Venereal Diseases in New Zealand (1922) by Committee Of The Board Of Health

C >> Committee Of The Board Of Health >> Venereal Diseases in New Zealand (1922)

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In regard to the teaching of sex hygiene in schools some interesting
evidence was given to the Committee by Mr. Caughley, Director of
Education, Mr. T.R. Cresswell, Principal of the Wellington College
(speaking on behalf of the Secondary Schools Association), and by some
of the women doctors and others who were good enough to attend as
witnesses.

Mr. Caughley stresses the point that it is not mere knowledge of
physiology that will meet the case. He considers that the most important
thing of all is to establish in the minds of the children noble ideals
with regard to infanthood and motherhood. Lessons in connection with the
care of all birds and animals for their young, with the love and
devotion of parents for their young, with all that is beautiful and
tender connected with the homes of animals and birds, would establish a
kind of reverence about everything that is connected with birth. He
deprecates mechanical, systematic, and consecutive instruction in the
mere facts of sex hygiene, for even the fullest knowledge on this
subject is known to have very little deterrent effect in the temptations
of life. He would rather aim at creating the right atmosphere in a
school, such as would make any coarse or unworthy mention of any of
these matters in the hearing of a child appear more or less repulsive,
and would in general enable him to put in its proper setting any
knowledge that might come to him from various sources.

Mr. Cresswell gave the Committee an extremely interesting _resume_ of
the answers to a _questionnaire_ which he addressed to the head of every
secondary school in the Dominion. He suggested--(1) That a determined
public effort should be made to rouse parents to a sense of their
responsibility in regard to this matter by means of broadcasted
pamphlets, and that they should be furnished with simple, specially
written leaflets to assist them in giving instruction to their children;
(2) that sex hygiene be made a compulsory subject in all
training-colleges, the instructors being specially qualified doctors;
(3) that regular courses of public lectures be delivered in suitable
centres; (4) that teachers, and especially physical instructors, be
encouraged to stress the value of physical fitness to pupils
collectively, and, where need is indicated, to have private talks with
individuals; (5) that teachers be advised to take every opportunity
during lessons in hygiene, physiology, botany, &c., to give children a
sane and normal outlook on sex matters.

Incidentally it was suggested that girls' schools suffer somewhat
through being staffed almost exclusively by celibate teachers. "The
knowledge and sympathy of a real mother would," it was urged, "be
invaluable to many girls in our secondary schools. Does it seem a
trivial suggestion that in every girls' school there should be one
honoured official, the 'school mother,' a sympathetic motherly person
whose duty it should be to get into personal touch not only with
individual girls but also with individual parents?"

The views expressed by the Swedish Committee of Experts in Medicine and
Pedagogy are well worthy of quotation: "It is illustrative of the broad
view taken by the committee of their task," says the _British Medical
Journal_, "that they deal with the education of the child from the time
it learns to speak and address inquiries as to how it came into the
world. The committee look forward to the time when parents will be so
enlightened that they will not tell their children silly stories about
babies being brought into the home by storks, but will give a simple
account which the child in later years will not discover to be
mendacious. The committee hope that the child, who is gradually taught
more and more about sex hygiene as it passes from one school grade to
another, will eventually become a parent wise enough to instil in the
next generation a frank and healthy attitude towards sex problems.
Parents, it is hoped, will learn to protect their infants from the
undesirable caresses and kisses of strangers ... As for sex teaching in
school, this should be associated with the teaching of biology,
Christianity, sociology, and psychology. The question of venereal
disease should not come into the curriculum until comparatively late,
and until the physiology of fertilization and reproduction has been
fully taught. Advanced sex teaching should preferably be in the hands of
doctors; but they are not always available, in which case other teachers
should give instruction on this subject, male teachers dealing with boys
and female teachers with girls. Teaching of sex hygiene in high schools
for girls should include the subject of venereal disease, and special
emphasis should be laid on the protection of infants from infection. A
further recommendation is that a carefully supervised library of works
on sex hygiene and venereal disease should be compiled at the cost of
the State for the use of teachers and classes."

