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Some factors involved in the spread of venereal disease Peyman, Douglas Alastair Ralph 1946

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Some Factors Involved in the • Spread of Venereal Disease. by Douglas Alastair Ralph Peyman.  A Thesis submitted i n Partial Fulfilment of The Requirements for the Degree of MASTER OF ARTS in the Department of PHILOSOPHY AND PSYCHOLOGY  The University of British Columbia September 1946. s  TABLE OF CONTENTS Preface Introduction Chapter I.  The Problem.  1.  The Nature of the Problem.  2.  The Extent of the Problem.  3.  Geographical Distribution of Cases.  4..  Occupational Status of Infected Persons.  5.  Marital Status of Infected Persons.  Chapter I I . Factors Involved:  Prostitution and Promiscuity.  1.  Organized or commercialized Prostitution.  2.  Clandestine Prostitution and Promiscuity.  Chapter III. Factors Involved:  Economic.  1.  Housing.  2.  Lack of Recreation.  3.  Lack of Educational Opportunities.  4.  Necessarily High Age of Marriage.  Chapter IV. 1.  Factors Involved:  Social.  Lack of Social Relationships.  2. ' Lack of Education and Interests. 3.  Lack of Recreation.  4. Alcohol. 5.  Influence of Companions.  Chapter V.  Factors Involved:  Psychological. -  1.  The Sex Drive.  2.  Lack of Satisfactory Substitute Activity.  3.  Loss of Security.  A.  Lack of Marital Adjustment.  5.  Lack of Fear of Infection.  *  6. Lack of Recreation. 7.  Lack of Interests.  8.  Conditioning Influence of Environment.  9.  Increasing Disregard of Sex Mores.  10.  Wartime Philosophy.  11.  Mental Qualities of Infected Persons.  12.  Promiscuity as a Compensatory Response.  Chapter VI. Factors Involved:  Early Life of Individual.  1.  Home L i f e .  2.  Parental Maladjustment.  3.  Ignorance.  4.  Prudish Attitudes i n the Home.  Conclusion.  i  PrefaceThis study i s an attempt to find some of the major factors i n volved i n the present day prevalence of venereal disease* emphasis i s given to some of the psychological factors that are too often omitted from discussion of this topic* The subject of venereal disease can be, and has been approached from many points of view:  some approaches have stressed economicsj others,  moralityj and s t i l l others such particular problems as alchoholism, too much sex knowledge, too l i t t l e sex knowledge, lack of parental control, -lack of legislation, and a host of others. Some of the studies have been very influential and have paved the way for action on the part of various interested individuals and groups, but no single study has concerned i t self with a l l the aspects.  This paper i s a far cry from such an attemptj  however,-mention w i l l be made of the recognized major factors known or thought to-be involved in this complex problem. It must be pointed out that this paper i s i n no way an attempt at a statistical survey, nor i s i t an attempt to find common factors predisposing to the spread of infectionJ  I f such attempts were feasible,  they would not be valid i n this study because of the inadequacy of the data. Although the paper i s based on numerous c l i n i c a l records, accounts of interviews with patients, actual interviews with c l i n i c patients and a mass of reports from a l l parts of the world dealing with the problem of venereal disease control, most of the records are of free c l i n i c patients and thus any serious statistical study would be of dubious value i f i t s conclusions were applied to B. C. as a whole. On the other hand, c r i t i cism that the conclusions given i n this paper can apply only to c l i n i c patients of a lower economic and social class, would be too harsh.  ii C l i n i c patients under treatment f o r venereal disease are from a l l s o c i a l and economic strata:  i n B. C. C l i n i c s there i s no question raised whether  one can afford to pay f o r treatment, and, more importantly, the treatment at a c l i n i c i s always as good as, or better than, the treatment given by private physicians.  (In many cases, t h i s l a t t e r point i s not  by some infected persons who  considered  fear that they would be seen v i s i t i n g a c l i n i c  by someone they knew. A discussion of the pros and cons of such attitudes need not be gone i n t o i n t h i s paper; i t s u f f i c e s that such attitudes are prevalentj and prominent (self-thought or r e a l ) men f e r private physicians.  and women u s u a l l y pre-  The f i l e s on such patients are not complete enough  to warrant a s t a t i s t i c a l survey, but are complete enough to give  information  of value i n formulating general factors responsible for the spread of venereal  disease.)  iii Introduction; Within the eight year period (1938-1945 i n c l u s i v e ) i n B. 28,021 new cases of venereal i n f e c t i o n were reported:  C,  the term 'reported'  should be emphasised, because there i s evidence that p r i v a t e physicians are not reporting a l l cases as required by the Venereal Disease Suppression Act of 1924.  (Estimates that the actual number of new cases i s about twice the  f i g u r e given, are of l i t t l e consequence i n t h i s paper because even the given figure i s s t a r t l i n g enough.) Whether there i s an annual increase i n the number of new i s an important, but d i f f i c u l t point to determine.  cases  Because the reporting  of new cases by private physicians i s thought to be improving i n B.  C.,  there i s often doubt whether the f i g u r e s given i n annual reports r e f l e c t an actual increase or decrease i n the number of new i n f e c t i o n s . . However, i f i t can be assumed that the Vancouver C l i n i c s t a t i s t i c s r e f l e c t the true s i t u a t i o n , i t would appear that there i s a f l u c t u a t i n g annual attack rate of venereal disease and that t h i s attack rate i s increasing annually. From the outset, venereal disease control i s concerned p r i m a r i l y with sexual a c t i v i t i e s .  However, the domain of sex being as extensive as  i t i s , f o r the purposes of investigating the problem of venereal disease, heterosexuality can be considered as the e s s e n t i a l f i e l d of study.  In t h i s  i n v e s t i g a t i o n , only heterosexuality i n the form of coitus w i l l be considered, because i t i s from coitus that the vast majority of i n f e c t i o n s are acquired. (Cases of homosexually; acquired i n f e c t i o n s have been reported, but tljey w i l l not be considered i n t h i s workj neither w i l l those i n f e c t i o n s , sexually acquired, of very young children who have been c r i m i n a l l y assaulted by adults.)  Even further, every case of venereal i n f e c t i o n , with the main  exception of prenatal s y p h i l i s and p a r t u r i e n t l y acquired s y p h i l i s and  and gonorrhoea, and a few other rare exceptions, indicates that there has been promiscuous sexual behaviour on the part of at least one member of the pair acquiring infection.  Possibly the use of the term "promiscuous"  i s not clear, so for the purposes of discussion, i t will be defined as 'sexual (probably copulatory) behaviour with at least two persons within a period of four years . 1  Disregarding any moral or ethical principles involved, the cont r o l of venereal disease i s concerned primarily with the control of promiscuity rather than with the control of sexual activity between two persons, married or unmarried.  Chapter It  The Problem: 1,  The Mature of the Problem:  The term "venereal disease" i s one generally applied to two distinct infections, syphilis and gonorrhoea.  (It i s also applied to a  number of other infections of a venereal nature, but they are quite rare in British Columbia.) At the present time, these two infections, combined, are the most prevalent of the serious communicable diseases i n • British Columbia, and i n most western countries. They constitute a serious health problem, not merely an individual health problem, but especially a public health problem —  several authorities have stated that they  constitute the most serious public health problem of today,  (l) (2).  The serious consequences that may result from these diseases are themselves important fields of study for medical practitioners, psychiatrists, and social workers; for i t i s the consequences that remove venereal disease from the realm of an individual health problem to that of a public health problem. However, i t i s not the intention of this paper to dwell upon the problems which may follow the acquisition of an infection, but rather to explore some of the existing factors which precede infection. . Before discussing these factors, a broader enquiry into the problem must be made:  such an enquiry must include the geographic origin  of the infections, and some information concerning the individuals who have acquired infections.  The information elicited from such an enquiry  i s far from sufficient to warrant any immediate conclusions being drawn concerning the control of venereal disease, but i t does narrow the f i e l d of enquiry to limits within which control can be exercised. (1) (2)  Parran, T., Shadow on the land, p. 53. Snow, W.F., Venereal Diseases, p. 13.  '  2.  The Extent of the Problems  In British Columbia, adequate records concerning the prevalence of venereal disease exist only from 1 9 3 8 : factory reporting system operated.  prior to this time, no satis-  Since then, however, the reporting of  new infections by medical practitioners throughout the province has improved, although i t i s s t i l l far from being complete. The passing of the f i r s t Venereal Disease Suppression Act i n British Columbia in 1924,  made i t compulsory for medical practitioners i n  the province to report to the Provincial Board of Health a l l cases of venereal disease (syphilis, gonorrhoea, and chancroid) which came under their care. Nevertheless, despite this legislation, there i s evidence that i n many instances f u l l reporting of new infections i s not being made. Furthermore, due to the ignorance which s t i l l surrounds venereal disease, many infected persons resort to quacks and charlatans, purchase some home remedy from their drug store, or else do nothing.  How many  untreated or improperly treated infections exist eannot be even approximated, but that there i s a large number i s evidenced by the number of positive tests for syphilis which appear i n mass blood testing surveys such as those i n employment examinations at large industrial plants, and in the medical examinations of the armed forces. Thus, considering these few points, i t can be readily seen that the o f f i c i a l figures regarding the prevalence of venereal disease do not reveal the true situation.  However, as they are the only ones available,  and are the ones used i n a l l o f f i c i a l surveys, for the present they w i l l have to suffice. The following tables indicate the number of infections of gonorrhoea and syphilis acquired i n British Columbia from 1 9 3 8 to 1 9 4 5 inclusive.  These figures are the o f f i c i a l totals as reported by c l i n i c s ,  private physicians, hospitals, the armed forces, and some minor reporting agencies. Table I indicates the total number of new notifications i n B. C. from a l l the reporting agencies.  It should be pointed out that  though the figures given are notifications for the f i r s t time i n B. C., they are not necessarily new infections.  A person might have had treat-  ment outside of B. G. and then on coming to this province continued his treatment* purposes.  such a person would be considered a new case for statistical However, such cases are few, and the number of new n o t i f i -  cations i s considered as the criterion of the venereal disease problem in a given area.  For general purposes, the number of new notifications  and the number of new infections are synonymous. TABLE I Year  Syphilis  Gonorrhoea^  Total Venereal  1938  1430  1604  3034  1939  1222  1391  2613  1940  996  1502  2498  1941  998  1747  2745  1942  1002  2409  3411  1943  1183  2555  3738  1 9 4 *  1379  3358  4737  1945  1534  3711  5245  Table I:  Source;  Total Notifications of Venereal Disease i n B. G. from a l l Reporting Agencies.  Division of V. D. Control, Vancouver, B. C. Tables II and III indicate the numbers of new notifications  from private physicians, free clinics of the Provincial Board of Health and other sources.  These tables indicate that with the passage of time,  reporting of venereal disease i s improving, and that each year the figures published by the Provincial Board of Health give an ever improving portrayal of the actual prevalence of the diseases i n the province. The  - 4improvement in the completeness of reporting by private physicians is due in part to education, to the supplying of drugs by the Government, and to the growing realization on the part of the private physicians of the importance of complete reporting in the control of venereal disease. TABLE II  Yeay  1938 1939 1940 1941 1942 1943 1944 1945  No. of Syphilis Notifications from Private Physicians 597 522 465 483 562 688 708 700  No. of Syphilis Notifications from Other Sources  116  717 549 358 331 271 340 492 632 Table II:  Source:  No. of Syphilis Notifications from B. C, Clinics  151 173 184 169 155 179 202  Total notifications of syphilis in B. C. from a l l reporting agencies.  Division of V . D, Control, Vancouver, B. C, TABLE III  Xear  1938 1939 1940 1941 1942 1943 1944 1945  No. of Gonorrhoea Notifications from Private Physicians  No. of Gonorrhoea Notifications from B. C. Clinics  523 482  524  600 952 958 1143 1329' Table III:  Source:  No. of Gonorrhoea Notifications from . Other Sources  1059 871 826 779 842 863 1176 1565  • 22 - •  38 152 368 692 734 1039 817  Total notifications of gonorrhoea in B. C. from a l l reporting agencies.  Division of V . D„ Control, Vancouver, B. C.  Private physicians, who probably treat the majority of venereal disease i n B. C , do not always notify the Provincial Board of Health as required by the Venereal Disease Suppression Act of 1924.  I t has long  been suspected that many private physicians have not been so doing. One source of suspicion of their failure to report a l l venereal infections coming under their care i s obtained from a comparison of the ratio of syphilis to gonorrhoea reported by private physicians to that reported by government c l i n i c s .  I t can be safely assumed that a l l infec-  tions coming under the care of the Venereal Disease Clinics i n B. C. are f u l l y reported:  and i t can be seen In the tables that the ratio of syphilis  to gonorrhoea infections i s more than 1:2 i n a l l years since 1940.  The  ratio of syphilis to gonorrhoea as reported by private physicians i s less than 1:2 i n a l l years since 1938.  If i t can be assumed that approximately  the same ratio of both diseases come under the care of private physicians and free clinics, there i s certainly evidence that many infections are not being reported.  However, by these premises, i t i s also evident that  reporting by private physicians i s improving.  (No conclusions are drawn  from the ratio of syphilis to gonorrhoea as reported by "other" sources, because the ratios of the disease vary greatly" e.g., the ratio of syphilis to gonorrhoea as reported by hospitals i s far greater than 1:1; as reported by the Armed Forces, i t i s far less than  1:1.)  Another indication of the lack of f u l l reporting by private physicians is occasionally shown by c l i n i c patients themselves. When a patient v i s i t s the c l i n i c a brief case history i s taken.  If the patient  reports a previous venereal infection treated by a private physician, that infection should have been reported to the Division of V. D. Control, and a record of i t should be on f i l e .  When no such record can be found, i t  becomes evident that a l l infections are not being reported as required by  - 6  -  the Venereal Disease Suppression Act. A third and probably more reliable indication of the lack of complete reporting of new infections i s obtained from the laboratory reports sent to the Division of V. D„ Control by the Division of Laboratories.  The latter Division monthly furnishes the Division of V, D,  Control with a l i s t of the positive and doubtful serological tests for syphilis, and of the positive smear and culture examinations for gonorrhoea, with the name or identification of the patient from whom the sample was taken, and the name of the physician who took the sample.  These l i s t s  are checked with the records of the Division of Venereal Disease Control, and when a suspected infection has not been reported the physician responsible i s requested to send i n a Notification of Infection or an explanation. The fore-going evidence i s presented merely to indicate that the available statistics concerning the prevalence of venereal disease i n the province are incomplete.  The combined totals of infections not reported  by private physicians, of those treated i l l e g a l l y by unqualified persons, and of those totally neglected are inestimable. The laxity of reporting of venereal infections by private physicians i s not solely a problem of B. C.j i t i s present i n the other provinces of Canada, i n the United States, and probably i n every other country.  Thus when a comparison i s made of the prevalence of venereal  disease i n different provinces or countries, the degree of reporting i n those provinces or countries must be considered. Table IV shows the number of cases of syphilis ( a l l types) i n the provinces of Canada and the rate per 100,000 of syphilis i n 1944 and 1945.  - 7-  TABLE IV 19/JL  1245  CANADA  Cases Rate  P.E.I.  Cases. Rate  35 38.5  34  N.S.  Cases Rate  496 81.0  664 106.9  N.B.  Cases Rate  573  124.0  413 88.2  7,120 203.4  7,037 169.5 4,930 123.1  Que.  Cases Rate  16,475 137.8  •  15,278 126.2 37.0  Ont.  Cases Rate  5,365 135.3  Man.  Cases Rate  663  90.6  622 84.5  Sask.  Cases Rate •  360 42.6  410 48.5  Alta.  Cases Rate  573 70.0  599 72.5  B. C.  Cases  1,290 138.4  1,569 165.3  ,Table IV: Incidence and Rate per 100,000 per annum, of Syphilis, a l l types: Reported by Provincial Health Departments to the Dominion Bureau of Statistics. Source:  Division of Venereal Disease Control, Department of National Health and Welfare, Ottawa.  Table V shows the number of cases of gonorrhoea i n the provinces of Canada and the rate per 100,000 of gonorrhoea i n 1944- and 1945. TABLE V  CANADA  —  Cases Rate  19/JL  19A5  22,282  25,237  186.3  208.5  P.E.I.  —  Cases • Rate  20 22.0  42 45.7  N.S.  —  Cases Rate  1,663 271.7  1,176 189.4  N.B.  —  Cases  913  Rate  197.6  230.6  1,079  Que.  —  Cases Rate  4,259. 121,7  5,106". 143.4  Ont.  —  Cases Rate  7,908 199.4  8,224 205.4  Man.  —  Cases Rate  1,737 237.3  2,336 317.4  Sask.  —  Cases Rate  Ti;i23 132.7  1,685 199.4  Alta.  —  Cases Rate  .1,522 186.1  1,881 227.7  B. C.  --  Cases  3,137  Rate  Table V:  Source:  336.6  3,708 390.7  Incidence and Rate per 100,000 per annum, of Gonorrhoea, Reported by Provincial Health Departments to the Dominion Bureau of Statistics.  Division of Venereal Disease Control, Department of National Health and Welfare, Ottawa.  - 9 "Prior to 1944, the machinery for collecting statistics on the incidence of venereal disease for Canada as a whole did not exist.  Each  province had a different notification form, using different nomeclatures. In some provinces, the notification of venereal disease did not become compulsory until 1941•" (l) (It is seen that the numbers of cases given i n Tables IV and V do not concur with those i n Table I.  Those i n Table I are correct:  those  in Tables IV and V are totals of the cases reported weekly to the Department of National Health and Welfare by the various provincial departments of health. The discrepancy arises from minor errors that occur in the weekly reports to the Department of National Health ~  cases are reported  more than once, known old infections are reported as new infections. Later these errors are discovered and the corrections made i n the provinc i a l statistics, but the Department of Health statistics remain unchanged.) Tables IV and V indicate that the venereal disease problem i n British Columbia i s serious:• i n fact, the rate per 100,000 i n British i s the highest^of a l l the provinces, for both total syphilis and gonorrhoea. In the case of syphilis acquired early, (syphilis of less than five year's duration) primary and secondary stages only, i n 1945 British Columbia again had the highest rate per 100,000j this i s shown i n Table VI,  (l)  Division of Venereal Disease Control, F i r s t quarterly statistical report on the incidence of venereal disease in Canada.  - 10 -  TABLE V I . Canada  Cases • Rate  5,695 47.1  P.E.I.  Cases Rate  27 29.3  N.S.  Cases Rate  31 5.0  N.B.  Cases . Rate  200  42.7  Que..  Cases Rate  1,594 44.8  Ont.  Gases Rate  2,455 61.3  Man.  Cases Rate  295 40.1  Sask.  Cases Rate  220 26.0  Alta.  Gases Rate  210 25.4  B. C.  Cases Rate  663 69.9  Table Vis  Source:  Incidence and Rate per 100,000 per annum, of acquired Syphilis, Primary and Secondary, Reported by Provincial Health Departments of the Dominion Bureau of Statistics.  Division of Venereal Disease Control, Department of National Health and Welfare, Ottawa.  Of those individuals reported as being infected i n British Columbia, i t i s of interest to note the age at which the infection was diagnosed. Table VII shows the number of venereal disease cases reported for the f i r s t time i n British-Columbia, classified according to diagnosis, sex, and age-groups for 1944 and 1945. TABLE VII 1244 Sex  Total  Gonorrhoea (All Types)  Total  Total  Total Male Female  47373388 1349  3358 2460 898  1379 928 451  254 190 64  126 58 68  Under 15 yrs.  Total Male Female  57  24  20 12 8  1 1  1 1  33  37 12 25  —  —  15-19 yrs. Total Male Female  426 221 205  362 193 169  64  23  20-24 yrs.. Total  Male Female  1141 741 400  974 659 315  25-29 yrs. Total Male Female  772 572 200  30-34 yrs. Total Male Female  28 36  Syphilis Primary Secondary  10  -  H 9  10  167 82 85  63 37 26  30 12 18  629 487 142  143  48  85 58  42 6  16 7 9  481 365 116  341 282 59  140 83 57  36 28 8  11 4 7  35-39 yrs. Total Male Female  347 284 63  216 180 36  131 104 27  18 17 1  9 4 5  40-44 yrs. Total  Male Female  330 267 63  197 164 . 33  133 103 30  14 12 2  45-49 yrs. Total Male Female  176 140 36  83 68 15  93 72 21  11 10 1  14 9 5  7 6 1  12 Over 54  Total Male Female  Not Stated  Total Male Female  260 221 39 582 422 160  56 54 2 418 318 100  204 167 37 164 104 60  9 8 1 23 14 9  6 5 1 19 7 .12  1245 Sex  Total  Gonorrhoea (411  Total  Under 15 yrs.  Total, Male Female . Total Male Female  15-19 yrs. Total  Male Female  2G-24 yrs.  . Total Male Female  25-29 yrs.  Total Male Female  30-34 yrs.  Total Male Female  35-39 yrs.  Total Male Female  40-44 yrs. Total  Male Female  45-49 yrs.  Total Male Female  5245 3769  1476  53 16 37 • 441 217  224 1233 786  447 853 610 243 600 460 140; 467 373 94 345 287  58 235 204 31  Total  Types) 3711  2682 1029 36 4  32 380 184 196 1017  674 343  693  508 185 431  343 88 296 250 46 211 182 29  98 86 12  Syphilis Primary  Secondary  1534 447  450  195 91 104  17  _  -  —  —  1087  12 5 61  33  28  216 112 104 160 102 58 169 117  52  171  123 48 134 105  29  137 118  19  360 90  -  33. 21 12 106 69 37 59 46 13 59 51 8 55 44  11 , 38 36 2 31 31 -  -  9 4 •5 44 13  31 31 13 18 28  11  17  23 14 9 17  8 9  13 9 4  - 13 -  50=54- yrs.  Total Male Female  160 140 20  52 49 3  108 91 17  21 20 1  6 5 1  Over 54  Total Male Female  294 249  227 188 39  21 21  45  67 61 6  7 7  Total Male Female  564 427 137  430 341 89  134 86 48  27 21 6•  Not Stated  Table VIIj  Source:  -  -  17 7 10  Persons with Venereal Disease Reported for the f i r s t time i n British Columbia, according to diagnosis, sex, age group, for the years 1944 and 1945.  Division of V. D. Control, Vancouver, B. C. It i s seen i n Table VII that the modal age group for both sexes  for gonorrhoea and for primary and secondary syphilis i s the 20-24 years group.  In the older age groups, the number of gonorrhoea and primary and  secondary syphilis infections decreases. It i s interesting to compare the age distribution of gonorrhoea and primary and secondary syphilis in New York City, from 1940 to 1943 inclusive: group.  i n a l l these years the modal age group i s also the  20-24 years  (1) From Table VII, i t i s found that i n 1944 and 1945, 67 percent  and 64 percent of gonorrhoea infections, and 56 percent and 46 percent of primary and secondary syphilis infections were acquired by individuals under thirty. Here then i s an indication of the widely made observation that the majority of venereal infections are acquired by men and women i n their teens and twenties. (An exception i s to be noted i n the case of primary and secondary syphilis i n 1945.  However, the Health League of  Canada probably exaggerates somewhat when i t states:  "Fully 75 percent  of a l l venereal disease i s spread among persons between the ages of (l)  Rosenthal, T. & Kerchner, G., Trend i n age of acquiring venereal disease In New York City 1940-1943: V.D.I., Vol. 25, pp. 361-363.  -- H fourteen and twenty-nine",  (l)  Despite the doubt that such a high percentage of infection i s acquired i n the under 30 years group, the general observation s t i l l remains:  venereal disease i s a disease of youth, and thus i t i s among the  young people that attention and preventive action i s most required, " 3.  Geographical Distribution of Cases:  Tables IV and V show that i n 1944 and 1945, B r i t i s h Columbia hafl the highest reported rates i n Canada per 100,000 population, of primary and secondary syphilis.  Whether British Columbia had the highest actual  rate of these infections i s not known, mainly because there i s no assurance that the standards of reporting infections in the other provinces are equal to the standards in British Columbia,  However, despite the  absence of adequate data for comparing the venereal disease problem here with that i n other provinces or countries, the essential point remains: British Columbia does have a high rate of infection. In British Columbia, as elsewhere, venereal disease i s most often acquired and spread i n the c i t i e s , because i t i s i n the cities that promiscuity i s rampant. The Scandinavian countries, which made such significant progress in the reduction of syphilis, also have their greatest number of infections i n the larger c i t i e s .  For example, Sweden, one of  the most cited instances of a country which has developed successful syphilis control, from 1930 to 1934 reported 4,106 cases of primary and secondary syphilis for the whole country and 1,437 cases of primary and secondary syphilis for the city of Stockholm. The population of Stockholm was estimated at 533,884 and of a l l Sweden 6,249,489. (1) (2)  (2)  Health League of Canada, The Social Hygiene Voice, p. 2, January, 1946. Harrison, L.W., Dudley, C.L.W., Ferguson, T., and Rocke, M.j Report on anti-venereal measures i n certain Scandinavian countries and Holland, p. 41, Ministry of Health.  • - 15 Thus Stockholm which has only 8.5 percent of the population of Sweden, has 34*9 percent of a l l early syphilis cases. In British Columbia, the one large city, Vancouver, has more than one-half of a l l venereal infections and i n addition to the infections reported in Vancouver, there i s evidence that a large number of the infections reported elsewhere i n British Columbia are acquired in Vancouver. Table VIII indicates the cities i n which twenty or more venereal infections were reported during 1945. The figures given represent only those cases reported for the f i r s t time i n British Columbia; they do not include known "cases that were acquired i n British Columbia but discovered in another province or i n another country. TABLE VIII Population  No- of Infections  Sity Vancouver City Victoria-Esquimalt Prince Rupert New Westminster Kamloops Richmond Burnaby North Vancouver City Vernon Trail Nanaimo Chilliwack City Nelson Port Alberni Delta  2712 330 147 124 73 64 63 43  . .  42 39 33 32 30 29 23  316,496 86,890 12,000 25,000 8,500 9,160  32,500  19,943 8,667 12,711 9,918 . 7,078 7,165 5,500 2,651 "  (Populations are from the Provincial Directory and are estimates based on 1941 census.) Table VIII:  Source:  B. C. Cities Reporting more than twenty venereal infections during 1945.  Division of V. D. Control, Vancouver, B. C.  -16During the period covered by Table VIII, there were 5,2A5 reports of venereal disease:  of these 520 did not state the city or area  from which the disease was reported. - It i s seen from Table VIII that Vancouver and the surrounding municipalities and cities of Richmond, North Vancouver, Burnaby, New Westminster, and Delta, are responsible for by far the greatest amount of venereal disease i n the province, approximately 65.5$. It i s quite probable that most of the infections reported i n the areas around Vancouver were actually acquired i n Vancouver. Although the attack-rate of infection i s not proportional to the population, i t i s seen that ports, railSheads, and industrial centres are the areas i n which venereal disease most often attacks. That the source of venereal disease spread i s i n the larger cities of a country i s to be expected.  In Vancouver, conditions are excellent for  the introduction and spread of venereal infections:  Vancouver i s an  international port and a continental railhead; numerous visitors and transients are received at a l l times during the year.  No other city i n  the province offers conditions so conducive to the spread of infection. (Victoria i s a seaport but receives a far smaller number of visitors and transients than Vancouver; as seen i n Table VIII Victoria ranks a poor second i n the provincial venereal disease prevalence.) In the city of Vancouver, which accounts for about 57.5$ of a l l reported infections i n the province, a small area i s responsible for most of the venereal infections because i t i s this area that i s responsible for the largest number of pick-ups leading to the acquisition of venereal disease,  This area i s the downtown business section of the city where  housing conditions are probably the poorest.  I t i s this social area, too,  that has the highest combined rank (indicating that i t i s the area of  - 17 ~ of greatest need) on five economic and social indices, as determined in 194-5 by Norrie and his staff.  The indices used were crowded households,  family income, low rental, ratio of persons divorced and separated, to persons married, and juvenile delinquency.  The boundaries of this area  are from Burrard Street to Main Street, and from False Creek to Burrard Inlet.  (1) Thus, a survey of +he province indicates that venereal disease  strikes most often i n the larger centres, and particularly centres which have a large transient, population. surveys i n other communities:  Such an observation i s borne out by  one study made in the United States indi-  cated that the chief venereal disease control problem to be met was "the occurrence of unusual industrial activity...  This i s understandable when  we think of... the almost necessarily transient nature of the present day industrial portion of the population".  (2)  Within the larger areas of infection, smaller areas, the foci of infections, are to be found. In Vancouver, the mentioned area of greatest need accounts for the largest number of infections, but i t i n turn can be analyzed to discover the specific premises that make i t easy for healthy persons to meet or become exposed to infected persons.  Such  premises are called "places of f a c i l i t a t i o n " . It i s these places of f a c i l i t a t i o n that are considered of great importance in any city's venereal disease control program. I t i s true that facilitation i s not the fundamental factor involved in the spread of infection, but i t is certainly of importance i n any consideration of undesirable or unwholesome•spots in a community, and indicates where immediate corrective measures can be taken. (1) (2)  Norrie, L.E., Survey report of group work and recreation of Greater Vancouver, 1945. Heller, J.R., J r . , Wartime changes i n the age distribution of females infected with syphilis. A.J.P.H,, v o l . 36, p. 509.  - 18 4. Occupational Status of Infected Persons; Because of the widespread aversion of many people to the mere mention of the venereal diseases, there i s a serious d i f f i c u l t y in obtaining an adequate knowledge of infected persons. Most of those who are infected or who suspect infection, i f they can afford i t , seek examination and treatment by a private physician, rather than at a public c l i n i c . In British Columbia, reporting of patients infected with syphilis or gonorrhoea is required by the Venereal Disease Svippression Act of 1924, but i t i s unquestionable that a l l cases are not reported; also since i n i t i a l s or other identification rather than the f u l l name of the patient . may be used i f the physician does report the case, any infected persons who wish to hide their identity from everyone except their physicians can do so by attending a private physician. In .addition to these points, i t must be noted that the Notification Cards used in the reporting of infected persons do not require that the occupation be stated.  (Until 1944, the notification cards in B. C.  did request this information, but the present cards, issued by the Dominion goyernment, do not.)  For this reason, a survey of the occu-  pational status of infected patients can only be made on c l i n i c patients, because clinic records contain information not given on the notification forms. As was previously suggested, clinic patients do not represent a f a i r sampling of the infected population.  However, one study has been  made at the Vancouver Clinic of patients infected with early syphilis, primary and secondary; and as these particular stages of the disease are often referred to the c l i n i c by private physicians for diagnosis and treatment, probably such a clinic study offers the best basis for generalization.  Table IX shows the occupational status of patients diagnosed  - 19.with early syphilis, primary and secondary, during the years 1944 and  1945.  When a man infected his wife, or vice versa, and both were diagnosed at the Vancouver Clinic, only the one f i r s t acquiring the infection i s i n cluded i n this study.  (In this way, only infections acquired from non-  marital sexual exposures are involved.)  The occupational groupings used  in the table are from the Dictionary of Occupational T i t l e s ,  (l) .  TABLE LX Prof. Service Agric.. Sales Labor Students Unemployed Not Stated Sex  M. F.  M. F.  M. F.  M. F. M. F.  M. F.  1. F.  If.  F.  1944  0  0  7  21  1  0  2  3  52 11  0  0  1  0  3  2  1945  4  1  8  39 11  0  6  2 103 11  3  0  1  0  3. 1  Table IX:  Source:  Occupational Status of Persons Diagnosed at the Vancouver Clinic i n 1944 and 1945 as having acquired Early syphilis, primary and seoondary stages. (Nonmarital exposures.)  Division of Venereal Disease Control, Vancouver, B. C. It i s seen from Table IX that among males, the greatest number  of infections i s to be found in the "Laborer" grouping, and among females, in the"Service" grouping. Other studies substantiate these c l i n i c a l findings. One of these, a survey of positive serologic tests for syphilis i n 531,236 men of draft age in the United States, indicated a correlation between the prevalence of syphilis and occupation- among single white men the professional class had the lowest rates. (l)  U.S. Department of Labor, Dictionary of occupational t i t l e s .  - 20There i s a considerable jump-' to- the next group, and i t i s found that the rates for proprietors and managers, clerical workers and salesmen, are a l l about the same. There i s a sharp rise then, and the three groups — craftsmen,- operatives, and service workers — have much higher rates.  The highest rate of a l l occurred among laborers, though they are  not much higher than those of the nearest three groups", ( l ) Another study, made of 172- white females admitted to a Missouri rapid treatment centre, showed that 152 of the 172 were engaged i n service or laboring occupations. (2) This undoubted correlation between occupation and the prevalence of syphilis does not imply a causal relationship.  It does suggest,  however, that those engaged i n unskilled or semiskilled occupations are i n the lower wage earning brackets and hence may have less opportunity for medical information or care. Education concerning the diseases, ability to pay for treatment, accessibility of medical services (particularly i n rural areas), are other factors involved, particularly for the low wage earner. More closely related to the actual job, and also applying to the semiskilled worker, tedium, boredom and dissatisfaction a l l play a role i n the acquisition of infection.  Many workers, especially female  workers, who are unemployed or employed i n i l l paying numdrum routine, seek exciting recreation which too often leads to exposure to infection. In such cases the occupation may be a causal factor i n the acquisition of disease, as well as a concommitant factor. (1)  Usilton, L.J., Bruyere, M.C., The Frequency of positive serologic tests for syphilis in relation to occupation and marital status among men of draft ages J.V.D.I., v o l . 26, pp. 216-222. (2) Rachlin, H.L., A sociologic analysis of 304- female patients admitted to the Midwestern Medical Centre, St. Louis, Mo.s V.D.I., v o l . 25, pp. 265-271.  - 21 - 5.  Marital Status of Infected Persons;  The discussion here of the marital status of infected persons is concerned with the marital status on acquisition of the disease and not necessarily on discovery, the intention being to discover the number of infections acquired apart from marital relations,  (It i s assumed that an  infection acquired maritally implies i n f i d e l i t y on the part of the marital partner.)  This, of course, does not imply that the marital status of per-  sons already infected i s unimportant i n the spread of venereal disease; such a view would be quite erroneous, especially in the case of prenatally or parturiently acquired infections.  However, since i t i s the  intention of this paper to discuss the factors responsible for the spread of infection, i t i s of more value here to survey the marital status of persons on acquiring infection.  For this reason, i t i s of l i t t l e value  to investigate the marital status of individuals involved i n mass blood testing surveys: .such surveys uncover many hitherto unsuspected cases of syphilis, but give l i t t l e direct information concerning the patient at the time of acquisition of the disease. However, even when the marital status of the individual at the time of acquiring infection i s known, there i s often confusion as to whether some persons should be classified as "married" or "separated". Some married persons, especially during the war years, are separated from their mates for long periods of time, and might well be considered as being "separated", even though they are legally married.  At this point,  only the broad headings of "married", "single", and "other" w i l l be usedj consideration w i l l be given later to the influence of long separations on the acquisition of venereal disease by married persons. Table .X summarizes the marital status of persons diagnosed at the Vancouver Clinic during 1944-  and 1945  as having acquired primary  - 22 and secondary syphilis.  "Married" implies that a person'is married  either legally or by common-lawj "single"' implies that a person i s not and never has been married; "other"' implies that a person i s separated, divorced, or widowed. In Table X, the cases used are those in which the infections were acquired extra-maritally. TABLE X 1945 Single  Married  Other  Sinele  Male  48  15  4  Male -  97  43  12  Female  2L  12  1  Female  22  2L  -2  Total  72  27  7  Total  69  21  126  Married  Other  Table Xj Marital Status of Patients Treated at the Vancouver Clinic during 1944 and 1945 for Primary and Secondary Syphilis. Source:  Division of Venereal Disease Control, Vancouver, B.C. It i s seen, as would be expected, that among both males and  females, the single person i s more prone to acquisition of syphilis; but i t i s also noted that a considerable number of married persons do acquire infection.  Some of the factors involved w i l l be discussed on other pages. It i s of interest to note that there are differences when the  marital status of infected persons found i n surveys of recently infected individuals i s compared with that found i n mass serologic surveys for syphilis. One of these mass surveys made on inductees into the United States Armed Forces, i s given i n Table XI. of white men only:  The table includes the results  the figures relating to negroes are omitted.  TABLE II. Single Age 18 19  20 21 22  23  Number Examined  Number Positive  87,751  300 334  106,324 48,609 12,379 9,762 8,311  29  6,611 6,049 5,347 4,934 3,533 4,913  31 32  3,300 3,123  24  25 26 27 28 30  33  34 35 36 37  3,666  2,882  2,794 2,633 2,327 2,087  181 157  142 149 133 135  144 146  108 191  165 149 151 154 155  154 155 137  Married Rate per Number Examined 1,000 3.4 3.1 3.7  12.7 14.5 17.9  20.1  22.3  26.9 29.6 30.6  38.9 45.0 45.2 48.4 53.4  3,052 8,985 7,430 3,870  4,665 4,994 5,342 6,015 6,224  6,474 5,362 7,446  6,152  55.5  58.5  66.6  4,918  65.6  3,982  Table XI:  Source:  5,538 5,601 5,359 5,206 5,238  Number Positive  13 37 42 41 42 49 67 97 102 131 99  160 121 125 145  155 174 153  200 143  Other Rate per Number Number Examined Positive 1,000  Rate jjgE 1.000  514 904 641 395 420 518 650  5 7 9 17 8 11  9.7 7.7  819 903 755  42 62 47 94  4.3 4.1 5.7  10.6  9.0 9.8  12.5 16.1 16.4 20.2 18.5  21.5  19.7  22.6  25.9 28.9 33.4 29.2  40.7 35.9  708  1,230 1,033  1,010 1,037  1,069 1,111 1,187 1,217 1,099  30  27  80  84  89  80  91  104 88 92  Prevalence of Syphilis among men aged 18-37 years by marital status and age. (Only white men are included.)  Journal of Venere a l Disease Information, October, 1945. p. 221.  14.0 43.0 19.0  21.2 46.2 38.1 51.3  68.7 62.3 76.4 77.4  83.2 85.8 74.8 81.9 87.6 22.3  83.7  - 24 It is seen, except in the 18-20 age group, that the infected rate per thousand i s lowest i n the "married" group and highest (with one exception) i n the "other" group. Note that of the total 6,503 infections reported, less than 5.2/?> were i n men under the age of thirty: this i s especially significant because of the very limited age group involved. Here, then, i s an example of the inadvisability of using serological survey results as a basis of determining the age or marital status of an individual at the time of disease acquisition, for undoubtedly many, i f not most, of the men i n their thirties acquired their infections when they were younger. The foregoing has been a general discussion of the problem of venereal disease and of the persons infected. One aspect of the problem, important i n controlling the disease i n some areas has been omitted: this i s the racial origins of the infected persons.  Despite i t s many  shortcomings, the "color" classification of individuals i s almost universally used: and a knowledge of the color or "race" of infected persons is often of some value. In the United States where discrimination against the Negroes is common, venereal disease among the. colored population constitutes a complicated problem.  Ignorance and poverty are widespread, and necessary  treatment neglected* there i s a lack of trained Negro health personnel, a lack of free treatment centres, and where they do exist there are separate or no f a c i l i t i e s for Negroesj Negro physicians are often disqualified from working as clinicians i n free clinics:  these are a few of  the factors that are involved i n the Negro venereal disease problem in the United States. In British Columbia, Negro discrimination is not so noticeable, and the comparatively small colored population does not constitute a  - 25 separate venereal disease problem. But British Columbia does have a significant Indian population, and discrimination against the Indians i s present.  Promiscuity i s common among some of the Indian g i r l s who go to  the c i t i e s .  They are looked upon by some white men as common property,  and many of the Indian g i r l s believe that through indiscriminate sexual relations, they w i l l be able to marry a white man. Other factors involved in a discussion of venereal disease among the Indians w i l l be mentioned i n other places, but because the Indian population i s small and because i t has comparatively few infections, there w i l l be no separate consideration of the Indians or of the many other minority racial or 'color' groups found in the province.  - 26 Chapter I I . Factors Involved;  Prostitution and Promiscuity;  Prostitution, no matter what form i t may take, i s a problem that i s a source of discomfort to many individuals and organizations i n a community. In this paper, there i s no need to deal with the undesirab i l i t y of the practice of prostitution other than i t s being responsible for the spread of venereal infection. It is not easy to arrive at a satisfactory definition of prostitution because of the diverse forms that i t may take.  Flexner  states the prostitution i s characterized by "three elements variously combined;  barter, promiscuity, emotional indifference.  The barter need  not involve the passing of money, though money i s i t s usual medium; gifts or pleasures may be the equivalent inducement. Nor need the promiscuity be utterly choicelessj a woman i s not the less a prostitute because she i s more or less selective i n her associations. Emotional indifference may be f a i r l y inferred from barter and promiscuity", ( l ) Garle maintains that prostitution must involve venality and promiscuity.  "There must be both, and whilst the lack of .emotional  '  motives raises a presumption of venality, i t i s only when these two elements are present, that the sexual act i s prostituted, and only that person whether male or female, who has habitual recourse to sexual practices fro venal motives may f a i r l y be called a prostitute.  I t i s the  presence, or the absence of these two essential elements, which makes an identical act, mutually performed by two persons, an act of prostitution in the one and not i n the other.  Both parties may be equally blameworthy,  but i t is the one who habitually barters the favours of the body, who i s the prostitute." (1) (2)  (2)  Flexner, A., Prostitution in Europe, p. 11, Garle, H.E., Social Hygiene Today, p. 20.  - 27 In both these definitions i t i s apparent that the criteria of prostitution vary i n degree, and that on the basis of these definitions, the term '"prostitute"' can be applied not only to girls and women working in bawdy houses and soliciting on the streets, but also to the many promiscuous girls who make no formal charge but exchange themselves for a. night's lodging or a few meals.  (The term "prostitute" can be applied  to males but male prostitution i s a rare phenomenon and, so far as i s known, i s not a significant factor i n the spread of venereal disease. Thus, i n this paper, the term "prostitute" w i l l be used as applying only to females.) 1.  Organized or commerc'ialized prostitution-  For purposes of this paper a distinction i s made between organized prostitution and unorganized prostitution, the former refers to prostitution which i s practised i n a house of prostitution, brothel, or bawdy house and which involves a monetary transaction.  This form of  prostitution usually involves persons, other than the prostitute who reapc profits directly or indirectly from the practice —  landlords, lessors or  agents of the houses of prostitution, madams or keepers, "pimps" and procurers.  This distinction i s irrelevant for legal purposes but i s  important for the control of venereal disease, because i t i s the contention of most health departments that organized prostitution i s the greatest single menace towards the successful control of venereal disease, ( i t must be emphasized that the term "bawdy house", as here used, i s somewhat more restricted than the one defined in the Criminal Code of Canada: "A common bawdy house i s a house, room, set of rooms,- or place of any kind kept for purposes of prostitution or for the practice of acts of indecency, or occupied or resorted to by one or more persons for such purposes", (l) (1)  The Criminal Code of Canada, 1917, c. IA, s. 3.  .- 28 .The term as used in this paper refers to a house or place of any kind where the entire premises are kept solely for purposes of prostitution; thus one room used for purposes of prostitution in a hotel accomodating non-prostitutes would not be considered as a bawdy house.) Organized prostitution has long been recognized by most Canadian Health Departments as a constant barrier to the successful control of venereal disease. Williams states! "Commercialized  prostitution is the  i l l e g a l exploitation of venereally disease young women i n bawdy-houses. It i s a purely mercenary business intimately associated with the criminal elements of society in which the more evident exploiters are madames, pimps, and procurers.  The profits emanating from this i l l e g a l business,  however, do not stop with these exploiters.  The monetary streams i n their  diverse ramifications reach persons so remote that their participation in the business i s only recognized by their indignation when the source of profit i s disturbed by the activity of a health department." briefly describes the exploiter.  This, then,  The exploited are physically attractive  young women who represent the merchandised product.  