Frontline Scotland: Sex Bomb
In some areas clinics are finding one in four young women are infected by the chlamydia bacteria that could make them infertile and could be associated with the development of cancer.
Dr RAK NANDWANI: Most people haven't heard about some of these newer generation sexually transmitted infections, and again, think that it doesn't apply to them.
Chlamydia is one of the things that really does concern me. It's so common I think it's a time bomb.
In the long term it's going to cause infertility, pelvic inflammatory disease, and many other complications.
EUAN: The Scottish Executive have issued guidelines on stepping up the fight against chlamydia.
But the final say in the allocation of funding and resources rests with individual health boards and trusts.
But many don't seem to have heard that Scottish Executive message. So far in Scotland we're failing in the battle against chlamydia.
Thursday night and young people from across Glasgow arrive at Shagtag.
The name says it all. It's simple - everyone gets a number when they arrive.
If you're attracted to somebody simply jot it down, put down a message, and then stick it up on the board.
No ambiguity, no confusion of body language. If you're interested - pick up the tag. And - it works.
FEMALE: I put one up for him and he put one up for me. I went and collected mine and met him at the bit he asked me to.
INTERVIEWER: What did he write on your message?
FEMALE: Let's meet at the bar where you pick the shagtag up.
INTREVIEWER: What does the night ahead hold, you've met. You're at Shagtag, does that mean you go and have a shag?
FEMALE: No (laughs) No.
EUAN: It's an uninhibited sexual market place. So we asked the promoter is it just fun for the young, or encouraging sexual risk taking.
RICHARD STARRETT (Promoter, Shagtag): Well, firstly I would say that the people are doing things that we encouraging on safe sex tend to be from the older generation.
And with all due respect to the older generation I'm sure that they were doing this when they were our age.
Everybody's young, they're having a good time, they're having a good laugh, and for generations gone by that's what every young person has done.
That's what you do when you're young. You experiment, you have a good time, you do things that may be you wouldn't do when you're older.
EUAN: Those in the club and young women in particular are increasingly at risk from catching chlamydia, which could have serious effects ten years on.
Dr SUSAN LOGAN (Gynaecologist, Aberdeen Hospital): A very common way that it's been described is as a silent epidemic and I think that that's an appropriate label because the vast majority of infections are asymptomatic, and certainly in young women, which is who we've got most information on, it is a very, very common problem - one in 10.
And it's frightening to think that¿that the lot of women who are sexually active and believe themselves to be healthy are wandering around with this infection which can have both life threatening and certainly life ruining complications.
EUAN: This woman, now in her late twenties, discovered that the chlamydia she contracted 10 years ago, has now led to those complications.
FEMALE: I had one fallopian tube which was completely blocked, and one fallopian tube which was partially blocked. And they said that I had had chlamydia probably for five years before.
They could tell from the extent of the infection that I'd had it for at least five to six years, and at that point I didn't know, I had no idea, there had been no symptoms whatsoever, and at that point obviously it was too late to do anything about it.
The extent of the damage was too bad. There was nothing they could do at all.
Having the tubes, the damaged very unhealthy damaged tubes has obviously affected the rest of my life now.
I was absolutely devastated. It took me a long time to get over that because at that point they told me straight away that I had to think about going on an IVF list for the future, you know, if I wanted to conceive children at some point in the future.
I have to come to terms with that, that I may never have children, absolutely devastating news, it was terrible.
EUAN: And for her it wasn't the result of a promiscuous life style. Chlamydia needs only one chance to strike.
FEMALE: I've only ever had three sexual partners. All long term relationships.
You don't have to sleep around and have lots of partners. Your partner just has to have had one other partner, and that partner has had other partners, and then you know, it just spreads like that.
And it's something that I never thought I would be at risk from, and it was absolutely the very first sexual relationship that I had that I had chlamydia.
EUAN: If it's detected chlamydia can easily treated with antibiotics to prevent the spread and long term problems.
But getting people to be tested is the hurdle. VD, or clap clinics, haven't traditionally been attractive places to visit.
