THE CD ACTS AND WARTIME MEASURES: PROSTITUTES AND SOLDIERS

Post-Crimean military medical reforms and the 1857 Royal Commission report on army health revealed the high incidence of VD in the army. One way of containing the spread of VD was by improving the sexual health of prostitutes. This intervention, sanctioned by the CD Acts (1864, 1866, 1869), was not a nationwide measure. Instead, it targeted particular bodies, transactions, and spaces. Known and suspected prostitutes working in about twenty garrison and seaport towns, mostly in the south of England, were required to undergo compulsory medical examination to establish whether or not they were suffering from VD—syphilis, gonorrhea, or soft chancre.Footnote 14 If they were, they were then required to enter a lock hospital for treatment and to stay there until cured or for up to a maximum of nine months. The soldiers and sailors who spent their money and their leisure time in the bars and brothels of the selected towns would, it was hoped, be less likely to become infected. Britain's fighting forces and imperial defenses would be restored to full strength and troublesome towns given a moral makeover. However, the treatments available in an era before arsenic-based and, later, antibiotic cures—mercury, sweating, disinfection, and douching—were elaborate but generally ineffective.

In Britain, the CD Acts were suspended in 1883 and repealed in 1886, although they remained in force in many parts of the empire.Footnote 15 The repeal was prompted by a huge popular campaign against their sexual “double standard” and “continental-style” state regulation of “vice” led by Josephine Butler and the Ladies National Association. Furthermore, the acts had simply not diminished military infection rates and had thus failed in their primary purpose.Footnote 16 The repeal did not, however, signal the end of coercive approaches.

During World Wars I and II, two similar and well-documented measures were introduced. In March 1918, a new regulation, 40D, was added to the Defence of the Realm Act, which allowed the compulsory examination and treatment of women suspected of having sex with military men while infected. If found guilty, women could face a large fine (up to £100) or be sent to prison with or without hard labor for up to six months. Regulation 40D sparked its own mass repeal campaign, which had many echoes of the original anti-CD protests, and which was, in fact, led by the Association of Moral and Social Hygiene, the new incarnation of Butler's Ladies National Association. By June 1918, over fifty “social, religious, political and industrial organisations of men and women with a membership of well over a million members” had signed up to the campaign.Footnote 17 By September, even before the end of the war, 40D had been withdrawn.

Three years into the Second World War and against a backdrop of a sharp rise in military and civilian infection rates, a rise all the more marked given that infections had been falling since the 1920s, another wartime measure was implemented.Footnote 18 In November 1942, an extra regulation was added to the 1939 Emergency Powers (Defence) Act. Regulation 33B made it an offense for any person identified by two separate patients as the source of their infection to fail to report for examination when asked to do so by a Medical Officer of Health or to fail to continue being treated until no longer infectious.Footnote 19 Significantly, the new measure attracted little public attention—almost certainly because it did not (on paper at least) differentiate between men and women but also because, by then, the tenor of discussions of compulsion had changed. In a lengthy Commons debate on the matter in 1942, only thirty-three MPs voted to annul the regulation—some because they were against all forms of compulsion, but others because they wanted much greater levels of compulsion and thought that it did not go far enough down that road.Footnote 20 In fact, 33B remained in force until 1947. Even after it was withdrawn, it was replaced by central government recommendations to local authority VD clinics on contact tracing, which survived in different forms into the 1980s. Contact tracing—seeking out the sexual partners of all infected patients and persuading them to be treated—was carried out by health visitors, social workers, and hospital almoners. It involved an intriguing kind of “very labour intensive detective work” in homes, pubs, clubs, and discos—an area of work ripe for further historical investigation.Footnote 21

The wartime regulations discussed here differed from each other and from the original CD Acts in some key respects. The CD Acts dealt with (suspected) prostitutes in designated urban spaces. Regulation 40D dealt with women (likely to be prostitutes) accused of infecting soldiers (mainly around military camps and bases). Regulation 33B dealt with men and women (but in reality female prostitutes and “amateur” prostitutes) accused of spreading infection (mainly among military men). The measures thus became less spatially and gender specific. It was clear, however, that professional and casual prostitutes and the “growing” numbers of sexually active girls were still imagined to be the primary source of infection, that military men were viewed as the group who needed the most protection from that infection, and that clear-cut compulsory measures were thought more justifiable in times of national emergency.

Where large numbers of women were dealt with over time under the CD Acts, much smaller numbers were subject to proceedings under Regulations 40D and 33B. For example, in the first six months of 33B's operation, only sixty-four women were subject to proceedings.Footnote 22 Care should be taken here, however, as these measures are not directly comparable and were not enforced or recorded by comparable agents. More importantly, while actions under these clauses were remarkable and important, they were not necessarily representative of the history of compulsory treatment for VD.

These measures need to be examined alongside more everyday and less visible uses of compulsion and coercion within British efforts to control VD among the working class in particular. Many more women, teenage girls, children and babies, as well as certain kinds of men, were subject to different levels of “compulsory” treatment, delivered in different settings across the period considered here.

