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A social work approach to the venereal disease problem in British Columbia : an analysis of the social… Wyness, Enid Stewart 1950

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A SOCIAL "WORK APPROACH TO THE VENEREAL DISEASE PROBLEM IN BRITISH COLUMBIA  An Analysis of the Social Problems involved i n Controlling the Infected Individual, with particular reference to Recidivism at the Vancouver Clinic, Division of Venereal Disease Control, British Columbia.  by  ENID STEWART WYNESS  Thesis Submitted i n Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK In the Department of Social Work  1S>£0 The University of British Columbia  ABSTRACT  Because the venereal diseases are acquired as the direct result of behaviour, this study takes as i t s focus the infected individual, and analyzes the venereal disease problem i n British Columbia i n terms of the incidence of infection, the treatment procedures as they affect the i n dividual patient, and the unsavoury community conditions that facilitate promiscuous behaviour. The study reveals that i n spite of the great advances that have been made i n the medical treatment of gonorrhoea and syphilis, i n 19U8 i n British Columbia, there was one case of venereal disease for every 25>0 people i n the province. The ratio between male and female patients was approximately two to one, and gonorrhoea was four times as prevalent as syphilis. The community problem has always been concentrated i n Vancouver, and i n 19U8, 76 percent of the f a c i l i t a t i o n reports received by the Division related to premises i n Vancouver. In 19U8, patients treated at the Vancouver Clinic accounted for almost half the total venereal disease population i n the province, and a review of the new admissions to this c l i n i c for the f i r s t six months of the year revealed that approximately every third patient had been previously infected. To determine why these people had failed to learn from the clinic experience, the medical records of each of the 21?? men and 130 women i n this repeater group were analyzed. While there was l i t t l e specific information in the charts about these patients as people, i n general the repeater group was made up of young adults who were l i v i n g a rootless existence; they had no close personal relationships and most of them described their sex partners as casual friends or strangers. Broken marriages and marital discord were reported by a large proportion of these repeaters, and alcohol was an important' factor i n the acquisition of repeated infections. More than half the group were chronic repeaters. The majority of the male repeaters were unskilled workers and hO percent of the women had no gainful employment. Among the female repeaters, approximately three out of four had police records; one out of three had had illegitimate children; and 19 out of the 130 were described as chronic alcoholics. For most of these repeater patients, the acquisition of a venereal disease was a relatively minor complication i n their disordered lives. The study then reviews the f a c i l i t i e s available in British Columbia for controlling the venereal diseases. The policy of the Division of Venereal Disease Control i s outlined and the programme of the various sections of the Division are discussed. The development of the Social Service Section i s described from i t s inception i n 1936 when i t was responsible for the epidemiological activities of the Division until 19U9 when the case work s k i l l s of the members of this section were directed ' toward making the treatment process a more positive personal experience for the infected person.  Studies relating to the psycho-social aspects of the venereal disease problem i n other countries are examined. As with the Vancouver Clinic repeater study, these projects show that the promiscuous behaviour which results i n a venereal infection i s usually symptomatic of more serious social i l l s . The present set-up at the Vancouver Clinic, where case work services are now an integral part of the treatment process, i s described. This shows the unique contribution that social work can make i n a venereal disease control programme. Now at the Vancouver ^ l i n i c , at the time of a patient's f i r s t infection, he i s helped to gain a better understanding of himself and of the cause-and-effect relationship between his infection and his pattern of behaviour. In this way recidivism i s being reduced among those patients who are capable of taking responsibility for themselves. This study points out that treatment of the infected individual i s not enough; i t i s society that i s sick. The venereal diseases are rooted In poor human relations; to attack this problem, an expansion of the mental hygiene programme i s recommended. To give every person his rightful place i n the community, the development of more neighbourhood projects i s advocated.  ACKNOWLEDGMENTS  -I wish to acknowledge my indebtedness to the staff of the Division of Venereal Disease Control for their cooperation i n making this study possible, and I am especially grateful to Dr. Charles Hunt, Director of the Division, for his careful review of the manuscript. I also desire to express my appreciation of the efforts on my behalf of Miss Marjorie Smith and Dr. Leonard Marsh, of the Department of Social Work of the University of British Columbia.  TABLE OF CONTENTS  Page Chapter 1.  The Venereal Disease Problem i n British Columbia  1  A survey of the problem i n terms of incidence of infection, treatment procedures as they relate to the individual patient, and the • community conditions which facilitate the spread of venereal disease i n British Columbia. Chapter 2.  18  Recidivism at the Vancouver Clinic A study of the repeater problem at the Vancouver Clinic, and an analysis of the social characteristics of the repeater group.  Chapter 3.  The Provincial Control Programme  HO  An outline of the development of the provincial control programme and a review of the present control f a c i l i t i e s . Chapter h.  Psycho-Social Characteristics of Patients i n Other Countries  59  A review of other patient-group studies that have been made i n the United States and Great Britain. Chapter 5.  Social Treatment - The Individual Approach  79  A description of the application of case, work principles i n venereal disease control.  TABLES IN THE TEXT Table 1.  Age Distribution of Venereal Infections British Columbia - 19U»  3  Table 2.  Sex of Persons Affected and Type of Disease British Columbia - ifUE  k  r  Table 3.  Venereal Disease Facilitators British Columbia  im  —  13  TABLES IN THE TEXT  Page Table h.  New Notifications of Venereal Disease January - June 19Ub Showing Repeaters"  19  Table 5.  Repeater Group by Family Status and Occupation  31  CHAPTER 1  THE VENEREAL DISEASE PROBLEM IN BRITISH COLUMBIA  Because the venereal diseases are u s u a l l y spread through promiscuous sexual behaviour, the problem i n venereal disease control i s not the disease, but the person who  has the disease.  Today the causative  organisms of each of the venereal diseases h ve been i d e n t i f i e d ; medical a  science has produced e f f e c t i v e therapeutic agents f o r t h e i r control; and yet i n spite of t h i s , i n Canada i n 19U8  the venereal diseases r nked second a  only to chicken-pox among the communicable diseases. Vancouver, the venereal diseases headed the list.-'with a t o t a l of h$3k new  In the C i t y of In B r i t i s h Columbia,  cases of venereal disease reported during the  year, oneout of every 2$Q persons i n the province was infected i n 19h-8. Beginning i n 19 UO the rate per 100,000 population of new i n f e c t i o n s reported i n the province increased s t e a d i l y from 310.3 year to 6?7.0 i n 19U6.  venereal i n that  In actual cases reported, the increase was from  2U98 to 6790 i n t h i s six year period.  From t h i s all-time high, the  incidence of venereal disease i n B r i t i s h Columbia has declined.  In  19h7  there were 5999 new n o t i f i c a t i o n s , i n d i c a t i n g a rate per 100,00 of 57U.6;: with k53k new cases reported i n 19U8, 19U3.  the rate of 1*19«0 i s the lowest since  While venereal disease i n B r i t i s h Columbia has decreased almost a  t h i r d since 19U.6, the 19U8 rate i s s t i l l nearly 32 percent higher than the 19U0  1958, 2  rate of 310.3  per 100,000 population.  2  i s h Columbia, Annual Report of the D i v i s i o n of Venereal Disease Control page 13. ~  Ibid, page 20.  The declining incidence of venereal disease i n the province i s more significant than appears from a study of the Division's statistics, because the rate has continued to drop i n spite of better reporting of newly diagnosed cases by private physicians i n the province, and improved methods of case finding such as the operation of the diagnostic examination centre at the Vancouver City Gaol and the small blood-testing surveys carried out' i n 19kB among certain occupational groups i n the province. In the 1°1|8 Annual Report of the Division, most of the credit for the improved situation i n the province i s given to the increased efforts made i n case finding, and the earlier and more rapid treatment of cases and of contacts. In 19U8, patient»sbetween the ages of 20 and 29 contributed almost half of the total new cases reported i n the province for the. year. Gonorrhoea infections among.this group accounted for 5>f> percent of the total gonorrhoea notifications and about UO percent of the early syphilis cases diagnosed i n British Columbia i n 19U8.  (See Table 1.)  TABLE 1 AGE DISTRIBUTION OF VENEREAL INFECTIONS BRITISH COLUMBIA - 1°U8 Age  Gonorrhoea Other Total Syphili s (a) Early Latent Tertiary Pre- Other Total V.D. V.D. Natal  9  10  1  1  a  2k  26  5  55  2  386  11U3  53  6U  3  2 12a  5  1272  25 - 29  aui  39  62  1  3 105  7  953  30 - 3k  k2h  32  30  3  1  2  68  2  a9a  35-39  28U  23  U6  12  2  a  87 ,  2  373  ao - aa  171  15  ao  16  2  73  3  2a?  U5 - U9  113  9  36  13  8  66  50 - 5U  58  10  38  21  '5  7a  a a  136  55 - 69  60  10  71  7  135  1  196  7  2  18  8  3  31  159  18  32  2  1  1  6a '  3608  238  a6a  13a  23  37  Under 5  7  1  5 - 11;  12  2  15-19  329  20 - 2U  70 - over Not stated Total Source:  2  •  ^1  .  896  17  .  1 6  38 223 30  a53a  Annual Report, Division of Venereal Disease Control, 19a8 Table III.  (a) Including one report of Opthalmia Neonatorum. Diagnosed i n 1 - a . years age group. In the distribution of venereal infection, male patients outnumbered females by more than two to one.  (See Table 2.)  « k TABLE 2 SEX OF PERSONS AFFECTED AND TYPE OF DISEASE BRITISH COLUMBIA - 19U8 Age  Gonorrhoea Male Female  6  13  15 - 19  133  196  20 - 2U  777  25 - 29  Rate per  100,000  10  Ik  ll  kk  523  366  60  6k  Hil3  6U2  199  51  $k  1036  30 - 3k  333  91  ho  28  555  35 - 39  227  57  55  32  U95  Uo — UU  138  33  16  28  361  16 - h9  95  18  HQ  18  308  50  8  5Ii  20  238  56  k  115  20  12L  26  5  62  Under 15  50 - 5U  ;  55 - 69 70 - over  7  Not stated Total Source:  Syphilis Male Female  k  111  h8  38  26  2575  1033  5U7  3U9  1x19  Annual Report, D i v i s i o n of Venereal Disease Control, 19U8, Chart I I , C h r t I I I , and Table IV. a  THE DISEASES The present study i s p r i m a r i l y concerned with the incidence of gonorrhoea and s y p h i l i s and not with the l e s s common venereal diseases. In 19U8 gonorrhoea i n f e c t i o n s accounted for 79.o percent of the total new cases reported, s y p h i l i s cases contributed 19.7 percent and the other venereal diseases 0.7 percent.  A l l of these are communicable diseases,  usually acquired through intimate contact with an infected person. Accidental infections from contaminated articles have been known to medical science but are rare i n c l i n i c practice.  Syphilis infections do  sometimes occur among doctors, dentists, and nurses, through faulty techniques i n working with infectious lesionsj and infants and young female children may become infected with gonorrhoea through careless handling by a person who has touched material fouled by a gonorrhoeal discharge.  As  i s well known, the eyes of newborn infants may become infected i n the birth process, i f the mother has gonorrhoea. Gonorrhoea Until the discovery of the sulphonamides and later p e n i c i l l i n , the treatment for gonorrhoea wa.s a long and often painful process, consisting of repeated irrigation of the genitals followed by the application of medicated packing.  Sometimes the patient had to stop work and there  were unhappy social and economic consequences to the acquisition of gonorrhoea.  The sulphonamides made i t possible to give treatment orally,  by p i l l s taken at regular intervals throughout each 2h hours for a period up to two weeks. Even this treatment was not without discomfort for those patients who were unable to tolerate a sulpha compound. Today p e n i c i l l i n i s the drug of choice for the treatment of gonorrhoea because i t i s rapid, highly effective, non-toxic and practically painless.  It i s administered  in one injection i n the buttock, symptoms usually disappear and the patient i s rendered non-infectious i n a matter of hours.  If the recom-  mended three tests of cure taken at weekly intervals are negative, the p tient i s discharged as having been cured of gonorrhoea. a  He i s advised  to report back'for a blood test four months after treatment and again at six months i n order to rule out the possibility of syphilis having been  -6 acquired concurrently with the gonorrhoea infection, because the 'developing symptoms of syphilis may have been masked by the dosage of p e n i c i l l i n used to treat the gonorrhoea.  Where there i s any suspicion of syphilis  (as i n the case of a penile or other genital lesion), streptomycin i s used rather than p e n i c i l l i n , since the latter might delay or prevent an early diagnosis of concurrent syphilis.  With this rapid treatment, from  the point of view of the patient, gonorrhoea i s less disabling than the common cold. • From the standpoint of public health, i t i s the undetected reservoir of gonorrhoea among the female population that i s the problem. Y/hereas with a man the symptoms of gonorrhoea are usually so insistent that the patient seeks medical care, without delay, with a woman the symptoms may be so slight as to go unnoticed. In British Columbia i n 19U8 the ratio of new gonorrhoea cases between males and females was slightly more than five to two, with most of the female patients reporting for examination at the suggestion of their infected male sex partner, or as a result of the case finding activities of the Division of Venereal Disease Control.  These women rarely complained of symptoms but on exam-  ination were found to be infected. Syphilis Like gonorrhoea, syphilis i s a communicable disease that i s spread through intimate contact, but i t i s the more insidious enemy because i t s early symptoms may be hidden or so inconspicious as to escape detection, while the organism of syphilis carries on i t s destructive processes against the various organs and tissues of the body. Indeed a syphilis infection c n imitate any of the bodily i l l s . a  Improved methods  of syphilology are beginning to bear fruit i n the reduced morbidity o f  syphilis.  In 19U8, of the 896 cases of syphilis reported i n British  Columbia, only 18 percent related to tertiary syphilis - that i s , late syphilis with complications involving the central nervous or cardiovascular systems, the bone structure, or the skin.  Now early and adequate treatment  i s preventing these disasters. Primary and secondary syphilis accounted for 26 percent.  The  public health significance of this i s important, because syphilis i n the early stages i s highly infectious.  Serum removed from a primary sore,  (or chancre) and examined under a special microscope, w i l l show the presence of living, moving spirochaetes. From such a lesion, which usually occurs on the genital area or occasionally i n the mouth, th£se organisms can be transmitted to another person, i f the infected part of the diseased person i s brought i n contact with the soft mucous membrane- parts of the healthy person.  The warm, moist mucous membranes of the genitalia, or of  the mouth, are ideal media for the growth of the spirochaete.  According to  medical authority, the organism of syphilis cannot enter the body through unbroken skin.  However even an infinitismal break i n the skin can serve as  the site of infection. .Similarly a person with syphilis i n the secondary stage i s a menace. Any moist lesions appearing on the skin or i n the mouth or around the genital area are very infectious.  Like the chancre, they  usually occur i n sites where only intimate contact, as i n sexual intercourse or i n kissing, i s l i k e l y to result i n the transmission of the disease. In latent syphilis, which i n British Columbia i n 19U8 accounted for 52 percent of the reported cases, the disease i s quiescent and can be detected only by blood tests showing a positive reaction. In the early years of latency, the disease may be transmitted by sex contact, but such  - 8 a patient i s not infectious to ordinary contact; the longer the disease remains latent, the less l i k e l y that patient i s to be a menace even to a sex partner.^-. In this stage however, a mother may infect her unborn child, the disease being transmitted from the mother to the child through the placental circulation.  This tragedy i s now 100 percent preventable by  adequate treatment of the syfMLitic mother early i n pregnancy.  It could  be wiped out i f a l l pregnant women were routinely blood-tested as part of their prenatal care.  A syphilis infection acquired by a child while s t i l l  in the mother's womb, can have very serious social implications. Inters t i t i a l keratitis causing blindness, i s one later manifestation of prenatal syphilis which continues to baffle syphilologists.  Various ther-  apeutic agents have been tried, and sometimes the condition responds and sometimes i t does not, without any apparent reason.  It can occur i n  childhood or i t can manifest i t s e l f as late as early adult l i f e . . Similarly prenatal syphilis can result i n an involvement of the central nervous system causing insanity, or a defect i n the motor nerves of the body (called tabes dorsalis), or deafness.  This preventable form of  syphilis, therefore, can cause problems of serious social consequence to the patient, and to his family, and to the community as a whole.  -According to a publication of the Division entitled Venereal Disease Information for Nurses published i n 19U8: "The f i r s t two years i s the significant period of communicability i n untreated syphilis and the i n fectivity then declines rapidly, so that at the end of five years the danger of transmission i s slight. In general i t may be stated that the lesions of early syphilis are infectious and those of late syphilis are • not .... in most instances treatment renders the patient non-infectious very rapidly. One injection of an arsenical or p e n i c i l l i n may render surface lesions non-infectious within a few hours, but continued, regular, adequate therapy i s necessary to maintain and establish permanent noncommunicability."  In tertiary syphilis, transmission of the disease i s rare, except by a pregnant mother to her child.  Even open skin lesions resulting from  the syphilis infection having destroyed the body tissues, -while they are unsightly, are not infectious.  The idea of a person "in the last stages  of syphilis, covered with horrible sores, and constituting a dreadful public health menace", i s popular misconception. The chancre, the i n fectious lesion of syphilis i s small and usually hidden. While syphilis i n the primary, secondary and early latent stages i s a public health problem , the patient may not feel any particular i l l effects.  The most dramatic manifestation of early syphilis, which may  occur i n the secondary stage i s a condition known as "alopecia", or patchy loss of hair.  The syphilis rash which may be another symptom of  secondary syphilis i s most commonly seen on the trunk, palms of the hands and soles of the feet, or around the hair margin.  But not a l l  patients can give a history of such a rash and not until the infection had succeeded i n destroying some organ or tissue did the patient become aware of his syphilis. While treatment for syphilis varies with the stage of the disease, great strides have been made i n simplifying anti-luetic therapy. In 1°H8, treatment for primary and secondary syphilis, for syphilis i n pregn ncy and for congenital syphilis, as well as for certain types of a  tertiary syphilis, was a hospital procedure, with p e n i c i l l i n being administered at two or three hour intervals for a period of from seven and a  half to 15 days, depending on the diagnosis. Latent syphilis, both  early and late was treated on an ambulatory basis, with daily p e n i c i l l i n injections being given for ten days.  To reinforce the effects of the  penicillin, follow-up courses of mapharsen and bismuth (the drugs of  -10 choice for the treatment of syphilis before the advent of penicillin) were prescribed for nine weeks with bi-weekly treatments, or 26.weeks with weekly treatments, again depending on the type of syphilis infection being treated. Now i n 1950, at the Vancouver Clinic syphilis of a l l types (with the exception of cardiovascular syphilis) i s being treated with penicillin alone, on an ambulatory basis, over a period of from ten to twenty days. However, although p e n i c i l l i n now seems to have proven i t s e l f the wonder drug for the treatment of syphilis, there are s t i l l treatment failures, and syphilis patients are kept under medical surveillance for at least five years after treatment, i n order that any signs of relapse^may be detected.  