The Committee of the Board of Health agree with the suggestion that
teachers should be trained to deal with this question, and that school
medical officers or other qualified practitioners should give occasional
"talks" to the elder boys and girls. A great deal may be done by
physical instructors preaching the gospel of "physical fitness" and
personal cleanliness in thought, word, and deed. Bathing and outdoor
sports and games of all kinds should be encouraged. The Committee would
point out, however, that not all teachers and not all medical men
possess the qualities fitting them to give instruction and advice in
this delicate matter. The task should be entrusted to those who have
shown themselves specially adapted by sympathy and tactfulness for the
work, and preferably those who are parents, otherwise harm instead of
good may result.

More than one witness spoke with approval of "The Cradleship" and other
books by Miss Edith Howes as suitable for use with young children.

The Committee are of opinion that addresses on sex questions by lay
persons, except selected teachers, to young people in mass are of
doubtful value.

Sufficient instruction should be given to adolescents regarding venereal
diseases and their effects to ensure that if they do contract them it
shall not be through ignorance. The Committee cannot too strongly
emphasize their belief, however, that knowledge of the effects of
venereal diseases is in itself by no means a sufficient safeguard; that
in addition to such knowledge the cultivation of a high moral standard
is necessary, and if this is reinforced by religious sanctions it is
likely to be more effective.

The Committee agree with the view expressed by Dr. E.T.R. Clarkson in a
recent text-book, entitled "The Venereal Clinic," that in many instances
an excessive stress has been placed upon the factor of fear. He says
that a very small proportion of the community are restrained from
indulging in promiscuous sexual intercourse through fear, and it is
irrational to rely so much upon an emotion which at the best is but
slightly inhibitory, and which cannot in itself exercise a direct
energizing influence for good. "We do not," he continues, "wish to deter
the community from living a life of sexual promiscuity by rendering them
fearful of the possibilities of acquiring venereal disease, but we want
rather to instil such an ideal into them, whether it be of a religious,
ethical, or altruistic nature, as will tend to make them regard such a
life as incongruous with those tenets and therefore as undesirable,
however much it may be desired on other grounds." He adds that the
emphatic reiteration of fear possesses another and dangerous
disadvantage. "There is no doubt, as venereologists will testify, that
many individuals are seriously suffering from the effects of fear thus
engendered in their minds. In some instances the resultant damage to
their mentality is more serious than the venereal disease from which
they are suffering: whilst in others an obsession that they are
infected, when there is no foundation for the fear, may develop in such
a manner as to inflict serious and permanent damage."

SECTION 2.--CLINICS FOR THE TREATMENT OF VENEREAL DISEASE.

Early in 1919 clinics for the treatment of venereal disease were
established in each of the four main centres. Arrangements were made by
the Department of Health for the treatment by Hospital Boards throughout
the Dominion of cases of venereal disease, and in the absence of local
institutions arrangements were made with private practitioners. There is
therefore opportunity for all to receive free treatment, wherever they
may be, in New Zealand.

Table B sets out the work done at the four clinics during the two and a
half years ended 30th June, 1922. From this table it will be seen that
3,038 males and 596 females attended these clinics during the period
named. The total number of attendances was 110,792--101,995 males and
8,797 females. The disproportion between the number of males and females
attending is notable. It is clear from the evidence that this does not
represent a difference in the incidence of these diseases in the sexes,
but that women do not attend so freely when suffering.

These clinics are attached to the public hospitals in each centre, and
all evidence goes to show that this is most desirable. If the clinics
were apart, the object of the patients' visits would be obvious, whereas
the actual purpose for which they go to a hospital is not so. It is to
be strongly emphasized that the less publicity given to the attendance
of these patients, the greater the number of patients who will be likely
to take advantage of the treatment offered. This applies especially to
the attendance of women.