VD CLINICS AND MASS VOLUNTARY TREATMENT

In the early twentieth century, the treatment of VD was revolutionized as a result of series of connected social changes, some medical, some military, some political, and some concerning governance more generally. Between 1905 and 1910, Fritz Schaudinn and Erich Hoffmann had identified the microorganism causing syphilis, August von Wassermann had designed a diagnostic test for it, and Paul Ehrlich and Sahachiro Hata had created Salvarsan, an arsenic-based treatment for it. As Mary Scharlieb, a leading female doctor, later wrote, “We [knew] the cause of syphilis, we [knew] how to detect syphilis, and we [knew] how to cure syphilis.”Footnote 23 This powerful new knowledge was used by the military to contain high infection rates among soldiers on all sides during the First World War. Mass (masculine) military practices went on to shape mass public health policy at a time when the political ground was already shifting toward more interventionist social policies. In Britain, new welfare measures, from maternity services to school meals to pensions, were beginning to reshape the national body, literally and figuratively. As Nikolas Rose might put it, the governed were being imagined in new ways, not least as a national resource to be maximized.Footnote 24 For Kathryn Ellis, this shift was connected to a shift in corporeal governance, in which public policies of different kinds were motivated to secure “physical efficiency,” usually through measures to protect existing and future labor power.Footnote 25

The result was dramatic. In Britain, the 1913 Royal Commission on Venereal Disease, reporting in 1916, famously estimated that up to 10 percent of the urban population had syphilis and that a higher percentage was likely to have gonorrhea.Footnote 26 Given that these conditions could cause sterility, mental incapacity, and blindness as well as high infant mortality rates, the commission required all local authorities to establish VD clinics or treatment centers. These were to be based in existing hospitals where possible and were to offer free and confidential treatment on a voluntary, outpatient basis. Patients could attend clinics outside their local areas in order to preserve their privacy. Public education programs would inform people about the dangers of promiscuity and the dire effects of VD but also tell them about the new facilities where they could be cured. By 1920, there were 190 treatment centers that had seen over 105,000 new patients and 1,400,000 total attendances.Footnote 27 Taken together with more general improvements in living standards and public health, these new mass means of diagnosing and treating certainly did much to reduce infection rates. Between 1920 and 1923, for example, Hall reports that the number of cases of syphilis fell by nearly a half, and that of gonorrhea by nearly a quarter.Footnote 28

On the surface, this was a system that operated without recourse to compulsion. The question of whether VD should be added to the existing list of notifiable infectious diseases (set up in 1889) was considered by the 1916 Royal Commission. According to the 1889 measure, people found to be suffering from the listed diseases were required to undergo treatment and to accept other infection suppression measures.Footnote 29 Supporters of compulsory notification argued that treating VD in the same way as other common diseases would combat the stigma and ignorance that prevented people from seeking proper treatment. Opponents drew on a variety of views, many unchanged since the 1880s. Compulsion was “continental,” “authoritarian,” and “un-British.” It would sanction “vice” rather than rooting it out—in other words, sexual continence was the best “cure.” It would target women over men, as the CD Acts had done. Most important, it would deter sufferers from seeking medical help because to notify a doctor of their “shameful” condition would be tantamount to notifying relations, neighbors, and employers as well. Instead, they might seek ineffective but secret treatment from unregulated quacks, chemists, and new mail order companies. Either route would only lead to greater levels of infection.Footnote 30 Eventually, the 1916 commission decided not to put VD on the list.

However, the rejection of compulsory notification in favor of voluntary treatment and public education did not mean, as Baldwin has argued, that the British people effectively had “a perfect freedom to suffer and spread VD.” His claim that the British policy makers “rejected regulation,” “avoided coercion,” and “treated all diseased, men or women, alike” is wrong. Britain did not adopt “legal constraints on the infected” that were “considered commonplace” in much of Europe and North America, but it certainly did find other ways to enforce the treatment of key groups.Footnote 31 Davidson has shown how coercion worked in the Scottish context, but he attributes this to the “strong tradition of civic authoritarianism in Scotland,” a tradition connected to the continuing strength of the churches in Scottish social policy, and one that, moreover, was “increasingly at odds with an English government intent on marginalizing the State from sexual politics.”Footnote 32 In effect, Davidson's work implies that Baldwin's voluntarist argument works for England but not for Scotland. This opens two questions: how did coercion work within English VD measures, and why has it been less well documented?

As outlined below, not all patients sought treatment at the new clinics of their own accord. Rather, some were referred for treatment by other agencies that closely monitored their attendance. Not all patients chose to complete their course of treatment—in fact, a very high proportion “defaulted” in this respect. Some defaulters were put under much greater pressure than others to continue with treatment—a key element of the “voluntary” system. Further, in 1914, doctors were required to notify authorities of one variant of VD—ophthalmia neonatorum, a gonococcal infection that babies could acquire during birth and that could cause blindness if left untreated—as part of broader infant health initiatives.Footnote 33 As Evans has noted, the new clinics were an important step on the road toward what would become “comprehensive, state-funded, free and nationwide health service.”Footnote 34 As will be seen, however, the clinics offered different levels of service to different kinds of patients. The new health care may have been free, but it never set out to be fair.

Clinics did not have a monopoly over the treatment of VD. The Royal Commission aimed to direct the majority of patients toward authorized treatment centers where they would receive effective treatment from trained staff. A consequent piece of legislation, the 1917 Venereal Diseases Act, forbade anyone other than a qualified doctor from offering treatment, in order to prevent people from being mistreated. Taken together, this legislation could be assumed to have precluded the treatment of VD in any setting other than the official clinics. However, a number of private doctors, poor-law infirmaries, mental institutions, military hospitals, approved schools for delinquent girls, rescue homes, and children's homes continued to treat people for VD. These spaces, while subject to other kinds of inspection, were not subject to clinic regulations about, for example, the principle of voluntary treatment, the right of the patient to confidentiality, or the right of the patient to pull out of treatment. Rather, different tactics of governance were used in these spaces.

COERCIVE VOLUNTARISM

The coercive elements of the post-1916 voluntary system of venereal treatment can be better understood in the context of the coercive elements that survived the 1886 repeal of the CD Acts. The repeal put an end to the compulsory examination and treatment of (suspected) prostitutes working in certain locations. It also withdrew most state funding from the facilities certified to receive such cases: old lock hospitals set up before the 1860s, newer ones set up as a result of the acts, and designated lock wards in other general, voluntary, and poor-law hospitals.Footnote 35 However, many of these places continued to function, raising revenue by reverting to earlier philanthropic means. They continued to admit mainly young women (as they had tended to do during the operation of the CD Acts) on a quasi-compulsory basis long after the 1886 repeal.Footnote 36 Surviving evidence strongly suggests that these were working-class “wayward” girls and prostitutes, with a very similar profile to those admitted to the vast network of mainly Christian charitable rescue homes. With no unified statutory regulations governing their admissions policies, these homes and hospitals were able to exercise enormous control over their inmates by effectively confining them for long periods of time.