For the f i r s t six months, blood tests are taken monthly. I f  the patient's condition i s showing improvement at the end of this period, the blood i s tested every three months for a year.  Again I f there i s no  indication of trouble, the tests are repeated every six months for the balance of the five year period.  In order to detect any involvment of  the patient's central nervous system, his spinal f l u i d i s checked before treatment i s commenced'or early i n the course of treatment, at two and a half years after treatment, and again at the end of the surveillance period.  This spinal f l u i d examination i s done by means of a lumbar  puncture which i s distressing to many patients because'of an innate fear of any interference with the spinal column, and because of the severe headache which sometimes follows a lumbar puncture.  At the end of the '  five year period, the patient i s given a thorough physical examination including an investigation of his cardiovascular system.  I f the -results  of a l l the various examinations are negative, the patient i s then discharged as having had sufficient treatment.  However, he i s advised to  have yearly blood tests because the medical experts are unable to give  - 11 positive reassurance that a specific syphilis infection i s completely cured. They can only say that according to the latest methods of treatment and of scientific testing, and i n the absence of physical manifestations, the patient appears to have had adequate treatment.  The longer a patient  remains free from symptoms,the less likelihood there i s of the infection becoming reactivated.  However, for a sensitive person, this kind of  guarded medical prognosis may cause him to live under the shadow of a fear that can inhibit a l l of his social relationships.  For the female patient,  syphilis i s the spectre that haunts every pregnancy; old anxieties are reexperienced; and irksome treatment must again be undertaken for the sake of the unborn child.  No measure has been taken of the emotional impact  of this treatment on an expectant mother, but there may be serious ramifications i n terms of the relationship of the mother to her child. Treatment which cures the venereal diseases does not give the patient any immunity.  Indeed, the whole course of the disease can be  re-experienced following exposure to an infected person.  To date medical  science has not produced an anti-toxin for either syphilis or gonorrhoea. , Only the patient, by his behaviour can safeguard himself against re-infection. The Oommunity Problem Wherever there i s a high incidence of venereal disease, there are unsavoury community conditions f a c i l i t a t i n g the spread of these diseases. This "facilitation process" described as the "intermediate means whereby the bearer of a venereal infection gains access to the healthy individual"^ i s under constant surveillance by the Division of Venereal Disease Control. A l l newly diagnosed patients are questioned as to the source of their infection, the place of meeting and the place where the exposure occurred. ^British Columbia, Annual Report of the Division of Venereal Disease Control,  19U2.  -1  -  12  This information i s then summarized and presented at quarterly meetings called by the Division of Venereal Disease Control and attended by the senior medical health officers of Vancouver and Victoria, and by representatives of the Provincial Police, Vancouver City Police, Vancouver Licensing Department, Provincial Liquor Control Board, B.C. Hotels Association, and other interested organizations. These meetings provide an opportunity for frank discussion of the problems i n venereal disease control and the action that can be taken by the various authorities to improve conditions in the province.  It i s recognized that the community control of venereal  disease i s a problem requiring the concerted efforts of a l l those who  are  responsible for safeguarding the health and welfare of the people. According to the records of the Division, i n British Columbia, hotels and rooms have always beei the most frequently reported type of facilitator, with the greatest number of facilitation reports relating to premises i n the City of Vancouver.  In 19U8, out of 1;266 reports received  by the Division, 323>1 or 76 percent related to places i n Vancouver.  5  (See Table 3.)  Infections diagnosed i n Vancouver for the same period •  amounted to 61 percent of the total infections reported i n the province, which would indicate that some of the infections reported i n the rest of the province were acquired i n Vancouver.  This i s to be expected since  Vancouver i s the holiday centre for the surrounding area. **-In discussing f a c i l i t a t i o n reports i t must be borne i n mind that they do not represent the number of infections acquired, since a patient with one infection may report having been exposed to several contacts i n various premises. Neither do the f a c i l i t a t i o n reports indicate the actual number of facilitating premises, because the same premises may be reported by several different patients. The object i n obtaining such information from infected persons i s to keep track of the places in the province where venereally diseased persons are coming i n contact with healthy persons and spreading their infection.  - 13 TABLE 3 VENEREAL DISEASE FACILITATORS • BRITISH COLUMBIA - 19U8 Type of Facilitator Hotels and Rooms  Distri" Dution Between Vancouver Rest of Province 1759  '  300  Vancouver Proportion (Percent)  Total Reports(a)  85  2059 1117  Miscellaneous Places (b)  727  390  65  Beer Parlours  257  53  83  310  Private Homes  129  131  h9  260  Cafes  186  65  lh  • 251  Dance Halls  190  61  76  251  3  15  Bawdy Houses Total Source:  3251  1015  1  18  7  76  U266  Summary of Facilitation Reports, 19U8, Division of Venereal Disease Control, British Columbia.  (a)  Excluding U82 reports relating to infections innocently acquired from a diseased marital partner.  (b)  In Vancouver 370 out of 727 miscellaneous reports related to street pick-ups.  In Vancouver i n 19U8, reports naming hotels and -rooms accounted for more than half the total c i t y reports. For the most part these premises are cheap hotels and rooming-houses i n the problem area of the city, which i s located i n the older downtown business d i s t r i c t .  They  present great d i f f i c u l t i e s i n community control, since they are usually owned by "absentee" landlords or corporations, and they are operated for quick profits by a continually shifting management. They are frequented  by promiscuous women and are the headquarters for an itinerant male population comprised of loggers, sailors, miners, and other mobile workers who come to Vancouver to spend their money. Whether or not any hotel becomes a facilitator of venereal disease, depends on the management.  The  records of the Division show premises side by side i n the worst section of the city, one of which w i l l be frequently named while the other w i l l not be reported at a l l . What i s required i s a tighter control i n the licensing of such premises.  As i t stands now, the only reason for a  license being refused to an applicant seems to be a record of police convictions for an offence such as violation of the liquor or morality laws. It i s not necessary for the proprietor to speak or even understand English, or to adhere to Canadian ways of l i f e .  While the housing prob-  lem remains acute, i t i s d i f f i c u l t to have any action taken to close premises, even when they are known to the authorities to be a public health menace. Meanwhile, the Division i s pressing for action by way of local by-laws to make possible the enforcement of proper standards of management and supervision i n hotels and rooming-houses, particularly i n Vancouver. During the year, streets and other miscellaneous places such as parks, fields, boats, cars, constituted approximately 26 percent of the reports relating to the means by which a healthy pe rson met or was exposed to the person who was spreading infection.  This represents a  serious problem i n community control, since there i s no law that prohibits these casual encounters.  Similarly there i s no public action that can be  taken to prevent private homes from being used to f a c i l i t a t e the spread of venereal disease, and yet i n 19k8, according to Table 3, they were more frequently named as the place of meeting or exposure than either cafes  -15  <  or dance-halls. In I9I4.8, i n spite of excellent cooperation from the Liquor Control Board of the province, beer parlours continued t o be a serious f a c i l i t a t i o n problem. Now by arrangement with the Commissioner of the Liquor Control Board, whenever a report indicates that the pick-up occurred when a male patron improperly entered the ladies' section of the premises, this information i s forwarded to the Commissioner for immediate disciplinary action against the operator of the beer parlour, who i s responsible for the proper supervision of his premises.^ Despite this constant check on the management of beer parlours i n the province, because these premises are the social centre for a certain group i n the community, they are repeatedly named as the place i n which a patient met the infected person to whom he was later exposed. As with beer parlours, i n cafes and dance-halls even under the most careful management, pick nips take place between men and women who are legitimate customers of such premises. Vigorous action to disperse the promiscuous element i n beer parlours, cafes, and dance-halls only increases the number of encounters made on the street.  Among certain  types of men and women, casual meetings - and just as casual sexual relations - are going to occur, and this situation w i l l persist as 3.>.r long as each individual i n the group finds that his or her need are met by Under the regulations governing beer parlour operations i n British Columbia, a male customer who i s not accompanied by a woman must use the section of the beer parlour that i s reserved exclusively for men. This segregation only serves to increase the number of women picked up outside the beer parlours by men who want to enjoy the convivial atmosphere of the ladies' section, where mixed parties as well as unescorted female patrons are served.  - 16 this kind of relationship. By 19U8, established houses of prostitution had ceased to be a serious venereal disease menace i n the City of Vancouver, according to the facilitation reports of the Division of Venereal Disease Control. Although the Division received three reports during the year i n which the patient described his place of exposure as a bawdy house i n Vancouver, prompt investigation by the staff of the Division and by morality officers of the Police Department failed to reveal any evidence of organized prostitution i n the premises named. Until 19k7 there were several well  :  known houses of prostitution operating i n Vancouver, and they were continually reported to the Division as venereal disease facilitators.  Each  time, a complaint was forwarded promptly to the Police Department but no effective action was taken to close these "disease dispensaries" u n t i l there was a change i n the police administration and law enforcement against morality offenders became an important part of the war against vice.  Now  Vancouver has demonstrated that by sincere and persistent activity by the police, organized prostitution can be suppressed i n a large urban sea-port. In  other parts of the province, the problem-of bawdy houses  showed very l i t t l e improvement. During the year the Division received fifteen reports naming established premises i n both Nelson and Trail as the source of a venereal disease.  Although the Division advised the  local authorities each time such a report was received, very l i t t l e was done to improve the situation. As both Nelson and T r a i l had their own municipal police force at that time, there was l i t t l e pressure that could be applied from the provincial level to enforce the law against the ; operators of these houses of prostitution.  Since 19U8, however, police  administration i n T r a i l has been taken over by the Provincial Police, and  - 17 cooperation with the Division of Venereal Disease Control has improved. In Nelson the bawdy house problem w i l l l i k e l y remain chronic u n t i l the c i t i e n s themselves demand police action to protect them from this threat z  to their health and welfare. In any programme to control the spread of the venereal diseases, the f a c i l i t a t i o n process i s a problem that demands attention. I t i s not enough to treat the diseased individual.  Community trouble spots, like  festering sores, are persistent foci of infection and must be cleared up i f the control programme i s to be effective.  - 18 CHAPTER 2 RECIDIVISM AT THE VANCOUVER CLINIC  Although the 19kB statistics of the Division of Venereal Disease Control showed a venereal disease rate of I4I9.O per 100,000 population i n British Columbia, the records of the Vancouver Clinic indicated that a nucleus of problem patients were reporting time and again for treatment of newly acquired infections.  Nothing was known about the repeater rate  and this present study was undertaken to determine what proportion of the venereal disease problem i n the province was attributable to patients . who had been previously known to the Division, and what kind of people became repeater patients. The only patients about whom there was any specific information were those who were diagnosed at the Vancouver Clinic.  Here the complete  medical history was available on each patient, as was a l l the epidemiological notations and social service interviews carried out during the course of the patient's c l i n i c experience.  Accordingly, the records of  the Vancouver Clinic were selected for study.  An analysis of the new  cases reported to the Division during the f i r s t half of 19U8 showed that Vancouver Clinic cases accounted for approximately k$ percent of the total new infections reported i n the province during this period, and 73 percent of a l l notifications received from the Vancouver Metropolitan area.  (See Table ILV)  - 19 TABLE U NEW NOTIFICATIONS OF VENEREAL DISEASE JANUARY - JUNE 19U8 SHOWING REPEATERS Month  Female  Male  Total  Total  Total  Vancouver Repeaters Vancouver Repeaters Vancouver Met. Area Province  Clinic  (c)  Clinic  Clinic  Jan.  172  58  68  19  2ii0  326  530  Feb.  127  39  67 •  20  19k  282  kkk  Mar.  157  32  69  32  226  297  k22  Apr.  127  32  60  2k  187  239  101  May-  83  27  1|2  21  125  183  329  June  95  35  52  26  Ikl  197  331  Total  761  223 (a)  358  1U2 (b)  1119  152U  2U67  Source:  Division of V.D, Control monthly statistics January to June 19U8  (a) Diagnosed i n 215 individuals. (b) Diagnosed i n 130 individuals. (c)  Includes notifications from provate physicians and clinics i n metropolitan area of Greater Vancouver.  In order to get some idea of the size of the repeater problem, the notifications of new infections diagnosed at the Vancouver Clinic for a six months period from January to June of 19li8 were checked against the central index. For the purpose of the study, a repeater was defined as a perscmtreported as a new case by the Vancouver Clinic between January 1st and June 30th, 19U8 who had had a previous diagnosis of venereal disease i n British Columbia.  Patients who gave a history of venereal  disease diagnosed elsewhere than i n this province were not included i n the study.  In this period, out of 1119 new infections diagnosed at the  - 20 Vancouver Clinic, 365 occurred i n people who had been previously known to the Division of Venereal Disease Control, In other words, at this c l i n i c approximately one out of every three patients was a repeater.  Some of  these repeaters were treated for more than one infection during the six months period, and the 365 new notifications related to 3U5 individuals 215 men and 130 women, (See Table h)  Among the female patients treated  at the Vancouver clinic i n this period thenepeater rate was 36 percent, while that for men was 29 percent. In an (effort to determine whether or not repeater patients were more characteristic of the Vancouver Clinic case load, the records of new patients diagnosed by private physicians i n Vancouver for the month of January, 19U8 were checked, and out of 67 reported cases only three could be classified as repeaters.  Recidivism, therefore, seemed to be  more of a problem among "the people who came to the free c l i n i c than to those who received private medical care. What kind of people comprised this repeater group?  From the  clinic records, a l l the available information about each of the 3hB patients was analyzed i n terms of age, racial origin, family status, place of residence, occupation, number of infections, type of contact usually reported, and certain other particulars relating to criminal convictions, drug addiction, and alcohol as a precipitating factor i n the acquisition of a venereal disease.  For the women patients, a history  of illegitimate pregnancy and of prostitution v/as recorded.  None of the  charts gave any indication of the patient''s educational achievement or mental ability, and only i n isolated instances was there any notation with regard to the patient's family relationships, work adjustment, leisure-time activities.  Although the records were scrutinized i n  - 21 detail, nothing could be learned from them about the impact of these i n fections on the individual as a person.  Chart after chart contained only  the briefest statistical information about the patient, recorded at the time of his f i r s t admission to the Clinic, and consequently out-of-date at the time of the study.  Subsequent admissions were entered on the chart  with l i t t l e more than the comment of the examining physician relating to the patient's current symptoms. Judging from the charts of the male repeater patients, many of them appeared to have presented themselves at the Clinic for examination and gone through the diagnostic and treatment process without any exploration by the clinic staff of the-significance of their repeated infections.  Indeed i n so many instances, these male  repeaters seemed to have preserved their status as a "number" throughout their entire c l i n i c experience. They were not a problem to the Epidemiology Section because theyreported with symptoms before they could be named as contact by their sex partners; then after treatment they returned for the required number of tests of cure and i n due course were discharged from the clinic records. Each time they returned with a new infection, the whole process was repeated - medical examination, diagnosis, treatment, then contact history, tests of cure, and again discharged. The clinic had a revolving door. With regard to the female patients, more detailed information was available from their clinic charts, and more often they were personally known to the clinic staff.  Usually these women reported to the clinic for  treatment as the result of epidemiological investigation after they had been named as a contact to a known infection, rather than because they had symptoms of a disease.  From the medical standpoint, diagnosis and treat-  ment of a female patient i s more individualized than for a man.  The pelvic  - 22  examination which i s routine for detecting venereal disease i n a female i s an internal procedure and i s more comprehensive than the usual external examination required by a male patient.  Because i n the female, symptoms  may be.hidden, the doctor must take a more qjecific medical history and i n this way the female patient tends to get more individual medical attention. Sometimes i n the course of an examination for a venereal infection i n a woman, a diagnosis of pregnancy i s confirmed for the f i r s t time gnd this involves a more detailed explanation of her condition from the doctor. In the.treatment process, the female patient receives-more personal consideration than i s given to a man.  On the women's side of the- c l i n i c there in  i s less crowding and more privacy; ^6he male treatment room, t h e case-load i s heavier; pressure of time on the medical and public health nursing staff make i t impossible to devote much time to each individual patient. With repeaters, the repetition of the experience of acquiring a venereal infection should indicate a need for something more than a routine examination and an injection of p e n i c i l l i n .  Because the acquisition of a  venereal disease i s the .direct result of the behaviour of the individual patients, unless the patient i n the course of the treatment process i s helped t o see the connection between his beh viour and the end results of a  i t , he w i l l not learn from the treatment experience. In spite of the fact that the information about these repeater patients was not specific, a general picture of this patient-group was obtained.^Age Grouping Vancouver Clinic repeaters were predominately from the younger adult group, with two-thirds of them between 20 and 29 years of age.  This  ^•For a statistical analysis of characteristics of r epeater patients see .Appendix A.  - 23 i s considerably higher than the proportion of this age-group i n the total venereal disease population for the year, which was just less than 5>0 percent.  (See Table 1 ) .  As a group the female repeaters 7/ere more  homogeneous. They were younger than the men, with 70 percent of the women as against 58 percent of the men i n this 20 to 29 age-group.  Out of the  130 female repeater patients, 18 or almost Ik percent were under 19 years of age, while there were only 5 , or approximately two percent of the men in this youngest group. Racial Origin With regard to racial origin, of those for whom this information was available, a l l the women and over 70 percent of the men were Canadian born.  