VENEREAL DISEASE.MEDICAL KNOWLEDGE
INCIDENCE OF VD
STRATEGIES FOR COMBATING VD
PUBLIC HEALTH EDUCATION AND MORALITY
VD AFTER WORLD WAR II
By the beginning of the twentieth century, venereal disease had become a metaphor for the physical decay and moral degeneration of society in many European countries. Syphilis and gonorrhea, the most widely recognized of the venereal diseases at that time, were perceived as sources of pollution and contamination, threatening the social and moral order as well as racial health and military power. Subsequently, VD was to become a leading issue in public health policy in many European countries in the first half of the twentieth century.
Medical knowledge relating to VD had advanced significantly since the nineteenth century. In the 1830s Philippe Ricord showed that gonorrhea and syphilis were two different diseases, and in the 1870s another French venereologist, Alfred Fournier, made the connection between syphilis and progressive paralysis and other nervous diseases. In 1879 a German venereologist, Albert Neisser, identified the gonococcus as the causal agent of gonorrhea. The long hunt for the syphilis germ took three more decades until, in 1905, a German biologist, Fritz Schaudinn, and a dermatologist, Erich Hoffmann, successfully established that the Treponema pallidum was the cause of syphilis. In the following year, the German scientist August Paul Wassermann developed a serological test for syphilis, which became the leading diagnostic tool for physicians, despite its notorious unreliability. With the Wassermann test (also known as the Bordet-Wassermann test) it became easier to diagnose syphilis even in the later stages of the disease. By the end of the twentieth century, new diagnostic methods such as dark-field microscopy and blood tests (rapid plasma reagin and Treponema pallidum hemagglutination assay) for syphilis and strand displacement amplification for gonorrhea and Chlamydia trachomatis had simplified the diagnosis of VD considerably.
Central issues in medical research on VD were therapeutic improvements. Up until the 1940s, mercury remained an important part of any syphilis therapy. Spurred by the development of successful inoculations against infectious disease, medical researchers in the late nineteenth and early twentieth centuries tried in vain to develop an inoculation against syphilis. However, the efforts of the German physician and Nobel Prize winner Paul Ehrlich and his team to identify some form of chemotherapy proved more successful. In 1910 they produced a powerful and effective new drug, an arsenic compound called Salvarsan (literally, "healing arsenic"). The administration of this so-called magic bullet proved to be problematic, and Salvarsan caused many side effects, some quite serious. Nevertheless, Salvarsan and its later improvements remained, often in combination with mercury or bismuth, the main treatment of choice for syphilis well into the 1940s. In addition, in 1917 the Austrian psychiatrist Julius Wagner von Jauregg introduced a therapy for the hitherto untreatable general paralysis of the insane, one of the many forms syphilis can take in its tertiary stage. For reasons largely unexplained, when infected with malaria, patients suffering from paralysis showed remarkable improvements, and for his therapeutic discoveries Wagner von Jauregg won the Nobel Prize for medicine in 1927.
Until the introduction of sulfonamides in 1937, the long-lasting therapy for gonorrhea remained often ineffective and painful with its damaging irrigations of the urethra. With sulfonamides treatment became easier, faster, and more effective, but the gonococcus soon became resistant to the new therapy. The introduction of penicillin in 1943 in the United States revolutionized VD therapy. At first it was only available for soldiers, but increasingly penicillin was employed for the treatment of syphilitic civilians in postwar Europe. However, it took some time before physicians became convinced of its effectiveness. Soon penicillin was also used to treat gonorrhea and eventually became the standard treatment for both diseases. As a result, syphilis and gonorrhea were no longer perceived with the same fear and moral reproach, a trend often regretted by physicians, who feared that penicillin would undermine patient compliance and remove one of the last bulwarks against promiscuity.
Although contemporary statistics were highly unreliable, they shaped public perceptions of VD, and it was believed that VD rates were increasing. In Germany a first, nationwide VD survey from 1919 suggested that about half a million Germans (some 8.7 per thousand of the population) were catching VD each year; subsequent statistics from the interwar period, however, indicated a decline from 5.8 per thousand in 1927 to 3.4 in 1934. In Britain the Royal Commission on VD shocked the public by concluding in its 1916 report that the number of syphilitics in large cities would not fall below 10 percent of the population, and the percentage of those affected with gonorrhea greatly exceeded this proportion. The French government calculated that in 1925 about four million French (one-tenth of the population) were suffering from VD. Moreover, estimates suggested that the situation was further deteriorating, with estimates of eight million recorded in 1929. It was suggested that over the previous ten years, syphilis had killed about 1.5 million French people, as many as died in World War I. Moreover, VD rates escalated again during World War II, even in those countries where, as in the Netherlands, there had been a low incidence previously.