Lock hospitals have been overlooked in discussions of twentieth-century VD, yet they played an important part in patterns of local medico-moral provision. Manchester and Salford Lock Hospital, for example, admitted 229 (mostly unmarried) women as inpatients in 1914 and 221 in 1915. After their treatment, the majority of them were discharged to “various Charitable Homes,” where it can be presumed that they were “detained” for a further period of time.Footnote 37 Other cities—not all of them included in the 1916 Royal Commission's survey of provision—offered similar facilities. Bristol and Dublin's lock hospitals continued to function until at least 1918 and Glasgow's into the late 1920s.Footnote 38 The London Lock admitted patients for a full two centuries, from the 1740s to the 1940s, and operated as one of the capital's statutory VD clinics between 1916 and 1929.Footnote 39 As shown below, a good proportion of its latter-day patients were girls and young women of the type admitted in Manchester. Female inpatient admissions to the London Lock did fall after the repeal of the CD Acts but notably rose again in the 1910s, so that in 1916, its 650 admissions were close to the nineteenth-century levels (730 in 1890 and 683 in 1886).Footnote 40

In addition to surviving lock hospitals, many poor-law infirmaries continued to operate old-style “lock wards” for male and female paupers with VD. Some contemporary reports document poor facilities and restrictive practices; one Local Government Board investigator found that patients were “kept in bed, even when it was not necessary from a medical point of view, because there was no-one to look after them [and because] it was felt that they were likely to be very unmanageable if they were allowed to have their clothes and to walk about.”Footnote 41 Another described “a Lockward situated in one of the richest towns in England” in 1918: “The bare, whitewashed walls have no pictures, the tables no flowers, a general air of discomfort reigns supreme. You ask if anyone visits this ward. In a hushed whisper the nurse replies: ‘This is a Lockward.'”Footnote 42 Medical treatment of these pauper patients clearly varied. Some workhouses treated patients in-house; treatment in those cases would have probably continued for as long as the patients opted not to discharge themselves—a complicated issue in itself. Others referred patients elsewhere. For example, the Paddington Board of Guardians (local administrators of the poor law) sent a number of women to the London Lock in the 1920s, where they were apparently required to stay until formally discharged by medical staff.Footnote 43

Rescue and charitable homes specializing in venereal cases provided further spaces for treatment that, if not compulsory, was not entirely voluntary either. The Highbury VD Home (ca. twenty beds), the Liverpool Medical Home, the Southwark Diocesan Medical Home (ca. twelve beds), the Salvation Army's Mothers’ Hospital in the East End, and the Streatham Magdalen Hospital (ca. ninety-eight beds) were just some of the many homes operating in the 1910s, 1920s, and 1930s.Footnote 44 Some were subsidized by local councils, and others were dependent on fund-raising or legacies. Archived records of these homes, and rescue homes more generally, are rare, at least compared with those of statutory facilities. As a consequence, their place in the mixed economy of coercion and wider histories of modern English governance and welfare building is often overlooked.Footnote 45

It would be wrong to see these “old-style” institutions as nineteenth-century hangovers. Lock hospitals, poor-law lock wards, and specialist rescue homes may have been less visible, but they formed an integral part of post-1916 VD treatment regimes. The key to this was their established custodial function and the fact that they were often able to admit girls and young women formally sent to them by the courts. Crucially, the legal bases on which the courts could properly refer cases to such places expanded in the early twentieth century. As I discuss in my wider work on this area, the 1907 Probation Act, the 1908 Children and Young Persons Act, and the 1913 Mental Deficiency Act together allowed large numbers of girls and young women to be admitted to custodial care on the grounds that they were variously vulnerable, promiscuous, abused, homeless, criminal, or defective.Footnote 46 A proportion of them inevitably had VD—indeed, this could be a decisive factor in their committal to custody.

The 1907 Probation Act allowed offenders to be given noncustodial sentences for the first time. However, young female offenders put on probation were much more likely than their male counterparts to be given a “residential probation order”—effectively a custodial sentence but one to be served somewhere other than a prison. A number of young women were committed to existing rescue homes on this basis. If they were suspected of having, or were found to have, VD, they might be committed to a specialist rescue home like one of those outlined above or to a lock facility. Once detained, they could be “given” treatment.

The 1908 Children and Young Persons Act allowed juvenile courts to commit those aged up to the age of sixteen (seventeen after 1933) to custodial care if they were found guilty of an offense or if they were found to be in “need of care or protection.” A court could send such cases to a certified school (approved school from 1933) for a number of years or to another institution, again, such as a rescue home or lock facility. Concerns about VD ran high among authorities dealing with these girls. Infected girls were held in special remand homes pending their court appearances and were transported in special cars. Their court hearings were scheduled early in the day to keep them away from other cases, and their toilet arrangements were monitored. If committed to custody, they were likely to be sent to an institution for “sexually knowing” as opposed to “sexually innocent” girls—even though their infection may have been “innocently” acquired.Footnote 47 From the mid-1930s, at least two approved schools for girls were designated as “treatment schools” for VD cases. The “sentences” of those sent to them were determined by the length of time staff thought it would take to “cure” them, both physically and morally.Footnote 48

It follows from these elaborate arrangements that the courts or the custodial institutions (or both) must have required many girls to undergo some kind of gynecological examination, perhaps as part of a general medical check, as a means of separating the infected from the noninfected and virgins from nonvirgins. There is very little acknowledgment of these presumably compulsory examinations, yet they were a crucial component of judicial decision making, a very particular form of what Valverde has termed “judicial diagnostics.”Footnote 49 Within the juvenile justice and probation systems, then, it was routine for a young thief or prostitute, runaway, or abuse victim to spend her period of punitive or protective custody in a place where her VD could be compulsorily treated.