The clinics are now open only at certain hours. The Committee suggest
that they might with advantage remain open continuously (except at
certain fixed hours on Sunday). In the absence of the Medical Officer a
sister could take charge of the women's clinic, and a trained orderly of
the men's clinic. It would be necessary in this case to have separate
clinics for male and female patients--the same rooms would not be
available for both sexes.

The majority of witnesses asked were of opinion that if a lady doctor
were made available for the treatment of women the number of women
attending would increase.

It is suggested that in certain cases of gonorrhoea, where it is an
advantage that the treatment should be carried out twice or more often
daily, arrangements might he made for the supply of the necessary
apparatus and drugs to patients at cost price, and in indigent cases
free of charge. This is particularly important to women who may have to
continue treatment for several months.

The clinics should be more widely advertised by notices in public
conveniences and other suitable places.

The Committee are impressed with the valuable work done at these
clinics, and recommend their extension to other centres as opportunity
offers and necessity is shown to exist.

The existing clinics are conducted by medical men who have had special
experience and training in the treatment of these diseases. The Dunedin
clinic is attended by medical students for purposes of instruction. In
view of recent advances in the processes of diagnosis and treatment of
these diseases, the Committee consider that opportunity should be given
to medical practitioners to attend these clinics in order to familiarize
themselves with the most recent advances in this field. It would he an
advantage also if nurses in the course of their training attended the
female clinics, so that they might he taught to recognize the commoner
manifestations of these diseases.

The most disappointing feature in the records of the clinics is the
cessation of treatment by so many patients before they have ceased to be
infective. The following evidence was given in this connection:--

_Percentage of Cases attending till Non-infective._ Auckland Clinic: 80
per cent. cases of syphilis, 50 per cent. cases of gonorrhoea. It was
stated that no woman suffering from gonorrhoea continued treatment till
non-infective.

Wellington Clinic: 40 per cent. of all cases continued treatment till
non-infective, and very few of these were women.

Christchurch Clinic: Men with syphilis, 75 per cent.: men with
gonorrhoea, 98 per cent.: women with syphilis, 50 per cent.: women with
gonorrhoea, 14 per cent.

Dunedin Clinic: In this clinic only thirty-one males suffering from
gonorrhoea were discharged cured: thirty-two absented themselves while
still infective; three female cases remained under treatment till cured,
and six ceased to attend while still infective. Forty male syphilitics
remained till non-infective, and seventy-four ceased treatment before it
was completed. For female syphilitics the figures are four and eighteen.

It will be noted that in each case the proportion of women who attend
till non-infective is much smaller than of men, especially in cases of
gonorrhoea. The reasons for this are probably that owing to anatomical
considerations women infected with venereal disease suffer less pain and
the disease is less obvious than in men. On cessation of the more urgent
and obvious signs and symptoms they stop treatment. Again, it is
probable that the publicity of attending the clinics is felt more by
women than men. A third reason is the prolonged period of treatment
(often extending over many months) necessary to eradicate gonorrhoea in
women. These difficulties could to some extent be mitigated by the
provision of arrangements for women to carry out treatment in their
homes, which would avoid the publicity and loss of time entailed in
attending clinics.

The Committee were impressed with the value of the work done by the lady
patrol in Christchurch, and considers that lady patrols would help
greatly in securing the attendance of women at the clinics. It is
recommended that these patrols should be attached to the Hospital Boards
and that they should be trained nurses. They would be available to give
advice to patients as to treatment in their homes.

The Committee would also draw attention to the very valuable work done
by the Social Hygiene Society in Christchurch, and recommended the
establishment of similar voluntary societies in other centres.

The Committee recommend that all bacteriological and other examinations
required for the diagnosis and treatment of cases of venereal diseases
should be carried out in laboratories of the Department of Health and
public hospitals free of cost, on the recommendation of medical
practitioners.

The Committee made inquiries from competent witnesses as to the present
position of the complement fixation test in gonorrhoea. It appears that
this test has not reached yet such a degree of reliability as to render
it of great diagnostic value, but that it is reasonable to hope that it
may be perfected to such an extent to give it a value in the diagnosis
of gonorrhoea comparable to that of the Wassermann test in syphilis.