As i n any business,  volume i s an important factor in creating lucrative monetary returns. The merchandise must be kept fresh and attractive and this entails the constant procuration of new young women from the ranks of the unemployed and the less well remunerated occupations and the discarding of worn-out merchandise to add to the already large volume of street walkers and other prostitutes who work on their own. This i s the purely monetary side of this i l l e g a l business and as such i s not a direct problem or interest of a health department. In this unsavoury commerce, however, there i s inseparably associated a serious public health problem. In this i l l e g a l business there l i e s a prolific source of fresh venereal infections. has long been recognized by public health authorities. (l)  This fact  Rosenau (l) has  Rosenau, J . , Preventive Medicine and Hygiene, p. 438,  ibid.  considered i t so important in the problem of venereal disease control that he writes as follows:  "Any sanitary measures taken for .the preven-  tion of venereal diseases which do not include some method of handling the 4  problem of prostitution are doomed in advance to failure, since they w i l l ignore the main source and root of these diseases."  Flexner (l) i n his  monumental study on "Prostitution i n Europe" came to the conclusion that? "It i s everywhere purely mercenary, everywhere rapacious, everywhere perverse, diseased, sordid, vulgar, and almost always f i l t h y . " are the other authorities who support these statements.  Numerous  Indeed one i s  impressed with the unanimityof opinion among experts regarding the public health menace which commercialized prostitution constitutes.  (2)  This description specifically associates commercialized prostitution and venereal disease, and i t typifies the attitude of most health authorities in Canada and the United States. From a public health standpoint, commercialized prostitution implies the spread of venereal disease, and this alone i s sufficient to condemn prostitution. However, stressing of this intimate association of prostitution and venereal disease has been mainly responsible for the popularly held opinion that prostitution i s undesirable solely because of such association.  That i t i s undesirable apart from i t s association with venereal  disease has, of course, been stressed for many years by numerous individuals and organizations, including health authorities.  However, despite  commercialized prostitution being an indictable offence under the Criminal Code of Canada, and despite i t s being proved as a breeding ground of disease and crime, there are s t i l l some who advocate i t s continuance under state control. (1) (2)  Flexner, A., ibid., p. 33. Williams, D. H., The suppression of commercialized prostitution i n the City of Vancouver, J.S.H., v o l . 27, p. 365.  -- 3 0 —  Many of these apologists realize the intimate relationship between prostitution and venereal disease, but believe that by segregating bawdy houses and by legally forcing the prostitutes to have regular medical examinations, the venereal disease rate w i l l decrease, and the undesirab i l i t y of prostitution w i l l be for the most part removed. The underlying premise, sometimes stated, sometimes not, i s that the continued practice of prostitution i s inevitable — "It i s the oldest profession i n the world" — and that i t might as well be made as safe as possible. It is not the intention here to answer the various arguments raised i n favor of "controlled prostitution", numerous authorities have successfully shown that commercialized safe, nor be satisfactorily controlled.  prostitution can neither be made Among the authorities the uni-  versally accepted conclusion i s that i f venereal disease i s to be eradicated, commercialized  prostitution must be abolished,  (l) ( 2 ) ( 3 ) ( 4 )  The ensuing discussion on the bawdy house situation i n British Columbia i s based almost entirely on various records of the Division of Venereal Disease Control. These records are compiled only after an individual i s diagnosed as having acquired a venereal infection and has given a history to his physician of having been allegedly exposed i n a bawdy house. I t must be emphasized that notification of disease reports on which the source of infection i s actually stated, constitute only a minority of the notifications of venereal infections; thus the given number of infections allegedly acquired in a bawdy house i s only the minimum number, and probably a far cry from the actual number of infections acquired there. During 194-5, the Division of Venereal Disease Control received information that venereal disease was allegedly acquired i n bawdy houses in only four cities i n British Columbia, Vancouver, Nelson, Prince George and Prince Rupert. Of these four c i t i e s , Vanccu'ver presented by far the (1) (3)  Flexner, A., i b i d . Snow, W.F., i b i d .  ( 2 ) Parran, T., ibid. U) League of Nations, Report by committee on traffic of women and children.  - 31  -  most serious problem. Table XII indicates the number of i n f e c t i o n s a l l e g e d l y acquired i n bawdy houses i n Vancouver from 1939  to 194-5  inclusive.  TABLE XII  Year  No. of Reported Infections  1939 194-0 1941 1942 1943 1944 1945  9 26 46 49 42 19 37  '  Table XII:  Source:  No. of Bawdy Houses Reported ( l House) (9 Houses) ( l l Houses) (11 Houses) (13 Houses) (10 Houses) (12 Houses)  Number of i n f e c t i o n s a l l e g e d l y acquired i n Bawdy Houses i n Vancouver C i t y from 1939-1945.  D i v i s i o n of Venereal Disease Control, Vancouver, B. C. Bawdy houses have been i n existence i n Vancouver from very early  times.  A report published as early as 1912  deplored the e x i s t i n g commer-  c i a l i z e d p r o s t i t u t i o n and urged that action be taken by the authorities to completely  eliminate i t .  ( l ) But U n t i l 1936,  D i v i s i o n of Venereal Disease Control i n B r i t i s h Columbia was comparatively  appropriate when the reorganized,  l i t t l e p u b l i c i t y was given to the r e l a t i o n s h i p of community  p r o s t i t u t i o n and venereal disease.  Shortly a f t e r the reorganization,  however, "...commercialized p r o s t i t u t i o n was uncloaked i n i t s true l i g h t as a serious public health menace.  This was due c h i e f l y to an e f f i c i e n t  epidemiological service i n the C i t y of Vancouver.  The P r o v i n c i a l Board  of Health drew the attention of c i t i z e n s and c i v i d o f f i c i a l s to t h i s matter, The bawdy houses which had been f l a g r a n t l y v i o l a t i n g the Criminal Code of Canada were closed i n February, 1939. the houses, remained almost completely  In the f i r s t few months thereafter inactive* gradually, however, a num-  ber of these disease dispensaries began to operate s u r r e p t i t i o u s l y and (l)  Moral and S o c i a l Reform Council of B r i t i s h Columbia, S o c i a l Vice i n Vancouver, p. 16.  - 32 have continued to do so since, though to a far lesser degree than previous to the institution of.the policy of suppression."  (l)  After the closing of the bawdy houses, noticeable reductions . in reported venereal disease became evident. of 58,5  From a median monthly level  male gonorrhoea admissions for e. period cf 14 months brforo  suppression, the level dropped to 41,5  for a period of 28 months after  suppression; and for male primary and secondary syphilis admission, the median monthly level dropped from 9.5  to 4.  Although an examination of Table XII would seem to indicate that bawdy houses are not so serious a source of venereal disease as here implied, several points must be remembered in evaluating these figures. In only a small minority of diagnosed infections is a report of the alleged source of that infection furnished to the Division of Venereal Disease Control. Most men frequenting such places can afford to pay a private physician for treatment and private physicians (in the majority of cases) do not report the source of infection.  There i s also evidence  (verbal only) that prostitutes in bawdy houses have told their clients to attend a particular physician i f vcneroal symptoms appeared, and a l l expenses would be paid. When these points are considered, and when i t i s realized that prostitution can never be made"safe" u n t i l venereal disease i s eradicated, the anxiety of public health organizations to abolish prostitution i s understandable.  Yet, there are s t i l l some persons and organizations who  relegate bawdy houses to a minor position as a source of venereal infections; for example, Rae, Inspector ir? Charge, Morality Branch of the Vancouver City Police Department stated i n a report;  "It i s my opinion  that the large increase i n venereal disease reported i n the City (Vancouver) is due to the loose, immoral conduct of persons in the "non-prostitution" (1)  Williams, D.H.,  ibid., p.  367.  - 33 category, and this opinion i s substantiated by statistics of the Venereal Disease Control Division". (l) In discussing organized prostitution one last point must be considered:  a bawdy house, i n order to maintain i t s e l f , must have a large  clientele and i f one infection i s acquired from a bawdy house, at least one of the prostitutes i s infected — and being infected, she exposes infections to everyone of her customers until she i s rendered non-infectious.  This, i n i t s e l f , i s the major indictment of bawdy houses, from a  public health standpoint:  the bawdy house i s a constant threat to the  health of the community because i t i s at least a potential source of infection which can be spread in a geometric progression throughout the population. 2,  Clandestine Prostitution and Promiscuity:  Although prostitution i s divided, i n this paper, into two types: organized or professional, and unorganized or clandestine, the division is made only to indicate that commercialized prostitution, as conducted in bawdy houses, represents a zenith i n the selling of vice, and that a l l other forms of prostitution do not approach i t s level of efficiency. These other forms of prostitution are herein considered as clandestine or.unorganized; i.e., they are not practised i n a bawdy house as previously defined. Clandestine prostitution involves a large number of persons: i t includes a l l prostitutes, other than those i n a bawdy house who make a formal charge (usually monetary). However, to classify one woman as a prostitute because she makes a formal charge and another as being promiscuous because she exchanges her body for a meal or two, for a room for a night, or for some other favor, serves only to demonstrate that (l)  Rae, S., Report on control of venereal disease i n Vancouver.  - 34 p r o s t i t u t i o n and gross promiscuity are too c l o s e l y linked to be c l e a r l y defined. Prostitutes and grossly promiscuous g i r l s do not form a "class" or "type":  they are i n d i v i d u a l s .  "Even the most confirmed commercial  prostitutes d r i f t e d into t h e i r trade f o r widely d i f f e r i n g reasons.  Many  of them would never have become part of this dangerous community swamp i f we had r e a l i z e d what was happening to them as children or young g i r l s . . . We know now that there ere profound psychological as well as economic reasons f o r t h e i r sinking into t h i s morass."  (l)  "The g i r l i n the r e d - l i g h t d i s t r i c t , the g i r l who plays the hotels, the adolescent who hangs around street corners a f t e r school, the serviceman's wife who d i s t r i b u t e s her favors i n return f o r a good dinner are simply more or less acute sufferers from the same dangerous tangle of d i f f e r e n t kinds of s o c i a l , economic, psychological, and sometimes mental lacks."  (2) These g i r l s and women, whether or not they make a formal charge  are exploited by the unscrupulous:  as i n the case of organized p r o s t i -  t u t i o n , pimps, landlords, t a x i - d r i v e r s , and others glean a p r o f i t from the g i r l who earns from p r o s t i t u t i o n .  In the case of the non-charging  prosti-  tute, the free pick-up or V i c t o r y g i r l , the p r o f i t - t a k i n g i s less obvious and involves the r e c e n t l y coined concept of " f a c i l i t a t i o n " .  Facilitation  i s the process by which i t i s made easy f o r an infected person to meet or become exposed to a healthy person; and anyone who i s responsible f o r such f a c i l i t a t i o n i s called a " f a c i l i t a t o r " .  Thus restaurants, dance h a l l s ,  theatres, beer parlours, and other premises that constitute easy meeting places; hotels, rooming houses and other places that offer no encumberances to exposure are places of f a c i l i t a t i o n , and t h e i r owners and managers are facilitators. (1) (2)  Federal Security Agency, Challenge to community action, p. 2. i b i d . , p. 5.  Table XIII summarizes the f a c i l i t a t i o n records for Vancouver during 1943 to 1945 inclusive.  It w i l l be noted that the totals of "met"  and "exposed" do not coincide:  this i s because the information gathered  is not always complete — often there i s information about only the place of pick-up, or the place of exposure.  (The low totals for most f a c i l i t a -  tion premises in 1943 are due to the lack of information concerning such premises during that year:  the f i r s t complete records are those kept  during and after 1944.) TABLE XIII  1242  Where Met  98  Dance Halls Cafes Beer Parlours Hotels and Rooms Private Homes Miscellaneous  25 123 information.  no no information. 8  1244  1245  375 300 159 98 26 397.  207 407 221 261 64 586  Where Exposed. 98 no information.  Hotels and Rooms Private Homes Baivdy Houses Miscellaneous  42  5  Table XIII:  Source:  1149  121 19 243  1688 231 37 252  Summary of Facilitation Reports for Vancouver form 1943 to 1945 inclusive.  Division of Venereal Disease Control, Vancouver, B. C. It i s to be emphasized that in a l l such premises, no matter how  rigidly they are supervized and no matter how sincere the owners or managers may be in attempting to keep their establishments unblemished, some f a c i l i t a t i o n w i l l exist.  I t i s not the intention of health authorities  to c r i t i c i z e such places, but there are a few premises (in comparison with the total existing number) that are repeatedly reported as being the place of meeting or exposure resulting i n the acquiring of an infection. The responsibility for these new infections lies indirectly with the owners  - 36 or managers:  they seldom, i f ever, take an active hand i n preventing such  f a c i l i t a t i o n , rather they encourage i t because i t brings new customers and new revenue. It might be pointed out in passing that the location and "grade" of such facilitation premises, especially of cafes and rooming houses, bear l i t t l e relation to their amounts of facilitation:  cafes of equivalent  "grades" and within the immediate v i c i n i t y of one another may have contrasting reports —  in one, the manager prevents promiscuous pick-ups and dis-  courages loitering; in another, he silently encourages or carefully disregards them. Clandestine prostitution and gross promiscuity constitutes a problem numerically far more serious than that presented by professional prostitution, but fundamentally secondary to i t .  True, clandestine prosti-  tution and gross promiscuity account for the vast majority of new infections; but each individual involved i s exposed to only a fraction of those reached by the professional prostitute. It can be concluded then that the best preventative for venereal disease lies in the prevention of gross promiscuity, whether that promiscuity i s found i n paid or non-paid prostitutes, and whether in males or females.  It i s clear that.if gross promiscuity i s to be abolished, the  present day practice of fining or imprisoning the prostitute i s merely palliative:  i t removes, for a short time, the symptom of the basic problem,  but accomplishes nothing in correcting the underlying factors responsible. It i s some of these factors that w i l l now be considered in this paper.  Chapter I I I . Factors Involved! 1.  Economic.  Housing!  Housing conditions are important both as a concommitant and a predisposing factor i n the spread of venereal disease.  The present day-  c r i t i c a l shortage of adequate housing serves only to accentuate conditions present before the war. Poor housing i s not only a factor i n the spread or acquisition of venereal disease* i t i s also a factor involved i n delinquency.  Glueck  reports that of 367 delinquent girls under the care of the Massachusetts Reformatory for Women, "only 2A% of the girls lived i n homes the physical conditions of which might be termed 'good', i n that they contained adequate space for wholesome living (not more than two people, excluding an infant, to a bedroom), were light, clean, and well ventilated, and had at least the minimum of furniture needed for comfort; A£.3# of them spent their childhood i n 'poor homes which were overcrowded, f i l t h y , scantily 1  and shabbily furnished, and not infrequently even lacking ventilation and light.  Almost a third (31.7$) of our g i r l s grew up i n hornet that might  be considered ' f a i r  1  i n that they had some features of the good home and  some features of the poor one." ( l ) Since the presence of venereal disease implies the presence of promiscuity, and since promiscuity and delinquency are both "manifestations of human and social maladjustments" (2), i t i s not surprising that there should be at least some overlapping between factors involved i n delinquency and the acquisition of venereal disease.  Thus i t was found in a  study of promiscuous g i r l s i n San Francisco that "approximately two-thirds of the promiscuous patients were living alone or with friends, usually i n third or fourth rate hotels. Patients would sometimes begin living with a g i r l friend immediately following their chance meeting on a street car (1) (2)  Glueck, S. and E.T., Five hundred delinquent women, p. 68. ibid., p. 308.  - 38 - or i n a dance h a l l .  No semblance of home l i f e or family l i f e was possible,  and such living arrangements were conducive to unstable, promiscuous behaviour", (l) In the particular case of the spread of venereal disease, poor housing i s a factor.  In Vancouver, the areas i n which housing i s most  unsatisfactory (2) are responsible for the greatest amount of venereal disease spread. When there i s overcrowding and squalor, there can be no room for relaxation or recreation; relaxation and recreation must be found elsewhere.  Permanent residents, and their families, new comers to the  city, and transients find no incentive to remain i n an unattractive room of a hotel or rooming house. It i s people living i n such conditions that constitute a source or potential source of venereal disease spread. Time after time, newly infected persons have reported that they had l e f t their rooms in boredom and had picked up, or had been picked up by someone on the street, i n a cafe, dance-hall, or beer parlour-.  These men and women regretted their having acquired infections,  but inevitably asked, "What else was I to do?"  The statement of a  San Francisco promiscuous g i r l can?well be applied elsewhere:  "I go  crazy staring at the four walls of that hotel room. I get so lonesome that I go out to bars just to have someone to talk to." (3) In one study made by Fraser of f i f t y boys and g i r l s diagnosed at the Vancouver Clinic as having acquired early syphilis, primary and secondary stages, i t was found that:  "Forty or eighty percent of the  whole group of f i f t y l i v e alone i n a rooming house or cheap hotel.  With  the exception of three, a l l of these rooming houses and hotels are situated i n the centre or- at the edge of the slum area i n Vancouver on the border of Chinatown, where they are exposed to the activities of organized (1)  Lion, E.G., et a l . , An experiment i n the psychiatric treatment of promiscuous g i r l s , p. 20. (3) Lion, E.G., ibid., p. 20. (2) Norrie, L.E., et a l . , ibid.  - 39 vice, such as molestation, gambling, prostitution and other underworld activities.  There cannot possibly be even a semblance of decent home l i f e  or stable behaviour i n such surroundings.  The proprietors of these hotels  and rooming houses are almost without exception Orientals or Eastern Europeans whose standard of living i s low", ( l ) Young g i r l s , especially, have reported that they had l e f t their homes, had been picked up, and subsequently had acquired venereal disease.  In many cases they had l e f t because their homes were so unattrac-  tive, because there was no room to entertain their friends, or for numerous other reasons and perhaps, rationalizations, reflecting on the inadequacy of their dwelling places for recreation and relaxation. It i s significant that venereal infections appear most often, not among members of a family, adults or children, living i n their own homes or i n several roomed suites, but among adults and youths living i n single rooms, usually i n cheap hotels and rooming houses. The problem of housing i s complex, but even more complex i s the f a c i l i t a t i o n associated with i t .  When unscrupulous, money-eager landlords,  own and manage hotels or rooming houses, promiscuity and prostitution may quickly become rampant. Unmarried couples can easily acquire a room for the nightj visitors of either sex can come and go at their leisure; guests can pick up other guests i n the halls; these and other activities can be condoned or abolished at the whim of the landlord.  I f oondoned, as so  often they are, promiscuous sexual exposures multiply and commercialized vice i s encouraged. Poor housing, then, i s of importance i n the spread of venereal disease:  i t concerns the family, in which the child, eager for normal  relaxation, privacy, and room to entertain, i s thwarted; i t concerns the single man or woman, who i s actually encouraged to have i l l i c i t sex (l)  Fraser, J., Study of the social factors involved i n the acquisition of venereal disease.  - AO -  relations; i t concerns the transient, who, bored with the squalor, seeks more exciting surroundings; and i t concerns the community because i t i s the community that pays for the damage caitsed by venereal disease. 2.  Lack of Recreation;  Recreation i s considered i n this section only from an economic standpoint, and as such, i t i s of interest i n a consideration of the venereal disease problem, but to what extent recreation i s involved i s not f u l l y known. For a great many individuals, recreation implies attending theatres, dances, cabarets, beer parlours, or other commercialized recreational establishments; for such persons, recreation requires money. When money i s lacking, substitute forms of recreation are found, and i n some cases, erotic activities result.  However, heterosexual activity  in such circumstances i s probably not very common. In the case of the adult male, i t i s most unlikely that a lack of funds i s conducive to his finding entertainment with some woman or g i r l off the streets;  he must have some sort of inducement to offer.  If  he can afford a bottle of cheap liquor, he can probably pick up an interested female, and probably, a venereal disease. In the case of women and older g i r l s , the problem of recreation is usually a social not an economic one.  When i t i s an economic one, some  sort of prostitutidn i s usually i n the offing. Younger girls whose families are i n poor economic circumstances, who are s t i l l associated with their parents or guardians, and who are prohibited by school attendance from earning legitimate wages, often have no money available for recreation.  In such cases, the g i r l s may become  promiscuous with school mates or with older youths and men, and usually receive, at most, an inexpensive evening's entertainment i n exchange for  - a  -  for their favors. Girls such as these constitute a serious problem i n the control of venereal disease because they are not legally considered as being prostitixtes, and when their proniscuity i s known they are i n demand by many, and hence become a serious potential source of infection. Poor economic conditions and the association between money and recreation may start very early in l i f e .  When this i s so, when there  is a lack of funds for recreational purposes, when there i s ennui associated with the monotonous l i f e of a young single man or woman dissociated from the home, or when one earns a living i n a tedious job, a reaction v/ill often occur.  At the present time, the reaction a l l too often results i n pro-  miscuous sexual relations as being the easiest and most satisfying or tension releasing of the means available. 3.  Lack of Educational Opportunities!  When an inspection i s made of Table IX, i t i s seen that students and professional persons acquire the smallest number of infectionsj i t i s also noted that these two groups are rated lowest i n the acquisition of venereal disease i n studies of serological studies, (l) Other studies and surveys bear out the conclusion that the acquisition of venereal disease and occupation correlate. Just why the professional and student groupings escape the attack of venereal disease i s for the most part a matter of conjecture; i t i s probably not because these two groups have a higher moral standard or expose themselves less often. One reason that might be offered to explain this phenomenon i s that both professionals and students necessarily have a certain amount of formal education, and a somewhat broader understanding of most matters than individuals i n other occupational groupings. When this broader understanding i s applied to sexual matters i t does not presuppose continence, but i t does presuppose care, care not only i n the (l)  Usilton, L.J., and Bruysre, M.C.,  ibid.  - - 42- choice of a partner, but also in the taking of precautions when such are deemed advisable. Such men and women are seldom promiscuously indifferent because they have a well grounded fear of infection (and possibly conception)* and i f they are involved i n some dubious exposure, usually chemical or mechanical prophylaxis i s used. Certainly, errors of judgment are made, and infections are often acquired, but to a strikingly less degree than i n other occupational groupings. Whether or not the reason offered i s sound, is of l i t t l e consequence* the basic correlation between the attack of venereal disease and the occupational grouping (or educational attainment) holds. In the study of Fraser at the Vancouver Clinic, only four boys and five girls entered High School, and one boy and three g i r l s of 8% of the group completed Grade XII.  (l) Here then, i s one indication that a  large number of boys and girls leave school long before there i s any opportunity to learn even the basic facts about venereal disease, i t s nature, mode of transmission, and other essential information.  (This  statement implies that the school i s the only source of information regarding the venereal diseases:  such an implication applied to the total  juvenile population i s admittedly unsound but when applied to the many boys and girls who have had l i t t l e or no home training, i t i s quite sound.) If the assumption that the venereal disease attack rate diminishes with increased education i s sound, there seems to be no immediate solution:  to raise- the minimum number of school years might be of  some value, although this would increase the economic d i f f i c u l t i e s probably responsible for the early leaving of school. No mention i s made of mental inability to progress further.) Another suggestion has been to give sex education and venereal disease information in earlier grades: whether this i s advisable i s a matter far from being satisfactorily (2)  Fraser, J., i b i d . p. 37.  - 43 -  settled.  Both those in favour of such instruction and those against i t  are vehement i n their assertions and both offer reasonable arguments. For the time being, i t i s assumed that such instruction would be unsatisfactory, i f only because of the lack of cooperation from some parents, religious groups and educators. Barriers to the obtaining of information concerning sex and the venereal diseases apply not only to the school age population but also to the adult population.  I f the family i s too economically insecure  to allow the child to continue his education, the chances are that the family i t s e l f i s unable to afford either the time or money for a continuation of i t s own education i n order to instruct the child i n the home. Thus i t i s that often the only source of such v i t a l information i s from companions, as ignorant of the facts as the child himself. It i s true that anyone can obtain adequate information on these subjects from several sources, but a knowledge of the sources i s often obtained i n one's education or, too late, after one has.become infected. Scientific information concerning the venereal diseases does offer some prevention i n the acquisition of venereal disease,  (l) When this infor-  mation i s not obtained because of economic insecurity, the latter i s the faultj and with i t s remaining ramifications, economic insecurity plays a v i t a l role i n the continuation of the prevalence of venereal disease. 4.  Necessarily High Age of Marriage;  It has been seen that the largest number of nev; infections i s acquired among single, divorced, or widowed men and women; fewer cases are found among married persons, and even fewer among married couples living together. This relationship of venereal disease acquisition to marital status has long been known, and the necessarily high age of marriage i s (l)  Bigelow, M.A., Why Youth Should Know the Important Facts about Venereal Diseases: J.S.H., v o l . 29*  - u c i t e d as one of the reasons f o r the present day r i s e i n attack rate i n comparison with the attack rate of a few generations ago.  A c t u a l l y , with  the many changed conditions, i t i s u n f a i r to compare the attack rate of • these two periods, and even more so when i t i s remembered that the reporting of new infections has only recently been encouraged by health departments. A s a t i s f a c t o r y marital adjustment as a preventative of promisc u i t y has been a precept of most r e l i g i o n s .  The Church states that i s i s  a s i n f o r anyone to have sexual r e l a t i o n s outside of marriage: thus marriage i s encouraged among young people.  However, with the e v e r i n c r e a s :  ing number of years required by today's youth to prepare f o r economic security when they leave the homes of t h e i r parents, unless f i n a n c i a l assistance i s forthcoming from some source, marriage i s a serious r i s k . I f a couple contemplating marriage i s forced to postpone, almost i n d e f i n i t e l y , the marriage, the taboos concerning premarital i n t e r course are often broken.  This premarital intercourse when confined to the  two persons involved, plays no-part i n the spread of venereal disease, but when one or more other persons enter the picture a threat to the health i s present. When this unmarried couple, engaged i n intercourse, i s unable to have regular exposures because of any number of intervening and thwarting circumstances, or i f the two are separated from one another, one or both may given i n to the temptation of a promiscuous exposure.  ( I t can  be argued that such a s i t u a t i o n can just as r e a d i l y occur with a married couple; this i s quite so, but the factors of i r r e g u l a r i t y of intercourse and of the r a t i o n a l i z a t i o n that one i s not morally bound by marriage vows, do play a r o l e that i s not so often found with the married couple.)  "It must be admitted that continence beyond the age of about tv;enty-one may not be good for the individual, but apparently i s required by social structure. This puts man in a dillema from which i t i s d i f f i cult to extricate him, for a l l civilization seems to be tending toward city l i f e and late marriage, both of which are contrary to normal sex hygiene. ture."  The roots of sex hygiene l i e deep in economic and social struc(1) Certainly, i t i s admitted that there are arguments against  very early marriage —  the high failure rate among them i s an excellent  one, but at the present time young men and women in this society are supposedly faced with two alternatives, sexual continence or marriage.  It i s  quite obvious that a significant part of the physiologically mature population i s accepting neither, but i s seeking sexual gratification outside of marriage.  Whether such behaviour i s good or bad, advisable or not,  need not be discussed here, but i f the mores of the society are to be obeyed, early marriage i s to be considered as at least part of the solution in the prevention of promiscuity.  (l)  Rosenau, M.J., ibid.> p. 4-90.  - 46 Chapter IV.  Factors Involved: 1.  Sociali  Lack of Social Relationships;  To suggest that a person who acquires a venereal disease has lacked any social relationships appears absurd when i t i s quite obvious that he or she has experienced what i s probably the most intimate of social relationships.  However, what i s intended to be conveyed here i s that i n -  dividuals who lack social relations with the opposite sex for any of the numerous possible reasons, are inclined to be easy marks for the prostitute, professional or clandestine, or for the promiscuous pick-up, male or female. A common reason found for lack of friends and acquaintances is- that one i s a stranger: he knows no one, he i s not interested i n v a r i ous social or religious organizations that might assist, and so wanders the streets, drinks i n a bar, or v i s i t s a theatre.  If he gravitates to  the slum or near-slum areas, he may be approached by some prostitute; or i f he actually desires a female companion, he merely has to inquire from taxi drivers until he finds one.  These are but two methods which are i n  vogue with the non-aggressive male. If he be aggressive, his opportunities are unlimited, and i t would be exceptional for him to f a i l to find a prostitute. It i s just this sort of situation that can be applied to seamen, visiting members of the armed forces, and other travelling men:  they  arrive i n a city and being strangers are less prone to criticism than i f in their own home c i t i e s .  The attraction of a uniform undoubtedly adds to  the f a c i l i t a t i o n of a promiscuous exposure.  (For the professional pro-  stitute, the absence of a uniform of the armed forces would be more satisfactory, because of the fear of repercussions by the Federal Government i f she infected a member of the Armed Forces.)  Under such pircumstahces, both  - 47 the p r o s t i t u t e and the' bored stranger are s a t i s f i e d , and the spread of i n f e c t i o n continues. There are, however, quite d i f f e r e n t cases e x i s t i n g :  these are  the men, young and o l d , who may have l i v e d i n a c i t y f o r years, and s t i l l have formed no friendships with women or g i r l s .  Probably, p e r s o n a l i t y  or appearance d i f f i c u l t i e s are responsible f o r t h e i r i n a b i l i t y to f i n d f r i e n d s , but the f r i e n d l e s s man w i l l f i n d l i t t l e comfort i n such knowledge. I f he i s 3roung, he may associate himself with a l o c a l s o c i a l or r e l i g i o u s group, but beyond t h i s , l i t t l e presents i t s e l f .  I f he can dance, he might  f i n d companionship a t some of the public dances, but i f neither of these suggestions appeal to him, he i s i n a p o s i t i o n p a r a l l e l to that of a stranger, and the next steps are easy"to take. In the case of the female, the conditions are somewhat r e versed:  she i s permitted by s o c i a l convention to adopt only a passive,  or a t post a cooperative r o l e i n the making of male f r i e n d s h i p s . To be too aggressive e l i c i t s b i t t e r c r i t i c i s m from her female f r i e n d s , and often disgust or a f a l s e sense of pride from her male pursuer.  I f she be  unattractive, and unable to obtain male companionship, she can, i f she wishes, be picked up on the s t r e e t , i n a cafe, or elsewhere, and be quite convinced that she has passively acquired a man.  Unfortunately, she may  also have acquired a venereal disease. The v a r i a t i o n s of the finding of companionship when one lacks • friends are almost i n f i n i t e , and a l l do not end i n sexual exposure or i n infection.  The ones that do end i n prom? caucus  that are of interest here.  coxv.s.1 exposure  are those  - 4-3 2.  Lack of Education and Interests;  In su££e&tir£ that education, or the leek of i t , i s a factor in the spread of venereal disease, i t is the intention that a broad education and resulting broad interests serve as effective weapons i n combatting ennui. Education, as the term is used here, does not necessarily mean formal education or aca-J.er.ic education;  i t ray be a self-acquired,  purely cursory knowledge of a few fields of knowledge or activity.  With  that knowledge, one can find new interests, new things to do or learn during leisure hours. For many, these interests may become hobbies that can afford sreat pleasure and often financial returns for the efforts expended in acquiring them. The opportunities for such education are almost unlimited, and the individual who has formed various interests and hobbies i s indeed fortunate, for he usually finds that with them the passage of time is almost too' fast. money i s unnecessary;  For nany of these interests and hobbies,  materials, i f necessary, are easily available.  However, one of the prime necessities for such multi-interests i s the expenditure of some effort on the part of th.e seeker.  It i s at this  point that a £reat many young men and women, faced with no other responsi b i l i t y than their own existence, f a i l to make such an effort. pleasure is found only in basic physiological satisfaction;  For them,  when such  satisfaction is sexual satisfaction, then unless other circumstances prevent i t , promiscuity often results. In this succ'sstion that the cultivation of interests and hobbies night serve to prevent the acquisition and hence the spread of venereal disease, i t i s to be noted that the sublimation in the Freudian sense i s not being discussed here; rather, what i s being suggested i s that interests and hobbies might remove, perhaps only temporarily, ennui,  -  49  -  and that the sexual drive might not be 30 easily aroused as during periods of complete boredom. 3.  Lack of Recreations  The factor of recreation i s broad: social end individual psychological factors.  i t involves economic, Here i t i s loosely consi-  dered as being purely a social matter, in which more than one• person i s involved. For the very young, the elementary schools offer physical and some- mental relaxation i n recreations  i t i s almost compulsory to take  part, and even the poorest players or participants are reluctantly allowed to play. From about the Junior High School level onward, however, definite distinctions arise, and the poor and mediocre would-be participants are eliminated. These distinctions apply both i n and out of school, to both boys and girls, and i n both physical and mental activities.  Only  the best are welcomed, and only the best take part. The good players are always i n demand, bu.t i t i s not they but the mediocre players who constitute any problem i n the organizing of recreational activities.  It i s the latter who probably need the recreation  most, and i t i s they who, failing to find satisfaction in one type of activity, w i l l find other activities which often border on delinquencies. When such delinquencies manifest themselves as sexual promiscuity, they become v i t a l l y important i n the venereal disease control program. In Fraser's study, (l) only two of the total group, both boys, belonged to any organized recreational group:  the others professed to have  no desire whatever to take part i n any organized activities.  This same  report shrewdly points out that although there are now three clubs catering to boys between eight and eighteen existing i n areas of high delinquency (  rates, "in the downtown rooming house and .cheap hotel areas where BOf. of (l)  Fraser, J., ibid.  - 50 our group live and where many more congregate, there i s not one boys' and g i r l s ' club or any organized recreational activity". In a l l fairness to the boys' clubs i n Vancouver, i t must be said that efforts are made to include a l l who want to take part regardless of special s k i l l s ; however, the few that exist cannot possibly 'meet the needs.  (2) Recently, mixed clubs have come into prominence, under the  t i t l e of "Teen Towns", or something similar.  At this early time of their  existence i t would be unfair to evaluate their worth, but from discussions with teen aged boys and girls in various parts of the province, i t i s apparent that the Teen Town i s not a panacea for juvenile delinquency. Many of the boys i n their early 'teens are physiologically, mentally, and socially less mature than £irls of their own chronological age and find no pleasure i n dancing.  Some offer unusual rationalizations to  explain their lack of enthusiasm for the plan. One of the best criticisms offered i s that the Teen Towns are not operated often enough, and thus do not allow one to.give them a l l the support one would like. Whatever criticisms are made of the Teen Towns, and no matter bow useful or useless they may prove to be, s t i l l their formation does constitute a positive step forward i n meeting some of the needs of the 'teen aged population. It i s such positive measures that are needed, measures that furnish sound prevention by offering enjoyable, wholesome activities for everyone concerned. In the problem of venereal disease control, although the young persons i n their 'teens are worthy of serious consideration, those, in their twenties, thirties and older age grouping must also be considered. With them, the problem of recreation i s more complex than with those i n their younger years:,  sports, for the most part, become highly specialized,  - 51 and other recreational outlets are unsuitable because of the sophistication brought on by maturity.  For many of these more mature persons, sports  and social clubs are synonymous with drinking and gambling organizations. Thus even i f the boys' clubs, g i r l s ' clubs, Teen Towns, and other associations solve the recreational problem for boys and girls under twenty, the problem remains for single men and women o^er twenty. A.  Alcohol;  The relationship of alcohol to the acquisition of venereal disease demands attention:  the majority of pick-ups, preliminary to  sexual exposure resulting in the acquisition of a venereal infection are made while one or both parties are at least partially under the influence of alcohol. This i s quite understandable when i t is remembered that alcohol not only releases the higher inhibitions, which include the sexual inhibitions, but also acts as an aphrodisiac. To determine why an individual was intoxicated, or why he had been drinking prior to exposure, would be to uncover the numberless reasons for dissatisfaction with l i f e — and countless others.  thwarting, repressed desires, ennui,  If suffices here to state that alcohol i s an  important factor in the spread of venereal disease. The use of alcohol i s both an individual and a social.problem; an individual may drink because alcohol furnishes a means of escape, or he may drink because everyone else i s drinking. Whatever the reason, a great many individuals do drink, and as a direct consequence of their drinking, sexually expose themselves with less discrimination and precaution than they would had they not been drinking. The importance of alcohol in the spread of venereal disease is suggested in the "facilitation" records.  Table XIII, which gives the  relative frequency of pick ups i n various premises i n B. C., resulting  - 52 in infection for the years 1944- and 1945, shows that in both years beer parlours account for a significant number of pick-ups. This i s particul a r l y noteworthy because escorted and unescorted women drink on one side of the parlor, and unaccompanied men on the other. There i s supposed to be no traffic from one side to the other, although i t s existence i s quite apparent,  (in most licensed premises i n the larger cities, however, i t i s  kept to a minimum by the various managements who with but a few exceptions have discouraged facilitation i n their premises.)  But i n evaluating the  true role beer parlours play i n facilitation, two points must be stated: f i r s t l y , a woman can be excorted into a beer parlour with almost any number of men, and once inside the women's section pick-ups by her escorts might be relatively easily arranged (although this i s supposed to be especially watched for by management) and secondly, some pick-ups that are attributed to beer parlours are probably made on the street just outside them ~  these latter cases should not be considered as pick-ups occurring  in beer parlours; they would not be with careful reporting. In this consideration of the role of alcohol i n the spread of venereal disease only a few observations have been made, and these only to inidicate that i n many cases where an infection has been acquired, alcohol has played a part and — be accepted —  i f the statement of numerous clinic patients can  had i t not been for alcohol the sexual exposure would not  have occurred. As Rosenau has said: and gonorrhoea. sex hygiene.  I t i s intricately interwoven into the warp and woof of  The story of many cases of sexual immorality begins with the  influence of drink." (l) (l)  "Alcohol i s the bedfellow of syphilis  Rosenau, M.J., ibid., p. 576.  - 53 -  5. Influence of Companions: In this brief discussion of the extent to which companions are responsible for an individual's exposing himself in non-marital sex relations, the assumption i s made that those being discussed here are at least i n their later teens and have not hitherto been tempted to experiment i n any such relations.  This introductory assumption i s made to  eliminate factors which might have been influential during earlier years. There i s great range in the young adult's susceptibility to a companion's influencing him to have i l l i c i t sex relations. With the male, especially, a chance suggestion made while drinking, that female company be sought, often meets with instantaneous agreement. Possibly this i s due to the heightened suggestibility, the lowered inhibitions, and the aphrodisiac effects produced by alcohol.  The suggestion of the  companion may have had but l i t t l e influence on an inevitable process. At the other end of the scale i s the young woman (usually) who firmly maintains that such erotic behaviour i s wrong, and who even under the influence of alcohol remains adamant. She i s continually pleaded with, and even coerced, by. her inamorato, and argued with by his friends, male and female, so that eventually she may succumb to the majority. In such a case, and i t i s not rare, the influence of one's companions probably i s primarily responsible for submission. Between these extremes, the f i r s t merely a precipitating factor, the other tantamount to a conditioning factor, are infinite variations:  i n some cases the influence of the companions might be merely  supplementing other environmental influences, or vice versa.  Thus among  men i n the armed forces or i n the merchant navy, the influence of the older men on the younger ones may be important.  For instance, some  younger men, unable to bear the taunts of the older companions, are almost  forced to take part i n activities which are quite foreign to them and their desires.  But even here the influence of the companions i s to be questioned.  One study made in the American Army states:  "The sex habits of the man of  military age have been largely determined before he. enters the Army.  The  man who has been promiscuous i n c i v i l l i f e w i l l probably not change his habits upon entering military l i f e .  A study at one Army post showed that  half of a l l the soldiers contracting venereal disease gave a history of having had a similar infection before entering the Army." (l) Another American article states:  "The men i n a successfully  trained army pr navy are stamped into a mold. Their barracks talk becomes typical, for soldiers are taught i n a harsh and brutal school. They cannot, they must not, be molly coddled, and this very education befits nature, induces sexual aggression, and makes them the stern, dynamic type we associate with the men of the armed forces... This very sex drive. is..v:: exaggerated by the salacious barrack talk."  (2)  It would be unfair to generalize on the influence of companions, casual or otherwise, because a careful individual case study would have to be made to determine just what part each factor played i n the pattern of the person prior to sexual exposure. Certainly, c l i n i c interviews would be valueless, because most of the patients regret having, acquired a venereal disease and are only too willing to find a scapegoat projection i s inevitable.  (1) (2)  Anderson, G.W., Venereal disease education i n the army: J.S.H., vol. 30, p. 20. Boone, J.H., The sexual aspects of military personnel: J.S.H., vol. 27, p. 116.  —  - 55 Chapter V.  Factors Involved; 1.  Psychological.  The Sex Privet  The sex drive and i t s heterosexual manifestation, coitus, are fundamental to the spread of venereal disease.  It i s a truism that  i f sexual intercourse were avoided in persons not married to each other, within a generation the venereal diseases would almost entirely disappear. Of course few authorities believe that the necessary continence outside of marriage.can be universally attained, but most do believe that every effort should be made to dissuade incontinence. For the purpose of venereal disease control, only one of the numerous and diverse manifestations of sexual activity, coitus, need be considered:  homosexuality and other perversions play such a limited role  in the spread of venereal disease that they need only be mentioned. Homosexuality, especially among incarcerated men, i s responsible for the spread of a limited amount of venereal disease. Prison Farm in 1945,  In Oakalla  two inmates who had been prisoners for some time  showed symptoms of early syphilis.  Questioning of one of these men revealed  that he had had several homosexual exposures with other prisoners. These exposures, which had a l l occurred in one particular part of the prison, were quickly halted, and" a l l the men involved examined and, when necessary, treated. Some clinic patients too, have given a history of homosexual activities, but infections arising from such activities when they do appear are so few that they invite special attention.  