The London Lock certainly admitted considerable numbers of these kinds of cases. A 1929 inquiry into its work observed that “a substantial number of [the 169 female residential] patients are under probation or have been sent to the Hospital by Boards of Guardians, or are brought by rescue workers.” A witness to the inquiry (almost certainly Lilian Barker, governor of the women's borstal institution at Aylesbury and one-time welfare worker at the London Lock) described them “as women of much the same type as those at Aylesbury.”Footnote 50 At the time, Aylesbury operated as a reform prison for young women between the ages of sixteen and twenty-one found guilty of routine criminal offenses, such as theft, soliciting, and drunkenness. Significantly, prison commissioners reported that over 80 percent of Aylesbury's own 1917 intake (of 115) had VD, a proportion high enough to suggest that this was in itself a key factor in their committal.Footnote 51 Throughout the 1920s and 1930s, the London Lock had special wards for, among others, prostitutes, older teenage girls, and children.Footnote 52 In addition, it continued to maintain its own Rescue Home for up to thirty patients who were medically cured but who were judged to require further moral and practical training.

The London Lock also dealt with “mental defectives” who were subject to the third legislative area discussed here. The 1913 Mental Deficiency Act required local authorities to identify mental defectives and to make appropriate provision for them. Those with VD could be committed to approved hospitals or workhouses for treatment. The London Lock was certified to receive such cases, which it admitted to yet another specialist ward. By 1918, over fifty workhouses had been approved by the Board of Control (the national body regulating the treatment of the mentally defective) “for the reception of defectives under detention orders,” some of which “afford[ed] facilities for the treatment of venereal disease.”Footnote 53 Those detained were very likely to be young women. Doctor A. F. Tredgold, an expert in this field, believed that young men should be detained if necessary but also believed that “the feeble-minded youth is, by reason of his defect, less likely to have opportunities for intercourse than is the feeble-minded girl” and was therefore “a less active agent in the spread of venereal disease.”Footnote 54 It is also likely that officials of mental institutions could require their inmates to be treated—with or without their consent. They feared that if they released patients for treatment elsewhere, they might escape. There was no formal procedure governing an institution's right to treat (or not to treat) a patient until the 1983 Mental Health Act.Footnote 55

Significantly, contemporary texts on VD that covered legal questions did not discuss these kinds of cases. For example, F. G. Crookshank's account of “the medico-legal relations of venereal disease” simply advised doctors of the legal rights and obligations involved in this work.Footnote 56 Douglas White, a doctor and firm opponent of compulsory notification, made a rare, brief reference to the gray area investigated here: “At present, treatment is offered to all, free and entirely confidential, saving the exigencies of a court of law.”Footnote 57

Two arguments were used—sometimes explicitly, mostly implicitly—to justify the combination of treatment and detention for the kinds of women and girls referred to above. The first was rooted in a long-established and widely held belief that the only long-term cure for VD was sexual continence. According to this view, the minority of women and girls who were sexually promiscuous needed help to change their ways. Their medical cure was less important than their moral cure. To reform this minority group would be to tackle the social root of sexual corruption. Men might continue to want casual sex, but if there were no women prepared to make it available to them, VD would disappear. Within this argument, work—usually domestic service—was frequently presented as the practical key to spiritual moral reform. Wayward girls needed respectable trades to allow them to support themselves without resorting to the wages of sin. This view shaped the reform regimes and daily routines of countless certified schools for girls, rescue homes, and lock facilities that invariably involved some level of domestic service training up until the Second World War.Footnote 58

This older justification for detention remained powerful even in the post-1916 age of new outpatient, clinic-based treatment for VD. The London Lock treated thousands of people through its male and female outpatient facilities. Yet its board of managers defended their continuing use of inpatient treatment for certain groups to treat this “insidious … evil”: “In these times when unemployment is so rife in our country, it cannot be conducive to the well-being of young women afflicted with these woeful diseases and in many cases out of employment, to be only attending an Out-Patient Department. Far better to be in comfortable surroundings with skilled Medical-Nursing service and supervision available, until ready for discharge from the Institution.”Footnote 59

Officials also justified residential measures on the grounds that the only successful treatments for VDs were “continuous treatments,” administered regularly over a long period of time. The new Salvarsan-based injection treatments and more traditional irrigations took several weeks to be effective. Patients dropped out of the new clinic programs for various reasons: because they found the treatments painful, inconvenient, embarrassing, or difficult to access, or because they believed themselves to be cured, since in syphilis's infamous latent second stage external symptoms (sores and discharges) disappeared. The proportion of patient “defaulters” within the British voluntary treatment system was very high and a matter of much concern to clinicians, moralists, and health officials. Estimates of the precise proportion varied. Davidson calculates that around one-third of Scottish clinic patients did not complete their treatment.Footnote 60 The very groups most likely to default were also those thought most likely to spread venereal infection—men in the services or other mobile occupations, those moving between jobs and cities, and “rootless” girls, or, as one doctor put it, “the migratory class.”Footnote 61

Officials working in older lock facilities used the importance of continuous treatment to justify their detention of female patients: as the London Lock's managers saw it, they provided “the right environment … necessary to a complete cure” and therefore served the cause of “national economy.”Footnote 62 Those working in the new clinics also used continuous treatment to rationalize the more coercive, if less well-documented, aspects of their ostensibly voluntary project.