But the groundbreaking Sandyford Clinic in Glasgow is trying a new approach. It's the only clinic of its type in the country. It's aim - to entice young people in particular through their doors to be tested.
They want to break down the stigma about sexually transmitted disease.
Dr RICHARD HILLMAN (Consultant, Sandyford Institute): There doesn't seem to be a Glasgow word for penis.
I get guys coming along and saying 'I've got a problem with my em...em...', and that's as far as you get.
And if guys can't even know what word is appropriate to use with ¿. I believe I've heard most of them in my time¿.if guys can't even be comfortable talking about the name it makes it very difficult for them to actually be able to articulate their concerns.
A lot of time we spend here is... giving people the space in a confidential supporting way to talk about these things. It makes a huge difference.
EUAN: The aim of the Sandyford is to make a trip to the clinic like a visit to the dentist.
When you get a new partner both of you go to get the all clear before you have unprotected sex.
Greg has been persuaded by his girlfriend to come for a check-up. He's embarrassed and doesn't want to be filmed.
DR HILLMAN: Now I need to ask one or two questions here which are a bit sensitive, and I want you to answer them as best you can do for me. When was the last time you had sex?
GREG: This morning.
DR HILLMAN: This morning, OK, was that the regular partner or casual?
DR HILLMAN: And how long have you been together for?
GREG: Two years.
DR HILLMAN: Two years, good. And what sort of sex are you having with your partner - fabulous I'm sure.
DR HILLMAN: Normal sex, that's vaginal sex?
DR HILLMAN: Oral sex?
DR HILLMAN: Anal sex?
DR HILLMAN: OK. Do you use condoms at all?
DR HILLMAN: Sometimes. When was the last time you had sex with anyone else apart from your current partner?
GREG: Last year we had a fall-out.
DR HILLMAN: Last year, sorry.
GREG: We had a fall out, so.
DR HILLMAN: You had a fall-out. So that would be about a year ago?
DR HILLMAN: How many partners did you have about a year ago?
GREG: About three or four.
DR HILLMAN: Three or four.
EUAN: For the clinic Greg is a success story. All the tests proved negative and Greg is in the clear.
Now he's relaxed and happy to talk about the experience. His girlfriend is still camera shy.
What was the run up to actually coming here today?
GREG: My girlfriend. She basically wanted us to come. Before I was always saying no I didn't want to go, but I thought I should do it, just get it over the done with.
EUAN: So why did you want to come?
GREG'S GIRLFRIEND: Because I feel that you should always get yourself checked out to be safe.
EUAN: So why were you so worried about coming?
GREG: To find out if I had anything, that's basically the worry. After the verdict I was all right.
EUAN: How tense was it when you arrived?
GREG: I didn't actually want to come, I started swearing and all that it was that bad.
But after they checked out, it was just basically how have I not been before.
It gave us a, I don't know, a better outlook knowing that being clear is the best way to come. It's not going to be a hassle to come back that way.
Sandyford Clinic staff:
FEMALE: This is the basic samples we would use for a male client. It's slightly different for a female client, we do a few more tests.
In the male client we have the two glass urine tests which is a test for basically non-specific urithritis, and non-gonococcal urithritis.
The slide and the Petri plates are a check for gonorrhoea, which we have a result more or less immediately from the lab on the slide. The plate gets sent away for culture.
FEMALE: There's a lady who had an appointment for tomorrow. She'd been in the past and she feels that her condition is resolved, so she didn't want to waste her time by coming along.
But she didn't really understand some of the implications of it, so she's going to come along anyway to speak to somebody just to explain it all to her.
FEMALE: One of things I had help with the doctor is public lice. The doctor fished it out, and got it on the slide, and took it through to give me a result, so he could look under the microscope with it and all that, a monster thing, you know like its claws.
EUAN: Was it scary?
FEMALE: Not scary, just it really interesting.
FEMALE: Every client that comes here get checked for chlamydia, male and female.