SECTION 3.--LICENSED BROTHELS.

Inasmuch as one of the many letters addressed to the Committee favoured
the adoption of the Continental system of licensed houses of
prostitution, with medical inspection of the inmates, it seems desirable
to examine the arguments for and against such a proposal. Those who
support it contend that so long as human nature remains as it is
prostitution will continue, therefore it is better that it should be
regulated with a view to controlling the spread of disease. It is also
urged that the system acts as a safeguard against sexual perversion by
providing an outlet for the unrestricted appetites of men; that in its
absence clandestine prostitution increases, and innocent girls are more
likely to be led astray or become the victims of sexual violence. Apart
from the moral aspect of the case, these arguments are entirely
fallacious; and even in the countries where the licensed-house system
prevails enlightened public opinion has come to that conclusion. In the
first place, the idea that the system tends to lessen disease is a
dangerous delusion. Owing to the fact, already referred to, that
venereal disease in the early stages is difficult to detect in women,
even by skilled experts working with the best methods and with
practically unlimited time at their disposal, the routine inspection
given, for example, in the French and German houses is no guarantee of
the inmates being free from communicable disease even at the time of
inspection.

Flexner, who spent two years in making inquiries and writing his classic
work on "Prostitution in Europe," is most emphatic on this point. The
experience of the American troops in the Great War is further strong
confirmation. The following is an extract from an article published by
the American Red Cross in May, 1918: "During the months of August,
September, October, and the first half of November, the houses of
prostitution flourished and were half-filled with soldiers. On November
15th rigid orders were issued placing these houses out of bounds, and
the immediate result was a great reduction of sexual contacts. As a
result there was a steady decline in venereal infections, and the
monthly rate per 1,000, which in October reached 16.8, dropped in
January to 2.1 among the white troops. During the same period there was
an even more striking drop in the infections among the negro labourers,
the percentage dropping from 108.7 per 1,000 a month to 11 per 1,000. No
statistics could speak more eloquently for the doctrine of closing the
houses of prostitution. Our studies showed numerous infections coming
from houses 'inspected' three times a week."

In May, 1921, a conference (the North European Conference on Venereal
Diseases), in which England, Finland, Germany, Holland, Norway, Sweden,
and Denmark participated, passed the following resolution: "This
conference, having considered the general measures for the combating of
venereal diseases which have been adopted by the participating
countries, is unanimously of the opinion, so far as the experience of
these countries is concerned, that the legal and official toleration of
professional prostitution has been found to be medically useless as a
check on the spread of venereal diseases, and may even prove positively
harmful, tending as it does to give official sanction to a vicious
trade."

On the same point Flexner says: "It is a truism that physicians
requiring to equip themselves as specialists in venereal disease resort
to the crowded clinics of Paris, Vienna, and Berlin, all regulated
towns, because there disease is found in greatest abundance and richest
variety--a strange comment on the alleged efficacy of regulation."

Dr. Clarkson, in "The Venereal Clinic," already quoted, says, in
reference to the fancied security of licensed houses, "It may strengthen
the hands of practitioners to be able to tell interrogators in this
subject that in the opinion of leading venereologists, &c., no
foundation exists for any such feeling of confidence or security. In
other words, the system of licensed houses is a failure, and the 'red
light' of lust shines out as the lurid signal of disease and death."

It is surely hardly necessary to urge the moral objections to the
proposal. The United States Public Health Service not long ago sent out
a _questionnaire_ to representative citizens in various walks of life
asking for opinion in regard to open houses of prostitution. There was
an overwhelming preponderance of replies against the system on moral as
well as hygienic grounds. One Illinois miner answered: "The life of a
prostitute is short, and her place must be filled when she dies, and,
being the father of two girls, I would not want mine to fill a vacancy,
and I think all parents think the same." A Colorado carpenter replied:
"The woman engaged in such business may not be my wife, mother, sister,
or daughter, but she is somebody's wife, mother, sister, or daughter. It
is a violation of all law." One Chief of Police wrote: "Open houses of
prostitution breed disease, crime, increase the number of prostitutes,
corrupt the morals of the community, and are a menace to the youth of
the country." Another replied: "The only reason I have ever heard
advanced in favour of houses of prostitution is that they protect
innocent girls. I am opposed to sacrificing any woman to benefit
others."