Heterosexual perversions,  usually only suspected by the examiner and rarely admitted by the patient, are not responsible for a significant number of infections.  In the control  of venereal disease, they need not be considered separately from copulatory behaviour, because both are essentially sexual exposures which can  • - 56 constitute a source of infection. In considering the relationship between coitus and venereal disease, i t should be stressed that, exc?pt in rare instances, at least three persons are involved. Thdt is,, in order to acquire-a venereal disease, an individual must h& sexually exposed to another person who has previously acquired an infect: on probably not longer than five years before, because untreated late syphilis i s relatively nor.-infectious. (l) TThen this involvement of more than two persons i s recognized, i t is seen that the venereal disease attack-rate i s not an index to the amount of non-marital sexual intercourse in a given area, but an index to the promiscuity.  (The term promiscuity as here used i s arbitrarily  defined as "the act of haying sexual relations with more than one person within a period of five years". for general usage:  This definition i s admittedly unsuitable  i t omits entirely reference to marital status. It i s  intended only to convey the involvement of more than two persons in sexual activity within the period of time in which infection can be spread.) It can be seen that i f one infected person in a community i s promiscuous, he or she may start a chain of infection which can be spread in a geometric progression. From this brief discussion i t might appear that, from a venereal disease control standpoint, i t is unnecessary to discourage sex relations between any two individuals married or unmarried, providing those sex relations are confined to the two individuals.  However, because  there are no means available to control absolutely any person, and because the factors responsible for promiscuity are so numerous, to advocate such a policy would invite chaos, not only from a health standpoint, but from the opposition of numerous individuals and organizations, (l)  Moore, J.E., The modern treatment of syphilis:  p.  26.  - 57 -  Despite the v e i l of secrecy, the prudery, and denials of many well meaning organizations, end despite their threats and pleas concerning continence, the basic fact remains that the sex drive exists and must somehow he satisfied.  "Biology indicates that with the exception  of some few individuals, men and women require expression of the sex impulse as a physiologic necessity."  (l) When this drive i s strong, and i s  satisfied by sexual intercourse, gross promiscuity (especially among the unmarried) may result.  The problem arises whether this promiscuity i s a  manifestation of nymphomania or satyriasis.  Most authorities maintain  that these conditions are rare, and that most cases appearing to be hyper-, sexualism are nothing more than manifestations of individual maladjustment. Even among prostitutes, cases of hypersexualism are rare.  (2)  But other cases, not of gross promiscuity, but of regular exposure are often found among single, divorced, or widowed men and women. These persons assure the questioner that they must have intercourse regularly, that i t i s v i t a l to their health. The expressions they use to describe their heeds are much the same, a l l stress the absolute necessity of intercourse. Tith such people a complex problem i s present:  the sex  drive apparently can be gratified only by a promiscuous exposure, and for them, no other solution —  or no easy solution presents i t s e l f :  they are  firmly convinced that their behaviour i s the only possible behaviour. Here then are two apparently different situations, gross promiscuity and "regular" exposures:  both are responses to a powerful sex  drive and except in degree they are identical.  "The sex urge i s so deeply  implanted i n living beings that complete repression i s impossible." (3) Concerning the sexual aggressiveness of men in. the armed forces, i t has been suggested that "This sexual aggressiveness cannot be stifled... (1) (2) (3)  This very sexual drive, i s amplified because of fresh a i r ,  Rosenau, M.J., ibid., p. 4-79. Kemp, T., ibid., p. 5 1 . Rosenau, M.J., ibid., p. 4-79.  good food and exercise, and exaggerated by salacious barracks talk.  It  cannot be sublimated by hard work or the soft whinings of V i c t o r i a n minds." (1) In addition to the physiological tensions evoking sex activity, there are emotional tensions that can often be released, or part i a l l y released, through sex activity.  Because sex activity seldom requires  much effort, i t furnishes an excellent means for some to make an adjustment, albeit an-unsatisfactory one, to their environment. True nymphomania and satyromania are rare; promiscuity, on the other hand, i s common, because tension, can and often does appear as sexual tension. The release of this tension is easily accomplished through erotic behaviour — course —  i n adults i t i s usually through sexual inter-  thus this easy method i s used in preference to other, more  socially acceptable methods. For purposes of venereal disease control, this matter i s of concern:  mass public education would be of doubtful value —  explanations,  advice, and guidance can be given only after individual analyses and studies have been made- and unless control can be exercised over the individual concerned, measures to counteract promiscuity w i l l often be wasted effort. "The very nature of the sex urge i t s e l f . . . tends to cancel out much of the effects... educational efforts." 2.  (2)  Lack of Satisfactory Substitute Activity:  Much of the available data concerning persons suffering from venereal disease i s purely introspective, and from the persons themselves- this data i s often obtained from the c l i n i c patients only as a voluntary statement, or as an admission after careful questioning.  This i s  because the work of the Division of Venereal Disease Control i s concerned primarily with the treatment (or rendering non-infectious) of venereal (1) (2)  Boone, J.T., ibid., p. 118. Larimore, G.W., and Sternberg, T.H., Does health education prevent venereal disease? A.J.P.H., v o l . 35, p. 802. -  -  59  -  diseases, not the criticizing of patients for moral laxity.  However, when  a patient i s diagnosed, the social history taken often reveals some of the •underlying problems involved; and special case studies made at the Division of Venereal Disease Control are intended to discover what factors are involved, i n order that any possible remedial measures may be taken. That "sexual engergy" can be directed from a personal, tension releasing response into altruistic and social channels was stressed by Freud in his concept of sublimation.  Numerous other individuals, even  i f they do not agree with the psychoanalytic theory, have agreed that sublimation, in varying degrees, i s possible. In this paper, the sex drive is assumed to be a tension, capable of arousing diffuse organismic activity, and that such activity can be channelized, within limits, into socially acceptable behaviour through the process called sublimation. That the mores requiring continence on the part of the unmarried man and woman are being ignored i s quite obvious from the venereal disease attack rate and illegitimate birth rate. Young men  and  women do have sex tensions, and they do require a release of those tensions, but the society i n which they live has sex mores.  "It would be d i f f i c u l t  to invent a convention more directly opposed to biologic realities than . the insistence of sexual abstinence, especially during the long period when v i r i l i t y i s most active... Biologic teaching leans toward selfexpression, indicating that, the problem i s individual, while the pressure of the social code is toward self-repression, demanding group conformity. The pendulum swings from one extreme to another i n a futile attempt to reconcile or compromise these two conflicting disciplines."  (l)  Rather than supplying f a c i l i t i e s for such substitute activities, Stokes argues that modern civilization i s ever removing them, (l) Rosenau, M.J., ibid., p. 497.  - 60 "For  a very sound physiologic reason well borne out i n psychosomatic  medicine, the disappearance from a c i v i l i z a t i o n of the need f o r muscular e f f o r t as a means of neural tension discharge, leads i n e v i t a b l y to an overbalancing of the i n d i v i d u a l economy toward the emotional side.  To  bring this p r i n c i p l e to the American scene, no i c e to break on the p i t cher i n the morningj no chores; no 2-mile walk to.school; no f i e l d to plough; no axe to wield —  i n t h e i r place, the running hot and cold water,  the inner spring mattress, the soft car-seat, without even the necessity for twiddling a thumb to s h i f t a gear, the sit-down job, the over-sized meal —  a l l such devices tend to create'or to accumulate.instead .of drain-  ing o f f , the emotional p o t e n t i a l of which sex forms so large a part. I n the l i f e of today, massive' physical weariness o b l i t e r a t i n g a l l t i t i l l a t i v e stimuli from ankles to curvesome l i p s under a thick p a l l of muscular exhaustion, forms just no part at a l l . A r i s e i n sexual tension and tempo would therefore seem i n e v i t a b l e .  Nor does the upswing i n the worry  curve of modern l i f e exert a necessarily compensatory depressant i n f l u ence.  In f a c t , one of the paradoxical things about worry i s i t s d i r e c t  drive into sexual hyperactivity and abnormal sexual p r a c t i c e . v i t y i s a major mechanism of escape.  Sex a c t i -  Another elementary c r i t i c a l reversal  i s that row developing between the role of man and of xvoman i n the carrying of the physical load of l i f e .  Increasingly one sees the woman,  liberated by marriage or a job from the time-honored but exhausting routine of washboard, i r o n , and kitchen sink, to say nothing of the children, pigs, and chickens, who has now become through accumulated and released emotional tensions, the sexual d e s i r e r , seeker and aggressor, of the malefemale combination i n the family l i f e .  The man comes home from a bad day,  f l a t , to meet the woman, with her warpaint on, ready f o r the night-club and what have you.  The r e s u l t —  adventurousness i n sexual forms a t an  i  - 61 age and i n s o c i a l groups i n which the good older days sheer fatigue applied i t s damper, and the i n t e g r i t y of the home was assured, at l e a s t , of the s t a b i l i t y of inertness and exhaustion."  ( l ) This viewpoint of Stokes  serves to stress the need f o r f i n d i n g s a t i s f a c t o r y substitute a c t i v i t i e s for a l l concerned. The task of f i n d i n g the.se substitute a c t i v i t i e s hss been taken on by S o c i a l Hygiene as one of i t s duties:  S o c i a l Hygiene must:  "endeavour to d i r e c t sexual relationships into higher paths instead of trying to deny t h e i r existence or to trample them out. Unless S o c i a l Hygiene succeeds i n t h i s , the volume of male and female incontinence w i l l remain high; i t w i l l continue t o form that nucleus of supply and demand which i s fundamental as regards p r o s t i tution and the venereal diseases, which are the blossoms of promiscuity, w i l l persist."  (2) 3.  Loss of Security:  In the following b r i e f discussion, i t i s to be made clear that only a most s u p e r f i c i a l and incomplete survey w i l l be made: the individuals being considered are mature, i . e . , i n t h e i r l a t e teens or older. With these i n d i v i d u a l s who are, or l e g a l l y can be independent of t h e i r parents, behaviour problems occasionalDjr arise:  freedom  from parental or guardian c o n t r o l brings r e s p o n s i b i l i t i e s , and one of the most important responsibili.ti.es i s that of economic security —  security,  not n e c e s s r r i l y f o r the d i s t a n t future, but s e c u r i t y f o r the present. When t h i s security i s absent —  and admittedly i t s absence i s only one of  the causes of behaviour problems —  problems a r i s e so diverse i n c o n s t i -  tution and content, that they might, i f listed., be a catalogue of s o c i a l and i n d i v i d u a l i l l s throughout the world;. (1) (2)  One of these problems may  Stokes, J.H., Some general considerstions a f f e c t i n g present-day sex and sex education problems: V.D.I.j v o l . 25, p. 197. Garle, H.E., i b i d . , p. 173.  - 62 manifest i t s e l f , directly or indirectly, as promiscuous sexual behaviour: directly i n the case of some professional prostitvites, indirectly in the case of some neurotic patterns. However, economic security i s not always a l l that i s lost in the bid for independence:  a form of social security i s often lost.  Gone too are the intimate familial relations, the friends and  acquaintances,  the associations, the recreation, the sympathetic solving of personal problems. not.  These losses are usually overcome, but in some cases they are  Just what adjustment the individual makes- to the new conditions  is important to him, and sometimes to the community.  If perchance the  adjustment entai.ls promiscuity, i t may become of importance to the health authorities. Another form of security, somewhat related to the last mentioned, is often absent i n the recently widowed man and woman:  here,  though, sexual activities are involved. The readjustment i n such a case, 'especially i f the person i s young, may involve promiscuity. Here then are examples of loss of economic or social security: ous:  probably the variations of, and additions to these are numer-  they serve o n ^ to indicate that loss of security may be related  to promiscuity and thus to the spread of venereal disease. Despite the probability of this, there are no actixal studies available to indicate that i t is so.  There i s far insufficient available material concerning  the factors predisposing to the exposure to venereal disease -- the general c l i n i c a l material i s usually too superficial, and special c l i n i c a l studies are slow to appear. What should be pointed out' concerning the relationship of loss of security to the spread of venereal disease (or promiscuity) is that i t , i n i t s e l f , is probably negligible but combined with other factors,  - 63 becomes of special significance. 4.  Lack of Marital Adjustment;  It i s almost a truism that venereal disease mainly attacks i l n ^ l e , separated, and divorced persons, and married persons who have failed to adjust themselves satisfactorily either to their mates or to the institution cf marriage i t s e l f .  The actual reasons for the malad-  justments of the latter are not important here, but they embrace every aspect of a man's l i f e .  Testimony to the numerous causes for such malad-  justments may b3 found in the grounds for divorce cited, particularly i n the U.S.A. Various polls of both men and women also indicate that there are almost countless faults that one finds with husband or wife, which can and do lead to separation or divorce when an unsatisfactory adjustment i s made. In British Columbia, most of the grounds considered satisfactory for divorce i n the U.S.A. are not permissible. Columbia, adultery must be proved,  In British  ( i t i s of course understood that a  great many cases i n which adultery i s "proved" are arranged solely to procure the divorce, whereas the factors leading to the desire for the divorce may be any one or more of numerous causes.)  S t i l l , divorces i n  British Columbia, even though the grounds required are repugnant enough' to discourage many persons, are increasing every year. In considering the number of infections acquired due to marital maladjustment, i t i s probably permissible to include not only the married persons who are living with their mates, but also those persons who are separated or divorced, although i t i s admitted that other factors are involved i n these latter cases. During the war years, particularly, with many husbands and wives separated for long periods of time, the number of infections acquired by married persons rose startlingly.  This was  -M to be expected, but i f would be f a i r e r to count manjr of these men and women as "separated" rather than "married"' because the latter usually implies living with one's mate. For this reason, i t becomes very d i f f i cult to determine just how many extra-marital exposures resulting in infection were acquired \sy married persons directly because of marital maladjustment.  (The notification of venereal disease sent po the Provincial  Board of Health states the marital status cf the infected person, but except for clinic cases and isolated ones from private physicians, no mention is made of the whereabouts of the husband or v/ife.) In a sur^r of 292 consecutive cases of venereal disease among male soldiers i n one military d i s t r i c t of Canada, i t was reported that "the percentage of marital incompatability (divorce, separation or frequent quarrelling) was three times as high" among the venereal patients asin the control group. The "control group was secured by making comparative personality studies of 153 soldiers selected at random from a group of 1000 consecutive f i l e s i n the Hepot personnel Selection office".(1) One factor that is responsible for some infections among married men more than among married women is exposure while under the influence of liquor.  This group, relatively small, does not include those  men who are using alcohol as a substitute for marital adjustment, but only those men who are apparently happily married arid who, for some reason or another, become intoxicated and a re picked (rather than pick up) by a prostitute.  When an infection is acquired i n this manner, the man i s  usually regretful and makes every effort to conceal his infection from his wife.  Such an infection, however, generally serves as an object lesson  for extra-marital continence, and so long as his marital status and adjustment remains constant the man can seldom i f ever be expected to (l)  Watts, G.O., and Wilson, R.A., A study of personality factors among venereal disease patients. C.M.J., v o l . 53, p. 120.  - 65 become infected i n the future.  Thus, such men are of only limited impor-  tance in a consideration of the factors responsible for the spread of venereal disease. In conclusion, then, i t can be stated that because of the inadequacy of the available s t a t i s t i c a l material, a consideration of the relationship of marital adjustment to the acquisition of venereal disease is unfair when only married men and women living with their mates are considered (and only incomplete material i s available), marital maladjustments account for but a few infections.  However, i f those individuals  who are divorced, or separated by choice are included,'marital maladjustment can be considered as accounting for a significant number of infections, and hence as constituting an important factor in the spread of venereal disease. 5.  Lack of Fear of Infection;  Of the two diseases, syphilis and gonorrhoea, the former has usually been recognized as a serious disease, the latter as "nothing worse than a bad cold". Since 1910, a successful but long treatment for syphilis hrs been known, but i t i s only relatively recently (since about 194-0) that a rapid, effective treatment for gonorrhoea has been available. Prior to that time, local treatment was given, which was often quite painful. Fith the advent of the sulfa drugs, medical authorities looked for the eradication of gonorrhoea (the drugs were ineffective against syphilis); but after widespread use the rate of cure of gonorrhoea bpgan to f a l l —  sulfa resistant strains of gonoccocci had developed.  At about this time, penicillin became available for general use and i t s remarkable properties were soon made known throughout the world.  One of  these properties was emphasized more than any-other to the general public  —  - 66 p e n i c i l l i n could be successfully used i n the treatment and s y p h i l i s , and treatment  of both gonorrhoea  time was only a matter of hours or days  whereas formerly i t had been a matter of weeks, months or even years. Hardly any popular magazine i n existence has not had some a r t i c l e a t l e a s t mentioning the miraculous treatment of venereal d i s e a s e i l t h the "wonder drug"; and hardly any of these a r t i c l e s suggested  that the r e s u l t s  of s y p h i l i s treatment with p e n i c i l l i n are s t i l l l a r g e l y experimental, and that no v a l i d evaluation of s y p h i l i s treatment v/ith i t can be made f o r several years to come.  Nor have these a r t i c l e s stressed the p o s s i b i l i t y  that p e n i c i l D i n - r e s i s t a n t s t r a i n s of the e t i o l o g i c a l factors might be produced i f the drug i s c a r e l e s s l y used.  w  h a t has been stressed i s that  p e n i c i l l i n affords a quick, almost painless, and almost c e r t a i n cure f o r e i t h e r ^ s y p h i l i s or gonorrhoea; the l i m i t a t i o n s and f a u l t s of the drug, more and more of which are being discovered, are seldom stated  they  would probably now be disbelieved by the p u b l i c , even i f they were stated. One of the immediate r e s u l t s of the p u b l i c i t y given to p e n i c i l l i n was that-many i n d i v i d u a l s who formerly dreaded the p o s s i b i l i t y of acquiring a venereal i n f e c t i o n , e s p e c i a l l y s y p h i l i s , have now become indifferent.  Such an a t t i t u d e i s r e l a t i v e l y prevalent among the younger  menc.and women, among boys and g i r l s i n high school and among those who are quite unfamiliar with the serious complications which might r e s u l t from the diseases.  Among older men and women, a respect f o r the disease has  remained. Thus p e n i c i l l i n brought with i t a removal of fear of the venereal diseases; paradoxically, t h i s has been one of the objectives of venereal disease education, but to a somewhat less degree.  In an e f f o r t  to counteract e a r l y venereal disease education, which concerned i t s e l f l  mainly with ghastly i l l u s t r a t i o n s of untreated s y p h i l i s , and with rash  - 67 statements about the infectiousness of the diseases, modern venereal disease education has stressed that venereal disease should be considered as merely another communicable disease and that as such i t should be regarded objectively.  In a d d i t i o n , an e f f o r t has been made to use the  positive approach of exemplifying good health .rather than the negative approach of fearing i n f e c t i o n .  In addition, however, a healthy fear of  the venereal diseases has always been stressed i n t h i s province's educational program; but since the a r r i v a l of p e n i c i l l i n , fear of the venereal diseases among the younger people i s disappearing.  Evidence f o r t h i s  l a s t statement appears s t r i k i n g l y i n interviews with individuals and groups but evidence of a more.material type i s found i n the large number of r e i n f e c t i o n s being acquired a t the present time. In a three month period, February 1 t o A p r i l 30, 194-6, 741 persons, 4-76 male and 265 female, were diagnosed a t the Vancouver C l i n i c (including Oakalla),  "200 (4-2$) of the men are known to have or  have had more than one venereal disease. These 200 men have had a t o t a l of 506 infections which i s an average of 2^- each. once and gonorrhoea nine times.  One man hag had s y p h i l i s  Another man has had gonorrhoea ten times.  "113 (4-2$) of the women are known to have or have had more than one ?venereal i n f e c t i o n .  These 113 women have had a t o t a l of  310 i n f e c t i o n s , which i s an average of nearly three each. had s y p h i l i s once and gonorrhoea nine times."  One woman has  ( l ) Later i n v e s t i g a t i o n  indicated that several more of the patients i n t h i s group had had p r e v i ous i n f e c t i o n s , thus the percentages of r e i n f e c t i o n s are only minimal. Clarke has t h i s to say concerning p e n i c i l l i n i n the t r e a t ment of venereal disease:  "Under p e n i c i l l i n treatment a person can be  cured of gonorrhoea and get a new i n f e c t i o n , a l l i n the period of one week. (l)  As a matter of f a c t , case records i n rapid treatment centres and  D i v i s i o n of V.D. Control, Vancouver, Patients diagnosed a t the Vancouver C l i n i c from February 1, 1946 to A p r i l 30, 1946.  - 68 clinics abundantly show that many patients are infected, cured and reinfected over and over again..." It must be admitted by those who are honest enough to face the known facts, that gonorrhoea has lost some of i t s terror i f &5% of cases can be cured i n a few hours of only mildly uncomfortable treatment, and that fear of infection may not continue to be a potent deterrent to exposure —  i f i t ever was one.  