Venereal Diseases in New Zealand (1922) Report of the Special Committee of the Board of Health appointed by the Hon. Minister of Health online

infectious diseases. They think that it is inadvisable to particularize
venereal sufferers, or, indeed, to draw any distinction between
different classes of diseases in a hospital, and that the ordinary
subsidy should be paid in all cases.

In this Act also is power to make regulations for the "classification,
treatment, control, and discipline of persons _detained_ in such
hospitals," but apparently, owing to the opposition to the almost
analagous provision in the Hospitals and Charitable Institutions Act,
1913, no such regulations have as yet been made.


PART II - PREVALENCE OF VENEREAL DISEASES IN NEW ZEALAND.


SECTION 1. - STATISTICAL.

(A.) _Medical Statistics._

The first item on the Committee's order of reference is "To inquire and
report, as to prevalence of venereal diseases in New Zealand."

One of the first matters which engaged the attention of the Committee
was the question how reliable information could be gathered which would
indicate the present prevalence of these diseases in this country.
Recognizing that it would be impossible to obtain trustworthy figures
without securing the widespread co-operation of the medical profession,
the Committee at an early stage sought and was readily given the help of
the British Medical Association in the matter. Representatives of the
Association gave their assistance in the preparation of a form to be
sent to and filled in by all practising members of the profession, and
in the current number of the _New Zealand Medical Journal_ an appeal to
members for their collaboration was made. Suitable circular letters were
also prepared by the Committee asking medical practitioners for their
co-operation, and the Committee are pleased to be able to report that
out of about 750 in actual practice, no fewer than 635 medical
practitioners sent in completed returns. A copy of the form used for
these returns will be found as an appendix to this report, as also a
tabulated return of the replies received and compilations therefrom.

It will be seen that the total number of cases of all forms of venereal
diseases and of diseases attributable to venereal disease under the
personal care of the doctors reporting is 3,031; and, taking the
population of New Zealand as 1,296,986 (estimated population 31st March,
1922), this means that about one person in every 428 of our population
is at present being treated for venereal infection or for the results
thereof. Acute and chronic gonorrhœal infections give a total of 1,598,
being about one person in every 812 of the population. This is most
likely a very low estimate, for the Committee have had it very
definitely in evidence that many persons suffering, at least from acute
gonorrhœa, seek treatment at the hands of persons other than registered
medical practitioners. For syphilitic infections in all forms the total
is 1,419, about one person in every 914 of the population. The return
bears out other evidence showing that the chancroid or soft-sore type of
infection is rare in this Dominion.

The Committee regard the result obtained as furnishing some indication
of the amount of active venereal disease existing in the Dominion. The
Committee consider, however, that these figures must be considerably on
the low side, for these reasons: (_a_) that a number of medical
practitioners have not replied: (_b_) that some diseases attributable to
venereal disease may not have been conclusively diagnosed as such, and,
therefore, not included in the return. The return necessarily does not
include cases, probably numerous, which have not been under medical care
for some time, if at all; (_c_) to secure a complete return would have
involved the keeping by each doctor of full records of all cases and a
careful and laborious collation of figures.

With respect to the expression of opinion asked of medical practitioners
upon the question "If venereal disease in this Dominion has or has not
increased in a greater proportion than the population during the last
five years," it will be seen that of 322 who replied, 199 answered "Yes"
and 203 "No." This is necessarily purely a matter of impression, and it
must also be borne in mind that the evidence shows that patients are now
using the clinics in large numbers, while others who formerly went to
general practitioners now consult specialists who have recently started
in practice. On the other hand, it is possible there is a compensating
influence in the fact that the public are being educated to the
importance of seeking skilled medical treatment for these diseases.