If statistics could be obtained it would be probably found that the
system tends not only to increase disease, but the volume of sexual
immorality and crime. From the most materialistic point of view the
system is indefensible; while, looking at it from the moral aspect, it
is inconceivable that British people, who spent millions of money to
stop the traffic in black slaves, would ever officially countenance a
system which enslaves the souls as well as the bodies of its victims and
defiles the community in which it exists.

SECTION 4.--EXCLUSION OF VENEREAL CASES FROM OVERSEAS.

The Committee are of the opinion that by the strict exercise of the
provisions of section 111 of the Health Act, 1920, much may be done to
prevent introduction of venereal diseases from overseas. They suggest,
however, that where any person so suffering is required or permitted to
attend a clinic he should be accompanied by some responsible officer of
the ship, or person authorized by the shipping company concerned, and
that the question on the "Report of Master of the Ship" defined by
regulations--"Are you aware of the presence on board of any person
suffering from ... _(b)_ venereal disease?"--might be strengthened by
adopting the Australian quarantine service equivalent viz., "Is there
now or has there been on board during the voyage any person suffering
from demonstrable syphilis in an active condition, or other communicable
disease?"

The evidence given does not show that the number of venereal-diseases
cases already in the Dominion is greatly added to by the introduction of
cases from overseas. Since 1903 persons suffering from syphilis have
been "prohibited immigrants" within the meaning of the Immigration
Restriction Act.

SECTION 5.--PROPHYLAXIS.

Before discussing this question it is desirable clearly to distinguish
between the procedures which are included under this term. These are--

(1.) The supply of drugs and appliances which are made available
for use by the individual before exposure to infection. This may be
described as "anticipatory prophylaxis," and has commonly been
designated the "packet system."

The Committee condemn this procedure, for these reasons: (i) That
the system suggests a moral sanction to vice; (ii) that the
individual is lulled into a false sense of security, and may
thereby be encouraged repeatedly to expose himself to infection;
(iii) that the individual may be thereby deterred from seeking
early advice or treatment; (iv) that the drugs supplied may be used
for treating disease should it arise, and so delay may result in
seeking skilled treatment in the early stages when it is likely to
be most effective.

(2.) Treatment applied after exposure to infection. This is called
"early treatment." This term is inapplicable, as a disease cannot
be treated before it exists. It is also likely to be confused with
"abortive treatment," which implies treatment immediately on the
appearance of symptoms.

The evidence before the Committee shows that this form of
prophylaxis, if applied by skilled persons and within a few hours
of exposure, is effective in preventing disease in a great majority
of the cases in which it is used.

The Inter-departmental Committee on Infectious Diseases set up by the
Ministry of Health in 1919 in connection with demobilization, in a note
on "Prophylaxis against venereal disease," reported among its
conclusions based on service experience, "That where preventive
treatment is provided by a skilled attendant after exposure to infection
the results are better than when the same measures are taken by the
individual affected, even after the most careful instruction." After
exposure to infection there appears no reason why these diseases should
not be regarded in precisely the same manner as other infectious
diseases, and precautions taken to sterilize the parts which have been
exposed to infection.

It is to be noted that it is recommended that the prophylactic treatment
is to be carried out by some properly instructed person. This need not
necessarily be a medical man. It is suggested that this form of
prophylaxis might be carried out by an orderly at the venereal-disease
clinics. The notices posted in the public conveniences and other
suitable places indicating the existence of the clinics and the
necessity for treatment might include a guarded reference to their use
for this purpose.

This form of prophylaxis applies to males. In the case of females the
methods adopted would be also contraceptive, and the Committee do not
recommend that facilities should be provided for this.

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