Almost half the total group were of British origin, with Indians  and half-breeds as the largest minority group accounting for less than 15 percent of the total group.  However, the proportion of Indians to the  total female repeater group was nearly three times the proportion for the men.  The study showed that Indian g i r l s i n an unprotected urban setting  constitute a real problem because, like the negroes i n certain areas i n the United States, these g i r l s are l i v i n g outside their own social group; they are anxious to associate themselves with white people and they gain favour by being sexually accessible.  Having tasted c i t y l i f e they are not  content to return to the reservation way of living; they are not trained to do anything but menial work; and they can exist on the generosity of their casual men-friends easier than they can find a place for themselves in the economic l i f e of the city. About 15 percent of the total repeater group came from northern or central European stock.  There were very few negroes only threepprcent  of the repeater group being so classified.  With the exception of the  -  2k  Indian women patients, cultural conflicts did not appear to play any real part i n precipitating repeated venereal infections among these repeaters. Family .Status In our culture, the family i s s t i l l the basic social unit, and the better integrated an individual i s i n his family group the less need there i s f o r him to seek satisfactions i n anti-social behaviour.^  For  the venereal disease repeater group the nomenclature "attached" and "unattached" was used to describe the patient's position i n relation to his family group.  A patient was considered to belong to the "attached"  group i f he or she was single and l i v i n g with parents, or married, or living i n common-law relationship.  In the "unattached" group were i n -  cluded the single people living apart from their families, and those who were separated, divorced or widowed. Although there was no specific information on the charts about the quality of the patients' family relationships, most of the records indicated that, patients' marital status and whether or not they were living at home with their families. The ccuracy of this information i n terms of the current situation at a  the time of the repeater study may be questioned however, as on many of the charts no entry regarding change of status had been made since the patient's f i r s t admission to the clinic* Judging from the particulars that were available,, approximately 72 percent of these people belonged to the "unattached" group; their %amily instability as a contributing factor i n the acquisition of a venereal disease was the concern of over half the experts who participated i n a poll of professional opinion conducted i n 19kQ by a joint committee of the Department of Public Health of Yale University and the V.D. Division of the U.S. Public Health Service. The report of this study committee, entitled The Social Control of Venereal Disease, i s referred to i n more detail i n Chapter k.  family ties had been severed; they lived a rootless existence; and what they did was important to nobody but themselves.  The history revealed by  the charts of John T. and Mary L. was f a i r l y typical of the repeater patients. John was 22 at the time of the study, and had been known to the clinic for over a year during which time he had acquired gonorrhoea twice. He was born i n Canada to parents who had come from Central Europe. His parents vrere divorced and their present whereabouts was not indicated. He had two sisters and one brother but there was no information about them on his chart. John lived by himself i n a room i n the slum area of Vancouver and gave his occupation as that of a logger. His f i r s t infection manifested i t s e l f after a drinking party where he said he had "blacked out" so that he could give no particulars about his sex contacts. At the time of his second infection a year later, he described his sex partner as a g i r l about whom he knew nothing, although he had been^'introduced to her by a friend. That i s a l l that could be learned about John from his clinic record, and this record contained more information about John as aprson, than most of the male repeater charts. Mary L. was 21 and had been known to the c l i n i c for a year,, during which time she also had had gonorrhoea twice. She was Canadian born, of Russian background. She lived i n the downtown area but not i n the slum section; She was the eldest of a large family who lived i n Vancouver, but Mary visited them infrequently. She was irregularly employed although she was a trained powermachine operator, and she spent most of her time hanging around the cafes and beer parlours i n town. She had never been arrested, but she was known to the police because the crowd she was with were usually on the fringe of petty crime. She was one of the "good-time g i r l s " who lived from week-end to week-end on the bounty of their American servicemen!, boyfriends. Mary had been reported to the Division of Venereal Disease Control seven times as a contact during the year prior to the study, and she was being sought continuously by the epidemiology staff of the Division. The second time she was admitted to the clinic, she came i n because she was worried about the possibility of pregnancy, and on examination she was found to be three and a half months pregnant, as well as infected with gonorrhoea. The f a c i l i t i e s of. the M ternity Out-patient Clinic of the Vancouver General Hospital were explained to her and she readily accepted referral for prenatal care. However, when the services of the appropriate social agency were interpreted to her, she a  - 26 indicated that she d i d not v/ant that kind of help but would make her own plans. She named as the father of her baby a man whom she described as her fiance, but i n the contact h i s t o r y given by the man < he described Mary as a .casual street pick-up. Mary was intermittent i n her attendance at the Maternity - C l i n i c and t h i s agency l o s t track of her before the baby was born. There was no information on her venereal disease chart to indicate what happened to her or the baby, or whether she ever a v a i l e d h e r s e l f of the community resources f o r helping unmarried mothers. •Among the female repeaters, nearly 80 percent belonged, l i k e Mary, to the "unattached"  group.  who were "unattached" was  s l i g h t l y lower, being 70 percent of the t o t a l  male repeater group.  The percentage of the male repeaters  Among the male repeaters single men  accounted f o r  almost 1$ percent of the group as against h$ percent f o r the women, and a higher proportion of the single men  l i v e d at home with t h e i r f a m i l i e s  than was the case with the single g i r l s .  Out of the t o t a l female repeater  group, there were only three single g i r l s l i v i n g as part of a family group!. Approximately  l l ; percent of the repeater group were married  included i n the "attached" group.  and  However, among these married patients,  three out of f i v e of them blamed t h e i r Infections on extra-marital sex partners.  Where there v/as any s p e c i f i c information available, i t i n d i c a t e d  that most of them had a h i s t o r y of marital discord i n which sexual i n f i d e l i t y was only one o f many contributing f a c t o r s .  Nothing ?ras recorded  about the meaning to the i n d i v i d u a l family group, of the experience of a venereal i n f e c t i o n being brought into the marital relationship through the extra-marital e x p l o i t s of one of the partners. happened repeatedly.  Yet i n some cases t h i s  Such a family were the J's.  The J s. had been known to the c l i n i c since I9I4I during which time -Mr.. J . had had gonorrhoea f o u r times. Each time that he reported to the c l i n i c with symptoms, h i s wife accompanied Mm, and three 1  - 27  out of the four times she was found to have acquired the infection from her husband. Although Mr. J . and his wife were living together, each time a diagnosis was made, his contact history read "dance-hall pickup, exposure in his automobile", or "cafe pick-up, exposure later i n contact's room", or "prostitute in • bawdy house in a small town i n the interior of British Columbia" or "pick-up i n cheap hotel, drinMng". Each time he 'admitted.exposing his wife to the dangers of infection following these episodes. A l l that was noted on either of their charts was that they were living with Mrs. J's. parents and helping operate a rooming-house i n the downtown area of Vancouver. The last entry related to a letter which "the Epidemiology Section received from Mrs. J . stating that she and her. husband were now l i v i n g i n a small mill-town up the coast and they would both report for tests of cure the next time they were i n Vancouver. Broken marriages resulting i n separation or divorce were recorded for approximately 30 percent of the female repeater group and 9 percent of the male group. Place of Residence To determine whether or not any particular area i n the City of Vancouver contributed the major share of the repeaters, the c i t y was divided roughly into three zones.^  Zone 1, which took i n the slum area  known as the "skid-road", i s characterized by cheap rooming-houses and poor hotels situated above small stores or other business property.  In  the days when the Division received frequent reports involving exposures which had occurred i n bawdy houses, most of these premises were located in this section of the city.  Zone 1 i s a congested area, with a hetero-  geneous population of orientals, Indians, half-breeds of various races, negroes, and single white men and women. The recreational f a c i l i t i e s are a l l commercial and consist of cheap movie theatres, shooting galleries, pool halls and beer parlours. There are numerous small restaurant's which •For the street boundaries of the various Zones, see Appendix B.  - 28 cater to the itinerant population that crowds the poor hotels and roominghouses i n the vicinity.  There are no parks or playgrounds, the only open  green space being the grounds of the Canadian National Railway station. Zone 2 included the remainder of the downtown area and the East and West End of the city.  Here there i s a concentration of apartment blocks and  large old houses converted into furnished rooms and housekeeping accommodation. In many sections of this zone, living quarters'are crowded i n among commercial property.  In the East End there are some family dwellings  but most of these houses shelter more than one family. In the West End section of Zone 2, the outdoor recreational f a c i l i t i e s are very good, since the area borders on Stanley Park and English Bay bathing beach. The East End section does not fare so well, although i t does have some small parks and playgrounds.  For purposes of this study, Zone 3 included  the suburban residential areas of the city.  Those patients who gave an  address outside the City of Vancouver were included i n Zone U. Contrary to the popular conception that a l l venereal' disease patients come from the slums, only L|Q percent of the total repeater group gave their place of residence as Zone 1.  Here i t must be borne i n mind,  that while many of the male patients (like the loggers, miners, fishermen) made the hotels and rooming-houses in'Zone 1 their headquarters when'they came to town, they had no permanent residence i n Vancouver. Twenty percent of the repeaters came from the residential districts of Zone 3, and 22 percent were from outside the City of Vancouver. With regard to the total venereal disease population i n Vancouver there was no comparable break-down by zones. Among the female repeaters a much higher percentage came from the slum area of Zone 1 than was the case with the men, 53 percent as  - 29  against 33 percent respectively, and out of the 30 women who were described as prostitutes among the female repeater patients, 33 of them lived i n this Zone. Only 17 percent of the women repeaters came from the resident i a l districts of Zone 3, and while they gave a street address as their place ofresidence, most of their waking hours were spent i n the beer parlours, cheap cafes and poor hotels i n Zone 1. Nine percent of the group indicated that they lived outside the City of Vancouver, and among these were many Indian g i r l s whose homes -were i n rural areas adjacent to Vancouver but who slept i n town wherever they could get a bed for the night. In terms of venereal disease control, where these repeaters met their sex partners was more significant than their place ofresidence. '','As we have seen from the f a c i l i t a t i o n reports (Table 3) the problem area was that section of the city containing the cheap hotels and rooming-houses frequented by the sexually promiscuous group i n the community. Occupation In considering the occupation factor of this repeater group, i t must be remembered that the Vancouver Clinic i s a free c l i n i c , i t i s . favourably known, and i t i s reasonably accessible. It i s used by those who cannot afford private care or who do not object to coming to a free government c l i n i c .  As might be expected therefore, n analysis of the a  occupational characteristics of these repeaters showed a preponderance of unskilled yrorkers.  Taking into account the fact that the information  on the charts was not always accurate or current, i n cateloguing the patients by occupational groups, only three broad job classifications were used - unskilled, skilled, and c l e r i c a l .  A patient was considered  to belong to the unskilled group i f he was doing manual work that re-  - 30 quired no specific or technical training.  This included those who were  engaged i n primary industries like logging, mining, fishing, longshoring, as well as those i n the service trades i n laundries, canneries, cafes, and in domestic service.  In the skilled group were included a l l those who were  required to have some special qualifications, such as workers i n transportation services, i n industrial or building trades, artisans of various kinds, cooks, barbers, hairdressers. The third classification of clerical workers included a l l the "white collar" people such as merchants, salesmen, clerks, stenographers, students, musicians.  Because of the importance of  V ncouver as a seaport and the specific problem of the transient seamen a  coming i n and out of Vancouver, this group of patients was separately listed.  Similarly patients who stated they were unemployed were so  classified. An analysis of the characteristics of the repeater group from the point of view of their occupational status showed that among the men, approximately two out of three were i n the unskille d class, 12 percent were skilled workers, and only 2 percent were i n clerical jobs. Seamen accounted for 12 percent of the male repeater group and 9 percent indicated that they were unemployed. The female repeaters showed a different grouping with a much higher percentage (I|l percent) classified as unemployed.' This included the women who had no visible means of support but lived from day to day on the generosity of their male friends.  Very few  of these women were interested i n gainful employment; they enjoyed their promiscuous existence, and as a venereal disease control problem they were being sought continually by the epidemiology staff of the Clinic.  Over I4O  percent of the female repeaters were unskilled workers, and out of the total group of 130 there were only two women i n skilled trades and two  - 31 doing clerical work. Housewives accounted for lh percent of the female repeater group. Table 5 shows the correlation between family status and occupational classification among the repeater patients. With the men, there was approximately the same proportion of unskilled workers i n both the attached and unattached groups, while the percentage of clerical workers was considerably higher among the men who were living as part of a family group. Unemployed men'constituted 12 percent of the unattached group as against 5 percent of the attached group. Among the unattached female repeater patients, hi percent were engaged i n menial jobs with the same proportion classified as unemployed. In the attached group over half the women described themselves as housewives with the remainder either unskilled workers or unemployed. TABLE 5 REPEATER GROUP BY FAMILY STATUS AND OCCUPATION Occupation  Attached Unattached Total M Alale Female ale Female No. Percent No. Percent No. Percent No. Percent No. Percent  Unskilled  95  6h  hQ  Skilled  17  12  Clerical  1  -1  17  12  Seamen Housewives Unemployed Total  hi  h2  62  6  21  191  l  1  10  1U  1  h  29  8  2  2  h  6  7  2  9  13  26  8  3  15  53;  18  5  5  6  22  lh  22  100  28  100  3U5  100  3  17  12  h8  hi  1U7  100  102  100  3 68  55  - 32 Multiple Re-infections A repeater was defined as a patient .-who had acquired a venereal disease more than once, according to the records of the British Columbia Division of Venereal Disease Control, and out of the total repeater group 60 percent of the men and 32 percent of the women had repeated their i n fections only twice.  For the majority of these patients, both male and  female, the length of time between the f i r s t and second infections was from one to two years. Multiple re-infections (or more than two) occurred i n 52 percent of the totalrepeater group with, as we have seen, a much higher proportion of the women patients repeating their infections more often than was the case among the. male patients. Only 9 percent of the male repeaters had more than four infections, while 22 percent of the women were so reported.  One woman and two men h d had eight different infections, a  and one female repeater was reported to the Division as having been i n fected nine separate times.  Harry B. and Tom S. were f a i r l y typical of  the chronic repeater group. In 1948 Harry B. was i n his late twenties, he described himself as a labourer, and he lived i n the slum area of the city. He was single and nothing was known about him other than that he was Canadian born, his sex contacts .were usually women whom he had met on the street while he was drunk. He had been i n the Canadian army where he v/as twice diagnosed as having gonorrhoea but these infections were not included i n his British Columbia medical record. In the six months period from January to June, 19U8, he was treated twice for new gonorrhoea! infections. There was no recorded information about him as a person, his family background, his growing up experiences or his work adjustment. The root causes of his promiscuous behaviour were not known. Only his medical history was charted. Tom S. was an Indian who had been dishonourably discharged from the Canadian army. He lived i n Zone 1, was an unskilled worker, and was i n his middle twenties. Following his army discharge he had made the rounds of  - 33  the social agencies, he had been provided with transportation to Eastern Canada where he said his home-was, but he sold the warrant'which had been issued to him, and he was sent to the provincial gaol. He was given a psychiatric examination, but was diagnosed as a chronic complainer and not one i n need of psychiatric treatment. He described his sex partners either as prostitutes or as women whom he picked up on the street. At '.one time he stated that he was divorced and had four children who were living with his-parents i n northern British Columbia but i t was f e l t that this information was not reliable. From the l i t t l e that was known about this man he appeared to be completely irresponsible and incapable of much change i n behaviour pattern. The repeater patient-with the highest number of infections was a woman who had been diagnosed as having a venereal infection nine . different times over a period of six years.  i  Jane L. had had syphilis, once and gonorrhoea eight times. In 19hQ when she was 2k years of age, she Y/CLS described as a chronic alcoholic who spent most of her l i f e in the beer parlours in Zone 1. She .had been arrested twice on a charge of pro.stituting, and once for assault. She had two illegitimate children. From her clinic record, she had come to Vancouver from the prairies early in the war, and nothing was known about her prior to that time. She became illegitimately pregnant soon after she • arrived-in Vancouver and was under the care of a social agency. She managed to work and support her f i r s t child, but following the birth of her second illegitimate child two years later, she began to neglect her children. After a long and bitter struggle with her, the authorities f i n a l l y obtained permanent guardianship over her children, on the ground of neglect. At the time of the study, she was rather an attractive white g i r l whose male companions were negro servicemen from the United States. According to her she married one of them, but because of her criminal record was prohibited from crossing into the United States to join her husband. Because of the way i n which this Batient i s now l i v i n g , she i s under almost constant police surveillance and thus she can be examined frequently by the clinic staff at the Examination Centre at the City Gaol. Although she i s a public health nuisance, she i s not a problem because she-is reasonably accessible. How can she be helped? Apparently the social agency - resources were exhausted at the time her children had to be removed from her care. What can be done about her by the Division of Venereal }  -  3U  Disease Control? At .this point the only nswer seems to be to keep her cooperating with the clinic, and so far this has been accomplished by the epidemiologist who i s responsible for the operation of the City Gaol Examination Centre-. This 'worker .is particularly skilful in- working with anti-social people who have lost their faith in humanity, and by her warmth and understanding she has been able to give this g i r l , for perhaps the f i r s t time i n her l i f e , the experience of a positive relationship with someone i n authority. Actually, the only person in the world to whom this g i r l i s important, i s the worker who i s concerned about her health. For this g i r l , her venereal condition i s a relatively minor affliction but because of the reg rd .she has for this worker, this otherwise completely anti-social individual has been able to cooperate in:aeporting for ' examination and treatment whenever requested to do so by the worker. So far as this patient i s concerned, the effectiveness of the venereal disease control programme rests on the quality of the relationship inhich this one worker can maintain between the g i r l and herself. a  a  Types of Contact Named What kind of encounters resulted i n a new venereal disease for these repeater patients? As might be expected 75 percent of them chose as their sex partners people who were strangers to them except for a chance meeting on the street or elsewhere, or who were casual friends.  