In response to evidence of what appeared to be an alarming rise in the incidence of VD, members of the medical profession, public health officials, representatives from women's and social purity organizations, and politicians from many European countries met at two international conferences in Brussels in 1899 and 1902 to discuss how to control prostitution and VD more effectively. At the 1899 conference, an international society for combating VD (Société Internationale de Prophylaxie Sanitaire et Morale de la Syphilis et des Maladies Vénériennes) was founded. For many countries, this was the starting point of efforts to tackle the VD problem. Subsequently, national societies for combating VD were founded, for example, in France in 1901, Germany in 1902, and somewhat later in Britain (1914).
Until the beginning of the twentieth century, in most European countries, with the notable exception of Britain, the main strategy for combating VD was to control prostitution. For centuries prostitutes had been targeted as the main vector of VD. This epidemiological model assumed that it was the unfaithful husband and the irresponsible young unmarried man who, driven by their uncontrollable sexual urges, contracted VD from prostitutes and passed it on to their innocent wives or partners, who then might infect their offspring. Treatment in such cases was problematic, given that physicians were reluctant to divulge the medical condition and hence the moral lapses of husbands to their partners. This epidemiological model was also the basis for the assumption that syphilis was a hereditary disease that was passed on from the father to his offspring.
To control prostitution, France in the early nineteenth century developed an elaborate system designed to control brothels and regulate the public behavior of prostitutes. To ensure their medical surveillance, prostitutes were required to register with the vice squads of the police. This system of state regulation was copied by many other European countries. (Britain was an exception: although some local regulation of prostitution was imposed for a limited period in the 1860s and 1870s, this was speedily suspended in the face of vociferous protests from the women's movement.) However, by the beginning of the twentieth century, regulatory systems were increasingly recognized as ineffective in the control of VD, not least because an increasing number of so-called amateur prostitutes were evading registration. One of the main issues at the Brussels conferences was therefore to find alternative routes to control the spread of VD. These concerns were reinforced by contemporary fears of "urban degeneration," viewed as threatening bourgeois concepts of hygiene and morality, especially as they affected the issue of female and working-class sexuality.
After Word War I, it became increasingly evident that the old epidemiological model that focused on professional prostitutes as the main sources and culprits of VD was no longer wholly applicable. With the increasing economic and social independence of women and a relaxation of nineteenth-century standards of sexual morality, people more often experienced sexual relations outside of marriage. Again, what caused most concern was the dangerous sexuality of women who, under the enduring double moral standard, were labeled promiscuous "pick-up girls." One of the consequences was that in the 1930s and 1940s the old epidemiological model that had informed public health policy was replaced by a "chain" model that was based on the idea of promiscuity, with infection spreading from one venereally infected person to all the sexual partners in an endless chain.
The ensuing debates on VD in the twentieth century raised fundamental and contentious issues relating to the use of legal compulsion to control VD. European governments had to find an appropriate balance between the interests of public health and the liberty of the individual. At the same time, debates over VD raised a broad range of concerns related to sexual morality within society that had a strong impact on VD policies.
Some European countries adopted a more coercive strategy, within which the law was employed extensively to regulate the infected and to penalize the willful neglect of treatment or spread of disease. On the other end of the spectrum were countries whose public health strategies for combating VD can be broadly defined as voluntaristic. Instead of utilizing coercive measures, these countries provided confidential, free, and easily accessible VD treatment. The response of Scandinavian countries, Italy, and Germany to VD in the twentieth century could be categorized as toward the compulsionist end of the spectrum, whereas England and France can arguably be characterized as on the libertarian end. Countries such as Scotland occupied a middle ground. A more detailed analysis, however, would reveal that, in all countries, contentious debates over the issue of control and compulsion persisted. In Germany strands of the medical, legal, and public opinion remained skeptical of the value of compulsion and concerned over the issue of medical confidentiality. Conversely, in England there was always a vocal minority within the medical profession and public health administration advocating more stringent measures to control the spread of VD.
