Book Review
Sex, Sin and Suffering. Venereal Disease and European Society since 1870
Reviewed by: Virginia Berridge
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.
February 2002