What was  significant was the comparatively few professional prostitutes named as contacts by the male repeater groupj before the; war, the prostitute was regarded ,,s a formidable obstacle to venereal disease control.  In 19U8  prostitutes were named as contacts by only 9 percent of the men i n the repeater group.  The promiscuous amateur, the "good-time g i r l " had replaced •  the prostitute as the chief venereal disease menace. Other Problems Alcohol s a precipitating factor was named by 5U percent of the a  male and 70 percent of the female repeater patients, and 19 out of the 130 females were described as chronic alcoholics.  - 35 With regard to police records, here again the female repeater group showed more homogeneity with 70 percent of them having been known either to the adult or to the juvenile court authorities while only l U percent of the male repeaters had a police record. Most of the female repeaters were living on the fringe of crime; 30 pe rcent of them were prostitutes,^and five were active drug addicts. The offenses with which ;  these women were charged were primarily under the morality sections of the Code or those relating to drunkenness, although some of the women had been charged with other offenses such as theft, assault, breaking and entering, robbery with violence, etc. Many of them had been known to the juvenile court authorities before becoming adult offenders. According to the c l i n i c charts, only lit percent of the male repeaters had a police record but this information may not be accurate since the male charts gave fewer details than the female charts. However, of those who were reported to have been i n difficulties with the police, 73 percent of them had had multiple infections. With regard to other problems manifested by the male repeater group only one patient was a convicted drug addict, and three were described as homosexuals.  There was a history of mental illness in only six  patients (four men and two women); three of the women were described as mental defective; and six repeaters (four men and two women) were diagnosed as having syphilis of the central nervous system. Among the women repeaters, nearly one-third of them had had illegitimate children while three of the men patients had been named as the father of children born out of wedlock. -^For the purposes of this study, a woman was considered to be a prostitute i f she had been convicted of a morality offense under Sections 228 or 229 of the Criminal Code of Canada, or i f she was described by her sex partners as having given favours i n exchange for the payment of money.  - 36  A Non-Repeater Group Are the patients who do not become re-infected with a venereal disease, very different from those who do?  To answer this question a  study was made of 100 consecutive patients, 5>0 men and SO women, who were diagnosed as having a venereal infection i n January and February, 1°U6, who were not previously known to the Division, and who, up to the end of April, 19h9 had not been reported as having become re-infected.  The  repeat interval was taken as the length of time between the f i r s t and second infections of a repeater patient, and to arrive at an average repeat interval for the group, the record of every tenth repeater patient was considered.  For the male repeaters, the median repeat interval was  15.5 months, and for the females 13.0 months. Therefore, any patient who was reported as a newly infected person i n January, 1°U6 and who had not become re-infected by the end of April, 19h9, was'considered to be a nonrepeater. Among these hundred non-repeater patients, the highest proportion (63 percent) was s t i l l i n the 20 to 29 year age-group. However, there were fewer unattached people among the non-repeaters, only I4.2 percent f a l l i n g into this category whereas i n the repeater group over 70 percent were living apart from their families.  The racial origin of the patients was  f a i r l y comparable i n both groups, but so far as residential area was concerned, almost half of the non-repeater patients came from the residential districts i n Zone 3, and only 17 out of the 100 gave Zone 1 as their place of residence.  Among the non-repeaters, 50 percent of the male patients  were engaged i n skilled or clerical jobs, while among the repeater group only 15 percent of the men were i n these categories. Among the women, the difference was even more striking, with 10 out of the 50 i n the non-  - 37 repeater group doing jobs that required special training, and only four out of the 130 women repeaters similarly engaged. In 19U8,  20 percent  of the repeater patients were either unemployed or had no regular occupation; i n the 19U6 non-repeater group, only 8 percent were so classified. Alcohol as a factor i n facilitating the spread of venereal disease  was-  much lower among the non-repeater patients, with only one-third of these patients indicating that they had been drinking prior to the incident that resulted i n their infection.  Among the repeaters, half of them stated  that they were under the influence of liquor at the time.  None of the men  and only two of the women i n the non-repeater group had any police record; only two of the female patients had had-illegitimate children; and only one was described as a prostitute. • Patients who did not repeat the experience of acquiring a venereal infection, therefore, were about the same age as the repeaters, but their home background w s more stable, and they were engaged i n more a  skilled employment; fewer of the patients admitted that alcohol was a factor which influenced their behaviour at the time of the encounter which • resulted i n their infection; and there was less evidence among these patients of other symptoms of social disorganization such as police records and illegitimate pregnancies. The present study makes clear that i n a representative six months period at the Vancouver Clinic, nearly every third newly diagnosed patient was a repeater.  Recidivism was higher among the female patients  than among the males, with more of the female repeaters having multiple reinfections.  From the l i t t l e information that was available about these  repeater patients, the majority of them appeared to- have d i f f i c u l t i e s i n personal relationships, as evidenced by lack of family ties, broken homes,  - 38 marital discord, casual sex partners. A higher percentage of the women' were leading a rootless existence than was the case with the men.  Most of  the men coming to this free clinic were unskilled workers and almost half of the women were either unemployed or had no employment.  In terms of age,  two-thirds of the repeaters were between 20 and 30 years of age, the average age of the women being lower than that of the men. Because the women were more often a problem i n contact tracing, they were better known to the epidemiology section than the men, and their medical records contained more detailed information than the men's charts. Whereas the men usually reported to the c l i n i c with symptoms which responded quickly to treatment, most of the female repeaters were brought i n as the result of epidemiological efforts because they had been named as contact, to a known infection.  These women had no symptoms; treatment merely incon-  venienced them; and the routine follow-up to ensure that they were free from infection was more important to the Division of Venereal Disease Control than i t was to the women themselves. The female repeaters were a more homogeneous group than the men. For most of them their venereal condition was a relatively minor complication i n a l i f e situation that included many more serious social i l l s prostitution, illegitimacy, alcoholism, drug addiction.  The majority of  these women were living a precarious existence, which they preferred to a more ordered way of l i f e because i t made few demands on them. This repeater study, revealed how l i t t l e was actually known about these patients as people, about their background, and about the underlying causes of the behaviour which was resulting i n repeated venereal i n fections for them. Viewed as a group, they presented a bleak picture. The problem of a venereal disease was incidental to them, and the eradication of this menace would make l i t t l e basic change i n their lives.  -  However, a more individualized approach to the problem of venereal  39  disease  might have yielded information about resources within the personality structure of- these people which could have .been utilized in enlisting their cooperation i n the programme of venereal disease control.  How much .  of the problem of recidivism was due to lack of understanding on the part of the infected individual of the relationship between his behaviour and his repeated infections; how many of these repeater patients were confused and behaving in a sexually promiscuous way in a neurotic attempt to satisfy their basic needs? V/as the acquisition of repeated venereal infections . symptomatic of a more deep-seated personality disorder in which the selfdestructive processes could not be reversed with the professional s k i l l s available either at the c l i n i c or in the community? more information was needed.  To find the answer,  To be effective, treatment had to be geared  to the needs of the individual patient and this could only be done when these needs had been assessed.  - ho CHAPTER 3 THE PROVINCIAL CONTROL PROGRAMME  In British Columbia, since 1919 the government has been responsible for venereal disease control.  Until 1936 the programme was under the  direct supervision of the Provincial Health Officer.  By then the growing  incidence of these diseases called for a more specific direction to the programme and a separate Division of Venereal Disease Control was set up under the Provincial Bo rd of Health i n the Department of the Provincial a  Secretary.  When the Department of Health and Welfare was established i n  19U7, Venereal Disease Control became one of the Divisions under the Health Branch of the new Department.  Control measures are financed by funds from  the provincial government, supplemented by an annual grant from the federal government.  In 19U8 the venereal diseases cost the taxpayers of British  Columbia approximately $173,500 while $U3,500 of federal tax money was diverted to this province for i t s venereal disease control programme.^ The venereal diseases emerged as a serious public health menace during the f i r s t World War.  The human misery and destruction created by  these whispered diseases had reached such proportions by 1919 that growing public opinion demanded government action on a national scale to institute proper control measures.  Accordingly federal funds were made available to  the provinces on a matching basis for the establishment of provincial venereal disease control programmes. British Columbia was one of the f i r s t provinces to take advantage of this federal offer, and i n 1919 this province passed i t s f i r s t Venereal Diseases Suppression Act. This •'•-'-British Columbia, Venereal Disease Control Programme of the Health Branch Provincial Department of Health and Welfare, Victoria, B.U. 19WJ, page 3.  p  - ia legislation provided for compulsory treatment of a l l persons suffering from a venereal disease and i t required private physicians i n the province to report a l l newly diagnosed venereal infections to the Provincial Health Officer.  By 1920 British Columbia's venereal disease programme was well  under way; two free clinics had been established i n Vancouver- and Victoria; in areas where there were no free clinics, doctors received payment from the provincial government for professional services to indigent patients suffering from a venereal disease; and even for their private patients, doctors received free drugs for the treatment of venereal diseases. Under the inspired leadership of Dr. Henry Esson Young, the Provincial Health Officer, the coopration of professional and lay groups through the province was enlisted; the churches joined i n the fight against these public enemies; and leading citizens throughout the province were given the responsibility of organizing public meetings at which information about the venereal diseases was broadcast to the people of British Columbia. In 1930, reviewing the f i r s t ten years of the provincial programme,, the Provincial Health Officer acknowledged the gains that had been made on the medical front by crediting the venereal disease programme with reducing the mental hospital admissions by £0 percent, but he deplored the lack of a preventive aspect to the programme. -As Dr. Young saw i t nearly 20 years ago, the problem i n venereal disease control was "how to control the infected person".  At that time Dr. Young f e l t that a programme of  venereal disease prevention was more than just a public health measure and he looked to the influence of the home and the church to encourage young people to live i n such a way as to avoid the risk of a venereal infection. He saw the role of the health department as one of treating and curing (or at least rendering non-infectious) every person i n the province who  - U2  was suffering from a venereal disease, and his goal was, by education, to bring the venereal diseases out into the open where they could be dealt with in the same way as any other contagious disease. By 1936 the venereal disease problem had outstripped the control f a c i l i t i e s and a separate Division of Venereal Disease Control was set up within the Provincial Board of Health, with headquarters i n Vancouver. The Vancouver Clinic became the main diagnostic and treatment centre for the province-wide activities of the Division.  , .  The year 1938 was a banner one for venereal disease control i n • British Columbia when i t brought Dr. Donald H. Williams to the post of Director of the Division.  Dr. Williams was a visionary who recognized  that venereal disease control was more than a medical problem, and that to be effective the control programme must attack the a l l i e d social, legal, and moral issues on a broad front.  He saw the need for community action,  and within a month of his appointment, he had formed an Advisory Committee on Venereal Disease comprised of representatives of a l l the health and welfare organizations i n the province.  An Educational Supervisor was  appointed to the Division and public education about the venereal diseases became one of the Division's most important functions. Every medium for disseminating information was u t i l i e d and a veritable "blitzkreig" of z  ,  venereal disease information was launched on the public. An all-out campaign against organized houses of prostitution was launched.  Labelled "disease dispensaries" by Dr. Williams, the  fallacy of segregation of prostitutes into specific areas and of medical certification of these women, was vigorously attacked by the Division of Venereal Disease Control. The medical profession i n British Columbia was urged to refrain from issuing certificates to women stating that they were  - h3 free from a venereal infection, and the Division based i t s arguments on the fact that while such persons might have no evidence of a venereal disease, they could become infected by their f i r s t exposure following the examination.  It was pointed out that a certificate i n the possession of a  prostitute, only served to make her a greater venereal disease menace,, by giving her customers a false sense of security. In the early days of the war there was the closest working relationship between the military authorities i n British Columbia and the Division of Venereal Disease Control, and when-Dr.-Williams was called to Ottawa to organize the national programme for the control of venereal disease i n wartime, he used the British Columbia set-up as a model. In 19U3 the National Venereal Disease Control Conference adopted a FourSector strategy against the venereal diseases by which they would be attacked simultaneously on the Health, Welfare, Legal and Moral Fronts. The battle on the Health Front was the responsibility of the various provincial Divisions of Venereal Disease Control, and a .Six-Point programme was outlined. This included the provision of proper health education f a c i l i t i e s , good medical care, laws to abolish quackery i n the treatment of venereal disease, campaigns to encourage prenatal blood-testing and pre-marital examinations, and the development of efficient contact-tracing. British Columbia's programme has continued to develop along the lines recommended by the National Conference, and i n 19H8 the objectives of the programme were outlined as follows:-^ "1.  Health (a) - Wholesome, dignified health education concerning syphilis and gonorrhoea.  •^British Columbia Department of Health and Welfare, Division of Venereal Disease Control, Venereal Disease Information for Nurses, 19U8, page U.  - hh (b)  Adequate diagnostic and treatment f a c i l i t i e s for a l l persons suffering from venereal disease. (c) S k i l l f u l contact tracing and case holding. (d) Early adequate prenatal care including blood tests for expectant mothers to prevent prenatal syphilis. (e) General", health examination including blood tests for syphilis before marriage. 2.  Welfare (a) (b) (e) (d)  3.  Adequate minimum standard of living to ensure economic and social security. Proper housing f a c i l i t i e s . Opportunity for wholesome recreation. Skilled case work service as part of medical care to help problem patients understand their medical condition and how i t i s directly related to their behaviour pattern.  Legal (a)  Effective legislation providing for compulsory examination for venereal disease and necessary treatment of uncooperative ' , individuals. (b.) Vigorous law enforcement to suppress conditions of vice. Close cooperation between the health and law enforcement authorities i s essential i n order to control the promiscuous element i n a community, since the spread of venereal disease goes hand i n hand with other problems such as prostitution, bootlegging and i l l i c i t drug t r a f f i c . (c) Cooperation with civic authorities to improve unsavory community conditions that facilitate the spread of venereal disease. There should be local by-laws to provide for disciplinary action by way of cancellation of license against owners and operators of premises frequently named as a place of meeting or exposure which resulted i n a new venereal infection.  k*  Moral On the moral front the fight must be waged i n the home, in the church, and i n the school to raise standards of behaviour, to strengthen family ties and to encourage every citizen to accept his rightful responsibilities. The control of venereal disease, i n the last analysis, must be the responsibility of the individual." In the over-all programme of the Division of Venereal Disease  Control i n British Columbia, the aim of the Division i s to seek out a l l the infected individuals i n the province; to ensure that they receive early and adequate treatment; and to educate them to take responsibility for  -  U5  safeguarding their health and the health of others by behaving in such a way as not to acquire a venereal infection. ORGANIZATION OF THE DIVISION There are five operating sections of the Division of Venereal Disease Control - Administration, Diagnostic and Treatment Services, Epidemiology, Education and ^ocial Service.  The Director of the Division  meets once a week with the Assistant Director and the heads of the various sections, to discuss problems of operation and to formulate policy. The Assistant Director shares the executive responsibility;and supervises the Diagnostic and Treatment Services Section of the Division. Both of these senior officers are f u l l y qualified medical practitioners with special training in public health. The base of operations of the Division i s the Central Office, 1  which i s located i n the old frame building on the Vancouver General Hospital grounds that has housed the Vancouver Clinic since 1920.- From here the Director of the Division supervises the work of the Division staff, and coordinates the activities of the local health units and the private physicians throughout the province i n controlling venereal disease. Central Office contains the provincial index of a l l venereal disease patients diagnosed and treated i n British Columbia. Whenever a diagnosis of a venereal infection i s established either by a private physician or at a public clinic, a notification form giving the name of the patient and other identifying information, together with particulars of the infection, i s forwarded to the Central Office of the Division. Here each new case i s assigned a record number, and an index card giving the name and number of the patient i s inserted in the provincial index.  