There w i l l have to be other  strong motives for avoiding promiscuous sex relations which spread gonorrhoea, otherwise there w i l l be such an epidemic of gonorrhoea as the world has not seen in modern times.  It i s interesting to note that con-  commitant with -fche introduction of quick easy methods of treatment there has been an increase i n the incidence of gonorrhoea, but just what the relation may be between these two phenomena i s not known at present. "At least i t appears that penicillin has not solved and is not l i k e l y to solve the public health problems of this infection. Its solution must be found i n other approaches to the problem including those which influence the conduct which leads to infection, i.e., sexual promiscuity." ( l ) In addition to the possible influence of penicillin i n removing fear of infection there has been the wide spread distribution, particularly among personnel of the armed forces, of information concerning prophylaxis and early preventive treatment. Prophylaxis and early preventive treatment are undoubtedly effective i n the prevention of infection, but have been criticized as encouraging promiscuity by removing fear of infection from promiscuous exposures.  (In addition, prophy-  laxis and early preventive treatment may build a false sense of security in individuals, and thus be responsible for symptoms being overlooked or discounted by infected persons who made use of these health measures.)." (l)  Clarke, C.W., Penicillin: help or hinderance i n venereal disease control: J.S.H., vol. 31, pps. 601-602.  - 69 It i s impossible to predict the future trend of attitude towards the diseases, but with the indications that strains of p e n i c i l l i n resistant gonoccocci have developed or are capable of being developed, i t i s certain that unless new drugs are developed, the venereal diseases must be considered to be well worth avoiding and at least healthilyfeared.  (1) 6.  Lack of Recreation;  The factor of recreation, discussed earlier, i s seen tobe of importance in the control of venereal disease.  From the individual  point of view, recreation can be a factor predisposing-to acquisition or the avoidance of venereal disease.  either the  If the recreation be  socially and morally acceptable, the chances are that i t w i l l assist in the avoidance of promiscuous sexual contacts; but i f i t be socially and morally unacceptable or doubtfully acceptable,- such recreation may  en-  courage, directly or indirectly, exposure to infection. Which forms of recreation are socially acceptable constitutes a problem which w i l l not be solved here. individual one:  The problem i s an  what might prove to be satisfactory for one person might  be most unsatisfactory for another.  Thus, although the individual, young  or old, requires some recreational outlets, the choice of such recreation, i f i t i s to be applied in the control of venereal disease, cannot be indiscriminate.  Recreation must be constructive, wholesome, and enjoyable. The need for recreation by everyone has long been known,  and some effort has been made to provide organized recreation in special cases:  playgrounds exist for the young, physical recreational courses  for adults, even some industrial plants have recreational f a c i l i t i e s for employees.  These are private-or public contributions:  many more and  many more varieties are required-. (l)  Bahn, J.M., Ackerman, H.., and Carpenter, C.M., Development i n vitro of penicillin resistant strains of gonoccoccus: Proc. Social Experiment.. Biology and Medicine, v o l . 58, pps. 21-2A.  - 70 Organized group recreation sponsored by the community can do much to overcome boredom, and perhaps prevent promiscuous sex exposures, but such recreation i s often shunned by those who do not consider i f to be s u f f i c i e n t l y exciting or who may be too shy to take part.  Among  the g i r l s studied by Lion and his a s s i s t a n t s , i t was found that the "major recreational a c t i v i t i e s f o r the group as a whole were frequenting  bars;  attending movies; public dances, and beach concessions; and read 'pulp romances and detective s t o r i e s " .  1  Recreation such as t h i s can never be  considered constructive or wholesome, but f o r many i t i s a l l that appeals. Unfortunately, unless provisions are made f o r the young, i t w i l l be j u s t such forms of recreation that w i l l serve the coming generations of adults-. A solution i s needed, and at l e a s t a p a r t i a l one i s offered by Fonde:  "The school recreation centre, the playground with adequate  f i e l d house, the church, l i b r a r y , settlement, Y.W.C.A., Y.M.C.A., Scout House, or what have you, w i l l o f f e r every adolescent, with every member of his  family, the chance to exercise and further develop his i n t e r e s t s and  skills —  during a l l of the l e i s u r e hours every month i n the year.  places w i l l be v e r i t a b l e temples of culture and happiness —  These  of games,  music, drama, a r t , and c r a f t s , l i t e r a t u r e , current a f f a i r s , comradeship, congenial grouping, adventure, romance, enthusiasm and creative e f f o r t . " (1) 7.  Lack of Interests;  The r e l a t i o n s h i p between i n t e r e s t s and r e c r e a t i o n i s probably very close;  those who have numerous i n t e r e s t s can f i n d recreation  at almost any time, those who have few i n t e r e s t s , and r e l y on occasional group a c t i v i t i e s for recreation, may become involved i n s o c i a l l y undesirable a c t i v i t i e s , including promiscuous behaviour.  The l a t t e r are more  i n c l i n e d to seek a c t i v i t i e s of any exciting sort to compensate f o r t h e i r (l)  Fonde, C., Modern youth and recreation:  J.S.H,, v o l . 22, ppgs. 2L4-215.  - 71 otherwise d n l l or routine existence. In the case of both men and women, promiscuity may become common i n such instances, and venereal disease may be spread. Dominating interests or numerous interests on the parts of men and women w i l l not alore solve the problem of promiscuity, but combined with other factors they w i l l serve to circumvent some individuals who might otherwise have become promiscuous. 8.  Conditioning Influence of Environment;  Probably at no other time i n history has there been so many opportunities to reach the population in diverse ways; radio, motion pictures, newspapers, magazines, billboards, and numerous other media can be used directly or indirectly for advertising and propaganda. With the development of these media there has been an ever increasing use of "sexflavoured" material;  sometimes obvious, sometimes veiled. - Manufacturers  of cosmetics, soaps, wearing apparel, patent medicines and almost every other marketable product have linked their produce with the sex drive the advertised product i s essential to a satisfactory sexual adjustment. Wylie (l) has stressed this relationship of commercial advertising to sex in a blunt by effective manner. Many of the motion pictures from both the United States and Great Britain are dominated by an emphasis on sex, either by scantily clad women, a specialty of Hollywood, or by risque references, a specialty of London. The complex narratives connecting the sex material are often l i t t l e less than transparent covers for pornographic swamps. The presence of provincial and state censoring officials i n addition to filmdom's own cen- . sor' office i s an. indication of the number of films considered unsuitable for public consumption." Although i t i s true that censor boards do not exist solely for passing judgement on the "moral" content of films, such judge(l)  Wylie, P., Generation of vipers.  - 72 ment i s an important duty. In the case of B r i t i s h Columbia, sympathy can be extended to the Board of Censors who public entertainment.  must approve or r e j e c t a f i l m designed f o r  " A l l f i l m s or s l i d e s to be used i n connection with  any kinematograph s h a l l , before being exhibited f o r public entertainment, be inspected by the Censor, .who  s h a l l determine and pass upon the f i t n e s s  f o r public exhibition of a l l such f i l m s and s l i d e s , with a view to the prevention of the depiction of scenes of an immoral or obscene nature, the representation  of crime or pictures reproducing any b r u t a l i z i n g spec-  t a c l e , or which indicate or suggest lewdness or indecency, or the  infi-  d e l i t y or unfaithfulness of husband or wife, or any other such pictures which he may  consider injurious to morals or against the public welfare,  or which may  o f f e r e v i l suggestions to the minds of children, or which  be l i k e l y to offend the public."  may  (l)  The wording of t h i s section might suggest that only most innocuous films would be shown i n the province, but with the proximity of Canada to the United States, and the strong influence  the  close of  American advertising on the Canadian public, a well advertised f i l m i s assured of a large attendance long before i t s a r r i v a l , e s p e c i a l l y i f the showing of that f i l m might be, with c a r e f u l i n t e r p r e t a t i o n , contrary  to  the Moving Pictures Act. The f i l m s , the advertising of f i l m s , and the private l i v e s of the actors and actresses taking part i n them are factors i n influencing the audience.  I f the influence i s i n the d i r e c t i o n of an  undesirable  stress, on sex, then there i s the p o s s i b i l i t y that some members of the audience w i l l through i d e n t i f i c a t i o n or d i r e c t v i s u a l stimulation, seek promiscuous exposures. (l)  B r i t i s h Columbia Legislature, Moving pictures act, R.S. S. 7.  1924., c.  178,  - 73 It would be d i f f i c u l t to measure accurately the influence of moving pictures and related advertising on audiences, especially juvenile audiences, but Van Waters early mentioned the matter, pointing out cases i n which young persons through emulating their movie heroes and heroines, have faced charges i n juvenile court, (l) Related to moving pictures i s vaudeville, which often degenerates into nothing more than pornography.  The dialogue, action, and  dress i n some vaudeville probably has a much more direct and pronounced effect i n encouraging sexual immorality than do moving pictures.  It i s  significant that both of the theatres that have vaudeville i n Vancouver are i n the immediate vicinity of known bawdy houses and street walkers, and that the one which advertises "burlesque" i s situated i n the same block as some of the city's most notorious centres of vice. Newspapers, too, are open to criticism when they luridly give accounts of "human interest" stories, stories which often include intimate details of sex crimes, divorce actions, and other matters tainted by i l l i c i t sex relations.  I f these stories serve to offer some vicarious  satisfaction to frustrated sadists, they may have some controlling value, but i f they influence anyone, particularly young people, to adopt an undue or undesirable interest i n sex, their continued existence i s not to be condoned. Like the foregoing, many radio programs, comic strips, books, magazines, and other media of entertainment also stress sex, and do so i n a lewd or suggestive manner: many of today's best-sellers are but thinly veiled accounts of sex orgies.  These types of relaxatory  entertainment may be responsible for l i t t l e delinquency among most adults, they may ever serve as means i n which identification may assist i n the release of repressed desires. (l)  With children and youths, however, this  Van Waters, M., Youth i n conflict.  - 74 substitute response may become a substitute stimulus and actually be responsible for over aggressive sex activity contrary to the sex mores. Such sex-laden materials were considered to constitute one of the important factors i n counteracting health education among U. S. Army personell. Larimore and Steinberg describe' i t as "education for venereal disease. Writing of this they stated:  "This i s comprised by the sexually stimu-  lating motion picture, the sex comic strips, the pin-up g i r l s , and the mass use of sex as a selling agent i n certain advertising.  A l l of these tend  to glamorize and romanticize sex and i t s ever-present by-product,' promiscuous sexual intercourse.  Unfortunately, this propaganda for sex  exerts the greatest influence on the younger, more easily impressed groups." (1) Stokes, discussing some of the considerations affecting present day sex problems, states:  "One's chief concern in thinking about  the sex coloring of modern l i f e must be not to forget his own youth, lest he substitute en endocrine atrophic viewpoint for a just psychologic and social appraisal.  The thinning and disappearance of clothes, the r i -  baldries of and near pornographies of 'cheese-cake , beauty parades, and 1  pin-up g i r l s , the.literature of erotic frankness, and the under-the-counter stuff which we have always had with lis can be discussed pro and con, ad infinitum.  Sex i n the barnyard, i n the school out-house, i n the hay-mow,  has been replaced by sex i n the school club, sex i n the all-night theatres, sex on wheels, i n the rooming house, and i n the bush. As c i v i l i z a t i o n takes on a more and more frankly sensuous nature, i t i s to be expected that the mode of dealing with the placement of sex i n human conduct must undergo change." (1) (2)  (2)  Larimore, G.W.- and Steinberg, T.H., ibid., p. 802. Stokes, J.H., ibid., pps. 197-198.  - 75 In Vancouver, a spokesman for one of the churches deplored the ever spreading "sexualization of c i v i l i z a t i o n " .  He stated that the  causes of the high prevalence of venereal disease included: "Photographs in our daily press, almost every edition, of undressed or under-dressed girls i n shameless poses. "Vice-ridden movies with their unspeakable ads'... 'Suddenly nothing else mattered except that she was a woman... and he a man.  'Blazing beacons of desire that led her to the dark brink.'  1  "Lewd magazines:  we are always going to stop them, and  they f i l l our news-stands s t i l l . "Indecent floor-shows... at the regular Cabarets and at the Society Cabarets.  The latter should set a better example than they  do, when they produce their immodest 'leg shows', which are.no less offensive to morality than the lower-type productions of places run for profit. And for weeks ahead, the papers are disgraced with the photographs of the 'fun i n store'.  ... A l l such are incentives to lust."  (l)  This brief discussion has suggested some of the means i n the environment which can and do build undesirable sex attitudes among the population, especially among the young or unstable. However, the population i s for the most part stimulated by not one but a l l of these entertainment media: escape.  i n toto, they exert an influence from which no one can  They, by means of sustained stimulation, sway the population to  a broader and more tolerant attitude towards sex.  Undoubtedly, this has  been of value i n the progress and health of the society, but i t has also been a factor i n the disregarding of the sex mores by some members of society. (I)  Challoner, Monsignor F„, Remarks prepared for panel discussion of venereal disease control, Vancouver, November 16, 19A5.  - 76 When the population i s conditioned by many parts of the environment towards an attitude to sex leading to activities contrary to the mores, a serious problem arises:  the mores w i l l have to be changed,  satisfactory substitute responses w i l l have to be formulated and practised, or the stimuli w i l l have to be changed. 9.  Increasing Disregard for Sex Morest  As has been stated, venereal disease i s transmitted almost entirely by means of sexual intercourse with an infected person, and every infection must come from another infection; thus every acquired infection (omitting prenatal and accidental infections) w i l l show a history of promiscuity on the part of at least one of the two persons involved in a newly reported case of venereal disease.  Since this i s so, the  attack rate of venereal disease in any area i s a reliable index to the amount of promiscuity in that area. On the basis of these observations, i t i s readily seen that the increasing prevalence of venereal disease during the past few years i s an indication of a risingrate of promiscuity.  One objection to  such a conclusion as this i s immediately raised by some health authorities:  they state the.t the rising attack rate of infection i s mainly due  to improved reporting on the part of private physicians; to improved self-referral of persons who may have been exposed to infection (due to increased knowledge of the diseases); to improved case-finding; and to population increases.  One must agree that these reasons are of some value  in explaining the rise i n the number of reported infections, but there i s a general rise of attack-rate throughout the nation, and in c i t i e s , towns, and villages where there i s a population increase, the rise in the reported attack rate is usually above the expected rise due to populational i n crease.  - 77 A popular misconception i s that returning of the armed forces i s responsible f o r the spread of many i n f e c t i o n s , but i t should he remembered that members of the armed forces have a complete examination before being discharged,  i n addition to periodic examinations f o r venereal  disease: thus men returning from overseas, even though infected, would not constitute a serious i n f e c t i o n sotirce problem, even though reports from the European Countries indicate that v e r e a l disease i s rampant.  (It i s  of course possible that some of the infections acquired overseas are not discovered, and are transmitted i n Canada, but these are few.) The matter of improved reporting by private physicians probably accounts f o r part of the increase, but i t i s d i f f i c u l t to bel i e v e that a large number of physicians who were.lax during previous years of practice would suddenly cooperate with the health aiithorities and begin reporting i n f e c t i o n s .  (Physicians, however, who have been i n the armed  forces and are being discharged,  w i l l probably report a l l i n f e c t i o n s com-  ing under t h e i r care, take routine blood t e s t s , and perform any other measures required i n the c o n t r o l of venereal disease that are asked of them —  they probably w i l l cooperate i n t h i s way because of the stress  l a i d on venereal disease c o n t r o l i n the armed forces.  At the time of  writing, however, these younger physicians have not had s u f f i c i e n t time i n private p r a c t i c e , or have not been discharged make a marked impression titioners.)  i n s u f f i c i e n t numbers to  i n the number of cases reported hj private prac-  The matter of improved case f i n d i n g i s of some importance,  because public health nurses a l l over the province are lendi.ng t h e i r assistance i n the finding of contacts to known or suspected i n f e c t i o n s and are having those contacts examined, and where necessary, treated.  The  l a s t point i s that persons who-may have been exposed to infections are reporting to private physicians and c l i n i c s more often than i n the past  —  - 78 with an increased stress on education, t h i s i s hoped to he so, hut +here i s no s t a t i s t i c a l proof as 3 et. r  In conclusion, then, i t i s suggested  that despite the  objections of so""? authorities to the b e l i e f that the s t c t i s t i c a l increase 1  i n the prevalence of venereal disease i s not a true one, the increase i s a true one and t h r t the spread of venereal disease i s , i n r e a l i t y , becoming more and more serious.  I f this conclusion and the long established  b e l i e f that the venereal dicerse attack rate i s a r e l i a b l e index'to the amount of promiscuity i n an area be accepted, then promiscuity i s increasing  rapidly. Promiscuity, i n turn, i s rn i n d i c a t i o n of a disregard  for  the'sex mo^es, and p a r t i c u l a r l y f o r the mores that p r o h i b i t sexual  intercourse out of wedlock. this:  But promiscuity i s only one i n d i c a t i o n of  i n addition, there i s evidence that t h i s p a r t i c u l a r sex mores i s  frequently di sre^arded by young men and women i n sex a c t i v i t y confined to the two persons.  Just how many of these l a t t e r mentioned cases there  are can he only a conjecture.  Questionnaires or the subject are open t o  serious c r i t i c i s m ; what r e s u l t s they do given can be considered as only un absolute minimum.  For example, i n a questionnaire cvirvey concerning  the sex l i f e cf'women, Davis found that only 7.If' admitted premarital sexual intercourse. Davis ar'-its that "Our owr. judges :r.t would he that the figures given on the questions r e l a t i n g to eroticism may be taken as a minimum f o r the group studied."  ( l ) The group studied i n t h i s  case was a superior one, and not a f a i r sampling of the adult female population, The matter of the disregard f o r the sex mores i s of importance i n the venereal disease problem, whether an i n d i v i d u a l confines his (l)  sexual a c t i v i t y to one other person or whether that i n d i v i d ^ s ! i s Davis, K.B., Factors i n the sex l i f e of twenty-two hundred women, p. x i v .  -  79  -  promiscuous, because he or she usually does not know anything about the' health of the partner. Parents are interested In the children's disregard of the sex mores for other reasons i n addition to the possibility of acquiring  infection, but i n no::t cases, they believe that these mores arc being  broken by persons outside their own families.  To suggest tc r.cst parents  that their children, at any age, may be talcing part i n " i l l i c i t " sex relations would bo considered as an insult, yet on the basis of the venereal disease attack rate alone, i t can be seen that i l l i c i t sex relations are more prevalent that most parents realize. In considering the disregard of the sex mores as a factor  i n the spread of venereal disease., a question arises?  do the mores  command obedience from a large part of the population because thoy are moral laws, or because other more influential factors are present which increase or decrease the effectiveness of the mores as a means of con- . trolling the population? For some individuals, i t i s somewhat, futile to suggest that disregard for the mores i s at any time increasing or decreasing. However, since the mores are imposed upon the entire population, increasing  disregard fDr them can be considered as a factor i n the spread of  venereal disease, and, at the same time, as a challenge to interested individuals and organizations to attempt to enforce.them.  If they were  enforced, obvious!}' the attack rate of infection would decrease. Churches differ i n their attitudes;  some recognize the  prevalence of moral infractions, and agree that although they are to be discouraged, they are committed and health information should be available* others insist that to admit the prevalence of moral infractions i s to indirectly condone them;  health information can be given under  - 80 s p e c i f i e d conditions but continence i s the only true prophylactic. Certain i t i s that most health a u t h o r i t i e s recognize the importance of the moral f a c t o r i n the c o n t r o l of venereal disease. However, health authorities do not accept the r e s p o n s i b i l i t y of teaching morals to the population:  as was pointed out i n an e d i t o r i a l i n the  Canadian Journal of Public Health:  " I t i s true that emphasis has been  placed by public health a u t h o r i t i e s on me%*hods of c o n t r o l apart from moral control, but t h i s does not n e c e s s a r i l y mean that the importance of moral r e s t r a i n t i s not appreciated; rather, that the r e s p o n s i b i l i t y f o r moral i n s t r u c t i o n i s not a function of the health department. primarily the dntj  Moral teaching i s  of the Church and of parents and children; and i n t h i s  e f f o r t a l l the resources of the community, including the press, should be utilized...  The control of venereal disease cannot be achieved by public  health measures alone." 10.  (l) Wartime Philosophy:  Homes temporarily broken, an abnormal amount of transiency, d i s r u p t i o n of normal family l i f e , s o c i a l unrest, are a l l present to some degree during war time, and one of the r e s u l t a n t effects i s seen i n the war time increase of promiscuous sex r e l a t i o n s and venereal disease. This increased attack-rate of venereal disease becomes more s i g n i f i c a n t when i t i s remembered that during war years, various precautions which are normally disregarded, are enforced.  In the l a t e war, f o r instance, such  measures as education, prophylaxis, suppression of p r o s t i t u t i o n and  the  placing of f a c i l i t a t i o n premises out-of-bounds f o r the armed forces were taken to a s s i s t i n maintaining a p h y s i c a l l y f i t armed force and a product i v e home front; yet a l l t h i s d i d not prevent a serious upsurge i n the venereal disease attack r a t e . (l)  D e f r i e s , R.D., The importance of the moral f a c t o r i n the c o n t r o l of venereal disease: C.J.P.H., v o l . 