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Medicine, Morality, and Political Culture
Legislation on venereal disease in five Northern European countries, C.1870-C.1995
By Ida Blom
Nordic Academic PressCopyright © 2012 Nordic Academic Press and Ida Blom
All rights reserved.
The European background
Venereal diseases have a long history. They have been understood in very different ways, and policies to contain them have varied strongly over time. During the nineteenth century, European policies to some degree followed similar patterns, but from the end of that century and throughout the twentieth century national differences in VD policies became marked. This chapter will present a survey of this development, with special consideration paid to British and German policies. First, a short presentation of the most important types of VD.
From syphilis to HIV/AIDS
Throughout history contagious diseases have caused panic and suffering. Until the late fifteenth century, Western medicine focused on the diseased person rather than on the disease as such. It was believed that disease was due to congenital weaknesses or to certain behaviours that might disturb the balance of the four humours, the chief fluids of the body (blood, phlegm, black bile, and yellow bile). Consequently, curative medicine meant restoring this balance in the ailing person. But when many people succumbed to the same disease, it was sometimes seen as a punishment from God for sinful behaviour. Immorality might make God allow noxious miasmas–putrefied air–to cause disease. Certain unfortunate conjunctions of the planets might have the same effect.
The appearance of plague changed such beliefs. Plague was easily diagnosed. Everyone was at risk and death came within a very short time. Mortality was high. The disease attacked large numbers of people simultaneously, and people who had been in contact with someone suffering from the disease were affected in the same way. This experience led to a questioning of the importance of the intervention of supernatural powers. Instead of seeking explanations within the individual sick body, causes were now looked for in their surroundings. This also gave rise to the idea that a disease might be transmitted from one person to the next in the form of some infectious matter. During the fourteenth and fifteenth centuries, state authorities, especially in the city-states of the Italian peninsula, sometimes appointed local boards of health that controlled the movement of people and merchandise. Attempts to stop contagion might result in quarantining ships that arrived from foreign ports. Theories of contagion and infection–preventive medicine, in other words–were budding.
Plague was not the only cause of a change in medical approach to contagious diseases. The spread of VD from the end of the fifteenth century also had an effect. Syphilis was the most feared of these diseases. Different from plague, syphilis was hard to diagnose. It appeared in three distinct phases. First, painful pimples would be found on the genitals; however, they would disappear within a few weeks, even if untreated. The second stage would come months later, with a fever, sore throat, painful joints, and general physical weakness. Ulcers would appear on the genitals, around the mouth and other moist parts of the body, and a rash would cover the whole body, except for the face. A few months later the sick person would apparently recover. But after some time the patient would reach a third stage, characterised by non-malignant tumours on the skin and bones. The disease might look like leprosy, but the central nervous system and the brain would also be affected, resulting in paralysis and finally insanity and death. The disease was transmitted by sexual intercourse, but a syphilitic mother might also transmit it to her newborn baby. Congenital syphilis would in most cases lead to the child's early death. No wonder this disease was feared.
Syphilis was also known as the great pox, in contrast to smallpox. The name 'syphilis' came from a poem by the Italian physician Girolamo Frascatoro (1478–1553). Some physicians maintained that the disease was not new, but had existed among the Greeks and Romans. The most likely theory is that it was brought to Europe when Columbus and his men returned from the Americas in 1493. It spread through Spain, Italy, France, Germany, and the rest of Europe in the course of five or six years. The threat represented by VD was usually seen as coming from outside. Each country blamed its neighbour for the disease. In Germany and Britain it was called 'the French disease', in France 'the Italian disease'. The Portuguese are believed to have carried syphilis to Africa, India, and Japan.
The slow course of the disease made it hard to diagnose. At first it was associated with war, and to some it continued to be seen as God's punishment for men's evil behaviour. There seemed to be a link between sexual behaviour and syphilis, but since the disease was also found among Catholic churchmen, other possible means of transmission were also posited. It was feared that water might transmit the disease, and this contributed to a decline in public bathing. Soon prevention was followed by attempts at curing the disease.
Remedies were first sought in concoctions from the Americas, but soon Paracelsus (1493–1541), a Swiss medical practitioner, recommended a chemical treatment–mercury–that was already a common folk medicine for skin diseases. In time mercury would be used both as an ointment on the afflicted parts of the body and as internal medication. Mercury treatment had serious side-effects in the form of loose teeth, a sore mouth, and sweats, and it attacked the bone structure, but still, until the early twentieth century, it was the only treatment that showed any effect on syphilis. 'A night with Venus, a lifetime with Mercury' indeed.
