Shigella In Gay Men: What You Need To Know About The Outbreak

Shigella is in the community right now, team, and it’s spreading through sex between guys. Australia is seeing ongoing clusters, the UK and Europe have been tracking a drug-resistant strain for years, and the US has put out repeat alerts. If you’re a gay or bisexual man, or anyone whose sex involves the anus, this one’s worth understanding properly.

Let’s go through what shigella is, how it gets passed on, what to watch for, and the practical things you can do.

What is shigella?

Shigella is a bacterium that causes a gut infection called shigellosis. It’s a notifiable disease in every Australian state and territory, which means labs and doctors have to report it to public health. ¹

There are four species we see in humans. The two that matter most for gay and bi men are Shigella sonnei and Shigella flexneri. Both cause similar illness: cramping, fever, and diarrhoea that can be bloody. The reason shigella keeps making the news comes down to the resistance.

Strains of Shigella sonnei circulating in men who have sex with men (MSM) in Australia, the UK, Europe, and North America are now classed as extensively drug-resistant, or XDR. That means resistance to azithromycin, ciprofloxacin, and trimethoprim-sulfamethoxazole, the three oral antibiotics we’d normally reach for. ^{2 3 4}

XDR shigella first showed up in MSM populations in the UK around 2021, then turned up in Australia not long after. NSW Health and the Victorian Department of Health have both flagged increased detections in gay and bi men over the last few years, often clustered around large community events. ^{5 6}

It’s also worth knowing that a tiny dose of shigella causes infection. As few as 10 to 100 bacteria can do it. Compare that with salmonella, where you typically need millions. That low infectious dose is the single biggest reason shigella spreads so well through sex.

How shigella is transmitted

Shigella lives in the gut. It gets out in faeces and gets in through the mouth. That’s it, mechanically. The faecal-oral route.

In a household setting that usually means contaminated hands, food, or water. In a sexual setting, the route gets much shorter.

How it spreads during sex

Sex that involves the anus moves microscopic amounts of faeces around. You can’t see it, smell it, or wash it away completely. A few common scenarios:

• Rimming (oral-anal contact) is the most direct route. Tongue to anus puts bacteria straight into the mouth.
• Fingers and hands that have been near or inside the anus, then touch the mouth, lips, penis, or another person’s anus, can carry shigella across.
• Fisting involves prolonged contact with the rectum and produces a lot of bacterial transfer onto skin, gloves, lube, and surfaces.
• Shared sex toys that have been in one person’s anus and then another’s, especially without washing or a fresh condom, will carry shigella.
• Shared douching equipment is a known transmission route. The nozzle and bulb both get contaminated.
• Group sex environments mix all of the above with multiple partners over a short period.

You don’t need to swallow anything obvious. The bacterial dose required is so small that residue on a finger is enough.

Other ways shigella spreads

It still spreads the old-fashioned way too: contaminated food, water, and surfaces. Travellers picking it up overseas is common, and outbreaks have been linked to childcare centres, swimming pools, and food service workers. ¹ For the sexual transmission angle, though, the data on MSM is consistent across Australia, the UK, and the US.

Symptoms of shigella

Symptoms generally start 1 to 3 days after exposure, sometimes up to a week.

The classic picture:

• Watery diarrhoea, often with blood or mucus
• Cramping, painful abdominal pain
• Fever (often 38 degrees Celsius or higher)
• Headaches, muscle aches, and that general “hit by a bus” feeling
• Nausea, occasionally vomiting
• Tenesmus, which is the urgent feeling that you need to go even when there’s nothing left
• Feeling wiped out and dehydrated

For most healthy adults the illness lasts around 5 to 7 days and settles on its own. Some people stay infectious in their stool for weeks afterwards, even once they feel better, which is why the public health advice on returning to sex and food handling is so specific (more on that below).

If you’re living with HIV and not on effective treatment, immunocompromised for any reason, pregnant, very young, or older, shigella can be a more serious illness.

Red flags: when to seek urgent medical care

This is the section to actually read, team. Don’t tough it out at home if any of these apply.

