Sex, Sin and Suffering. Venereal Disease and European Society since 1870
edited by: Roger Davidson, Lesley Hall
London and New York, Routledge, 2001, ISBN: 9780415234443; 272pp.; Price: £85.00
London School of Hygiene and Tropical Medicine
Date accessed: 1 June, 2023
Research on the history of venereal diseases (VD), syphilis, gonorrhoea, sexually transmitted diseases (STDs in more recent parlance), has flourished in recent years. Both the editors of the current volume have recently published books on the topic, Davidson on VD policy and practice in Scotland, Hall a more general synthetic work. When I mentioned to a colleague that I was reviewing this book, she enquired whether there was anything left to write about. Its contents demonstrate that quite clearly there is.
The main concentration of currently published work has been in two areas-studies of the British response to the Contagious Diseases Acts and their repeal in the second half of the nineteenth century; and country specific studies (focussing on Britain and the US) of the role of science and the development of VD policy in the early decades of the twentieth century. This was the history which has had some recent policy significance. It was drawn upon when AIDS came on to the scene in the 1980s. The history of STDs seemed to offer a model, in England at least, of the defeat of punitive policies and the rise of a voluntaristic model. Britain's rejection of the penal regulation of the Contagious Disease Acts in favour of medical regulation via the post World War one clinic system offered a template for anxious policy makers. Historical 'lessons' from VD were, if only temporarily, centre stage in the 1980s and historians developed a policy advisory role which has had later ramifications for their public image.
This volume covers a wider chronological range. It starts in 1870 when major challenges had emerged to the extension and operation of the Contagious Disease Acts model, and takes the story into the post Second World War years, with chapters on policy development in Scotland and England in the last half century and on Hamburg in the immediate post war period. This wider time span is paralleled by a country specific approach, which sees chapters on a variety of European countries, ranging from France to Sweden and Russia, but also on the links between VD control, colonialism and imperialism. Here there are chapters on the Far East, and on Uganda, as well as a general discussion of the interrelationships in a chapter by Philippa Levine.
A wide ranging editorial introduction touches on the broader historiography as well as some of the issues raised by the individual chapters. Davidson and Hall are concerned to place responses to VD in the context of changing ideas about public health and what were considered to be appropriate forms of regulation and intervention. They also discuss the impact on those patterns of regulation of the significant developments in scientific knowledge about VD which emerged from the late nineteenth century.
The policing of prostitutes, a strategy related to nineteenth century quarantine responses to infection control, was widespread in the late nineteenth century. Originating in France, it spread throughout much of Europe, even to the Netherlands, which later instituted liberal responses to VD. But increasingly this police response to control came under attack from an emergent 'preventive' medico-moral discourse at the turn of the century. This had its roots in a multitude of factors. VD, and syphilis in particular, also formed a powerful component of fin de siecle unease about the future of the race. It was one of those 'racial poisons' which seemed to vouch for the veracity of eugenic and degenerationist theories. An international abolitionist movement emerged which opposed the 'double standard' embodied in the regulationist agenda. Increased medical surveillance by the state and insurance based health systems underlined that agenda's failure. Medical advance - the differentiation of gonorrhoea from syphilis in the 1870s, the discovery of the etiological agent of syphilis, treponema pallidum in 1905, the introduction of the Wassermann test and of Salvarsan as a 'magic bullet' treatment in 1909 - enabled VD to be identified and treated. Changing responses were part a wider move towards laboratory based models of scientific investigation of disease.
But to draw connections between scientific advance and policy change would be simplistic. The chapters in this book show how the new preventive public health response had very different country specific histories. In France, for example, police regulation of prostitution lasted until 1960. The well known British history of this period - of the First World War Royal Commission on VD leading to the institution of a clinic system based on voluntary, confidential and open access - was not a universal model. In Spain the abolition of regulation and medicalisation came with the Second republic in the mid 1930s. Davidson and Hall relate these differing responses and the different models of regulation adopted to differences in political culture; the relative identification of VD with concerns about national efficiency; the nature of the military system; and the relative influence of the abolitionist movement.
