Continuing my series of posts on sex work and public health, I thought I might take a brief look at some of the historical debate over sex work and public health. Sex work can be a major risk factor for the transmission of sexually transmitted infections (STIs), and the sex industry can play the role of a classic “high risk” group in epidemiology, maintaining a pool of individuals with some disease and spreading it to low risk groups through sexual contact. This is a well-recognized aspect of the epidemiology of infectious disease, and isn’t in and of itself a stigmatized or morally compromised position for a part of society to occupy. Travelers are a high-risk group for the spread of influenza, prisoners for TB, and children for a range of infectious diseases. But the particular form of the risk that sex workers engage in – sexual – and some of its historical “victims” (that is, the types of men who purchase sex from sex workers) have been of sufficient concern to the authorities that sex workers have attracted a great deal of moral opprobrium for their behavior. Public health interventions of various kinds have been advocated in modern societies since at least the 1870s, and historically have tended to instrumentalize sex workers as a risk group: that is, they only see the health of sex workers through the prism of the harm they may “do” to others, and don’t consider the health, welfare or rights of these women in and of themselves to be of much (or any) value. Examination of the approach to public health in previous eras can be instructive: it helps us to understand the types of political and moral forces that are brought to bear on those who might put the rest of the community at risk through their “immoral” behavior.

Sex Work and the Future of the Nation

Sex work entered the national consciousness in the UK in the 1860s, after the Crimean war. Returning soldiers, and soldiers in camp during and after the war, were targeted for business by, and very frequently visited, sex workers. Gonorrhea and syphilis became serious public health issues, and in this era neither were treatable, so attention naturally turned to prevention efforts. With soldiers who contracted these diseases being rendered unfit to serve, there was a genuine fear that the soldiers’ actions might lead to such a high rate of disease as to compromise the fitness of the army. The UK Government established a commission to investigate the problem in 1864, and debate on the issue became quite public. In 1870, the Daily Telegraph wrote in an editorial:

the question can be suppressed no longer – that it concerns the very life and future history of the nation, and must be carried, as is our wont, before the tribunal of national opinion.

With this, the Telegraph decided to confront the issue of prostitution as it was then imagined: not just as a public health issue, but as an issue that affected the future of the nation. Somewhat hyperbolic, one might think, but the British Medical Journal (BMJ)  in the same year showed were the leadership of the medical profession stood on the importance of the issue of sex work and the national good:

Shall we find that, by the control of prostitution, we shall have irretrievably lost in morality and gained not at all in health?[1]

This letter was written in response to proposals to introduce controls on prostitution. These controls would largely have consisted of mandatory health checks for soldiers, proposals to educate them in hygiene and safer sex, and possibly also some extremely punitive measures targeted at sex workers (including, possibly, the right for police to “inspect” any woman considered to be a possible worker). The concern of the correspondent was not just that these measures might prove useless, but that by even so much as considering education of soldiers about the risks of sex with sex workers, Britain would have given up something of its moral core. Merely admitting that ordinary men visit sex workers, and that this could not be stopped, was seen as a potential moral scourge. One imagines that these “prostitutes” must have been a truly terrifying force for evil, that even to speak their name in the presence of soldiers would so corrupt them as to lead to the “irretrievable” loss of some moral value – and with it, we shall see, physical decay.

Nationalism and Sexual Health

There was a strong nationalist aspect to debates about sexuality and sexual health during the period of empire, and a fear that the failure of proper moral controls on certain segments of society would lead to a failure to check

that dire disease, syphilis, which is, more than any other disease, undermining the human constitution in this and other countries[2]

He linked the physical decay associated with this disease directly to the moral decay of prostitution and “immorality.” But the effect of the disease on the national constitution was not believed to be due to its debilitating physical effects alone; the weakening of the nation as a whole that comes about through “moral decay” was also of great concern. In amongst multiple letters to the BMJ describing genuinely terrifying levels of STI infection (up to 20% in one cohort during world war 1), we find doctors such as John Armstrong, who asked in 1921,

Shall we preach indulgences and recommend appliances and disinfecting agents, and so call evil good? By these means we might possibly, but not probably, stamp out syphilis, but the remedy would be a hundredfold worse than the disease, inasmuch as it would lead to a universal physical weakness and degeneracy unparalleled in history[3].