(B.) _Clinic Statistics._

A second source of information as to the prevalence of venereal diseases
was provided by the statistics which have been compiled by the
Department of Health as the result of the establishment of the
venereal-diseases clinics. Among the appendices to this report will be
found a return showing the number of persons attending at each of these
clinics for the years 1920, 1921, and part of 1922, and recorded under
the headings "Sexes" and "Diseases." These statistics are valuable
insomuch as they record facts, but with respect to the total prevalence
they are but an indication, since they relate only to a small proportion
of the population who have become infected and sought treatment. From
this table (B) it will be found that the males attending for the first
time represent 83.60 per cent. of the total, and females 16.40 per
cent., or, roughly, a ratio of six males to every female.

_Clinic Distribution._ - In the figures for syphilis the following points
are worthy of note: Auckland: A distinctly higher number of cases than
the other centres. A marked drop in 1921 for males, but the return for
this year indicates a rise; female cases show a rise for this year.
Wellington: Returns appear fairly uniform, with a slight falling
tendency, most marked in the females. Christchurch: A drop in male
cases, with a fairly uniform rate of females. Dunedin: Here the rates
appear uniform, with exception of a fall for males in 1922.

As to gonorrhœa, these points may be noted: Auckland: A marked rise.
Wellington: Steady rise with exception of females. Christchurch: Slight
rise since 1920: females uniform rate. Dunedin: Slight rise, with
indication of male increase in 1922.

_Age Distribution._ - The age-period of persons attending the clinics is
mainly eighteen to thirty.

_Marital Condition._ - From the evidence of the clinics it is very
apparent that venereal disease is especially a problem associated with
the unmarried.

(C.) _Mental Hospital Statistics._

A third source of estimation of prevalence was opened to the Committee
by the Inspector-General of Mental Hospitals. The method of
investigation adopted by Dr. Hay is based on Fournier's estimate that 3
per cent. of the cases of syphilis existing at any one time will
ultimately develop dementia paralytica.

The introduction of the Wassermann test and treatment by salvarsan or
other arsenical preparations will vitiate this index in future, for the
reasons that by the Wassermann test more cases will be diagnosed, and by
the use of recent remedies the complete cure of many more cases will be
effected, and consequently fewer will develop dementia paralytica. This
disability does not develop until about ten to fifteen years after
infection. The Wassermann test and the modern arsenical preparations
have not yet been in use for that period, therefore these figures, as an
estimate of the prevalence of syphilis in 1921, would not be materially
affected by these developments. An estimate based on these data may
therefore be regarded in the meantime as approximately correct.

During the past ten years 4,763 males and 3,747 females have been
admitted into New Zealand mental hospitals. The percentage of syphilitic
admissions of all types was 4.74, while the percentage of cases of
dementia paralytica was 3.89. In other words, of the admission of
syphilitics 82 out of every 100 cases were dementia paralytica. The
average yearly number of deaths from dementia paralytica according to
the Government Statistician's returns between 1908 and 1921 was just
under 40.

If Fournier's estimate that 3 per cent. of syphilitics ultimately
develop dementia paralytica be accepted, one would arrive at the annual
infection by multiplying 40 by 33, which gives 1,320. Assuming the
average duration of life, after infection, to be twenty-five years, this
means that at any given time there are twenty-five years' infections on
hand. Dr. Hay computed from this the number of persons in New Zealand
now who have, or have had, syphilis to be 1,320 x 25, equalling 33,000,
or 1 to every 38 of the population. If the average duration of life
after infection were assumed to be thirty years, the figures would be 1
to every 32 of the population.

Taking the figure for syphilitic infections over a period of years at
1,320 per annum, this would mean for the population of New Zealand
(exclusive of Maoris) 1 fresh infection annually in about every 850
persons.

(D.) _Incidence among Maoris._

It is even more difficult than in the case of the European population to
say what is the prevalence of venereal diseases amongst Maoris. The
Director of the Division of Maori Hygiene (Dr. Te Rangi Hiroa) in a
statement to the Committee says: -

"Venereal disease made great ravages amongst the Maori population in the
early days of colonization. To this may be attributed much of the
sterility, with histories of repeated miscarriages, that existed in the
transitional period of Maori history. Most of the old men - hemiplegias,
and paraplegias, and subsequent general paralysis of the insane - gave an
old history of syphilis. These cases that I saw twenty years ago have
now disappeared.