Policy and public health change is one dimension of the historical picture. But, as this book shows, VD encompasses a broader range of social and cultural responses. Bernstein's chapter on revolutionary Russia uses public health posters to demonstrate the fundamentally different position of health education after the Revolution and the states' recognition of its importance in the remaking of society. The posters stress the role of the male doctor on his white coat - or the health of the young working class male. Class and gender dimensions were important in responses to VD more generally. Chapters on Germany in the nineteenth century, and on post war Hamburg are among those which emphasise how women who crossed boundaries of acceptable behaviour were perceived as polluting and as reservoirs of infection. The classic 'innocent victim' in this respect was typically male. The class dimension of societal fears focussed on the role of the 'working girl' and how she could be rescued and appropriate standards of middle class behaviour inculcated. Male sexuality and assumptions about male sexual behaviour were also embodied in responses to VD. Chapters by Hall on the UK and by Wanrooij on Italy point to the idea of infection as a rite of passage into manhood. Such cultural norms underwent significant change; by the time of the second World War; the 'manly man' was one who took precautions against infection.
Protecting the health of the armed forces had been the initial impetus behind contagious disease legislation. The military impetus behind regulation remained strong, although again differing according to country. The role of war in stimulating prevention and control has been considerable; and the protection of the army also involved the military presence in the colonies. This book valuably includes chapters relating responses to sexuality to the role of medicine and imperialism. Philippa Levine's chapter shows how contagious disease legislation tended to be more wide ranging in its colonial incarnations than its British counterpart. It was a critical prop for British imperial rule in the nineteenth century. Because medical care was aimed at protecting the British colonial residents, policies were always more preventive in their orientation. Levine therefore traces a line of 'policy transfer', not just from Britain to its colonies, but also the other way round with colonial approaches transferring the Mother country. Macpherson, in her chapter on campaigns against VD in Shanghai, Hong Kong and Singapore, also criticises the notion that universal 'mother country' models of policy were applied without consideration in the colonial context. She shows how, in her three locations, the implementation of the CD Acts varied according to local conditions and there were different responses among the local communities to the controversies they inspired. She uses a Far Eastern tour by members of the NCCVD (National Council for Combating Venereal Disease) in the early 1920s to highlight these differing responses.
Davidson and Hall make the obvious point that medical and moral discourses round sexuality were, and continue to be, entwined. The response to AIDS in the UK for example, saw prostitutes identified as 'vectors of infection' and the language of the 'innocent victim' revived. There has also been a continuing strand of compulsion embodied even within ostensibly medical responses. Davidson shows in his chapter how the interwar Scottish tradition of 'civic authoritarianism' in VD control was modified post war with a new focus on health education and on epidemiological contact tracing. David Evans' chapter on the same period in English policy shows how the VD services were incorporated into the NHS; the continuing low status of venereology (redefined as genito urinary medicine or GUM) and the changing clientele of the clinics with immigrant and homosexual populations using them in the post war years.
Writing such reviews, it is easy enough to identify areas on which one might like to have read more, or to make statements about how strange that the editors have not considered including a particular area of research. The chapters cover many issues which could have been given separate consideration - for example the changing status and nature of the specialisms which deal with VD. How the response to HIV/AIDS intersected with existing traditions of VD control is little considered - yet again, this appears to have depended on country specific cultures and traditions of medicine. One particular 'spectre at the feast' is the international aspect of regulation and control. At several points, both the editors and their authors draw attention to the strong international dimension to abolitionism in the late nineteenth century. It would have been valuable to have had a chapter taking forward this aspect of developing 'global health governance' into the era of the League of Nations and post war United Nations/ WHO activities. Little has so far been published on these aspects; yet the international dynamic was an important component of the later response to HIV/AIDS.