Measures taken by the clinics to foster compliance by ensuring patient privacy are well known. Patients were assured that their cases would be treated confidentially. They were able to receive free treatment in any clinic, not simply in their local one where they might run into neighbors or colleagues. Many clinics opened in the evenings and on Saturdays so that patients could avoid awkward questions about regular absences from work. Many clinics were located in the basements or back buildings of established hospitals, in part to extend patient privacy but also surely as an architectural echo of the earlier isolation of lock wards. When a patient first registered, medical staff would stress the importance of regular attendance and the need to complete the prescribed treatment. If, despite all these measures, they still defaulted, the patients would be sent a standard reminder in the first instance, followed by a personal letter in the second.Footnote 63

For some patients, that was as far as the clinic went in attempting to persuade them to continue with their medication. “Higher risk” groups, however, were pursued more rigorously and by a wider range of agencies. As outlined above, doctors took on some of this follow-up work, but in many clinics it was considered the responsibility of almoners (hospital welfare workers), often working in close collaboration with newly established state-paid social workers, health visitors, and infant welfare officers, as well as with existing charitable rescue workers. Surviving accounts of this work suggest that this network of women focused their efforts on teenage girls, pregnant women, mothers, babies, and young children. These groups were already subject to some kind of outside scrutiny, mostly conducted by female welfare workers who had established access to the homes, workplaces, and clubs of these groups. These women workers crucially lacked such access to male defaulters.

The memoir of Dorothy Manchée, an almoner at St. Mary's Hospital in Paddington in the 1930s and 1940s, is a rare and unapologetic acknowledgment of the coercive edge to British voluntarism. If encouragement and formal letters failed to bring a patient back, almoners (or one of their contacts) would pay her a home visit. According to Manchée, it could be enough on these occasions for such a visitor simply to walk around the patient's home area in the hope of catching her eye: “The patient herself … may be met in the road, and even though recognition is not admitted on either side she will attend clinic as speedily as possible.” If a home visit proved unavoidable, the visitors apparently never revealed precisely why they were there and always had “a cloak for enquiry,” some other reason for calling that might have to do with child or family health or a school or work matter.Footnote 64 This was a system of persuasion that worked on the threat of revelation and shame. In certain cases, the patient confidentiality at the heart of the voluntary clinic practice could be compromised in the interests of securing continuous treatment.

Hospitalization, or “hostelisation,” was another possibility. According to Ernest R. T. Clarkson, hospitals “in most towns” set aside a certain number of beds “for patients recommended from associated venereal disease clinics.”Footnote 65 As demonstrated earlier, these were in addition to the beds made available by other institutions. It can be reasonably assumed, I think, that the patients concerned had little option but to agree to be treated. Manchée wrote that almoners were “ruthless” in their follow-up of women “known to be pregnant.”Footnote 66 An unmarried mother-to-be could be referred to a special hospital or medical hostel. These would “usually take the girl at about the sixth month.” She would stay there after the birth with her baby, both presumably undergoing treatment, “until both are sufficiently strong—the baby to be placed out with a foster-mother and the girl to work.”Footnote 67 Some young women resisted this process: “Many independent spirits reject the proposal of hostel from the start, and for these, like those considered insufficiently stable to settle in that atmosphere, hospital accommodation has to be arranged. … In the last resort, if she will not co-operate or attend regularly, or where for some reason she is unsuited to work, she is best in hospital even at an early stage of pregnancy.”Footnote 68

Young girls with vulvovaginitis, a form of gonorrhea, were also likely to be hospitalized. According to Manchée again, “admission” was deemed “in nearly every case the best course” regardless of a family's willingness to attend outpatient clinics. She writes that parental consent “had to be sought,” although this could be a notoriously gray area in the field of child protection more generally. The rationale behind residential treatment was that outpatient treatment was somehow insufficient—most likely because these girls were thought to need more stringent protection from their families if not some kind of chastisement for “being dirty” and a risk to others. Gonorrhea could be “acquired by little girls with fatal ease,” namely, through poor feminine and family hygiene but very likely, too, through incest and abuse. Contact with “the gonococcus [was] possible through a soiled lavatory or towel, sleeping with an infected parent or sister … as well as by criminal assault.” If a girl was to remain at home, she “must be isolated from any other little girl, be kept from school and become a source of danger to her sisters; and since frequent treatment will be necessary, she must pass constantly in and out of the clinic, obviously undesirable for many reasons.”Footnote 69

Babies and children infected by their parents could also be hospitalized. In 1914, ophthalmia neonatorum, a common cause of infant blindness, became a notifiable infectious disease—the only form of VD to be so designated. Midwives or doctors who suspected that a newborn baby had been infected (through contact with vaginal membranes during labor) had to notify the local medical officer within twenty-four hours of the birth. Every local authority was required to make hospital provision for these babies and, if need be, their mothers. London cases were sent to White Oak Hospital in Swanley (northwest Kent), where, Manchée says, they were “retained as long as necessary.”Footnote 70

Syphilitic children could be similarly treated, although there was no formal legislation governing their care or their parents’ obligation to facilitate it. Congenital syphilis became a pediatric and public health priority in the early twentieth century. A raft of studies revealed more about the condition and its possible treatments.Footnote 71 Babies born with the condition could appear healthy for their first few weeks. Soon after, however, they commonly developed respiratory, skin, and nutritional problems. According to Dr. Mary Scharlieb, such “a wretched baby is often seen in the hospitals and work-house infirmaries of our big towns. … They are what [nurses] understand by the word `wasters' or … `marasmic babies.'”Footnote 72 The children that survived these early phases often went on to appear to have recovered. The infection could present itself in other ways, however, and they were likely to experience problems later with their sight and hearing, and their dental, digestive, and mental development. The new Salvarsan remedies cured large numbers of children in the early twentieth century but arguably only because of the mechanisms put in place to secure children's continuous access to those remedies. Securing that access was a priority. In 1934, a Ministry of Health survey of 150 VD clinics found that 20 percent of them believed that the attendance of infected pregnant women and children was “unsatisfactory.”Footnote 73