32, p. 367.  - 81The factors involved i n t h i s upsurge are obviously complex, but one which arises pronouncedly during war time i s the reaction of the people to tensions of various forms.  Tension, psychological or physio-  l o g i c a l , may be released by sexual a c t i v i t y .  This being so, the combination  of other factors with the war time tensions o f f e r s an explanation f o r the increase i n venereal disease during the war years, and the following years of reconstruction. During the recent war, a new phenomenon appeared, the Victory G i r l .  She usually was nothing more than an adolescent or young  woman who devoted herself to the task of furnishing erotic enjoyment to men of the armed f o r c e s . promiscuous: perience.  These V i c t o r y G i r l s were u s u a l l y completely  f o r them promiscuity was a core or less indiscriminate ex-  The explanations offered by many of these young women f o r t h e i r  conduct often are r a t i o n a l i z a t i o n s involving the duty of g i r l s to keep the boys i n the armed forces happyj a l l such r a t i o n a l i z a t i o n s , however worded, not only exonerate the g i r l from any c r i t i c i s m but laud her f o r her sexual promiscuity. In addition to the appearance of these self-admittedly promiscuous g i r l s there was a r i s e i n promiscuity among the remainder of the population.  Whatever the true factors were which predisposed  this  r i s e i n promiscuity, a common explanation came from the individuals involved: 'during times of stress, one never knows i f one must leave tomorrow, probably to face dangers and deathj therefore i t i s advisable to have some pleasure while one can'.  This explanation and those s i m i l a r to i t are no  more than expressions of pessimistic hedonism. Larimore and Sternberg i n t h e i r study of 8,000,000 men i n the U.S. Army, considered t h i s a t t i t u d e as one of the important f a c t o r s influencing motivation to avoid venereal disease.  They c a l l e d i t "war  - 82 psychology":  " I t i s the same mass reaction that has brought about an  increase i n juvenile delinquency and a flood of the so-called 'Victory Girls'.  B a s i c a l l y of course, t h i s prevalent trend i s to a great extent  a current v a r i a n t of the old 'eat, drink, and be merry' proverb of long standing, accentuated  through a wartime release of i n h i b i t i o n s .  Trans-  lated into terms of our problem (the teaching of soldiers to avoid venereal disease), we observe men  throwing aside what they have been  taught i n a burst of so-called l a s t f l i n g a c t i v i t y , or giving vent to a flood of pent-up emotions upon returning from the months of arduous and often dangerous duties",  (l)  This pessimistic hedonism i s both a predisposing f a c t o r i n the spread of venereal disease and a r a t i o n a l i z a t i o n s to explain behaviour brought about by other f a c t o r s . To what extent i t i s a predisposing f a c t o r or merely a r a t i o n a l i z a t i o n would be d i f f i c u l t to determine, but i t does appear that during times of s o c i a l unrest, i t a r i s e s prominently  to r e f l e c t the tensions among the population, and.thus becomes  a factor i n the r i s e of promiscuity and the spread of venereal disease. 11. Mental Q u a l i t i e s of Infected Persons: The i n t e l l i g e n c e , as determined by various i n t e l l i g e n c e t e s t s , of infected persons has received comparatively  l i t t l e attention.  Various surveys of i n t e l l i g e n c e have been made i n c l i n i c s , prisons, and other i n s t i t u t i o n s , using patients and p r o s t i t u t e s as subjects, but unfortunately, no such surveys have been made of venereally infected persons i n B r i t i s h Columbia.  The information available i s from elsewhere.  Kemp, w r i t i n g of h i s findings among 530 p r o s t i t u t e s i n Copenhagen, found that"J'23.2$ were s l i g h t l y retarded, 19.1$ (dullards) 6.8$ 22,5% (l)  retarded  s l i g h t l y feeble-minded .(debite morons) and 0.8$  imbeciles:  were pronounced psychopaths, 7.9$ had other mental diseases such as Larimore, G.W.,  and Sternberg, T.H.,  i b i d . , p.  802.  - 83 demention p a r a l y t i c a , h y s t e r i a , cyclothymic temperament or schizoid tendencies, pronounced nervousness, neurasthenia, marked p s y c h o - i n f a n t i l ism, climacteric insanity, dipsomania or psychogenic depression of a more or less t r a n s i t o r y nature... defective i n t e l l i g e n c e " ,  Only 29.4$ were mentally normal and without  ( l ) Kemp also reports various other European  studies of prostitutes and states, "The majority of writers on the subject have therefore found that over 50% of a l l prostitutes must be classed as backward, d u l l , or feeble-minded".  (2)  At the Midwestern Medical Centre i n St. Louis, Missouri, a group of f i v e hundred venereally infected females were given i n t e l l i gence t e s t s .  "The i n t e l l i g e n c e of the patients was determined by the  Beta Test, Form A and B, of the Otis Series ( f o r grades IV to-IX) to r e duce the l i k e l i h o o d of reading d i f f i c u l t i e s that a more advanced of test might cause.  form  Furthermore, preliminary study revealed that the  majority of the group f e l l between the fourth and ninth grades l i m i t s i n t h e i r educational achievement.  That this decision was sound i s seen  i n the f a c t that none of the group 'cracked' the t e s t and only one of the patients was able to approach that point."  (3) Of the 500 females, 34-0  were white cases f a l l i n g at 20 years and 10 months (4 months greater than that of the Negroes and 2 months grerter than that of the group.) A l l the patients were admitted between February and August, 1944- and a l l had been approached by community health authorities and directed to the Centre f o r treatment.  (No voluntary patients were included i n the study.)  "The mental a b i l i t y of both the white and Negro patients was found to be well below normal.  The median i n t e l l i g e n c e quotient f o r  the 34-0 white cases was found to be 84-, whereas the 160 Negro g i r l s showed a median I.Q. just below 70... (1) (2)  Approximately 24$ of the (whites)  Kemp, T., Physical and psychological catises of p r o s t i t u t i o n , p. 4.8. i b i d . , p. 50. (3> Weitz, R.D., and Rachlin, H.L., The mental . a b i l i t y and educational attainment of f i v e hundred venereally infected females: J.S.H., v o l . 31, p. 300.  - 84 and 51$ of the (Negroes) showed defective i n t e l l i g e n c e " ; i . e . I.Q. was below 70.  Only 63 of a l l the patients, or 12.6$ reached or exceeded  a 100 i n t e l l i g e n c e quotient; of these 63, 56 were whites and 7 colored.  were  "In other words, approximately 16$ of the white g i r l s and 4-$  of the Negroes reached or exceeded the r i d point of the normal mental a b i l i t y range, ( l ) • In another study a t the Llidwestern Medical Centre, Rachlin made a study of 304 consecutive unselected patients. of t e s t s , the Stanford-Binet  "Two sets  (Termar-Merrill Revision, form M) and the  Otis Beta B, were given to two separate groups.  The Stanford-Binet.  vc.3 given to a group of 93. The Otis B was given to a group of 200... On the Stanford-Binet, Form 11.  f  the patients achieved  age of 11 years 2 months, and a median  of 75.3,  a median mental on the C t i s the  r e s u l t s were somewhat higher, as they usually are i n a group t e s t . I n the l a t t e r they achieved a median I.Q. of 80.3...  This reveals that we  are dealing i n the main with the i n t e l l e c t u a l l y i n f e r i o r i n d i v i d u a l s i n the community."  (2) Among 100 v i o l a t o r s of the ?.2ay Act committed to a fed-  e r a l reforaatory f o r women, only eight showed normal i n t e l l i g e n c e . (I.Q. 90-110).  Sixteen were c l a s s i f i e d d u l l normal (I.Q. 80-89), eleven  borderline defectives ( i . y . 70-79), f i f t y - s e v e n morons (I.Q. 50-69), and eight as imbeciles (i.W. under 50).  (3)  The r e s u l t s c f these studies of p r o s t i t u t e s and venerea l l y infected female c l i n i c populations cannot be generalized to apply to a l l prostitutes or a l l venereally infected females, f o r the obvious reason that prostitutes apprehended by the p o l i c e and female c l i n i c patients do not necessarily constitute f a i r samplings of the respective t o t a l groups.  I t i s the non-representative  samplings i n c l i n i c  that make any generalized conclusions open to question. (1) i b i d . p. 301. (2) Rachlin, H.L., i b i d . , p. 266. (3) Hironimus, H., i b i d . , p. 32.  studies  -  85 -  Airong venereally infected men i n the armed forces, some studies have been made of p s y c h i a t r i c f a c t o r s , and the results tend to agree with those found i n c l i n i c studies.  In the armed forces, the  opportunities of comparing studies of infected personnel with a control group are better than i n c i v i l i a n l i f e * thus, conclusions more s a f e l y generalized  obtained can be  than those obtained from studies of c l i n i c  patients.  Watts and Wilson i n t h e i r Canadian Army study found that 43$ of the venereally infected group compared with 5% of the control group had been referred to the p s y c h i a t r i s t (for reasons other than being i n f e c ted.)  "Ninety-five percent of. the men i n the V. D. group who had been  p s y c h i a t r i c a l l y examined were found to have emotional or i n t e l l i g e n c e handicaps e x i s t i n g i n a chronic state.  This handicap was s u f f i c i e n t to  lovcer t h e i r categories and s e r i o u s l y impair t h e i r usefulness to the Army. Approximately one-half of those referred f o r p s y c h i a t r i c examination were discharged from the Army with a diagnosis  of psychopathic personality..."  (J) In a somewhat similar•study of 200 infected men i n the U.S. Army, Wittkower and Cowan had a control group of 86 skin cases.  These  investigations found a much higher percentage of immature p e r s o n a l i t i e s among the infected men than among those i n the control group.  They also  found a much higher percentage of criminals and heavy drinkers i n the i n fected group.  (2) These various  studies suggest that the mental a b i l i t y  and adjustment of the i n d i v i d u a l are fundamental factors i n the venereal disease problem.  The i n t e l l i g e n c e and adjiistment of the i n d i v i d u a l are  important not only ss factors predisposing  to the a c q u i s i t i o n of i n f e c t i o n ,  but also as factors i n the continued existence, hence the spread of venereal disease. (1) (2)  This l a t t e r  point has been stressed by Fessler i n his  Watts, G.O., and Wilson, R.A., i b i d . , p. 120. Wittkower, E.D., and Cowan, J . , Some psychological aspects from promiscuity, Psychosomatic Medicine, v o l . 6, 1944.  .- 86 consideration of defaulters from treatment.  He states;  regarded usually as persons with antisocial tendencies.  "Defaulters are I t seems that i n  •the majority of cases these antisocial tendencies are the outcome of a subnormal mentality." ( l ) On the basis of these observations, i t can be seen that the intelligence of the individual, a factor seldom mentioned i n discussions of venereal disease problems, i s of importance i n the control of infection.  Fessler adds, "As general experience has shown l i t t l e can be  expected from the imposition of a fine or even from imprisonment (of subnormal infected persons).  It i s suggested, therefore, that we. should  approach the problem of the defaulter — or, to use a wider term, the problem of the uncooperative venereal disease patient-psychologically." (2)  Possibly a further step can be taken:  the psychological approach  might be applied, not only to the control of infection, but also to the prevention of exposure to infection.  Some action has been taken i n study-  ing the possibilities of this approach, for example by the San Francisco Department of Health, but far more work w i l l have to be done. 12.  Promiscuity as a Compensatory Response;  That promiscuity, i n many cases, i s an adjustment mechanism has been stressed by many authorities.  The study made at the  San Francisco Department of Public Health by Lion and his assistants (3) substantiates this viewpoint.  They classified the promiscuous patients  according to motivation of promiscuity.  (lO (2) (3)  a.  Affectional group — Promicc\iity i s primarily an expression' of affection. (10$)  b.  Episodic group — Promiscuity i s an episodic, circumstant i a l experience. (20$)  Fessler, A., Sociological and psychological factors i n venereal disease: London, The British Journal of Venereal Disease, v o l . 22, p. 22. ibid., p. 27. Lion, E.G., ibid.  - 87 -  c.  Habitual group — Promiscuity i s a habitual and more or less indiscriminate experience. (57$). 1.  g  d.  Non-conflictional group — Promiscuity i s a. means of satisfying sexual desires and presents no known conflicts within the patient or between her and her social group. (5$ of the total group or 8$ of the Habitual group).  2.  Dependent group — Promiscuity i s an expression of dependency and immaturity causing relatively few concerns since responsibility for behaviour is placed on sexual partners. (9$ of the total or 17$ of the Habitual group).  3.  Conflictual group — Promiscuity i s an expression of intra-psychic conflicts. (28$ of the total or A9$ of the Habitual group).  4.  Maladapted group — Promiscuity i s an expression of maladapted behaviour characteristic of the unstable patient who lacks social responsibil i t y and self restraint. (11$ of the total or 19$ of the Habitual group).  5.  Undetermined group — Basis for promiscuity i s undetermined, although promiscuitjr i s known to be habitual and more or less indiscriminate. (4$ of the total or 7$ of the Habitual group).  Not Classified — Motivation for promiscuity was not classified either because the patient's story was questionable or because there was insufficient information. (13$). In this study, an arbitrary criterion was set up to  differentiate promiscuous from non promiscuous females.  Promiscuous  patients were diagnosed.as* 1.  Married women who had engaged i n any exfeaiaarital sexual relations within six months prior to registration i n the Psychiatric Services.  2. " Single women who had engaged i n sexual relations with more than one man within the six months preceding registration. 3.  Single women who had engaged i n sexual relations with one man more than twice within the same period. A distinction was made between those patients who were  •habitually promiscuous and those who were not.  Patients who did not f i t  into the above definition, or who were considered likely because of  - 88 personality and situational factors to become promiscuous during a year's period following their registration, were classified as 'potentially promiscuous . 1  In addition, those patients who were not promiscuous or  were unlikely to-become so, were classified as 'not promiscuous . 1  This criterion of promiscuity i s somewhat different from the one used i n this paper, but the essential difference i s the inclusion of single women who prior to registration had engaged i n sexual relations with one man more .than; twice within a six months period.  How-  ever, this difference w i l l not interfere with the discussion at this time, because only the Habitual group i s involved, and i t would not include these g i r l s . Two groups i n the San Francisco classification serve to reinforce the suggestion that promiscuity i s often an adjustment mechanism!  these are the Conflictual and the Maladapted groups, both sub groups  of the Habitual group. Probably some of the patients included i n the Episodic and Dependent groups could also be considered, but this would require a complete reclassification. In the Conflict group, "Promiscuity was an expression of intra-psychic conflicts, usually of a sexual nature, among one-half of the habitually promiscuous g i r l s .  Promiscuity was a symptom of personality  maladjustment, and neurotic disturbances were present from a mild to marked degree. There was no homogeneity among the patients as far as psychosexual development was concerned; some patients had remained at an infantile level whereas others were relatively mature i n their emotional development..." ( l ) Among this group of patients unmistakable neurotic symptoms had occurred.  It was noted that on some occasions the patient  would show, instead of neurotic symptoms, an outbreak of promiscuity. (1) ' Lion, E.G.,  ibid., p. 37.  - 89 In t h i s case i t seemed as though promiscuity were a neurotic equivalent. Promiscuity appeared to be one way of attempting ing the repressed sexual perturbations.  to solve c o n f l i c t s concern-  For a time expression of these  c o n f l i c t s would be held i n abeyance, but under c e r t a i n conditions of stress they would p e r i o d i c a l l y surge f o r t h to the point that promiscuity would develop, ( l ) In the Maladjusted  group, "promiscuity was an expression  of non-adaptability among some of the patients where r e s t r a i n t in. personal behaviour was either lacking or so poorly developed as to be inoperative i n the face of inner drives and Environmental s t i m u l i .  The outstanding  personality c h a r a c t e r i s t i c s of patients i n this group were extreme emotional i n s t a b i l i t y , lack of s e l f - r e s t r a i n t , faultj^ judgement, impulsiveness, i n a b i l i t y to assume r e s p o n s i b i l i t y . s o c i a l controls.  There was a disregard f o r  H o s t i l i t y and d i s t r u s t were u s u a l l y present, and i n  some instances there were strong paranoid tendencies.  In carrying out  their d e s i r e s , and i n behaving according to t h e i r impulses,  these patients  disregarded the f e e l i n g s of others and frequently exploited others.  Poor  personal r e l a t i o n s h i p s were conspicuous, and the relationships that were established were not l a s t i n g . psychopathic  In the extreme of t h i s group was the  personality, alth.ou.gh not a l l patients within the group were  diagnosed as such. "Pror.iscu.ity was only one expression of the non-adapta b i l i t y which had been characterized since early childhood.  Difficulties  with authority were evident from the number of juvenile court, j a i l and I n s t i t u t i o n a l experiences  among patients i n t h i s group."  (2)  Here then has been an outline of some p o s s i b i l i t i e s of promiscuity manifesting i t s e l f as a compensatory response, d i r e c t or i n d i r e c t , and often as only one small part of a gross compensatory response. (1)  Lion, E.G., i b i d . , p. 37.  (2)  Lion, E.G., i b i d . , p. 41.  - 90 -  Chapter VI;  Factors Involved; 1.  Early l i f e of individual.  Home Life:  Of a l l the factors associated with the acquisition of venereal disease through promiscuous behaviour, none i s mentioned more often by investigators that the early home Influence on the individual concerned.  Actually the statement can be made much broader i f promiscuity i s  considered as a form of delinquency, end i t can be said that th-> early home influence i s the most important contributing factor to delinquency and crime. In surveys of sexual deli.nc_u.ents, which are of course made after the delinquency has appeared, an analysis i s made, and come common factors are assumed to be the ones responsible for the delinquency. Such a method of determining the factors involved could probably be greatly improved or revised, but i t does offer a relatively quid: method of determining some of the more obvious factors. Generally, the assertion i s made that poor homo conditions are primarily responsible for the development of delinquency, but "poor home Conditions" appears to he a label capable of almost any interpretation. What actually constitutes poor home conditions i s a complex problem; i n addition to the need for economic security, social adjustment, and an acceptable moral standard, the manner of living of the parents i s of great importance i n judging whether the home i s "good" or "bad". Some of the factors involved i n evaluating the home conditions can at least be estimated "by an investigators  the economic standard can ho judged; the moral stand-  ard may be indicated by church a f f i l i a t i o n and attendance (and by other means); and the social standard can probably be evaluated from data of club affiliations, neighbourhood gossip, and other means.  -  91  -  Adjustment of tho parents to each other and to their children is often almost impossible to estimate without prolonged and objective observations.  A casual observer visiting the home once or twice  could conclude that conditions were very satisfactory when, i ~ reality the parent's adjustment was most unsatisfactory.  The concealing of the actual  adjustment difficulties from an. investigator mi^ht well be unintentional i f parents and children did not recognize the factors involved. The foregoing brief discussion i s given .only to suggest that possibility that many homes of delinquents might be classified as "good" or "satisfactory" on the basis of partial investigation,. whereas they might rate only as " f a i r " , "unsatisfactory" or "poor" i f a careful investigation were made*  and similarly, homos rated as "unsatisfactrry" ,  or "poor" might equally unwarrantably be raised to a higher bracket. Rappaport in discussing her work with prostitutes in Baltimore points out:  "It seems clear that the homes from which they  (the prostitutes) have cone have not raade i t possible for them to begin to solve their problems there. i t is a subtle one.  There i s an economic base for prostitution but  Girls do not prostitute, we find, so much because they  need money to live one —  but rather they get into d i f f i c u l t y because there  has not been enough sound substance in their, lives and in the lives of their families to help them become useful citizens to live as happy and free people, creating something- i n their -work and;.play." Fraser (2),  (l) .  whose unpublished survey of f i f t y consecutive  cases of early syphilis treated at the Vancouver Clinic i s a pioneer effort in this field, in B. C , did careful case work' studies on each. Her study, the survey made in the San Francisco Clinic, and many other studies on promiscuous women agree that the home l i f e of the individual, especially in the early years of l i f e , i s the most important factor in the formation (1) (2)  Rappaport, M.F., Towards a new way of l i f e : Fraser, J., ibid. '  J.S.H., vol. 31,  p.  59A.  - 92or prevention of delinquent sexual behaviour leading to the acquisition cf venereal disease. In the case of the San Francisco Clinic patients, "no appreciable differences were found between the promiscuous patients and those potentially promiscuous as regards family background. A majority of patients i n both groups cane from families of marginal incomes, some of whom had received public or private assistance during the depression years. Lack of social and economic advantages was characteristic of a majority of the group... "Family disorganization was characteristic i n the case histories.  Approximately 4-0$ of the patients' parents were married and  living together, although among these many had marital d i f f i c u l t i e s , including separations followed by reconciliations.  Among 60$ of the patients,  parents were either separated, divorced, or deceased.  In many of these  broken homes the parents had remarried one or more times.  In a few instan-  ces the patients had no knowledge of their fathers, and illegitimacy of the patients was known or suspected.  To this story of broken homes there  was the sequel of placement i n boarding schools, foster homes, or i n the homes of relatives for varying periods of time. "The effect of broken homes was evident i n a majority of cases, especially i n those instances where the parents had remarried and patients had been reared i n homes with stepfathers or stepmothers. The patients reported d i f f i c u l t i e s i n adjusting to successive changes i n the family pattern. Inconsistencies i n training and discipline were frequently the result of constant shifting from the care of one parent to that of •another.  Divided loyalties between parents who were incompatable were  common. Emotional ties to one parent and rejection of the other were frequently seen.  In some instances there was an absence of loyalty to the  - 93 family group and affectional ties to any member of the family.  Those  patients whose familial pattern was most disrupted were more inclined to express strong preferences for one parent or another during childhood. Many who preferred their fathers i n childhood identified themselves with men and rejected women and their own feminine role. "Most patients had siblings, the number ranging from one to twelve.  Among the broken homes there were frequently step and half-  siblings, in addition to f u l l siblings.  Except i n a few cases, birth  order did not seem to be an important factor i n the patient's psychological development or in their promiscuity.  