EUAN: Dr Rak Nandwani is one of the country's leading genito-urinary, or GU specialists.
DR RAK NANDWANI (Clinical Director, Sandyford Initiative): One thing that's really been concerning me is that the number of cases of chlamydia had doubled in the last five years.
Chlamydia is a sexually transmitted infection that causes symptoms in about half the men that have it, and about a third of the women that have it.
In men it might cause symptoms like a painful discharge, pain on passing water, pain in the testicles or the genital area. In women it could be a vaginal discharge, or pain in the pelvis, or even in the tubes.
EUAN: Infertility expert, Dr Susan Logan, has been researching the link between increasing rates of infertility, and chlamydia infections. A disease that in many cases acts silently, and goes undetected.
DR SUSAN LOGAN: Most people will feel healthy. They may have some minor symptoms. But most people will feel healthy with it.
The problem is particularly with women far more than men is that it can be life ruining.
And there's a lag time for it in the fact you can be well, and then when you say go on to reproduce, you decide to have a baby, you find that you can't have a baby, and when investigations are done they find that your tubes are blocked, or you go on to try and have family and it turns out that the pregnancy is in the tubes.
And these are...ectopic pregnancy can be life threatening, but certainly tubofactor infertility, and infertility in general is life ruining, and that's very important.
The other thing it can cause from pelvic infections is painful sex, so that obviously has relationship implications; chronic abdominal pain; irregular bleeding; painful periods, that sort of thing.
And women who've had chlamydia in the past certainly are more likely to be seen at their GP surgeries, at gynaecology outpatient clinics to go on and need hysterectomy surgery, that sort of thing.
EUAN: But it's not just the serious worries over infertility. A study of 700,000 women in Finland suggests that the chlamydia could be linked to cervical cancer.
DR LOGAN: They found that a past infection concurred a significant higher risk of developing invasive cancer of the neck of the womb.
Independent of human papilloma which we know is associated with cancer of the cervix, and also smoking which increased your risk.
Cancer of the cervix is a sexually transmitted infection. We know that women who have¿.who start sexual intercourse at a very young age, and who have more partners, are at increased risk of it.
And that would also put them at increased risk of chlamydia as well. So whether it is a cause in effect, or whether the two just go hand in hand we don't know, but if it builds in another reason why a screening programme, a national screening programme may be appropriate in this country from a long term point of view.
EUAN: So, if we're to tackle the problem we need national screening.
Countries like Sweden introduced a programme 25 years ago, and cut infertility by 60%.
But here, only a handful of clinics offer routine testing and organise the all-important follow-up of partners.
If one partner is tested reinfection is inevitable.
In the past Sandyford farmed out services to neighbouring health trusts.
But due to demand in Glasgow they had to withdraw from places like Paisley who had to set up their own clinic with just one consultant.
DR NOREEN MIR (GU Consultant, Argyll & Clyde Health Board): When we first opened we didn't really know what to expect. There was very little advertising of the service. It was really just opened quite quickly.
We've been very busy, there's been a consistent high demand for services here.
I've looked at the figures for the first six months of the service being opened, and during the first six months I actually found that of men being tested for chlamydia 19% actually had the chlamydia infection. And for women the figure is about 27%.
EUAN: And that rate in her clinic is nearly four times the national average. And she believes there could be many more infected people still out there.
DR MIR: I think that certainly the chlamydia infection that we're seeing here is the tip of the iceberg.
I think there's a large reservoir of infection in the community. People really need to come forward for screening because many of these people would have no symptoms at all.
DR NANDWANI: One of the difficulties that occurs that if you see someone in general practice, when you first see them you may not know that they are chlamydia positive, and that's the time that the statistics are compiled, is what did people come along with rather than what their final diagnosis was.
I think the other thing that concerns me is that a lot of people with infections just don't go anywhere, either because they don't know they've got them, or because there are no local services.
And what's always struck me is every time we open a new service, or launch a new service it's packed out from day one with often minimal advertising, and, you know, these people must be...are out there, and obviously not accessing services.