This book indicates that there is indeed more work to be done on the history of STDs. The cross national approach is clearly one way forward; this has been demonstrated by earlier cross national comparisons, for example Milton Lewis et al's study of STDS and HIV/AIDS in Asia and the Pacific, which is not mentioned in the introduction to this book. The previous absence of studies at the European level reflects on the relatively underdeveloped state of social history of medicine and health in some European countries as well. The editors of this volume have rightly avoided adopting a 'one size fits all' model of country by country comparison, and thus constraining the authors within chapter models which might not suit all they wanted to say. The book's genesis was aided by a conference for the various authors, and that has clearly aided the process of production and interaction. The editorial introduction is a valuable lead into the many and varied issues raised by studies of sexually transmitted disease. The recent efflorescence of 'sexual histories' has been underpinned by many issues, the earlier rise of interest in womens' history and the later advent of HIV/AIDS among them. The production of this volume shows that the area now has a growing European and international critical mass of historical interest which should sustain research interest. It indicates, too, that there are allied areas - youth culture, policy making in the last fifty years for example, - which await more attention.
We are delighted with this positive, generous and wide-ranging review by Professor Virginia Berridge, approbation from whom on this subject is praise indeed.
We were very much aware when compiling this volume that there were many topics relating to the European history of venereal disease which we were not going to be able to include, partly for reasons of space and partly for lack of appropriate or available contributors.
Professor Berridge rightly notes - as the 'spectre at the feast' - the lack of a chapter addressing the international diffusion of ideas and provisions relating to the treatment and control of VD. Inspired by the earlier work of Paul Weindling (1) and the more recent magisterial overview by Peter Baldwin of State responses to the 'Great Scourge' in modern Europe, (2) further research is certainly needed to chart and explain the multi-lateral trade flows in medical, legal, and cultural discourses surrounding VD. Our essays already signal the importance of these flows; for example, the impact of the 1899 Brussels International Medical Congress of 1899 on venereologists and policy-makers in a range of European countries; the evident international significance of Parent-Duchatelet in shaping the regulatory discourse surrounding prostitution and disease; and the explicit 'export' agenda of the imperial campaigns of the Social Hygiene Movement.
A second theme which is perhaps too implicit in the book and deserves, as Professor Berridge suggests, somewhat more transparent treatment, is the changing status and nature of the specialisms which dealt with VD. What emerges from the case studies is a continuing dialogue between medicine and the law in defining the relationship of the State to the diseased citizen, and a shift, albeit often contested, in the nature of medical expertise surrounding VD associated with the rise of a new public health, laboratory-based specialism. A common feature is also the degree to which VD policy-making remained a contested area of professional power both within the medical profession and between the agencies of public order, public health and public morality. Thus, Bolea documents the tensions between private and public practitioners in defining the new medical space of the VD clinics in 1920s Spain, Macpherson and Tuck reveal the tensions between western and 'native' medicines in interwar Hong Kong and Uganda, and Evans notes the protracted tensions between local authority medical officers and hospital venereologists within the post-1945 British National Health Service. Other chapters, such as those of Bolea on Spain and Freund and Sauerteig on Germany, reveal similar professional conflicts over the control of VD cases between medical, police, and social work authorities. We would add that there is certainly a good deal more to be written on the more internalist professional aspects of the international medical history of venereology and the relationship between treatment and scientific advances.