The patient's medical  history and any correspondence about him, bears the original record number  - U6 assigned to him at the time of his f i r s t diagnosed infection i n British Columbia.  Subsequent infections are reported to the Division and numbers  assigned to them for statistical purposes; although these numbers are entered on the index card as they are assigned, the patient's record i s f i l e d under his original number. Besides the provincial index, Central Office f i l e s contain the medical records of a l l patients examined or treated i n the clinics at Vancouver, New Westminster, Oakalla, Girls' Industrial School and Juvenile Detention Home, and the Vancouver City Gaol Examination Centre.  Medical  records for the Victoria and Dawson Creek Clinics are kept locally, -with identifying'information only being sent to the central index.  Similarly  the only information which the Division has about patients of private physicians i s what i s on the notification form sent i n by the doctor. Admini stration 'The smooth running of the entire organization depends on the Administration Section.  It i s responsible for the efficient operation of  the records system of the Division, and i t collects and compiles statistics relating to the incidence of venereal disease in the province.  The pur-  chasing and distribution of a l l medical and other supplies comes under the Administration Section. Diagnostic and Treatment Services This Section of the Division i s responsible for the operation of the free clinics, for the distribution to private physicians of free medication for the treatment of venereal disease, and for; arranging payment to doctors for professional services rendered to indigent patients in areas where there are no clinic f a c i l i t i e s .  This Section also provides  consultative service i n a l l branches of venereology to the practicing  -1*7  physicians i n the province. • Free out-patient clinics established i n Vancouver and Victoria ' have been i n continuous operation since 1920, and today there are also free c l i n i c s at New Westminster and Dawson Creek.  Clinics staffed by  members of the Vancouver Clinic"are conducted at Oakalla Prison Farm, the Juvenile Detention Home and the Girls' Industrial School.  At the Vancouver  City Gaol, a l l persons i n custody each morning are examined for venereal disease by public health nurses from the Vancouver Clinic, who have been specially trained i n examination techniques. The medical staff of the various clinics i s composed of general medical practitioners i n the local areas, who are employed on a part-time basis.  In addition, specialist consultants i n syphilology, urology,  gynecology, neurology, cardiology, pediatrics, dermatology, and diseases of the eye, ear, nose and throat, are attached to the Vancouver Clinic.  Any  physician i n the province can refer cases to the Vancouver Clinic for consultation by the appropriate specialist, or consultative service w i l l be given by correspondence to doctors i n the outlying areas. The Vancouver Clinic, which i s the medical nerve-centre of the Division, i s staffed by ten part-time physicians besides the eight consultants mentioned above, seven registered nurses, eight public health nurses, and three social workers.  At each c l i n i c session, there are at  least two general practitioners, one for the male clinic and one for the female c l i n i c , and each consultant i s at the c l i n i c one day a week i n accordance with a set schedule.  The Clinic i s i n operation every morning  (except Sunday), Monday and Thursday evenings, and Wednesday afternoon. In addition a special pediatricclinic i s conducted every Monday afternoon. For diagnostic purposes there i s a laboratory set up at the Vancouver  . - U8  Clinic, but the general laboratory services for the Division are provided by the Division of Laboratories of the Department of Health and Welfare. Weekly conferences of a l l the medical staff review the cases which present some diagnostic or treatment problem.  The recommendations  of the various consultants are discussed by the group and the patient receives the benefit of the combined thinking of the medical staff.  These  conferences also have an educational value for the staff members, and papers describing the latest advances i n medicine as they, relate to the venereal diseases are presented from time to time.  The heads of each of  the other Sections of the Division are invited to sit i n on these medical conferences.  The Division keeps i n close touch with the medical profession  in the province by means of letters, bulletins, and articles i n the, various medical journals, and i n this way. the Division keeps the doctors up-to-date on improved methods of diagnosing and treating venereal diseases. .The 1  aim of the Division i s to keep i t s programme constantly before the practicing physicians, and to enlist their cooperation i n the matter of complete reporting of cases to the Division, Epidemiology In a programme aimed at eradicating the venereal disease menace in British Columbia, i t i s not sufficient that medical care be made available, free of charge, to a l l infected persons.  Aggressive action  must be taken to seek out the undetected, untreated reservoirs of infection in the community, and to bring the spreaders of disease under prompt and 1  adequate treatment.  This i s the work of the Epidemiology Section and i t s  staff of public health nurses.  The Provincial Supervisor of Venereal .  Disease Epidemiology directs case-finding throughout the province. Six of the public health nursing staff work i n the City of Vancouver, while one  - h9 nurse travels throughout the rest of the province, acting as consultant i n V.D. epidemiology to the local medical health officers, health unit personnel, and to the generalised public health nurses who; are responsible for case-finding i n areas outside Vancouver and Victoria. As a venereal infection i s usually acquired through intimate contact with an infected person, i t i s the newly diagnosed patient whose aid must be enlisted in locating the people in.the community who are spreading venereal disease. -Accordingly, whenever a patient i s diagnosed as having a venereal infection, he i s carefully questioned about the people with whom he was i n contact during the probable incubation period of his infection, as well as during the period prior to treatment when the patient himself was i n an infectious stage.  In the clinics, this i n -  terviewing i s done by the public health nurses.  Private physicians are  encouraged to take responsibility for examining the contacts of their patients, and on the notification form that i s required to be sent i n to the Division, there i s space for the doctor to indicate whether he has taken this responsibility, or whether he prefers that the necessary followup be done by the staff of the Division.  If the contact i s outside the  City of Vancouver, the information i s forwarded to the appropriate health ' unit or public health nurse in the local area.  If the contact i s reported  to be in Vancouver, then the Division epidemiologists take over.^ Armed Vancouver a small share of the contact-tracing and case-finding i s done by the public health nurses on the staff of the Metropolitan Health Department. To coordinate this work one of the nurses from the Metropolitan"' staff works full-time at the Vancouver Clinic. In recent years" efforts have been directed toward turning over more and more of the venereal disease epidemiology to the Metropolitan, nursing staff, but there i s now some question as to the efficacy of including this work i n a generalized nursing service in an urban area as complex as Vancouver, v/here success i n venereal disease epidemiology depends on a specialized knowledge of the problem areas in the city, and the people who inhabit them. It requires an accumulation of knowledge about the venereal disease population, to do^an effective casefinding job among them. The public health nurses on the ivision staff have this advantage. • " -  , - 5o with a l l the available information, they set out to find the person who  •  has been reported to the Division as having been exposed to a knovm venereal infection.  Once the contact has been located, then the nurse must'  persuade that person to have a proper medical examination.  This takes  great s k i l l on the part of the nurse, for to achieve her goal (which i s tohave the person examined for venereal disease), she must establish a relationship of confidence with this person to whom she i s a stranger.. Often the nurse meets great hostility, because i n talking to a contact, the nurse cannot reveal the identity of the patient who gave the contact information. If a person has been exposed to a known infection, that person i s a potential new case.until he has been examined, since absence of symptoms i s no safeguard. Contacts are given the choice of going to their own doctor or reporting to a free c l i n i c for the examination; i f they go to a private physician, the Division checks vdth him as to the results of the tests. Besides locating new cases, this section i s responsible for seeing that old cases remain under care until they have completed the prescribed course of treatment and follow-up. This i s known as case-holding and i s another important part of the control programme.: A patient who has been inadequately treated has a false sense of security; without the patient being aware of i t , his disease may become active again, and he may become a public health menace once more. Because the manifestations of gonorrhoea and syphilis can be so slight as to e scape the notice of the patient, he or she must be persuaded that treatment i s required.  Treatment can become  an irksome burden, and much of the time and energy of the epidemiology staff are spent i n tracing patients who have lapsed from treatment, or who require further surveillance before they can be discharged as having had sufficient treatment.  -51 When a l l efforts to enlist the cooperation of a patient f a i l , the epidemiologists can refer the matter to the local medical health officer-. He has power'under the Venereal Diseases Suppression Act of 19h7, to compel a person to submit to a. medical examination whenever the medical health officer has reasonable grounds for believing such a person might have a venereal disease or might have been exposed to.an infection.  Failure to  comply with the order of the medical health officer i s an offence under the Act, and i s punishable by imprisonment.  Similarly the health officer can  order a person whom he knows to be infected, to take and continue adequate , treatment; again failure to comply i s punishable by imprisonment.  The Act  also provides for compulsory examination, and i f necessary, treatment of a l l persons i n custody i n the province, whether awaiting t r i a l or serving a sentence.. Imprisonment for failure to' carry .out the order of the medical health, officer i s usually set at the time required to adequately examine or treat the offender. In practice, action under the Venereal Diseases Suppression Act i s used'as a last resort, only when the person i s known to constitute a.public health menace. The primary function of the venereal disease control programme i s not to punish, but to safeguard the general • public from the dangers of infected, promiscuous persons. Another responsibility of the Epidemiology Section i s to keep track of the f a c i l i t a t i o n information that i s gathered at the time the patient i s asked to give a history of his contacts. The role of epidemiology in the programme of venereal disease control i s today assuming I major importance,. because this i s the means whereby infected persons are brought under treatment early i n the course of their disease, and are supervised until they have completed the prescribed course of treatment.  - $2 Section of Education Education about the venereal diseases i s a job shared by the Division of Venereal Disease Control and the Division of Public Health Education, with a l l undertakings relating to venereal disease education being jointly planned by the two Divisions.  The Venereal Disease Division  has major responsibility for the professional education which includes keeping the medical practitioners throughout the province abreast of developments i n venereology, as well as for organizing training courses for public health nurses from the University of .British Columbia,, and for nurses i n training at the Vancouver General Hospital. In order to coordinate the educational activity of the Division, one of i t s public health nurses has been appointed Nursing Educator, and i t i s hoped that she w i l l be able to help other nurses' training-schools i n the province to organize their curricula to include lectures i n venereology. The Nursing Educator i s also i n charge of the distribution of the venereal disease literature available, from the Division.  The most  recent publication to be distributed i s a good example of venereal disease education g e a r e d to the tastes of the greatest proportion of patients who come to a free c l i n i c for treatment.  It i s entitled "My .Story", i t s format  i s that of a popular magazine, and the articles are written i n a "true confessions" vein. They are very well done and get their point across i n a way that a more formal pamphlet would not achieve.  When copies f i r s t  appeared i n the waiting rooms at the Vancouver Clinic, they were read avidly by the patients. This kind of venereal disease literature i s in line with the policy of the Division, which i s , that education about venereal disease should be directed to the person who has the disease. In the clinics, patient education i s stressed, and the public  ~*3 health nurses in a l l their work with'patients, carry out on an individual basis, a continuous programme of venereal disease education.  There Is now  some question as to the effectiveness of widespread propoganda about venereal disease directed toward the general public, since i t i s f e l t that the information often f a i l s to reach that section of the public that i s becoming infected.  In the experience of the armed services, knowledge  about the disease had relatively l i t t l e effect on whether or not a soldier became infected. Judging from venereal disease studies made of military' personnel during World War II, the problem seemed to be rooted in the personality of the individual soldier.  Those who became infected were more  immature, more unstable, more prone to drink to excess and more discontented with army l i f e than the soldiers in the various control groups who did not acquire a venereal disease.. With most of .the soldiers who contracted venereal disease, promiscuous behaviour was precipitated by some acute emotional disturbance.-^ Social Service The specific contribution which social workers can make i n a venereal disease control programme has been recognized i n British Columbia, and three professionally trained case-workers from the Welfare Branch of the Department of Health and Welfare have been detailed to staff the Social Service Section of the Venereal Disease Division.  Under this administrat-  ive set-up, social work i n venereal disease control i s included i n the over-all programme of provincial social services. At the same time, these ^Lumpkin, Margaret K., The Individual and Venereal Disease, Cooperative Study, Department of PubTic Health, lale University.and Venereal Disease Control Division, U.S. Public Health Service, New Haven, Conn. Julyj 19U8. (mimeo.) Chapter !(..  - 5k case-workers are regarded as an integral part of. the staff of the Division and are responsible to i t s director i n a l l matters except those relating to administration.  Liaison between the welfare Branch ,and the Division i s  maintained through the Medical Social Work Consultant on the Welfare staff who, at the present t i m e / i s assuming supervisory responsibility for the social services i n the Division of Tuberculosis Control as well as i n the.' venereal Disease Division. Within the Division, the senior worker acts as the case work supervisor and i s responsible for planning the social work programme. Case work services are provided at a l l the sessions of the Vancouver Clinic; consultation on social problems arising at the other clinics i s available to the workers staffing these clinics; and in areas where there are no clinics, the health workers who are responsible for venereal disease control u t i l i z e the services of the provincial social work staff for patients who .present special problems. Mien the Division of Venereal Disease Control was set up in 1936,  i t included a Social Service Section.  At that time the concept of  venereal disease epidemiology was new and the social workers, because of their knowledge of community conditions, were given the job of case-finding; they had to seek out the undetected reservoir.of infection by bringing i n for examination a l l persons who had been i n contact with a known venereal disease.  At the same time the social workers were responsible for seeing  that known cases continued to take regular treatment.  In 1936  v/ith  approximately 60 percent of the patients unemployed, the work of the Division had to be coordinated with that of the other social agencies and organizations in-the community, and the Social Service Section took over the supervision of admissions and discharges at the Vancouver Clinic.  55 When time permitted, brief social histories were prepared on a l l new patients, and patients being discharged from the Clinic were given special counselling to ensure that they understood the recommended follow-up procedure. The war years brought special problems i n venereal disease control when young g i r l s from a l l parts of the Dominion flocked into Vancouver to share i n the excitement of war-time l i v i n g i n a big city.  In cooperation  with the City of Vancouver and the Vancouver Council of Social Agencies, the Division of Venereal Disease Control was instrumental i n setting,up a . hostel to which g i r l s who were just beginning a l i f e of prostitution could be sent until they had been treated for a venereal disease or until some plan for their rehabilitation could be made. Admissions to the hostel were arranged through the Social Service Section of the Venereal Disease Division.  The venture ultimately f a i l e d because the g i r l s who needed to  live under supervised conditions resented any attempt to redirect their , . . . . energies; they were not economically dependent because work was easy to,.get; and they lived what seemed to them an exciting existence. By contrast plans designed to give them a more stable way of living had no' appeal for them. After the hostel was closed, the social workers on the Division staff continued to maintain a case-work relationship v/ith the girls, who wanted help, and the resources of other agencies were u t i l i z e d to help re-establish these g i r l s i n the community. When the Division was re-organized i n 19U5, the Social Service Section was relieved of i t s case-finding and case-holding functions to allow the social workers to concentrate their efforts on the social problems presented by the individual patients, and on the community conditions that were impeding progress i n controlling the venereal diseases. The  - 56 community problem of facilitation continued to be a responsibility of the Social Service Section until 19U8, when i t was taken over by the Epidemiology Section. At that time i t was agreed that since i t was the public health nurses and not the social workers who were doing the contact i n vestigations and follow-up of patients i n the community, facilitation was properly a function of the Epidemiology Section. The facilitation job i s now shared by a l l the Sections, because the entire Division.is v i t a l l y concerned with a l l community problems as they relate to the control of .. venereal disease. Until May 19U7, the social work staff at the Vancouver Clinic acted as liaison between the Division and the Vancouver Police Department in arranging to have  iromen  i n custody examined for venereal disease.  Many times, women being sought by the epidemiology workers were released from custody before, the clinic staff knew these patients were i n gaol. Those who were caught i n the police net had to be brought up to the Vancouver Clinic under police escort; this interfered with their court hearing; i t was time-consuming for the police officers,' and i t was embarrassing for the Clinic to have patients brought into the waiting-rooms under guard. Early i n 19U7 changes i n the Police Department and the passage of the new Venereal Diseases Suppression Act made possible the setting up of a medical examination centre at the City Gaol, so that examination for venereal disease became a routine procedure for a l l women in custody. Later this was extended to include blood-testing of a l l male prisoners. When this examination centre was established, liaison with the Police Department became the responsibility of the public health nurse i n charge of the centre. By 19U8 the focus of the Social Service Section had become the "problem patient" - that i s , the patient whose medical condition was  -57 complicated by some personal difficulty.  For patients coming to the  Vancouver Clinic, case work services were available to them from the c l i n i c social workers; outside the City of Vancouver, patients with problems were referred to the social workers i n the local area by the public health nurse who was arranging the patient's medical care.  Private doctors were en-  couraged to use the social service f a c i l i t i e s of the Division for Venereal disease patients under their care who needed help i n working through some of their non-medical problems.  '  At the- Vancouver Clinic, patients who were emotionally disturbed by their infection or y/ho were upset by the diagnostic; and treatment procedures were referred to the social workers by the medical and nursing staff.  The social workers also gave special counselling to a l l the- patients  who were juveniles (that i s , under 18 years of age), i n an effort to redirect their energies into community recreational activities.  I f , in- the  course of the examination for a venereal disease, a female patient was found to be pregnant, the help of the Social Service Section was enlisted, particularly for the g i r l who was not married and for whom this diagnosis was the confirmation of her worst fears. In helping such a g i r l face her problem, the resources of, the appropriate social agency i n the community were interpreted to her, and she was reassured and encouraged i n her planning to meet this c r i s i s .  J  With a l l these problem patients, it, was by means of the interpersonal relationship, between the patient and the case worker that the patient was helped, to the limit of his capicity, to sort out his problems and to plan how he could begin to deal with them. While the case work service took the patient's venereal disease as i t s starting-point, i t was recognized that the disease was only one of a constellation of problems  -58 which the patient, i n h i s present face.  state, of disorganization, was unable to  The aim of t h e - s o c i a l worker was to work with the "whole patient"  i n such a way as to help him gain some i n s i g h t i n t o the causes of h i s d i f f i c u l t i e s , and i f he needed outside help, to d i r e c t him to the community resources that were available to him. In an e f f o r t to stimulate the r e f e r r a l of patients to the S o c i a l Service Section, much of the time of the s o c i a l workers was taken up i n i n t e r p r e t i n g to. the doctors and the nurses on the c l i n i c s t a f f , the needs of these patients as people who, besides t h e i r venereal condition, had many problems f a r more pressing than t h e i r i n f e c t i o n .  A l l the s t a f f ,  were encouraged to become more sensitive i n detecting personality d i s orders i n patients which might be helped on a case work b a s i s . Since/191$, i t has become routine procedure f o r a l l newly diagnosed patients to be interviewed by the S o c i a l Service Section a t l e a s t once i n the course of t h e i r c l i n i c attendance.  The interview i s  exploratory and serves to screen f o r a more intensive case work r e l a t i o n ship, those patients who are emotionally disturbed.  For those who are  f a i r l y w e l l integrated p e r s o n a l i t i e s , the interview gives them an opport u n i t y of gaining some i n s i g h t into the cause-an-effect r e l a t i o n s h i p between t h e i r behaviour and t h e i r i n f e c t i o n .  In September 19U9, p s y c h i a t r i c  consultation became available f o r patients with serious personality d i s orders, and t h i s has expanded the scope of\the S o c i a l Service Section, since i t i s now responsible f o r preparation o f the s o c i a l h i s t o r i e s of a l l patients r e f e r r e d to the D i v i s i o n ' s p s y c h i a t r i s t .  - 59 CHAPTER k  '  PSYCHO-SOCIAL "CHARACTERISTICS OF PATIENTS IN OTHER COUNTRIES  What kind of people become infected with a venereal disease and what can be learned about them that w i l l serve as a guide i n planning an effective control programme? Much had been written about the medical aspects of venereal disease control, but nothing was done to bring together a l l the available information about the broader, problems involved until 19U8, when a joint committee of the Department of Public Health of Yale University and the Venereal Disease Division of the United States Public Health Service undertook to enquire into the social and educational aspects of venereal disease control.  The results of their investigation  have been published i n a series of three Cooperative Studies.  The f i r s t  outlined the scope of the enquiry, and the second Study, entitled The Social Control of Venereal Disease, described the "climate of professional opinion" about the fundamental problems i n controlling venereal disease. Here over 700 professional persons who were engaged directly or indirectly in venereal disease control participated i n an opinion p o l l .  The third  Study, The Individual and Venereal Disease, analyzed a l l the available literature dealing with the psycho-social characteristics of patients. This project took as i t s starting-point "the individual as a patient or a potential patient and his relationships to disease, case-finding and medical care; to other community health, welfare and related f a c i l i t i e s ; and to the personnel involved. " I 1  5  A l l the material was scrutinized i n terms  ^-Lumpkin, Margaret, Introduction to The Individual and Venereal Disease, Cogpegatiye Study No. h 4 University Department of Public Health ancL U.S. Public Health Service Division of V.B. Control, New Haven, July 19U8. Y  e  - 60 of five general criteria: 1. 2. 3. U. 5.  I t must relate to individuals infected with a venereal disease. It must deal with the psycho-social characteristics of patients. The data must have been obtained primarily through personal interview by professionally qualified persons. The analysis and interpretation of the data must have been made by professionally qualified personnel. The data must have been treated objectively by the use of sound quantitative methods.  Although over 200  studies were reviewed by the Committee, only  26 were considered to be pertinent to a study of the psycho-social aspects of venereal disease control. STUDIES RELATING TO VENEREAL DISEASE PATIENTS The following studies related to individual patients under treatment for a venereal infection. Lumpkin Study (St. Louis) 19i|2  16  This study, made by a medical social worker i n a part-pay genito-urinary evening c l i n i c , analyzed the characteristics of 2U2 patients whom the worker had interviewed on their f i r s t admission to the c l i n i c . In this group, male patients predominated, and negroes outnumbered white patients two to one.  F i f t y percent of the patients were under 2$ years of  age, and nearly 90 percent were 35> or younger. A l i t t l e more than k0 percent of the patients were married.  About half the patients had had some  high school experience, and another 20 percent had grade school standing. Over a third of the male patients were labourers. Most of these people manifested some difficulty i n personal relationships, some emotional complications, and some lack of understanding of the need for medical care. -^In the text these studies are identified by the name of the author, the setting and the date.of the study. See Appendix C. for complete b i b l i o graphy of the studies.  - 61 Fifty-two percent of the group had had more than one infection and the majority of these repeaters were married male patients with high school grades; they were engaged i n manual jobs and had an adequate income. The negro repeater patients were i n the 20 to 30 age-group and the white patients were slightly older. The repeater rate among these patients was higher than at the Vancouver Clinic.  However the composition of the two  patient groups was not comparable because of the preponderance of negroes attending the St. Louis Clinic.  There, 69 percent of the patients were  negro while at the Vancouver Clinic only a small proportion of the patients came from this racial group. While a broad generalization that negroes are more promiscuous than white people i s not valid, experts i n venereal disease control i n the southern United States are of the opinion that the American negro i s less inhibited sexually than the Caucasian, and that he follows a different cultural pattern. The study recommended that there should be free medical care for indigent patients and psychiatric service available for those patients who were disturbed and wanted help with resolving some of their more basic difficulties.  Only by a better understanding of the individual needs of  each patient could case-holding become effective. Rachlin and Weitz Studies. (St. Louis) 19UU Three studies were undertaken at a rapid treatment centre for women i n St. Louis.  One investigator was a psychiatrist and the other was  a psychologist, and they examined the psycho-social characteristics of 301; women brought into this treatment centre by law-enforcement officers. The purpose of these studies was to determine what kind of person was ^The Social Control of Venereal Disease. Cooperative Study No. 2, Department of Public Health Yale University and the V.D."Division of the U.S. Public Health Service, New Haven, July 15, 191*8, .pages 35-36.  - 62 being dealt with i n this setting, and what rehabilitation measures would be appropriate. Although the study group included negro as well as white patients, the latter predominated. Over 80 percent were between the ages of 15 and 2lt; two out of three had been married before they were 16, and one out of three was either separated or divorced at the time of their examination. Their educational attainment ranged from no schooling to college level, with 125 out of the 30U i n the high school group.  On testing, they had a  median I.Q, of 80. The majority of the girls were employed either as waitresses or as industrial workers. Among the g i r l s on whom there was sufficient data about their family background, over 50 percent came from broken homes. Only one g i r l i n eight had parents who were living together and between whom there was no serious conflict.  Most of the g i r l s had had their f i r s t sex experience  in their early teens; nearly half the married women had had premarital relations; and fifteen of the patients had illegitimate children. The findings of the psychiatrist showed the majority of these young women were unstable, emotionally immature, intellectually hanclicapped, and without any "social consciousness".  This was considered to be due to  their early conflicts and environmental insecurity.  It was his opinion ., ..  that their indiscriminating sex behaviour was either an aggressive protest against society or a manifestation of their amorality. He concluded that any programme for controlling venereal disease should take into account the social pressures which were affecting these g i r l s ; also that community action to provide f a c i l i t i e s to meet their more basic needs must accompany any medical control programme. The same professional team carried out a programme of mental  - 63 testing of 500 consecutive female patients at this rapid treatment centre. Again the patients were both  white  and negro. The median age was found to  be 20.8 years; the educational level, 8 years k months; the I.Q. ranged from kk to 123, with the median I.Q. for white patients 8ii, and that for the.negroes 70. Mental defectiveness was found i n one out of every five white patients, and i n over half the negro girls. At the same time 16 . percent of the white patients were of superior intelligence while only.U percent of the negroes were found to be i n this category. This study pointed out that educational material on venereal disease had to be geared to a low intelligence level, and the recommendation was made that mental defectives should be institutionalized for their own protection, since educational efforts did l i t t l e to affect any behaviour change among this group.^ The third study, undertaken by the psychologist on the team, compared the work adjustment of a group of 225 girls from the rapid treatment centre, with a group of applicants to the National Employment Service, selected to match the patient-group.  The findings were that the patient-  group changed jobs nearly twice as often as the applicant-group; there were no professional or managerial workers among the patient-group  and  very few skilled or semi-skilled workers. Most of the patients were engaged in service occupations (waitresses, bar-maids, domestics).  In  intelligence the patient group was below normal, the majority being i n the defective or borderline classifications. There were no comparable data available on the applicant-group.  The recommendation here was that since  •^This seems like rather an academic proposal, with the problem of the female mental defective much larger than that of her sex deviations. The authors of the study did not seem to consider that a meeting of the basic needs of these handicapped girls i n terms of emotional and other security might be effective in redirecting their sex drives into less hazardous channels.  - 6U work adjustment i s a very important factor i n rehabilitation, an adequate vocational guidance programme i s a necessity, i n any venereal disease contr o l set-up. Andrews Study (St. Louis) I9U7 This project described the emotional and environmental factors influencing the response to treatment plans of a group of ten female syphi l i s patients admitted to the St. Louis Rapid Treatment Centre.  The average  age of these women was 2U yearsj one patient was single, three were married, three had remarried, and three were separated.  Half of them were engaged  in unskilled jobs and their educational levels ranged from the third grade to high school graduation.  Amongst the reactions to diagnosis and treat-  ment, fear was the predominating emotion.  The patients i n this group were  found to be emotionally unstable, most of them had had unhappy childhood experiences and very few of them had been able to establish a secure and lasting marriage.  None of them responded to the educational material pre-  sented to them, and the conclusions were that before they could be helped to face the problems presented by their total l i f e situation - including their venereal infection - they needed the understanding and expert counselling of a case work relationship. Parker Study (St. Louis) 19^2 The social, economic and emotional factors presented by 3 0 syphilitic pregnant women attending a free out-patient clinic i n St. Louis, were analyzed i n this study.  Two-thirds of these patients were negroes.  The majority of the women were Ignorant of the facts about their disease and i t s implications, and the group as a whole were irregular i n their c l i n i c attendance.  Ignorance was considered the greatest obstacle to  effective treatment, and the need for an educational programme that was  - 65 geared to their intelligence level was stressed.  Almost two out of every  three patients were known to other social agencies i n the community and most of the women i n the group had problems i n personal relationships, environmental d i f f i c u l t i e s and mental retardation. Ross Study (United States) undated This report by the physician i n charge of an unidentified public c l i n i c was concerned with the problem of redirecting the energies of promiscuous young g i r l s who were referred to his c l i n i c during the war years.  In a three months period, this physician examined k2 girls who  manifested some emotional problem.  He found that most of these patients  had developed a pattern of delinquent, promiscuous behaviour through which the;/ acted out their hostility to authority of any kind.  Their problems  included marital maladjustment, unsatisfactory war marriages, poor family relationships, and economic d i f f i c u l t i e s .  Each g i r l presented a "cluster  of problems" common to young girls living away from their family groups during the period of social disorganization that i s war-time l i v i n g .  This  study pointed up the need for expert counselling and of these g i r l s at the beginning of their promiscuous career, and for more community resources to give them practical help i n re-establishing themselves i n the community. Torregrosa Study .(Louisville) 19k7 A rapid treatment centre at Louisville, Kentucky was the setting for a study project which analyzed the emotional problems that a diagnosis of syphilis created i n kk male patients.  The group was almost equally  divided between white and negro patients and over half, of the patients were single. The majority were employed, and approximately one-quarter of the group were engaged i n construction work. More than half of these men stated that their sex partner was either a casual pick-up or a prostitute.  •66 A l l of the patients interviewed, agreed that they f e l t better after' talking with the social worker and many of them were able to use this service to resolve some of their -conflicts.  The importance of understanding the i n -  dividual patient was again emphasized as a necessary preliminary to any kind of effective treatment. Wesoloske Study (St. Louis) 1?U7 The study related to 13 patients found to have latent syphilis at the time they were exanined at a genereal medical clinic operated by an employees' union.  Here the average age was U7, the patients had steady  jobs and financial security.  They were relatively stable individuals;  nine out of the group were married, two were single and two were separated. The majority of these patients had had good family relationships and they reacted favourably to authority.  The clinic f a c i l i t i e s were excellent and  each patient received individual attention from the physicians on the staff.  Although a l l the patients were shocked at a diagnosis of syphilis  being made i n the course of their routine medical examination, they responded positively to the treatment outlined for them. Stein Study (New York City) 1?U2 This thesis study which investigated the medical social problems presented by 20 patients i n a syphilis c l i n i c , found that syphilis patients had problems common to a l l types of patients, and that i t was necessary for the social worker In the venereal disease setting to understand the ramifications of many illnesses i n order to be able to help the syphilis patient work through his problems.  I t was f e l t that the social worker had  to be free from personal prejudices and from emotional blocking about venereal disease before she could work successfully with these patients.  - 67 Roll son Study (Detroit) 19UU The role of the social worker i n a quarantine hospital i n Detroit was described i n this study.  Here the social worker interviewed a l l  patients on admission and again later i n their treatment process, to determine what could be done to prevent re-infections among these patients. The study included 681 female patients which the social worker had seen i n one year.  Over half this number were negroes and most of the patients  came within the young adult age-group.  Oyer 20 percent were prostitutes,  many of them under the supervision of the courts. A large proportion were frankly promiscuous, without any deep affectional relationships. Most of the girls presented the usual problems basic to delinquent behaviour, such as broken homeSj parental rejection, family conflict, lack of moral training, poor housing, marginal incomes, lack of recreational opportunities.  Few of the girls had the capacity or the desire to be  helped with resolving their underlying problems and only 2 percent would accept referral to other community agencies.  Their behaviour vra.s inter-  preted as an aggressive revolt against authority, and the only hope for them lay i n community action to provide f a c i l i t i e s to meet their basic needs and i n this way to curb their delinquent tendencies. Malzberg Study (New York State) 19h$ In this study the characteristics of 68U patients admitted to the mental hospitals i n New York State with a diagnosis of general paresis of thei insane,^ were compared with those of patients admitted during the 9  same period with other mental diseases. The syphilis group was younger than any other group, with an average age of U8.7 years for men and h&,9 for women; urban admissions were higher than from rural areas; and the l^The mental disease caused by syphilis.  - 68.  prevalance was greater among the foreign-born than among the native white population,  ^he number of patients who were divorced or separated was  high among the syphilis patients, most of whose histories showed some basic personality dL sorders before the diagnosis of general paresis was established.  There was an inverse ratio between educational attainment  and the incidence of this manifestation of syphilis and i t was pointed out that this was not necessarily indicative of lack of education but of low economic status which tended to create an attitude of indifference to treatment among these syphilis patients.  There was a high correlation  between intemperance and general paresis, and i t was concluded that certain l i f e habits tend to lead to both alcoholism and the behaviour that results in the acquisition of a venereal infection. Fessler Study (Great Britain) 1916 This patient-group study w s undertaken by a medical practitioner a  i n Great Britain i n 1916.  He studied 200 patients under treatment at  public clinics i n three adjacent areas, one industrial, one commercial and the third a seaport.  Almost half of these patients were i n the young  adult age-group (21 - 30), and most of them came from the "working class".20 Although over $0 percent of the patients were married, casual acquaintances were named as the sex partner i n about 30 percent of the men and 20 percent of the women. The problem of defaulters was considered.  Although both male  and female patient-groups had about the same defaulter rate, the women "This was the only study that mentioned the low incidence of patients from the "middle class" i n the community. It was suggested that such people either sought medical care privately, i n which case their records would not be available for study; or they used more prophylactic measures; or they did not acquire an infection because they were more selective i n their choice of sex partners.  - 69 patients were less responsive to case-holding methods. The promiscuous woman rather than the professional prostitute was named as the chief source of infection.  The point was made that case-holding can only be effective  i f the needs of the individual patients are considered, and the approach made on a "psychologically sound" basis. In the studies relating.to c i v i l i a n patient-groups, the majority of the patients were unskilled workers.  This i s to be expected since most  of the studies were made at free or part-pay c l i n i c s .  Nowhere does there  seem to be any information about patients under the care of private practitioners, so that i t i s misleading to consider the findings of these studies as characteristic of venereal disease patients. They are characteristic only of that group of patients whose records are available for study.  In British °olumbia i n 19U8,  numbered  1992  out of  during the year.  U3>3&  patients reported by private physicians  newly reported cases diagnosed i n the province  This means that other than the most meagre statistical  information, nothing i s known about nearly 1|5 percent of the venereal disease patients i n British Columbia. With regard to the patient-group studies reviewed by the Cooperative Study Committee, there i s no information as to what proportion of the venereal disease population i n each area was under treatment i n the settings described.  This must be borne  i n mind when drawing general conclusions from any of the studies that have been made to date. STUDIES RELATING TO MILITARY PATIENT-GROUPS Three studies described the characteristics of military personnel who acquired venereal diseases during World War II. In each of these studies, control groups were used for the purpose of comparison.  -  70  V/ittkower and Cowan (Great Britain) 19U5 This study, undertaken by medical officers i n the British Army, was concerned with the psychological aspects of sexual promiscuity, and undertook to answer the following questions:  In personality and attitude,  do venereal disease patients represent a random sample of the army population?  Is there any particular personality type among these patients?  What are the motives for promiscuous behaviour?  What factors affect the  use of prophylactics? Promiscuity was defined as "transient sexual relationship which ends after intercourse".  Two hundred venereal disease  patients were compared with a control group of patients under treatment for impetigo.  Among the venereal disease patients, 59 percent were found,  to have an immature personality pattern, 30 percent were borderline cases, and only 11 percent were rated as mature.  Of the immature group, about  half the men were described as being unaggressive; the borderline cases were labelled "latent aggressive personality types"; and only those i n the mature group were "controlled" i n their behaviour pattern. In the use of alcohol, 30 percent were heavy drinkers; 68 percent were moderate i n the use of alcohol, and 2 percent said they were teetotallers.  More than half of this group of patients expressed them-  selves as being discontented with army l i f e , only 17 percent being keen soldiers.  One-third admitted habitual promiscuity, one-third said they  were occasionally promiscuous, and the others stated that they had not been promiscuous until they joined the army. Nearly 70 percent said that they did not use any prophylactic measures following exposure, and less than 10 percent stated that they used adequate precautions. cent of the men  Over 50 per-  stated that their promiscuous behaviour was precipitated  by their unhappiness at being i n the army; about 30 percent said that  - 71 they were promiscuous when they were drunk; about 20 percent l a i d the trouble to family worries; and only 2 percent admitted active seduction. The majority of those who were only occasionally promiscuous, said their lapses were caused by some acute emotional disturbance. Accordingly, this study concluded that venereal disease patients were not representative of army personnel; that among them there was a higher percentage of malcontents, and more heavy drinkers; they were more immature, more promiscuous, and more irresponsible with regard to prophylactics supplied by the army. In the opinion of these medical officers, the promiscuous behaviour of this soldier patient-group was not the result of a mature interest i n the sex partner, but an immature attempt to relieve themselves of some acute psychological stress.  Like absenteeism  and  drunkenness, the incidence of venereal disease i n the army was considered to be more a matter of "morale than morals". Watts and Wilson (Canadian Army) 19U5 This study analyzed of the personality factors contributing to the acquisition of a venereal disease among Canadian soldiers.  Using as  "controls", a group of men from the depot personnel office, these Canadian Medical officers found that a significantly larger proportion of the venereal disease patients had personality d i f f i c u l t i e s .  The soldiers i n  the patient-group were more immature and more unstable than the control group; they were heavier drinkers and duller i n intelligence than the soldiers who did not have a venereal disease.  The majority of these  soldier-patients had had abnormal childhood experiences; many of them gave a history of marital incompatability; and most of them had made an unsatisfactory army adjustment. This study recommended psychiatric help for soldiers whose infection was precipitated by an anxiety neurosis  - 72  and expert counselling for those who were temporarily upset by some marital I or family c r i s i s .  he importance of environmental factors which promote  the acquisition of a venereal disease through lowering morale, v/as emphasized. Brody Study (U.S. Army Hospital, Italy) World War II The other military study which the Cooperative Committee reviewed related to American soldiers i n an army hospital i n Italy.  There  200 venereal disease patients, 100 surgical cases, and 50 psychoneurotic patients were analyzed.  In contrast to the British and Canadian reports,  the results of this study showed that the majority of these venereal disease patients were no different i n personality pattern from any other group of normal individuals.  The number of venereal disease patients with  constitutional psychopathology was no greater than would be found i n any hospital ward. There was no correlation between neurotic personality and the acquisition of a venereal disease except i n isolated instances.  The  most distinguishing characteristic of the venereal disease patient was that he was younger than the other members of his group; he was less restrained, more irresponsible and ready to take chances i n a l l areas of his l i f e , and was more easily influenced.  He did not make as good an adjust-  ment to any l i f e situation as the ordinary soldier; he. was more often drunk or guilty of military misdemeanours. He started his sexual experiences earlier, and sex relations were more important to him than to other men.  He was more often solicited than selective i n his sex partners, and  he did not learn from his experiences.  The medical officer making the  study found the venereal disease patient was more often mentally healthy because of his positive libidinous nature, than manifesting the inhibitions of the psychoneurotic.  In this study venereal disease patients were con-  - 73 sidered to be more the concern of the padre or of the sociologist than of the psychiatrist, because these patients were normal men living under abnormal conditions. STUDIES IM PROMISCUITY These studies related not to venereal disease patients but to promiscuous people who were referred for medical care by law enforcement officers or other social agencies. Yecker Study (Chicago) 1932 The f i r s t of these studies enquired into the environmental, economic, and social opportunities of 558 women between the ages of 16 and 20 who were referred f or examination to the I l l i n o i s Social Hygiene League of Chicago i n 1932.  The majority of these young female patients came from  broken homes or from families i n which there was much conflict.  Many of  them had had unsuccessful marriages, and ignorance about sex was characteri s t i c of the group. Most of them had started to work early, i n poorly paid jobs, and their social l i f e was limited to commercial recreation. In this study there was no correlation between low economic status and the acquisition of a venereal infection; rather, promiscuous behaviour was prompted by a desire for male attention.- This group of women were considered to be f a i r l y representative of the young American working g i r l of the period, who was engaged i n routine employment of an unskilled nature and receiving wages which were barely enough to cover the-girl's basic physical needs. The role of the social worker i n providing skilled counselling b sed on an understanding of the needs of these g i r l s , was described as a  helping them solve some of their social and economic problems. At the same time i t was urged that more sex-education material suited to the  - Ik capacity and interest of these g i r l s be provided. Lumpkin Study (St. Louis) 19k3 In this study, Miss Lumpkin reported on the, characteristics of !>0 white g i r l s referred to the St. Louis Health Division by law enforcement authorities i n 19k3» have an infection.  On examination, only 30 percent were found to  The majority were under 21 years of age, and about  one-third of them had higher than eighth grade education.  Eighteen out  of the group were chronic offenders and of that number, 12 were below average intelligence.  Over h0 percent of the g i r l s were unemployed and  the others were working i n service employment or i n factories.  There were  12 married women referred to the c l i n i c , and a l l of them had a history of marital disharmony. Of the 19 single girls who were living with their families, 7 stated that their home l i f e was characterized by severe family discord.  Most of the g i r l s lacked the opportunity of .normal development  and they turned to sexual experiences to give them the attention and excitement they craved.  This study pointed out the need for more f a c i l -  i t i e s to protect and shelter these g i r l s when they came to the attention of the law. Mental testing for those who appeared to be mentally defective was recommended, since this kind of handicapped g i r l does not respond to the usual rehabilitative efforts.  For those who were capable of gaining  insight into the root causes of their d i f f i c u l t i e s , i t was suggested that the social worker could be helpful to these patients i n re-establishing themselves i n the community. Hironimus Study (Washington, D.C.) 19U3 In this project, 100 May Act violators i n a federal reformatory for women were studied. Most of these women were i n their late teens or early twenties; their average I.Q. was 67; and only eight had reached high  -75 school level.  Thirty-one of the g i r l s had had illegitimate children, and  of the 53 "who were married, 13 were either separated or divorced.  Although  6U of the prisoners had been previously known to the authorities, their crimes were relatively minor and only a small proportion of the g i r l s were described as chronic offenders. Most of these women came from rural families.  Forty-three out of the 100 gave a history of disrupted family  living, delinquent behaviour, alcoholism, neglect and cruelty i n their experiences.  Over 50 percent of the group drank to excess, and only 9 .  were abstainers. There was a correlation between alcoholism and sexual promiscuity which developed after the age of 30. The report indicated that these g i r l s got into d i f f i c u l t i e s i n urban settings because they were not equipped emotionally or otherwise to withstand the confusion of wartime Bring i n the city with i t s excitement of soldiers, taverns, freedom from the l i f e of drudgery from which they had come, and plentiful war jobs paying good money;for easy work. San Francisco Psychiatric Studies - 19k3-19h7 This material was published under the joint auspices of the San Francisco Department of Public Health, the California State Health Department, and the U.S. Public Health Service, and enquired into the causative factors of promiscuity.  Promiscuity was defined as follows: For a  married woman - extra-marital relations ?dthin six months preceding her referral to the clinic; for a single woman - relations with more than one man i n the preceding six months, or relations with one man more- than twice in the same period. A distinction was made between the h bitually promisa  cuous,, the potentially promiscuous, and those who were not promiscuous. t  Patients were referred to the clinic from various sources, including social agencies, other community groups, and friends and relat-  - 76 ives of the patients.  The examining team consisted of a psychiatrist,  social -workers and a psychologist,  '•'•he f i r s t report describing these  experiments in psychiatric treatment of promiscuous g i r l s was published in 19U5, and in 19U8 a further report covering the entire four year period and including 235 male and 365. female patients was published under the t i t l e of A Psychiatric Approach to the Problem of Promiscuity. In the total group, the predominant.age was between 18 and 23, and white patients outnumbered negro and other racial groups about four to one.  There were many more married women than there were married male  patients, the proportion being about seven to two. Sixty percent of the patient-group  came from broken homes or had a history of marital or fam-  i l i a l conflict.  About one-third of the men were living as part of a  family group while only one-sixth of the female patients had this security. More women than men had been i n d i f f i c u l t i e s with the authorities, although over half the total group had had some previous criminal record. In educational achievement, the group compared favourably with the national average of grade 10 schooling, and i n intelligence, for white male patients the median I.Q. was 102, and for females 95, while for the negro group the comparable ratings were Qk for men and 86 for women. Most of the men were engaged i n skilled or unskilled occupations while 60 percent of the women were either i n war industry or i n service employment. The other women were classified as unemployed. With regard to sex experiences, two-thirds of the women and three-quarters of the men admitted that they had had sex experience before they were 18. With the women who had voluntary premarital intercourse, most of them stated that their experience was an unsatisfactory one. many of these patients, their knowledge of sex was inadequate and  With  - 77 unscientific. Seventy-six percent of the men and 57 percent of the women were so classified as being habitually promiscuous. Women tended to begin sex relations later than men; the men had twice as many sex partners as the was more  women patients; and there/homosexuality and sexual perversion among the men. For the men, their f i r s t experience was with pick-ups, prostitutes or casual acquaintances; the women gave friends as their early contacts. In terms of motivation of promiscuity, there were few differences between the male and female patients, the root cause for both sexes seeming to be personality d i f f i c u l t i e s and active conflicts.  Among the men, an important  factor was the separation of sex and love relationships. Out of. the total group, two-thirds of the women and one-half of the men took advantage of the psychiatric service available to them at the clinic$ many of them gained real insight into their d i f f i c u l t i e s and no > longer needed to behave i n a promiscuous way.  The studies pointed out  that while no single factor or even group of factors determine whether or not a person w i l l be promiscuous, but there appears to be a direct relationship between promiscuous behaviour and early unsatisfactory family and interpersonal relationships.  Promiscuity was described as "symptomatic  behaviour" arising out of neurotic conflict, with environmental factors a contributing rather than a "primary cause of any case of habitual promiscuity".  It was pointed out that psychiatric referral could only be made of  selected patients who were prepared to accept such service voluntarily. However, the necessity of having psychiatric help available for disturbed patients as part of a venereal disease control programme was emphasized. In terms of the kind of people who acquire a venereal disease, the findings of these studies are f a i r l y comparable to the repeater study.  ' -  78  The same psychological factors are present - emotional immaturity, poor family relationships, retarded personality development, social insecurity and for most of these people, promiscuous behaviour i s symptomatic of more basic disorders.  -•79  CHAPTER 5 SOCIAL TREATMENT - THE INDIVIDUAL APPROACH Because the venereal diseases are spread through intimate contact with an infected person, i t i s the diseased individual who holds the key to control. On him depends the effectiveness of the control programme as far as case-finding i s concerned, since the tracing of contacts i s only as complete as the information that i s given by the infected person. Similarly adequacy of treatment follow-up i s dependent on the cooperation of the person receiving the treatment.  Thus, case-finding and case-  holding, which along with improved medical care are the chief weapons i n the fight against venereal disease, are ineffective unless the patient i s an ally.  His cooperation cannot be legislated, i t can only be enlisted,  and the patient as a point of control has been too long ignored by those responsible for planning venereal disease campaigns. At the Vancouver Clinic, beginning i n 19U9 the treatment procedure was extended to include an interview with a social worker for a l l patients coming to the c l i n i c .  This was begun as a study project when  15>0 consecutive newly diagnosed patients between 15> and 2$ were interviewed by the Social Service Section, as a means of f i l l i n g i n some of the gaps i n the clinic's knowledge about the kind of people who were being treated.  In the course of this study, the socially oriented interview  proved to be so effective i n gaining the cooperation of the patients, that i t Yfas continued on a routine basis for a l l newly diagnosed patients. This 19U9 project demonstrated how many of these patients had comcommitant non-medical problems that were hindering response to medical care. Some of these people were disabled by external pressures which could be relieved  (  - 80  by referral to other agency resources i n the community; with some of them the pressures were internal resulting from the patient's confused feelings about himself and his infection, and these could often be released through the skilled counselling service of a medically trained social case worker. Although the f i n a l results of this study have not yet been published, statistical information a bout recidivism i n this group of patients was made available.  Out of 97 men and 53.women included i n the  study, 37 men and 20 women.had been previously infected, which gave a repeater rate of 38 percent with the male and female groups showing about the same proportion of r epeaters.  This was slightly higher than the 19U8  repeater rate but i t was based not on total new admissions, but on a selected group, namely those between 15 and 25 years of age.  The general  picture to be seen from this 19h9 study showed the same kind of personality disorganization that was indicated i n the repeater patients of 19k& broken homes, unhappy family relationships, poor marital adjustment, unsatisfactory work records - with sexual promiscuity just one of a number of anti-social activities. In terms of reducing recidivism, what was significant was that i n the year following the 19^9 study, only 13 out of the 150 again repeated their infection.  Of the four male repeaters who did repeat, one had been  infected prior to the study, two had acquired new infections twice and one had been reinfected three times since the study.  Of the nine female re-  peaters, six had been repeaters before 19U9 and the other three had been reinfected once since then.  In percentages, i n the year since these l50 .  patients had passed through the Social Service screen, only U.l percent of the men and 16.9 percent of the women had acquired new infections. In view of the former rate of 38 percent, progress had been made.  - 81 For too long, treatment for a venereal disease had been an impersonal experience. From the time the patient was admitted to the c l i n i c , he was a number on a piece of paper which he clutched i n his hand.  Orig-  inally the purpose of this was to protect the identity of the patient, but i t made the clinic routine a mechanical procedure.  Then as the volume of  patients grew, the medical examination and epidemiological interview were conducted on an assembly-line basis, which made i t possible for a patient to go through the whole experience without i t having any personal effect on him.  Ideally, the personal counselling that should accompany any kind  of medical treatment would be given by the doctor making the diagnosis. However, i n a busy public clinic this ideal i s d i f f i c u l t to attain. The public health nurse might be expected to take over this function, but her interview with the patient has a specific purpose - to get accurate and adequate information from the patient about his sex partners so that these potential public health problems in the community can be located and.examined, and to obtain particulars as to how the patient himself can be reached in'the event that he lapses from treatment or surveillance. This interview i s important from the public health point-of-view and the nurse cannot extend her discussion with the patient to deal with his personal troubles. Because the main focus of the social worker i n the clinic setting i s the patient as a functioning social being, the job of getting to know the patient as a person i s this worker's unique contribution to the treatment process.  