EUAN: But at least Paisley now has a clinic.
If you live in many other areas of Scotland it's much more difficult to get access to a consultant.
There are only 15 GU doctors in the whole country, most of them in the central belt.
For those in the Borders, the Western Isles, Shetland, Dumfries and Galloway, Ayrshire, or Orkney it's a different story. They have no GU consultants.
Fife has the highest rate of chlamydia infection in the country, but they only have one GU consultant.
According to the Royal College of Physicians there should be at least three. Doctor Carolyn Thompson has been doing her best to provide a service.
DR CAROLYN THOMPSON (GU Consultant, Fife Health Board): In Fife we've got very high rates. We've got for women 159 per 100,000 women aged 15-65, which I think is the highest rate in Scotland.
I think that is...it sounds dreadful, but I think actually predominantly that's because we've got a very good awareness amongst health care professionals in Fife.
I've been here 11 years and during that time I've really been promoting chlamydia testing, and so I've got GPs, gynaecologists, family planning clinics all testing as much as they can, and referring into the GU clinic any positives that they find.
So our reported numbers are extremely high.
EUAN: Dr Thompson is hampered by another problem. Her rates of detection would be even higher if she was using an up-to-date test.
A new urine test introduced two years ago is almost totally accurate. But most trusts are using an older swab test which is only 70% accurate.
That means that three in 10 of those tested could actually be infected and go on to infect others. But it's slightly cheaper than a urine test.
DR THOMPSON: At the moment this health board has not been able to fund urine testing.
As you are aware the NHS is a finite pot, and I've put forward a case for PCR testing for chlamydia, but that has to go along with breast unit /cancer services, a new cardiologist and its prioritisation, and unfortunately at the moment chlamydia testing hasn't received top priority.
EUAN: So it's stacking up against you. I mean you've got the highest rates in Scotland, you're here on your own and using an old-fashioned test.
DR THOMPSON: We're doing the best we can.
EUAN: And Fife is not alone. Our investigations found that none of Scotland's health areas use solely urine tests.
At the moment many women and men can't be sure if they're carriers of chlamydia or now, even if they have been tested.
DR NANDWANI: I'm concerned about the old test as it missed about 30% of cases of chlamydia compared to the new test.
And the difficulty arose for individuals when they came along, they tested positive and their partner was negative, did it mean that someone had been having an extra-marital, or extra relationship?
I think the other difficulty is that they may have been given a negative all-clear - and in fact that's still going on - and in fact they really are carrying asymptomatic chlamydia, chlamydia without any symptoms whatsoever and, therefore, are transmitting it to other people, and that's my major concern and I think that's an absolute scandal that that continues.
EUAN: The solution to stop the chlamydia epidemic would seem fairly simple - the NHS trusts need to provide more specialist clinics with consultants and more up-to-date tests.
Already infertility associated with chlamydia is costing the country dearly.
DR LOGAN: It's a very expensive disease indeed, and it's estimated cost to the National Health Service about £200m per year, but that's just an estimate.
EUAN: So how aware are those most at risk? We went out on the streets of Glasgow to find out.
INTERVIEWER: Do you know what chlamydia is? It's multiple choice OK, is it...an infection; a flower; a girl's name; or a paint colour?
FEMALE: What was the word again?
INTERVIEWER: Any ideas?
FEMALE: I would say a flower?
INTERVIEWER: A sexually transmitted infection that may cause infertility, and in Scotland is a common STI.
FEMALE: It's a sexually transmitted disease, a most common one isn't it?
INTERVIEWER: Well done.
MALE: I would go a stomach bug.
MALE: It's a flower, a tropical flower or something.
EUAN: Safe sex will always be an option for many people, but the explosion in sexually transmitted infection in the 17-25s means that that message of using a condom has been lost for this age group.
So, even younger children have to be targeted.
Condom / Chlamydia cartoon:
EUAN: This group of under-16s in Ayrshire are being taught about sex in a new project to heighten the awareness of possible infection.