Once a child with congenital syphilis had come to medical attention, by whatever route (midwife, infant welfare officer, health visitor, venereal clinic staff, or school medical officer), decisions had to be made as to their treatment. According to Manchée, “treatment must be arranged somehow,” even if a child's parents were reluctant to recognize the condition or cooperate with treatment.Footnote 74 This position was corroborated by an American observer of British VD policy, Arthur Towne, the secretary of a New York social hygiene group. Towne wrote in 1939 that “almoners … are not allowed to use any methods involving or in any way suggestive of coercion” but noted the “only exceptions” to this were antenatal cases and children with congenital syphilis. However, the only method he mentioned was the diplomatic home visit, when in fact others were used.Footnote 75

Outpatient treatment was preferred, with a child's clinic attendances time-tabled around their school day or their mother's work or family commitments. Teachers, health visitors, school medical officers, and child protection charities worked together to ensure continuous treatment in the community. However, as always, they could increase the coercive pressure if they had to: Manchée writes, obliquely yet powerfully, that “in those cases where parents will not co-operate,” admission to a hospital or special home “becomes necessary.”Footnote 76 Child cases were prominent among those admitted to the London Lock, which ran at least three specialist residential facilities in the 1920s and 1930s: a maternity ward (opened in 1917), a “welfare department” that offered “mothercraft” training to new mothers over a period of three to six months, and a children's ward. The hospital notably made extensive use of images of these children in its fund-raising campaigns of the 1920s and 1930s. One appeal read “Rescued babies. Of 701 babies born in the New Maternity Department 631 were born free of Venereal Disease”; another stated: “This Hospital has the most pathetic Children's Ward in the Kingdom,” yet “Beds are closed for need of funds.”Footnote 77 The infected child had arguably become the new public “victim” of VD, displacing the fallen woman as the new image of tainted innocence.

The compulsory treatment of infected men and boys is more difficult to address, yet there is evidence to suggest that this did occur. It is well documented that men serving in the army were, from at least the mid-nineteenth century, required to report any venereal infections to their medical officers and to agree to accept whatever treatment was prescribed. At various points between the 1870s and the 1940s, men undergoing treatment forfeited their pay until they were able to resume their duties. They were required, at different points, to undergo full medical checks that included checks for VD. Genital inspections seem to have been a common experience for soldiers, especially those serving in the colonies, though the more public versions of these, known as “dangle parades,” were apparently phased out by 1900.Footnote 78 During the First World War, a soldier who concealed his infection could be court-martialed and was liable to a penalty of two years imprisonment with hard labor (without the option of a fine).Footnote 79 Similar, if less harsh, sanctions were applied during the Second World War.Footnote 80

These penalties were doubtless rarely invoked. Service sexual cultures were such that VD generally did not carry the same kind of shame that it did among civilian men or women. However, while prostitutes and “loose women” were cast as the main source of VD, soldiers were certainly seen by many as the source of the unruliness that caused its spread. Their youth, distance from home, disposable income, drinking cultures, and sexual freedom were referred to time and again in discussions of VD. As Levine has argued in the colonial context, the very men employed to protect the nation could also be presented as posing a threat to the health and morals of that nation, particularly around the communities where they were based.Footnote 81 The threat was differently embodied at different times. During the Second World War, for example, American and Canadian troops based in Britain—who were even further from home, who seemed to have even more money, and who had an additional exotic aura about them—were singled out by some as a major cause of the wartime increase in VD.Footnote 82

In the same way that rescue workers urged young women to change their social and sexual habits, so military chaplains, senior officers, and welfare officers aimed to persuade young soldiers to do the same. From the early 1870s, the Army Temperance Association aimed to replace dissolute drinking cultures with physical sports cultures. From the early 1900s, new recruits received at least one lecture on the dangers of VD. Speakers’ styles varied but often covered “Chastity, Continence, Temperance and Early Treatment.”Footnote 83 They appealed to men to be chivalrous. It was “criminal to infect a healthy woman,” “base to seduce a virgin,” and “dangerous to have to do with a prostitute.” Alcohol “interfered with self-control.” Men should take lots of exercise and “avoid filthy literature and lascivious thoughts and conversation.”Footnote 84 Senior officers—in their public writings at least—thus preferred to tackle VDs by advising sexual abstinence and requiring those who did become infected to report their condition and undergo treatment. They did not generally condone the distribution of “prophylactic packets” (containing disinfectants and later condoms), as favored by their Australian, Canadian, American, and many of their European counterparts.Footnote 85

These measures conveyed the often class-based message that there was more than one way to be a man, that sexual honor was as important as sexual prowess. But another message was that VD was a fact of life and should be dealt with honestly and openly. In this sense, the military culture of notification and compulsory treatment was less coercive than routine. Many of those in favor of extending notification to the civilian population hoped that it would secure a similar kind of routine, shame-free, and practical response to dangerous diseases.

Less is known about any kind of “coercive” measures used among civilian men with VD. The general and sexual health of sailors, many of them foreign, in the merchant marine was the subject of much debate in the 1920s, particularly in port cities. Local initiatives and international conferences together resulted in the introduction of special measures to prevent these men from acquiring and spreading VD.Footnote 86 Wholesome recreations, more registered hostels, and better health education aimed to stop men from acquiring the diseases in the first place. A system of international treatment cards (to facilitate continuous treatment regardless of location), better ship-based treatments, as well as new port-based dispensaries and clinics aimed to cure them before they could infect others. The Liverpool Seamen's Dispensary, one of the earliest, recorded over 27,000 attendances in 1924, its first year of operation. Whether any of these men were “required” to be treated, either by their employers or by dispensary doctors, is not clear. There are some possible precedents. Earlier but linked legislation in the early 1870s had allowed newly established Port Sanitary Authorities to “remove persons arriving on ships with infectious diseases to isolation hospitals” as part of their efforts to improve the sanitary condition of both ports and ships.Footnote 87 Certainly, census records suggest that Liverpool's Lock Hospital was unusual in the 1880s in its admission of male patients to residential wards. Given Liverpool's other efforts to police “the colour problem” apparently created by the presence of foreign seamen and by the white women attracted to them, it may be that some of the Dispensary's work had a coercive edge.Footnote 88 Similarly, it may be that some of London's special facilities for treating infected seamen—the Seamen's Hospital in Greenwich and a clinic based at the Albert Docks, for example—used particular tactics to encourage or secure continuous treatment.Footnote 89