The Scandinavian countries, where syphilis in the nineteenth century was largely endemic and nonsexual in its transmission (congenital syphilis), were among the first to introduce coercive measures to control VD. This policy, including most significantly general medical inspections, had already begun in the late eighteenth century but culminated during the early twentieth century. Venereally infected citizens were obliged to seek treatment, which the state offered them free of charge. To impose this requirement after the suspension of the state regulation of prostitution (officially, 1888 in Norway, 1906 in Denmark, and 1918 in Sweden), Scandinavian governments made mandatory the notification of all cases of VD to the public health authorities, the medical inspection of those suspected of suffering from VD, and, if necessary, their compulsory hospitalization. A system of contact tracing was also introduced, along with legislation to penalize the willful transmission of disease. Italy maintained its nineteenth-century state regulation of prostitution as its main strategy for combating VD up until 1958 but tightened control under the Fascist regime in the 1930s by introducing obligatory, free treatment and compulsory notification, despite the reluctance of doctors to comply.
In the debate over the issue of compulsion in Germany, World War I was decisive. Although strongly advocated by racial hygienists, the German government and public health officials remained reluctant to implement compulsion. However, this reluctance was eroded by the increasing incidence of wartime VD and the general tendency toward stricter controls. Under emergency legislation of 1918, a person could be convicted of assault when endangering a sexual partner with venereal infection. Given wartime exigencies, this legislation was also supported by the women's movement and leading venereologists. However, proposals for compulsory notification of VD patients met with strong resistance, especially from the medical profession and lawyers, who feared that notification would infringe on the principle of medical confidentiality. The interwar period saw a substantial extension of medical controls. The 1927 German VD act required all patients to undergo treatment with qualified physicians, who were now compelled to notify health authorities of any patients who failed to comply with their treatment regime, defaulted from treatment, or endangered public health by remaining sexually active. Health authorities could hospitalize such patients, even using police force if necessary. Under this legislation, it was not only the prostitute who was under medical control but her male client as well. However, in contrast to the Scandinavian model, where all infected, regardless of sex, were subjected to coercive measures, in Germany the sexuality of women remained the main target.
The Nazi regime further tightened VD controls. VD patients were not allowed to marry, and couples had to produce health certificates when marrying (although this measure was never fully implemented). VD patients and the promiscuous were registered by the authorities. Control of prostitution was assigned again to the police, who often sent prostitutes to concentration camps. However, the military ran their own brothels, and brothels were even established for slave workers and in concentration camps.
The Nazi regime exported their stricter VD control policy of coercion to occupied countries such as France and the Netherlands. In both countries these stricter measures, including compulsory VD treatment, were welcomed by public health officials and social workers, who had not been able to introduce compulsory measures in the years before. After the end of the occupation, France maintained these measures in their entirety, as did the Netherlands until 1952.
In 1953 West Germany reinstalled in essence the 1927 VD act and obliged physicians, largely in vain, to trace the sexual contacts of their VD patients. This act remained in force, albeit with some modification, until 2000, when VD and infectious diseases legislation was united in a new Infectious Diseases Act. This legislation marked a complete change in German VD policy. Based on a more liberal approach toward AIDS, German public health policy moved from control and coercive measures to the voluntaristic approach, stressing health education and offering patients, on a voluntary basis, anonymous and free advice and diagnostic services.
On the other end of the spectrum, England refrained from coercive measures. With the exception of some regulations imposed during both world wars, English VD policy throughout the twentieth century was based on the voluntaristic principle. Following the 1916 recommendations of the Royal Commission on VD, the government established treatment centers all over the country where patients could voluntarily seek free and confidential advice and treatment. After World War II, these treatment centers were integrated into the National Health Service. It was the central aim of English public health policy to encourage VD patients and those fearing that they had been infected to attend clinics at the earliest stage.
A similar strategy was pursued by the French government, which began to establish VD dispensaries, along with small laboratories for outpatient treatment, during World War I. Physicians could refer VD patients to these dispensaries for free consultations and treatment. Of course, physicians only referred those patients who could not afford treatment. But in contrast to Britain, France held on to its Napoleonic system of state regulation and control of prostitution. In the interwar period and during the German occupation and the Vichy regime, the focus shifted increasingly toward medical control, and control became even stricter. Although in 1946 the regulatory system was officially abolished and existing brothels closed, the French public health administration established a new health record system for prostitutes that subjected prostitutes to stricter medical surveillance. This system was only abolished in 1960, but the police kept on and even intensified their raids on prostitutes.
The change from the old infection model to the chain model also had consequences for other aspects of VD control. Public health authorities placed increasing importance on tracing venereally infected persons and their sexual contacts. As a result, after World War II, contact tracing became an important element in VD control in many European countries, even in essentially voluntaristic countries such as Britain.