Get seen the same day, or go to an emergency department, if you have any of the following:

• Blood in your stool, more than a small streak
• Fever above 38.5 degrees Celsius
• Severe abdominal pain
• Signs of dehydration: dizziness, light-headedness when standing, very dark urine, passing little or no urine, dry mouth, sunken eyes, a hoarse voice, a racing heart, or feeling like you can’t get up and move around
• Diarrhoea lasting more than 3 days
• Vomiting that’s stopping you keeping fluids down
• You’re living with HIV, immunocompromised, pregnant, or have another significant medical condition
• You’re a parent or carer and the affected person is a young child or older adult

Shigella can occasionally cause complications including severe dehydration, seizures (more common in kids), reactive arthritis, and rarely haemolytic uraemic syndrome with certain strains. Early review matters.

If you’re not sure, call your GP, your local sexual health clinic, or healthdirect on 1800 022 222 in Australia. Don’t wait it out for a week.

Treatment and the resistance problem

Most uncomplicated shigella in healthy adults will resolve without antibiotics. The mainstay of treatment is rehydration: water, electrolyte solutions, and rest. Avoid anti-diarrhoeal medications like loperamide unless your doctor specifically tells you otherwise, because slowing the gut down can prolong the infection. ⁷

Antibiotics are used when:

• The illness is severe
• The person is immunocompromised, pregnant, very young, or elderly
• There’s a public health reason to clear the bacteria faster (food handlers, healthcare workers, childcare)

Here’s where it gets complicated. Because XDR Shigella sonnei is resistant to the standard oral options, your doctor will usually send a stool sample for culture and sensitivity before starting antibiotics, unless you’re sick enough to need empirical treatment. Therapeutic Guidelines Australia and ASHM both recommend tailoring antibiotics to the lab result, with intravenous options like ceftriaxone reserved for severe or resistant cases. ^{7 8}

What this means in practice: if you’ve had recent anal sex, group sex, or contact with anyone with diarrhoea, tell your doctor. It changes how they investigate and treat you. They’ll want a stool sample, often a full STI screen at the same time, and they’ll likely contact public health.

Sexual practices that increase risk

Being direct here because vague advice doesn’t help anyone make decisions. The practices that carry the highest shigella transmission risk are the ones that move faeces, even invisibly, from anus to mouth or onto shared surfaces.

Higher-risk practices include:

• Rimming, especially without a barrier
• Fingering followed by oral sex, kissing, or touching the face
• Fisting, particularly in group settings or where gloves aren’t changed between partners
• Sharing sex toys without washing them and using a fresh condom
• Sharing douching nozzles, bulbs, or rinsing equipment
• Scat play
• Sucking on fingers, toys, or a partner who’s just been inside someone

These behaviours are common. Plenty of guys do all of them and don’t get shigella, especially when they’re with regular partners. The risk goes up sharply with more partners, less time between them, and shared kit. The UK and European data show clear links between XDR shigella cases and group sex, chemsex contexts, and venues where multiple partners are common. ^{3 4}

The point of all this is to give you what you need to make practical changes that lower the risk, while keeping the sex life you actually want.

Large events and venues where shigella spreads

Shigella outbreaks among gay and bi men cluster around events that combine lots of partners, shared spaces, and limited hand-washing opportunities. The patterns are pretty consistent across the world.

Settings where increased cases have been documented or where transmission is plausible based on the dynamics:

• Circuit parties and large dance events with afterparty sex contexts
• Pride and Mardi Gras weekends (Sydney has seen post-Mardi Gras upticks)
• ChillOut in Daylesford and other regional Pride events
• International circuit events: Folsom Street Fair (San Francisco), Matinee festivals, Berlin’s Folsom and Easter weekends, Madrid Pride, WE Party events
• Fetish weekends including rubber, leather, and kink-focused gatherings
• Sex-on-premises venues (saunas, cruise clubs, sex clubs)
• Private sex parties and group sex events
• Chemsex hookups, particularly multi-day sessions

What actually drives the outbreaks at these events is the combination of multiple sexual partners over a short window, shared lube and toys, less rigorous hand hygiene than you’d usually manage, and sometimes drugs that reduce attention to the small details. If you’re heading to one of these and want to keep enjoying them, the prevention section below is where you’ll get value.