Sibling rivalry was present i n many  instances but seemed to be important only i n the presence of other factors such as rejection by parents and preferential handling of siblings. "Patients who experienced material and social deprivations during childhood due to limited family resources were inclined to feel less privileged than their companions and schoolmates, and frequently feelings of inadequacy and insecurity developed out of such situations.  Economic  deprivations during childhood affected the personalities of some patients and was a remote contributing factor in their promiscuity. "Approximately $0% of the patients had unresolved conf l i c t s regarding their families.  This was observed among patients who had  been away from home several years as well as among those who were living with their families.  In the instances where familial conflicts were  most pronounced, there was a strong feeling that parents had been too strict and repressive regarding sex and companionship with boj'-s i n the cases where the family l i f e had been unstable and the patient had been entrusted to the care of f i r s t one person and then another."  - 94  —  Eraser's study concludes:  "The family i s the funda-  mental unit of society and i t i s the basic training in the family group which determines in which direction the child w i l l go.  Every child has a  deep seated emotional urge to belong in a normal family with two parents living in harmony together, having an adequate income and opportunities for recreational and social activities.  He has a natural desire for affec-  tion, security, approval and recognition i n his home. The family group is a complex relationship of different individuals and the anti-social behaviour trends which sometimes develop in i t s members are frequently a symptom of conflicts, frustrations and disappointments which were suffered during childhood."  (l) In a survey of the early lives of prostitutes from a l l  parts of the world, i t was noted that "the general impression of the homes and childhood of the women... i s that their moral environment was less favorable than their material environment.  It i s true that only a minority  appear to have had parents who were comfortably well off, but .the majority came from ordinary working-class.families and only a small percentage from the most poverty-stricken section, of the community. The moral atmosphere i n which the children grew up was on occasion actively harmfulj far more often though, i t was simply defective or unsuitable.  This was due some-  times to neglect or lack of control, sometimes to excessive strictness. Often the homes were troubled by disagreement between the parents or between the parents and children; this occurred frequently when there was a step-parent. "A considerable fraction of the women were brought up in homes, by relatives or by strangers, and many more were brought up by only one parent.  About 45$,  parents before they were 14. (1)  in fact, said that they had lost one or both This does not necessarily mean, of course,  Fraser, J., ibid., p. 17.  - 95 that they were a l l neglected: some indeed, are said to have had good homes, but a feature that recurs so constantly cannot be disregarded."  (l)  Among c l i n i c patients, male and female, and p r o s t i t u t e s , the early home l i f e has been observed to be a f a c t o r predisposing to t h e i r l a t e r promiscuity (or probable promiscuity.) men  Among venereally infected  included i n a study made i n the Canadian Army, i t was  of the infected men, compared with 18$ of the men had had an 'abnormal childhood environment : 1  found that  36$  i n the control group,  "'the term 'abnormal c h i l d -  hood environment' i s intended to include cases where at least one of the parents was dead, or was markedly unstable emotionally, or where there was  separation or divorce".  (2)  Thus i t i s with a l l studies of the early l i v e s of i n fected i n d i v i d u a l s :  the early home l i f e i s a f a c t o r i n the spread  of  venereal disease. The common conclusion of a l l surveys i s stated by Fraser i n her own  study at the Vancouver C l i n i c :  "From our study of the  home l i f e and family background of f i f t y young persons with new  syphilis  i n f e c t i o n s , we f i n d that the basic d i s a b i l i t i e s are the same and t h a t the roots of t h e i r present behaviour are i n their home t r a i n i n g and family (3)  relationships where both p h y s i c a l and emotional needs were lacking." 2.  Parental Maladjustment:  I t has been pointed out previously that some se:cually delinquent c h i l d r e n are reared i n broken homes or i n homes i n which the parents are incompatable.  Broken homes, however, are often concommitant  with or a c t u a l l y preceded by serious maladjustment on the part of the (1) (2) (3)  League of Nations, P r o s t i t u t e s : .their early l i v e s , p. Watts, G.O., and Wilson, R.A., i b i d . , p. 120. Fraser, J . , i b i d . , p. 17.  36.  parents.  - 96 Fraser, in her study at the Vancouver Clinic, states: "It i s known that one or both parents of seventeen girls and five boys, and there may be cany more, have for many years continually exhibited" anti-social and immoral conduct before their children..."  (l) Such con-  duct included extra-marital sexual relationships, alcoholism, prostitution, boot-legging, incest, and various other types of criminal behaviour. A study of 100 May Act violators committed to a U.S.  •  reformatory for women reported that "the social histories are replete with recitals of domestic d i f f i c u l t y in the parental background. Fortythree came from broken homes, and i n many of~these, as well as in the other cases, delinquency, alcoholism, neglect and cruelty were common... In many instances the mother i s reported to have been sexually promiscuous, cohabiting with various men and rearing illegitimate children in the home."  (2) These and other available studies stress the influence  of home l i f e and parental adjustment on the child who later acquires a venereal disease or is promiscuous. justment are often equivalent.  The home l i f e and the parental ad-  Both are important i n the development of  the child; i f one or both i s unsatisfactory, there i s a potential threat that the child w i l l be maladjusted and perhaps manifest his maladjustment in the form of promiscuity. 3.  Ipnorance,:  As a result of the ever-increasing publicity being . given to the venereal diseases, relatively few persons are totally unaware of the existence of these infections or know nothing of their nature and mode of transmission.  However, there are s t i l l many persons who, for one  reason or another, have a dearth of information and make no effort to obtain more. When such persons are parents, their children w i l l be just (1) (2)  Fraser, J., ibid., p. 13. ' Hironimus, H., ibid., p. 32.  as ignorant, until the information i s acquired from soir.e other source. At tho present time, most children who graduate from, high school do receive at least a smattering cf information about the venereal diseases from reliable sources, and judging from various (Surveys made, these children are less prone to infection than those who do not But i f venereal disease education i s to be of any  attain graduation.  value, i t must be given to a l l children, and particularly to those who do not reach the high school level.  This does not imply that the information  should be given i n the earliest school grades, nor that i t should be given before a child i s physiologically eld enough to comprehend i t .  But i t  does iniply that there should be. some individual or organization that, w i l l give adequate, factual, and wholesome information to children at an age. when i t can be understood. Of the various institutions available for educating the juvenile public, the home, school, church and youth organizations can a l l serve a purpose* but only one of these institutuiions can reach the greatest part of the juvenile population at a suitable time, and that i n s t i tution i s the home.  If the parents were well versed i n the facts about  venereal disease, and would pass on those facts to their children, ignorance and possibly promiscuity,would decline. However, such postulation i s not entirely warranted: those parents who do give information about these infections to their children, probably also guide them carefully i n most other matters dealing with adjustment to the environment, and particularly i n social adjustment so far as sex i s concerned. From c l i n i c a l Records of interviews with young persons acquiring infection, i t i s observed that they themselves had l i t t l e factual information concerning the venereal diseases, and what they did obtain was from unreliable sources, usually friends or acquaintances.  — 98 In almost no caso i s their evidence that information was given by parents; frequently, indeed, there i s evidence that the parents themselves were ignorant. Ignorance of factual information concerning the venereal diseases i s often cited i n pamphlets and lectures on the subject as one of the major reasons for the prevalence of venereal disease. However, a l l that i s probably necessary for a lay person to know.is that syphilis and gonorrhoea exist, that they are transmitted from one person to another usuallyrby sexual contact, and that they can be detected and successfully treated by competent physicians. Extensive knowledge of the infection i s in i t s e l f no guarantee of immunity: serve as ample evidence to this.  the records of the Armed Forces  That the number of venereal infections  among members of the Armed Forces has been the lowest i n history i s not a reliable indication that the intense venereal disease education given to them actually prevented many infections, because mechanical and chemical prophylaxis was an integral part of a l l such education.  It is  quite pbssible that many persons ore motivated by fear of the infections and thus abstain from promiscuous sexual exposures.  But i f one were .to  state that education prevented sexual exposures which might have resulted i n infection, he i s to say that education and fear of motivation are .. synonymous. Whether education i s directed toward preventing promiscuous sexual exposures or toward urging exposed persons to have exami-. nations, i t i s generally agreed that adequate factual information concerning the venereal diseases should be had by the entire population, and that such public enlightenment w i l l assist measurably i n the eradication of these infections.  - 99 The evaluation of ignorance as a factor i n the spread of venereal disease i s d i f f i c u l t *  certainly the number of late syphilis  infections discovered i n routine serologic tests do give an indication of infections hitherto unsuspected, and ignorance of the infections was responsible i n many cases for the infections not being discovered i n their early stages, but other factors are often involved. If there i s to be widespread education c oncerning the venereal diseases, probably that education should be had by young people before they are exposed tc infection.  If this i s to be done, tho children  must be reached, at the latest, during the early teens.  This i s not being  done, except by parents, because the schools i n British Columbia do not have a program covering a l l pupils.  For several years the Division of  Venereal Disease Control has supplied speakers and films to schools throughout the province, and has given lectures to the pupils, from Grades X to XIII (the assumption was that the pupils of Grade X were about sixteen years), and i n the near future, the Depa.rtr.ent of Education i s expected to integrate venereal disease information into the health course.  But i t  i s not just the students from Grade X onward who should have information concerning the venereal diseases. Those boys and girls who leave school before Grade X must be reached —  i t w i l l be remembered that in Fraser's  study, only 18% of her group entered High School and only 8% completed High School.  (1) In conclusion, i t can be'pointed out that i f ignorance  i s an important factor i n the spread 3f venereal disease, and i f education w i l l dispel this factor, then education must be given to the young people, before they are exposed to infection,'not after they have acquired i t . (l)  Fraser, J., i b i d .  - 100 4.  Prudish Attitudes i n the Home:  Many children grow up in a home atmosphere in which sex i s an unmentionable subject.  The children i n such homes receive no satis-  factory answers to their questions on sex matters, and may even by reprimanded for mentioning the subject.  Naturally when a child meets with  a rebuff from his parents on the mention of sex, he w i l l probably not broach the subject again to them, but w i l l gain his information from other quarters, sometimes reliable, sometimes not. However, i t i s not the information on sex, nor i t s source that i s of primary concern at this point, but the -secrecy,, prudery, and shame that i s associated with i t i n the home. Whatever the motivation of the parents be i n shielding the child fronijsuch knowledge, i t i s the child that suffers. He or she now has faced a sex taboo, not on any rational grbund, but solely on the basis that the entire subject is .n8t i,M  nice". The ramificationson the child of parental prudery are many and diverse.  Only one of the possible results i s of interest i n the  problem of venereal disease, and that, of course, i s promiscuity.  It is  to be emphasized that parental prudery is' only another factor contributing to the onset of promiscuity, and that i t must be combined with other factors.  Whether i t i s a major factor, in many cases could only be  determined after careful case histories were taken.  I t i s noteworthy that  the report of the San Francisco Experiment, discussing the Conflictual group states:  "In general, the patients who were most promiscuous were  those whose parents had been most repressive regarding sexual matters. Family attitudes that sex was sinful were reflected i n the patients' attitudes and anxieties. Repressive handling of sexual matters i n the homes did not deter those patients from sexual experience, but rather i f  -  1 0 1 -  the repression was excessive, i t often contributed to t h e i r promiscuity". (1)  5.  Sex Education;  The matter of sex education f o r c h i l d r e n has r e c e n t l y been mooted by various i n d i v i d u a l s and organizations. new, but the names given i t are: l i v i n g , and others.  The subject i s not  education f o r l i f e , education i n s o c i a l  These newer names are apparently to indicate that the  subject of sex education i s not s o l e l y confined to information  concerning  the human reproductive system, but includes the adjustment of the i n d i v i d u a l to a l l sexual  matters.  As was mentioned e a r l i e r , there are a t least two opposing viewpoints:  sex education should be taught i n the schools, and sex  education should not be taught i n the schools.  There are no apparent  objections by any r e l i g i o u s grganization to a b e l i e f that some sex education should be given to c h i l d r e n , Ibut there are objections r a i s e d by r e l i g i o u s advisers and l a y a u t h o r i t i e s of various creeds to the public teaching of such information to c h i l d r e n . Those who advocate public teaching point out that most parents are t o t a l l y incapable of giving the information to the c h i l d r e n , and since the information i s necessary, the school should assume the duty.  Those against public teaching point out  that there are varying developmental ages of c h i l d r e n , and maintain that such intimate and important  information must be given on an i n d i v i d u a l  basis by q u a l i f i e d persons, preferably by the parents, at the appropriate time, which depends upon the maturation of the c h i l d .  The point of  i n t e r e s t here i s not i n the disagreement of the method of sex education but i n tho agreement of the need. With the broad scope of sc-x education, i t i s c l e a r that i f i t achieves i t s objective, sex education w i l l be e f f e c t i v e as a  - 102  -  preventative of exposure to venereal disease.  ( I t i s to be pointed out  that "sex education' as considered by most a u t h o r i t i e s , does not include 'venereal disease information', a subject which i s to be taught as a communicable disease.)  (l)  Since sex education involves "education on the p o s i t i v e side of sex and morality as a basic p r i n c i p l e of character", and "to provide new opportunity f o r youth to grow up  strives  'physically strong  —  morally s t r a i g h t ' , and for the creation of a broad new r e a l i z a t i o n of the strength and permanence which may be given to marriage and family l i f e " , i t w i l l , i f the motivation be s u f f i c i e n t , serve as a deterrent to exposure to i n f e c t i o n , and thus be e f f e c t i v e i n curbing the spread of venereal d i s ease.  (l)  e.g., Eigelow, M.A., Ed acation and guidance concerning human sex r e l a t i o n s : J.S.H., v o l . 31, p. 231. _  Conclusion. In the preceding pages an e f f o r t has been made to note some of the factors involved i n the spread of venereal disease.  There  are other known factors and probably many more unknown, but those named serve to indicate the complexity of the problem.  When a man or woman i s  treated f o r a venereal disease, should only the disease be treated, or should not the disease be treated as but a symptom, and the underlying, factors be the r e a l target for therapy?  C e r t a i n l y , i t would appear that  the presence of the venereal disease i s but a part of the problem. Prevention, too, apart from medical means, must concern i t s e l f with corr e c t i n g the underlying f a c t o r s .  There must be a r e a l i s a t i o n that the  diseases are symptoms of promiscuity, and that promiscuity and the f a c t o r s responsible f o r promiscuity must be corrected i f the venereal diseases ere to be eradicated.  The task w i l l not be easy; the s t a t e , the family,  and the i n d i v i d u a l must a l l a s s i s t .  1.  Anderson, G. W.  Venereal disease education i n the army: New York, .Journal of Social Hygiene, vol. 30, 1944.  2.  Bahn, J.H., Ackerman, H., and Carpenter, C.M., Development i n vitro of p e n i c i l l i n reistant strains of the gonococcus: Utica, Proc. Social Experiment, Biology and Medicine, vol. 58, 194-5.  3.  Bigelow, M.A.,  Education and guidance concerning human sex relations: New York, Journal of Social Hygiene, vol. 31, 1945.  4..  Bigelow, M.A.,  Fhy youth should know the important facts about venereal disease: New York, Journal of Social Hj'giene, vol. 29, 194-3.  5.  Boone, J.H.,  The sexual aspects of military personnel: New York, Journal of Social Hygiene, vol. 27, 194-1  6. British Columbia Legislature, Moving pictures act, Victoria, Kind's Printer, 1936. 7. Canadian Parliament,  Criminal Code of Canada, Ottawa, King's Printer, 1937.  8. Challonor, F.,  Remarks prepared fcr panel discussion on venereal disease control, Hotel Vancouver, Vancotiver, November 16, 194-5.  9. Clarke, C.Vf.,  Penicillin: help or hindcrance in venereal disease controlj New York, Journal of Social Hygiene, vol. 31, 1945.  10.  Davis, K.B.,  11. Defries, R.D.,  Factors i n the sex l i f e of twenty-two hundred women, New York, Harper and Bros., 1929. The importance of the moral factor i n the control of venereal diseases: Toronto, Canadian Journal of Public Health, vol. 32, 1941.  12. Division of V. D. Control, First quarterly s t a t i s t i c a l report on the incidence of venereal disease i n Carada, Ottawa, Department of National Health and ?.el- • fare, 1945. r  13. Division of Venereal Disease Control, Patients diagnosed at the Vancouver clinic (including Oakalla) from February 1, 1946 to April 30, 1946, showing the number known to have had prev:" cue venereal • i n f e c t i o n s , Vanc-^ver, Provincial Beard of Health, 194-6. Unpublished.)  14.  Federal Security Council, Challenge to community action, Washington D.D., S o c i a l Protection Council, O f f i c e of Community War Services, Federal Security Council, 1945.  15.  Fessler, A.,  S o c i o l o g i c a l and psychological factors i n venereal disease spread: London, B r i t i s h Journal of Venereal Diseases, v o l . 22, 1946.  16.  Flexner, A.,  P r o s t i t u t i o n i n Europe, New York, Century, 1 9 2 0 .  17.  Fcnde, C.,  Modern youth and recreation:  New York,  Journal of S o c i a l Hygiene, v o l . 22,  1936.  IS.  Fraser, J . ,  Study of the "social factors involved i n the a c q u i s i t i o n of venereal disease, Vancouver, D i v i s i o n of Venereal Disease Control, P r o v i n c i a l Board of Health, 1945. (unpublished)  19.  Carle, H.E.,  S o c i a l Hygiene today, London, A l l e n and Unwin,  1936. 20.  Glueck, S., and E.T.,  Five hundred delinquent women, New. York, A l f r e d Knopf,  1934.  21.  Harrison, L.W., Dudley, C.L.W. Ferguson, T., and Rocke, M., Report on anti-venereal measures i n c e r t a i n Scandinav i a n countries, London, Ministry.'of Health, 1938.  22.  Health League of Canada, The s o c i a l hygiene voice: Toronto, S o c i a l Hygiene D i v i s i o n , Health League of Canada, January, 1946.  23.  H e l l e r , J.R. J r . ,  Wartime changes i n the age d i s t r i b u t i o n of females infected with s y p h i l i s : Now York, American Journal cf Public Health, v o l . 36 }  1946.  24.  Hironimus, H.,  Survey cf 100 May Act v i o l a t o r s committed to the Federal Reformatory f o r Women: Washington, D.C., Federal Probabtion, v o l . 7, 1943.  25.  Kemp, T.,  F h y s i c a l and psychological causes of p r o s t i t u t i o n , Geneva, League of Nations,  1943.  26.  Larimore, G.W, and Sternberg, T.H., Does health education prevent venereal disease? New York, American Journal of Public Health, v o l . 35, 1945.  27.  League of Nations,  Report by committee on t r a f f i c i n women and c h i l d r e n , Geneva, League of Nations,  1927.  28.  League of Nations,  Prostitutes: t h e i r early l i v e 3 , Geneva, League of Nations, 1932.  29.  Lion, E.G. et a l . ,  An experiment i n the psychiatric treatment of promiscuous g i r l s , San Francisco, San Francisco Department of Fublic Health, 1945.  30.  Moore, J.E.,  The modern treatment of s y p h i l i s , Baltimore, Charles Thomas, 1941.  31.  Moral and S o c i a l Reform Council of B r i t i s h Columbia, Social v i c e i n Vancouver, Vancouver, James F. Morris, 1912.  32.  Norrie,- L.E.,  Survey report of group work and recreation of Greater Vancouver, 1945: Vancouver, Community Chest and Welfare Council of Greater Vancouver, 1946*  33.  Parran, T.,  Shadow on the land, New York, Reynal and Hitchoock, 1938.  34.  Rachlin, H.L.,  A sociologic analysis of 304 female patients admitted to the Midwestern Medical Centre, St. Louis, Mo.: Washington, D.C., Venereal Disease Information, v o l . 25, 1944.  35.  Rae, A.S.,  Report on control of venereal disease i n Vancouver: Vancouver, Vancouver Oitj P o l i c e Department, September 22, 1945.  36.  Rappaport, M.F.,  Towards a new way of l i f e : New York, Journal of S o c i a l Hygiene, v o l . 31, 1945.  37.  Rosenau, M.J.,  Preventive medicine and hygiene, Ne?/ York, Appleton-Century, 1935.  38.  Rosenthal, T., and Kerchner, G., Trend i n age of • acquiring venereal disease i n New York C i t y : Washington, D.C., Venereal Disease Information, v o l . 25, 1944-  39.  Snow, W.F.,  Venereal Diserses, New York, Funic and Wagnall,  40.  Stores, J.H.,  Some general consideretions a f f e c t i n g presentday sex and sex education problems: Washington, D.C., Venereal Disease Information, v o l . 25,  1937.  1944.  41.  United States Department of Labor, Dictionary of Occupational t i t l e s * part I I , group arrangement of occupational t i t l e s and codes, Washington, D.C., U.S. Government P r i n t i n g O f f i c e , 1939.  4.2.  U s i l t o n , L . J . , and Bruyere, M.C., The frequency of positive serologic tests f o r s y p h i l i s i n r e l a t i o n to occupation and marital status among men of d r a f t age* Washington, D.G., Journal of Venereal Disease Information, v o l . 26, 1945.  43.  Van Waters, M.,  44.  Watts, G.O., and Wilson, R.A., A study of personality factors a n n g venereal disease patients: Montreal, Canadian Medical Association Journal, v o l . 53, 1945.  45l  Weitz, R.D. and Rachlin, H.L., The. mental a b i l i t y and educational attainment of f i v e hundred venereally infected females: New York, Jcvwncl of S o c i a l Hygiene, v o l . 31, 1945.  46.  Williams, D.H.,  47.  Wittkower, E.D., and Cowan, J . , Some psychological aspects of sexual promiscuity: New York, Pschosomatic Medicine, v o l . 6, 1944.  48.  Wylie, P.,  Youth i n C o n f l i c t , New York, New Republic,  1932.  The suppression of commercialized p r o s t i t u t i o n i n the C i t y of Vancouver: New York, Journal Of S o c i a l Hygiene, v o l . 27, 1941.  Generation of v i p e r s , New York, Farrar,  1943.  

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