The coverage of the book inevitably had limitations. Non-British Imperial and Colonial responses to the problem of VD deserved fuller treatment. A serious omission is a chapter on France in the twentieth century, where, in spite of the advent of salvarsan and the public health model which became pervasive in other European countries, regulation and licensing of prostitutes remained a major element until the post Second World War closure of the brothels.(There is some coverage of this in Baldwin's Contagion and the State in Europe but a more focused study would be extremely valuable). We would also have liked to include more on the situation in Central and Eastern Europe. Additional insights into the differing social responses to (and stigmas associated with) gonorrhoea and syphilis in European society would have been instructive. Much of the historical literature tends to treat VD as a monolithic category but culturally they were often differentiated. Moreover, even when one endeavours to include an exhaustive account of the existing historiography, to the point of inserting recently published or discovered items after the submission of the manuscript, there will always be some items that authors will be kicking themselves that they managed to leave out. This unfortunately happened with the Lewis et al. volume on STDs and AIDS in Asia and the Pacific (3) . This was an unhappy omission especially as, although we did not strictly follow the model of organisation used by the editors of that volume to draw out common themes, it formed a very valuable starting point for our own deliberations. As Professor Berridge comments, we decided to eschew a 'one size fits all' approach, while asking our contributors to bear in mind a number of common themes which we felt would be productive in a comparative context. Other bibliographic omissions include Philip W. Setel, Milton Lewis, and Maryinez Lyons (eds) Histories of Sexually Transmitted Diseases and HIV/AIDS in Sub-Saharan Africa (1999) and Karen Jochelson's The Colour of Disease : Syphilis and Racism in South Africa, 1880-1950 (2001), which appeared too late to be taken into consideration.
The omission of any specific consideration of HIV/AIDS was a policy decision taken at an early stage of the progress of this volume. We felt that the history of the 'classic' or 'traditional' STDs deserved attention in its own right, and that the implications for current issues should remain implicit. As Professor Berridge points out, the history of policies and attitudes towards VD has ramifications for a range of areas of interest which have, perhaps, been occluded by treating it as a precursor model or awful warning for the age of AIDS.
One final theme that might have fruitfully been addressed is the shift in the nature of the sources employed by historians of VD over recent decades and its impact on the historiography of the subject. The more traditional public health narrative has tended to rely on official publications and circulars - along with the archives of the major medical, social purity and social hygiene institutions - together with the reports of women's organisations and other pressure groups, sometimes leavened by the use of surviving photographs. However, with the greater use of content and discourse analysis, historians and sociologists have focused more on the texts and iconography of VD propaganda; whether those issued by the social hygiene agencies in the form of pamphlets or films or by government information departments - sources which often reveal much more of the underlying cultural assumptions and norms underpinning medical provisions and social policy. However, one of the major innovations in research into syphilis and other VD in modern Europe has been the use of case notes and hospital registers along with other demographic data to access for the first time the medical history and life-experiences of syphilitic patients as opposed to the views and concerns of policy makers. For reasons of confidentiality, especially of the census records, in most countries this exercise has not been feasible for the period after 1870. A major exception is the recent work of Anna Lundberg in Sweden (4) , With the help of the demographic data base in Umea, she has undertaken a very imaginative and extremely innovative exploration of the social make-up of the venereally- diseased patient population and of the impact of VD on their life-chances and patterns of family formation. What she finds is that adult mortality rates and marriage rates of venereally-diseased patients were not significantly different from the control group, and that, in late 19th century Sweden, there was every chance that former venereally-diseased patients could enjoy a relatively normal profile of life expectation and family formation. Clearly, this is the type of research that if replicated elsewhere will open up an entirely new phase in the social historian's interpretation of the 'Great Scourge' in Modern Europe.- giving an entirely new insight into the social meaning of VD in modern European society.
(1) P. Weindling, 'The Politics of International Co-Ordination to Combat Sexually Transmitted Diseases, 1900-1980s' in V. Berridge and P. Strong (eds) AIDS and Contemporary History (1993), ch. 5.
(2) P. Baldwin, Contagion and the State in Europe 1830-1930 (1999).
(3) M. Lewis, S. Bamber and M. Waugh (eds), Sex, Disease, and Society: A Comparative History of Sexually Transmitted Diseases and HIV/AIDS in Asia and the Pacific (1997)
(4) A. Lundberg, Care and Coercion: Medical Knowledge, Social Policy and Patients with Venereal Disease in Sweden 1785-1903 (1999).