In the first half of the twentieth century, European policy makers increasingly emphasized the need to educate the public on the risks of VD. With posters, leaflets, and brochures, health exhibitions, lecturer series, and slide shows, plays, films, and radio programs, VD became a central feature of propaganda and health education. By showing the dreadful symptoms of syphilis and gonorrhea and describing the serious consequences VD had for the family, the state, and the race, campaigns warned people of the dangers of nonmarital sexual activities. Hence VD campaigns were influenced by strong moral considerations. However, public health educators rapidly criticized this policy of deterrence as ineffective and prone to causing an obsessive fear of VD. Thus VD education materials in the interwar period began to focus more on removing the shame and secrecy that had for so long shrouded VD. The public was warned against alcohol consumption, and a healthy lifestyle was recommended, with regular exercise to overcome inappropriate sexual urges. Much effort was placed on convincing the public that VD was curable when treated without delay by a qualified physician, whereas treatment offered by lay healers promising quick and less painful cures was strongly condemned. By promoting a medical understanding of VD, these campaigns also aimed at removing folk myths such as the belief that VD was curable by intercourse with a virgin, which persisted well into the 1940s.
One contentious issue was whether the public should be informed about prophylactic measures such as disinfectants or condoms. Churches and social purity organizations strongly opposed any mention of prophylactics. They argued that by recommending the use of prophylactics, any remaining fear of infection would be removed and nonmarital sexual relations thereby encouraged. Therefore making prophylactics easily available would inevitably lead to a further decline of morality and undermine the stability of society. These moralists stated that the only way to avoid contracting infection was to remain chaste before marriage and faithful within it.
Members of the medical profession, especially medical officers in the military, favored advocating prophylactics. Although they also regarded chastity as the best safeguard against VD, they realized that an increasing number of people no longer adhered to these moral imperatives. Consequently they assumed a more pragmatic attitude; to avoid any further increase of VD rates, one had to tell the public how to protect against the risk of infection.
Germany was probably the leading country to promulgate prophylactics. Already before World War I, some military barracks installed vending machines for prophylactics. Although this move was contested and the vending machines had to be removed, the German military returned to advocating prophylactics during World War I. Health education campaigns in the interwar period even made it a moral obligation to use prophylactics in any risky sexual contacts. The 1927 German VD act eventually permitted the installation of vending machines in public toilets. Although the Nazi regime abolished these pragmatic regulations, it still provided German soldiers with condoms during World War II, despite a shortage of rubber. But Germany was not the only country where a more pragmatic attitude toward prophylactics succeeded. In the interwar period French public health education also supplied information about prophylactics and their use.
Great Britain and Sweden, by contrast, retained an emphasis on chastity as the central prophylactic. In Britain, attempts in the early 1920s to run so-called ablution centers, where men could get their genitals disinfected, had to be abandoned after vociferous protest from social purity organizations, the women's movement, and the churches. Consequently, Britain informed the public in their VD campaigns only about the treatment centers established since 1916. Only during the two world wars were prophylactics recommended by military officers, with prophylactic kits containing disinfectants being issued to soldiers. In Sweden, the government in 1910 strictly forbade public information on the use of condoms and even prohibited their advertisement, and this law was only abolished in 1938.
The introduction of penicillin and the associated sharp reduction in the incidence of VD in Europe brought a significant change of attitudes toward VD in the aftermath of World War II. Public debates surrounding the issue receded, and in many countries venereology as a medical specialty was in decline.
This situation changed by the late 1950s, however, when several European countries again experienced increasing VD rates; and in the 1960s VD recurred as an issue in debates on the "permissive society" and the social effects of the war, which had eroded many of the traditional familial and community controls. Furthermore, new sexually transmitted diseases gained prominence, especially mostly curable bacterial diseases (such as Chlamydia trachomatis, the most common sexually transmitted disease) and incurable viral infections (such as genital herpes, hepatitis B, or the human papillomaviruses). In public health debates, new culprits for infection gained prominence. Promiscuous teenagers, immigrants, homosexuals, and tourists were now being identified as the major vectors. An overconfidence in antibiotics seemed to have contributed to a more relaxed attitude toward casual sex. The public was alarmed by statistics demonstrating an inversion of the sex ratio, with now more girls than boys being affected with VD. But contemporaries blamed not only social and cultural changes but also the declining popularity of condoms after oral contraception became widespread in the 1960s.