Significantly, the London Lock ran a Male Hospital in Soho's Dean Street from 1862 to the late 1940s. This mainly operated on an outpatient basis but also had a residential ward with around thirty-five beds. Very different types of men were admitted. During the operation of the CD Acts, the War Office referred infected soldiers to a special wing of the hospital. In the early 1920s, patients included a number of Metropolitan police officers, who were perhaps admitted by their superiors as a means of ensuring their treatment (and return to duties), in much the same way as soldiers were admitted to military hospitals. Their inpatient treatment was followed by a course of outpatient medication, assuming that they could get the necessary time off from their shifts, which was apparently problematic. Intriguingly, some officers were “discharged from the Hospital for breaking the rules” by “gambling and burning light to waste after ‘lights out’” and were reported to the chief surgeon and the Met's commissioner.Footnote 90 By the late 1920s, the profile of men admitted to the Lock seems to have changed. Williams describes them as “a motley and mixed race crowd of virile young men,” adding that Ministry of Health criticisms of nursing standards at Dean Street were unfair. An “untrained Male Nurse” faced with such a group could not be expected to “respect the finer points of professional integrity.”Footnote 91 Soho's association with young, gay, bisexual, and migrant men was well established by this time; it is surely likely that they formed a significant proportion of patients. Dean Street also used the services of chaplains, missionaries, and male almoners, although, again, more research is needed into their tactics and targets.

With regard to younger men and boys, those with congenital syphilis or ophthalmia neonatorum were just as likely as girls to be treated in the ways outlined above. There is very little discussion in the sources consulted, however, of the treatment of teenage boys with sexually acquired diseases. They were too old to be picked up by school medical inspectors, unlikely to be judged in need of care or protection on sexual grounds, and perhaps too embarrassed to attend clinics, even if they were aware of their existence. Some agencies were aware that some urban teenage boys were involved in casual prostitution at various levels, but these agencies did not raise the subject of VD.Footnote 92

Men were required or encouraged to undergo treatment for VD on a different basis than women. Men in certain mass “public” professions—the military, the police, and the merchant marine—had regular medical and fitness checks as well as some access to employer-monitored treatments. Although women in certain fields of work—prostitution, casual work, and domestic service—were “targeted” for examination, other elements of their identity were just as important in determining who might be subject to hospitalization or to the “ruthless” community-based follow-up of the kind outlined by almoner Dorothy Manchée. Their age, sexual history, mental record, and parental status, as well as their previous brushes with authority, were all important. Moreover, women's “compulsory” treatment was much more likely to have been connected with some kind of court order. It was also more likely to have been delivered and monitored by charitable groups concerned with sexual standards and statutory agencies concerned with mothering and child welfare rather than by professional bodies concerned with workers’ fitness.

GOVERNANCE AND HISTORIES OF THINGS THAT “DIDN’T HAPPEN”

In 1928, the minister of health ordered a public inquiry into the work of the London Lock following the death of two working-class female maternity patients and the accidental blinding of another. In the first case, twenty-one-year-old Daisy O’Leary died from puerperal septicemia two weeks after the induced delivery of twins. It was thought that doctors had earlier attempted to induce her in the general ward, rather than in the (presumably more sterile) labor ward, thus contributing to her infection. In the second, a thirty-six-year-old woman, Elizabeth Downes, died of a “post-partum haemorrhage and exhaustion” after an eighty-eight-hour breech labor during which the consultant responsible failed to visit her, leaving an inexperienced house surgeon in charge. The baby was born dead, though was said to have been anacephalic and therefore unlikely to have survived even a more straightforward delivery. The third case involved twenty-one-year-old Mary Collins, who lost an eye after contracting a severe form of gonorrheal ophthalmia while staying in the Lock's eye ward. The contentious issue here was that Collins had been kept in the hospital (and thus placed at risk of infection) even though the eye condition for which she had been admitted turned out not to be gonorrhea related.Footnote 93

The inquiry had many agendas. The Lock was an old, specialist, voluntary hospital managed by aristocrats and whose working practices were at odds with those of new, professionally run general hospitals. It was also a VD clinic registered and partially funded by the state. The key questions pursued here were whether these (and other) incidents were the product of poor management, and how the quality of care might be improved in the future. The inquiry, and ensuing parliamentary and media discussions, were notably not concerned with the question of how and why these women had come to be in the Lock in the first place. Commenting on the Collins case, one member of the enquiry team made a telling point. If “the Hospital [had] given the patient the protective safety of a General hospital they [would have been] justified in keeping her. Without that security they were not.”Footnote 94 The message here was that all patients were entitled to good treatment, but some were less entitled to refuse that treatment. The post-1916 creation of the VD clinic network did, as Evans argues, help to cement a new kind of entitlement to a new kind of universal health care. But both “entitlement” and “universalism” had their limits.

This story has a significant coda: the London Lock lost its registration as a state-recognized and -funded VD clinic as a result of the inquiry. It nevertheless continued to operate as before, if more reliant on its charitable donors, for a further twenty years until its functions were dispersed into the new National Health Service in 1948. The London Lock had always occupied a unique and rather ambiguous position within the post-1916 clinic network, with its long-established traditions, its religious roots, and the sheer range of its activities. Rather than seeing it as an old-fashioned anomaly, however, it is more accurate to see the London Lock with its different approaches to different kinds of venereal patients as a microcosm of the British treatment system as a whole. It provided a voluntary outpatient clinic service, but it also served as a place of detention for particular kinds of polluted and polluting bodies.