Gonorrhoea, the other prominent VD, was much more common than syphilis, but had less frightening symptoms, especially for men. It was often difficult to diagnose in women, and if untreated might lead to serious infections. Babies born to mothers suffering from gonorrhoea would usually go blind or suffer from life-threatening blood infections. Ulcus molle (chancroid), which results in painful ulcers on the genitals, was a much rarer disease; it was long seen as a kind of syphilis, but it had none of the serious consequences of syphilis and gonorrhoea.
During the late nineteenth century medical advances prompted a greater medical interest in VD. The bacteria that caused gonorrhoea was discovered in 1879, the one responsible for syphilis in 1905. From 1907 the Wassermann blood test made it easier to diagnose syphilis, and in 1909 the discovery of Salvarsan offered a cure for the disease, although at immense cost. Various injections were used in the hope of curing gonorrhoea until in the 1930s sulphur preparations came in use. Gradually, prevention was complemented by curative medicine.
The connection between sexual activity, especially extramarital sex, and VD lent these sufferings a special moral character. They could be seen as the rightful punishment of illicit pleasure and as a sign of lack of self-control. Proper, moral behaviour would prevent VD. Consequently, people suffering from VD were frequently unwilling to admit to their disease or undergo treatment. The fact that mercury, at least in the earlier stages, caused as much, sometimes more, torment as the disease itself merely encouraged people to hide their sufferings. Further, since the disease was endemic, traditional ways of stopping contagion such as quarantine and isolation would not work. Other precautions were needed.
The solution was found in controlling the sale of sex. The best means of stopping transmission was to ensure that prostitutes did not suffer from VD. This implied regular medical examinations of prostitutes and strict rules laid down for their behaviour, limiting their mobility and submitting them to police control. If found to be suffering from VD, a prostitute would be sent to hospital, and would have to stay there until she was thought cured. This policy was adopted in most of Europe from the early nineteenth century until the 1880s. Until the 1970s young women continued to be the main target group for policies to curb VD. Sexual morality here amounted to a form of medical prevention.
Following the Second World War, the use of antibiotics greatly improved the possibility of curing VD. Within a decade, the number of reported cases of syphilis and gonorrhoea fell dramatically. However, new types of VD, chlamydia and herpes genitalis, now appeared. They were by no means as frightening as syphilis and gonorrhoea, but chlamydia could sometimes result in infertility. Now it was not just young women who were seen as being at risk, but the young generation as a whole. Sexual morality changed and information became important in the fight against VD.
The arrival of HIV/AIDS in the early 1980s again made VD a serious threat. It took time for researchers to identify the virus, HIV (Human Immunodeficiency Virus), which caused AIDS (Acquired Immunity Deficiency Syndrome). The infection weakened the immune system and left patients vulnerable to other fatal diseases such as pneumonia. Initially it was thought that HIV/AIDS only spread between homosexuals; sexuality continued to have an influence on medical approaches. However, it soon became apparent that infection might also be the result of blood transfusions and the shared use of needles. This weakened the century-long focus on sexual morals and brought a new target group into play. The morality of citizenship was challenged when individuals did not attempt to avoid behaviour that might spread disease. As we shall see, the shifting character of VD and the changing understanding of who was most at risk influenced medical strategies and the policies adopted to prevent contagion.
Medicine, morality, and sexuality
Since VD was transmitted through sexual contact, perceptions of sexual morality were of great importance. When the authorities discussed how to combat VD, their choice of strategy was influenced by what was seen as acceptable sexual behaviour on the part of good citizens. For most of the nineteenth century the main European countries fought the spread of VD with regulationist policies designed to control prostitution. Targeting prostitutes as sources of infection, this policy was introduced in France during the Napoleonic wars and was continued there until 1960. Prostitutes were submitted to regular, compulsory medical checks, and police regulations often demanded that they live in brothels. In some countries, the regulationist approach–'regulationism' –was embodied in national law, in others the authorities relied on regional by-laws or combined the two approaches.
Regulation built on a clearly gendered perception of sexuality. Female sexuality was understood as dormant until marriage and important only for procreation. Prostitutes were often seen as deviant females who of their own free will chose a degrading occupation. Respectable men were expected to show self-restraint in sexual matters. Some studies indicate that this was especially important as an ideal for middle-class men. But many saw male sexuality as a strong urge for copulatory orgasm that was a necessity for men's mental and physical health. With a high age at marriage, access to prostitutes was in many quarters deemed necessary to secure men the necessary sexual gratification outside marriage. Although frequenting prostitutes might stain a man's reputation, the regulationists at least gave him some protection from the shame of contracting VD by making sure that prostitutes did not suffer from such diseases. Regulationism created a sharp divide between prostitutes and decent women, between the whore and the Madonna, since regulated prostitution was also seen as protecting innocent wives, who might otherwise be infected by their husbands and in turn infect their new-born babies .