"In my experience of eighteen years' constant work amongst the Maoris
venereal disease has been comparatively rare. It disappeared amongst the
people, only to recrudesce in some localities as fresh infection was
introduced by the white man, or brought back to the settlements by
visits to the white towns. I see very little of it at present, but now
and again hear reports from medical officers that it has cropped up in
the settlements near them ... In all these cases I am convinced that the
origin is from a white source, and the problem amongst the Maoris is not
nearly so serious as amongst Europeans. It seems to me unjust that the
idea should be circulated that the Maoris are a source of danger to the
European community - the reverse is much more likely.

"It is impossible for me to supply accurate data as to the incidence of
the disease amongst the Maori race at present, but I am confident that
reports have a natural tendency to become exaggerated. I do not consider
that returned Maori soldiers, owing to the treatment they received
before being discharged from the service, have been a factor in the
introduction of the disease amongst the settlements. If they have in
some areas, it has been from fresh infection, which their experience of
prostitution in Egypt and Europe has made them more liable to acquire
from professional and amateur prostitutes in towns. At the same time,
the experience of returned soldiers as to the value of treatment makes
them more likely to seek such aid."

(E.) _Death-certificates._

There are no trustworthy statistics in any part of the British Empire of
the deaths due to venereal disease. Many persons die from illnesses
which result from an initial syphilis contracted perhaps many years
prior to death. It is well known that medical practitioners, from a
laudable desire to spare the feelings of relatives, refrain from stating
the primary cause of death in such cases, and merely enter the secondary
or proximate cause. For the same reason, the statistics regarding deaths
due to alcoholism, and perhaps in a less degree some other factors in
the mortality returns, are incomplete and consequently useless.

Both the Royal Commission on Venereal Diseases and the Birth-rate
Commission recommended that the medical attendant should issue two
certificates - one, which would be a simple certificate of death, to be
handed to the relatives, and the other, a confidential certificate
giving the primary cause of death, which would be transmitted to the
Registrar.

The Registrar-General for New Zealand, Mr. W.W. Cook, in his evidence in
chief, stated that he did not favour these suggestions. A certificate of
death, he said, cannot be regarded as confidential, as the information
contained therein is recorded in the death entry, which may be inspected
by the public, and of which a copy may be obtained by any applicant. In
reply to questions, however, he stated that the law could no doubt be
altered so as to make the death-certificate confidential, the
information to be given up only on an order from a Court of justice.
Apart from the fact that the insurance companies might object, he did
not see any objection from the public point of view.

Mr. Malcolm Fraser, the Government Statistician, said that there was
considerable division of opinion on this question at the British Empire
Statistical Conference held in London in 1920, when statisticians from
all parts of the Empire were present. It was generally agreed that the
system was good theoretically, but some doubt was expressed whether in
practice there would be as much improvement as was expected, since the
system would depend entirely on the medical attendant strictly complying
therewith and disclosing the true cause of death in every case. Any
system of confidential information always had that failing. The witness
thought the register must be open for persons having a right to call for
copies of entries. In dealing with insurance claims at death the truth
or otherwise of the statement in the proposal form was important, and
might require verification by inspection of the death entry. At the
Conference Dr. Stevenson, the Statistician to the Registrar-General of
the United Kingdom, was very pronounced in his advocacy of the
confidential form of certificate. The Conference passed the following
resolutions: "(1.) That the present system of open certification tends
to prevent candid statements of the causes of death, and thus introduces
a systematic error into death statistics. (2.) That the error would be
eliminated by a system of confidential certification."