Venereal disease treatment regimes helped to draw and to reinforce divisions between the responsible and irresponsible, between the competent and the vulnerable, and the trustworthy and the untrustworthy. As I have shown, these divisions were, not surprisingly, closely mapped onto existing categories of age, gender, class, mental ability, sexual status, and, for men, occupational status. Girls and young women were clearly not the only group to experience compulsory treatment: indeed, over the period considered here, they were probably outnumbered by babies, children, and soldiers. Yet, in my view, their experiences have a particular historical story to tell about governance and welfare state formation especially when considered in a wider context. Governmentality theorists have overlooked the specificity of this story in the illuminating but more overarching accounts of the changing “welfare subject.”Footnote 95

The sexual governance of girls and young women in early twentieth-century Britain was marked by a shadowy mix of formal and informal, statutory and charitable, and recorded and unrecorded measures. This governance could be characterized as a history of things that “didn’t happen,” drawing on critic Steven Lukes's view that there are certain dimensions of power where actions result from “nondecisions” and “nondiscussions.”Footnote 96 British courts “didn’t” order routine gynecological examinations for female offenders. British magistrates “didn’t” like to send girls to reform institutions. British mental hospitals “didn’t” sterilize women.Footnote 97 British VD clinics “didn’t” breach patient confidentiality. British treatments for VD “didn’t” operate on a coercive basis. Except when, on a regular basis and in all cases, they did.

The systematic silences around these issues are complex and deserving of a separate study in their own right. As far as VD treatments are concerned, they seem to have been the product of a number of factors. As suggested above, when treatments were administered in settings other than statutory clinics, they were administered as part of a wider relation of governance and perhaps, therefore, “routinized” out of discussion. Further, VD remained a shameful, secretive, and distasteful topic across the period considered here. Open discussion of it was still comparatively rare, especially in relation to young women, as many involved in contemporary public education programs testified.

The governance of young women was implemented as much by the charitable rescue sector as by emerging statutory agencies. The rescue “sector” was very diverse and is perhaps more properly described as a “network” made up of very different organizations, workers, and homes, some working independently, some working with the state. This network did not work as a coherent whole. Although different agencies working around VD kept in touch with each other as the need arose, they seem—quite understandably—to have had no detailed knowledge of each other's practices or facilities. Clarkson, for example, appealed to readers of his book to send him the names of other hostels for infected young women. Manchée's list of hostels, homes, and hospitals is very broad but not all-inclusive. M. Pendlebury's account of the shortcomings of poor-law lock wards ends with a call for more facilities for infected young women in addition to the few known to her.Footnote 98 Even the 1916 Royal Commission on Venereal Diseases made no mention of the extensive work of the rescue sector in this area and omitted to list some surviving lock hospitals. This implies that knowledge of facilities was held by key local individuals—particular doctors, policewomen, rescue workers, probation officers, and so on—but perhaps only for as long as they were at their posts.

This network slipped in and out of an emerging public sector audit culture (and therefore, to a large extent, in and out of the historical record). Some elements of its work were documented and, therefore, made visible to health and welfare policy makers. Many elements were not. Despite the rise of “scientific philanthropy” as practiced by larger organizations such as the Charity Organization Society, much rescue work was not structured around such regularized documentation, quantification, and standardization. Instead, rescue workers relied on tacit knowledge, word-of-mouth referrals, and the exchange of favors. For example, a good working relationship between a particular clinic almoner and the matron of a particular medical home would have helped to facilitate the hostelisation experienced by many female and child VD patients. Networks were activated by the movement of clients between regulatory sites following familiar but informal patterns of referral, transfer, and removal.

Officials presumably carried out much of that hostelisation in what they saw as the “best interests” of the patients, particularly when they judged that patients’ domestic circumstances were unhelpful to their recovery. If compulsory treatment was carried out “on the quiet,” it was perhaps because medical staff and welfare workers were concerned to preserve patient confidentiality and dignity as well as to protect public morals. Nevertheless, staff had to find ways of breaching patient confidentiality so that they could pass on the necessary personal, sexual, and medical details to those agencies whose help they believed their patient needed. This seems to have been done on an informal “need-to-know” basis. Manchée offers a telling example of how this was done: “In the case of Moral Welfare Workers and Probation Officers who send girls [to a VD clinic] for examination, the simple expedient can be adopted of saying either, ‘The doctor does not want to see the girl again’ or, alternatively, he ‘would like to see her again at once.’ In this way the worker can tell whether or not she may proceed with arrangements on hand for hostel, work or adoption or whether, the girl being infected, the Almoner will make the necessary plan.”Footnote 99

Sensitive and “confidential” information was passed in similar ways between child protection workers, probation officers, and police officers in the juvenile justice system.Footnote 100 It is not surprising that VD clinic records contain apparently little reference to such breaches given that their promise of discretion was vital to their maintaining public trust. It is equally unsurprising that few, if any, patients complained of poor or coercive treatment at the hands of the clinics or other agencies, as to do so would have been to advertise their condition.

Finally, these systematic silences and open secrets can further our understandings of British public policy making. I am not disputing the argument that Britain's voluntary system of VD treatment was unusual for its time, nor that it was founded on a particular mix of public policies that were at the same time morally charged yet pragmatic, coordinated yet piecemeal. What this article argues is that this voluntary system was dependent on the fact that certain categories of people continued to be subject to unquestioned nonvoluntary treatments—old-style sources of contagion (soldiers, and sexually transgressive women) and newly styled victims (babies and children). Securing the treatment of these particular groups made the national VD problem more manageable, whether or not this was acknowledged at the time. Contemporaries did not widely discuss these nonvoluntary treatments, and, with the exception of wartime measures, historians have not closely analyzed them. My aim here has been to highlight these treatments but also to begin to explain what made them both possible and largely invisible. They were the product of the powerfully patterned yet discontinuous workings of a regulatory network linking statutory and charitable staff and spaces. They are part of an intriguing history of things that “didn’t happen,” things that are too often overlooked in histories of British policy making and (welfare) state formation.