The purpose of the case work interview i s to explore the  personality pattern of the patient i n order to determine his specific needs and to gauge his strengths.  In the exploration process the patient i s  helped to see himself more clearly, f i r s t i n relation to his venereal  - .82 disease and then i n terms of his l i f e pattern. In this way he i s better able to sort out his problems and to mobilize his resources to meet them. This kind of social treatment then becomes a constructive part of the total treatment process and the whole experience takes on more meaning for the person who i s a patient. Because the aim of the case-worker i s to est blish a positive a  relationship with the patient, the interviews are conducted on a friendly informal basis.  They are not stereotyped but start from the point where  the patient i s ; throughout the discussion, the patient and his needs are kept i n sharp focus., From the worker, the patient experiences warmth and understanding and acceptance of him as he i s , with a l l his problems.  For  many of these people, this kind of acceptance i s a new experience i n personal relationships which i n i t s e l f has therapeutic value. Because the case worker respects the patient as a person with certain rights and responsibilities for determining his own behaviour, she i s able to help him clarify his thinking and feeling about his situation so that his energies can be redirected^ toward solving his problems instead of running away from them. The goal of this part of the total treatment for a venereal disease i s to help the infected person find a new way of living that w i l l be more satisfying to him and less l i k e l y to increase the problem of controlling venereal diseases. By u t i l i z i n g her diagnostic s k i l l s , the worker i s able to shape the case work service to the needs and the capacity of the individual patient.  For the person who i s f a i r l y well integrated, the interview with  the social worker i s primarily a frank discussion of the medical aspects of his infection.  Diagramatic material showing the anatomical structure  of males and females i s used to help the patient formulate any questions  -  8 3  he may have about his condition or about the venereal diseases in general, a  1  nd these questions are answered i n simple terms that have meaning to him.  For more specific medical information, the patient can be referred back to the medical consultant.  In discussing the patient's infection, i t s public  health significance i s emphasized by the case worker and the patient i s made aware of the important role he must play i f the control programme i s to be effective.  The purpose of the contact history i s stressed and the patient  i s reminded that since he i s the only person who has f u l l knowledge of his sex contacts, he i s i n a key position to help reduce the residue of undetected untreated venereal infection i n the community;  After these points  have been covered, the interview i s usually directed toward a general discussion of the patient's l i f e to date and of his plans for the future, and of how they can be jeapordized by the kind of irresponsible behaviour which has resulted i n the acquisition of a venereal disease.  In most  cases this kind of specific counselling enables the patient to face up to his responsibilities and eventually to effect a real change i n his pattern of behaviour. do so.  Such patients have the capacity to change and the w i l l to  Insight comes quickly and for them the whole e xperience of coming!  to the c l i n i c has been made a positive one. For tbe patient who i s emotionally disturbed about his infection but who i s not seriously disorganized, the case work interview can again be helpful by serving to drain off some of the patient's anxieties. Sometimes with these people, the acquisition of a venereal disease has made them feel defiled; i t has been a blow to their self-confidence, and the unreserved acceptance of them and their infection by the vrorker i s reassuring to them. By means of a simple non-technical explanation of what has happened to the patient's body as a result of the disease, some of  - 8U groundless fears may be allayed. Having shared his burden, the patient can cope with i t more effectively; having found support, he i s more able . to stand alone.  With these emotionally involved patients, the case work  service may have to be continued beyond the i n i t i a l interview.. Then the patient i s seen each time he comes to the c l i n i c , his progress i s reviewed with him, and the worker's reassurances are repeated.  ,As soon as the  patient no longer needs this kind of moral support, the relationship i s discontinued. With patients whose venereal infection i s symptomatic of a more serious personality disorder, the main purpose of the case work interview i s to detect the problem for psychiatric referral.  A f u l l social history  i s prepared for the consultant psychiatrist before he examines the patient. Sometimes this part of the diagnostic process serves as a preliminary sorting out and i s helpful to the patient.  On a highly selective basis  depending on the psychiatric diagnosis, short-term psychotherapy may be instituted for some of these patients as part of the medical treatment provided by the Division, Other patients may be carried on a case work basis-by the Social Service Section, under the direction of the psychiat r i c consultant.  With most of these patients the only kind of service  which they can utilize i s a supportive relationship with the worker until they are over the c r i s i s of their venereal infection.  Sometimes i t i s  possible to refer patients to outside psychiatric services for a more continuing kind of help, but adequate community resources are woefully lacking.  With these seriously disturbed patients, their venereal con-  dition i s a relatively minor part of a much bigger problem and'treatment for the specific disease has l i t t l e meaning for them. These are the chronic repeaters.  They are incapable of learning from experience; they  -85 have difficulty i n establishing.a meaningful relationship even on a supportive basis; and their prognosis from the point of view of venereal d i sease control i s poor.  However, with patience and persistence i t i s some-  times possible to gain the confidence of these people so that they w i l l cooperate i n treatment.  This has been shown by the public health nurse  \vho i s i n charge of the Examination Centre at the City Gaol. Over the years she has established herself as the trusted friend of that group of problem patients who are periodically caught i n the police net.  She has  been able to communicate her professional concern to them i n such a way that they f e e l they are important to her not only as patients but as people.  She i s firm with them i n insisting that they cooperate i n treat-  ment and she i s not afraid to use the legal authority provided i n the Venereal Disease Act when necessary, but this does not affect her status with these people.  Indeed i t seems to give them a certain security to  know that this worker always keeps her promises, for good or i l l .  In the  three years that the Examination Centre has been..in operation, there has been a steady growth of personal responsibility i n this anti-social group, and more and more of them are coming to bhe Examination Centre on a voluntary basis and requesting an examination i n order to be sure they have not become reinfected.  This i s the ultimate i n effective venereal d i -  sease epidemiology, because these people are irresponsible i n almost every other area of their lives. In terms of the problem of controlling the infected individual, at the Vancouver Clinic i t has been demonstrated that case work services can make the treatment process more meaningful to the patient by giving him some insight into the relationship between his d i f f i c u l t i e s and his behaviour.  In this way each patient i s helped to cooperate to the limit  -  86  of his capacity i n the programme of control. This individualized approach can reduce recidivism among those who are capable of assuming responsibility for their behaviour and for those who cannot or do not want to change their pattern of living, i t can improve their attitude to treatment. 1(1/11116 recidivism among these chronic patients may not be materially reduced, they can become less of a public health problem when they w i l l cooperate i n treatment. Case work services have been u t i l i z e d i n venereal disease programmes i n various parts of the United States, notably i n San Francisco, Baltimore, St. Louis, and Washington, .C.  However, the Vancouver Clinic  D  set-up i s the only one of i t s kind in'Canada at the present time. From a l l the studies that have been made of the kind of people who have become venereal disease patients, i t i s obvious that the infection i s a relatively minor problem i n a l i f e situation that i s fraught with difficulties. i s a cure.  Their venereal condition i s the one ailment for which there  However, treatment for this specific disorder w i l l affect  l i t t l e real change i n the lives of these people unless there are strengths within the personality structure of the individual which can be developed in the course of the treatment process.  The venereal diseases could be  eradicated by medical science^- and yet the l i f e situation of most of . these people would be improved very l i t t l e .  Their problems are bigger  than the invasion of their bodies by the gonococcus or the spirchaete. Their d i f f i c u l t i e s stem from early deprivations which prevented the normal  This a real medical possibility, according to Dr. John R. Stokes, world authority i n venereology, i n his address to the Vancouver Medical Society on May 10, 19k9.  - 87 healthy development of the personality of these individuals,  ^hey are  crippled people that cannot withstand the social, the economic, the emotional pressures of their everyday lives, because their fundamental needs - to be loved, to belong, to achieve, to have status in.the community have never been met.  That i s why they are problems to society. On.a  world-planning level, a Declaration of Human Rights has been proclaimed: "Everyone has the right to a standard of living adequate .for the health and well-being of himself and his family including food, alothing, housing and medical care and necessary social services, and the right to security i n the face of unemployment, sickness, disability, widowhood, old age or other lack of livelihood i n circumstances beyond his control."We could begin closer home i f we considered how many of our venereal d i sease patients are being deprived of these human rights. Unsavoury community conditions are allowed to exist i n a city like Vancouver where the resources to deal with these reservoirs of social infection are i n f i n i t e .  Money can be raised to undertake any pro-  ject that i s backed by the w i l l of the citizens.  Why i s the "Square-Mile  of Vice", the "Skidroad", the Zone 1 i n the 19U8 Repeater Study permitted? Time and again the authorities have been made aware of this public menace, but nothing been done to eradicate i t - because the citizens of Vancouver have not demanded action.  The community should not be l u l l e d into a  false sense of security because the venereal disease rates are declining. This only means that improved medical care i s reducing the infectiousness of these diseases, and better case-finding i s locating new infections before they have had a chance to spread. Problem children are bred by problem parents, and i t i s the 22  A r t i c l e 25-1, The Universal Declaration of Human Rights.  - 88 adults who need the help i n comming to a better adjustment frith the world in which they l i v e .  Until the needs of the parent group can be met, the  children are going to suffer.  Many of these adults need practice i n posi-  tive human relationships, and this could come i f the communities returned to the old "neighbourhood" type of organization where everyone worked and played together. This i s belonging, this i s how status can be achieved, this i s how responsible behaviour can be developed. Parents need to understand the growth processes of the children whose lives they are shaping, and this calls for an expansion of our mental hygiene f a c i l i t i e s .  The experts have a fund of knowledge that should be  imparted to the people who are doing the job - namely the parents of young children - and this instruction could be integrated into the neighbourhood activities i n such a way as to make the learning process a positive experience for the whole group.  For those with special problems, the comm-  unity resources should include a skilled counselling service. How can children grow up into healthy, well-adjusted citizens when they have never known the security of a happy family relationship? Lip-service i s given to the family as the basic unit i n our society, and yet on every hand we see the evidence of family disintegration - i l l - c o n sidered marriages, unhappy divorces, chronic disharmony - and i n i t s wake a rising tide of juvenile delinquency.  I f i s the social confusion of our  era which needs treatment - not the venereal diseases. They are incidental to this much graver problem i n human relationships that i s not being faced today.  APPENDICES  - 90 APPENDIX A TABULATION OF REPEATER AND NON-REPEATER GROUPS VANCOUVER CLINIC Factors  Male Non-ttepeaters Repeaters (215 patients) (50 patients)  Age Group 15 to 19 20 to 29 30 to k9 50 and over  5 136 69 5  Origin and ^irth-Place Canadi an-Borm British European Oriental .Indian Negro , Other foreign-Born: Not Stated Family Status Single (Unattached) Single (Attached) Separated Divorced Widowed Carried Sommon-Law Residence £one 1  gone 2  Zone 3 Zone U  Female Repeaters Non-Repeaters (130 patientp) (50 patients)  ii  18 91 19 2  6 3k 9 1  101 22 3 15 6 7 2k 37  29 9 1  5k 21  2k 9  2k 3 2  2  128 32  29 13 k  2 9  5 30 6 71 3k k6 6k  '  26  5 10  21  5k  11  lk 1 2  3 35 > 8 5 19 6  12 6  12  10 k 2k 12  68 28 20 h  Iii  2 17 1 7 10 2k 9  1  j  - 91 Factors  Male Repeaters Non-Repeaters (215 patients) (50 patients) 1  Occupation Unskilled Skilled Clerical Seaman Hou se-wive s Unemployed  Female Repeaters . Non-Repeaters (130 patients) (50 patients) 1  5k 2 2  19 2 8  5k 18  Ifi  12 9 lk 7  26  lk 1? 10 6  20  5  Type of Contact Marital Friend Casual Friend Pick-Up Prostitute No Information  12 15 50 117 21  1 1 6 23 3 16  18 20 18 7k  Other Problems Alcohol Police Record Drugs Homo sexuality Illegitimacy • Prostitution  117 30 1 3 3  19  81 81 5  137 27  1  8  ko  kO  10 1 2 1  -  APPENDIX B  RESIDENCE ZONES'- VANCOUVER  Zone  i  Boundaries  Zone 1  West from Dunlevy Avenue to Cambie Street South from Burrard Inlet toCN.R. Station  Zone 2  West from Cambie Street to English BaySouth from Burrard Inlet to Fraser River and East from Dunlevy Avenue to Commercial Drive  Zone 3  Residential Areas i n Remainder of City  Zone U  Outside City of Vancouver  92  - 93 APPENDIX G BIBLIOGRAPHY OF PATIENT STUDIES IN UNITED STATES AND GREAT BRITAIN Studies relating to Venereal Disease Patients Andrews, Mary Elizabeth, The Social Study of Ten Syphlitic Women, Thesis, George Warren Brown School of Social "fork, Washington University, St. Louis, Mo. June, 19U7. Fessler, A., M.D. "Sociological and Psychological Factors i n Venereal Disease", British Journal of Venereal Disease, Vol. 22, March 19H6. Lumpkin, Margaret K., A Study of Two Hundred and Forty-Two Patients under Treatment for~Tjonorrhoea at Washington University Clinics, St. Louis, Mo., 19U2, unpublished. Malzberg, Benjamin, Ph.D., "A Study of First Admissions with General Paresis to Hospitals for Mental Disease, i n New York State, year ending March 31, 1916", The Psychiatric Quarterly, Vol. 21, 19k7. Parker, Dorothy Veasey, The Social Implications of Pregnancy - a discussion of a Luetic Group of Expectant Mothers, thesis, School of Social Work of St. Louis University, St. Louis, Mo., 19it2. Rachlin, H.L. Surgeon (R), U.S.P.H.S., "A Sociologic Analysis of ^hree Hundred and Four Female Patients admitted to Midwestern Medical Centre, St. Louis, Missouri", Journal of Venereal Disease Information, Vol. 25, September 19hk. Rolison, harlotte, "Social Case Work among Venereally Infected Females i n a Quarantine Hospital", Journal of Social Hygiene, Vol. 32, January 19U6. c  Ross, Milton S., M.D., Social' Service i n the Venereal Disease Control Program of a District Health Department, undated and unpublished. Stein, Sylvia, Medical Social Problems i n a Syphilis Clinic, Thesis, New York School of Social Work, Columbia University, New York, N.Y., January 19k$»  Torregrosa, Judith, A Study of Forty-Four Syphlitic Patients under Treatment at the Louisville Rapid Treatment from March 1, 19U7 to April 15, 19U7, Thesis, Raymond A. Kent School of Social Work, University of Louisville, Louisville, Ky., 19li7. tffeitz, Robert D., "Occupational Adjustment Characteristics of a Group of Sexually Promiscuous and Venereally Infected Females", Journal of Applied Psychology, Vol. 30, 19u6. ,  -9k Weitz, Robert D. and Rachlin, H.L., "The Mental Ability and Educational Attainment of Five Hundred Venereally Infected Females - a Psychological Study of Sexual Promiscuity and Venereal Disease", Journal of Social Hygiene, Vol. 31, May 19U5. Wesoloske, Agnes Frances, Factors Associated with the Extent to which Syphlitic Patients follow Treatment and Social Treatment Plans, Thesis, George Warren Brown School of Social Work. Washington University, St. Louis, Mo., June 19U7. Studies Relating to Military Patient-Groups Brody, Morris Wolf,  . Men Who Contract Venereal Disease, Unpublished. t  Watts, G.O. and Wilson, R.A., "A Study of Personality Factors among V.D. Patients", Journal of Canadian Medical Association, Vol. 53, August 19U5. Wittkower, E.D Cowan, J., "Some Psychological Aspects of Sexual Promiscuity - a Summary of Investigation", Journal.of Psychological Medicine, Vol. 6, October 19kk* <  Studies i n Promiscuity Hironimus, Helen, "A Survey of One Hundred May Act Violators Committed to Federal Reformatory for Women", Federal Probation, Vol. 7, April-June 19U3. Lumpkin, Margaret K., Report of the Work of the Medical Social Worker for St. Louis Health division, April 1$, 19U3 to June 15, 19U3 ' mimeographed. ~ ' Lyon, Ernest G., Jambor, Helen M., Corrigon, Hazle GI, Bradway, Katherine P., An Experiment i n the Psychiatric Treatment of Promiscuous Girls, Published by the City and County of San Francisco Department of Public Health, 19U5. Sailer, Benno, Corrigan, Hazle G., Fein, Eleanor, Bradway, Katherine P. A Psychiatric Approach to the Treatment of Promiscuity, American Social Hygiene Association, New York, 19U9. Vecker, Edith Julia. A Social Study of *iye Hundred and Fifty-Eight Women Patients at the I l l i n o i s Social hygiene League, Thesis, University of Chicago School of. Social Service Administration, June 1932.  - 95 BIBLIOGRAPHY  Ennes, Howard, The Social Control of Venereal Disease, Report of a National Inquiry of Professional Opinion, Cooperative Studies i n the Social and Educational Aspects of Venereal Disease Control, Department of Public Health of Yale University and Venereal Disease Division of U.S. Public Health Service, New Haven, July 15, 19^8. Kinsey, Alfred C , Pomeroy, War dell B., Martin, Clyde, Sexual Behaviour i n the Human Male, W.B. Saunders Company, Philadelphia, 19U8. Lumpkin, Margaret K., The Individual and Venereal Disease - an Analysis of the Literature Dealing with Psycho-Social Characteristics of Patients, Cooperative Studies i n the Social and Educational Asps cts of Venereal Disease Control, Department of Public Health of Yale University and Venereal Disease Division of U.S. Public Health Service, New Haven, July 15, 19U8. Yfessel, Rosa, The Case Work Approach to Sex Delinquency, Pennsylvania School of Social Work, University of Pennsylvania, Philadelphia, Penn, 19U7. --. .  Fenske, A. and Rachlin, H.L., "The Social Redirection of Venereally Infected Women", The Family, Vol. 26, May 19U5 Koch, Richard A. and Wilbur, Lyman, "Promiscuity as a Factor i n the Spread of Venereal Disease", Journal of Social Hygiene, Vol. 30, December 19UU. Lumpkin, Margaret K., "Utilizing Medical Social Service i n a Venereal Disease Clinic", American Journal of Eublic Health, Vol. 35, November 19U5. Murchison, Lucia, "Rehabilitation i n Action", Journal of Social Hygiene Vol. 30, May 19hh. Rappaport, Mazie F., "Toward a New Way of Life", Journal of Social Hygiene, Vol. 31, December 19U5. , Silcox,  , "The Moral and Social Factors i n Venereal Disease Control", Canadian Journal of Public Health, Vol. 36, December 19U5.  Stokes, John H., M.D., njh Modern Venereal Disease Problem and Its Sex Education Front", Journal of Venereal Disease Information. Vol. 29, October 19U8. : e  "The Practitioner and the Antibiotic Age of Venereal Disease Control", Journal of Venereal Disease Information, Vol. 31, January 195o~7 :  -  96  "Venereal Disease as a Medical Symptom of Social Problems", Canadian Medical Association Journal, Vol. 57, October l°k7.  Publications of Government of British Columbia: Provincial Board of Health Annual Reports, 1919 to 1937. Division of Venereal Disease Control Annual Reports, 1938 to 19U8. Venereal Disease Information for Nurses, 19U8. Venereal Disease Control Programme of the Health Branch, Department of Health and Welfare, 191*9.  

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