The Committee, while agreeing that such a system of registration of
deaths would undoubtedly afford better means of approximating to correct
returns of mortality not only from venereal diseases but also from
alcoholism and some other diseases, would point out that, if New Zealand
were to adopt the reform while the rest of the Empire retained the
present system, the result would be to place the Dominion in an
apparently unfavourable light in comparison with other parts of the
Empire in regard to the mortality from these diseases.


SECTION 2. - CAUSES OF THE PREVALENCE OF VENEREAL DISEASES IN NEW
ZEALAND.

In discussing this order of reference the Committee desire it clearly
understood that these causes are not peculiar to New Zealand, and do not
operate more extensively in New Zealand than elsewhere. The Committee
are concerned, however, in discussing this question only as it affects
New Zealand.

The causes of the spread of venereal disease may be classified under two
main headings: (1) The presence of infected individuals acting as foci
of infection; (2) the occurrence of promiscuous sexual intercourse, by
which in the great majority of cases the disease is actually transmitted
from one individual to another.

(1.) _The Presence of Infected Individuals._

These sources of infection arise and persist for the following
reasons: -

(1.) Neglect by infected persons to undergo treatment. (2.) Neglect
to continue treatment till no longer infective. (3.) The treatment
of infected individuals by unqualified persons, such as chemists,
herbalists, chiropractors, &c. In these cases the disease becomes
chronic, and the best opportunity for its treatment and cure has
passed before the case is seen by a medical man. (4.) By the
introduction of venereal disease to this country from overseas.

(2.) _The Occurrence of Promiscuous Sexual Intercourse._

A striking portion of the evidence placed before the Committee was that
which showed the very small amount of professional prostitution in New
Zealand. This was supported by the valuable evidence of Mr. W. Dinnie,
ex-Commissioner of Police, and Mr. A.H. Wright, Commissioner of Police.
The latter witness stated that there were only 104 professional
prostitutes in the Dominion.

It would appear also that the professional prostitute, as a result of
her knowledge and experience, is less likely to transmit venereal
disease than the "amateur." It is therefore principally to clandestine
or amateur prostitution that one must look for the dissemination of the
disease, and inquiry into the conditions which tend to the production of
the amateur prostitute is a direct inquiry into the causes of the
prevalence of venereal disease.

The evidence before the Committee shows that this promiscuity is very
prevalent, and that it is not confined to any particular social strata.
The fact is also strikingly demonstrated by Table A in the appendix.
From this table it will be seen that during the period 1913-21 there
were 10,841 illegitimate births and 33,738 legitimate first births
within one year after marriage. If to the illegitimate births we add the
total number of live births occurring within the first seven months of
marriage viz., 12,235 - which may be safely considered to have been
conceived before marriage, we get a total of 23,076 births in which
conception took place extra-maritally. In other words, more than 50 per
cent. of total first births occurring within twelve months of marriage
result from sexual contact prior to marriage.

Some factors which contribute in a greater or less degree to the moral
laxity which leads to promiscuous sexual intercourse are: -

(1.) The relaxation of parental control, which was emphasized by
many witnesses. Girls stay less at home and assist less in the work
of the home, preferring whenever opportunity offers, to go to the
pictures or some other form of entertainment.

(2.) Lack of education of the young in the facts pertaining to sex.
Especially the Committee would call attention to the unfounded
belief of many that continence in young men is injurious to health.

(3.) Bad housing and general conditions of living. When members of
both sexes are crowded together in restricted accommodation in
which often insufficient conveniences are supplied, it is easy to
conceive of a relaxation of the proprieties of life which might
lead to acts of immorality.

In this connection the Committee desire to call attention to the
excellent work done by the Y.W.C.A. and other bodies in the
provision of hostels in which girls are provided with board and
lodging at very reasonable cost. The Committee were surprised to
learn that full advantage was not taken of these provisions, and
that the accommodation at these hostels was not fully occupied. It
would appear that many girls resent the very slight amount of
supervision and restraint exercised over them, precisely as they do
parental control.