If you’re unwell, please skip the event

I’ll say this plainly because it matters. If you’re sick, stay home. I know how much these weekends mean to people. Tickets aren’t cheap, mates fly in from interstate, you’ve been looking forward to it for months. But turning up to a sex party, sauna, or dance event with diarrhoea or a fever is how outbreaks happen. One infectious guest can pass shigella to plenty of people across a weekend, and you don’t know everyone in the room.

Some will be on PrEP, fit and well, and bounce back fine. Others might be living with HIV with a lower CD4 count, on chemo, post-transplant, or managing a chronic condition that turns a gut infection into something much more serious. Looking after each other is part of what makes our community work. The event will still be there next time.

Prevention: practical steps that actually work

These steps drop your risk substantially. The more of them you stack, the better, especially if you’re having anal-involved sex with multiple partners.

Hand and body hygiene

• Wash hands with soap and water before and after sex, between partners, and before eating
• Alcohol-based sanitiser doesn’t reliably kill shigella, so soap and water is the standard
• Shower before and after sex when you can
• Wash genitals and around the anus with soap before and after

Barriers

• Use a dental dam or a cut-open condom for rimming
• Wear nitrile or latex gloves for fingering and fisting, and change them between partners or between holes
• Use a fresh condom on sex toys, and change the condom between partners

Toys and equipment

• Don’t share douching equipment. Each person should have their own
• If you must share, clean nozzles thoroughly with soap and water, ideally with a disinfectant rinse, between users
• Wash sex toys with soap and warm water between uses; non-porous toys (silicone, glass, steel) clean better than porous ones

If you have symptoms

• Don’t have sex while you have diarrhoea, and for at least 7 days after symptoms stop, or as advised by your doctor or public health team
• Skip large events, dance parties, saunas, and sex-on-premises venues until you’re cleared, even if you’re feeling a bit better
• Don’t prepare food for others during that window
• Don’t share towels
• Tell recent sexual partners so they can get tested if they develop symptoms

Travel

• Be mindful of shigella risk when travelling, particularly in countries with less reliable water and sanitation, and around large international events
• The usual food and water precautions apply

Testing and follow-up

If you’ve got diarrhoea and any sexual exposure that could be involved, ask your GP for a stool sample and a full STI screen at the same visit. A few practical points:

• A stool sample with culture is the standard test, and it lets the lab work out which antibiotics will work
• Many sexual health clinics in Australia can do this and will also notify public health
• A negative test once you feel better is sometimes needed before you can return to food handling, childcare, or healthcare work, depending on your state’s rules ¹
• Shigella often travels with other infections, so a hepatitis A check, full STI screen (chlamydia, gonorrhoea, syphilis, HIV) and a check that you’re up to date with hepatitis A vaccination are all sensible

If you’re on HIV PrEP, your three-monthly review is a good chance to talk through enteric infections, hepatitis A status, and whether anything’s changed since last time. If you’ve had shigella in the past 12 months, mention it. It’s useful clinical context.

A note on hepatitis A

Hepatitis A is another faecal-oral infection that’s caused repeat outbreaks in gay and bi men globally. Unlike shigella, there’s a very effective vaccine. If you haven’t been vaccinated, talk to your GP about it. It’s a two-dose course and gives long-term protection. ⁹

The bottom line

Shigella is in our community, the resistant strains make treatment trickier, and the way it spreads through sex is well documented. You can keep enjoying your sex life. A few practical changes, particularly around hand washing, barriers for rimming, gloves for fisting, and not sharing douching gear, will lower your risk substantially.

If you get sick, see a doctor early, especially if you spot any of the red flags above. Ask for a stool sample, mention recent sex honestly, and let your partners know if you test positive. That’s how we break the chains.

Stay well, team.

Dr George

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This information is general in nature and not a substitute for personalised medical advice. Speak to your doctor about your specific situation.

Dr George Forgan-Smith, GP, practising in Sydney and Melbourne.