barrier methods with local male performers but I don’t know how long I can do that,” she said, worrying customers won’t pay for her content unless it features unprotected penetrative sex.

Grennan said the PASS requirement for testing every 30 days doesn’t seem like a rule made by an STI expert.

He encourages sex workers to speak with a provider about a testing regime that makes the most sense for them personally and professionally.

It’s “not easy or straightforward,” Grennan added.

No doctor wants to withhold treatment from a patient, but doctors also have to balance the threat of antibiotic resistance, which Bradshaw said is one of the top 10 threats to humanity.

“This is the first time people have been exposed to drug-resistant STIs for which we’ve run out of treatment,” she said. “We will all have to get more used to this. We’re going to see things like lung infections and gut infections that we can’t cure.”

“It’s not a problem unique to STIs, and people are dying globally from antibiotic-resistant bacteria,” she said. “And people are completely unaware of this disaster that is internationally unfolding.”