(4.) The presence in the community of individuals, especially
girls, who are to some degree mentally defective or morally
imbecile. The Committee were given several individual instances in
which such girls had acted as foci of infection; they are easily
approached, and facile victims for men. In spite of a degree of
mental or moral defect they may be physically attractive.

(5.) Economic conditions which delay marriage may reasonably be
regarded as a factor in conducing to an increased frequency of
extra-marital sexual relationship. Graph A in the appendix shows
clearly that the age of marriage in both sexes has, with slight
fluctuations, steadily increased from 1900 to 1921.

(6.) Alcohol tends to the dissemination and persistence of venereal
disease: it increases sexual desire, lessens control, causes the
individual to be less careful as regards cleanliness, &c., after
exposure to infection, and militates against effective treatment.
It is to be pointed out, however, that the lower control possessed
by some individuals may be the actual predisposing cause, both of
laxity in sexual matters and of the excessive ingestion of alcohol.
There appears no doubt that alcohol is an important factor in the
prevalence of venereal disease, although probably not so potent as
represented by some witnesses.

(7.) Accidental infections are undoubtedly rare. They may arise
from contact with W.C. seats, dirty towels, and eating and drinking
utensils in public places.

(8.) Other factors of minor importance which were mentioned in
evidence were the modern dress of women, which was stated to be in
certain cases sexually suggestive, and certain modern forms of
dancing. There appears some grounds to suppose that dances
conducted under undesirable conditions contribute to sexual
immorality, but the Committee see no reason to condemn dancing
generally because the coincident conditions under which it has been
or is conducted in some cases have contributed to impropriety. The
cinema was stated by some witnesses to have an immoral tendency
both in the nature of the pictures presented and in the conditions
under which they are viewed by the audience. The Committee suggest
that a stricter censorship might with advantage be exercised, and
should include the posters advertising the films.

It has been stated that venereal disease has increased in New Zealand
with the return of the Expeditionary Force from overseas. Ample
evidence, however, was given to the Committee that there has been no
increase of the disease due to returned soldiers. These men were treated
prior to their discharge until non-infective.


PART III. - BEST MEANS OF COMBATING AND PREVENTING VENEREAL DISEASE.


SECTION 1. - EDUCATION AND MORAL CONTROL.

There is no question that the most effective way of avoiding venereal
disease is to refrain from promiscuous sexual intercourse. The problem
which the Committee have been asked to consider has very important
medical aspects, but, while these must not be neglected, it is essential
to the health and well-being of the nation that the enemy should be
attacked with every moral and spiritual weapon: -

Self reverence, self-knowledge, self-control, -
These three alone lead life to sovereign power.

The absence of proper training and instruction of the young is
undoubtedly responsible for a great deal of the evil which has been
shown to exist. Children are led into bad habits through ignorance, and
young men and young women grow up with utterly false ideals of life, and
in many cases fall into deplorable laxity of conduct.

There is an impression among many young men that chastity is either
impossible or at least is inconsistent with physical health. There is
the highest medical authority for stating that this notion is absolutely
wrong, while there is no difference of opinion whatever as to the
serious risks of contracting diseases of a very loathsome character
incurred by those who do not restrain their passions. Apart from this
aspect of the question, it must be obvious to every thinking person that
looseness of conduct between the sexes such as is shown to exist in New
Zealand is destructive to the high ideals of family life associated with
the finest types of British manhood and womanhood, and if not checked
must lead to the decadence of the nation.

A sounder state of public opinion needs to be cultivated. The moral
stigma at present attached to sufferers from venereal disease should
rest upon all who sacrifice to their own selfish passions the
chivalrous relations which should subsist between the sexes. Those who
are unfortunate enough to contract disease incur a punishment so
terrible that they deserve our pity and our succour, always provided
that they seek skilled treatment and refrain from any conduct likely to
communicate the disease to others. The man or woman who negligently or
wilfully does anything likely to lead to the infection of any other
person is a criminal, and should be treated as such.

To bring about this healthier state of public opinion much might be done