Here we are now 50 years from the original debate over the Contagious Diseases Act, and yet still correspondents to the BMJ are presenting the epidemiology of syphilis as inseparable from the epidemiology of moral decay. In the intervening 50 years they had won world war 1 despite all these supposedly weakening measures, and 50 years of (at least) considering preventive measures and education in the army had hardly led to the debilitation of the nation. And yet … moral degeneracy was still seen around every corner, and even were the medical consequences of it to be stamped out, the moral decay that might result from a policy of permissiveness towards promiscuity and sex work would surely destroy the nation.

The Importance of Moral Enforcement

If this were not enough evidence that the public health benefits of pragmatism were in this time considered very much secondary to the moral interests of the body politic, consider this further editorial piece from the BMJ in 1884, after the passage of various Contagious Diseases Acts in the UK, which included punitive measures against sex workers and a variety of public health measures targeting sex workers:

The reformatory side of the question has not been fully and fairly recognized by those even who have pleaded the sanitary side. Without compulsion in some form or other, there can be no repression of this disease, and, without moral reforms, compulsion would not be tolerated[2].

The “compulsion” here referred to includes the right of police to stop and enforce medical investigation of any woman suspected of sex work, and the continuing abolition of sex work itself (with punishment for the women involved). This editorial makes it clear that morality cannot be separated from public health when talking about STIs, and that prevention of disease in this era was considered impossible without the right of “compulsion” over those who might be affected. The “moral reforms” referred to here are attempts to reinforce existing moral strictures on sex out of marriage and promiscuity – a return to traditional values was considered essential to support willingness to prosecute ordinary women over sex work, and to introduce nationwide measures against sex workers and those who visited them.

Moral debate on prostitution at this time was not entirely one-sided, though even medical men who took a more humane or enlightened approach to the benefits of public health intervention could sound quite judgmental by modern standards, not to mention hyperbolic. Again, from the BMJ of 1869:

My private opinion is, and I hope to have it supported by you, that the discussion of these matters by medical men has now satisfactorily shown that the Contagious Diseases Act is but a division of a still larger question-Prostitution, which, again, cannot be discussed, much less settled, without our possessing considerable knowledge of the kindred questions of Illegitimacy and Infanticide

Whether the nation will ultimately accept these Acts, and the benefits obtainable from their operation, or not, one thing is certain, the condition of our streets after nightfall will no longer be allowed to be a national disgrace: moreover, “The Ladies’ Anti-Contagious Diseases Association” now admits that the condition of their fallen sisterhood requires investigation, and they take blame to themselves for having so long neglected it. To conclude, I think you will agree with me that, as public feeling is now fully aroused to the necessity of investigating these questions, professional men must be prepared to take their part in the discussion; and Government must look to surgeons to carry out the preventive and sanitary measures which our special knowledge may recommend for the alleviation of the sufferings of women who are often more sinned against than sinning[4].

[Emphasis in the original].

This more enlightened view of the public health benefits of intervention still supports extending the punitive measures of the Contagious Diseases Act to the civil population, and refers to sex workers as “fallen” women. While it might be progressive for its time, it still admits of a need to control and change sex workers, and denies them agency or the right to control their workplace or their own future. At the time, with most STIs untreatable and the “situation” on the streets of London seen as urgent, this coercive approach to public health may have been appropriate, but it set the tone for much of the following 100 years of debate on STIs, sexuality and public health in the medical profession. This tone is perhaps best summed up in the policy statement of the National Council for Combating Venereal Diseases, which, writing fully 50 years after the initial Contagious Disease Acts were passed, stated the following in its policy:

As by far the most important cause [of STIs] is promiscuous sexual intercourse, the question cannot be dealt with apart from social and moral factors … The action of public-health authorities in dwelling in their publications on the medical prevention of these diseases, to the exclusion of moral considerations, is deprecated.[5]

Thus it was still well-accepted medical orthodoxy in 1921 that public health interventions based on education, information and the practice of safer sex were to be ignored in favour of punitive and moral measures. While debate on this was far from settled, we can see the debate has followed this tone and failed to settle on a compromise between morality and hygiene for more than 50 years. Is it any wonder then, that even after syphilis had become just another treatable disease – in the modern era – doctors continued to insist on the importance of fighting immorality in medical practice?