Although this way of understanding sexuality was dominant in Victorian society, it was not shared by everyone. This became obvious between 1864 and 1869, when the Contagious Diseases Acts, a combination of national and municipal laws regulating prostitution in certain garrison towns, were adopted in the UK. These laws met with strong opposition, from women and men of the middle class, civil libertarians, and moral reformers, as well as working-class men. Christian circles condemned prostitution and the women's movement claimed the same sexual morals for men as for women. The Ladies' National Association, under the leadership of Josephine Butler, and the Social Purity Alliance have been credited with the repeal of the Contagious Diseases Acts in 1888.
An abolitionist movement bent on fighting regulationism spread from the UK to a number of European countries. In Germany, police authority over prostitutes varied from state to state, both before and after the creation of the German Reich in 1871. In some cities, like Hamburg, brothels were officially accepted and supervised. In Italy, regulationism was introduced by a ministerial decree in 1860, covering all of the new state; the decree was revoked in 1888 as a result of abolitionist protests, but new and similar regulations were issued soon after. Firm Catholic beliefs and a perception of male sexuality that sat well with regulationist policies have been seen as the reason why regulation persisted in Italy until 1958. In France it was generally accepted that intervention by the public authorities in working-class lives–or at least in the lives of working-class women–was necessary in order to protect society from VD. Prostitution, like 'sewers, garbage dumps, and rubbish heaps', was seen as indispensable in modern society, but had to be controlled. In 1960, the United Nations' policy on prostitution led France too to lift its regulationist measures.
Italy and France held sexual morality to be an important instrument in the fight against VD. These countries continued their regulationist policies until after the Second World War. Northern European countries such as Britain and Germany opted for other solutions. Britain developed a liberal, individualistic policy, trusting each citizen to feel responsible towards society. Germany broadened its strict regulation to encompass all VD patients, not just prostitutes. Here control was seen as necessary to enjoin all to the morality of citizenship.
Liberal British Policies
Despite the liberal policies adopted in Britain, heated debate after 1900 singled out men as being responsible for the spread of VD to innocent wives and children. The problem increasingly occupied the attention of medical staff, welfare workers, and reformers. Suffragists such as Millicent Fawcett, leader of the National Union of Women's Suffrage Societies, alleged that men's insistence on their need for extramarital sex was a danger to the nation. They declared that the same sexual morals for men as for women would be a solution to the problem, and demanded economic independence and political citizenship for women. In a series of articles in 1913 Christabel Pankhurst coined the slogan 'Votes for women–chastity for men'.
The same year the Royal Commission on Venereal Disease was appointed on the recommendation of the International Medical Congress in London. Three distinguished women were among the commissioners. The Commission's recommendations led to the Venereal Disease Act of 1917. Notification and compulsory treatment was rejected as defeating the purpose of reducing the occurrence of VD. Instead the law made treatment readily available and free from stigmatisation. All VD patients were offered free, voluntary, and confidential treatment, and hundreds of consultation and treatment centres were now set up across the country. This liberal policy refrained from compulsory measures and offered free treatment with no strings attached. Although rough and condemnatory approaches could not be avoided, sources of infection were not criminalised. Respect for the civil liberties of the individual was much stronger in Britain than on the Continent. This did not mean that extramarital sex was accepted. A National Council for Combating Venereal Disease was set up in 1914 to promote information and education, which duly recommended chastity and sexual self-control as the best ways to avoid VD.
An acute rise in recorded cases of VD during the First World War brought matters to a head. It was important to keep soldiers healthy, and special lectures were arranged that offered medical advice on how to avoid VD. Early treatment in ablution areas and checks on prostitutes were other measures now introduced. Yet it was not only prostitutes who were seen as the problem: young 'amateur' women were said to offer sexual favours in return for being taken out for a meal or other amusements. This undermined the idea that controlling prostitutes would mean controlling VD. Sexual morality and disease remained closely intertwined. Consequently, in March 1918 a Regulation under the Defence of the Realm Act (DORA 401) allowed the examination of any woman suspected to be a source of infection for soldiers. This was met with strong opposition, not least from the women's movement and social purity organisations, and was withdrawn at the end of the War.
Excerpted from Medicine, Morality, and Political Culture by Ida Blom. Copyright © 2012 Nordic Academic Press and Ida Blom. Excerpted by permission of Nordic Academic Press.
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