Most significantly, terminology changed in the 1970s and 1980s. What was conceptualized traditionally as VD became framed as sexually transmitted diseases (STDs) and, at the beginning of the twenty-first century, as sexually transmitted infections. These changes in terminology reflect a shift of focus from specific disease entities to their ways of infection and transmission. By the end of the twentieth century, STDs were regarded as a mainly medical problem within the purview of physicians and not a moral one. But European governments remained concerned about STD rates, and in 1974 the Council of Europe agreed on common standards for STD surveillance. Although mandatory notification was subsequently introduced in many countries, surveillance regimes varied considerably, with a trend toward more voluntary and sample-based systems.
At a time that European governments thought to have STDs by and large under control, a new and deadly disease appeared and gained prominence in the mid-1980s, namely HIV/AIDS. Furthermore, since the mid-1990s European countries are again facing soaring STD rates, especially among young people, homosexual men, and tourists. It is assumed that homosexual men and the younger generation that grew up after the AIDS shock of the 1980s neglect safer sex. With all the furor surrounding AIDS there is a tendency to ignore this resurgence of STDs, which for many European countries still remains the primary threat to sexual and reproductive health at the start of the twenty-first century.
Baldwin, Peter. Contagion and the State in Europe, 1830–1930. Cambridge, U.K., 1999. Chapter 5 on VD provides an excellent overview of VD policies in England, France, Germany, and Sweden in the nineteenth and early twentieth centuries.
Corbin, Alain. Women for Hire: Prostitution and Sexuality in France after 1850. Translated by Alan Sheridan. Cambridge, Mass., 1990.
Davidson, Roger. Dangerous Liaisons: A Social History of Venereal Disease in Twentieth-Century Scotland. Amsterdam and Atlanta, 2000. Examines Scottish responses to VD during the twentieth century and contrasts them with England.
Davidson, Roger, and Lesley A. Hall, eds. Sex, Sin, and Suffering: Venereal Disease and European Society since 1870. London and New York, 2001. Most helpful collection of articles on VD in European countries, including England, Germany, Italy, and Scotland.
Davidson, Roger, and Lutz Sauerteig. "Law, Medicine, and Morality: A Comparative View of Twentieth-Century Sexually Transmitted Disease Controls." In Coping with Sickness: Medicine, Law, and Human Rights—Historical Perspectives, edited by John Woodward and Robert Jütte, 127–147. Sheffield, U.K., 2000. Compares English, Scottish, and German responses to VD in the nineteenth and early twentieth centuries.
Desenclos, Jean-Claude, Henk Bijkerk, and Johannes Huisman. "Variations in National Infectious Diseases Surveillance in Europe." The Lancet 341 (1993): 1003–1006. On STD surveillance in the European Community and Austria, Finland, Norway, Sweden, and Switzerland in the 1980s and 1990s.
Fenton, Kevin A., and C. M. Lowndes. "Recent Trends in the Epidemiology of Sexually Transmitted Infections in the European Union." Sexually Transmitted Infections 80 (2004): 255–263.
Hall, Lesley A. "'The Cinderella of Medicine': Sexually-Transmitted Diseases in Britain in the Nineteenth and Twentieth Centuries." Genitourinary Medicine 69 (1993): 314–319.
Lindner, Ulrike. Gesundheitspolitik in der Nachkriegszeit: Großbritannien und die Bundesrepublik Deutschland im Vergleich. Munich, 2004. This magisterial comparative study on public health politics in England and Germany after World War II includes a case study on VD politics in both countries from the mid 1940s to the mid 1960s.
Mooij, Annet. Out of Otherness: Characters and Narrators in the Dutch Venereal Disease Debates 1850–1990. Translated by Beverly Jackson. Amsterdam and Atlanta, 1998.
Quétel, Claude. The History of Syphilis. Translated by Judith Braddock and Brian Pike. Baltimore, Md., 1990. Mainly on France.
Sauerteig, Lutz. "Sex, Medicine, and Morality During the First World War." In War, Medicine, and Modernity, edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 167–188. Stroud, U.K., 1998. Examines the responses to VD during the World War I with a focus on the western front.
——. Krankheit, Sexualität, Gesellschaft: Geschlechtskrankheiten und Gesundheitspolitik in Deutschland im 19. und frühen 20. Jahrhundert. Stuttgart, 1999. An analysis of VD politics in Germany in the nineteenth and early twentieth centuries.
Lutz D. H. Sauerteig