Beyond Sex Work: Illness and Pregnancy as Moral Enforcers

There is an underlying tenor to much of the early correspondence on STIs that suggests they should be seen as the natural consequence of moral decay or that the prevention, through encouraging “immorality,” is worse than the disease. But although implicit in the published statements of these early physicians, they never manage to come out and say that the terror of syphilis could act as a deterrent to immorality[6]. Once the second wave of feminism had reared its ugly head, however, things got a little more heated in the medical literature. Consider this (not uncontroversial) piece from 1971:

Venereal disease being no longer a penalty it is not a Deterrent… if this new understanding and tolerance of an immense human problem is not to land us in one huge jumbo-jet hop from barbarism to decadence then new attitudes to the physical, psychological, and spiritual aspects of personal intimacy must be born.[7]

In this article the role of STI as moral enforcer is clearly stated. This link between promiscuity and disease was being researched in the 1970s, out of fear that the pill would lead to an explosion in STI prevalence, and the role of the pill in removing restraints to “barbarism” was seriously considered, but this opinion piece is one of the clearest statements of an underlying moral panic: that without fear of the negative consequences of sex, people would just get on with enjoying themselves. We’ll come back to this theme in later episodes of this series, because while the second wave feminists were very much in favour of liberalization of sex work laws and the breaking of boundaries on sexual behavior, their radical feminist successors have in common with Dr. Wigfield and their christian fundamentalist fairweather friends a desire to create “new attitudes to the physical, psychological, and spiritual aspects of personal intimacy.” Until the advent of HIV, when gay men entered the spotlight, sex workers and promiscuous women – often casually intermingled in the traditional view of “immorality” – were the ones who were most likely to be the victims of these experiments in returning to old social values[8]. We will see this casual elision of categories (of women, and of behavior) and the return to moral themes of 30, 50 or 100 years ago frequently in even the most modern debates over sex work, and we will see that those worried about “immorality” are very quick to place public health and the physical welfare of women behind their deeper moral concerns, and that it is always sex workers and poor women who suffer first and most from attempts to reverse the flow of sexual liberation. We will also see these nationalist and moralist themes return to the debate, though they may take on new and more modern forms, being confused with issues about European integration, globalization, trafficking in people, the objectification of modern sexual relations through capitalism, and the “pornification” of society. But fundamentally they derive from this same animating principle: that the welfare of people engaging in consensual acts, and the public health risks arising from same, are of secondary concern compared to the pressing need to prevent some form of moral slippage. It is, in essence, the conflict between liberalism and authoritarianism, in the most personal of spheres.

1: Drysdale C. Correspondence, British Medical Journal; July 23, 1870

2: Nason, J. An address on sanitation in some of its aspects, moral as well as general. British Medical Journal; July 5, 1884.

3. Armstrong, J. Correspondence, British Medical Journal; November 11, 1922

4: Acton, W. Correspondence, British Medical Journal; April 2, 1870

5: National Council for Combating Venereal Diseases. The prevention of venereal disease: statement of the national council. British Medical Journal; March 26, 1921.

6: I have a memory from long ago of an editorial in the BMJ where a doctor openly advocates leaving syphilis untreated as a deterrent to others, but much searching has failed to turn it up, so I can only conclude that it was a figment of my imagination. But there is a nasty letter in the 1895 BMJ from a woman advocating leaving syphilis untreated in pregnant women, for vaguely eugenicist reasons.

7: Wigfield, AS. Attitudes to Venereal Disease in a Permissive Society. British Medical Journal, 1971, 4, 342-5.

8: And it’s no surprise that once HIV entered the scene – even in 1987 – we had letters to medical journals from surgeons arguing their right not to treat those who engaged in “voluntary sexual perversion or mainline drug abuse”