But does the message work, and should those under the legal age be given such explicit advice?
MALE: It shouldn't by anything to do with age, it should be how mature you are and how if you feel ready for it or not. There shouldn't be an age on it.
MALE: You don't really think about disease and infection unless you're sitting thinking about it, but when you're out with a girl on the night you don't think about it, you just think about getting it done.
MALE: They only tell you about the diseases and everything, they don't really tell you the good stuff about it....
FEMALE: ....or the worst...getting pregnant¿.
MALE: ...they tell you the bad stuff and that, like the diseases and the pregnancies and everything, and not the good stuff, the thrill and everything.
MALE: You just talk about...sex, you don't talk about infections, because that's not what your friends are bothered about.
EUAN: So you're more worried about pregnancy than disease?
ALL TOGETHER: Ehem, aye....
EUAN: In an attempt to get the message home to children information has become increasingly graphic.
The Scottish Executive and Lothian Health now provide material like this to those teaching sex education in schools - for some a step too far, too young.
COLIN HART (Director, Christian Institute): Most parents would be really rather alarmed if they actually saw some of these explicit materials that are being proposed.
They do actually put ideas into kids' heads which are not there, and we will promote the very behaviour that we're all trying to stop.
EUAN: And according to Colin Hart it isn't working, and the only safe sex message is no sex.
COLIN HART: We've tried the message of safer sex and it just simply doesn't work.
More and more explicit sex education at very young ages is just simply not working.
The teenage pregnancy rates have not gone down, neither have the STD rates gone down, or the pregnancy rates gone down, it just simply has not worked.
Isn't it about time we started asking whether the experts have been right?
Chlamydia rates are up 75% over the last five years according to the executive.
Isn't it about time we started asking actually is it working?
I don't think it is. Certainly if we followed an absence approach I think we'd see a fall in teenage pregnancy rates and STD rates just as they've seen in other parts of the world where they've followed.
EUAN: If you can convince children to abstain, it's almost like kind of blind faith hoping it's going to be all right.
COLIN HART: Well it's still true that most of them do certainly before the age of 16.
I think there's a very great problem with teaching to the lowest common denominator and assuming they're all sexually active.
They're not, and we should discourage them, and we should encourage them to wait, and discourage them from being sexually active.
MARTIN RAYMOND (Health Education Board, Scotland): I don't think there's any evidence at all that education about sex will encourage earlier sexual behaviour.
In fact the evidence that we do have would point in absolutely the opposite direction.
The more sex education that you have available to young people the less likely they are to have early sexual activity.
So I think on that basic level the evidence is pretty clear in our mind.
I think what is important though is to look at the nature of the material and the appropriateness of the material, that's absolutely critical, but I think that does come down to a trust in the training and the professionalism of teachers who make the choice about what is appropriate material.
EUAN: Lothian Health say teachers very much have the final say in what they do and do not use.
According to the Scottish Executive the teaching resource in the 5-14 curriculum guidelines are well established packs and have been used for some time without incident.
FEMALE: Without a doubt there are girls out there now that have chlamydia and have got absolutely no symptoms, they don't know that they have chlamydia.
I'm sure that probably some of my friends have chlamydia and they've got no idea about it.
DR LOGAN: If it's as common as one in 10 in the under-20s then I would certainly want to know if I was that one.
DR NANDWANI: My dream for Scotland is if everyone can come along.
It's a bit like going to the dentist, you know, gum clinics, a bit like going to get your gums checked.
If people could come at regular intervals when they felt they needed it, or changed partners, or new relationships, and actually have sexual health MOTs, and they're very straightforward, very easy to do.
People just come along, have some tests done, they get same day testing with results the same day, and obviously if anything is picked up we deal with it in a very sensitive way.
And I think that's my ambition, and I think it's achievable.
EUAN: So where do we go from here? We're in the middle of a silent epidemic, an epidemic which could take years to stamp out. There are no immediate plans for national screening. There's no quick fix for chlamydia. As the debate rages the young continue to party.
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